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10142207-DS-14 | 27,739,425 | Dear Mr. ___,
You were admitted to ___ for increased seizures. You underwent
an EEG which initially showed some slowing but quickly improved.
No changes to your medications were made. We believe the trigger
for your seizure was due to seasonal allergies.
Please take your medications as prescribed. Please follow up
with your PCP as below.
It was a pleasure taking care of you,
Best,
Your ___ care team | Mr. ___ is a ___ right-handed man with history of
generalized epilepsy, well controlled on lamotrigine
monotherapy,
followed by ___ neurology, hypertension, who presented
for
multiple events consistent with breakthrough seizures in the
past
2 days. He underwent cvEEG which showed initial slowing but
quick improved without any epileptiform activity. The etiology
of his breakthrough seizures is not entirely clear at this time;
there is no evidence of medication noncompliance or decreased
absorption, metabolic derangements, or underlying infection. In
addition, pt denied any changes in alcohol intake. He does
endorse a hx of seizure during the ___, which he attributes
to seasonal allergies. His outpatient neurologist confirmed that
his last seizure was in the ___ and was attributed to
allergies in addition to maybe missed medication dose.
Furthermore, on exam pt was noted to have significant cognitive
problems, including persistent attentional problems, substantial
encoding difficulties, retrieval memory problems, as well as
phonemic paraphrases error. This is concerning for possible
bilateral mesotemporal problems with left lateralization. He
needs close follow up with his outpatient neurologist for
further w/u, starting with revaluation in about a week to assess
possible post-ictal contribution that may clear. If he continues
to have persistent cognitive problems he would benefit from MRI
brain. He has follow up with his outpatient neurologist next
week. He also has an appointment with cognitive neurology here
at ___. He was discharged home in stable condition. No changes
to his medications were made. | 67 | 239 |
15554295-DS-21 | 23,477,160 | 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. | Pt is a ___ year old male who has had multiple operations related
to a GSW to the abdomen in ___ (please see PSH). Most
recently, he has had abdominal wall reconstructive surgery in
the ___ of this year. His wound now currently has a known
entero-atmospheric fistula (EAF). He presented to the ED with
prolapse of his EAF. It was significantly engorged and tender,
however, appeared viable. We sprinkled sugar on it and then
reduced the prolapse successfully. We placed a pressure dressing
to keep the bowel in place. Subsequently, a CTAP showed that the
bowel was perfused but perhaps intussuscepted. The patient was
admitted for monitoring. On HD2, the patient's diet was advanced
to regular, which he tolerated. On HD3, the patient was doing
well, and was ready for discharge with appropriate follow up. | 293 | 138 |
10455683-DS-13 | 24,031,399 | Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body. | Mr. ___ was admitted to the Neurosurgery service on ___
after being transferred from an outside hospital with a
diagnosis of left subdural hematoma, hemorrhagic contusions, and
subarachnoid hemorrhage. He was loaded with Dilantin in the ED
and transferred to the floor for further observation and
management. A repeat Head CT performed on the morning of ___
was stable from the previous CT scan. The patient had presented
on ___ with a creatinine of 2.2 and was started on IV fluids;
the creatinine had decreased to 1.9 by the morning of ___ and
1.7 on ___. Sodium levels were decreased at 131 on admission
and slowly normalized. On ___, patient was cleared by ___ to be
discharged home. He was ambulating and eating appropriately. | 181 | 129 |
15539509-DS-15 | 29,080,071 | Dear Mr. ___,
You were admitted due to episodes of lightheadedness concerning
for ongoing seizures. You were monitored on EEG which did not
show seizures. Routine studies for infection were negative. Your
medications were not switched.
On discharge, please avoid driving or operating heavy machinery
for at least 6 months following your last seizure. Take all of
your medications as directed and do not miss doses. Please
follow up with your neurologist as scheduled.
It was a pleasure taking care of you.
Sincerely,
___ Neurology | Mr. ___ is a ___ yo man with a history of intractable complex
partial epilepsy (foci of onset in both temporal lobes based on
Phase II evaluation) who presented with frequent lightheadedness
and anxiety, with concern from his outpatient epileptologist for
unwitnessed seizures leading to post-ictal anxiety.
Orthostatic vital signs in ED and on floor were negative. Work
up for infectious etiologies was negative. A non-contrast CT of
the head revealed no acute abnormalities. On EEG, there were no
electrographic seizures, but he did have left mid-temporal
interictal sharp-and-slow-wave discharges. Patient indicated
strong preference to be discharged with follow up with primary
epileptologist - therefore, we did not make any changes to his
AEDs.
Transitional Issues
#Neurology
[ ] Follow up with Dr. ___ in ___
[ ] Continue current AEDs | 80 | 126 |
13651103-DS-16 | 24,710,905 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted with fever and found to have a
urinary infection as well as a pneumonia. You were treated with
antibiotics but developed a rash. You continued to have fevers
and you were seen by infectious disease. Your antibiotics were
changed. You had a CT scan which showed an infection of your
kidney. You were discharged on oral antibiotics as well as
intravenous antibiotics to follow up with your PCP and
oncologist. | Ms. ___ is a ___ with history of T4aN0M0, Stage III,
urothelial carcinoma of the bladder on C2D13 (___) of
gemcitabine/cisplatin who presented with fever and acute kidney
injury. | 88 | 31 |
15974477-DS-22 | 24,382,776 | You were admitted to the hospital with upper abdominal pain. You
underwent an ultrasound of your abdomen and you were found to
have multiple gallstones and sludge. You were started on
intravenous antibiotics. As part of the work-up you were found
to have special enzymes in the blood which appear when you have
any damage to the heart. Because of this, you underwent cardiac
testing and you were seen by the Cardiologist who made
recommendations about your management. You were also found to
have a urinary tract infection. Your blood work is normalizing
and your abdominal pain has diminshed. You are now preparing
for discharge to a rehabilitation facililty where you can
further regain your strenght. You will need further work-up on
your heart and follow-up with a Cardiologist when you are
discharged. | The patient was admitted to the acute care service with
abdominal pain. On initial examination in the emergency room,
he was also found to have unequal pupils. Upon admission, he
was made NPO, given intravenous fluids, and underwent imaging.
