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16820326-DS-16 | 29,980,562 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why did you come to the hospital?
-You came to the hospital because you were having shortness of
breath.
What was done for you while you were here?
-You were evaluated by the interventional pulmonology team and
they decided that your lung does not have enough fluid to remove
and the benefits of this would not outweigh the risks.
-You underwent a CT scan of your chest which confirmed fluid in
the lung and some collapsed lung tissue.
What should you do when you go home?
-Please continue weighing yourself every day and call your
primary care doctor if your weight goes up more than 3 pounds.
-Please continue using your incentive spirometer to help keep
your lungs open.
We wish you the best.
Sincerely,
Your ___ Medicine Team | Ms. ___ is a ___ woman with HFpEF in the setting of atrial
fibrillation on apixaban, valvular disease including 4+TR and
2+MR, multi vessel CAD s/p DES to RCA, mod pulmHTN with
significant PR, tachy-brady syndrome s/p PPM, breast cancer s/p
left lumpectomy, and known left sided pleural effusion (from
last hospitalization ___, never sampled) who presented with
generalized fatigue/tiredness and worsening hypoxia.
# Hypoxia
# L sided pleural effusion
Patient has known L pleural effusion which developed during her
last hospitalization in ___. No intervention was made at the
time and she was to follow up with IP for re-evaluation outpt on
___. At ___ clinic on ___ pt found to be hypoxic with O2 sat of
86% in room air. She was sent to the ED. Patient reported on
admission her baseline O2 sat has been 89-91% on RA at home
since her last discharge. CXR showed her left-sided pleural
effusion is unchanged from prior but the opacities within the
mid to lower right lung were more pronounced suggesting possible
aspiration/infection. While she may have had some aspiration,
she was afebrile, has no cough, no fever, chills, etc. Did not
appear volume overloaded on physical exam and was stable at her
discharge weight. IP evaluated her lungs with ultrasound and
reported that there is a very small pocket of fluid if anything,
and that thoracentesis would be more risk than benefit in this
pt. CT chest on ___ showed a partially loculated left pleural
effusion and significant atelectasis, which is likely
contributing to her hypoxia. ___ reviewed this CT and again did
not feel that the effusion would drain easily and would probably
not improve her oxygenation much. Pt and son agreed that she
would likely not want a more invasive procedure (i.e. thoracic
surgery consultation), especially since the benefit would likely
not outweigh the risk. On ___ ambulatory oxygen saturations were
obtained and the patient was found to be hypoxic to 87% on room
air, thus she will qualify for home oxygen. She will be
discharged with home oxygen and follow-up with her primary care
physician.
# Chest wall pain
On admission pt reported having severe sharp pain across her
left anterior chest, then on R on day 2 of hospitalization. Has
had in past and was told it is musculoskeletal. This pain was
reproducible by palpation on physical exam and was intermittent
throughout her hospitalization. This was treated with Tylenol,
Lidoderm patch, and lidocaine jelly as needed.
# ___
Recently hospitalized on CHF service for acute diastolic HF
exacerbation requiring 40-160mg IV Lasix and IV Diuril boluses.
ECHO during previous admission showed LVEF >55% with less
vigorous RV free wall motion and mild aortic valve stenosis. CXR
on admission showed no signs of pulmonary edema. Currently, she
does not appear volume overloaded (stable weight since
discharge, no ___ edema, JVP elevated but in the setting of 4+
TR) and thus will continue home diuretic without additional IV
diuresis. We feel that her hypoxia is unlikely to be from acute
HF exacerbation. Of note, on ___ evening, we did give her an
additional dose of diuresis with 140mg IV lasix, given her acute
desaturation episode, and she improved afterwards, but do not
think improvement was from the lasix as she did not have drastic
output (and we think the O2 tubing was loosely connected to the
wall during this episode). She was maintained on and will be
discharged on her home heart failure regimen (torsemide 60 twice
a day, verapamil 160 every 8 hours). Her weight on day of
discharge is 126 pounds.
# Atrial fibrillation
# Tachy-bradycardia syndrome
Patient has known history of afib on apixaban and
tachy-bradycardia syndrome s/p ___ dual chamber pacemaker.
Pacemaker was interrogated in ED due to concern for bradycardia
and was found to be working properly. EKG showed afib. While she
has no history of stroke, her CHADSVASC score is 5 and thus she
was started on a heparin bridge for possible ___. AC
(apixaban) was held on ___ in case of procedure, restarted ___
evening when decision for no procedure was made.
# ___ on CKD
Baseline Cr 1.1. On last admission for CHF, Cr fluctuated from
1.2-1.7. On BID torsemide, likely bumped in the setting of
diuresis; improved to 1.2 on ___. Cr 1.1 on day of discharge.
__________________
CHRONIC ISSUES
# Gout
Flare in left great toe during last hospital course iso
diuresis. She was discharged on colchicine on her last
admission, which we discontinued this admission. We started her
on allopurinol ___ daily ___.
# CAD s/p DES:
Continued home atorvastatin.
# Hypothyroidism
Continued home levothyroxine
# GERD:
Continued home omeprazole | 132 | 767 |
13687321-DS-7 | 29,080,833 | Dear Ms. ___,
You were admitted to ___ for a
urinary tract infection. You have been treated with antibiotics
and will not need to take antibiotics after you leave the
hospital.
We also found that you have shingles of your arm, upper chest,
and back. Anyone that has not had chickenpox or the chickenpox
vaccine should not visit with you. You will need to continue to
take medication to reduce the pain associated with shingles.
You fell at home. There is no evidence of fractures from this
fall. You will be discharged to rehab for further treatment
after this fall.
Please follow up with you primary care provider after being
discharged from rehab.
Medication changes:
START taking gabapentin 300mg twice daily for pain control of
you shingles
START taking Valacyclovir 1000 mg by mouth every 12 hours for an
additional 6 days
START taking oxycodone 2.5-5mg every 4 to 6 hours as needed for
pain control
Continue to take all other medication as prescribed | This a ___ yo F with PMH sig for dementia (AxOx2-3 at baseline),
HTN, DM, CAD s/p MI, CVA in ___ with R side weakness/loss of
sensation, here after unwitness fall, UTI, and shingles in the
T1-2 dematome.
#. UTI- The patient per family report was a little more altered
for the 10 days prior to admission. She has bowel and bladder
incontinence at baseline. A UA concerning for UTI. Urine
cultures grew back a likely containment of between ___
colonies of Coag Negaive Staphlococcus. She was treated with 3
days of ceftriaxone and will not need antibiotics after
discharge.
#. Shingles- The patient has vesicular rash on erythematous base
in T1-T2 dermatome. The vesicle started approximately 1 day
prior to admission. The patient was started on a day course of
Valacyclovir 1000mg BID and will need an additional 6 days after
discharge. She was also started on tylenol ___ TID,
gabapentin and oxycodone prn for pain control. The pain was
still better controlled at the time of discharge.
# Diabetes mellitus type 2. sugars well controlled on home dose
with a humalog insulin sliding scale. Her home doses are NPH 32
units in AM and 14 units in ___
#. R leg venous stasis dermatitis- no obvious cellulitis or open
ulcers.
#. Dementia of Alzheimer's type. continued home dose of
donepezil
#. Hypercholesteremia. continued home dose of simvastatin
#. Hypertension. continued home doses of lisinopril and
furosemide. | 162 | 247 |
13319174-DS-10 | 23,579,173 | Dear ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
-You were having chest pain, difficulty breathing and you were
feeling lightheaded.
WHAT HAPPENED WHILE YOU WERE HERE?
-All of the testing on your heart came back normal. The pain you
were having is likely from a condition called costochondritis
and you got better with a medicine called naproxen.
-Because of your headaches we did some imaging of your brain.
You had a cat scan of your head that didn't show any
abnormalities.
-We sampled some fluid from your toe and there was no evidence
of infection.
-You were dehydrated so we gave you some fluids through the IV.
-Your iron levels were low so you got an iron infusion through
the IV.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
-Do not take metformin until you speak with your PCP
-___ taking naproxen for your chest pain through ___,
but not longer
-Follow up with your primary care doctor.
-___ up with the neurologists to discuss your headaches
further. We made you an appointment at the Headache Clinic. See
below for more details.
It was a pleasure taking care of you,
Your ___ Medicine Team | Outpatient Providers: ___ y/o F with h/o NIDDM, asthma,
hypothyroidism, GERD and right MTP septic arthritis in ___
presenting to the ED with chest pain (negative cardiac work-up),
shortness of breath, headache, dizziness, and generalized
malaise.
ACUTE ISSUES
========================
#Costochondritis
#Chest pain
#Palpitations. Cardiac etiology of chest pain unlikely given
negative trops, no EKG changes and negative stress test. Does
not appear exertional. Pain reproducible with palpation. No
events on telemetry. Treated with naproxen 500mg BID with
improvement in pain.
#Headache
#Right face numbness. History of migraine headaches though has
had daily headaches over the past ___ weeks associated with
sensitivity to light and sound. Also complained of right-sided
face numbness that may be associated with migraines. Head CT
without acute abnormalities. To follow-up at outpatient ___
headache clinic for consideration of trigger point injections
due to headaches possibly related to MSK pain.
___ MTP Pain. History of septic arthritis of ___ MTP in ___
s/p antibiotics and debridement. Has been followed with
orthopedics since given ongoing pain in the left toe with
evidence of hallux deformity of the toe as well as arthritis.
Had ___ arthrocentesis to r/o septic arthritis in ED per ortho
recs though exam without evidence of inflammation or erythema
concerning for an active infection. No generalized evidence of
infection though ESR 35, CRP 23.8 on ___ at ___.
Given stability of exam compared to priors, pain most consistent
with arthritis of the joint. Cell counts and cultures negative
for infection.
#Pre-syncope
#Orthostatic hypotension. Symptoms most consistent with
orthostatic hypotension iso symptom onset with standing and
resolved spontaneously. Has had poor PO intake over the past
week as well. No vertigo and non-focal neuro exam. Orthostatic
vitals positive initially that resolved after fluid
administration.
#Dyspnea
#Asthma. No apparent infectious etiology without fever,
leukocytosis, or evidence of infection on CXR though with poor
penetration given body habitus. No hypoxia, tachycardia or
changes on EKG concerning for PE with negative ___ Doppler and
Well's score of 0. Pro-BNP of 25 making CHF unlikely. Last PFT
in ___ without obstructive defect though with mild component of
airway hyperactivity. Continued on home fluticasone-Salmeterol
and given albuterol PRN. Shortness of breath improved at the
time of discharge.
#Hypoglycemia
#DM type 2
#Generalized malaise. Last HgbA1C 7.1%. Notes intermittent
episodes of symptomatic hypoglycemia to 60's throughout the day
while only on Metformin. Given only on Metformin would not
except medication induced hypoglycemia and may be related to
poor PO intake. No hypoglycemia noted in house. Metformin held
while in-house and at discharge to be restarted by PCP.
#Anemia
#Gastritis/GERD. Iron studies consistent with iron deficiency
anemia. Focal erythema in fundus on EGD in ___. No evidence
of melena or hematochezia. Started on lasoprazole outpatient
30mg BID by GI doctor. Last colonoscopy in ___ with polyp in
the rectum, diverticulosis of the sigmoid colon, and grade 2
internal hemorrhoids. Received IV ferric gluconate 125mg. | 190 | 474 |
17931647-DS-9 | 28,439,165 | Dear Ms. ___,
You were hospitalized because of abdominal pain and vomiting.
This led to worsening of your atrial fibrillation. You needed to
be taken care of in the intensive care unit because your blood
pressure was low. You were given IV fluids and your blood
pressure improved.
We think you may have had a partial blockage of your bowels and
this caused nausea and poor fluid intake and you became
dehydrated.
Once your symptoms improved you restarted all of your home
medications and we were able to send you to rehab.
Please continue to take all your medications as directed and
attend all of your follow up appointments.
It was a pleasure taking part in your care.
Sincerely,
Your ___ Care Team | Ms ___ is an ___ F with a past medical history of atrial
fibrillation, cauda equina complicated by bilateral ___
paralysis, chronic constipation s/p colectomy with
end-ileostomy, urinary retention s/p suprapubic catheter
placement presenting to OSH with abdominal pain/N/V complicated
by hypotension and afib with ___ transferred to ___ for
ongoing management with hospital course complicated by
hypotension, ___, and partial SBO.
# Abdominal Pain: patient presented with several days of
nausea/vomiting and increasing abdominal pain. OSH CT concerning
SBO. Given concern for need for surgical intervention, she was
transferred to ___. ACS was consulted on transfer, who felt CT
was not consistent with complete SBO or other acute surgical
pathology. Her abdominal exam was notable for mild distension,
LLQ TTP, no rebound/guarding. Stool studies and c diff were sent
and are negative so far. She was started on empiric antibiotics
but these were discontinued. She received IVF and was kept NPO.
Following transfer, her abdominal pain started to improved. She
had resumption of her ostomy output along with gas. She was
trialed on and tolerated a clear diet, which was advanced to
softs.
# Leukocytosis: patient presented to OSH with hypotension,
tachycardia, and leukocytosis concerning for sepsis. Exam
consistent with volume depletion. She received IVF with
improvement in her BPs. Her lactate was trended and downtrended
with IVF resuscitation. Etiology was felt to be viral. She was
started on empiric ceftaz, flagyl. She was pan-cultured. Culture
data notable for multi-organism urine culture, consistent with
colonization. Urology was contacted, who felt there was no need
to change her suprapubic catheter. She was narrowed to
cipro/flagyl but these were discontinued as no evidence of
bacterial infection was found and patients symptoms were
attributed to hypovolemia in setting of partial SBO.
# ___: on admission, patient with noted to have ___ with Cr 2.8;
she received IVF resuscitation with subsequent downtrend
consistent with pre-renal ___. Her Cr was trended and
nephrotoxic medications were avoided. She maintained good UOP
via suprapubic catheter.
# AFib with RVR: patient with chronic atrial fibrillation, rate
controlled at home on diltiazem and metoprolol. On presentation
to OSH, patient was noted to be in atrial fibrillation with RVR;
she received additional diltiazem and IVF with improvement in
rate control. She was restarted on home medications after
improvement in hypotension and initiation of antibiotics. Of
note, patient has refused anticoagulation and re-stated this
during her admission.
# ___: ECG on admission concerning for ST depressions, likely
type II in setting of demand. Trops were trended and were flat.
She remained chest pain free. The plan was to initiate a heparin
gtt, however patient refused. She was continued on medical
management with metoprolol and statin.
#Right breast fungal rash
Continued nystatin ointment
#Left eye bacterial conjunctivitis
polymyxin B QID for 7 day course (Day ___, last day ___ | 118 | 464 |
15514336-DS-32 | 29,363,644 | Dear Mr. ___,
You were seen at ___ for evaluation of nausea
and for decreased urine output. You received fluids, and your
urine output improved. You had an elevated creatinine, which is
a marker of your kidney function. This improved closer to your
baseline with fluids as well.
Your nausea improved with an antinausea medicines called Zofran
and compazine which you will take at home. Your nausea is most
likely multifactorial. It may be due to constipation in part.
You had an XRay that showed significant stool in your colon, and
you were started on an aggressive bowel regimen to improve you
constipation. You then had a follow up XRay that showed
improvement. Some of your medications that are cleared by the
kidney could also be causing your nausea as well, specifically
gabapentin. Your oxycodone and oxycontin can also contribute to
nausea. Finally, your kidney injury could also cause nausea.
Over the hospital course, you were able to tolerate food with
oral medication, and you will go home on these. You should
follow up with GI to manage your nausea if it does not continue
to improve.
Please take all the medications as prescribed and please follow
up with the appointments we have arranged.
It was a pleasure taking care of you at ___.
Your ___ care team. | Mr. ___ is a ___ yo man with a history of ESRD ___ T1DM /p
LRRT (___), ___ (___) with subsequent failure and explantation
in ___, and severe PVD, transferred for ___, oliguria, and
nausea. He had initially presented to OSH ED with a ___ week
history of nausea and poor po intake. His symptoms improved with
IV zofran and he was discharged from the ED. At home, he noted
decreased urine output and so re-presented to OSH ED, where he
was noted to have creatinine 2.3 from baseline 1.5-1.7. He was
transferred to ___ given ___ and his history of renal
transplant.
___ on CKD: Patient with history of ESRD secondary to DM-I,
with LRRT (___), on prednisone & tacrolimus. Urine electrolytes
were consistent with pre-renal etiology in setting of poor po
intake and nausea. Nausea may initially have been ___ uremia in
setting of ___. Renal ultrasound obtained in ED showed normal
transplanted kidney. Given a concern that his creatinine of 1.4
may represent more severe disease in this man with bilateral
BKAs, he had 24H urine and cystatin for more accurate estimation
of GFR, which was calculated to be 40. He was continued on his
immunosuppresion with tacrolimus and prednisone, with tacrolimus
levels checked daily. His lisinopril was held during the course
of the admission and held on discharge.
#Nausea: Unclear etiology. Most likely ___ constipation vs
medication effect vs less likely uremia. He had a KUB consistent
with severe fecal loading and so started on BID tap water enemas
and bowel regimen. However, follow up KUB showed improvement in
fecal loading and patient continued to c/o nausea. After
resolution of his constipation, the differential includes
primarily medication effect given that he does have a GFR of 40,
making uremia less likely. Given concern for medications causing
nausea, his gabapentin dosing was decreased substantially. His
narcotics may be a large contributor both to nausea and to
constipation; however, patient was not amenable to changing
narcotics regimen, as he has been stabilized on dosing for some
time. Gastroparesis is possible but his nausea is not related to
meals and is constant. He may have small bacteria overgrowth as
has been seen previously. GERD is less likely given the constant
nausea unrelated to meals or positioning. He does have a small
bowel resection of 26 cm due to incarcerated bowel but it is
less likely that he has short gut given that he has no other
symptoms except nausea. His lack of abdominal pain and fevers
points away from infectious etiology, and stool studies during
this admission have been negative. At this point, he may warrant
further work up that may be pursued as a an outpatient per GI.
By the time of discharge, he was tolerating po with oral
Compazine and Zofran, which he will be discharged on. GI was
consulted during admission and guided management.
#T1DM: s/p failed pancreas transplant and explantation (___).
A1c this admission 6.5%. Continued home insulin.
#Peripheral neuropathy: Continued gabapentin at reduced dose as
above
#CAD: S/P CABG. Continued home atorvastatin, aspirin, metoprolol
#PAD: S/P multiple stentings and bypass. Continued clopidogrel.
#HTN: Continued amlodipine at increased dosing, metoprolol.
Lisinopril held given ___.
TRANSITIONAL ISSUES
- Patient's home lisinopril was held upon admission due to ___.
He was subsequently hypertensive to 140s-160s and so his
amlodipine was increased from 5 to 10 mg daily with improvement
in blood pressure control. Consider re-starting as outpatient as
indicated | 216 | 571 |
17797856-DS-16 | 20,135,323 | Dear Ms. ___,
You were admitted to the hospital for dizziness,
light-headedness, and some difficulty breathing. Because of your
shortness of breath, you were treated with steroids,
antibiotics, and a nebulizer in case you had a COPD
exacerbation. These medications were stopped in the morning,
once your symptoms improved. Most likely, you were dizzy because
you dehydrated after not eating or drinking well over the past
few days. We gave you some fluids through the IV and encouraged
you to drink and eat normally.
It was a pleasure to take care of you.
Best wishes for the future,
your care team at ___ | ___ is a ___ woman with severe COPD (on 3L
home oxygen, with hospice care), who developed light-headedness
and shortness of breath after standing up from a chair in the
context of reduced PO intake over the past several days.
ACTIVE DIAGNOSES
================
# Lightheadedness/dizziness: Patient reports feeling unbalanced,
mostly with standing but occasionally occurs at rest as well.
Likely orthostatic presyncope, given decreased PO intake over
the past several days, dry mucus membranes, and orthostatic
hypotension on exam. There was a creatinine bump concerning for
dehydration-related ___, but BUN was not elevated. Neuro exam
was nonfocal. No signs of cardiac etiology. Her symptoms
improved with 2L NS and at the time of discharge, orthostatics
were negative and she had no dizziness with standing or
ambulation.
#Shortness of breath: the patient originally reported mild
shortness of breath, prompting initial treatment for COPD
exacerbation. CXR was unrevealing. At time of discharge,
however, the patient does not report any dyspnea and says that
her presentation is not similar to her previous COPD
exacerbations. Her oxygen saturation has been 100% on home
oxygen levels. We continued her home medications.
# ___: Last Cr 1.1 in ___. Cr on admission 1.7, which then
trended downwards to 1.5 after 1L NS. Patient has had decreased
intake over the past several days, in the setting of bactrim.
The creatinine bump may be due to dehydration (although BUN is
not disproportionally elevated), a bactrim-related drug effect,
or more chronic kidney disease, given no recent Cr on file.
CHRONIC ISSUES
===============
# HTN: we held her triamterine/HCTZ due to ___, but continued
her metoprolol. She was instructed to restart her home
medication on ___.
# GERD: Continued home omeprazole.
# SPINAL STENOSIS: Continued home oxycontin and tylenol.
Oxycodone PRN written for breakthrough pain.
TRANSITIONAL ISSUES
===================
- would avoid Bactrim in the future as it seems patient did not
tolerate well
- patient instructed to retart her home antihypertensives
(diuretic) on morning of ___
- Patient may benefit from further goals of care discussion as
outpatient with providers who have long term relationship with
her - she remains on hospice care and has been on hospice for ___
years | 100 | 358 |
18807122-DS-15 | 29,860,394 | You were admitted to the surgery service at ___ for evaluation
of the new onset abdominal pain. Abdominal CT revealed small
bowel obstruction. You bowels were rested with NPO and IV
fluids. When you started to pass flatus, diet was progressively
advanced to regular and was well tolerated. You are now safe to
return home to complete your recovery with the following
instructions:
.
Please call ACS service at ___ if your symptoms
return, or if you have any question or concerns.
.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
. | The patient with h/o multiple abdominal surgeries was admitted
to the ACS Service for evaluation of abdominal pain. CT scan on
admission revealed small bowel obstruction. Patient was made NPO
and started on IV fluid for hydration. Patient did not required
NGT placement. On HD 2, patient had a bowel movement. On HD 3,
patient's diet was advanced to regular and was well tolerated.
Patient was discharged home in stable condition.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 231 | 120 |
16796107-DS-14 | 20,529,674 | Dear Ms. ___,
It was a pleasure taking care of you during your
hospitalization. You were diagnosed with stroke recrudescence
and angina pectoris. You were treated for your angina and your
neurologic exam has improved. You also have a new baseline in
your kidney disease. You will be discharge to rehab and should
follow up with a kidney doctor/nephrologist regarding your
chronic kideny disease.
Sincerely,
Your ___ Team | ___ y/o female with hx of CHF, HTN, HLD, CKD (baseline Cr 2.0),
multiple strokes/TIAs presenting today with word finding
difficulties and acute on chronic renal failure. Hospitalization
complicated by several episodes of chest pain. | 66 | 35 |
11102011-DS-6 | 26,136,045 | Dear Ms ___,
Why did I come to the hospital?
-You came to the hospital because you fainted
What happened while I was in the hospital?
-We checked your blood work, which was normal. We looked at the
rhythm of your heart using an EKG, which did not show any
arrhythmia. -You were fitted for a heart monitor, which will
monitor the activity of your heart for a month. This will help
us see if your heart is causing you to pass out.
-We are not sure why you have had these fainting episodes but
there is a small risk of fainting with donepezil so we have
stopped this medication.
What should I do when I leave the hospital?
-Please make sure you attend all of your doctor appointments
-___ taking donepezil
Best,
Your ___ team | Ms. ___ is a ___ year old woman with a history of
dementia, and hypothyroidism who presents for evaluation of a
syncopal event.
# Recurrent syncope:
Hx not consistent with seizure. Patient had EKG w/o arrhythmia
or AV block and telemetry monitoring was unremarkable.
Orthostatic vital signs were normal. Hx was not c/w seizure.
Patient has had outpatient echo, which was normal, and a
___ hour holter monitor this month, which was
unrevealing. Per the patient's husband, her events have been
related to donepezil administration, which does have a 2% risk
of syncope. Donepezil was discontinued during this
hospitalization. Her labs were only note-able for a mild
leukcocytosis upon admission, that resolved on hospital day 2.
She did have a faint opacity on CXR but no other clinical s/sx
of infection or pneumonia, so she was not treated with full
course of abx. The etiology of her syncope remains unknown
although donepezil may be the culprit. She was set up with a
long term 30 day cardiac monitor upon discharge and has follow
up with her PCP and cognitive neurologist. | 126 | 183 |
11388315-DS-19 | 26,862,846 | Dear Mr. ___,
You were hospitalized due to symptoms of left facial droop,
slurred speech and left sided weakness resulting from an ACUTE
ISCHEMIC STROKE, a condition where a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
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:
-pancreatic cancer
-high blood pressure
-high cholesterol
We are changing your medications as follows:
-started lovenox (injectable blood thinner medication)
-started florinef, a medication to treat orthostatic hypotension
(when blood pressure drops upon standing)
-Discontinued your aspirin in favor of lovenox
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 | SUMMARY: ___ is a ___ year-old man with a PMHx of
pancreatic cancer with metastasis to liver on chemotherapy
(gemcitabine and abrexane, last dose 2 weeks ago), melanoma,
HTN, HL, and T2DM who presents with recurrent episodes of
dysarthria,
left facial droop, left hand weakness and left arm and leg
paresthesias. By history His exam is notable for dysarthria
(waxing/waning, worse with guttural sounds), mild left upper
motor neuron pattern of weakness (in 4+/5 range), and question
of mild left nasolabial fold flattening. He was found to have
multiple punctate, bilateral, cortically based infarcts on MRI.
Etiology for the patient's symptoms is most likely due to
underlying hypercoagulability from his malignancy, given the MRI
findings of stroke in multiple vascular distributions. Unlikely
related to intracranial stenosis given no significant stenosis
noted on CTA Head/Neck. Patient remains in house due to
persistent orthostatic hypotension.
HOSPITAL COURSE BY PROBLEM:
#Acute bilateral, punctate ischemic strokes: Workup included MRI
brain with and without contrast revealed several small cortical
based subacute infarcts in the right precentral gyrus, as well
as a focus in the left postcentral gyrus. Distribution is
concerning for embolic etiology. No evidence of intracranial
metastases. For stroke workup, risk factors included LDL 78,
hemoglobin a1c 6.0. Given that stroke from underlying
hypercoagulability was most likely--given pancreatic cancer
(particularly prone to hypercoagulability related complications)
and multiple affected vascular distributions--the patient was
started on therapeutic lovenox. This was discussed with his
oncologist, Dr. ___. Initially, given concern for perfusion
related deficits the patient was placed head of bed flat, but he
was able to advance his activity without neurologic symptoms.
Otherwise his sugars were well controlled, UA negative for
infection and CXR with mild cardiomegaly without infiltrate.
Patient expressed willingness to continue therapeutic lovenox
moving forward. Neurology follow up was arranged.
#Orthostatic hypotension: Patient was noted to have profound
orthostatic hypotension during ___ eval on ___. His SBP went from
120s sitting to ___ upon standing. He was symptomatic with mild
lightheadedness upon standing as well. He received IVF bolus,
low dose IV fluids and started on ___ stockings. Etiology was
thought to be due to hypovolemia given poor PO intake in setting
of cancer. On ___, he was started on fludrocortisone 0.1mg
daily.
#Pancreatic Cancer: Defer chemotherapy given acute illness.
Patient's oncologist was contacted to inform her about the
hospitalization. For pain control, increase MS contin to 60mg
TID with immediate release morphine 30mg q4h PRN after
discussion with the patient's outpatient palliative care
provider. Follow up was arranged with palliative care and
oncology.
#Anemia of chronic disease: The patient's hemoglobin remained at
baseline of ~7.8-8.5. No clinical evidence of bleeding. This was
trended daily.
************** | 267 | 444 |
10082701-DS-16 | 20,717,652 | 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:
- nonweightbearing on the left upper extremity, range of motion
as tolerated in elbow, wrist, shoulder and fingers; sling for
comfort as needed
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin daily for 4 weeks
WOUND CARE:
- You may shower. 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.
- Leave soft dressing on | Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left distal humerus fracture and left proximal humerus
fracture was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for an open
reduction internal fixation of the left distal humerus, 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. The patient was given ___ antibiotics
and anticoagulation per routine. The patient's home medications
were continued throughout this hospitalization. The patient
worked with OT who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. | 204 | 187 |
17194276-DS-48 | 20,557,856 | Ms. ___:
It was a pleasure to take care of you. You were admitted to the
___ because of fevers. We treated you with antibiotics and
performed many studies to evaluate you for potential sources of
fever and you were found to have an infection called Clostridium
difficile which was causing diarrhea. We treated this with an
antibiotic called vancomycin, which you should continue to take
for a total of 10 days.
Weigh yourself every morning, and call your primary care doctor
if your weight goes up more than three pounds.
Please start:
VANCOMYCIN 125 mg by mouth every 6 hours, take through ___
*Prescription has been faxed to ___ pharmacy on ___.*
Please see below for your follow-up appointments.
Wishing you all the best! | ___ with hx of secondary sclerosing cholangitis and biliary
cirrhosis complicated by recurrent hepatic encephalopathy,
ascites, portal hypertension with varices, portal hypertensive
gastropathy, who has had upper GI bleeding from polyps, s/p
thermal therapy as well as portal vein thrombosis seen on recent
CT, who presented with fever.