Because of the pupillary finding, a head cat scan was done
which showed no acute intracranial abnormality. On ultrasound
of the abdomen, he was found to have multiple gallstones and
sludge. Further work-up with a cat scan demonstrated findings
concerning for cholecystitis. In addition to these findings, he
was found on initial lab work to have a mild elevation in the
bilirubin and a mild troponin leak without EKG changes. Routine
urinalysis was suggestive of a urinary tract infection. He was
started on unasyn which provided coverage for both the urinary
tract infection and cholecystitis. His abdominal pain gradually
subsided. His troponins were cycled because of the troponin
leak.
During his hospitalization, his mental status improved and he
became alert, oriented, and conversant. His vital signs and
electrolytes were closely monitored and his electrolytes were
repleted. There was a mild decrease in the tropnin level to
0.02 from 0.03, but the current level has stabilzed at 0.03.
Cardiology was informed of these findings and recommended
resumption of his home medications, along with aspirin, and a
out-patient echocardiogram.
His vital signs have been stable and he has been afebrile. He
has been tolerating a regular diet and has a indwelling foley
catheter. His total bilirubin has decreased to 1.4 and his
white blood cell count has decreased to 12.5.
On HD #3, he was discharged to a ___ facility in
stable condition on a 2 week course of augmentin. He has an
appointment scheduled for an out-patient echocardiogram and a
follow-up visit with a cardiologist. The rehabilitation
facility has been informed of the date and time of the
appointment. | 140 | 324 |
13607080-DS-13 | 23,969,583 | Dear ___,
You were admitted to the hospital because you had low blood
counts.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We gave you blood transfusions
- We gave you IV iron transfusion
- You had a colonoscopy which showed a polyp in your colon
which was not taken out.
- We removed fluid from your abdomen. You did not have an
infection of that fluid but you did find blood in that fluid.
- You improved and were ready to leave the hospital.
- Nutrition saw you and recommended nutritional
supplementation.
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 ___ h/o newly diagnosed locally advanced HCC,
HCV, cirrhosis (decompensated by ascites, grade I varices and
right PV thrombus, not on AC) and acute anemia who was referred
to the ED for low Hb. He was given blood transfusions and
underwent a paracentesis and colonoscopy.
ACUTE ISSUES ADDRESSED
========================
# ACUTE ON CHRONIC MICROCYTIC ANEMIA
# IRON DEFICIENCY ANEMIA: The patient presented with hgb of 5.5
from baseline of 9.2 and was transfused 2u pRBCs. Recent EGD w/o
signs of bleeding. Colonoscopy on ___ found 4 cm non-bleeding
polypoid lesion of multilobular in the appendix. Biopsies
performed. In addition, his diagnostic/therapeutic paracentesis
had high RBCs, raising suspicion for intraluminal bleed related
to his HCC. The patient was transfused 2u pRBCs with adequate
response, given IV iron infusion x2. Hemolysis labs negative.
# DECOMPENSATED CIRRHOSIS
Cirrhosis see on ___ RUQUS. MELD 30 CHILDS B (MELD 16 in
___. Presumed EtOH + HCV cirrhosis, decompensated by
ascites, portal vein thrombus (not on anticoagulation) and
esophageal varices. Currently decompensated with worsening
transaminitis and complex ascites. Negative for SBP on
paracentesis.
EGD on ___ showed chronic portal HTN, grade 1 varices.
Portal vein thrombus present likely tumor thrombus and not on
anticoagulation given anemia and blood loss. Home furosemide and
spironolactone initially held and restarted.
# HCC
Triphasic CT A/P scan on ___ consistent with multifocal HCC.
___ RUQUS was concerning for portal vein thrombosis, likely
tumor thrombus. Patient was discussed at tumor board on ___,
saw Dr. ___ and then Dr. ___ here.
They have not yet decided on next steps but per wife, quality
over
quantity is valued but patient seems to prefer more aggressive
options. CT Chest/Abd/Pelvis w/ and w/o contrast ___ - no
thoracic
mets, interval enlargement of liver tumors, possible pelvic
mets. There were no plans for biopsy due to c/f intraluminal
bleeding, Dr ___ he may be candidate for nivolumab
(bleeding risk from sorafenib). If appropriate, Dr. ___ plans
on referral to ___ for local treatment. Patient and
wife plans on meeting with ___ care as outpatient to
discuss goals of care.
# HYPONATREMIA
Patient was hyponatremic. On this admission UNa <20 and UOsm 365
making SIADH less likely. Hyponatremia likely secondary to poor
PO intake and hypovolemia
from ascites. Hyponatremia was monitored, persistent and stable.
# SEVERE MALNUTRITION
Patient had temporal wasting and is cachectic on examination.
Nutrition followed and recommended supplementation and tube
feeds if within goals of care.
=============== | 221 | 390 |
14921417-DS-19 | 28,108,723 | You were admitted to ___ with sigmoid diverticulitis. While
you were hospitalized, you were treated with IV Antibiotics and
stayed on strict bowel rest. At the time of your discharge, your
pain had improved and you were tolerating a regular diet. You
will be discharged home with a 2 week course of antibiotics
along with followup appointments listed below. | This patient is a ___ year old male who presented to the
emergency room with abdominal pain. He was admitted to the Acute
Care Surgery service after CT Scan imaging revealed "Sigmoid
diverticulitis with a contained perforation in association with
an intramural abscess." The patient had a white blood cell count
of 15.5 on admission. The patient was initiated on Intravenous
fluids, Intravenous antibiotics and strict bowel rest. He was
kept NPO until his diet was advanced to clear liquids on HD 3,
which he tolerated well. His pain was well controlled with IV
pain medications, however after receiving IV Antibiotics, pain
did improve. On the day of discharge, the patient was able to
tolerate a regular diet without experiencing nausea or vomiting.