# C diff: Pt presented with report of fevers and increased
stools and was placed on empiric abx with ceftriaxone and flagyl
to cover SBP vs. acute hepatobiliary infection. There was
insufficient ascites on ultrasound for paracentesis.Pt's
indwelling port-a-cath was considered as an infectious source,
but blood cultures were negative. Urine cultures were also
negative. Stool studies revealed positive c diff PCR and
patient was switched to PO vancomycin given prior episode of C
diff in ___. Stool frequency decreased and patient was
discharged with plan to complete 10 day course PO vancymycin.
# Secondary biliary cirrhosis: Complicated by varices, hepatic
encephalopathy and SBP and recently found to have likely chronic
portal vein thrombosis. Home lasix and aldactone were continued
as was home nadolol given h/o grade 2 varices. Bactrim
prophylaxis was held while patient on ceftriaxone/flagyl, but
restarted at discharge. She was discharged with plan to
follow-up with Dr. ___ have MRI in ___ for portal vein
evaluation.
# Hepatic encephalopathy: Patient had a history of recurrent
hepatic encephalopathy, but without signs of HE this admission.
Home lactulose and rifaximin were continued.
# Anemia: Iron deficiency anemia as well as anemia of chronic
disease. Iron supplementation was continued. | 120 | 247 |
14216260-DS-22 | 20,636,200 | Dear Ms. ___,
It was a pleasure taking care of ___ at ___.
___ first came to the hospital after a mechanical fall. A CT
scan of your head and neck was normal. Fortunately, we do not
think ___ had any serious injury from that fall. We had physical
therapy come to see ___ to evaluate for problems with your
walking. They recommend ___ get ___ more sessions of physical
therapy to get stronger on your feet. ___ may need to use a
walker for getting around after leaving the hospital.
Your thyroid medication was not at the right dose, which we
adjusted. ___ will have to go see your regular doctor in about 6
weeks to get your thyroid checked again.
We stopped some of the medicines ___ were on so that ___ will
have to take fewer pills.
We wish ___ the best of future health,
Your ___ Care Team | ___ female with dementia, hypothyroidism s/p thyroidectomy
presented s/p mechanical fall, after several recent mechanical
falls.
================ | 146 | 16 |
10781100-DS-13 | 26,128,575 | Dear Mr. ___,
You were hospitalized due to symptoms of L sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
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:
Diabetes
Hypertension
We are changing your medications as follows:
INCREASE AMLODIPINE TO 5 MG DAILY
START ASPIRIN 81 MG DAILY
Please discuss increasing your dose of Metformin with your PCP
___ take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below. | Mr. ___ is a ___ yo male who was admitted on ___ due to concerns for acute ischemic stroke. He was admitted
with a 3 day history of fluctuating L arm and leg weakness. In
the ER a NCHCT was performed and did not demonstrate an acute
infarction or hemorrhage but was notable for old occipital
stroke. CTA demonstrated significant stenosis of multiple
intracranial arteries likely related to atherosclerotic disease.
Although there was concern for stroke, TPA was not given as it
was deferred by the patient's family. He was started on Aspirin
and admitted to the Neurology service for further workup. An
MRI w/o contrast was performed and demonstrated a right pons 11
x 7 mm acute to subacute infarct without hemorrhagic
transformation. His home Amlodipine of 2.5 mg qDay was
increased to 5 mg qDay due to ongoing high blood pressure.
Closer BP control with SBP 120-150 was recommended along with
improved glucose control with goal 150-180.
He was observed overnight with slight improvement in LUE
strength but persistent LLE weakness. There were no new
symptoms. He was evaluated by ___ who recommended ___ rehab
but family preferred discharge to home with outpatient ___.
Patient was advised to follow up with his PCP regarding
adjustment of his Metformin for better blood sugar control.
Lipid panel was notable after discharge for elevated
Triglycerides, low HDL (37), and normal LDL (89); no medications
for hyperlipidemia were started during this hospital course;
further treatment will be deferred to PCP. Of note, his MRI
demonstrated a R globe vitreous hemorrhage, likely contributing
to pain. This was discussed with ophthalmology who recommended
further evaluation with his primary opthalomogist. Finally, Mr.
___ was on a course of Levofloxacin at the time to
admission for CAP; daughter reported he had completed a 5 day
course so the medication was discontinued.
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 -ASA () No
4. LDL documented? (X) Yes (LDL = 89) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (X) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? () Yes - (X) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet -ASA () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A | 164 | 539 |
19542943-DS-13 | 26,379,787 | Dear Mr. ___,
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management
of your healthcare-associated pneumonia. You had evidence of
mental status changes and this improved with antibiotics.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms. | IMPRESSION: ___ with extensive PMH including dementia, COPD,
atrial fibrillation, and myeloproliferative disoder who was
admitted for congestion, lethargy, and hypoxemia with CXR
concerning for healthcare pneumonia.
# HEALTHCARE ASSOCIATED PNEUMONIA - CT chest revealed multilobar
PNA with bibasilar atelectasis. Recent hospitalization within
90-days warrnated treatment with Vancomycin and Cefepime. Had
received Levofloxacin previously without resolution. There was
also some concern for aspiration, so metronidazole was added to
the regimen. He clinically improved and was weaned from
supplemental oxgyen to ambient air. PICC line was placed, but
was pulled back to midline given that it was inadvertently in
the inominate vein. Leukocytosis and fever resolved. Cough
improved. Discharged with 8-day course of cefepime IV and oral
metronidazole.
# CHRONIC ASPIRATION - Video swallow evaluation was reassuring
per speech therapist. Was cleared for monitored oral intake.
Treated for pneumonia, as above.
# TOXIC METABOLIC ENCEPHALOPATHY - Patient had evidence of
hypoactive delirium in the setting of above infection which
rapidly improved with antibiotics. | 176 | 159 |
13828841-DS-12 | 21,708,986 | Dear ___,
___ was a pleasure taking care of you at ___
___. You were admitted because there was concern
that you may not be able to take care of yourself at home. You
are going to go to a rehabilitation facility to try to get back
to your baseline.
Please continue to take all of your medications as prescribed.
No changes have been made.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ yo F with multiple medical problems (obesity, hypothyroidism,
DM, HTN, DJD), admitted for worsening depression, failure to
thrive, new T wave inversions with elevated troponin, and facial
assymetry of unclear duration.
. | 78 | 36 |
12607933-DS-11 | 23,177,182 | DISCHARGE INSTRUCTIONS:
Please have your INR checked on ___ and contact Dr. ___
coumadin instructions
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** | Mr. ___ is a ___ year old man with stage II squamous cell
lung CA who was being treated with chemo/radiation for the past
___ weeks because presumably his PFTs showed that he would not
tolerate a R pneumonectomy that would have been required for
removal of the mass. He had a presyncopal event in his PCP's
office, and his ___ work up showed INR 5.9 and CT
scan showed proximal ascending aortic dissection (5.5cm),
beginning at sinuses of Valsalva and extending to just proximal
to the origin of the brachiocephalic artery with coronary
sinuses arising from the true lumen. This dissection was not
seen on his prior imaging ___.
He was transferred to ___ for further evaluation and admitted
to the ICU for blood pressure control with IV nicardipine and
INR correction. His transthoracic echocardiogram here was
evaluated by Dr. ___ and the dissection was felt to be
subacute. Given his lung CA history, severity of his PFTs,
previous cardiac surgery, significantly elevated INR, and his
asymptomatic condition, medical management was recommended.
His coreg was increased to 25mg BID, lisinopril 40mg daily was
added, and he was weaned from nicardipine and transferred to
stepdown ___. Norvasc 10mg daily was added ___ AM for
asymptomatic hypertension (160s) and the lisinopril was
increased to BID, and he remained inpatient for further blood
pressure monitoring. His SBP remained 110-120s at rest during
the day, increasing to 130s with ambulation. On the day of
discharge, he did have random elevation to 158 at 4am that was
asymptomatic and resolved to 100-110 with his AM medications.
His INR decreased to 2.7 after Vitamin K 10mg po on ___. He
was restarted on coumadin ___ with goal INR ___ for atrial
fibrillation. Dr. ___ for Dr. ___, was
contacted and notified of the hypertension and coumadin
medication changes during this admission, and Dr. ___
___ will receive the INR on ___.
He repeatedly denied chest pain, palpitations, syncope, or
lightheadedness. His only complaint was headaches, which are
chronic for him and relieved by tylenol. | 41 | 345 |
17117048-DS-19 | 27,277,428 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated in right lower extremity
MEDICATIONS:
- Please continue and complete the two week course of oral
antibiotic (Keflex ___ by mouth four times per day).
- Continue all home medications unless specifically instructed
to stop by your surgeon.
WOUND CARE:
- A visiting nurse ___ come to help you with daily dressing
changes for your knee wound. Please keep the area clean and dry.
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:
WBAT RLE, ROMAT
Treatments Frequency:
Right knee wound needs daily wet-to-dry dressing changes. Please
monitor for signs and symptoms of infection (ie: increased
redness, warmth, swelling or drainage of pus). | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right lower extremity wound dehiscence and chornic
non-healing wound, and so was admitted to the orthopedic surgery
service. The patient's wound was evaluated by both orthopaedic
and plastic surgery and it was determined to treat this
conservatively with daily wet to dry dressing changes after
bedside debridement by plastics. The patient was continued on
her previously prescribed oral antibiotics (Keflex ___ QID)
and anticoagulation per routine. The patient's home medications
were continued throughout this hospitalization. The patient
worked with ___ who determined that discharge to home with
services was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity, and
will be discharged on should not require 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. | 223 | 224 |
18337792-DS-18 | 24,846,781 | Discharge Instructions
Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
NO DRIVING for 6 months, until you have been cleared to drive
by neurology and neurosurgery. If you experienced a seizure
while admitted, you are NOT allowed to drive by law.
DO NOT DRINK ALCOHOL until you have been cleared by neurology
and neurosurgery; alcohol increases your risk of having another
seizure.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instructions. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | On ___ the patient was admitted to the neurosurgery service at
___ after having multiple witnessed seizures. A NCHCT was
performed and was consistent with a 7mm left frontal vertex EDH.
On exam the patient was intubated and his pupils were equal
round and reactive to light, 5 to 3 mm bilaterally. he had
normal bulk and tone bilaterally. No abnormal movements,or
tremors, and strength equal and strong throughout. Neurology was
consulted for his seizure presentation and he underwent a trauma
evaluation in the ED for fall hx. CT Cervical spine was
performed at OSH and was negative for fracture.
On ___ the patient remained hemodynamically and neurologically
intact. He had a repeat NCHCT which was stable. The patient was
transferred to the floor on telemetry and placed on EEG to rule
out seizures.
On ___ pt refused EEG leads and requested they be removed. He
remained neurologically intact. His and his mother's questions
were answered in full.
At the time of discharge he is tolerating a regular diet,
ambulating without difficulty, afebrile with stable vital signs. | 438 | 179 |
10935878-DS-11 | 28,554,612 | Dear ___,
You were hospitalized due to symptoms of right leg numbness,
right leg pain and weakness, and difficulty swallowing. These
symptoms were concerning for a possible stroke, however the head
CT and MRI which did not show any evidence of stroke. You also
had a muscle and nerve study which showed some injury. We sent
blood work and tests of your spinal fluid to see what is causing
your nerve problems and these tests are pending.
You were seen by the GI doctors who looked at your esophagus and
stomach using a camera. They did not find any reason for your
difficulty swallowing. They will contact you regarding the
results of the biopsy.
You should follow-up with neurology for ongoing work-up of your
sensory neuropathy and dysphagia.
Please take your medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
Sincerely,
Your ___ Neurology Team | Transitional Issues:
====================
[] Follow up on pending labs, including ___, protein
electrophoresis, lyme antibodies and CSF studies (paraneoplastic
studies)
[] Follow up on biopsy results from EGD
[] The CT abdomen and pelvis is mostly negative with the
exception of dilated left ureter with recommendation to consider
urology for further evaluation with cystoscopy.
[] Ongoing work-up of weight loss as outpatient | 148 | 57 |
16095488-DS-23 | 21,953,271 | Dear Ms. ___,
It was a pleasure to take care of you during your stay at ___
___. You had to stay in the hospital
for a UTI which was treated with antibiotics.
You then had diarrhea and you were found to have an infection
called C diff.
Please follow up with your regular doctor.
Please return to the hospital for fevers > 100.4F, worsening
confusion that doesn't improve, shortness of breath, or chest
pain.
Sincerely,
Your ___ Team | This is a ___ woman with recent admissions for traumatic
SAH and SDH, as well as ___ and hyponatremia in the setting of
hypovolemia, who initially presented with confusion, found to
have an ___, and a UA consistent with urinary tract infection.
# Toxic Metabolic Encephalopathy: Thought to be likely
multifactorial delirium given waxing and waning mental status.
Contributors include UTI, hypovolemia recent fall, recent
hospitalizations, ___, uremia, medication induced. CTH negative
for new intracranial process. Her exam is not suggestive of a
post-ictal state, making seizure an unlikely cause of her
altered mental status. She was treated for her UTI as below. She
was frequently reorientated, her sleep/wake was optimized, and
disturbances were minimized. Sertraline was d/c'ed and
Mirtazapine started. at discharge, patient was near her
baseline, oriented to self and date and alert.
# UTI: Her confusion and poor orientation on presentation to the
ED are most consistent with delirium, the source of which could
be a urinary tract infection, given her leukocytosis and UA
consistent with UTI and suprapubic tenderness on exam. There is
nothing to suggest another source of infection, and her negative
chest x-ray and clear lungs on exam suggest pneumonia is
unlikely. She received a 3 day course of ceftriaxone 1 gm IV
Q24h, from ___. Urine culture grew pan-sensitive pseudomonas
aeruginosa, and she received a 3 day course of ceftazidime 500
mg IV Q12H from ___.
#C Diff: uptrending leukocytosis during admission and then
patient developed diarrhea. c dif was sent and positive. patient
started on oral vancomycin QID x 10 days. Day ___.
# Hypernatremia: serum Na rose to 148 on ___, resolved w/ fluid
resuscitation and stable with PO intake prior to discharge.
# ___: Admission Cr 2.9, baseline around 1.1. Her initial BUN:Cr
ratio was elevated at ~25:1, suggesting a pre-renal cause of
decreased kidney function. In the context of her previously
observed hypotension and exam findings, hypovolemia, perhaps due
to poor PO intake in the setting of altered mental status, could
be the precipitating factor. Her Cr improved to baseline (down
to 1.1 from 2.9) with IV hydration.
# Chronic hypertension: BPs remained within acceptable range
throughout her admission. Given ___, her lisinopril and
hydrochlorothiaze were initially held pending improved renal
fxn. She received her home amlodipine and metroprolol. Given
that patient has had multiple readmissions for ___, decision was
made to tolerate a more liberal blood pressure goal to prevent
recurrent ___. Discharged on amlodipine and metoprolol. HCTZ and
lisinopril were held during admission and at discharge.
# Chronic constipation: She received a bowel regimen of docusate
sodium and senna.
# Recent SAH/SDH/seizure ppx: Home Keppra was discontinued per
recommendation from patient's outpatient neurologist.
# HCM/home meds: Her home sertraline was switched to remeron
(for improved sleep/in light of recent weight loss). She was
continued on her home aspirin, multivitamin, thiamine 100 mg,
and folic acid.
CODE STATUS: DNR/DNI OK FOR NIV
================================= | 73 | 479 |
16337484-DS-16 | 27,666,454 | Dear Mr. ___,
You were admitted to ___ because you were having worsening
kidney function along with swelling in your lower legs. The
worsening in your kidney function was concerning for acute
rejection versus a lupus flare. We sent antibodies to test for
rejection and although these were negative, we still believe
that the worsening in your creatinine is most likely due to
rejection.
We placed you a medication called furosemide intravenously to
eliminate this additional fluid. You were able to get rid of 5L
of fluid and your leg swelling improved. We then started you on
a higher dose of oral furosemide to keep the fluid off. You
should continue to take this medication daily.
We also gave you a dose of IVIG to treat rejection on ___. You
tolerated this medication without issues. You will need to
complete your course of rituximab on ___. You should follow up
with your kidney doctor to continue to monitor your kidney
function.
You liver enzymes were slightly elevated during the
hospitalization. Your primary doctor ___ continue to monitor
this.
It was a privilege taking care of you and we wish you the best.
Sincerely,
Your ___ Team | ___ w/ PMH of ESRD ___ to SLE s/p DDRT renal transplant ___
who presents with worsening renal function. Patient had
significant proteinuria and volume overload, particularly of the
lower extremities. He was started on Lasix IV and diuresed 5L
with improvement in his lower extremity edema. He was
transitioned to oral Lasix. Additionally, his carvedilol was
increased to 6.25mg BID. Patient was given IVIG at 1g/kg for
treatment of acute rejection with plan to complete course of
rituximab on ___.
# ___ ___ acute rejection s/p DDRT
# Volume overload
History of renal transplant ___, recently admitted for ___
with Cr ~ 2.0 on discharge on ___ with Cr elevated to 3.3 on
admission. Patient has transplant ultrasound that showed mild
hydronephrosis around the transplanted kidney. Foley was placed
with mild improvement in hydronephrosis, but without significant
change in Cr. He had a negative urine culture. Given significant
volume overload likely due to nephrotic range proteinuria, he
was started on diuresis with intravenous Lasix for volume
overload. He was diuresed with Lasix 80mg BID with good output.
He received 62.5mg albumin BID for two days, but was diuresed on
the remaining days without albumin with good response. He was
net negative 5kg over the hospital stay. He was then
transitioned to Lasix 80mg twice daily, which he will continue
after discharge. Acute worsening in kidney function was felt to
be due to acute rejection as opposed to worsening of SLE based
on most recent renal biopsy. He received 1 dose of IVIG at 1g/kg
on ___. He will complete course of rituximab on ___ for
rejection. Prednisone was decreased to 50mg daily and will
continue to be titrated at 10mg per week. He was continued on
valgancyclovir for ppx at a reduced dose of 450mg daily based on
kidney function. He was continued on immunosuppression with
cyclosporine and MMF, with doses unchanged. He will need repeat
BK virus testing in ___.
# SLE:
Patient with positive ___ in the past although negative dsDNA.
He was continued on home hydroxychloroquine 200mg daily.
# HTN
Patient had hypertension to SBP 150s during the admission.
Carvedilol was increased from 3.125mg BID to 6.25mg BID.
# TRANSAMINITIS: Patient had mild elevation in transaminases
during admission with ALT 115 and AST 47 at discharge. Hepatitis
serologies were negative. ___ be related to underlying
inflammatory process vs medications vs ___. Will continue to
trend after discharge and perform RUQ u/s if continues to be
elevated with consideration of biopsy if significantly worsens.
# RASH: Pustular/papular rash on extremities likely steroid
induced. Patient was not bothered by the rash and it was stable
during the admission.
Transitional Issues:
====================
- Discharge Cr: 3.1
- Discharge Weight: 94.8kg
For any questions, please contact outpatient nephrologist
___, MD: ___.
- Ensure f/u with transplant nephrology
- Increased furosemide to 80mg BID
- Please re-check labs in ___ days with CBC, Chem 10, and LFTs.
Please send results to Dr. ___: fax ___.
- If LFTs continue to increase, consider - Please continue
prednisone taper according to the following schedule:
___ 50mg daily
___ 40mg daily
___ - ___ daily
___ 20mg daily
___ 10mg daily
- Prophylactic valgancyclovir reduced to 450mg daily based on
GFR. Continue daily for total of 4 week course to end on ___.
- Continue to adjust carvedilol for goal <140/90
- Elevated ALT/AST: HBV/HCV/CMV testing negative,
would trend and consider RUQ ultrasound as an outpatient
# CODE: Full (confirmed)
# CONTACT: ___ | 196 | 571 |
13729279-DS-17 | 21,264,400 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
You were admitted to the hospital because you had a urinary
tract infection and an infection of your scrotum.
While you were here you were given antibiotics to treat your
infections. Urology evaluated you and felt that the scrotal
infection was superficial and limited to the skin, meaning that
antibiotics were the only treatment needed. A foley was placed
to keep the area clean and dry.
When you go home you should continue all your medications as
prescribed. Please follow up with your outpatient doctors as
listed below.
We wish you the best!
Your ___ Care Team | SUMMARY
==========
___ w/ hx of recent admission for ___
___, urethral strictures s/p dilation, DMII,
and COPD on nocturnal 2L O2 who presented with urinary
frequency, fever, AMS, and scrotal swelling concerning for CAUTI
and scrotal cellulitis. Urology evaluated the patient and
assessed his infection as superficial, and not a recurrence of
___ gangrene. A foley was replaced to prevent urinary
contamination to the scrotal area. The patient was started on
broad spectrum antibiotics until urine cultures from ___
showed Serratia marcescens and Enterobacter cloacae,
sensitivities, allowing for tailored therapy. Because of the
resistance patterns, the patient was transitioned to ertapenem
as an outpatient to complete a 10 day course.
TRANSITIONAL ISSUES
====================
[] Please continue ertapenem for a 10 day course (___)
[] A foley was placed this admission to keep the penoscrotal
area dry. The patient should have urology follow up with a
voiding trial to determine if the foley can be discontinued.
[] TSH was found to be mildly elevated, please repeat thyroid
studies as outpatient.
[] Would recommend repeating CBC and chemistries in PCP follow
up. | 105 | 174 |
16556053-DS-9 | 21,131,158 | You presented to the hospital with bloody stools. You received
2 units blood transfusion. Your bleeding self-resolved. CT
scan suggests underlying diverticulosis, which ___ have caused
diverticular bleeding. You were seen by the GI doctors, but
they did not recommend pursuing a colonoscopy at this time. Of
note, there were 2 incidental findings seen on your CT scan: a
renal lesion and a lung nodule. You will need a dedicated MRI
to further evaluate the renal lesion and you can consider a
follow-up chest CT in 12 months. Please discuss with your PCP
to obtain these further imaging studies. You should also
follow-up with your GI physician at ___ to decide if you should
pursue further work-up with an elective outpatient colonoscopy.
.
You also developed left arm superficial thrombophlebitis at the
antecubital fossa where a peripheral IV had been sited. This
improved with hot packs alone. You should continue to apply
warm compresses three times daily for the next three days. 20
min at a time. Continue to monitor the site for resolution of
the redness, and IF there is expanding redness, pain, or any
drainage from the site, or if you experience any fevers - call
Dr. ___ present to our emergency department
immediately for repeat evaluation as we discussed. I expect
that the area will improve to normal within the next several
days with warm compresses alone. | ___ yo F w/ PMH of HTN, HLD, CKD who presented with one day of
BRBPR with associated tachycardia and hypotension responsive to
IVF and blood transfusion.
.
# BRBPR
# Acute blood loss anemia
# Presumed diverticular bleed
Presented with two episodes of BRBPR. She was hemodynamically
stable apart from episode of orthostatic hypotension to 90/60 in
the ED. She received 2L NS and 2 units of PRBCs. Her HCT nadir
was 29.3 and responded appropriately to 35 with the 2 units
PRBC. CTA was negative for any active source of bleeding. Home
anti-HTN's (atenolol, amlodipine, torsemide and losartan) and
ASA were initially held. She was restarted on low dose
metoprolol after she remained hemodynamically stable in the ICU.
She remained without further episodes of BRBPR. She was seen
by GI consult, and GI consult felt that her bleed was most
likely secondary to diverticular bleeding that self-resolved.
They did not recommend inpatient colonoscopy, and would defer to
outpatient setting for consideration of colonoscopy if within
patient's goals of care.
.
# HTN: Longstanding hypertension. Had orthostatic episode in ED
prior to blood transfusion. Home anti-HTN's were initially held.
She was later restarted on metoprolol as above in the ICU, but
this was transitioned back to atenolol, and her other home
antihypertensives and diuretic were resumed without incident
.
# CKD: III Hx of partial nephrectomy (for renal oncocytoma),
longstanding hypertension, proteinuria
Creatinine was at baseline. Held home torsemide given
hypovolemia and concern for developing hypotension, but this was
ultimately resumed. . Continued calcium and vitamin D.
.
# Preglaucoma: continued home latanoprost eye drops.
.
# HLD:
- held ASA in the setting of active GI bleed - ultimately pt.
confirmed that she has not been taking this (not one of her
medications - confirmed with pt. and dtr at bedside)
- Held statin in hospital, as she has listed adverse reaction to
atorvastatin and simvastatin but her home lovastatin is not on
formulary at ___ ultimately pt. confirmed that she had not
been taking a statin (not one of her medications - confirmed
with pt and dtr at bedside)
. | 241 | 344 |
19282143-DS-22 | 28,355,865 | It was a pleasure taking care of you at ___!
You were admitted due to excessive diarrhea and a change in your
mental status. In the hospital you were also found to have a
urinary tract infection (UTI). You were given intravenous fluids
and treated with antibiotics for your UTI. Your mental status
improved although you continued to have diarrhea and, on
occasion, blood in your stool. You underwent colonoscopy that
showed changes consistent with radiation proctitis. You are now
ready for discharge with close outpatient ___.
See below for changes made to your home medication regimen:
- Please CONTINUE Ciprofloxacin 500mg twice daily for an
additional 4 days
- Please STOP Macrobid until after completing the course of
Ciprofloxacin
- Please INCREASE your dose of Loperamide (Immodium) to 2mg
every 6 hours while diarrhea persists
- Please START Magnesium supplementation 400mg every other day
- Please CONTINUE Potassium supplementation 40meq daily
Please visit your primary doctor's office to have blood work
done this ___.
You were also having bad headaches while in the hospital. If
these persist after discharge please call your primary doctor
for further instructions.
See below for instructions regarding ___ care: | Ms. ___ is a ___ year old female with history of stage ___
cervical cancer (s/p chemo and xrt), multiple pelvic fractures,
nephrostomy tube with recurrent UTIs/prior urosepsis, who was
admitted with severe watery, and ocassionally bloody,
diarrhea.
Hospital Course
---------------
#. The patient presented to the emergency department in the
setting of frequent episodes of diarrhea and confusion. In the
ED the patient was noted to be very confused and agitated.
Laboratory studies remarkable only for mildly elevated lactate
of 1.2 and abscence of leukocytosis. A UA was concerning for UTI
and she was started on ceftriaxone. A head CT was performed and
was unremarkable. A CT abdomen/pelvis was also largely
unremarkable and did no explain the ___ symptoms. Given 2L
of IVF and stress dose steroids (on chronic steroids). Admitted
to the floor.
On the floor the patient remained confused and combative.
Required restraints. Fluid resus was continued. The ___
mental status improved by HOD #2 however she continued to have
diarrhea. Her hematocrit trended downwards and she developed
grossly bloody stool with clots. Received 2 PRBC transfusions
and seen by GI who performed a colonoscopy revealing radiation
proctitis. The patient had no further bleeding and was
discharged with plans for close oupatient PCP ___. The
patient required frequent electrolyte repletion in the hospital
and was discharged on a potassium and magnesium repletion
regimen.
#. UTI: In the ED, the patient had a UA concerning for UTI and
she was started on ceftriaxone. Her urine culture grew
klebsiella and she was switched to ampicillin. THis was further
modified to ciprofloxacin after sensitivities returned. Planned
to complete 8 day course of antibiotics for complicated cystitis
then return to macrobid prophylaxis. The ___ right
nephrostomy tube functioned well and was not changed.
#. Known Pelvic Fractures: Appeared stable on imaging. Has
chronic pelvic pain due to this and is on hydromorphone at home
for the pain. Independent on ambulation/ADLs. Continued on
opiates for pain control once delerium cleared.
#. Hx benign pituitary adenoma: Resected many years ago. Was on
levothyroxine and low dose predisone for years as a result of
hypopituitarism that followed. Got stress dose steroids in the
ED then returned to ___ daily of prednisone. A TSH was checked
and measured <0.02 in the setting of acute illness. A T4 was
WNL. The patient was continued on her home levothyroxine dose. | 187 | 396 |
16880672-DS-20 | 27,145,355 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted to the
hospital because of pain around your bladder. You were first
started on antibiotics, but the antibiotics was stopped because
your urine did not show any signs of infection.
You have an appointment with your urologist, Dr. ___
___. Please make sure you make it to this appointment. | BRIEF SUMMARY STATEMENT: Mr. ___ is a ___ y/o male with past
medical history significant for renal colic without evidence of
nephrolithiasis, interstitial cystitis status post simple
cystectomy with suprapubic prostatectomy and creation of ileal
neobladder in ___, and multiple admission for recurrent
orchitis and sterile pyuria ___ and ___, treated with
pain control and anti-inflammatories; of note admission ___
- pt. had presumed episode of acute coronary syndrome, status
post cardiac cath which was negative for coronary artery
disease) who presents with acute exacerbation of his chronic
suprapubic pain.
# Suprapubic and Testicular Pain: The patient presented with
worsening sharp waxing and waning suprapubic pain. He has
several recent admissions with scrotal pain with sterile pyuria.
On these admissions, his urine analysis was without positive
nitrites. On this admission, his presenting urine analysis was
positive for nitrites As such, the patient was placed on broad
spectrum antibiotic treatment with meropenem given his history
of extended spectrum beta-lactam E.Coli. He continued to have
some symptoms despite antibiotic treatment. The patient
remained without fevers, without leukocytosis, and with no
growth on urine culture. Given the lack of infectious findings,
the patient was discharged home with PO pain control off of
antibiotics. On the day of discharge, the patient's urologist,
Dr. ___ was contacted who also agreed with the plan. The
patient remained hemodynamically stable and was discharged with
outpatient follow-up.