Blood cultures were drawn on admission and they are still
pending. The patient was seen by gastroenterology prior to
discharge in light of his diverticulitis. They recommended he
followup as an outpatient with a colonoscopy. On HD 4, the
patient denied abdominal pain and was transitioned to oral
antibiotics. He was discharged home with instructions to finish
a two week course of Cipro/Flagyl. | 59 | 187 |
19460387-DS-7 | 27,837,737 | Dear Ms. ___,
You were admitted to ___ because you had high fevers and body
aches.
You were given IV antibiotics. We looked for an infection. We
found bacteria in your urine, and think that you had an
infection in your kidney called pyelonephritis.
When you leave the hospital:
- Please follow up with your doctors ___
- ___ finish your antibiotics as directed
It was a pleasure taking care of you!
Your ___ Team | ___ is a ___ year old woman p/w fevers and dysuria,
clinical picture most consistent with pyelonephritis. A
transvaginal ultrasound ruled out PID. Renal ultrasound revealed
a trace amount of perinephric fluid adjacent to the upper pole
of the right kidney, which could be associated with
pyelonephritis. No perinephric abscess was seen. Ultimately the
clinical picture was most consistent with pyelonephritis, with
urine cx growing E.Coli sensitive to both ceftriaxone and
ciprofloxacin.
TRANSITIONAL ISSUES:
====================
CODE STATUS: Full Code
CONTACT: Father (___) ___
- Patient will complete antibiotics for pyelonephritis with IV
ceftriaxone with transition to oral ciprofloxacin for 7 days
total (___).
- Urine Chlamydia and Gonorrhoeae pending on discharge
- Given her extensive maternal family history of cancer at early
ages and multiple types of cancer, please discuss genetic
counseling with the patient. | 69 | 133 |
13467723-DS-4 | 25,443,066 | INSTRUCTIONS:
- You were in the hospital for your orthopaedic injury.
- 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 on bilateral lower extremities
- weight bearing as tolerated on right 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 lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
weight bearing as tolerated on b/l lower extremities
<br><br>RUE: weight bearing as tolerated. can range fingers,
elbow, wrist as tolerated. sling for comfort only
Treatments Frequency:
none | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right superior pubic rami fracture, right comminuted
ilium fracture, right distal minimally displaced clavicle
fracture and was admitted to the acute care surgery service. She
was transferred to the orthopedic surgery service where it was
determined that her fractures were non-operative at the time.
The patient was given anticoagulation per routine. The patient's
home medications were continued throughout this hospitalization.
The patient worked with ___ who determined that discharge to
rehab was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications and the patient was voiding/moving bowels
spontaneously. 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. | 181 | 175 |
18462562-DS-6 | 26,489,621 | Dear ___,
___ was a pleasure to take part in your care during your stay in
the hospital. You came into the hospital with left sided
chest/rib pain. You had multiple imaging studies which showed
that your did NOT have a heart attack nor clot in the lungs.
Your pain was likely from inflammation around your rib cage or
from your spleen.
You were seen by your oncology team while in the hospital and
they discussed with you and your family that your lymphoma had
returned dispite the chemotherapy. You were started on a new
chemotherapy while in the hospital and completed your first
cycle without complication. You were also given your injection
of Neulasta prior to leaving the hospital. You will follow up
with Dr. ___ on ___ in clinic. You will
receive another chemotherapy medication in clinic, but you will
be able to return home after the administration. If you
experience fevers, chills, shortness of breath or any other
concerning symptom, please call the clinic number.
Thank you for allowing us to participate in your care during
your stay.
Sincerely,
Your ___ Team | ___ year old female with high-grade activated B-cell like diffuse
large B cell lymphoma s/p 6 cycles R-CHOP (last was about 1 mo
ago) who presents with severe LUQ pain and LL chest pain.
Patient's PET scan recently showed recurrence of her lymphoma
and relapse despite chemotherapy.
The patient presented with acute onset of left lower chest pain
and left upper abdominal pain. In the ED there was concern for
splenic infarct based on CT with contrast. Given acute onset of
presentation and recent hospitalization for chemotherapy and
high tumor burden, PE was high on the differential.
V/Q scan showed no signs of PE on ___. Trop, BNP, MB, CK were
all normal. Chest xray to evaluate for acute pulmonary process
was normal. LENIs were negative. Splenic US showed no signs of
infarct and patent splenic artery and vein. The most likely
cause was ___ to costochondritis. Patient's pain improved after
initiation of ICE and dexamethasone. Patient was on no pain
medications and her symptoms were significantly improved on day
of discharge.
Recent PET CT showed relapse of the disease. Patient's
outpatient oncology team (Dr. ___ Dr. ___ held a
family meeting to inform the family. Patient initiating on ICE
salvage therapy and will likely undergo an Auto BMT. Patient was
C1D4 of ICE on day of discharge. She tolerated the chemotherapy
without complication. The patient received her home dose of
Neulasta on day of discharge. She will f/u with Dr. ___
___ Dr. ___ in clinic for Rituxan on ___.
ACUTE ISSUES
#Left Lower Chest Pain/RUQ Abdominal Pain: The patient presented
with acute onset of left lower chest pain and left upper
abdominal pain. In the ED there was concern for splenic infarct
based on CT with contrast. Given acute onset of presentation and
recent hospitalization for chemotherapy and high tumor burden,
PE is high on the differential. The patient describes pleuritic
chest pain that is consistent with PE versus chostocondritis.
The patient's VS are normal making PE unlikely but possible. ACS
is unlikely given no changes on EKG.
V/Q scan showed no signs of PE on ___. Trop, BNP, MB, CK were
all normal. Chest xray to evaluate for acute pulmonary process
was normal. LENIs were negative. Splenic US showed no signs of
infarct and patent splenic artery and vein. No anticoagulation
at this time given stability in vitals. The most likely
diagnosis is costochondritis or inflammatory pain of the ribs.
Pain significantly improved by day of discharge. Patient
required no medications to control her pain on day of discharge.
# high-grade activated large B-cell lymphoma s/p 6 cycles R-CHOP
(last was about 1 mo ago). Recent PET CT showed relapse of the
disease; patient's outpatient oncology team (Dr. ___ Dr.
___ held a family meeting to inform the family. Patient
initiating on ICE salvage therapy and will likely undergo an
Auto BMT. Patient tolerated ICE without complication. Patient
received home dose of neulasta on day of discharge.
# Hypotension: Resolved with IVF in the ED. Patient taking good
PO. asymptomatic.
CHRONIC ISSUES
# Hepatitis B: Patient was continued on her pre-admission
Entecavir. She is being followed by Hepatology as an outpatient.
# Anemia: chemotherapy induced, stable.
# Thrombocytopenia: chemotherapy induced, Stable.
# Infectious prophylaxis:
- PCP: ___
- HSV/VZV: acyclovir
TRANSITIONAL ISSUES
============================
-patient will f/u with her oncology team in clinic on ___
___
-patient will receive rituxan in clinic on ___
-patient was started on allopurinol ___ PO Daily
-ciprofloxacin was stopped at discharge; can be restarted
pending instructions from outpatient oncology team if needed
-patient given dose of Neulasta on day of discharge (patient
family brought home medication in to hospital from pharmacy)
-patient will have all other doses per outpatient oncology team | 185 | 621 |
16764990-DS-9 | 21,529,238 | 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:
- Left lower extremity: Weight-bearing as tolerated with ___
locked in extension.
- Left upper extremity: Non-weight-bearing in sling.
- Right upper extremity: Non-weight-bearing in splint.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
Weight-bearing as tolerated left lower extremity with brace
locked in extension.
Non-weight-bearing left upper extremity in sling.
Non-weight-bearing right upper extremity in splint.
Treatments Frequency:
Wound monitoring
Dry sterile dressing as needed | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left clavicle fracture, left patella fracture and
right fifth finger metacarpal fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction/internal fixation
of her patella fracture which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. Nonoperative
management was recommended for her left clavicle fracture and
outpatient follow up in Hand clinic in one week (with Dr. ___
___ recommended for her right fifth metacarpal
fracture. 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 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. | 246 | 292 |
12599826-DS-12 | 23,908,859 | You were admitted to the hospital with abdominal pain and found
to have disruption of your staple line. You were placed on
bowel rest, given intravenous anti-acid medication, antibiotics
and and nutrition. You have elected to leave the hospital at
this time due to issues with insurance coverage. However, you
must seek ___ medical attention should you develop a fever
greater than 100, chest pain, shortness of breath, recurrence of
abdominal pain, nausea or vomiting, vomiting blood or dark
material, blood in your stool, severe abdominal bloating,
inability to eat or drink, or any other symptoms which are
concerning to you.
Stay on Stage III diet until your follow up appointment. Do not
self advance diet, do not drink out of a straw or chew gum. | The patient was transferred to the ___ Emergency Department on
___ after developing worsening abdominal pain and
dyspnea after eating steak four days earlier. The CT scan
obtained at the outside hospital was suggestive of staple line
breakdown at the site of the patient's previous sleeve
gastrectomy performed in ___ the previous month. Given these
findings, he was placed on bowel rest, given intravneous
imipenem and vancomycin and transferred to our ED for further
management. Upon arrival to ___, the patient underwent an UGI
series which confirmed a 4.3 cm defect along the staple line
with active extravasation of contrast. Given hemodynamic
stability, he was managed conservatively with bowel rest with
TPN, an intravenous pantoprazole gtt, meropenem/ vancomycin/
fluconazole, an NGT placed via fluoroscopy and left pleural
effusion drainage via thoracentesis .
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with intravenous
acetaminophen.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: As noted above, the patient underwent thoracentesis
with drainage of 350 mL pleural fluid dt dyspnea and findings of
a large left sided pleural effusion. An UGI obtained upon
arrival did not suggest any communication of leak with the
thoracic space. He continued to improve from respiratory
standpoint throughout his hospitalization, which was wihtin
normal limits at the time of discharge.
Good pulmonary toilet, early ambulation and incentive spirometry
were encouraged throughout hospitalization.
GI/GU/FEN: The patient was placed on bowel rest with TPN and an
NGT placed under fluoroscopy for decompression. On HD5, the
patient self-d/c'd his NGT and declined replacement. He then
underwent an EGD which was within normal limits. On HD8, the
patient underwent a repeat UGI which did not show active
contrast extravasation. On HD9, the patient began a gradual
diet advancement to a bariatric stage III; which was well
tolerated. Patient's intake and output were closely monitored.
The PICC and TPN were discontinued on HD11 per patient's request
to leave the hospital.
ID: Infectious disease was consulted on HD2 and recommended
transition to ceftriaxone and metronidazole. This was continued
throughout the hospitalization. Of note, the patient did
decline antibiotics on HD11 and was discharged without oral
antibiotics.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
On HD11, the patient requested to leave the hospital as
insurance was no longer covering the admission. He was
hemodynamically stable at this time and was without pain. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan and was encouraged to follow-up with Dr. ___ in clinic. | 128 | 470 |
15811429-DS-8 | 22,460,079 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had difficulty breathing and throat tightness and were
transferred to ___ from ___.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had a tracheostomy placed to help you breathe
- You received a PEG tube in your stomach for tube feeds
- You had a vocal cord biopsy showing cancer and plans were
arranged for further care
- You were treated for your lower leg rash which was consistent
with vasculitis
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ yoM with PMHx of DMII, COPD, HTN, recent acute
necrotizing vasculitis of lower extremities and pT1bN0M0 glottis
squamous cell carcinoma with involvement of bilateral true vocal
cord s/p XRT(last in ___, presenting with respiratory
distress, s/p fiberoptic intubation w/ trach placement ___,
now found to have invasive SCC of the vocal cord in the setting
of laryngeal edema and lower extremity vasculitis. PEG was
placed pending decision of treatment for invasive SCC. | 121 | 77 |
15374797-DS-20 | 26,833,721 | You were admitted to the hospital after you sustained a gunshot
wound to the left arm and chest. You had a tube placed into
your chest to drain the collection of fluid. The tube was
removed and your vital signs have been stable. You are now
preparing for discharge home with the following instructions: | The patient was admitted to the hospital after he sustained a
gunshot wound to his left arm and chest. He underwent a cat scan
of the torso at an outside hospital where he remained
hemodynamically stable. On review of the cat scan he was
reported to have a left hemothorax without pneumothorax. FAST
examination was negative. A chest tube was inserted with about
170 cc of frank blood. His vital signs remained stable. As a
result of the injury, he sustained an ___ left rib fracture. The
patient was neuro-vascularly intact in the left upper extremity
despite the through and through wound. Because of the nature of
the injury, the trauma service was consulted. The whole bullet
was removed from his back and the wound was packed. The patient
was started on a course of antibiotics. The patient underwent
serial hematocrits and his vital signs were closely monitored.