#Chest Pain: The patient complained of heavy chest pain
several days prior to admission. He had a normal CXR, ECG
unchanged from prior without evidence of ischemia, and negative
troponins x1. | 68 | 278 |
10032409-DS-18 | 25,997,537 | Ms. ___,
It was a pleasure treating you during this hospitalization. You
were admitted to ___ because of
increasing confusion and forgetfullness at home. Infectious and
metabolic work up did not show any specific cause for your
encephalopathy. Neurology was consulted and you completed an
electroencephalograpm, which showed that you were not having any
seizures. Our neurologists felt that your confusion was likely
caused by a combination of excess sedating medication, which we
have stopped, and sleep apnea, a medical condition that causes
you to stop breathing briefly many times a night during sleep.
The following changes to your medications were made:
- STOP Clonazepam (Klonopin) as this may worsen your confusion
- STOP Benadryl (diphenhydramine) as this may worsen your
confusion
- REDUCE your Tetrabenazine from 25mg to 12.5 mg (one half
tablet) every night
- START using your CPAP machine every night, as much as
possible, when you sleep.
- No other changes were made to your medications, please
continue taking as previously prescribed | ___ F with history COPD on 3L oxygen, DM on insulin, HTN,
schizoaffective disorder, tardive dyskinesia sent in to the ED
for increasing confusion and forgetfullness.
# Encephalopathy: Acute short term memory loss without obvious
preceeding event. Inattention on exam but oriented indicating
most likely delirium versus acute progression of dementia. Acute
onset and with possible stepwise decline is curious for vascular
dementia. CT head also showing some small vessel ischemic
disease which may be consistent with vascular dementia. MRI head
did not show acute process or acute stroke. In addition, chronic
psychiatric disease with dopaminergic medications may be
exacerbating her clinical status. Toxic-metabolic work up all
negative except for low TSH but FT4 is 1.0. B12, Folate and RPR
all normal/negative. After reading prior neuro notes she did not
seem far off from baseline. Neurology was consulted who
requested an EEG which showed mild diffuse background slowing
and disorganization, indicative of a mild diffuse encephalopathy
which is etiologically non specific. There were no epileptiform
features. Final diagnosis was polypharmacy induced
encephalopathy. Benadryl was discontinued, Clonazepam tapered
down and discontinued and Tetrabenzaprine dose halved. Plan to
discontinue Tetrabezaprine all together but patient requested it
continued. Neuro also felt she definatively has sleep apnea
which is likely contributing to poor morning arousability. CPAP
was started on the floor and continued as an outpatient.
# COPD: Oxygen-dependent COPD (3LPM), s/p respiratory arrest in
___ with protracted intubation course. Labored,
tachypnic breathing on admission though without oxygen
requirement. After being placed back on home O2 of 2L NC her
respiratory status improved and she maintained O2 sats in >95%.
Continued home regimen of Albuterol 0.083% Neb Soln 1 NEB IH
Q4H:PRN, Fluticasone Propionate NASAL 1 SPRY NU DAILY,
Ipratropium Bromide Neb 1 NEB IH Q6H, Dulera *NF*
(mometasone-formoterol) 100-5 mcg BID and supplemental O2 at 2L
NC. No acute exacerbation during admission. Patient is on
Azithromycin chronically as an outpatient, unclear if this can
be continued, defer to outpatient pulmonary for that decision.
# Glycosuria: 1000 Glu on UA. Serum glucose only 200 so unclear
why she is spilling so much glucose. Possibly Fanconi syndrome
though patient with normal renal function, phosphate and bicarb
slightly elevated. Elevated bicarb likely compensating for
chronic CO2 retention, no evidence of RTA to look for Fanconi's.
Dilute urine may also indicate she is not concentrating
appropriately. Repeat urine continued to show glycosuria. This
can be monitored as an outpatient.
# Hypertension: Chronic, uncontrolled, asymptomatic at this
point, not being treated as an outpatient. Allergy to ACE-I and
ARBs which would be first line given possibly renal dysfunction
with glycosuria. Consider starting Chlorthalidone as an
outpatient.
# Diabetes Mellitus: Type II, insulin dependent, complicated by
vascular disease. Continued Lantus 20 units QHS and QACHS ___ and
HISS, held Metformin while inpatient
# Schizoaffective disorder: On typical antipsychotics
complicated by movement disorders and tardive dyskinesia.
Consider changing medications as there may be contributing to
AMS deterioration. Discontinued Clonazepam 1 mg PO/NG QHS due to
lethargy but continued Perphenazine 8 mg PO/NG QHS, Olanzapine 5
mg PO HS, Tetrabenazine 25 mg Oral QHS | 165 | 533 |
16561649-DS-20 | 25,895,436 | Dear Mr. ___,
It was a pleasure taking care of ___ at ___
___.
___ came into the hospital because ___ had a fall approximately
a week before ___ were admitted and then the day before ___ were
admitted ___ had a motor vehicle accident. ___
performed a CT scan of your head and did not find any bleed.
While ___ were here, ___ had a CXR that was consistent with
pneumonia. ___ had a CT scan of your chest and abdomen, which
showed a mass that was most likely pneumonia, but there was the
possibility that the mass could be cancer. ___ had a
bronchoscopy on ___ that showed a lot of mucus in your
lungs. The biopsy results from that time are pending and will be
followed up by pulmonology (lung) doctors.
___ were also found to be anemic. Your blood counts were lower
than what they were in ___ at Dr. ___. We were
worried about ___ bleeding. ___ had a CT scan of your chest and
abdomen that did not show that ___ had a bleed.
On the CT scan, we discovered an aneurism (dilation) of the
aorta, the largest blood vessel in the body. ___ should follow
up with your primary care physician regarding management of this
condition.
We are concerned that your memory deficits may be impairing your
ability to drive. It is not safe for ___ to drive until ___ have
undergone formal neuropsychologic testing. We have booked an
appointment for ___ with cognitive neurology to initiate this
process. In the mean time, we have alerted the ___ who will be
contacting ___ to coordinate the steps to regaining driving
privileges.
The following changes were made to your medications:
Clindamycin 450mg Three times a day for a total of 3 weeks. | Mr. ___ is a ___ y/o male poor historian with a h/o anxiety
disorder ?h/o bipolar who has been admitted s/p MVA with
repeated falls found to have necrotizing pulmonary lesion. | 291 | 31 |
11392385-DS-24 | 24,656,171 | Dear ___,
___ was a pleasure taking care of you while you were admitted to
___. You were admitted with gait instability and were
evaluated by physical therapy who recommends that you will need
continued ___ at home. You were also evaluated by our Neurology
team who recommended you have a carotid ultrasound prior to your
outpatient clinic appointment with our stroke specialists on
___. This study showed that there is no narrowing if your
carotid vessels.
No changes were made to your medications. | Ms. ___ is a ___ with a history of likely Alzheimer's
disease, prior left Bells Palsy, HTN, and relatively recent left
basal ganglia ischemic stroke (incidental finding on mri few
months ago), who was admitted given concern of gait instability.
She had presented to ___ after a presyncopal event that led
to gait unsteadiness. This event was most likely
vasogaval/orthostatic event or TIA. She was transferred to
___ for stroke work-up. Her gait was veering with
unsteadiness and she warranted admission for both ___ evaluation
of gait and completion of her stroke work-up with a carotid
ultrasound.
Carotid ultrasound was negative for critical stenosis. Other
elements of stroke workup were done recently and thus not
repeated and are included in her OMR (A1c, LDL, MRI, echo). She
will follow-up with Dr. ___ on ___ in clinic. Her
medications (including ASA 81mg) were not adjusted.
Her gait was only mildly unsteady by the time she was evaluated
on the floor. She had veering to the right and motor
impersistence. She benefited from a walker, but was actually
able to maintain balance without an aide. After ___ eval, she
was recommended home with ___ ___ services. | 88 | 202 |
16388647-DS-10 | 24,644,659 | Surgery:
- You underwent surgery to remove a brain lesion from your
brain.
- The final pathology was consistent with meningioma.
- Please keep your surgical incisions dry until your sutures and
staples are removed.
- You may shower at this time, but keep your surgical incisions
dry.
- It is best to keep your surgical incisions open to air, but it
is okay to cover them when outside.
- Call your neurosurgeon if there are any signs of infection,
such as fever, redness, swelling, or drainage.
Activity:
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up.
- You may 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 narcotics or any other sedating
medications.
- No contact sports.
Medications:
- Please do NOT take any blood thinning medications such as
clopidogrel (Plavix), ibuprofen, warfarin (Coumadin) until
cleared by your neurosurgeon.
- You were taking aspirin 81mg once daily at home, which you may
resume on ___.
- You may use acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
- You may experience headaches and pain at the surgical
incisions.
- Feeling more tired or restlessness is also common.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high fiber diet. You may also try an over the counter
stool softener if needed.
When To Call Your Neurosurgeon At ___:
- Severe pain, redness, swelling, or drainage from the surgical
incisions.
- Fever greater than 101.5 degrees Fahrenheit.
- Nausea or vomiting.
- Extreme sleepiness and not being able to stay awake.
- Severe headaches not relieved with pain medications.
- Seizures.
- Any new problems with your vision or ability to speak.
- Weakness or changes in sensation in your face, arms, or legs.
Call ___ And Go To The Nearest Emergency Department If You
Experience Any Of The Following:
- Sudden numbness or weakness in the face, arms, or legs.
- Sudden confusion or trouble speaking or understanding.
- Sudden trouble walking, dizziness, or loss of balance or
coordination.
- Sudden severe headaches with no known reason. | #Brain Mass
MRI of the brain revealed an extra-axial homogeneously enhancing
mass arising from the posterior fossa with severe mass effect
and remodeling on the upper cervical spinal cord/craniocervical
junction, most consistent with a meningioma. The patient was
admitted to the neurosurgery service for further workup and
discussion for possible surgical intervention. She was started
on dexamethasone for cerebral edema. After review of imaging and
discussions with the family, it was determined that it was not
safe to remove the entire tumor, but to take her to the OR for
debulking.
Patient was taken to the OR on ___, for posterior fossa
craniotomy and C1 resection and debulking. Patient tolerated the
procedure well, please see separate documentation in ___ for
specific details of the operative case. An EVD was placed in the
OR for management of ICP and proper wound healing. EVD was
leveled at 10cmH2O at the tragus and kept open to drain as
needed. Patient remained intubated post-operatively and was
transferred from the OR to the Neuro ICU for close neurological
monitoring. Patient with increased blood pressures requiring a
nicardipine drip in the ICU, and was closely monitored and
titrated until she was able to tolerate PO medications and was
weaned off. Patient was extubated on POD 1, ___ and tolerated
well. Post-operative CTH with expected post-operative changes
with small amounts of scattered pneumocephalus. Post-op MRI
stable to prior CTH. On POD 3 patients EVD stopped draining with
interrupted waveform, EVD catheter was flushed distally and
proximally overnight and then again in the AM. EVD began
draining slowly, however waveform continued to be poor. Patient
was transferred to the ___ on POD 3. Shortly after transfer in
the evening of ___ patient became increasingly lethargic and
had 2 episodes of emesis, Zofran was given with another episode
of emesis. Patient was sent for STAT CTH which was stable to
improved compared to prior post-operative imaging. Patient with
continued lethargy and loose stools. CXR negative for any acute
process. KUB was obtained which revealed dilated loops of bowels
however no obstruction. UA and blood cultures were ordered on
___ and were unremarkable. Patients exam slowly began to
improve on ___. On ___, Ms. ___ exam was stable in
the morning. Her EVD was raised to 20. On ___, her
clinical exam remained stable, and the right frontal EVD was
removed after being clamped overnight. Her clinical exam was
followed after removal, and on ___ she was noted to be more
somnolent. Head CT was obtained which showed an increase in
pneumocephalus. She was placed on a NRB for 24 hours and her
exam improved. Her exam continued to improve. She was discharged
to rehab at her neuro baseline on ___ in stable condition.
#Tachycardia/Hypertension
Patient with acute tachycardia post-operatively. Patient was
managed initially with a nicardipine gtt which was weaned and
she was tolerating PO Labetalol. On ___ patient was
transitioned from labetalol to Metoprolol 25mg PO BID with IV
labetalol and Metoprolol PRN.
#Type II Diabetes
Patient with history of type II diabetes on home Metformin and
Glipizide. While hospitalized these medications were held due to
surgery as well as decreased PO intake. Patient's blood sugars
were evaluated before each meal and every night and she was
given insulin per sliding scale PRN. She may be restarted on
glipizide and metformin as appropriate.
#Disposition
___ evaluated patient and recommended rehab. She was
discharged to rehab on ___. | 355 | 566 |
10103318-DS-17 | 26,916,277 | * You were admitted to the hospital with right sided chest pain
and your xray showed a small pneumothorax laterally. A small
pigtail catheter was placed to evacuate the air and you then
underwent chemical pleurodesis with talc. Your chest tube is
now out and your right lung is.....
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you. | mr. ___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for management of
his right pneumothorax. His chest pain resolved and his oxygen
saturations were 95% on room air. On ___ he had a pigtail
catheter placed with subsequent talc pleurodesis. He had some
problems with pain from the talc and was placed on a Dilaudid
PCA. His chest tube remained on suction and serial films showed
improvement.
He daveloped nausea and vomiting from the Dilaudid but was
better after discontinuing it and his pain was relieved with
Ultram. He was then able to tolerate a regular diet and stay
hydrated.
His pigtail catheter was removed on ___ and the post pull
film showed persistent, small pockets of air in the R lung apex.
Pt remained hemodynamically stable, and was saturating well on
room air. He felt well enought to be discharged home. Prior to
discharge he was educated regarding his follow up plans post
discharge and he verbally expressed understanding and agreement
with these plans. | 73 | 177 |
18092532-DS-11 | 29,329,548 | You came to the hospital because you were told that you had a
pneumothorax (air that escaped from the lung into the chest
cavity) after a thoracentesis. You were admitted to the Medical
ICU because you needed a special oxygen delivery device
(non-rebreather), which helped to resorb some of the air. You
still have a pneumothorax, and it is STRONGLY ADVISED for you to
stay in the hospital for a procedure known as a bronchoscopy.
You stated that you understood this but still wished to leave.
At this time, although we recommend that you have this
procedure, you are stable to be discharged home with
Interventional Pulmonary clinic follow-up. It is strongly
recommended that you attend the pulmonary clinic.
.
In addition to your pneumothorax, you have a fast heart rate
which could be contributing to some fluid in the lungs. You
were started on a medication (Metoprolol) to slow the heart
rate.
.
We made the following changes to your medications:
-START Metoprolol
Please do not hesitate to return to the hospital if you have any
worrisome symptoms. | Mr. ___ is an ___ gentleman with Afib, HTN, MDS and new left
pleural effusion who underwent an outpatient thoracentesis
complicated by apical PTX requiring MICU admission for 100% NRB
to help reabsorption. He was discharged home the next day.
.
#. PTX: Complication from thoracentesis, resolving.
Interventional Pulmonology felt no chest tube was needed. He
was admitted to the MICU for non-rebreather treatment overnight.
On imaging, the PTX was still present but not growing. He had
no O2 requirement; will follow up in I.P. clinic after
discharge.
.
#. Left lung consolidation and airway plugging: no clinical
manifestations.
He had no change in his repiratory status; imaging revealed
these findings and he was advised to undergo bronchoscopy, but
he declined. He will follow up in I.P. clinic after discharge.
.
#. Afib: Not rate controlled.
Patient is not on Warfarin or beta blocker at home. Heart rate
was 100-120. It was felt that his tachycardia could be
contributing to an element of diastolic HF so he was started on
Metoprolol with resulting rate ~100. He will follow up in I.P.
clinic.
.
#. MDS: with cytopenias.
Not an active issue this admission. He will follow up with his
Oncologist.
.
#. Transitional Issues
-pending at discharge:
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ PLEURAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY; FUNGAL
CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY
--DVT: Pneumoboots
# Access: peripherals
# Communication: Patient
# Code: DNR/DNI | 178 | 243 |
16949991-DS-21 | 28,823,182 | Mr. ___,
It was a pleasure to take care of you at ___.
WHY WAS I HERE?
You were admitted to the hospital because you had increased pain
___ your left leg.
WHAT WAS DONE WHILE YOU WERE ___ THE HOSPITAL
- While you were ___ the hospital you had imaging done that
showed new fluid collection ___ your left leg.
- This fluid was drained and sent for culture
- You were given medications to help control your pain
- You were continued on your home antibiotics
- A new medication was started to help with your phantom limb
pain.
WHAT SHOULD I DO WHEN I GET HOME?
1) Follow up with your Primary Care Doctor.
2) Follow up with Infectious Disease
3) Follow up with Chronic Pain
4) Follow up with Vascular surgery
5) Continue your IV antibiotics
6) You will have ___ help you with your antibiotics and your
incision
We wish you the best!
Your ___ Care Team | ___ with hx of DM1, MRSA bacteremia with bilateral lower
extremity osteomyelitis that required bilateral BKAs, HTN, h/o
PE on warfarin, and recent admission for left stump abscess and
osteomyelitis currently on 6 week treatment (Start Date:
___ Projected End Date: ___ with daptomycin and
ciprofloxacin who presented after increased left stump pain
found to have new left leg abscess.
# Left stump pain with abscess and osteomyelitis: Patient
presented with increased left stump pain for two days. He has
been on daptomycin/ciprofloxacin since ___ for abscess and
tibial osteomyelitis (fluid collection were likely sterilized
prior to collection). He has a history of MRSA bacteremia with
bilateral lower extremity osteomyelitis that required bilateral
BKAs so he was discharged on daptomycin/ciprofloxacin (allergy
to vancomycin) for 6 week course. Representation with increased
pain, swelling, chills. CT done ___ ED was concerning for new
abscess and worsening osteomyelitis. There was worry for failure
of antibiotic therapy likely d/t lack of source control or gram
negative or polymicrobial infection that is not covered by
Cipro. His CRP and ESR were not elevated but he had been
experiencing rapid fluctuations ___ blood sugar and increased
lactate upon arrival was worrisome for inflammatory process. ID
was consulted and recommended ___ drainage of abscess. Fluid from
abscess was sent and had GPCs and GPRs on gram stain but did not
grow on culture likely d/t antibiotic therapy. He went for I&D
of medial abscess with vascular surgery on ___. Drainage
was bloody and old clots. Suggesting possible infected hematoma.
This fluid also didn't grow on culture. Wound from I&D was left
open to heal by secondary intention. Since only gram positive
organisms were seen on gram stain he was switched to monotherapy
with daptomycin. He will follow up with vascular surgery and ID
closely after discharge. Pt will need weekly OPAT labs drawn
and sent to ___ clinic for safety monitoring, instructions faxed
to ___ on ___. ___ addition, he will have wound care by
___ as an outpatient.
#Increased phantom limb pain : Pain was described as shooting
pain that runs up from phantom foot, behind his keen and up to
his hip. The pain was severe and sharp and causes a "pop rocks"
sensation. Description seemed consistent with neuropathic pain
possibly increased by irritation from worsening infection ___
stump or compression from new abscess. He had taken gabapentin
and lyrica ___ the past and both didn't help. Amitriptyline
helped but made him fatigued. We discussed with patient the
other options for neuropathic pain such as duloxetine or
restarting amitriptyline. He was interested ___ trying duloxetine
for his neuropathic pain. It was started while he was admitted.
His pain was difficult to control and he was started on
duloxetine, naproxen 500mg BID, Tylenol, lidocaine patch,
capsasin cream, and dilaudid. He was discharged with a small
dose of dilaudid with plan for aggressive wean off as the wound
heals. He was scheduled to see his PCP for pain control and
will follow up with chronic pain as an outpatient.
___: Initially Cr was increased to 1.1 from baseline of 0.9.
This was most likely d/t pre-renal etiology given evidence of
hemoconcentration on admission labs and mildly elevated lactate.
Cr down trended to baseline with fluid resuscitation.
# Diabetes type 1:Patient reported that sugars have been poorly
controlled recently with rapid hypoglycemia. During admission he
had episodes of rapid symptomatic hypoglycemia requiring D50.
___ was consulted for assistance ___ insulin regimen. He will
have close follow up with his PCP and endocrinology for
management of his insulin regimen. He was discharged on the
following insulin regimen.
Breakfast: Glargine 10u, Humalog 2u
Lunch: Humalog 5u
Dinner: Humalog 4u
Bedtime: Glargine 12u
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
___ mg/dL 0 Units 0 Units 0 Units 0 Units
101-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 0 Units 0 Units 0 Units 0 Units
201-250 mg/dL 1 Units 1 Units 1 Units 1 Units
251-300 mg/dL 2 Units 2 Units 2 Units 2 Units
301-350 mg/dL 3 Units 3 Units 3 Units 3 Units
351-400 mg/dL 4 Units 4 Units 4 Units 4 Units
# Prior venous thromboembolism: Prior dose of warfarin decreased
on last admission ___ setting of ciprofloxacin potential to
elevate INR ___ setting of warfarin. He was initially
subtheraputic on presentation. He was restarted on home dose
after ___ drainage and vascular I&D of left BKA abscess. He will
follow up with his PCP for monitoring of his INR.
Transitional Issues
==============
MEDICATIONS STARTED: Acetaminophen 1000 mg PO/NG Q8H, Capsaicin
0.025% 1 Appl TP TID neuropathic pain ___ left BKA, DULoxetine 30
mg PO DAILY, HYDROmorphone (Dilaudid) 2 mg PO/NG Q4H:PRN Pain -
Severe, Lidocaine 5% Patch 1 PTCH TD QAM, Naproxen 500 mg PO BID
left knee
MEDICATIONS STOPPED: Ciprofloxacin
[] Follow up with Chronic Pain for phantom limb pain
[] Follow up with ___ about your insulin regimen
[] Continue Daptomycin through ___ and follow up with
Infectious disease Dr. ___. OPAT MONITORING LABS TO BE DRAWN
WEEKLY BY ___ AND FORWARDED TO ___. ___ ___.
[] Follow up with Vascular surgery as scheduled
[] Consider up titrating duloxetine as an outpatient for phantom
limb pain
[] Consider adjusting insulin regimen to reduce hyperglycemia
but limit hypoglycemia
[] Discharged on short course of dilaudid for pain control with
plan to wean as wound heals. Pain regimen can be reevaluated by
PCP at his ___ appointment
[] Patient discharged on the following insulin regimen:
Breakfast: Glargine 10u, Humalog 2u
Lunch: Humalog 5u
Dinner: Humalog 4u
Bedtime: Glargine 12u
with insulin sliding scale | 156 | 936 |
19586697-DS-11 | 20,130,759 | Dear Ms. ___,
___ were evaluated at ___
your issue with lower extremity pain which progressed into your
left lumbar back and abdomen, with subsequent Left leg weakness.
We performed a abdominal X-ray to rule out any intra-abdominal
process, and performed an MRI study of your head and cervical
spine. Both of these studies did not demonstrate any new
exacerbation of your MS. ___ should follow up with your PCP
regarding your vaginal discomfort if it continues to be an
issue. | # NEUROLOGICAL:
The patient was admitted for further workup of a suspected flare
given her atypical distribution of weakness. Initially given
some disparity in her day to day symptoms, it was unclear
whether this was a presentation of MS ___ which she last
experienced a flare in ___ or if this was lower extremity
pain and some bloating causing her distress. After attempts to
control her pain with Ketorolac for 3 days which per the patient
was minimally helpful for her LLE pain, left lumbar and
abdominal pain, as well as headache of which all symptom
severity was out of proportion with presentation, an MRI Brain
and C-Spine were obtained which demonstrated no new active flare
which could explain her symptoms.
While inpatient, Ms. ___ was maintained on her home dosages
of clonezepam for anxiety.
# GASTROINTESTINAL:
Ms. ___ noted abdominal pain initially was not typical of
stomach pain, or normal GI distention, however as time
progressed, the patient endorsed her pain to be severe and
bloating in character. An abdominal plain film was obtained
which showed a normal bowel gas pattern and no obvious
intraabdominal process. To treat her pain - simethicone,
calcium carbonate, and tramadol were used.
# GENITOURINARY:
Ms. ___ noted some pelvic discomfort on discharge, but was
recommended to follow up with her PCP if complaints continue. | 83 | 219 |
14097226-DS-7 | 25,699,831 | You were admitted to the hospital with nausea and vomiting. You
were found to have a wound infection and a uninary tract
infection. A VAC was placed on the abdomen and you were also
treated with antibiotics. You did well and your lab tests
improved and you were able to go home. | Ms ___ was admitted after nausea, vomiting, and elevated
white blood cell count. Infectious workup was performed, and a
wound VAC was placed on her abdominal wound that had been
previously packed in clinic. Her wound became erythematous, so
Bactrim was started. A UTI grew GNRs, and Cipro was started and
discontinued because of similar coverage as Bactrim. Her WBC
count was 9.3 and so she was doing well, afebrile, and so
discharged to home. | 52 | 76 |
10152121-DS-21 | 24,401,913 | Dear Mr. ___,
You were recently admitted to the ___.
Why were you admitted to the hospital?
- You were admitted to the hospital because you developed
shaking and chills after your outpatient EGD and stent removal.
- We think that you developed rigors and chills because you
aspirated some stomach acid into your lungs.
What was done in the hospital?
- You were given 1 dose of antibiotics, some IV fluids, and some
Tylenol.
- You were monitored and did not show any signs of infection.
What should you do when you leave the hospital?
- You should continue taking all your medications as prescribed
- You should follow up with your primary care physical within a
week after discharge
- You should seek medical attention if you develop rigors/chills
or fevers
It was a pleasure taking care of you in the hospital. We wish
you the best of health.
Sincerely,
Your ___ Team | Summary
___ with a hx of T3N0 esophageal cancer s/p surgical resection
complicated by recurrent anastomotic stricture and stent
placement ___, underwent EGD and stent removal the day of
admission (___) and developed rigors and chills several hours
later.
Acute issues
# Rigors and chills
# Aspiration pneumonitis
The patient went to the ___ ED where his max temperature was
___. He got 1 dose of 4.5g IV zosyn, 1g Tylenol and some IV
fluids. He got a chest x-ray that showed bibasilar patchy
opacities, stable from prior imaging. His rigors and chills
resolved while he was in the ED. He was admitted to the medicine
floor for observation. He remained afebrile and had no focal
signs of infection and was well appearing, although his white
count remained elevated at 15.6. His presentation was most
consistent with aspiration pneumonitis in the setting of MAC
sedation for his stent removal. He was well appearing, afebrile,
euvolemic and discharged home after 24h observation without
additional antibiotics.
Chronic issues
#Esophageal stricture s/p stent removal ___. Pt has no pain,
no dysphagia or odynophagia at present, low concern for
perforation. Will follow with Dr. ___ as outpatient.
# T2DM: Last A1C 7.3%. Recently stopped insulin due to well
controlled sugars.
- Put on HISS while in house
# HTN: currently well controlled
- SBPs were 110s during this admission. His amlodipine was
stopped (was taking 2.5mg daily); his atenolol was reduced by
50% (was taking 50mg qHS, reduced to 25mg qHS). The atenolol can
be further tapered as outpatient if he remains normotensive. | 149 | 252 |
14027060-DS-2 | 21,546,125 | Mr. ___, you were brought to ___ ED by ambulance ___
after being struck by a car. You underwent complete physical
exam as well as multiple imaging studies and blood tests. You
were found to have left periorbital hematoma and left ring
finger middle phalanx dislocation, which was reduced in the
emergency department and splint was applied:
Please follow these instructions:
-your finger should remain in extension blocking splint that
limits extension at proximal interphalangeal joint to 30 degrees
until your follow up instruction with hand doctors. Please, call
the Hand Clinic to arrange follow up appointment in ___ days.
Please, find the information below
-please, lubricating eye drops for your left eye irritation as
needed,, if you have an eye doctor follow up with him in ___
weeks. If you don't have regular eye doctor you can call this
number ___ to arrange follow up appointment at ___
___
-you can use ice to your left forehead and left periorbital area
for the next 3 days as tolerated
Please, also follow these general 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.
*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.
Surgery team in ___ days. ___ flex freely at DIP/PIP | Mr. ___, was brought in to ___ ED by ambulance after being
struck by a car. He underwent complete physical exam, multiple
imaging studies and blood tests. Abdominal and pelvic Xray, CT
of head, C-Spine and Chest showed no injuries. He was found to
have left periorbital hematoma and left ring finger middle
phalanx dislocation in finger Xray, which was reduced and
splinted at bedside. Post-reduction Xray was taken which showed
soft tissue swelling following reduction of a dislocated
proximal interphalangeal joint of the left ring finger, no
fracture seen. He was admitted to Acute Care Surgery for
overnight observation. His pain was well controlled with oral
Tylenol and oxycodone. Tertiary survey was completed on HD2, no
additional traumas were identified.
Orthopedic surgery recommended the that the finger splint
should remain in place until the follow up appointment in ___
weeks. Ophthalmology was consulted as well to evaluate the left
periorbital hematoma and possible eye injury. No globe injuries
were identified. They recommended ice to the left forehead and
eye for 3 days and lubricant eye drops for eye irritation and
follow up in clinic in ___ days.
Pt's vital sings have been monitored and been within normal
limits, Ins and Outs have also been recorded and been adequate.
Physical and Occupational therapists also evaluated the patient
and they recommended that he would benifit from short term
rehabilition center. Mr. ___ was discharged to a rehabilitation
center on ___ in good condition with discharge and follow
up instructions. | 363 | 249 |
15834848-DS-10 | 27,796,523 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated in the right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox 40mg SC daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
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
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
weight bearing as tolerated in the right lower extremity
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right tibial shaft fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right tibial IMN, 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.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity, and
will be discharged on 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. | 570 | 256 |
11479393-DS-5 | 23,155,298 | Craniotomy for Hemorrhage
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with staples. You may wash your hair
only after the staples have been removed.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F. | This is a ___ year old male who presented on ___ s/p assault
while intoxicated with Right frontal depressed skull fracture
s/p crani for elevation. The patient was taken to the OR for
washout and elevation of depressed fx. The patient was extubated
in the afternoon. The patient was alert and oriented to person
place and time and was neurologically intact.
On ___ the patient was alert and oriented to person place
and time. The patient was moving all extremities with full
strength and his pupils were equal round and raectice to light,
3-2mm bilaterally. Transfer orders were written and the patient
was called out to the floor. A physical therapy consult was
placed for the patient, and the patient was started on a regular
diet.
On ___, the patient remained neurologically stable. His
dressing was removed. Physically therapy re-evaluated the
patient and felt he needed another day before discharge due to
issues with dizziness.
On ___, the patient remained neurologically stable. He was
re-evaluated by OT who recommended discharge to home with
24-hour supervision for all independent ADLs (includeing cooking
and medication management) and ___ recommended discharge to home
with a prescription for outpatient physical therapy. The patient
was discharged home in stable condition to the care of his
parents. | 235 | 210 |
15725489-DS-11 | 26,713,478 | Dear Mr ___,
Why was I admitted to the hospital?
You presented to ___ for a
scheduled procedure; however, the surgery was not done because
your blood pressure was found to be too low.
What was done for me while I was in the hospital?
While in the hospital, we were concerned that you were bleeding
from somewhere in your belly or intestines. You received blood
and got better with this treatment. We looked at your digestive
tracts with cameras (colonoscopy, EGD) and did not find any
source of bleeding. You also have bruising of your left arm, we
had our Neurology and Orthopedic team evaluate you. This got
better with Tylenol and an arm splint.
Please continue to take your home medications and follow-up with
your doctors as ___ and ___ yourself daily. If you gain
more than 3lb, please call your doctor.
We wish you all the best,
Your ___ care team | Patient Summary for Admission:
================================
Mr. ___ is a ___ y/o man with history of dilated cardiomyopathy
(LVEF 22%; s/p BiVICD), CAD s/p CABG, valvular heart disease
(3+MR, 2+TR), atrial fibrillation, DMII, HTN, HLD, infrarenal
AAA (6.1cm) awaiting endovascular repair, COPD, cirrhosis
secondary to congestive hepatopathy who presented for elective
AAA repair and was found to be hypotensive with acute on chronic
anemia. Anemia felt to be initially in setting of upper GI
bleed, however patient's EGD and colonoscopy were without acute
source of GI bleed. Additionally patient with a left arm
hematoma (and subsequent compressive radial nerve neuropathy)
that could have contributed. He received 2 units pRBC and
hemoglobin stabilized. His anticoagulation and anti-hypertensive
medications were initially held and restarted prior to discharge
once his hemodynamics stabilized. | 147 | 127 |
19380434-DS-16 | 25,250,897 | Dear Mr. ___,
You were admitted to the hospital with a pneumonia and blood
clot in your left leg. Your pneumonia improved with antibiotics,
which you should continue through ___ (levofloxacin). Your blood
clot was treated with a medicine called apixaban, which you will
need to take at a dose of 10mg twice a day until ___, after
which you should reduce the dose to 5mg twice a day. Continue
this medication until instructed to stop by your primary care
doctor.
In addition, you were found to have small nodules in your lungs,
likely to be of no importance. Please address the possibility of
follow up imaging with your primary care doctor.
It is critically important that you quit smoking, if possible,
to reduce your risk of further blood clots. Please also monitor
closely for worsening of the blood in your sputum, which - if
evident - should prompt return to the emergency room.
With best wishes,
___ Medicine | ___ male with history of central hypogonadism (on HCG)
and Rathke's cleft cyst presenting with cough/hemoptysis and L
leg pain, found to have community-acquired RLL pneumonia and LLE
DVT.
# Dyspnea on exertion:
# Cough:
# Scant hemoptysis:
# RLL community-acquired pneumonia:
Patient presented with a few days of high fevers and cough 1
week prior to admission. Fevers resolved, but mild cough with
scant hemoptysis persisted. Outpatient CXR at time of initial
fevers without clear evidence of pneumonia. CTA chest this
admission showed no e/o of PE but did demonstrate focal RLL
opacity consistent with community-acquired PNA, likely
explanatory. Although he is from ___ originally, TB was
thought very unlikely in the absence of immunosuppression (HIV
neg) or other clear risk factors and without LAD or weight loss
(of note, his respiratory symptoms preceded his recent trip to
___. He was treated with CTX/azithromycin in the ED,
transitioned to levofloxacin on admission with improvement in
his cough and dyspnea. No e/o hypoxia. Hemoptysis had resolved
at discharge, despite initiation of therapeutic anticoagulation
as below. He will be discharged on levofloxacin 750mg daily to
complete a 5-day course through ___. PCP ___ scheduled for
___.
# Provoked LLE DVT:
P/w L leg pain that developed a few hours after return flight
from ___. Found to have nonocclusive deep venous
thrombosis in the anterior left posterior tibial vein. CTA chest
neg for PE. Likely provoked in setting of immobility, but
patient reports that his father was recently diagnosed with
extensive blood clots raising possibility of underlying
hypercoagulable disorder. Home HCG therapy may put him at
increased risk, as does his tobacco use. Treated initially with
heparin gtt, transitioned to apixaban on ___ after discussion
of the risks and benefits of therapy. Hgb remained stable
without e/o ongoing hemoptysis with therapeutic anticoagulation.
He will be discharged on apixaban 10mg BID x 7d (___) then
5mg BID; would likely treat for 3 months for provoked DVT.
Consideration of hypercoagulable w/u deferred to PCP. He was
counseled on the importance of smoking cessation.
# Central hypogonadism:
# Rathke's cleft cyst:
Followed by Dr. ___ at ___. On HCG 2500u 2x/week. ___
increase risk for VTE as above. Would recommend addressing with
outpatient endocrinologist.
# Pulmonary nodules:
3 mm nodules seen on CT chest. Low suspicion for malignancy
given young age and social tobacco use, but likely warrants 12
month ___ CT.
** TRANSITIONAL **
[ ] levofloxacin through ___
[ ] apixaban 10mg BID through ___, then 5mg BID thereafter;
likely 3 month course for provoked DVT
[ ] consideration of hypercoagulable w/u deferred to PCP
[ ] consider alternative therapies to HCG if feasible given
reports of slightly increased risk of VTE with therapy
[ ] ongoing smoking cessation counseling
[ ] ___ CT chest 12 months for pulmonary nodules | 155 | 451 |
10682488-DS-16 | 22,073,138 | Dear Mr. ___,
You were admitted to the hospital because you had too much fluid
in your body.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We removed fluid from your abdomen (called "paracentesis").
We took off 1.75 liters of fluid from your abdomen on ___.
- We gave you IV medications to remove excess fluid from your
body.
- Before you left the hospital, we switched to an oral
medication to keep fluid off your body.
- We continued studies for your liver transplant.
- We placed a feeding tube to help with nutrition
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | Mr. ___ is a ___ year old man with Child C alcoholic and HCV
cirrhosis decompensated by ascites w/ a history of SBP, hepatic
encephalopathy, and variceal bleeding s/p banding who was
admitted for fluid overload, malnutrition, and expedited
transplant work-up. diuresis and initiation of enteral feeding.
He was actively diuresed with IV Lasix and switched to PO
torsemide 40 BID prior to discharge. ___ ___ guided para was
performed with removal of 1.75L fluid. Dobhoff was placed on
___ and tube feeds were initiated on ___.
#CIRRHOSIS
#ANASARCA
#ASCITES
Patient presenting with anasarca and refractory ascites. No
clear
reason for decompensation at this time. Reports compliance with
medication, no signs of bleeding, RUQUS showed cirrhotic liver
and large volume ascites. ___ guided paracentesis on ___ was
performed with 1.75L removed - no e/o SBP at that time, but he
was continued on home cipro. He was diuresed with IV Lasix 40
and switched to PO torsemide 40mg BID with discharge weight of
220 lbs.
#MALNUTRITION.
___ was placed ___ and tube feeds were started, with plan
to continue at home.
#LIVER TRANSPLANT EVALUATION.
Per outpatient provider, liver transplant eval was expedited
during admission. He is hepatitis C positive and is untreated
and has higher chance to receive an organ with a lower meld
score if there is a positive hep C organ offer. Most of his
work-up was completed during this admission. Labs ordered, but
pending at discharge include: LMK antibody, IGRA. Studies to be
performed include: DEXA which could not be done as inpatient,
and EGD which he preferred to get done as outpatient.
# CODE: Presumed FULL
# CONTACT: Name of health care proxy: ___
___: wife
Phone number: ___
Cell phone: ___
TRANSITIONAL ISSUES
====================
[]Will need to complete DEXA, EGD for transplant work-up.
[]Will need ___ antibody, IGRA.
[]Monitor for fluid overload. Discharge Weight: 220 lbs,
Discharge Cr: 1.0
[]Should have weekly MELD labs
[]Should continue to have therapeutic paracenteses as needed | 235 | 317 |
16480720-DS-21 | 24,828,694 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- TDWB | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L tibia fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF L tibia, which the patient tolerated well
(for full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
medical service was consulted for a sinus tachycardia. He was
started on Amlodipine and will follow-up with the medical
service. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is TDWB in the LLE extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up in two weeks per routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge. | 150 | 255 |
17400716-DS-25 | 26,742,691 | It was a pleasure taking care of you during your recent
admission.
You were admitted with shortness of breath, related to too much
fluid. You were given medications to help you urinate to take
off the fluid, and your breathing improved.
Please weigh yourself daily to ensure that you are not gaining
weight. Your weight on the day of discharge was 63.7 kg
(140lbs). If you gain more than 3 lbs, please call your doctor.
You also were seen by the pulmonologists, who felt that some of
your breathing issues were related to sleep apnea, or not
breathing properly while asleep.
You were started on a CPAP machine, and you felt much more
rested during the day. You should continue this at rehab, and
Dr. ___ pulmonologist, will help arrange for you to have
a machine at home prior to discharge from rehab.
The following changes were made to your medications:
- STOP amlodipine
- STOP carvedilol
- START metoprolol twice a day for your heart
- START imdur once a day for your heart
- START torsemide once daily for help removing fluid
- STOP metolazone
- DECREASE tacrolimus to 2mg twice a day (from 3mg twice a day) | ___ yo F with h/o CAD s/p DES to RCA, ___, DMII, ESRD s/p
transplant, with multiple recent admissions for SOB attributed
to decompensated heart failure, now re-presenting with worsening
dyspnea.
# SOB/dyspnea/hypoxia- Patient has had multiple episodes of
flash pulmonary edema with the acute onset of shortness of
breath with evidence of volume overload on exam. She has been
difficult to diurese secondary to worsening renal function s/p
transplant.
During this admission, while diuresing patient on lasix gtt,
other underlying causes for shortness of breath were explored.
CT of the chest did not show any evidence of interstitial lung
disease or other intrapulmonary processes. She was noted to
have some pulmonary hypertension on echocardiogram, however this
was more likely related to volume overload with elevated left
sided pressures. Pulmonary was consulted and recommended
re-trying CPAP, as patient had severe OSA on a past sleep study
___ years prior. Patient tolerated CPAP well.
In addition, patient was ruled out for acute coronary
syndrome with negative cardiac enzymes x 3, stable EKG, and
normal stress test.
Patient was diuresed on lasix gtt and lung crackles,
shortness of breath, and hypoxia resolved. Once euvolemic, she
was transitioned to oral torsemide 100mg daily. She maintained
weights and her ins and outs were even on this dose.
# ESRD s/p transplant- Baseline creatinine was 2.0-2.4, which
has steadily risen during the last 3 admission. Urine sediment
has been bland, supporting more hemodynamic instability and poor
forward flow, as underlying cause of worsening renal function.
Ultrasound of transplanted kidney showed no evidence of arterial
stenosis or rejection. Tacrolimus levels were monitored
throughout admission, and tacrolimus was titrated to goal trough
___. Patient was continued on mycophenolate mofetil as well.
With lasix gtt, creatinine began to downtrend, likely due to
improved renal perfusion. Creatinine was slightly increased to
4.5 on torsemide, and renal was aware. She will follow up
closely with her nephrologist.
# Diastolic heart failure- As above, decompensated heart failure
drove shortness of breath and hypoxia. Ruled out for acute
ischemic event causing decompensation. no clear precipitating
factor for decompensation identified. Patient was diuresed on
lasix gtt. Medical management of CHF was altered to decrease
risk of ischemia; carvedilol was switched to metoprolol and
isosorbide mononitrate was started. Amlodipine was also
discontinued as blood pressures were well controlled on the
above regimen.
# Left leg pain- Patient complained of left leg pain, with point
tenderness along tibia. X-ray showed no acute fracture. She
was able to bear weight on the leg, and pain improved with
standing tylenol ___ TID which should continue until pain
improves.
# CAD s/p DES to RCA- As above, ruled out for acute ischemic
event. Continued aspirin 81mg daily and atorvastatin.
# DMII- Patient's blood sugars have been very labile during past
admissions, with hypoglycemic episodes. ___ followed closely
during last admission with several changes, including
discontinuing NPH BID and starting lantus 12 units qHS and
repaglinide with humalog sliding scale. Patient was continued on
this regimen and blood sugars remained stable. No changes were
made to this regimen.
# Hypothyroidism- Continued home levothyroxine
# Transitional issues-
- please continue autoset CPAP at ___
- patient will follow-up with pulmonologist Dr. ___
home CPAP
- weight on discharge 63.7kg (140lb)- if weight increases,
please increase torsemide dosing | 197 | 580 |
14319843-DS-13 | 21,862,629 | You were admitted to ___ when your gallbladder drain stopped
draining bile. On CT scan, the drain was noted to be dislodged
and was no longer within the gallbladder. Interventional
Radiology attempted to reposition this drain but they were
unable to. You were becoming increasingly sick and had to be
transferred to the ICU for close monitoring and medications to
control your heart rate and treat your blood pressure. You were
taken to the operating room for an exploratory laparotomy,
extensive lysis of adhesions, washout, removal and replacement
of gallbladder drain.
Post-operatively, cardiology was consulted to help manage your
uncontrolled atrial fibrillation. They have made adjustments to
your medications. You were then taken for cardioversion, as the
medications alone were not working. You tolerated cardioversion
well, and you have remained in sinus rhythm. It is crucial for
your INR to remain therapeutic. Please check your INR at least
twice/week and follow-up with your home Cardiologist.
Physical therapy has worked with you and you have been cleared
for a discharge home with ___ services to help with the drain
and VAC dressing. You are now tolerating a regular diet, your
pain is well controlled, and your heart rate is controlled. You
are ready for discharge. Please note the following:
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.
Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | Mr. ___ is a ___ old man with a history of
cholecystitis and atrial fibrillation with rapid ventricular
response and recent cardiac ablation, who presented ot the ED on
___ when he noted that his percutaneous cholecystostomy
tube had been dislodged. He did get a drain study in the ED,
which noted the cholecystostomy tube in his subcutaneous tissue.
He was admitted to the hospital thereafter because he felt
uncomfortable, but that this point he was afebrile with stable
vital signs within normal limits, he had no abdominal
tenderness, and he had normal LFTs. Interventional radiology was
consulted for replacement of the perc chole tube, but given that
he had normal labs and was asymptomatic and they were hesitant
about reinserting the tube, we agreed to obtain an MRCP to
discern if the cystic duct was still obstructed and that he
would still need gallbladder drainage.
On HD#2, he received 2 units of FFP for elevated INR (patient
takes Coumadin at home for afib), and MRCP was performed showing
persistent obstruction of cystic duct. Overnight, he developed
afib with RVR, and was treated with IV metoprolol.
On HD#3, he was triggered for Afib RVR and hypotention requiring
fluid bolus, IV metoprolol, and IV diltiazem. He was given
another 1U FFP and 10mg IV vitamin K to reverse his INR. With
the development of Afib RVR, Mr. ___ then also started to
appear diaphoretic, and he did develop some abdominal pain. At
this point, since his clinical picture appeared to be trending
towards sepsis/recurrent cholecystitis, he was taken urgently to
___ for replacement of the cholecystostomy tube. At this point he
was also started on antibiotics. For full details of this
procedure, please refer to the separately dictated procedure
note. Briefly, the cholecystostomy tube appeared to be inserted
through and through the gallbladder and there was some concern
of other visceral organ penetrance as there was difficulty
withdrawing the tube. He did also develop rigoring and continued
to be in rapid ventricular response from afib. He was
transferred emergently to the ICU for resuscitation where he was
intubated, got an arterial line and central line, and was then
taken to the operating room for exploratory laparoscopy. He
underwent an exploratory laparoscopy, right upper quadrant
washout, removal and replacement of percutaneous
cholecystostomy, and midline would vac placement. He appeared to
tolerated the procedure well, but was on a low dose of
neosynephrine drip by the end of the case, so remained intubated
and was transferred back to the ICU for further monitoring. For
full details of this procedure, please refer to the separately
dictated operative report. He was started on an amiodarone drip
overnight for improved rate control with good effect.
On POD#1, as he was still on vasopressor, this was changed from
neosynephrine to levophed for presumed sepsis. He was weaned to
minimal ventilator settings.
On POD#2, he was weaned off of levophed. He was extubated
without issue. He started to trial a clear liquid diet which he
tolerated well. His amiodarone drip was transitioned to PO;
however, he then briefly required a diltiazem drip for rate
control. He was changed to PO overnight. He was briefly on
neosynephrine again overnight, but this was weaned off by POD#3.
On POD#3, his PO diltiazem was increased in dosage. He was
allowed to have a regular diet, which he tolerated well. His
wound vac was changed and the base appeared to be clean and
healing well. His foley was discontinued, along with his
arterial line and central line. He was restarted on his home
Coumadin. At this point, he was deemed stable for transfer to
the floor.
POD4 the patient completed course of antibiotics. Physical
therapy worked with the patient and was recommending rehab. The
patient continued to have episodes of atrial fibrillation with
RVR. Cardiology was uptitrating medications without good effect
in controlling heart rate. The patient was also having episodes
of hypotension, which were responsive to fluid resuscitation.
Given the inability to control the patient's rates with
antiarrhythmics and nodal blockade, cardiology opted to proceed
with TEE due to subtherapeutic INR ___ followed by DC
cardioversion. On ___, the patient underwent successful DC
cardioversion, which he tolerated well. Post cardioversion, the
patient was in normal sinus rhythm. He resumed his home AF
regimen of digoxin and amiodarone, and was educated on the
importance of maintaining a therapeutic INR and cardiology
follow-up.
Physical therapy re-evaluated the patient and he was cleared for
discharge home with ___. During this hospitalization, the
patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin until INR was therapeutic, and venodyne
boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The percutaneous cholecystostomy tube was draining
bile and the patient's surgical wound was filling in with
healthy granulation tissue. The JP drain was draining
serosanguinous fluid. The patient was discharged home with ___
services for wound VAC care and drain care. The patient and his
partner received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. | 581 | 879 |
12000782-DS-19 | 21,446,046 | You were admitted to the hospital with abdominal pain. It was
initially thought that a stone may have been blocking a duct in
the pancreas, which caused your pain, but the MRCP showed that
this was not the case. You had a colonoscopy out of concern for
GI bleeding; this showed internal hemorrhoids, but was otherwise
normal. Upper endoscopy (scope of the stomach) showed that
there was a stitch that was 5-6cm left from the previous
surgery. In discussion with your outside bariatric surgeon,
this was removed as a possible culprit of the pain. If the pain
recurs, it would likely be because of an internal hernia, which
is when the bowel gets "stuck" from time to time as a result of
the previous surgery. The treatment for this is to have an
operation to fix it. If you experience ongoing pain, we advise
to go to ___ where your primary surgeon is in order to
figure out the next steps .
It was a pleasure to participate in your care,
Your ___ Team | Ms. ___ is a ___ female with the
past medical history of Roux-en-Y gastric bypass ___, recent
laparoscopic cholecystectomy, recent admission for abdominal
pain
and transaminitis thought to be secondary to passed stone
(discharged ___, who presents to the ER with continued
abdominal pain and concern for GI bleeding. | 180 | 44 |
15704389-DS-10 | 26,042,076 | Dear Mr. ___,
It was a pleasure caring for your during your most recent
admission. You were admitted for back pain. You had a Ct scan
of your lumbar spine which showed L4 vertebral lesion with
pathologic fracture and epidural mass causing severe spinal
canal narrowing. You were evaluated by orthopedic surgery and
per discussion with them decided to forgoe surgical intervention
at this time. You were given a back brace which you should
continue to wear it at all times while out of bed. You were
instructed to limit lefting objects no more than 10 lbs.
Steroid taper:
8 mg in the morning and 4 mg in the evenings- ___
8 mg in the morning ___
6 mg in the morning ___
4 mg in the morning ___
2 mg in the morning ___
No more steroids starting ___.
Once your morning sugars are running below 150, please stop
using nightime lantus.
Please note given your elevated blood sugars, you should have a
hemoglobin A1C in the future drawn by your primary care
physician to make sure that your hyperglycemia has resolved. | ___ year old male with metastatic esophageal cancer to bone s/p
recent left
femur intramedually nail placement and XRT and recent
hospitalization with discovery of new spinal mets presenting for
pain control. Hospital course is summarized by problems below:
# Back Pain/Spinal metastasis: At time of last presentation
patient found to have new spinal mets to T8, T12 and L5 with
pathologic
compression fracture of L5 with retropulsion, S1 cord
impingement and spinal stenosis. He was evaluated by the
ortho-spine service and kyphoplasty was considered but his pain
improved with conservative therapy and this was deferred. He
was also seen by XRT and underwent a session of radiotherapy to
his spine for pain control. His home oxycontin was increased and
he was continued on oxycodone for breakthrough pain. Currently
patient is presenting with worsened back pain poorly controlled
on home medications. CT of lumbar spine was done and showed new
L4 lesion with repropulsion resulting in severe spinal canal
narrowing. Patient was evaluated by orthopedic surgery and
declined surgical intervention at this time. He was provided at
___ back brace to wear at all times while out of bed. He was
evalauted by physical therapy and did well, thus being cleared
for discharge home. He was continued on oxycontin and oxycodone
for pain control. He was started on steroid taper with
demathesone 8 qam and 4 qpm. He was continued on calcium
carbonate for. He was instructed to wear back brace while out of
bed.
# Metastatic SCC of the esophagus: Patient is status post liver
biopsy with pathology consistent with metastatic esophageal
adenocarcinoma. Dr ___ was made aware of patient's
admission.
#Hyperglycemia: Patient had recordings of critically high blood
sugars since starting steroids. He was started on lantus and
ISS. Wife was taught how to administer insulin. Patient was
provided detailed instructions to stop lantus once am blood
sugar less than 150. Hyperglycemia will improve with steroid
taper. Patient will benefit from HgA1C in the future.
# Prostate CA - ___ 6, s/p XRT, in remission.
# EtOH-related cirrhosis: No current asterixis or signs of
hepatic encephalopathy. Continued on rifaximin and lactulose
# ___ disease s/p left hepatic lobectomy and cholecystectomy
for left hepatic duct stricture ___: Continued on ursodiol. | 175 | 372 |
16848080-DS-18 | 29,632,932 | 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, left upper 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 Aspiring 325 MG daily for 4 weeks to help prevent
blood clots that may occur after orthopedic surgery.
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
Physical Therapy:
Non-weight-bearing LUE in sling, gentle pendulums to shoulder
ONLY
Active ROM elbow, wrist, fingers
Treatments Frequency:
Non-weight-bearing LUE in sling, gentle pendulums to shoulder
ONLY
Active ROM elbow, wrist, fingers | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left proximal humerus fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, 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 home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
moderate risk for DVT 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. | 229 | 251 |
12017780-DS-23 | 26,362,089 | Dear Ms. ___,
Thank you for choosing us for your care. You were admitted for a
cellulitis (infection of the skin) on your hand. We treated you
with a day of the intravenous antibiotic Vancomycin before
switching you to the oral antibiotic Bactrim. Please continue to
take Bactrim and keflex as prescribed for a total 10 days of
antibiotics.
Please follow with your primary care physician as illustrated
below. Please keep your arm elevated and keep the splint until
you are evaluated by your primary care physician. | HOSPITAL COURSE AND ACTIVE ISSUE
89 ___ speaking woman with left wrist pain, redness,
swelling concerning for cellulitis. Seen by Plastics in ED for
rule out compartment syndrome. No proximal tendon involvement or
significant pain on palpation of cellulitic area. Given mobility
of joint this is unlikely septic arthritis although
osteoarthritis in that joint would predispose. Given diabetes
treated this as complicated skin infection with one day of
vancomycin switching over to Keflex and Bactrim to complete a 10
day course of total antibiotics (to finish on ___. Overnight
on ___ had sundowning which was treated with 2.5mg olanzapine.
INACTIVE ISSUES
# DM: Non insulin dependent at home. Held home glipizide,
metformin and placed on diabetic diet with ISS in house.
# HoThyroid: cont home Levo
# HTN/Hyperlipidemia: continued home atenolol, amlodipine,
lisinopril, ASA
TRANSITIONAL ISSUES
# DNR/DNI cooberated with patient
# Assess for resolution of infection | 85 | 139 |
16929130-DS-11 | 25,704,038 | Dear Mr. ___,
You were admitted to ___ for
evaluation of abdominal pain and were diagnosed with a small
bowel obstruction. Please follow the instructions below to
continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please take any new medications as prescribed. | Mr ___ was recently admitted to our institution after an
unwitnessed fall on ___ while intoxicated. He broke his ankle,
and was admitted to the Ortho service after ORIF of the ankle.
He returned to the hospital on ___ with abdominal pain and was
diagnosed with SBO. He was managed conservatively initially, but
ultimately went to the ___ for exploratory laparotomy on ___. No
transition point was identified, and no bowel resection or
further intervention was required. Since then, Mr ___ was
doing well until he became acutely short of breath, and was
transferred to the TSICU. He was intubated, and required
pressors- his lactate was elevated to 10. Cardiac troponin was
also elevated to 0.15. A bedside echocardiogram was performed
with RV enlargement, and in this setting a CT angiogram was
performed that identified
proximal R and L main PA clots. MASCOT and cardiac surgery were
consulted for additional recommendations and management of
massive PE. He was again brought to the operating room on ___
for emergent pulmomary embolectomy/VA ECMO(right femoral). He
was brought to the CVICU in critical condition with an open
chest. He returned to the operating room the same day for
re-exploration related to bleeding, the bleeding was controlled
and he returned to the CVICU in critical condition on multiple
pressors and inotropes. He continued to be supported for
cardiopulmonary failure on ECMO for several days, during that
time he was paralyzed and sedated d/t open chest, he was also
found to be HIT positive and was started on bivalrudin. He
weaned from ECMO and returned to the operating room for chest
closure and decannulation on ___. Over the next week he was
started on tube feeds and gradually weaned from the ventilator
and his vasopressors. He was extubated on ___ but remained in
the CVICU for several more days to monitor his pulmonary status
and to wean off hiFlo oxygen. He finally transferred to stepdown
floor on ___ for continued care and recovery. During this time
he continued to be evaluated by speech and swallowing service
and his diet was gradually advanced. He was found to have a
Pseudomonas UTI and was initially started on Cipro but developed
a prolonged QT and was therefore changed to Ceftazidime. He
continued to be extremely deconditioned, progressed slowly and
was screened for rehabilitation. He transferred to ___
___ on ___. | 191 | 391 |
13834338-DS-21 | 28,703,498 | Dear Mr. ___,
It was a pleasure to take care of you during your
hospitalization. You were admitted to the hospital after having
blood in your urine. While here your Foley catheter was
continuously flushed in order to help clean out the blood from
your bladder. The amount of bleeding in your urine continued to
improve and was clear of blood prior to your discharge. The most
likely cause of this bleeding was minor trauma from the presence
of the Foley catheter.
While in the hospital, you developed a clot in your left leg
(Deep Vein Thrombosis; DVT). This DVT is the cause of your leg
swelling. Certain risk factors for developing a DVT include
having cancer and being immobile. You are being treated with a
drug called Lovenox, which is injected underneath the skin in
your abdomen. This will help to keep your blood thin so that
your body can dissolve the clot. You will remain on this for at
least 6 months and possibly longer, but this will be decided at
a later time by your PCP.