The patient received intravenous analgesia for management of his
pain. After tolerating a regular diet, the patient was
transitioned to oral analgesia. The chest tube drainage was
closely monitored. On HD #2, the chest tube was placed to water
seal. The patient continued to have minimal drainage and the
chest tube was removed on HD # 3. The social worker met with
the patient to address his fears and concerns. The patient was
discharged home on HD #4 in stable condition. He was encouraged
to follow-up with the acute care service in 2 weeks. | 57 | 257 |
16648079-DS-7 | 22,214,032 | Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
You also underwent a cerebral angiogram to look at the vessels
of your brain. There was some injury to your vessels to your
brain.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may 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.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
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 symptoms 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 | Mr. ___ was brought to the OR on ___ from the ED for an
emergent sub-occipital craniotomy for evacuation of his
cerebellar hemorrhage. His intraoperative course was uneventful.
However, intraoperatively, his hemorrhage was thought to be from
an AVM. A CT/CTA of the head was obtained post op and showed
expected post operative changes and did not show AVM or
aneurysm. The plan is to obtain a repeat head CT in the morning
and an Angiogram on ___. Please refer to the operative for
further information. The patient was transferred intubated to
the ICU for close monitoring.
On ___, the patient was stable over night. He was extubated and
other than some mild confusion and a ___ nerve palsy on the
right, was stable neurologically. CT showed no evidence of
hydro. A diagnostic angiogram was planned for the following
day.
On ___, the patient's exam improved somewhat. His
nausea/vomitting was controlled.
On ___ Stable exam. Complained of GERD. EKG normal.
On ___ Ambulatory to bathroom. ___ eval recommending rehab.
On ___ He went for a diagnostic angiogram which showed fusiform
dilitation of the right distal vertebral artery.
On ___: He was workign with ___ and will need rehab. Overnight he
required 20mg of hydralazine and a 500cc fluid bolus.
On ___: he was stable and awaiting rehab palcement which was
complicated by his lack of insurance.
On ___ he was neurologically stable, was working with ___, and
was awaiting rehab placement and resolution of his insurance
issues.
Mr. ___ continued to recover well on ___. Physical Therapy
was asked to re-evaluate the patient because he was ambulating
with the nurse, versus previous evaluation where he needed
assistances with two people.
On ___ the patient was stable neurologically and there were
no significant events. He was pending rehab placement.
On ___, the patient remained neurologically and hemodynamically
intact. His staples were removed without any difficulty. The
inferior portion of his incision was red and warm to touch with
no drainage, he was starated on Keflex TID.
On ___, rehab placement was denied. ___ continued working with
the patient. Discussion was had with the family yesterday about
planning for 24hr care at home. Case manangement continued to
look for accessible benefits. On ___ patient was cleared for
home with 24hr supervision and teaching was done with the
family. He was discharged home with family. | 536 | 396 |
16666202-DS-13 | 25,285,457 | You were admitted with infection due to bile stone impaction in
your bile passages. You underwent endoscopic procedure for
removal of the stones followed by surgery for removal of your
gallbladder. Your infection was treated with antibiotics. You
should follow-up as outlined below with your PCP and with out
patient surgery clinic.
- please complete your antibiotic treatment as prescribed.
- You should get your blood tested for liver functions in two
weeks to make sure these have normalized.
- Please present to the emergency department or call your PCP
without delay for any fever, chills, worsening abdominal pain,
vomiting or any other symptom that concerns you.
-You do not need to take any antibiotics | The patient was admitted and made NPO, started on IV ceftriaxone
and flagyl. ERCP was done, sphincterotomy performed, sludge and
pus found consistent with cholecystitis and cholangitis. Started
clears, then made NPO for operation. Underwent lap chole, which
he tolerated well. On POD1, was advanced to regular diet, had no
N/V, passing flatus, ambulating, discharged home doing well. | 115 | 59 |
18057037-DS-24 | 22,698,077 | Dear ___,
___ you for choosing ___ for your medical care. You were
admitted after developing shortness of breath caused by a rapid
buildup of fluid into your lungs. You required a medication
called furosemide, or Lasix, to help remove extra fluid and
improve your breathing ability. You stated that you had bad
reactions to Lasix in the past, including GI distress and
diarrhea, but you tolerated it well on this admission. You were
then started on torsemide which you also tolerated well. You
were also started on antibiotics to treat a skin infection at
the site where you injured your right leg. You should continue
these antibiotics for 2 more days with end date ___.
It is very important you weigh yourself daily. Call your doctor
if your weight goes up by more than 3 lbs.
Upon discharge, please continue to take all medications as your
doctors have ___. Please continue to keep your
appointments with your doctors, and bring a copy of your
medication list to these visits.
Please inform the staff members at your living facility if you
develop any of the following: chest pain, trouble breathing,
increasing weight gain, loss of conciousness, abdominal
swelling, swelling of your legs, spreading redness around the
site of your leg wounds, fever, chills, night sweats, or any
other symptoms that concern you. | Mrs. ___ was admitted to ___ on ___ for management
of acute respiratory distress. She was determined to be in mild
heart failure and diuresed with bolus IV furosemide. Of note,
she had a TTE on ___ which identified new wall motion
abnormalities. She did not undergo catheterization during this
admission due to her advanced age and poor risk:benefit ratio. | 218 | 61 |
19518600-DS-15 | 24,597,605 | You were admitted to ___ on
___ with abdominal pain. On further evaluation using CT
scanning, you were found to have a small bowel obstruction. You
were given bowel rest (nothing by mouth), given IV fluids and a
___ tube was inserted for gastric (stomach)
decompression. As your obstruction resolved, your diet was
slowly advanced. Your obstruction has now resolved and you are
being discharged home with the following instructions.