It is important that you follow-up with the doctor's
appointments listed below. Please call your doctor or come to
the Emergency Department if you develop any concerning symptoms
such as chest pain, shortness of breath, pain with breathing, or
more blood in your urine. | Pt is an ___ y/o M with PMHx significant for prostate CA c/b
recent large bowel obstruction s/p resection with colectomy and
end-ileostomy and with chronic indwelling Foley presented with
hematuria since ___. | 220 | 33 |
18248001-DS-8 | 27,622,987 | Dear Ms. ___,
You were hospitalized due to language difficulties 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. Your stroke was treated with a medication that
breaks up blood clots, and this likely helped resolve your
symptoms. You also had a seizure, which can sometimes result
from a stroke.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Atrial fibrillation
We are changing your medications as follows:
- START apixaban (Eliquis) 2.5mg DAILY. This is a blood thinner
and will reduce your risk of blood clots leading to a stroke.
- START levetiracetam (Keppra) 500mg DAILY. This is an
anti-seizure medication to prevent future seizures like the one
you had after your stroke. This will likely be stopped upon
follow-up with Dr. ___.
Please take your other medications as prescribed.
Please followup 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
As you had a seizure, it is state law in MA for you to not drive
for 6 months starting from the date of your seizure. After this
time, if you have not had another seizure you can resume driving
providing other factors are also stable. | Ms. ___ presented with aphasia and was given tPA. She was found
to be in atrial fibrillation. She also had a GTC seizure shortly
after the tPA administration, for which she was briefly
intubated. She was monitored and her symptoms improved the day
after admission. She continued to have mild aphasia, but by day
2 was at baseline. CTA and MRI brain were negative for
occlusions or infarcts, old or new. EEG was negative for any
epileptiform activity.
- She was started on Eliquis 2.5mg BID as she was also found to
be in new onset afib. We discussed this with the patient and
told her of the risks benefits and she decided to accept
treatment in order to prevent any future strokes given her
a-fib.
- She was also started on Keppra 500mg BID. This will be
continued for 2 months only.
- She will follow-up with Dr. ___ of stroke neurology.
-Patient was also monitored closely on ___ protocol given her
history of heavy recent alcohol use (multiple drinks of wine per
day). She did not require any additional medications. She was
also started on folate and thiamine for nutrition supplements.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (x) Yes (LDL =82 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? () Yes - (x) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
TRANSITIONS OF CARE ISSUES:
1. Patient to take apixaban 2.5mg BID for new onset afib for
stroke prevention
2. Patient to also take keppra (levericeteram) 500mg BID for the
next two months
3. You will follow up with the neurologist after discharge on
the appropriate appointment date
4. Please also follow up with your PCP ___ ___ weeks from
discharge | 383 | 476 |
18738396-DS-20 | 28,844,141 | Dear Ms. ___,
It was a great pleasure to take care of you at ___. You were
admitted to the hospital because of right groin and thigh pain.
You also had a seizure while you were at the hospital. The
neurology team saw you and determined that you can continue with
the same dosage of your seizure medications. Orthopedics also
saw you and reviewed your right leg x-rays. You do not have a
fracture or infection. Your right groin/leg pain is most likely
a muscle strain and should get better with physical therapy. | ___ year old female with pulmonary sarcoidosis, seizure disorder
on lacosamide and zonesamide, chronic back pain on ___, closed
treatment of her right proximal humerus fracture in ___, right bimalleolar ankle fracture and psychotic disorder
NOS presents with one day history of right thigh pain
complicated by seizure in the ED.
# Seziure. History of seizure disorder on AED. It appears she
missed her AEDs in setting of the all the events of the day. s/p
ativan and versed. Could be secondary to underlying metabolic
or infectious etiology. Has normal electrolytes. CXR normal.
UA normal. Restarted home lacosamide 250 mg po BID and
zonesamide 100 mg TID
. Neurology saw the patient with no new recs and concluded
seizure likely part of her known seizure disorder. Patient had
no other seizure episodes in the hospital.
.
# Right thigh pain: Physical exam intact with no signs of
neurological cause, septic joint or trauma. Pain is diffuse
throught the thigh and not localized to one anatomical site or
structure. Negative straight leg raise, no neurological deficits
on physical exam. Studies for fracture and DVT negative. Likely
IT band or muskuloskeletal.
.
# Leukocytosis: Unsure of the etiology. Stress vs infectious.
UA normal. CXR normal. Blood cultures are pending. Low pre-test
probability for septic joint. Leukocytosis normalized prior to
discharge.
# Psychotic disorder NOS: One night during hospitalization
reported hearing voices. Continued home haldol 10 mg po qhs. EKG
normal QT interval. Made appointment to follow up with Dr. ___
(___) on ___.
# chronic overactive bladder: patient on enablex ___ qd but did
not take during hospital stay. | 92 | 272 |
10301609-DS-12 | 21,707,591 | Mr. ___,
You were admitted for management of a bowel obstruction. During
your hospitalization you first underwent a colonoscopy with
ileocolic dilitation. You continued to experience emesis(
vommiting) and a repeat CT scan showed continuing bowel
obstruction. You then underwent a jejunocolostomy on ___ for
the obstruction. You tolerated the operation well with a return
of bowel function. You tolerated a regular diet and are now
ready to return home.
General Discharge Instructions:
Please resume all regular home medications. Please
take any new medications as prescribed.Please take the
prescribed analgesic medications as needed. You may not drive
or operate heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed,but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water.
Gently pat the area dry.
Your staples will be removed at your followup appointment with
Dr. ___ on ___ at 2pm.
You received an injection of B12 during this hospitalization.
You are to continue receiving B12 injections monthly as an
outpatient.
If you fail to tolerate your diet at home, become febrile, or
fail to have bowel movements you are to call your physician
immediately or report to the local emergency deparment. If you
are having too frequent bowel movements (more than 2 bowel
movements per day), notify your physician. Take your Lomotil as
prescribed. Stop taking it if you experience constipation.
Your PICC line will be removed at your follow up appointment on
___ ___.
Note your heart rate was elevated during this hospitalization,
you were started on Metoprolol 25 mg BID. You are to continue
this medication until you follow up with your primary care
physician and have your medications reconciled. You are stop
taking this medication if your heart rate measures less than 60
beats per minute or your blood pressure is less than 100/60 at
the time of your scheduled dose.
Your pain medications were changed to Methadone 8 mg orally
every 8 hours. This is your new pain medication regimen. You are
to STOP taking any other narcotics while on this regimen. Follow
up with your primary care physician to have your pain
medications reconciled. | The patient was admitted on ___ to the General Surgical
Service for evaluation and treatment of his small bowel
obstruction. Patient was initially managed conservatively with
bowel rest. He had a nasogastric tube inserted and was NPO/ IV
fluids with antiemetics for nausea. On ___ the patient had a
colonoscopy performed along with dilitation of the ileocolonic
anastamosis. Following the procedure the patient continued to be
NPO and on IV fluids. Over the course of the next few days the
patient had episodes of emesis of both "feculent material" and
bilious material. A repeat CT scan on ___ showed progression
of the small bowel obstruction with dilatation of the small
bowel loops up to 5.3 cm from the previous 4.1 cm. The patient
had a PICC line inserted and was started on TPN. On ___ he
was taken to the operating room for an intestinal bypass. The
operation went well without complication. Please refer to the
Operative Note for details. After a brief, uneventful stay in
the PACU, the patient arrived on the floor NPO, on IV fluids,
with a foley catheter, and an epidural and PCA for pain control.
The patient was hemodynamically stable.His hospital course
following the jejunocolostomy is described below:
Neuro: The patient received an epidural and pca with good effect
and adequate pain control. When tolerating oral intake, the
patient was transitioned to oral pain medications. The patient
complained of pain with several pain medication regimens. His
pain was well controlled with Methadone PO 10 mg q 8 hours and
methadone IV 10 mg every 8 hours. The patient was discharged on
this regimen and advised not to take any of his home
narcotics(morphine), sedatives, or alcohol with this medication.
The patient was neurologically stable during this admission.
CV: Following the operation the patient had episodes of sinus
tachycardia with heart rates as high as 130-140's. Patient was
asymptomatic and continued to produce good urine output. Over
the following days the patient's tachcardia improved and fell to
the low 100's and high 90's. He was started on metoprolol 25 mg
bid and was discharged on this medication. Patient was
hypertensive throughout this hospital admission with blood
pressures as elevated as high 160's/ high 80's. He does have a
past medical history of hypertension. Vital signs were routinely
monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO/TPN/IV
fluids. The patient tolerated the TPN well and as his bowel
function returned his diet was advanced appropriately. Patient's
intake and output were closely monitored, and IV fluid was
adjusted when necessary. Electrolytes were routinely followed,
and repleted when necessary. Given that he was experiening
frequent bowel movements of 5 loose bowel movements per day, he
was restarted on Lomotil 1 tablet every 4 hours as needed for
diarrhea with a goal of no more than 2 bowel movements per day.
Patient had his indwelling foley removed on post-op day 4 when
his epidural was removed. Patient had no difficulty voiding
afterwards. Patient was transitioned to a regular diet and was
taken off TPN. He had no issues tolerating the regular diet.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Wound was routinely
monitored and showed no signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
his stay;
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin;He was
encouraged to get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. He was discharged with
nursing for ___ care with the understanding that his PICC would
likely be removed on ___ in his followup visit with Dr.
___. He received 1 B12 injection while in house and was
advised that he would need these injections monthly as an
outpatient. Patient was instructed that his narcotic regimen and
metoprolol would be adjusted with his PCP or oncologist on the
follow-up visit. His oncologist was verbally informed about the
plan and agreed to manage his narcotics on an outpatient basis. | 446 | 736 |
18919567-DS-22 | 25,133,588 | Dear Ms. ___,
You were hospitalized at ___
because of your back and hip pain. In the emergency room, you
had X-rays taken of your hip and pelvis that was normal except
for some changes associated with arthritis. Orthopedic spine
doctors also ___ images of your back taken before you
came to the hospital and a physical therapist assessed your
injury. You were given medications to manage your pain.
We recommend that follow up as an outpatient with physical
therapy, pain clinic, and your primary care doctor to continue
treatment of your back and hip pain.
It was a pleasure taking care of you.
Sincerely,
Your ___ team | ___ is an ___ year old woman with HTN, and cervical
radiculopathy and DJD who presents with acute on chronic low
back pain. On admission she had already had outpatient workup
with X-rays of her hip showed only arthritis of the L-spine and
no pathology of the R hip and MRI of the lumbar spine reportedly
showing foraminal narrowing but no cord compression. Prior to
admission, she had been treated with trigger point injection of
the R piriformis without relief and had had minimal to no relief
from NSAIDs, acetaminophen, cyclobenzaprine, prednisone (5 day
course of 50 mg). In the ED, X-rays of the pelvis and hip were
done and were were consistent with the earlier X-rays. She was
seen by ortho spine and by ___ and was ultimately admitted for
pain control. She was treated with ketorolac, oxycodone, and
acetaminophen overnight with some relief of pain. The following
day she described a burning, tingling pain on her thigh, so was
given gapabentin with improvement of this pain. She was
discharged with instructions to follow up with pain clinic,
ortho spine, and ___. For short-term pain management, she was
given IM toradol and discharged with acetaminophen, gabapentin,
and oxycodone 5 mg. | 104 | 201 |
11305575-DS-11 | 20,046,375 | Dear Ms. ___,
You came into the hospital because you were having headaches.
WHAT HAPPENED TO ME IN THE HOSPITAL:
- You received radiation therapy for your cancer
- You received steroids
- Your blood glucose was monitored closely and you were given
insulin accordingly
- You were confused at times during the hospitalization
When you leave the hospital you should:
- Take all of your medications as prescribed.
It was a pleasure taking care of you,
Your ___ Care Team | PATIENT SUMMARY
===================
Ms. ___ is a ___ woman with extensive poorly
differentiated carcinoma in the right temporal fossa s/p
rightcraniotomy for resection of intracranial portion in ___
and 6 cycles of Carboplatin-etoposide (C6D1 ___ who
presented with severe right-sided headache that was most likely
due to tumor invading the right skull base & sphenoid/maxillary
bones and complicated by intracerebral hemorrhage. She received
radiation therapy which she completed on ___. She was
started on a steroid taper in the last week of her radiation
therapy to help her mental status which was then complicated by
some asymptomatic hypoglycemic episodes secondary to increased
insulin. Given her persistent altered mental status, lethargy,
and poor candidate for rehab, family meeting was held with her
HCP and decision was made to send her to hospice.
TRANSITIONAL ISSUES
===================
[] please control pain with po liquid oxycodone and IV ketorolac
and increase frequency as needed
[] please turn q2hrs
[] for diet, recommend small bites with soft solids and thin
liquids
[] patient on dexamethasone taper for her altered mental status:
discharged on 8mg qam ___, 6mg qam ___, 4mg qam
___, 2mg ___, 1mg ___
ACUTE ISSUES
============
# Poorly Differentiated Neuroendocrine Carcinoma
# Headache
# Right-sided head & face pain
# Focal neuro deficits: facial droop, LLE weakness
# Encephalopathy
Has poorly differentiated neuroendocrine carcinoma in R temporal
fossa s/p resection and 6 cycles of chemotherapy. CT torso w/o
evidence of metastatic disease. Her hospital course was
complicated by a brain bleed (new foci of intraparenchymal
hematoma and small subarachnoid hemorrhage in the right
frontotemporal region). Neurosurgery evaluated and said there
was no plan for surgical intervention. Chronic Pain team was
consulted and she was not a candidate for pericranial nerve
block due to tumor invasion through temporal bone at that site.
She was started on SBRT by Radiation Oncology on ___, received
15 daily fractions during this admission with improvement in
headache and facial pain. She was given dexamethasone 4mg Q6H
with calcium (with planned taper) and Bactrim for PCP
prophylaxis while on dex. Palliative Care was consulted for
goals of care discussion and symptom management, recommended
regimen of tapering her steroids and not checking her vitals at
night. Throughout her hospitalization, the patient had episodes
of hypersomnolence. Repeat NCHCT showed stable bleed. Her mental
status also waxed and waned in the few days prior to discharge.
It was deemed that waxing and waning encephalopathy is partly
related to intraparenchymal hemorrhage, hospital stay induced
delirium, fluctuating blood glucose, and residual effects from
her tumor.
# GOALS OF CARE
Given patient's somnolence and confusion in her final week in
the hospital, her deconditioned state, and her poor candidacy
for rehab, family meeting held and goals of care clarified.
Patient's HCP ___ expressed that patient did not want to "be
connected to lines and tubes without chance of recovery."
Medical team described that she would likely not benefit from
immunotherapy given her current clinical state and decision was
made to arrange for hospice.
# HYPOGLYCEMIA
During her steroid taper, she continued to have BGs in the AM
around 50's and 60's. For this we decreased glargine to 9 units
and short acting to 6 BF, 10 lunch, 4 dinner. We continued to
monitor for signs of hypoglycemia. As she is going to hospice,
she will not need further insulin.
# HYPERCALCEMIA
Serum calcium level gradually trended up while she was here.
Initially this was attributed to HCTZ. She was also given IV
fluids to help correct her calcium. Corrected calcium on
discharge 11.
# SHOULDER PAIN
Patient complained of right shoulder pain acutely, likely
secondary to her myeloma. X-rays on ___ showed no acute fracture
or osteosclerotic lesions
# Acute Kidney Injury
She had ___ while she was here, most likely ___ her poor PO
intake. She received IVF 500cc bolus x 2 and the ___ resolved.
On discharge, Cr was 0.9.
# Thrush
During her hospitalzation she was found to have oropharyngeal
thrush. She attempted clotrimazole troches but could not
tolerate this well. Her thrush improved on oral fluconazole
200mg q24hours for 7 days and nystatin suspension four times a
day. On discharge she had no signs or sx of thrush.
# Internal iliac vein thrombosis
CT abdomen with incidentally noted filling defect in the left
internal iliac vein concerning for thrombus. Given her recent
IPH (___), she was not put on systemic anticoagulation.
# Dysphagia
# Nutrition
Pt with poor PO intake in setting of dysphagia ___ IPH and
midline shift. Nutrition consulted, started multivitamin with
minerals, Glucerna shake supplements. SLP evaluated, recommended
small bites with soft solids and thin liquids.
# Hypertension
Continued home amlodipine at higher dose as well as lisinopril.
Her HCTZ was discontinued as she was hypercalcemic during her
hospitalization. Stopped anithypertensives on discharge.
# Mild leukocytosis
Mild leukocytosis likely ___ dexamethasone. Pt afebrile and HDS.
No new localizing infectious symptoms. UA without bacteria.
# Anemia: microcytic, has been stable above transfusion
threshold throughout her hospital stay
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. | 75 | 870 |
18711534-DS-15 | 28,910,332 | Dear Ms. ___,
You were admitted to the hospital with constipation. You were
given bowel medications and disimpacted in the Emergency
Department. You can to the medical floor and continued to have
bowel movements. You are now ready to go home.
Please take the bowel regimen as prescribed and *please avoid
opiate medications as these will worsen constipation.*
For your musculoskeletal back pain, you can take naproxen
(prescribed) and follow up with your PCP.
It was a pleasure taking care of you.
Your ___ team | #Opioid induced constipation, resolved
-Seemingly resolved since disimpaction in ED and passage of
large
bowel movement on day of admission and ongoing bowel movements
and passing gas this morning.
-Etiology is probably from her taking the oxycodone several days
prior. She was counseled on this.
-The patient was given an option of discharge yesterday but said
she preferred to stay until the morning to make sure she doesn't
have recurrent constipation
-Given that she continues to move her bowels well, will
discharge with bowel regimen.
-Regular diet
-Daily miralax, senna, Colace - prescriptions given for
discharge
#Question of enteritis
-Fluid filled ascending/transverse colon on CT A/P. This is
nonspecific and she does not likely have true inflammatory
colonic
pathology at this point; may have been related to her
constipation that is now relieved. Clinically she is afebrile,
well-appearing, and her slight leukocytosis yesterday is
downtrending.
#Lower back pain
Patient endorsed musculoskeletal lower back pain today. She was
able to ambulate in the hall though she was concerned about
managing at home, especially with her disabled husband, so
arranged home ___. She received toradol x1 and naproxen x1 which
helped her. Discharged with prescription for naproxen.
#Hypothyroidism
- continued home synthroid
#HTN
-Continued home lisionpril
#Bipolar disorder
-Continued home valproate | 80 | 189 |
11148709-DS-21 | 20,077,209 | Dear Ms. ___,
You were admitted to ___ for a skin infection. You were
treated with antibiotics and you should complete a ___ day
course of the two antibiotics as you have been prescribed.
We wish you the best. | ___ with hx. asthma, bipolar disease, eczema, hypothyroidism,
MRSA colonization with recurrent cellulitis presenting with foot
pain.
ACUTE CARE
# Foot pain: plain films of foot reveal possible stress fracture
and patient has pain to palpation over area of ___ metatarsal.
Also with overlying area erythema. Pain likely due to stress
fracture, although there was also mild concern for cellulitis.
The finding of the stress fracture was discussed with the
patient's orthopedic surgeon who she had seen in clinic who
recommended possible MRI, which was discussed with the patient.
She was advised to avoid strenuous, high-impact activity.
# Cellulitis vs Eczema: the patient had 3 areas of erythema: an
area on the dorsum of her foot, and areas on her bilateral
forearms. Her forearms were scaly with areas of excoriations,
thus raising concern for eczema with possible super-infection
given erythema that did improve with antibiotics. She also had
erythema on the dorsum of her foot which did not have an
eczematous appearance. She was empirically started on IV
Vancomycin and was discharged on Bactrim with Keflex (she has a
history of penicillin allergy but has tolerated Keflex in the
past). This plan was discussed with her ID team as well as her
PCP, both of whom she will see in clinic within the next week to
ensure improvement. Of note, the patient had significant anxiety
that she was apparently re-infected with MRSA given the fact
that she had previously gone through decoloniziation. A MRSA
swab from ___ was sensitive to bactrim thus prompting
this antibiotic choice.
CHRONIC CARE
# Eczema: patient evaluated by ___ clinic today, recommended
continuing outpatient steroid therapy. Of note, patient with
multiple hives, suggesting allergy/histamine component and was
advised to take an anti-histamine and continue home eczema
medications.
# Bipolar Disorder: Continued quetiapine, gabapentin, ativan at
night
# Asthma: Continued advair, zafirlukast
# Hypothyroidism: Continued home synthroid
TRANSITIONS IN CARE
CODE: Full
EMERGENCY CONTACT HCP: ___ ___
PENDING: BLOOD CULTURES X2 | 39 | 327 |
16870412-DS-16 | 23,578,040 | It was a pleasure to care for you in the hospital.
.
You were admitted because of alcohol withdrawl seizures. Your
symptoms improved with supportive care. You were found to have a
urinary tract infection.Please complete 3 days of antibiotics
for this. You were also unsteady on your feet and physical
therapy recommended outpatient physical therapy. Please stop
drinking alcohol.
.
You were started on:
Multivitamins 1 tab daily
Thiamine 1 tab daily
Folic acid 1 Tab daily
Omperazole 40mg daily
Bactrim 1 Tab daily for 3 days. | ___ yo F with PMH etoh abuse p/w withdrawal seizures with exam
findings concerning for ___'s encephalopathy.
# EtOH withdrawal: completely disoriented and speaking gibberish
on admission exam. in setting of poor po intake, etoh abuse, and
history of gait disturbance, behavior was concerning for
wernicke's ___ thiamine deficiency so treated empirically for
this with high dose thiamine 500mg IV x 1 after which patient
improved and switched to 100mg thiamine daily. She was also
treated with IVF, multivitamin, and folate. CXR neg for acute
process. Maintained on CIWA scale in house q2h with diazepam
10mg po for score >10 and scored four times. Electrolytes
repleted aggressively. AAOx3 on discharge. Social work consulted
and recommended therapy, which pt was open to and expressed
desire to stop drinking. Unable to arrange therapist prior to
discharge but PCP is aware she needs this and is willing to
assist with it. PCP states that her office will call to schedule
a follow up visit in one week if patient does not call.
# hypokalemia: Upon review of prior EKGs, findings on the EKGs
that were provided were not consistent with torsades. Therefore,
it is possible that she was not in torsades but rather having
runs of Vtach. On arrival to ___ she continued to have runs of
NSVT. Her hypokalemia was aggressively repleted and her rate
normalized. Also checked cardiac enzymes which were neg x 3.
# UTI: WBC and bacteria on u/a. unable to obtain ROS so were not
sure if pt symptomatic or not. Awaited UCx results (pansensitive
E. coli) and then treated with Bactrim for 3 day course. Pt
later denied dysuria.
# gait instability: per partner, pt has had multiple falls and
often expresses fear of losing her balance. She was evaluated by
___ who recommended home with ___. They also noted a ___ strength
with left dorsiflexion and ___ strength in all other muscle
groups. PCP aware of this and will work it up when she comes in
for follow up.
# pos urine bHCG at OSH: neg at our ED. serum bHCG done to
confirm and was also neg | 84 | 350 |
17189698-DS-10 | 23,243,666 | Mr. ___,
You were admitted with a cellulitis (infection) of your right
leg. This occurred after an injury sustained during your
motorcycle accident. You also had a small abscess of your anlke
that was incised and drained. You were treated with several
days of IV antibiotics and will be discharged to complete a 14
day course of oral antibiotics. You should change your bandage
daily and ensure that your wound remains clean and dry.
It has been a pleasure taking care of you at the ___ and we
wish you the best of luck. | Mr. ___ was admitted on ___ with cellulitis of his right
lower extremity ___ days after having a leg laceration primarily
repaired in the ___ ED. A small collection overlying the medial
malleolus was I&D'd in the ED. He was treated initially with IV
vancomycin and ceftriaxone (1 dose) and transitioned to oral
antibiotics once he remained afebrile for 48 hrs. The leg
dramatically improved on examination and he was discharged to
complete a fourteen day course of oral antibiotics. | 98 | 82 |
10822193-DS-20 | 23,542,322 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place. | Ms. ___ was admitted to urology for nephrolithiasis
management with a known 0.9mm obstructing left proximal ureteral
stone and presenting with fever, tachycardia; sirs. She was
immediately started on IV antibiotics and tolerated the
procedure well and recovered in the PACU before transfer to the
general surgical floor. See the dictated operative note for full
details. Overnight, the patient was hydrated with intravenous
fluids and received appropriate perioperative prophylactic
antibiotics. On POD1, catheter was removed. At discharge on
POD1, patients pain was controlled with oral pain medications,
tolerating regular diet, ambulating without assistance, and
voiding without difficulty and without fever for over 24hrs. She
was explicitly advised to follow up as directed as the
indwelling ureteral stent must be removed and or exchanged. | 373 | 124 |
16984024-DS-8 | 23,266,105 | You were admitted to the hospital with weakness and a fall.
These symptoms were atttibuted a urinary tract infection. You
were also started on steroids to help your weakness and to treat
the small amount of swelling near the known lesion in your
brain. Dr. ___ will see you next week and be able to discuss
the results of the MRI and PET CT scan that you will have today.
Please see below for your follow up appointments.
Medication changes:
dexamethasone 4 mg twice a day
ciprofloxacin 250 mg twice a day, last day ___ | .
# UTI - u/a suggestive, urine culture showed no growth.
Continued cipro for total 3 days.
.
# Cerebral edema - from brain metastases. Patient was
maintained on dexamethasone. Initial read of MR brain showed
increased size of parietal and frontal lesions on left, with
some edema. MR final read pending at time of discharge. After
discussion with Dr. ___ was discharged to obtain
previously scheduled PET CT for restaging. Dr. ___ NP ___
follow up with patient once results are finalized. Continued
dexamethasone, instructed patient to monitor weight, as steroid
therapy may lead to increased fluid retention.
.
# Fatigue with Syncope s/p fall - secondaty to poor PO intake
and global weakness for months in setting of acute UTI. ECG no
ischemic changes, and with no chest pain, do not suspect this
was a malignant arrhythmia. TSH and cortisol normal. Will need
to follow up PET CT and MR brain as noted above.
.
# Chronic, stable, diastolic CHF
- Lasix 20mg PO PRN at home, monitoring weights as above
- Continued carvidelol and lisinopril
.
# Metastatic breast CA
- Pt and family are discussing home hospice, last treatment was
in ___
.
# PPx - heparin BID, continued home PPI
.
# FULL CODE
___ M.D.
___
___ M.D.
___ | 94 | 205 |
12620320-DS-11 | 21,285,802 | Dear Mr. ___,
It was a pleasure participating in your medical care during your
stay at the ___. You came to
the hospital after your custom T-tube migrated down your
trachea. It was revised by Interventional Pulmonology. You
were monitored overnight in the ICU. A Passy-Muir valve was
placed and you were subsequently evaluated and cleared.
**Please schedule the following appointments (phone numbers are
listed below), including: **
- For an echocardiogram (within 1 week)
- For pulmonary function tests (within 2 months)
- A chest x-ray (within 2 months)
- With your renal transplant team and for Prograf monitoring
(within ___ months)
- With cardiologist Dr. ___ (within ___ weeks,
___
Thank you for letting us participate in your care.
We wish you all the best,
Your ___ Care Team | Mr. ___ is a ___ with history of IDDM, RCC s/p renal
transplant, dCHF, tracheal stenosis from prolonged intubation
after cardiac arrest ___ sepsis from HD catheter infxn) in ___
and elective T-tube placement on ___ who s/p
uncomplicated OR placement of custom T-tube, w/ current
migration of T tube s/p retrieval on ___.
# S/P T-tube retrieval
Patient s/p elective T tube placement on ___ s/p recent
custom T tube placement, removal of subglottic granulation
tissue, s/p migration and retrieval on ___ with IP. Patient
monitored over the evening in the ICU, given albuterol nebs,
continued on 7 day course of Bactrim for tracheitis
(___). Pain management with home oxycontin/oxycodone for
chronic knee pain, breakthrough pain with dilaudid PRN and magic
mouthwash for throat pain.
# Chronic HFpEF
Recent TTE ___ with EF >55%. CXR with evidence of pulmonary
edema, and patient has evidence of bibasilar crackles and lower
extremity edema consistent with volume overload. Per recent
discharge patient needs outpatient cardiologist for management
and optimization of medications. Patient digressed with IV lasix
bolus, resumed home torsemide on discharge, continued ASA.
Currently not on beta blocker at home or ___. TTE as
transitional issue below.
# IDDM:
Poorly controlled, last HbA1C ___ was 10.6%. Home regimen
lantus 90 u BID, humalog 24 u with meals TID.
# RCC s/p right partial nephrectomy in ___, ESRD s/p LRRT in
___
Current Cr 1.4, stable. Patient did not take AM dose of
tacrolimus on ___ prior to procedure
# HTN
Currently normotensive. Not on home beta blocker or any other
anti hypertensives at this time.
# Chronic pain:
- Continued home oxycontin and oxycodone for chronic knee pain
# HLD
- not currently on statin, appears to have been discontinued
when patient had been prescribed colchicine
TRANSITIONAL ISSUES
[] Needs to follow-up with new cardiologist (Dr. ___,
___ for a TTE and to optimize his medications. He
reports not taking carvedilol after it was discontinued in a
prior admission.
[] Patient will call to schedule outpatient CXR and PFT.
[] Patient will call to follow-up in clinic with interventional
pulmonology in 2 months.
[] Follow-up procedure in OR: Fleb bronch + /- rigid bronch + T
tube revision in 2 months.
[] Patient will call to schedule regular follow-up with renal
transplant team and for tacrolimus level monitoring.
[] Keep T tube capped during the day, uncapped at night.
[] Continue Guaifenesin 1200 mg po bid
[] Bactrim for 7 days ___ to ___
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (wife), ___ | 125 | 407 |
16835199-DS-22 | 28,887,064 | Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted with new neurological deficits
including left sided weakness and a left facial droop. You also
developed seizure and were started on new medications for this.
Your seizures are now controlled and your weakness greatly
improved. | ___ yo F with right frontoparietal oligoastrocytoma (discovered
in ___ s/p radiotherapy, chemotherapy and a resective
procedure who prsented with left-sided weakness and facial
droop.
# Oligoastrocytoma: Patient has Grade 2 R frontoparietal
oligoastrocytoma s/p chemotherapy, radiation and resection.
Patient presented with new L sided facial droop and left upper
extremity weakness. A CT head showed... She was initially
started on dexamethasone 4 mg every 6 hours tapered to 4 mg
every 12 hours. On ___, she developed new onset seizures while
on video EEG monitoring. She was loaded with 1600 mg phenytoin
and started on 150 mg IV q 8hrs. She continued to frequent have
seizures and was started on lacosamide 200 mg IV load and
lacosamide 100 mg IV BID with resolution of seizures. This
regimen was transitioned to PO lacosamide 150mg BID and
phenytoin 200 mg BID. Her neurological status improved
significantly with near complete resolution of left lower face
paralysis and left upper extremity weakness.
# Hypertension, seconsary to bevacizumab. Well-controlled with
therapy, continued metoprolol Tartrate 25 mg BID.
# Cough: Patient has had for 6 months, secondary to viral URI.
Continued home Tessalon and Albuterol PRN.
#GERD - Continued PPI, and increased dose as prophylaxis while
on steroids. | 50 | 205 |
19550692-DS-7 | 25,163,326 | Dear Mr. ___,
You were admitted to ___ due to lower extremity swelling and
some new shortness of breath with walking. You were found to
have signs of fluid overload and heart failure on exam and were
treated with a medication called Lasix. You will need to
continue this medication at home. You were also found to have
very high blood pressure. You were started on carvedilol, a
medication that helps treat your heart disease and high blood
pressure. You were also started on Lisinopril for blood pressure
control. You were also started on Lipitor for your heart
disease. A stress echocardiogram was done to evaluate your
heart for worsening heart disease and for heart pumping
function. This showed no major abnormalities. We have set up an
appointment for you with ___ cardiology (see below).
You need to take these medications every day. Please weigh
yourself daily and call your doctor if your weight goes up by
more than 3 lbs in one day.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team | ___ year old male with past history of CAD s/p stent at ___ E's
___, NIDDM, hypertension, hyperlipidemia who presents with
several weeks of intermittent chest pain and a week of
exertional dyspnea concerning for fluid overload and heart
failure.
# Coronaries: 100% chronic total occlusion of proximal total R
PDA, s/p PCI to midLAD and Lcx, stent in midLAD, unknown type.
(per ___ records)
# Pump: normal EF
# Rhythm: sinus
#HFpEF exacerbation: Patient had progressive swelling of lower
extremities with DOE and PND concerning for heart failure
exacerbation. Trop neg x1. EKG had T wave flattening but no
specific ST changes concerning for acute MI. Patient was
started on IV Lasix for diuresis and transitioned to PO regimen
of 40 mg Lasix. He was started on lisinopril 10 mg and
carvedilol 12.5 mg PO BID. Echo records from outside hospital
showed normal EF in ___. He also had records from ___ which
showed chronic total occlusion of RCA and stent placed to
mid-LAD. Stress echocardiogram was done which showed no
inducible ischemia and stress ECG was without ischemic changes.
He was discharged on atorvastatin 40mg, carvedilol 12.5mg BID,
furosemide 40mg BID and lisinopril 20mg. He will follow up with
an outpatient cardiologist, Dr. ___, for further
management. Discharge weight: 130.8kg
#Hypertensive urgency: Patient non-compliant with HTN meds at
home (takes HCTZ intermittently) and found to have elevated SBP
180s on floor, asymptomatic. Home amlodipine, HCTZ, and
verapamil were d/c'ed and patient was transitioned to lisinopril
20mg and carvedilol 12.5mg for both HTN and CAD/HF management.
BP should be monitored and medications titrated as needed.
#Low back pain - patient uses gabapentin, tramadol, and naproxen
at home. Naproxen was discontinued given concern for ___ and
cardiovascular risk.
#Diabetes: Insulin sliding scale while inpatient. Restarted
metformin on discharge.
#Asthma: Controlled with Albuterol inhaler prn
#OSA: non-compliant with CPAP. Encourage use as outpatient. | 173 | 309 |
12022911-DS-16 | 27,589,843 | Dear Mr. ___,
You came to ___ from ___
___ after you had trouble breathing and passed out.
You were found to have a big blood clot in your lungs, which was
making the right side of your heart work poorly. This likely
came from a blood clot that we found in your leg. You received
medication through your veins to break up the blood clots, and
more medicine to keep your blood thin so that your body can get
rid of the rest of your blood clots. Your breathing improved
afterward. You have been started on a new blood thinner to be
taking by mouth, and you will have appointments to continue to
follow this as an outpatient.
We wish you the very best of health!
- Your ___ care team | This is a ___ with PMHx significant for cognitive impairment,
who presented to ___ due to syncope with questionable
cardiac arrest, who was found to have saddle pulmonary embolus.
#) UNPROVOKED ACUTE SADDLE PULMONARY EMBOLISM: The patient
presented to ___ with syncope and respiratory arrest after
being at his usual state of health. His initial exam was
consistent with PE which was confirmed with a CT angio of the
chest showing massive saddle PE. He was given 60mg of enoxaparin
prior to transfer. Upon arrival to the ___ echo showed RV
dilation. The patient received half-dose lysis with tPA, which
he tolerated well. After receiving tPA the patient was
transitioned to ___ to Rivaroxaban, with medication
obtained with the assistance of case management.
#) LEUKOCYTOSIS: Patient presented with leukocytosis to 17.5,
which was attributed to a stress response both from the
pulmonary embolus and the chest compressions he received prior
to presenting to ___. WBC count downtrended to 12.8 on
the day of discharge. No signs or symptoms of infection were
noted throughout hospital stay, urine culture was negative.
CHRONIC ISSUES:
================
#) COGNITIVE IMPAIRMENT: The patient suffers from cognitive
impairment. However, he can fully engage in a conversation. The
patient has a legal guardian (___). He was cleared for
discharge back to his prior caregiver arrangements, with
assistance from both case management and social work.
#) Bipolar disorder: The patient was continued on his home
regimen of buspirone, gabapentin, olanzapine, and risperidone.
===================
TRANSITIONAL ISSUES
===================
# Medication changes. The patient has been started on
rivaroxaban daily for anticoagulation.
# Unprovoked pulmonary embolism. Please consider
hypercoagulability work-up with antithrombin functional tests,
factor V leiden, homocystein, protein C/S, and prothrombin
mutation analysis as an outpatient.
# Hypertriglyceridemia. Please consider treatment and follow-up
as outpatient
# Code: Full
# Contact/HCP: ___ (___) | 130 | 292 |
15928453-DS-21 | 27,409,939 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital for facial swelling and jaw pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital a CT scan of your neck revealed that you had
an infection surrounding the teeth that you were planned to have
pulled. An incision and drainage was done around this area to
manually clear some of the infection. Afterwards you were
started on an antibiotic, clindamycin, to help clear the
remainder of the infection.
- You saw our oral maxillofacial team, who set you up to have
your teeth extracted on ___, at ___, ___ Floor Oral and
Maxillofacial Surgery Clinic.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
-If you notice any of the danger signs listed below, please
contact your PCP or go to an emergency room immediately.
We wish you the best!
Sincerely,
Your ___ Team | ___ is a ___ year old with past medical history of ESRD
on HD TThS, reported GPA, prior PE and recurrent DVT on
warfarin, h/o ischemic bowel s/p resection, reported ulcerative
colitis, nutcracker syndrome, chronic pain who presented with
facial swelling and jaw pain, found to have mandibular abscess
s/p I&D discharged on oral Clindamycin. | 180 | 55 |
19832014-DS-7 | 22,531,080 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital with acute
appendicitis (inflammation of your appendix). You were taken to
the operating room and had your appendix removed
laparoscopically. This procedure went well, you are now
tolerating a regular diet and your pain is better controlled.
You are now ready to be discharged home to continue your
recovery. Please follow the discharge instructions below to
ensure a safe recovery while at home:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Ms. ___ is a ___ y/o F with no pmh, who was admitted to the
General Surgical Service on ___ for evaluation and
treatment of abdominal pain. Admission abdominal/pelvic CT
revealed acute appendicitis. On HD1, the patient underwent
laparoscopic appendectomy, which went well without complication
(reader referred to the Operative Note for details). After a
brief, uneventful stay in the PACU, the patient arrived on the
floor on IV fluids, and po oxycodone and acetaminophen for pain
control. The patient was hemodynamically stable.
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 actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. On POD #1, the patient had a urine test positive for
chalymadia trachomatis. The patient was informed of this
finding and she was written for a one time dose of azithromycin
1gm and an educational packet was provided.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 773 | 235 |
18796351-DS-19 | 29,433,757 | Dear Dr. ___,
___ were hospitalized due to symptoms of aphasia resulting from
a TRANSIENT ISCHEMIC ATTACK, a condition where a blood vessel
providing oxygen and nutrients to the brain is transiently
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed ___ for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-atrial fibrillation
-history of heart disease
-high blood pressure
-high cholesterol
We are changing your medications as follows:
-Increasing your warfarin dose, and considering changing to
Apixaban after discussion with your cardiologist.
Please take your other medications as prescribed.
Please follow up 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
Sincerely,
Your ___ Neurology Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | Dr. ___ is a ___ year old right-handed man with a past
medical history of atrial fibrillation on coumadin, prior left
MCA distribution infarction and TIAs with Left CEA for
symptomatic stenosis and CAD with prior MI who presented on ___
for evaluation of an acute language change.
History is notable for a possible last known well at perhaps,
though not clearly 1215 on ___, followed by a mild aphasia
characterized principally by paraphasic errors. The symptoms
were quite similar to his prior stroke. He was admitted due to
concern for a TIA or stroke in the distribution of the left MCA
in the setting of a subtherapeutic INR.
Patient underwent MRI brain on ___ which was negative for acute
infarct, revealing findings consistent with his prior, chronic
strokes. By examination on ___ in the morning, the patient's
aphasia had resolved and he felt back to baseline.
Discussion was held with the patient regarding optimal
anticoagulation moving forward. Consideration of changing to a
newer anticoagulation such as Apixaban was discussed given his
fluctuating INR and for improved ease of administration.
However, the patient reported he was not willing to change his
anticoagulation at this time until discussion with his
outpatient cardiologist, Dr. ___. Patient was counseled about
importance of remaining in house to clarify the anticoagulation
situation and promptly place him on therapeutic anticoagulation.
However, he reported strong desire to leave the hospital due to
personal affairs. He expressed understanding of the risks and
benefits of remaining in house to clarify his anticoagulation
issue and be placed on optimal therapy for stroke risk
reduction. Stroke risk factors included LDL 25, hemoglobin A1c
5.9 at time of discharge.
************* | 264 | 276 |
15383233-DS-6 | 28,450,410 | You were transfered to ___ for concern regarding increased
seizure frequency. We believe you had increased seizures because
of a respiratory infection. Your urine also tested positive for
cocaine. Although this might be a lab error, it is essential
that you avoid any illicit drugs or narcotics as these increase
the likelihood of seizures.
Please note that you should continue taking two new medications:
- Azithromycin (continue taking for 4 days for respiratory
infection)
- Depakote ER (extended release, twice every day 1500mg in the
morning and 2000mg in the evening)
You should get your Depakote level checked as an outpatient, 1
week from today.
Please do not stop taking your anti-epileptic medication as this
increases the likelihood of seizure. | ___ yo M with Epilepsy and multiple cardiovascular risk factors
presents with increased seizure frequency in the setting of a
likely URI and cocaine+ urine. He has not had a seizure since
transfer. However he appeared to have a worsening respiratory
function with an Aa gradient on the morning after admission.
.
.
# Neuro: seizures under control during this hospitalization on
outpatient regimen. Likely triggerd by cocaine and alcohol use
and recent infection (URI). He was continued on VPA 1000mg Q8H
.
# Respiratory: new oxygen requirement without clear finding on
CXR. He was 93% on RA on arrival to outside hospital and
continued with slightly low oxygenation during his
hospitalization. He had a recent URI, is a smoker and might have
aspirated during his seizures. The differential included PE and
PNA. He had a D-dimer that was low. His repeat CXR did not show
evidence of acute processes.
He was started on Azithromycin and his respiratory status
improved during the day
.
# RLS: continue home meds ropinirole, pramipexole
.
# HL:
- continued statin
.
# CAD:
- continued aspirin/plavix | 116 | 199 |
12233085-DS-24 | 25,022,602 | Dear Mr. ___,
It was a pleasure to take care of ___ during your recent
admission to ___. ___ came to the hospital
because ___ were having palpitations. We found that ___ were
having an irregular heart rhythm, and we gave ___ medications to
help with this. We also found that ___ had a heart attack. We
performed a procedure to help open one of the blood vessels of
your heart. We discharged ___ on several new medications for
your heart. We wish ___ a fast recovery.
Sincerely,
Your ___ Team. | Mr. ___ is a ___ yo M w/ hx Hodgkins and non-Hodgkin's
Lymphoma, hypogammaglobulinemia, HTN, HLD, CKD, asthma,
psoriasis, pAfib p/w palpitations and found to have Afib with
RVR as well as elevated troponins with EKG consistent with
NSTEMI now s/p DESx1.
================ | 88 | 43 |
15177726-DS-16 | 21,672,994 | You were admitted to the hospital after a fall onto steps. You
were found to have a large right sided gluteal hematoma. You had
a CT scan which showed active bleeding at the time of your
presentation. You were evaluated with frequent hematocrit
checks. They were found to be stable and you are now ready for
discharge. This hematoma will take sometime to completely
resolve. You may continue to have pain, and you will be
discharged with pain medication and a stool softener to continue
to take while on the narcotic medication. You may also continue
to take advil and tylenol as directed. You will follow up in the
Acute Care Surgery clinic. | Mr. ___ was admitted to ___ following a fall and a right
gluteal hematoma. He had a CTA which showed mild extravasation
of blood into the hematoma. He was admitted for observation and
serial hematocrits. On HD 2 his HCT had stabilized and he was
assymptomatic for this. He did have some pain, which was
controlled with dilaudid and tylenol. He was able to ambulate
without difficulty, but did continue to experience some
discomfort when sitting. However, since he was doing well, he
was discharged home with PCP and ___ clinic follow up. He was
tolerating PO without difficulty, his pain was well controlled
and he was independently ambulating at the time of discharge | 113 | 115 |
13255997-DS-20 | 28,233,979 | Dear Mr. ___,
You were admitted to ___ for a
low blood pressure that you had at your psychiatric facility.
You also were very confused on presentation. In the Emergency
Department you were given fluids for dehydration, and your blood
pressure improved. You were admitted to the floor to further
work up your confusion. Your dextroamphetamine-amphetamine was
discontinued as well as your bupropion as it may have been
contributing to your confusion. Labs were checked which did not
show any signs of infection. Labs did show that you had an
injury to your kidneys, but this resolved with fluids. You were
started on multivitamins as well as thiamine to help with your
nutrition.
Your mental status improved and you were deemed medically
cleared for discharge to crisis stabilization.
It was a pleasure taking care of you,
Your ___ Team | Mr. ___ is a ___ yo male with a hx of seizure d/o,
schizophrenia, TBI, and ADHD presenting from OSH with report of
hypotension improved with fluids, as well as altered mental
status and ___, currently improved.
# Hypotension: Pt presenting from outside facility with report
of hypotension with SBP in the ___. Improved with 2L of IVF in
the ED. Likely hypovolemic possibly from poor po intake,
although unclear at events that occurred prior to admission.
Dehydration consistent with Cre 1.6, lactate 2.6, specific
gravity of 1.020 and hyaline casts in urine. No clear source of
infection with normal CXR, and U/A with WBC:3. Blood cultures
sent, and currently pending. Blood pressure has been stable
throughout admission, and he was eating and drinking well prior
to discharge.
# Altered mental status: Pt presenting with altered mental
status, and neurologic exam consistent with possible expressive
aphasia. Pt speaking in fluent language, although unable to name
objects or repeat phrases initially. Otherwise neurologic exam
was intact. Thought to be secondary to medications or less
likely his underlying schizophrenia. Non contrast CT of his head
showed atrophy with microvascular disease, although no acute
process. Serum and urine tox screen negative. Infectious work-up
negative including clear chest XRay, normal WBC, and no growth
in cultures. B12 and TSH wnl, and RPR nonreactive. Does not
appear to be post-ictal with no reported seizure activity,
tongue bites, or incontinence. Pt also on numerous medications
which could contribute to AMS. The patient was given IVF and
started initially on high dose thiamine as unknown ETOH use. His
bupropion and dextroamphetamine-amphetamine were held on
presentation, and his mental status improved greatly in 24
hours. He was transitioned to po thiamine, and was alert and
oriented x 3 prior to discharge.
# Acute kidney injury: Pt presenting with creatinine elevated to
1.6. OSH with Cre:1.23. After 2L of IVF, his creatinine improved
to 0.9, consistent with prerenal azotemia. He remained well
hydrated on PO fluids.
# Schizophrenia: Recently admitted to inpatient psychiatric
unit. Notes indicate that he was previously on quetiapine 300mg
po daily and clonidine 0.2mg po BID, although recently
discontinued on most recent med list from psychiatric facility.
These medications were not given, and he denied any auditory
hallucinations during hospitalization. His PCP was contacted and
did not have a record of schizophrenia.
# Depression: At home on buproprion 200mg po BID and clonazepam
2mg po TID. Due to concern that AMS was triggered by
medications, his clonazepam was made prn, and his bupropion was
discontinued. His mental status improved during admission as
stated above.
# ADHD: On dextroamphetamine-amphetamine 20 mg oral TID. As
patient was climbing out of bed on presentation, this medication
was held. His mental status improved off of medication, so it
was held on discharge.
He should not have amphetamines permanently.
CHRONIC ISSUES
# Seizure disorder: Pt with known seizure disorder with no
reports of recent seizure activity for about ___ years. He was
continued on his home levetiracetam 1000 mg po BID.
# BPH: Stable during admission and was continued on home
tamsulosin.
***TRANSITIONAL ISSUES***
-Pt admitted that he sometimes "cheeks" medications. He should
be monitored when he takes medications as this may have
precipitated altered mental status on admission.
-Of note, per pt's PCP ___ was not noted to have
schizophrenia on his last visit. His mood disorder may be
medication induced, and this should be further evaluated at
crisis ___
-Discontinued both dextroamphetamine-amphetamine and bupropion
during admission.
-Call ___ lab to follow up on final result of blood culture
from ___
-CODE: Full
-Contact: ___ (Friend) ___ | 135 | 589 |
12767555-DS-25 | 28,949,483 | Dear Mr. ___,
It was our pleasure caring for you at ___
___. You were admitted to the hospital with a
persistent cough. Because you had a liver transplant and are on
an immunosuppressive medication, we performed a CT scan of your
chest, which showed evidence of a small pneumonia. This is the
most likely cause of your symptoms. It is also possible that
you have bronchitis ___ addition to this, but ___ any case, we
think you should be treated for pneumonia and are sending you
home with a prescription for antibiotics, which you will take
until ___. We are also discharging you home on a stronger
anti-cough medication and an inhaler for symptomatic relief.
Regarding your dizziness, we were not able to determine the
cause of this. There was no evidence that you were dehydrated,
and we performed tests to determine if your dizziness was due to
a problem with your balance system (called vertigo), and there
was no evidence of this. Overall, we did not think that there
was anything dangerous causing your dizziness. You should
follow-up with your primary care physician if your dizziness
continues.
Thank you for allowing us to participate ___ your care. | ___ w/ PMH of HBV c/b HCC now s/p liver transplant ___ ___ on
sirolimus and previously azathioprine (stopped 3 months ago)
presenting with cough and dizziness. | 208 | 28 |
18305097-DS-20 | 27,761,065 | Ms ___,
It was a pleasure participating ___ your care while you were
admitted to ___. You initially
came into the hospitial because you were depressed and had some
thoughts of harming yourself. As you know you were admitted
because it was felt you were not safe ___ the shelter and would
benefit from a stay at a nursing facility. The incision site on
your foot was infected and you also had blood stream infections
with bacteria and yeast. We treated you with antibiotics and
anti-fungals and you need to follow up with Podiatry at ___,
your PCP, and infectious diseases at ___.
We advised you stay with us until we have more information from
your blood work, but you decided to leave against medical
advise.
We made the following changes to your medications
1. START Linezolid twice daily till ___ (unless directed
otherwise on follow up)
2. START Voriconazole twiece daily till ___ (unless directed
otherwise on follow up)
3. START Lasix 40mg PO daily | ___ y/o homeless wheelchair bound female with a history of
several traumatic spinal fractures who initially presented with
SI. Hospital course complicated by foot wound infection (recent
amputation at ___), blood stream infection with multiple highly
resistant bacteria and yeast while on broad-spectrum
antibiotics, raising high suspicion for self-contamination of
PICC line. Patient left AMA after her PICC-line was removed
after switching from IV to PO antibiotics.
# Multi-organism bacteremia: Pt was originally started on
bactrim for possible infection of site of left toes amputation.
Wound grew proteus not sensitive to bactrim, and patient was
started on vanc/zosyn, continued for 2 week course on
vanc/cefepime which was then changed to vanc/ctx. Blood cultures
negative until ___, the last day of her 2-week course, when
she spiked a fever to 103. Over the course of the next 2 weeks,
blood cultures from the PICC line, grew Ochrobactrum,
Enterococcus, Lactobacillus, Trichosporon, and Rothia
Mucilaginosa. Patient remained afebrile with normal WBC. It
was felt that pt was tampering with her PICC line as it seemed
unusual that she would be growing so many different organisms
from the blood ___ such a short period of time while on broad
spectrum antibiotics. Abx initially changed from from vanc/CTX
to vanc/cefepime, then patient developed eosinophilia, and
cefepime was felt to be the culprit. She was put on
vanc/meropenem. Her urine grew out VRE and so vanc was changed
to IV daptomycin. Micafungin started once blood grew yeast,
then narrowed to voriconazole once yeast identified as
Trichosporon. Ophthalmology eval showed no concern of eye
infection. TEE was negative and foot MRI x2 showed likely
post-op changes (though could not r/o osteomyelitis). ___ the
setting of patient likely contaminating her PICC-line, she was
given 2 weeks of Meropenem, then Daptomycin switched to
Linezolid (last day ___, Voriconazole was to end on ___.
Plan is to follow up ___ ___ clinic. However, patient left AMA
on ___ without an appointment. Case manager attempted to obtain
Linezolid and Voriconazole for patient at the ___ pharmacy,
but she refused and left AMA with prescriptions only.
# Eosinophilia - pt developed eosinophilia up to 20+%, with
absolute eosinophil count >1000 for several days. Was felt to be
possible allergic reaction to cefepime which was changed to
meropenem. However, eosinophilia did not resolve after cefepime
was discontinued. Unclear source. Could be from contamination
of PICC. Pt denies urticaria/shortness of breath. No evidence of
foreign objects.
# L toe amputation- Patient had amputation of a toe on her left
foot the week prior to admission due to ___ bite and
osteomyelitis. The incision site was noted to have a small
amount of purulent drainage with a foul odor. She was seen by
podiatry who recommended foot xrays which showed no clear
evidence of osteomyelitis but difficult to assess. Bone biopsy
sent during the amputation at ___ with report that there was no
concern for osteomyelitis, sample with clean margins. See
antibiotics course as above. MRI of foot x2 showed enhancement
at site of amputation, likely post-op changes but could not rule
out osteomyelitis. Given the multi-organism blood stream
infection, foot is a very unlikely source. At the time of
discharge, her foot wound was clean and dry.
# SI- patient initially endorsed SI with plan to overdose on
medications. She was initially met ___ criteria per
psychiatry. She subsequently reported resolution of suicidal
intent. Psychiatry felt she was no longer a threat to herself
and therefore did not require psych hospitalization.
# Placement- Patient was evaluated ___ the ED by physical therapy
and occupational therapy who felt she would benefit from SNF
placement. Patient reports she has not been doing well at her
shelter and also feels she would benefit from placement. Patient
was denied at ___ and other rehab centers due to prior poor
behavior. She was to be discharged home (ie, she would have to
arrange her own shelter stay or stay with friends), but left
AMA.
# Chronic pain- Patient has chronic pain resulting from several
past traumas. She was maintained on her home MS ___ with
PO dilaudid for breakthrough pain.
# Urinary incontinence- Patient with long history of urinary
incontience. Symptoms were stable throughout this
hospitalization.
# Lower extremity edema - Likely from dependent positioning. Pt
without known CHF and TTE without structural or functional heart
abnormalities. Pt has history of hep C, could be caused by
cirrhosis. RUQ u/s suggestive of cirrhotic liver. Started on IV
lasix with good diuresis and improvement ___ swelling. DC'd
on 40mg PO daily of lasix.
# Pancreatic mass -could be pseudocyst, pt w/ history of IVDA
probably significant alcohol use. Pt is complaining of abdominal
pain, although found to have evidence of cirrhotic liver on u/s.
Lipase 11. Abdominal pain improved by discharge. Plan for
outpatient follow up with imaging either CT/MRI to eval
pancreatitis mass.
# Transaminitis - pt with mildly elevated LFTS but h/o hep c. no
abd or RUQ pain. No diarrhea/n/vomiting. RUQ U/S showed
"coarsened hepatic echotexture" ___ hepatitis vs cirrhosis.
TRANSITIONAL ISSUES
- Patient was full code throughout this admission
- Plan to continue Linezolid (___) and Voriconazole (___) till
___ clinic follow up
- Started lasix this admission- follow up response and
electrolytes
- Outpatient imaging to eval pancreatitis mass
- Outpatient follow up with ___ Podiatry (amputation ___ ___
- PCP follow up with Dr. ___ on ___ | 160 | 906 |
10099869-DS-3 | 21,026,790 | You were admitted after developing chest pain ___ the ___
Emergency Room where you were found to have a blood clot
(pulmonary embolus) that travelled to your lungs. You were
seen by the hematologists who feel that this likely happened on
account of your coumadin and lovenox doses being lower than they
should be and we have made the necessary arrangements. You were
also taken to the operating room by plastic surgery where they
cleaned out the area under your flap, which was infected. The
orthopedic hardware you have is also felt to be infected. You
were started on antibiotics for this infection as well. | Patient is a ___ y/o male with recent leg immobilization after
motorcycle accident of ___, s/p Tib/fib fracture, now with
cement spacer, admitted after near syncope event at rehab. He
had been on Coumadin and lovenox for a DVT, but developed chest
pain and shortness of breath while ___ the ED and the CT scan
showed acute right sided pulmonary embolism, with question of
infarction, despite being on anticoagulation. He was
incidentally found to have an infection under his flap on the
right leg based on the physical exam performed by plastic
surgery.
# Pulmonary Embolism: Hematology was consulted - the patient
was taking lovenox 80 mg sc bid at rehab, and his weight based
dose is 100 mg sc/bid based on his weight. He has also had some
recent subtherapeutic INRs. It was felt that the development of
acute pulmonary embolism ___ the setting of a previously seen DVT
no longer visualized, was due to embolization and suboptimal
anticoagulation rather than warfarin failure. He was countinued
on warfarin and bridged to a therapeutic INR with a heparin drip
___ the ___ period. He may be bridged ___ the future
with lovenox, but he should be on the 100 mg sc bid dose. He
should be continued on Coumadin 8 mg dose and INR followed
closely. Recommend minimum of 3 months of anticoagulation for
provoked PE. He was seen by the ___ hematologists who made
these recommendations.
# Leg infection - under flap and over hardware: He was taken to
the ___ by plastic surgery and d "There was found to be fibrinous
debris and purulence directly over bone and plate" according to
the ___ report. They irrigated and derided the area as much as
possible. Cultures grew Coag+ staph, Enterobacter, and
Enterococcus.
Infectious diseases also saw the patient and recommended
treatment with IV vancomycin (1 gram tid) and IV ertapenem (1
gram daily) until ___. He has followup scheduled with
infectious diseases. He had a PICC line placed for this.
He fill followup with plastic surgery for removal of sutures and
the drain. | 110 | 363 |
10955604-DS-17 | 20,996,120 | Dear Mr. ___,
It was a pleasure to take care of you at ___. You went to the
emergency room with recurrent abdominal pain, which is likely
from another stone in your gallbladder. You were seen by
nutrition and should eat a low fat diet at home to help reduce
the risk of recurrent pain in your gallbladder. While in the
emergency room, your oxygen saturation dropped into the ___. You
had a CT of your chest which did not show any clot. It did show
concerning consolidations which may be related to your sarcoid
and you should follow up with your pulmonologists about this.