- Please resume all regular home medications, unless
specifically advised not to take a particular medication.
- It may be beneficial for you to avoid raw, uncooked vegetables
and nuts in the future. These food items may contribute to
obstructive symptoms, e.g. abdominal pain, no passing of
flatus/gas, nausea, vomiting.
At your request, a CD of your abdominal CT scan has been
provided. | Mrs. ___ was admitted to the Acute Care Surgery service for
management of her acute abdominal pain. CT scanning revealed
signs of a small bowel obstruction with a transition point
visible in the vicinity of the more superior surgical clip in
the mid abdomen. The patient was kept NPO, given IV fluids and
a ___ tube was inserted for gastric decompression. Her
WBC as normal on admission, but she did have an elevated
neutrophil count of 88%. She was transferred to the inpatient
ward for further management and observation.
Mrs. ___ was observed over the following days for return of
bowel function and improvement of her clinical symptoms. During
this time, she was given intermittent non-narcotic and narcotic
analgesics for pain. Serial abdominal exams were conducted.
While NPO, her electrolytes were checked daily and repleted as
necessary. As her initial nausea improved and her NGT output
decreased, her NGT was removed on ___ (HD 5). Her diet was
slowly advanced thereafter. She has tolerated her diet fairly
well, but had some frequent episodes of diarrhea. The frequency
has now decreased at the time of discharge. She had no fever,
nausea during this time. Consideration of c. difficile was
suggested, but due to lack of recent antibiotic use, the
diarrhea was likely due to her post-obstructive intestinal
motility. The patient has voided without issue and was
ambulating independently.
At the time of discharge, Mrs. ___ was afebrile,
hemodynamically stable and in no acute distress. Follow-up was
scheduled with her PCP. | 133 | 262 |
15978672-DS-14 | 26,683,682 | Dear Mr. ___,
You were admitted to the hospital because you had abdominal pain
and diarrhea and you were found to have lower than normal white
blood cell count.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We tested you for infections and did not find any source of
infection to cause your diarrhea. It is likely you had a viral
infection causing diarrhea and had irritable bowel syndrome type
symptoms after this.
- We got an ultrasound and CT scan of your abdomen which was
overall normal and we did not find anything that would cause
your pain and diarrhea.
- You improved with a new medication called dicyclomine 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
- Seek medical attention if you have new or concerning symptoms
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | SUMMARY STATEMENT:
==================
___ M with hx HCC (s/p TACE in ___ and on ___ for
recurrence), CAD(s/p stent and pacemaker placement), HFrEF (EF
___, chronic pancreatitis, NASH/HCV Cirrhosis, CKD, and GERD
who presents with abdominal pain after recent TACE procedure on
___ (discharged on ___ and diarrhea.
ACTIVE ISSUES:
==============
#Abdominal pain
#Diarrhea
Patient presenting with abdominal pain after recent TACE
procedure on ___ with 3 days of diarrhea that resolved day
prior to presentation and no nausea/vomiting. He denied any
dietary changes, medication changes, recent travel or sick
contacts. Given his recent TACE he was advised to go to the ED
for further workup. In the ED, ultrasound and CT abdomen showed
no acute abnormalities including no signs of infection,
obstruction or ischemia. Lipase of 5 lowered suspicion of
recurrent pancreatitis. Given no acute intraabdominal processes
seen on imaging and self-resolution of patient's diarrhea, we
felt that this was most consistent with viral gastroenteritis
with abdominal pain from post-infectious IBS. An infectious work
up including blood culture and urine culture were negative, and
stool cultures were pending on discharge. Patient was discharged
given resolution of his diarrhea, and he was advised to continue
dicyclomine for his abdominal pain and to follow up for his
scheduled EGD on ___.
#NASH/HCV cirrhosis c/b esophageal varices
#___ s/p TACE (___)
Patient with a hx of NASH/HCV cirrhosis complicated by ___ s/p
TACE in ___ and again recently on ___ for recurrence. Last
EGD in ___ showed 4 grade I cords of distal esophageal varices
with no bleeding. No known history of ascites, SPB, or HE. MELD
on admission 14. Abdominal ultrasound on admission though
limited showed reversal of portal flow most likely due to portal
HTN, though may also suggest a portosystemic shunt. Patient did
not demonstrate any signs of HE throughout admission.
#Myelodysplastic syndrome
#moderate neutropenia
Patient with a hx of MDS with baseline leukopenia to ~2,
admitted with WBC 1.8 with ANC 880 (normally baseline >1500).
This may be in setting of dilution as he had received 25g of 25%
albumin vs. viral infection vs worsening MDS. On discharge, his
WBC was 2.3 and ANC 1060. He was advised to have close follow up
with his outpatient hematologist/oncologist.
CHRONIC ISSUES:
===============
#CKD
Baseline Cr ~1.4-1.5; on admission Cr 1.6 with improvement to
___ s/p 25g albumin.
#CAD
History of prior MI with known 1 vessel CAD s/p stenting and hx
of pacemaker placement. Continued on home aspirin and statin
#Chronic pancreatitis
Continued on creon 2 caps with meals as home medication was not
available.
#BPH: continued home finasteride
#Depression: continued home citalopram
#Hypothyroidism: continue home levothyroxine
#GERD: switched home omeprazole to pantoprazole given known
interaction of citalopram with omeprazole
TRANSITIONAL ISSUES:
====================
[]Continued abdominal pain that improved with dicyclomine on
discharge - likely postinfectious IBS. Discharged with
dicyclomine for symptomatic relief and will have scheduled EGD
on ___ ___.
[]Home omeprazole switched to pantoprazole as there is a
drug-drug interaction between citalopram and omeprazole
[]Continue to follow neutropenia in setting of known MDS, ANC on
discharge 1060
#CODE: FULL
#CONTACT: Name of health care proxy: ___
Relationship: wife
Phone number: ___
Cell phone: ___
Date on form: ___
Proxy form in chart: ___
Filed on Date: ___
Comments: alternate daughter ___ ___
___ on date: ___ | 207 | 535 |
17728504-DS-26 | 23,878,108 | You were admitted with a cough, and were found to have a lung
virus. Even though you still feel sick, you feel like you will
recover better at home.
We are sending you home with a visiting nurse to check on you.
Do not take your hydrochlorthiazide until you see the doctor
next week. Do not take your valsartan until you see the doctor
next week. | ___ w/pAfib presents with cough and shortness of breath due to
viral infection.
Viral Upper Respiratory Infection: CXR without pneumonia. Flu
negative.
She was treated symptomatically with nebs, tessalon,
guaifenicin. Ambulatory O2 sat was over 95%.
Pulmonary Edema: no hypoxia. no history of heart failure but
echo ___ ago with LVH and Borderline pulmonary hypertension.
Outpatient ECHO could be considered.
Acute dehydration
Acute kidney injury
Mild hyponatremia
She was noted to have acute kidney injury and hyponatremia.
Lactate was elevated. HCTZ and ___ were held during
hospitalization and at discharge. She was rehydrated in the ED.
She will have lab recheck on ___ to determine need to
restart these agents.
Paroxysmal atrial fibrillation: currently in sinus. Her arixtra
was held due to acute kidney injury, and was held at discharge.
Risk of stroke was discussed, but she did not want to consider
other agents. She will have lab recheck in 4 days, and likely
restart arixtra at that point. If her ___ is persists Coumadin
therapy should be considered.
Hypertension. She was normotensive, or slightly low during
hospitalization. As above, HCTZ and ___ were held. Amlodipine
low dose was restarted (may not have been taking at home) | 68 | 204 |
18923181-DS-7 | 23,375,788 | You were admitted to the hospital with severe back pain and
underwent extensive imaging. The CT and MRI scans showed
multiple lesions concerning for cancer including a collapsed
vertebrae at T-10 and a large liver lesion. We found a large
lesion in your left breast, and a biopsy from your liver
confirmed breast cancer. You will be following up with Atrius
oncology for your treatment plan and I have recommended that
they have you meet with palliative care to assist with symptom
management while pursuing treatment.
You had very high calcium, and received a drug called
pamidronate to bring the levels back down to normal. You also
received a course of radiation therapy to your back to reduce
your pain.
It has been a pleasure taking care of you. We wish you the best
of luck with this journey. | On admission, a CT torso was ordered, which showed a large liver
metastasis, an endometrial mass, and a mass in her left breast.
A biopsy was performed over the liver mass, which returned with
ER/PR + breast cancer; mammogram confirmed that the breast mass
(felt on exam) was likely malignant. Pelvis ultrasound suggested
a polyp. Atrius oncology was consulted, who will see her on
___ in clinic to discuss treatment options. For
her ___ and hypercalcemia, she initially received IV fluids,
then received a single dose of pamidronate. Her calcium
normalized. Radiation oncology was consulted for her spinal
metastases, and she finished 5 days of radiation therapy. She
was seen by NSGY in the ED, who recommended TLSO for comfort
though pt found the brace very uncomfortable. Pt was evaluated
by ___, and will discharge to a skilled nursing facility for
rehab.
HOSPITAL COURSE BY PROBLEM
1. Metastatic breast cancer: newly diagnosed and would benefit
from palliative care while pursuing oncologic treatment given
large burden of disease and symptoms. Outpatient follow up with
___ oncologist Dr. ___ oncology on ___.
2. ___ of malignancy: Resolved after pamidronate
and aggressive IVF. Repeat Calcium was normal while inpt but
should be monitored in the next ___ weeks.
4. T-10 metastasis with cord compression: Pt received palliative
radiation therapy to spine and has a TLSO for comfort as needed.
She will need ongoing ___ at SNF
5. Diffuse bony cancer-related pain. Pt is very sensitive to
pain meds including NSAIDs and would benefit from pall care in
conjunction with Oncology care. Pt was treated with Tylenol,
Lidoderm patch, Ibuprofen 800mg TID x 10 days with H2 blocker
and Oxycodone 2.5-5mg q4hr as needed for pain with aggressive
bowel regimen.
>30 minutes on day of discharge including time spent on
coordination of care in transition. | 141 | 300 |
16076363-DS-5 | 24,509,535 | Dear Ms. ___,
You were hospitalized due to symptoms of right sided weakness
and difficulty speaking 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:
1. Atrial Fibrillation
We are changing your medications as follows:
1. Start apixaban 2.5mg BID
2. Stop taking aspirin
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
Sincerely,
Your ___ Neurology Team | Ms. ___ is a ___ woman with past medical history of
HTN, HLD, and recent UTI and recent hospital admission for
gallstone pancreatitis, who presents with global aphasia and RSW
s/p TPA at 1646 at OSH. Patient was admitted to the stroke
neurology team for further monitoring and work up.
# Likely L MCA stroke Stroke
-Throughout her hospitalization, exam was notable for increased
responsiveness to light touch and voice with eye opening, fluent
speech in response to questions (with paucity of language in
response) without paraphasic errors or dysarthria, and ability
to move all extremities anti-gravity with BLE withdrawal to
noxious stimuli. -Patient had MRI which was negative for any
evidence of ischemic stroke, hemorrhage, or tumor. However, she
did have extensive atrophy and periventricular white matter
disease. Echocardiogram was negative for any mural thrombus,
however it showed stage II diastolic heart failure.
-Bilateral lenis were done for leg swelling and low grade
temperature which was negative for DVT's.
-Vessel imaging showed minimal atherosclerosis with open patent
vessels.
-On discussing with the family, they stated that she has been
lethargic and not at her baseline since she received a flu shot
in ___. After this, she became ill due to gallstone
pancreatitis and was admitted to ___ in ___ and received
an ERCP. Since this time she has needed assistance with walking,
moving, and transferring positions.