You had no clinical signs of pneumonia. While inpatient, your
white blood cells dropped to a dangerous level indicating that
your immune system is suppressed and you are at high risk of
infection. You were seen by the blood specialists
(hematology/oncology) and had a biopsy of your bone marrow. We
advised that you stay in the hospital due to the risk of
infection. However, you insisted on leaving so we made you an
appointment with hematology/oncology on ___. You also
have an appointment with your liver doctor on ___. It is
very important that you keep these appointments. You may
continue to have problems with your gallbladder. We suggest that
you speak with your hepatologist about getting on the liver
transplant list in case you have a complication. At the time of
discharge, your bilirubin was improving and your white blood
cell count was still very low but slightly improved. Your oxygen
saturation dropped to 82% when you were walking. This is
dangerous and could be damaging to your lungs. We strongly
suggest that you wear oxygen when walking around. You were
discharged with a small amount of oxycodone for pain from your
bone marrow biopsy site. You should not drive, operate heavy
machinery, fly an airplane, drink alcohol, or take other
sedating medication while taking this medication. You should not
fly a plane with your low oxygen saturation. Please follow up
with your pulmonologist regarding this. As we discussed, you are
at high risk of infection and need to return to the ED with any
signs of infection such as fever, chills, cough, or not feeling
well in general.
We wish you the best!
Sincerely,
Your ___ medical team | ___ h/o cryptogenic cirrhosis (dx in childhood), ? sarcoidosis,
presented to ED with 1d of RUQ pain with radiation to side and
back. This is the ___ such episode in the last 2.5w RUQ US
showed only non-dilated common bile duct (although a recent
admission showed cholelithiasis on US and MRCP), pt also had CXR
for desat to 78%/RA in ED. He then received CTA after a
concerning opacity was visualized. He recieved one dose of
levofloxacin, but this was discontinued after learning more
about his extensive pulmonary history of ?sarcoidosis, with
large desats and consolidation on imaging at baseline. His CBC
also revealed pancytopenia. He was admitted to medicine for
symptomatic management of his biliary colic.
On the medical floor his pain was managed with oxycodone. He was
also seen by the Heme/Onc team who performed a bone marrow
biopsy for his pancytopenia. The transplant team also paid a
visit. They still believed that his operative risk for CCY was
too high, and so recommended that he try low-fat diet first.
Surgery also recommended listing Mr. ___ for liver transplant
prior to surgery given MELD=15 and risk of hepatic
decompensation after surgery.
After the bone biopsy, Mr. ___ pain was managed with
oxycodone. There was no bleeding or bruising from the site. He
was discharged in no pain, with stable but pancytopenic CBC, and
baseline low O2 sats.
___ with PMH of possible pulmonary sarcoid, cryptogenic
cirrhosis (since age ___, and recent admission for gallstone
pancreatitis who is presenting from OSH for further evaluation
of epigastric pain radiation to RUQ concerning for biliary colic
# Cholelithiasis: Patient with recent admission for gallstone
pancreatitis, for which no surgical intervention was offered
given high operative risk in the setting of cirrhosis and not on
transplant list. Patient now representing with pain concerning
for biliary colic. Lipase 60 and no signs to suggest
pancreatitis or cholangitis. Tbili was initially up but
downtrended. Placed on low-fat diet, met with nutrition, and
manage pain with conservative PO pain medication. Patient will
likely need cholecystectomy and should have expedited work up
for possible transplant listing prior to surgical intervention.
Was seen by surgery and scheduled to see transplant surgery as
outpatient with Dr. ___ ___. Patient was counseled about
risks of complications and possible need for future surgery.
Need to discuss transplant surgery referral if faster to work up
at ___ given testing already done at ___.
# Hypoxia: Patient with ___ years of chronic hypoxia, with
baseline O2 sat 90%RA. He is followed by Tuft Pulmonary (Dr.
___ who after extensive work-up has diagnosed him
with likely pulmonary sarcoid. However, some notes also mention
possibility of hepatopulmonary syndrome. Patient found in ED
initially to be at baselin hypoxia but then desatted
(asymptomatic to high-70s) of unclear duration. Saturation then
recorded as 92-93% on RA. Had elevated Ddimer and CTA which was
negative for PE but showed multifocal consolidations which could
be consistent with prior sarcoid but no prior imaging available
for review. Suspicion for pneumonia remains low given he states
his breathing is at baseline (has baseline AM cough), clinically
without fever, and no leukocytosis or left shift on labs (Flu
negative as well). Overnight, received diuresis with 10mg IV
lasix and was negative 1800cc. Likely overdiuresed given not
clearly overloaded and now not feeling well with mild
tachycardia, weakness, and headache. Received 500cc IVF back.
Will follow up with outpatient Pulmonologist (Dr. ___
of ___. He was given CD of CT scan from ___ which should be
compared by pulmonologist to prior CTs. Ambulatory sat was 82%.
Patient was counseled to use oxygen while ambulating but
refused.
# Cryptogenic Cirrhosis: Patient diagnosed at age ___ with
cryptogenic cirrhosis followed by Dr. ___ at ___.
Currently Child B and MELD 15. MELD 14 on discharge. Patient
has follow up scheduled for ___ with her. Would recommend
that patient be worked up for transplant listing given high risk
of complications from cholethiasis and if needs emergent surgery
at some point, would want to be listed for transplant prior.
# Pancytopenia: unclear etiology. Heme/Onc was consulted last
admission and recommended outpatient visit for work up. However,
patient was discharged prior to being seen by heme/onc and did
not return phone call for scheduling from secretary. Heme/Onc
saw the patient during this admission. Concerned for congenital
MDS vs. impact of liver disease. Continued home folate and B12
supplementation. Had bone marrow biopsy on the day prior to
discharge. Patient was neutropenic for the two days prior to
discharge but not significantly worse than prior admission.
Counts improving on day of discharge. Patient was counseled
multiple times to stay while he was neutropenic. However,
patient insisted on leaving. He understood the risks of
neutropenic infection. He understood to return to the ED at any
signs of infection or not feeling well. He will see heme/onc 3
days after discharge.
# GERD: Continued home omeprazole
# Code: Full
# Emergency Contact: ___ (Wife) ___
**Transitional Issues**
- continue to follow low fat diet, was seen by nutrition
- follow up bone marrow biopsy results and will need ongoing
evaluation by hematology for pancytopenia
- follow up beta-glucan, galactomannan, respiratory viral panel,
and IgG level
- Patient was discharged with CD of imaging from stay, please
compare CT chest here to prior CTs
- If CT chest from admission is not consistent with priors,
should have work up for possible indolent infection given
neutropenia and can consider bronch
- MELD 14 on discharge
- Consider working up patient for liver transplant list as he is
at high likelihood of having complication from his cholethiasis
and may need surgical intervention
- Patient was counseled to remain inpatient pending work up and
improvement of WBC. However, insisted on leaving. He was
counseled on risks and to return to ED at first sign of any
infection, fever, or not feeling well | 381 | 969 |
10021927-DS-25 | 23,373,975 | Dear Ms. ___,
You were admitted because you have been eating poorly at home
and your kidney has been functioning less well than before. You
were seen by nutritionists, neurologist and psychiatrist during
this stay, and we are glad to see that we have come up with a
plan to help you eat better at home. You will continued to be
followed by your primary care doctor and we have asked your
primary care doctor to provide referral to a nutritionist | ___ with a longstanding history of GERD/gastritis, ___,
HTN recent esophageal manometry this ___ showing occasional
esophageal dysmotility in 20% of the esophagus who presented
with dysphagia of solids and was found to have several impaired
electrolyte levels and acute kidney injury.
# Dysphagia: The patient has a long-standing history of GERD,
___ esophagus, and recent diagnosis of 20% esophageal
dysmotility on manometry. Barium swallow study showed mild
esophageal dysmotility and mild reflux. She also underwent a
video swallow that revealed no upper esophageal sphincter
dysfunction despite very mild narrowing at the sphincter, felt
highly unlikely to be the cause of her symptoms. Zinc level low
so on zinc supplementation. Neurology evaluated the patient, and
does not think there is neurologic contribution to dysphagia,
recommended outpatient follow-up for cerebellar process.
Psychiatry also evaluated the patient, and did not think there
was any particular pathology but did think patient had poor
coping with her dysphagia. Nutritionist also evaluated the
patient adn created a concreate list of foods/liquids that
patient can tolerate while providing adequate calorie and
nutrition intake. PCP follow up was arranged for the patient
with recommendation for nutrition referral as an outpatient.
# Acute Kidney Injury: baseline 0.5-0.6 (likely from
malnourishment) but up to 2.7 on admission. The acute kidney
injury is likely secondary to volume depletion given history of
poor PO intake and use of furosemide, as well as possible ATN
from prolonged dehydration. Pt was resuscitated with fluid.
Microscopic examination of urine was normal. Her creatinine
decreased to 1.2 with continuous PO encouragement, this new
value may be reflective for patien'ts new baseline.
#Electrolyte disturbances: hyponatremia (baseline 130), low
potassium, magnesium, chloride consistent with severely poor PO
intake. also may have contribution from lasix. EKG was without
significant abnormalities. Electrolyte abnormalities resolved
after fluid resuscitation as well as electrolyte repletion. Pt
was instructed to take multivitamins with minerals to maintain
magnesium levels.
CHRONIC ISSUES ISSUES:
# Insomnia: The patient was continued on her home trazadone 50mg
without complications.
# ___ swelling: The patient takes furosemide at home. Given that
this like contributed or preipitated her electrolyte
abnormalities, the patient was encouarged to stop furosemide. | 82 | 366 |
14482049-DS-8 | 21,899,596 | Dear Mr. ___,
You were admitted to ___ for workup of a new liver mass. You
had a biopsy, CT scans, and labs. We feel this is most likely a
cancerous liver tumor due to longstanding hepatitis C infection.
However, we will not know for sure until the final pathology
results return. You will need to be seen in the Liver Tumor
Clinic on ___. Instructions are below. Take oxycodone as
needed for pain. Be sure to take over-the counter laxatives like
Colace, senakot, and miralax as needed for constipation while
taking oxycodone. Avoid alcohol and Tylenol. | ___ with +smoking history, remote h/o CVA with residual L sided
weakness, and no medical care for the past several years
presented to an outside hospital with 6 weeks of worsening
abdominal pain and weight loss, found to have new liver lesion.
He was transferred to ___ for further workup.
# Liver lesion:
Imaging was initially concerning for HCC vs cholangiocarcinoma.
___ guided biopsy was performed on ___. Lab workup revealed an
elevated AFP and positive HCV antibody, making HCC the most
likely diagnosis. CT imaging for staging revealed abdominal LN
involvement as well as a large lytic T8 lesion. The patient will
follow up with oncology and hepatology at the multidisciplinary
liver tumor clinic on ___ for further management.
# T8 spinal lesion:
The patient did not have any neurologic findings suggestive of
cord impingement. An MRI T spine was performed for further
characterization.
# Possible cirrhosis:
Patient's CT a/p showed heterogenic, nodular appearance to the
liver consistent with cirrhosis. Although, labs indicate that he
has good liver function. No history of alcohol abuse. Likely
secondary to HCV. He was instructed to avoid tylenol and
alcohol.
# H/o CVA:
Patient reports having had a bleed in the brain ___ yrs ago with
residual L sided weakness, consistent on exam. CT interestingly
shows no evidence of stroke. He is not on ASA. | 96 | 215 |
16416296-DS-17 | 24,899,581 | 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 need for anticoagulation
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
-Splint must be left on until follow up appointment unless
otherwise instructed
-Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
-non-weight-bearing left upper extremity | As noted above, the patient was admitted to ___ on ___. He
underwent open reduction and internal fixation of left distal
radius fracture, as well as carpal tunnel release. This was
performed by Dr. ___ tolerated. Subsequently
admitted to the Orthopaedic Trauma service.
Neuro: Postoperatively, pain controlled with dilauid PCA and
then PO oxycodone and acetaminophen, to good effect.
CV: Hemodynamically stable.
Pulm: No respiratory issues.
GI: Tolerated regular diet postoperatively.
ID: Received periop ancef.
DVT: Received ASA 325mg; will complete a ___ctivity: Seen by OT while in-patient and deemed safe for home.
On day of discharge, POD1, he was afebrile with good pain
control. He had stable paresthesias in hand, secondary to acute
nerve insult following fracture. We expect this to improve
slowly with time. He will remain non-weight-bearing with left
upper extremity and follow-up in clinic in 10 day for orthoplast
splint. | 131 | 139 |
16909817-DS-26 | 23,110,898 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted to the
hospital because of an urinary tract infection. Your urine
culture taken by your primary care physician grew pseudomonas
and you were treated with IV zosyn for your infection. You will
need to continue with this antibiotic for a total of 10 days.
Imaging of your kidneys by ultrasound showed that your kidneys
look the same as before. Please hold off taking monurol until
you complete your 10 days of zosyn (last day on ___. | ___ F with b/l AKA and b/l medullary sponge kidneys c/b
nephrolithiasis and recurrent resistant UTIs/urosepsis,
presenting for UTI.
# Recurrent UTI: patient with dysuria, frequency, urgency and hx
of several UTIs growing pseudomonas resistant to
cipro/gentamicin/tobra and intermediate resistant to ceftaz,
sensitive to zosyn. At risk of recurrent UTIs and potential
complications (ie pyelo, urosepsis) given medullary sponge
kidneys. Physical exam with mild L CVA tenderness, but no casts
in urine, no leukocytosis, afebrile and hemodynamically stable.
Renal ultrasound was performed and showed no hydronephrosis,
small stable simple right renal cyst, and nephrolithiasis
consistent with the patient's known medullary sponge kidneys.
Urine culture was contaminated, but urine culture from PCP
obtained prior to admission were positive for pseudomonas
sensitive to zosyn. On admission, she was started on zosyn 2.25g
IV q6h and a PICC was placed on ___. ID was consulted.
Patient discharged with 3.375g q8h to complete a 10 day course
(last day on ___ as complicated UTI due to her anatomy.
Patient remained clinically well throughout her hospitalization.
Prior to admission, patient was taking monurol every 10 days
starting in ___ and cranberry juice to prevent UTI per ID
recommendations. No UTI from ___ until now since starting the
medication (previously had UTI every 2 months). Per ID
recommendations, holding monurol until after completion of
zosyn; fosfomycin sensitivities were also added to urine culture
from PCP (___) to determine if appropriate
to continue monurol for ppx.
# hx of bilateral nephrolithiasis: secondary to medullary sponge
kidneys, which likely contributes to the recurrent UTIs. ___
placement of stent and lithotripsy of left ureteral and renal
stones in ___. Last laser lithotripsy on ___. Followed by
urologist and last seen on ___ and at the time had a KUB
that only showed chronic medullary sponge kidney. Patient is on
potassium citrate BID at home for nephroithiasis, but was NF and
not available at hospital. She will resume taking medication at
discharge.
# cachetic/poor appetite: per patient, had anorexia from age
___, but has since been eating well, although has poor
appetite. Albumin on ___ was 4.4. She ate well throughout her
hospitalization and given ensure supplementation TID.
# phantom/amputation pain: continued with fentanyl patch,
gabapentin 600mg QID, and dilaudid 2mg q8h:PRN
# Depression: continued with duloxetine, mirtazapine, bupropion
# GERD: continued with Pantoprazole 40 mg PO Q12H
# chronic low BP: continued with midodrine
# TRANSITIONAL ISSUES
-PICC placed and patient to complete 10 day course of zosyn for
pseudomonas UTI (last day on ___
-holding monurol until after completion of zosyn
-fosfomycin sensitivities added to urine culture from ___
___, please follow up with results
-please follow up with pending blood cultures | 95 | 443 |
11841078-DS-10 | 22,151,475 | Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You came in with shortness of breath especially with exertion
and we found several blood clots in the blood supply to your
lungs which explains your symptoms.
What was done for me while I was in the hospital?
- We started you on a blood thinner (Lovenox, also called
Enoxaparin or Low Molecular Weight Heparin) to stabilize your
blood clot. We also performed an ultrasound of your heart to
rule out significant strain on your heart caused by the clot
burden, this was normal. Given your recent calf pain we
performed ultrasound testing of your legs as well and did not
find evidence of any blood clots on either side.
What should I do when I leave the hospital?
- Over time your body will break down the clot on its own but
it's important to continue the blood thinner for at least 6
months to reduce the risk of clot expansion or migration.
Sincerely,
Your ___ Care Team
It was a pleasure to participate in your care. | Mr. ___ is a ___ male with history of
testicular cancer s/p right radical orchiectomy and 3 cycles of
BEP who presents with shortness of breath and cough found to
have bilateral PEs.
# Pulmonary Embolism: Patient found to have bilateral PEs in
setting of shortness of breath and cough. Also has had
intermittent bilateral leg tenderness concerning for DVT but
this was ruled out by bilateral lower extremity dopplers. No
signs/symptoms of heart strain which was confirmed by TTE.
Currently hemodynamically stable with sinus tachycardia on
ambulation and dyspnea on exertion without hypotension or
hypoxia. Patient was started on Lovenox injections on admissions
with plan to continue this on discharge pending discussion with
Dr. ___ clinical trial comparing Apixaban to
dalteparin. Ultimately patient and wife decided to not enroll in
the clinical trial and he was discharged on enoxaparin for at
least 1 month.
>30 minutes spent on complex discharge | 196 | 149 |
10610033-DS-20 | 25,071,131 | Dear Mr. ___,
It is a pleasure to take care of you at ___
___. You were admitted to the hospital for
evaluation of your left knee pain after a fall. You said you
hit your head after the fall. The CT of your head does not show
any bleeding. Physical therapy evaluated you and thought that
it is safe for you to return home. Your pain is better
controlled. You will need to have further outpatient work-up
for your knee pain as it is already arranged for you.
Please note the following changes to your medications:
- START tylenol ___ mg, every 8 hours as needed for pain
- START lidocaine patch, 1 patch to the affected area, on for 12
hours and off for 12 hours.
- You can take stool softener such as colace and laxative such
as senna if you experience constipation.
- You can use ice pack to help with the discomfort in your knee
You should not drink, drive, or operate machinery while taking
oxycodone. This can make you drowsy and can potentially lead to
accidents. | HOSPITAL COURSE: ___ w/ recent fall ___ 'knee buckling' who
presented a few days after the fall for pain managment. Dc/ed on
home pain meds as has MRI and outpt followup with Orthopedics as
outpt.
Monoarticular Arthralgia:
The patient's pain is well out of proportion to this exam.
Likely traumatic injury, and given his ability to ambulate he
does not have a tibial plateu fracture or other major bone
injury, and while he may have ligamentous or tendon injury these
are not likely to be serious given the benign exam. It is
possible that his falls are related to instability which might
indicate a ligament tear or meniscal injury, however, the pt is
back to baseline on his home pain regimen. Physical therapy was
called to see him who cleared him for home d/c. He already has
an outpatient MRI of his knee arranged from prior to the
admission on in 3 days.
Benign Hypertension:
stable.
We continued HCTZ 25mg QD, atenolol 25mg QD and lisinopril 40mg
QD,
Bipolar Disorder:
stable.
We continued buspirone 30mg TID prn, alprazolam 2mg ___,
Chronic Lumbar Back Pain:
stable.
We continued gabapentin 600mg TID and restarted home oxycodone
10mg Q3h prn pain.
Insomnia:
stable
# CODE: Full | 182 | 219 |
13728328-DS-12 | 29,736,730 | Dear Ms. ___,
You were admitted here at ___ for difficulty swallowing. As
part of the workup, you underwent an upper endoscopy, which did
not show obstructing lesions, but instead showed a hiatal
hernia, inflammation in the stomach and a polyp in the stomach.
Biopsy was taken and results were still pending. You were also
seen by the speech and swallow specialists, who felt that you
are safe to continue eating. You were also found to have
significantly elevated coumadin level, which has been reversed
during this admission.
Please note the following changes in your medication.
- Please START to take pantoprazole 40 mg twice a day
- You may take one tablet of zofran after meal for nausea.
- Please HOLD lisinopril and hydrochlorothiazide before you see
your PCP. Please discuss when to restart these medication with
your PCP.
We also made followup appointments with your PCP and ___
gastroenterologist. | This is a ___ F with HTN, h/o colon cancer s/p colectomy, h/o
PE on coumadin, who presents with ___ weeks of dysphagia that is
recently worsened, poor PO intake, tachycardia, ___, and
supratherapeutic INR.
ACTIVE ISSUES
# DYSPHAGIA: The exact etiology for pt's dysphagia is still
unclear. Pt underwent neck X-ray and CT in the ED, without
evidence of foreign objects or mass. She also underwent EGD,
which showed a hiatal hernia with small tear vs erosion at EGJ,
a stomach polyp and erythema and erosion consistent with
gastritis. Pt also was evaluated by speech and swallow team,
whose studies showed normal swallowing with thin liquid, regular
and dry solids without concerns of aspriation. Yet, pt continue
to complain of dysphagia. She was therefore scheduled to have
motility studies at the ___ clinic. We started her on
pantoprazole 40 mg bid.
# SUPRATHERAPEUTIC INR: patient is on 2mg coumadin daily for
DVT/PE prophylaxis. Her INR on admission was 8.7 in the setting
of significantly decreased PO intake. She denies any history of
high INRs. No other clear etiology of the increase. We held her
coumadin initially, and gave her vitamin K 5 mg IV given the
need for urgent EGD.
# EKG CHANGES: Patient was found to have ST depressions and TWI
in the lateral and precordial leads. She has no known history of
CAD, but with carotid calcification on CXR suggesting likelihood
of coronary atherosclerosis. Her Tropononin were neg x3 during
this admission. There were never chest pain.
# ACUTE KIDNEY INJURY: Pt presented with ___ with Cr 2.5. Her
Cr improved with to 1.3 after fluid and nutrition support.
# HYPOTENSION: Pt has a history of hypertension. She however
presented with hypotension in the ED. We felt that this is from
dehydration and ___. We held her lisinopril, hydrocholothiazide
and amlodipine during this admission. Her BP at the discharge
was reassuring. We restarted her on amlodipine. | 152 | 337 |
15709378-DS-11 | 25,277,116 | Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had a blockage of your stomach that was not allowing food
to pass through your gut properly. Because of this, you had
nausea, vomiting, and abdominal pain. We believe that your
cancer was compressing your gut.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We did a procedure to fix the obstruction by placing a stent
in your gut.
- We gave you chemotherapy.
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 | Hospital Course:
Ms. ___ is an ___ y.o. female with poorly differentiated
neuroendocrine carcinoma metastatic to bone, nodes, and liver
(s/p 5 cycles carboplatin/etoposide (last ___, currently on
surveillance), HTN, Pathologic compression fracture at L3 (c/b
cord compression s/p XRT) who initially presented to ___
___ with non-bloody emesis, abdominal pain, and was
subsequently transferred to ___ on ___ for management of a
malignant gastric outlet obstruction.
================
Acute Issues
================
#Metastatic high-grade neuroendocrine tumor
She is s/p 5 cycles of carboplatin/etoposide (completed ___
and presented with evidence of disease recurrence, complicated
by gastric outlet obstruction. After a discussion with Dr.
___, Dr. ___, Dr. ___ the patient, it was
decided that she would undergo re-treatment with
carboplatin/etoposide after duodental stenting. She began C6
carboplatin/etoposide on ___ and had her last dose on ___.
Follow-up at ___ was coordinated such that she would
receive Neulasta there on ___.
#Malignant gastric outlet obstruction
#Non-bloody emesis
#Abdominal pain
She was scheduled for an outpatient staging CT abd/pelvis on
___ which showed increased size of two hepatic metastases and
an exophytic lesion arising from the pylorus with new invasion
into the liver and slightly increased size of periportal
lymphadenopathy concerning for disease progression.
Subsequently, she developed symptoms of nausea, vomiting,
abdominal pain and presented to ___ where a
repeat CT abd/pelvis on ___ re-demonstrated similar findings,
but with increased distension of her stomach since the prior
study, suggesting gastric outlet obstruction secondary to the
exophytic duodenal bulb/pyloric mass. An NG tube was placed at
___ and she was transferred to ___ where duodenal
stenting could be performed. Duodenal stenting was completed on
___. She was started on a clear liquid diet, eventually
advancing to a low-fiber diet, as per GI. She was seen by
Nutrition prior to discharge, who provided her with additional
information on diet s/p duodental stenting.
#Hypertension
She was hypertensive to 150-170s systolic and had one episode at
night in which her systolic BP was elevated to 190s. She was
given IV hydralazine and BP subsequently lowered to 150s
systolic. Although Lasix was originally written for lower
extremity edema, we restarted her home medications as she was no
longer NPO.
#Diarrhea
She had episodes of multiple loose stools after duodenal stent
placement. C diff assay was neg and she was given Imodium prn
with improvement in decreasing stool output.
#Hypernatremia
#Hypochloremia
As she was NPO throughout her initial hospital stay, she was
given continuous IVF (normal saline); however, she became
hypernatremic to 154 and hypochloremic. She was switched to ___
normal saline IVF and her electrolyte abnormalities resolved
thereafter.
#Hypokalemia
She was hypokalemic at admission and was replected with vitamin
K IV as needed.
#Leukocytosis
She initially presented with a WBC of 16.2 at admission, which
downtrended and resolved prior to discharge.
#Elevated Lactate
Her lactate was elevated to 2.8 at ___ and ___ thought to
be secondary to hypovolemia from GI losses. A repeat lactate
obtained prior to discharge was 1.2 after receiving continuous
IVF.
================
Chronic Issues
================
#Chronic Ankle Edema
Her home Lasix was held, as she was NPO upon arrival and prior
to her procedure. We resumed her home Lasix when she was no
longer NPO.
#HLD
Her home statin was held, as she was NPO upon arrival and prior
to her procedure. We resumed her home statin when she was no
longer NPO.
================
Transitional Issues
================ | 104 | 532 |
15290079-DS-24 | 24,389,577 | Dear Ms ___,
You were admitted to ___ because you lost weight and had
abdominal pain. We found that your liver enzyme levels were
abnormally high. This is likely due to a medication (amiodarone)
that you have been taking. We stopped that medication and your
liver enzymes downtrended. You also started eating more in the
hospital.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please follow up with your PCP as scheduled.
It was a pleasure caring for you.
Your ___ team | ___ is a ___ smoker with chronic HFpEF, paroxysmal
AFib (not on anticoagulation secondary to patient refusal),
craniopharyngeoma with subsequent panhypopituitarism
(DI/AI/hypothyroidism), CKD stage III (baseline Cr 2.0), and
COPD on home O2 2L who presents with failure to thrive without
having eaten or taken medications due to n/v (x2, white then
bilious) during 5 days prior to presentation, noting
intermittent abdominal pain and often productive cough, found to
have UTI, transaminitis, and possible COPD exacerbation.
# FTT - abdominal pain / nausea / anorexia: Patient presented
with intermittent tenderness to palpation in RUQ, yet
inconsistently reports pain. Most likely hepatotoxicity given
use of amiodarone therapy and transaminitis with AST>ALT
elevations (downtrending since ___ and modest-normal AlkPhos
elevations. ___ also have contributing depression given her
ability to eat (albeit decreased appetite) until brother's wife
departed from visiting Ms. ___ 1wk prior to Ms. ___
anorexia as well as impactful loss of her husband. Concerned
about malignancy given general malaise. CT Abd/Pel did not find
lesions but transudative pleural effusion w/u in the past was
not the best screening for cancer, esp given her long hx of
smoking. Unlikely mesenteric ischemia or biliary colic, although
this could drive previous subconscious nauseous reaction to
thought of food. Liver/GB US (___) describes focally
thickened GB fundus consistent with adenomyomatosis, also noting
cholelithiasis and a simple hepatic cyst. Patient does not
demonstrate symptoms typical for biliary colic. Currently
increasing dietary intake (___). HAV Ab positive indicating
past exposure to Hepatitis A virus. HCV Ab negative, HBsAg
negative, and HBsAb negative. GI consult unable to convince her
to have colonoscopy/EGD, patient aware that work-up would be for
malignancy. LFTs downtrended throughout admission. Nutrition
team was consulted. She was able to increase her food intake.
#UTI: On presentation, she endorsed a stinging pain with
urination, but noted resolution upon receiving 1mg of
ceftriaxone (___). Urine culture ___ found to contain
Klebsiella sensitive to CTX. US (___) did not identify
hydronephrosis.
She was transitioned to PO Cefpodoxime to be continued until
___.
#Chronic hypoxemia / PNA:
Patient on home O2 of 2L without current respiratory distress
but notable for increased cough +/- white sputum. Requiring 2L
to maintain O2sat 97% and requiring fluticasone-salmeterol
diskus 2x daily, montelukast, ipratropium-albuterol nebs w/
azithro during hospital stay. Presumed secondary to chronic CHF
vs. COPD exacerbation vs. PNA. Chest XR with possible infectious
process in L base, however symptoms inconsistent. Crackles but
no wheezing on exam. She was started on IV ceftriaxone and
azithromycin (for UTI and presumed COPD exacerbation, but would
also cover possible PNA), transitioned to PO Cefpodoxime and PO
azithromycin to be continued until ___. We continued inhalers,
montelukast, duonebs, and nasal spray.
# Social: Concern about her functioning status upon discharge
home. Spoke with brother, ___, who lives in ___
and ___ contacted Ms. ___ two weeks prior via phone
conversation. During this conversation, Mr. ___ insisted that
his sister went through rough times of being in and out of the
hospital following the passing of her husband, but had been
functioning well otherwise. He has hosted Ms. ___ at his
___ house several times over the past few years, and did
not notice any change in behavior. Since Ms. ___ usual
caretaker/home supporter, her cousin ___, has been visiting
___ recently, Mr. ___ wife has made two trips (1 wk, 3
___ to provide Ms. ___ with community. Mrs. ___ left two
___ ago, after which Ms. ___ called Mr. ___ to notify him
of her complete loss of appetite - "no matter how much she tried
to force food down." He has never heard her behave this way, but
he figured that the hospital would help her eat. When discussing
Ms. ___ discharge life planning, Mr. ___ would like for
Ms. ___ to move into his ___ house permanently,
where she has previously enjoyed her stay ___ yrs prior). He was
provided with Ms. ___ hospital room phone number, as she
has been unable to contact anyone due to her phone minutes
depletion. Although she may not have many local social supports,
she does have multiple ___ supports including a
___, telehealth, and a home care assistant. Her ___ was
contacted and had no concerns about patient's medication
compliance although agrees that patient has had a hard time
since her husband passed away. At time of discharge, patient
agrees that she would like to increase her food intake and is
amenable to appetite stimulants. She was seen by the inpatient
palliative care team as well and may benefit from palliative
care to help with her appetite.
Chronic issues:
# Hypomagnesemia: Unclear etiology and has been recurrent issue.
Could be associated with pt's PPI use or loop diuretic. ___ also
be in setting of malnutrition. Repleted 1x in ED.
# CKD: Patient remains near baseline Cr of 2.0.
# HFpEF: Echo ___ demonstrated mild ___, L-to-R shunt
across the interarterial septum at rest. Mild (1+) mitral
regurgitation. Estimated LVEF of 60-65%. Previous discharge
weight 62kg, whereas she is now closer to 58kg. Was on torsemide
40mg daily, but does not demonstrate ___ edema or JVD (negative
hepatojugular reflux). Received 1L NS in ED (___). Given
500 mL D5W bolus over 120 min (___) due to hypotension.
Negative orthostasis. Torsemide was held due to low blood
pressures.
# Craniopharyngioma: Supra-sellar mass most consistent with a
craniopharyngeoma by MRI characteristics (___) s/p XRT as
well as DI and panhypopituitarism including hypothyroidism,
hyperprolactinemia, hypogonadism, and ___ deficiency and adrenal
insufficiency due to exogenous steroid use (for COPD).
Originally found to be abutting and elevating optic chiasm with
bitemporal hemianopsia. Completed fractionated radiation therapy
from ___ to ___ (52.2 Gy over 29 fractions). Receives ddAVP
(desmopressin) for DI. TSH is within normal limits. We continued
hydrocortisone, desmopressin, and synthroid.
# Paroxysmal afib: CHADS2-VASC score 4. Not on anticoagulation
given fall risk, past discussion with NSG, and patient
reluctance. Currently in NSR with irregularly irregular rhythm
auscultated on exam. We continued ASA 325. We held amiodarone in
setting of LFT abnormalities.
# Adrenal insufficiency: Diagnosed originally in ___ due to
exogenous steroid use (for COPD). Continued home hydrocortisone
10mg in AM and 2.5mg in ___.
# Depression, anxiety: Continued home sertraline
# GERD: Continued home PPI
# Anemia: stable. Continued PO iron supplements
# Allergic rhinitis: Continued nasal spray
# OSA: refused CPAP | 84 | 1,050 |
16749603-DS-16 | 23,041,462 | You were admitted to the hospital after a mechanical fall. The
reason you were admitted was actually a bout of chest pain, but
you had a negative workup and your chest pain has resolved. You
were seen by the urologists for hematuria, and they plan to send
you home with the foley catheter and then see you as an
outpatient next week. You worked with ___ and they felt you were
safe for discharge home with home physical therapy. | ISSUES ADDRESSED THIS HOSPITAL STAY:
# Fall: Purely mechanical by history. Cleared by ___ for home
with cane and home ___. Daughter is very supportive and will
assist patient with all ADLs.
- Home ___
# Hematuria: Thought most likely BPH with some component of
trauma during the fall to explain the worsening on admission,
+/- UTI. Gross hematuria resolved by the AM of discharge. Seen
by Urology on ___ and again on admission. Plan is for foley
catheter to remain in place at least until Urology appointment
next ___. Urology recommended ciprofloxacin for a 5 day
course on discharge.
- Urology followup next week
# Chest pain: Resolved on its own. Trop negative. EKG stable
from priors. In setting of fall, ddx is stable anginal episode
versus musculoskeletal. Continued his home medications. ___ was
not put on a BB because of a history of bradycardia and syncope
that resolved with discontinuation of BB.
- Cardiology f/u in ___
# Anemia: Likely acute blood loss in setting of two bouts of
hematuria. Hct 30 (above goal even for CAD), worked fine with
___, so no transfusion given.
- Would certainly monitor Hct as outpatient, and if develops
symptoms or Hct continues to fall, would consider transfusion at
that time.
# Thrombocytopenia: Plt count was stable in the low 100s here.
Simply monitored.
- Deferred further workup to outpatient setting
# HTN: Continued his home medications. | 79 | 225 |
10717565-DS-22 | 29,422,467 | Dear Ms. ___,
You were admitted for slurred speech, unsteadiness and myoclonic
jerks, which were concerning for Fycompa toxicity. Your brain
imaging was normal. Your Fycompa and Vimpat were tapered off.
You had no seizure. You were started on clobazam (Onfi) a new
medication which you are tolerating well. You will take Onfi
___ tablet in the morning and at night. Dr. ___ will uptitrate
this if you are having further seizures. Please continue to
take lorazepam (Ativan) if you are have seizures at home. If
you need to take lorazepam, please call Dr. ___ office as she
may want to adjust your medications.
Please follow up with Neurology and take your medications as
prescribed.
Sincerely,
YOUR ___ Neurology Team | Ms. ___ is a ___ year old right-handed woman with a history of
idiopathic generalized epilepsy who presented to the ___ ED
with worsening slurred speech, myoclonic jerking, dizziness, and
unsteady gait following changes to her antiepileptic medication
regimen in ___. In the ED, CTA imaging of her head and neck
did revealed patent vessels, but a ? pons hypodensity. Her MRI
was negative for acute intracranial abnormality. Ms. ___ was
subsequently admitted to the epilepsy service for long-term
monitoring on video-EEG and optimization of her antiepileptic
medications. She was tapered off perampanel with subsequent
improvement of presenting symptoms and no electrographic
seizures. She was tapered off of vimpat and gabapentin were
discontinued, because both AEDs can worsen idiopathic
generalised epilepsy. Onfi was started. There were no
electrographic seizures, but her EEG was notable for subclinical
generalized epileptiform discharges. She improved to discharge
home with epilepsy followup. | 124 | 148 |
19768190-DS-20 | 20,688,808 | Dear Ms. ___,
It was a pleasure to participate in your care here at the ___
___. You were admitted for chest
pain and found to have large blood in your lungs. We started you
on blood thinners to treat this. You will need to be on Lovenox
(injectable blood thinners) while we transition you to the pill
form (coumadin or warfarin). You will need to follow up with
your PCP to adjust the dose.
Please follow-up with your outpatient providers as outlined
below.
We wish you the best,
Your ___ team
transitional issues:
- please make sure your visiting nurse checks your blood on
___. | This is a ___ yo F with recent immobility ___ achilles tendon
repair who presented with chest pain and was found to have
bilateral PEs.
# PULMONARY EMBOLISM: She was found to have large bilateral
pulmonary emboli. It was likely provoked by her recent
orthopedic surgery and subsequent immobility. Her case was
discussed with her oncologist, who felt that this was not likely
related to her malignancy as she has been in remission for the
last year. Her Chest CT and subsequent TTE showed some evidence
of right heart strain with dilation of the right ventricle.
However, LV function was not impaired and the patient did not
have any clinical evidence of hemodynamic compromise (no
hypotension, tachycardia only with exertion). She had lower
extremity venous dopplers that also showed DVT. She was started
on therapeutic lovenox to bridge to warfarin.
# Achilles repair (___): She was evaluated by physical
therapy who recommended the patient continue with ___, wear
bearing on LLE with boot. She will require ambulance or lift
assistance with the stairs to her apartment and will need to be
homebound for now.
# Pulmonary nodule: The patient was incidentally found to have a
4mm pulmonary nodule on Chest CT. She will need follow-up
imaging in one year.
# Glaucoma: Continued eye drops
TRANSITIONAL ISSUES
===================
[] Pulmonary nodule (4mm): Need f/u CT in ___ year to trend.
[] Anticoagulation f/u (titration of warfarin) | 103 | 227 |
13467921-DS-21 | 21,383,058 | Mr. ___,
You were admitted for a platelet transfusion reaction. We did a
work up and found you were allergic to certain type of blood
products and will not get this type from here on out. You were
also treated with antibiotics because you developed fever and
was found to have pneumonia. You will follow up with Dr.
___ as stated below. It was a pleasure taking care of you. | ___ is a ___ year old male with AML
who is admitted from the ED after developing fever and rigors
following outpatient blood transfusion and precipitous decline
in
H/H c/f acute hemolytic reaction. | 69 | 31 |
11192090-DS-7 | 28,709,764 | Surgery/ Procedures:
You had a cerebral angiogram to coil your MCA aneurysm. You
may experience some mild tenderness and bruising at the puncture
site (groin).
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
You make take a shower.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you must refrain
from driving.
Medications
Resume your normal medications and begin new medications as
directed.
Please do NOT take any blood thinning medication (Aspirin,
Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on a medication called Nimodipine.
This medication is used to help prevent cerebral vasospasm
(narrowing of blood vessels in the brain). Finish all doses of
this medication.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication until follow-up. It is important that you take this
medication consistently and on time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
Mild to moderate headaches that last several days to a few
weeks.
Difficulty with short term memory.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site or puncture site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | On ___, Mr ___ presented with 5 day history of headache,
followed by sudden pain behind his eyes and nausea/vomiting.
Head CT showed diffuse SAH. Follow up CTA showed a 4mm left MCA
bifurcation aneurysm. His neuro exam remained stable and
nonfocal. He was admitted to the ICU under Dr. ___ close
neuro monitoring.
On ___, the patient remained stable and was brought to the
neurovascular suite for cerebral angiogram. He was found to
have a left MCA bifurcation aneurysm which was successfully
coiled. He returned to ___ for close neuro monitoring. He
neuro exam remained stable with no focal deficit. Head CT was
done which showed the MCA coil and stable subarachnoid
hemorrhage.
On ___, the patient remained stable with a stable neuro
exam. He remains in the ICU for spasm watch and TCDs were
ordered.
On ___, the patient remained stable with a stable and
nonfocal neuro exam. TCDs showed some increased velocity within
the right MCA and ACA which was thought to be likely related to
hyperemia.
On ___, later in the morning the patient became lethargic and
developed a slight left pronator drift. A CTA was obtained and
showed mild vasospasm, however per prelim report was negative
for vasospasm. He was started on a Levophed drip to increase
perfusion and his IVFs was increased to 125ml/hr. TCDs showed
increased velocity to RMCA and RPCA. The patient complained of
leg pain, LENIs were ordered and showed no DVTs.
Over the weekend of ___ the patient remained neurologically
intact. He was weaned off the pressor and was kept even to
positive.
On ___, the patients neuro exam remained stable. He underwent
bot Head CTA and TCDs which showed increased velocities RMCA and
RPCA. The CTA showed mild vasospasm per ICU read, however the
radiology read was negative for vasospasm. The patient remained
stable and was therefore transferred to the floor.
On ___, the patient's fluid balance was running negative
overnight, so he was given a 1 liter bolus 0700 in the morning.
The patient's foley and TLC were removed; his IV fluid was kept
at 75cc/hr. He no longer necessitated in/out balance goals.
___: The patient remained stable overnight. He was stable and
ready for discharge with nimodipine and keppra. His discharge
exam was non-focal; he remained neurologically intact. | 351 | 389 |
14118349-DS-5 | 25,987,508 | ******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*******
NWB LUE; ok to come out of splint for supervised gentle PROM but
otherwise wear splint while ambulating / sleeping
******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******
-No anticoagulation needed. You should be ambulating a normal
amount.
******FOLLOW-UP**********
Please follow up with ___ in ___ days
post-operation 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 open grade 1 left both bone forearm fracture. The
patient was taken to the OR and underwent an uncomplicated I&D
and ORIF. 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: NWB LUE; ok to come out of splint for
supervised gentle PROM but otherwise wear splint while
ambulating / sleeping.
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 does not require further chemical
DVT prophylaxis since he is up and ambulating normally. He does
not need further antibiotics. All questions were answered prior
to discharge and the patient expressed readiness for discharge. | 223 | 202 |
16152195-DS-4 | 28,084,021 | Mr. ___,
You were admitted after you had an episode during which you were
'stuck' and couldn't move, particularly your legs. You were also
very pale during this time. We did tests including a CT scan
that showed there was no bleeding in the brain, a CT scan with
dye showing that the blood vessels going to your brain have
cholesterol plaques, but are all open, and an MRI scan showing
you did NOT have a stroke.
It is difficult to say for sure what it was that happened
yesterday. We will need to continue testing after you leave the
hospital to look into this. Though we don't know for sure what
caused this event, we have been able to rule out many dangerous
causes with the testing we did in the hospital.
We did an EEG test (a brain wave test) while you were here, and
the results are pending.
You were also seen by physical and occupational therapy, who
recommended continuing to see both physical and occupational
therapy as an outpatient.
We did not change any of your medications. You are already
taking the right medications to treat the cholesterol plaques in
your blood vessels.
It is very important to follow up with your Primary Care
Physician to continue to look into potential causes of this
episode. Talk to them about whether or not it could have been
related to your heart.
It is also very important to follow up with Neurology. Your
Primary Care Physician ___ refer you to a Neurologist at ___
(___), or to one here at ___.
___ will work with you to figure out why you have
had memory problems and falls over the past months-years, and
also continue to think about whether or not the episode
yesterday may have been from a brain problem.
Please do not hesitate to call us at ___ if you have
any questions/concerns.
Sincerely,
Your ___ Neurology Team | Mr. ___ was admitted with an episode of pallor, feeling
'stuck' or 'shut down', with particular difficulty moving both
legs, with preserved ability to stand and walk with assistance.
This does not localized to a focal neurologic deficit and is
therefore unlikely to reflect TIA. The closest localization
would be bilateral ACA territory, and to have vascular lesion in
this region alone requires an azygous ACA, which Mr. ___ does
not have. MRI brain confirmed no ischemia, but showed atrophy
and severe microvascular white matter changes. CTA head/neck
shows scattered moderate atherosclerotic changes, but they are
unlikely to be related to the etiology of this event given that
it cannot be localized to a vascular territory.
Possible etiologies for the event include hypertensive
encephalopathy (supported by SBP>200 on EMS arrival), arrhythmia
or vasovagal event(supported by pallor). Seizure possible, but
less likely. Extended routine EEG performed prior to discharge,
results pending at time of discharge but preliminarily without
epileptic activity.
Additionally, his history of a year or more of fluctuating
cognitive decline, falls (all backward), anosmia, restless leg
syndrome, combined with his exam findings of masked facies,
reduced blink rate, hypophonia, slowed and hypometric upward
saccades, bradykinesia and rigidity that augments, as well as
postural instability with retropulsion all raise high suspicion
for an underlying neurodegenerative condition, likely a
Parkinsonian syndrome. He will need follow up with Neurology.
===================================
Transitional Issues:
[ ] PCP: refer to ___ Neurology, prefer ___ if
possible given his subspecialization in movement disorders.
[ ] PCP: consider workup for cardiopulmonary causes of this
event.
[ ] Neurology: consider underlying Parkinsonian syndrome | 321 | 264 |
19259805-DS-16 | 21,664,484 | Dear Mr. ___,
You were hospitalized at ___ after your fall. You suffered
multiple injuries including a left maxillary sinus fracture,
left posteriorlateral orbital wall fracture, non-displaced left
sphenoid fracture, left sided subdural hematoma, focal right
lateral ventricular hemorrhage, and small left frontal
subcortical hemorrhage. You are now ready for discharge from the
hospital. Please follow-up with your scheduled outpatient
appointments. Please also see the following discharge
instructions for post-hospitalization care.
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.
Sincerely,
___ Surgery | Imaging studies were obtained to determine the extent of
injuries from his fall. The following injuries were found: left
maxillary sinus fx, left posteriolateral orbital wall fracture,
SAH, small left SDH, focal right IVH, small left frontal
subcortical bleed, non-displaced left sphenoid fracture. He was
evaluated in the ED and admitted to the ___ for further care.
Plastic surgery was consulted for the facial fractures and
concern for eye entrapement. Plastics concluded that because
there were no findings of entrapment, there was no surgical
intervention indicated at this time. Opthalmology was also
consulted and requested outpatient follow-up for dilated eye
exam. Neurosurgery followed patient closely during his
hospitalization regarding the ___ and ___. Repeat noncontrast CT
on ___ showed redistribution of multifocal intracranial
hemorrhage, a single new focus of right frontal intraparenchymal
hemorrhage, and no evidence of downward herniation. GCS remained
15 throughout the ICU stay.
The patient was deemed stable and was subsequently transferred
to the floor. His c-collar was cleared. By time of discharge, he
was tolerating a regular diet, ambulating, and pain was well
controlled. Patient was seen by ___ and social work and cleared
for discharge. He was discharged on ___ to report directly to
his opthalmology appointment for further evaluation. Follow-up
appointments were made with neurosurgery and plastic surgery.
Patient was in agreement with discharge plans and all questions
were answered. | 364 | 226 |
16493987-DS-19 | 23,635,378 | Dear Ms. ___,
You were admitted to the hospital because of a urinary tract
infection and confusion. You received fluids and antibiotics and
your blood pressure recovered. You were treated with antibiotics
and your infection showed signs of improvement. An special IV
("midline") was placed to allow you to continue your antibiotics
after you leave the hospital. You will receive a total of one
week of antibiotics, which will require three more days after
discharge.
The wound care team saw your bed sore ("decubitus ulcer") and
made recommendations on the best way to treat it and prevent
further progression. | Ms. ___ is a ___ yo lady with dementia who presented from her
nursing home with AMS found to have urosepsis.
ACTIVE ISSUES
# Urosepsis:
Prior to admission, she was diagnosed with a UTI (Proteus
mirabilis, sensitive to ceftriaxone) and give cefpodoxime - she
received one dose. The following day, she came into the ___ ED
with altered mental status and purulent urine. Given OSH
sensitivities showed Proteus mirabilis sensitive to ceftriaxone,
the patient was started on ceftriaxone with improvement in
symptoms. Her blood pressure and mental status improved with
antibiotic treatment. She remained afebrile during her stay. She
will complete a 7 day course of ceftriaxone.
# AMS:
Patient admitted to hospital with confusion. Likely ___
infection on baseline substrate of dementia. In house her mental
status improved to baseline (A&O x1).
CHRONIC ISSUES
# Neutropenia:
On admission patient labs demonstrated WBC 2.1 with N 47%. Upon
review of the patient's past medical records, the patient is at
baseline leukopenic between ___.
# Stage IV Decubitus Ulcer
Wound care consulted and recommended aggressive wound care.
Given CRP of 166 in the setting of a decubitus ulcer,
osteomyelitis underlying this ulcer was consider as a potential
contributing factor. However, the patient quickly improved with
treatment of her UTI. The possibility and further work-up of
osteomyelitis was discussed with healthcare proxy. HCP did not
wish to pursue invasive work-up or wound debridement. Given
these care goals, MRI was not done and surgery was not consulted
for debridement. Wound care was continued and will be continued
at rehab after discharge.
# HTN:
Antihypertensives were held in the setting of admission
hypotension. After IVF, BP normalized and patient remained
normotensive in house. Medications were held at time of
discharge with recommendation to restart as an outpatient if
needed. | 97 | 291 |
15210189-DS-18 | 29,577,008 | You came to the hospital with abdominal pain and nausea.
You underwent testing including imaging studies and a
sigmoidoscopy which raised concern for a likely crohns disease
flare with resultant bowel obstruction and pouchitis.
At the recommendation of the GI doctors and ___,
a rectal tube was placed to decompress your bowels and you were
started on IV steroids with improvement in your symptoms.
You should continue on steroids by mouth (prednisone) every day
to complete a ___s well as antibiotics by mouth
every day to complete a 7 day course.
It is very important that you reach out to your outpatient GI
doctors to ___ follow up in ___ weeks and consider
re-initiating humira at their discretion.
We will be in touch with their staff to ensure a safe transition
of your care.
It was a pleasure taking care of you. We wish you all the best! | Ms. ___ is a ___ female with US/
total colectomy presents with abdominal pain | 144 | 13 |
12796618-DS-19 | 24,403,813 | Dear Mr. ___,
You came to the hospital because you were not feeling well at
home and your granddaughter was worried about you. Your stool
was darker than normal.
You went to the emergency room and your blood count was found to
be low, probably because of a GI bleed. You were transferred to
___ and received 2 units of blood. You felt better after
that. You had an endoscopy to look in your stomach which did not
show any bleeding.
Your lungs got backed up with fluid from getting a blood
transfusion. You got better with IV medicine to help pee out the
fluid.
You had fevers. We found out that you have a urinary tract
infection. You need to finish antibiotics at rehab.
You had low oxygen at night. This might be because of sleep
apnea. A CPAP machine helped you. You will need a sleep study as
an outpatient in order to see if you have sleep apnea.
When you leave the hospital, please:
- go to rehab to get stronger
- take all of your medicines as prescibed
- see below for your followup appointments
It was a pleasure caring for you and we wish you the best!
Your ___ Team | Mr. ___ is an ___ year old gentleman with a
history of HTN, HLD, CAD, prostate carcinoma and dementia who
presents with GIB, NSTEMI, and hypoxia.
# GIB
# Acute blood loss anemia
Granddaughter reported change in stool appearance, increased
confusion, tremulousness and nearly collapsing at home, thought
to have melena on exam in ED, though more difficult to tell due
to chronically taking iron. Symptoms were most suspicious of
upper GIB given reports of melena. He was hypotensive to SBP 88
on arrival to ___, clinically improved after 2u pRBC with
no further episodes of hypotension, though was in the MICU on
arrival, quickly transitioned to the floor. He was started on
PPI. Risk/benefit of EGD was discussed extensively with
granddaughter. Patient underwent EGD ___ which was unrevealing
for a source of bleeding. Attempted to prep for colonoscopy to
further evaluate multiple times but patient was unable to
tolerate the prep and given his clinical stability, this was
deferred. He was discharged home with 40 mg daily Pantoprazole
for presumed UGIB which he could continue for empiric 8 week
course. He should have GI followup outpatient. Iron supplement
was held on discharge while on treatment for UTI.
# Pulmonary Edema
# Acute on chronic systolic heart failure
# Severe aortic stenosis
# Moderate pulmonary hypertension
Multiple cardiac comorbidities. Not on home O2, takes Lasix 40
mg daily at home. Cardiology consulted in MICU for NSTEMI (see
below). TTE ___ demonstrated severe AS with Grade 1 diastolic
dysfunction and mild regional left ventricular systolic dysfxn
___ CAD (EF 40%). Severity of AS reported as worse. Per prior
admission cardiology consult, he was advised last year to follow
up with Dr. ___ consideration of TAVR for his AS but
appears that he did not keep his appointment. Pt had new O2
requirement of 2L NC in setting of transfusion and decreased
mobility. CXR ___ showed new moderate pulmonary edema. This
resolved with 40 mg IV Lasix. Prior to discharge, he was
restarted on home Lasix and had intermittent desaturations to
high ___ which were thought most likely related to undiagnosed
sleep apnea (below). Discharge weight 202.82 lbs.
# Fever
# Complicated UTI
Patient with fevers for days without obvious source. No other
localizing symptoms for infection, although patient a poor
historian on exam. Urine and blood cultures initially were
unrevealing. CT chest performed ___ due to intermittent hypoxia,
was without evidence of pneumonia. Repeat UA was positive with
large ___ and 80 WBC, no bacteria, started empiric treatment for
UTI with Ceftriaxone ___, culture grew pan-sensitive E coli,
transitioned to PO Bactrim for 5 days to complete 7d course for
complicated UTI ___ - ___.
# Nighttime hypoxia
Noted to desat overnight regularly, per granddaughter, no
history of OSA, no witnessed periods of apnea, but he snores
heavily and she may have witnessed him gasping/grunting more
recently. Trialed empiric CPAP and patient had no recorded
episodes of hypoxia, suggesting possible sleep apnea. Will
continue CPAP at rehab, but will need outpatient sleep study
prior to getting CPAP at home.
# NSTEMI
# CAD s/p MI (STEMI ___ s/p RCA BMS, NSTEMI ___ s/p LCx BMS
Troponins elevated on arrival to the ED in the setting of acute
anemia in the absence of reported chest pain, peaked at 0.56.
Cardiology was consulted in the ED. Serial EKGs demonstrated an
intermittent LBBB which was not new. Echo relatively stable from
prior, did show somewhat worsening AS, but no new WMA. Taken
together, these were consistent with demand ischemia due to
active bleed on background of CAD. Home aspirin and metoprolol
were initially held, resumed prior to discharge, atorvastatin
was continued. Metoprolol was fractionated to tartrate 6.25 mg
Q6H however patient had episodes of SBP < 100 and HR in the ___
so was decreased to BID on the day of discharge. Home metoprolol
succinate was held until further dose adjustments could be made.
# Delirium on Dementia
Pt lives at home with granddaughter who says he is able to walk
at home without assistance and occasionally uses walker outside.
Mental status baseline is unknown, but granddaughter reports it
has worsened. Patient's first night in the hospital he became
agitated and required restraints but did not receive pharm
intervention, subsequently was calm and very pleasant, though
occasionally noted to be picking at his sheets. ___ was consulted
and recommended rehab prior to home. | 195 | 715 |
12312953-DS-4 | 20,909,768 | You were admitted to the hospital with right lower quadrant
pain. You then developed a fever and you were seen by your
primary care provider. You underwent a cat scan which showed a
perforated appendix with an abscess. You went to ___ drainage
where a drain was placed into the collection. Your vital signs
have been stable. You are now preparing for discharge home with
the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep ___ fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change ___ your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
You will be discharged with the drain ___ place with the
following instructions:
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid ___ the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself ___
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation | The patient was admitted to the hospital with 5 days of right
lower quadrant pain. She followed up with her primary care
provider where she was sent for a cat scan. On cat scan imaging
she was found to have perforated appendicitis with a 5cm
abscess. She was transferred here for further management. Upon
admission, the patient was made NPO and arrangements made for ___
drainage. The patient was started on a course of ciprofloxacin
and flagyl. On HD #1, the patient was taken to Interventional
Radiology where an ___ Fr. catheter was placed into the abdominal
abscess. Approximately 10 cc of purulent fluid was aspirated
with a sample sent for
microbiology evaluation.
The patient resumed a regular diet after the procedure. Her
vital signs remained stable with a white blood cell count of 8.
She was voiding and ambulating without difficulty. On HD #2, the
patient was discharged home with ___ services to assist with the
care of the drain. The patient was instructed to complete a 14
day of antibiotics. A follow-up visit was scheduled with Dr.
___ ___ 1 week. Instructions ___ care of the drain were
reviewed with the patient. | 367 | 206 |
13690694-DS-6 | 24,576,896 | Dear Mr. ___,
You were admitted to the Neurology Inpatient Service because you
had 2 seizures. We have increased your phenobarbital dose.
Your EEG did not show any seizures however we did not capture
your typical episode. Your MRI showed a chronic injury in the
left parietal area of your brain. It also showed 6 x 3 x 8mm, 2
x 1 x 2mm, and 2 x 2x 2 mm nonenhancing intraventricular
nodules, arising from the lateral and superior margins of left
lateral ventricle with no definite associated ventriculomegaly
and no definite blood products or mineralization. However,
these findings do not explain why you may have headaches. There
is no sign of increased pressure in your head. | Mr. ___ is a ___ year old right handed man with a past
medical history significant for epilepsy and intellectual
disability (both since birth per family), chronic kidney disease
and schizophrenia who presents from his group home after a
witnessed generalized seizure. The patient's seizure was likely
triggered by sleep derivation due to night time episodes of
grabbing his head and screaming/crying that can last for hours.
This are likely a primary headache disorder, though behavioral
episodes are difficult to rule out. Infectious workup is
negative and AED levels are at baseline. In the ED, in the
setting of missed night time AEDs, he had another seizure.
After being admitted to the Neurology Inpatient Service, his
AEDs were initially continued. However, during the
hospitalization, his Phenobarbital was increased from 45mg twice
a day to 45 mg in the morning and 60mg in the evening. He had
an overnight EEG to try to capture events. No typical events
were captured. However, his EEG did not show any epilptiform
activity. Additionally, due to possible headaches as the reason
for the patient of grabbing his head and screaming/crying, a MRI
was done. The MRI showed encephalomalcia in the left parietal
lobe. This is chronic. Additionally, 6 x 3 x 8mm, 2 x 1 x 2mm,
and 2 x 2x 2 mm nonenhancing intraventricular nodules were seen.
These arise from the lateral and superior margins of left
lateral ventricle. There was no hydrocephalus. No signs of
increased intracranial pressure. These findings are most likely
not the cause of possible headaches. Mr. ___ did not have
any further seizures after being admitted to the hospital. | 121 | 285 |
11308999-DS-6 | 25,825,068 | Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted with shortness of breath.
This was caused by cigarette smoking and a viral upper
respiratory infection.
We started you on medications to help open the airways and
reduce the irritation in your lungs.
It is important that you quit smoking to prevent these events
from occurring again in the future. | ___ yo female with PMH notable for significant smoking history
and metastatic breast cancer now admitted with shortness of
breath. | 67 | 20 |
Subsets and Splits