-Patient was switched from aspirin (considered aspirin failure)
to Plavix after hemorrhage was rule out on post TPA CT scans.
After this time, patient noted to be in paroxysmal afib and
after discussion with the family was switched to apixaban to
prevent further cardioembolic events.
-Patient also started on PO metoprolol 12.5mg bId. Patient only
had one episode of afib during hospitalization.
-Her initial NIHSS score at the OSH likely was due to deficits
in language and lethargy/in attention rather than significant
deficits.
-Patient recovered well and worked with ___. She was
recommended to be discharged to rehab.
#Pneumonia:
-Patient spiked fevers between 100-101.5. Mild leukocytosis.
Started on IV vancomycin, ceftriaxone. Blood, urine, cultures
and sputum did not grow anything. Patient treated with IV
antibiotics for 5 days and transitioned to PO augmentin for last
two days of treatment. Patient recovered without any fevers or
infectious signs on discharge.
#Sleep disturbances:
-Patient noted to be very somnolent during the day , which
family has endorsed , neuro checks were suspended during night
once her examination had stabilized. This helped the patient
stay awake during the day time. One consideration was to start
modafinil however patient improved after she slept through the
night with minimal interruptions.
#New onset afib:
-See above. Patient started on eliquis and PO metoprolol. Had
one episode of captured paroxysmal afib on telemetry and EKG
during hospitalization otherwise remained in sinus rhythm.
Transitions of care:
1. Patient to follow up with stroke Neurologist on scheduled
appointment date
2. Patient to stop taking aspirin, and to take apixaban
3. Patient to stop taking atenolol, as she was switched to
metoprolol 12.5mg BID for better heart rate control given her
new onset afib
4. Patient to follow up with her PCP ___ ___ weeks.
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? () Yes - (X) No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL =95 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: ()
Antiplatelet - (X) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (X) Yes - () No - () N/A | 273 | 746 |
19921471-DS-19 | 24,078,680 | Dear Mr. ___,
You were admitted to ___ due to
pain on urination and suprapubic pain. You were found to have a
urinary tract infection, however cultures we were unable to
identify any organisms. Given your history of recurrent UTIs,
you were given a 7 day course of antibiotics and started on
oxybutynin, a medication to help with bladder urgency. You
stayed in the hospital until the antibiotics were completed.
It was a pleasure taking care of you at ___. If you have any
questions in the care you received, please do not hesitate to
ask.
Sincerely,
Your ___ Care Team | Mr ___ is a ___ yo M w h/o papillary RCC s/p L nephrectomy,
bladder cancer, DM, CKD (Cr 1.2), presenting for evaluation of
recurrent UTI.
# Recurrent UTI: Has been treated for UTI at least 3 times in
past 1 month without resolution and with cultured organism.
Given leukocytosis and UA with positive WBC/bacteria/nitrates,
as well as leukocytosis there was a strong suspicion that this
represented infection. Patient underwent renal US shows bladder
wall changes (possible CA), but no signs of pyelonephritis or
renal dysfunction. Was started on CTX. Patient was discussed
case with ___, who recommend treating UTI, without
indication for continuous bladder irrigation or further
investigation. Speciated urine cultures, but only grew mixed
flora with gram + cocci concerning for skin flora. Patient was
transitioned to Cefepime given history of re-current UTIs with
no identified species. Straight cath UA was sent and grew no
colonies. Given recurrent history and lack of speciation, the
decision was made for the patient to complete a 7 day course of
cefepime. At discharge, the patient no longer had pain or
difficulty with urination, and no longer complained of
suprapubic pain. He was discharged with plans to follow up with
his PCP and ___ appointment.
# ___ on CKD: Cr baseline around 1.2, Cr 1.6 on admission.
Patient was given 1L IV and had improvement to 1.3 suggesting
pre-renal disorder. Given patients history of weak urine stream,
performed post void residuals to ensure no post-renal
dysfunction. Did not require straight catheterization.
Underlying CKD likely ___ DM, HTN, and only having one kidney.
Cr at discharge was 1.4.
# Bladder TCC: Patient with bladder cancer for several years. He
is s/p cystoscopy and TUR of bladder tumor ___. Renal US
earlier this month showing bladder wall irregularity concerning
for tumor recurrence. Inpatient Renal US showed no signs of
hydronephrosis, but did reveal markedly abnormal appearance of
the bladder with multiple mass-like
protrusions from the bladder wall. These areas could be
consistent with post
resection changes versus recurrent tumor. Urology was alerted,
patient has planned follow up with outpatient Urologist, Dr.
___. | 100 | 350 |
16852221-DS-20 | 22,774,870 | Dear Mr. ___,
You were admitted to fix your hip after a fall. Unfortunately
your heart failure is very severe and you required medical
support after surgery to support your hearts function. The
decision was made to treat your pain and support your needs
making you as comfortbale as possible as you come to the end of
your life. | Mr. ___ is a ___ man with PMHx of cardiomyopathy likely
secondary to cardiac amyloidosis, sCHF (EF30%; on supplemental
___ NC), sp PPM (?CHB), chronic afib, AS (valve 0.6cm2),
HLD, CKD (Baseline Cr ___, and HTN, who presents with R hip
fracture after a mechanical fall.
#) Right Greater Trochanter Fracture:
Repaired ___ by orthopedic service.
#) Congestive Heart Failure secondary to suspected cardiac
amyloidosis:
He was transferred from ortho service to heart failure for
diuresis/optimization for orthopedic surgery, and he continued
to be hypotensive to SBP's of ___'s (although able to mentate
normally at these pressures) with cool limbs. He was
transferred to the CCU for inotropes to allow for diuresis.
Post-surgery he was unable to be weaned from pressors. Mr. ___
and his family sat down for a family meeting with the primary
CCU team and palliative care team and he was transitioned to
CMO. Pressors were weaned at that time, and his blood pressures
returned to ___ of 70's. Monitoring was stopped, aside
from RR and manual HR. He initially mentated well, but then
experiened increasing confusion and decreased responsiveness as
the narcotic dosing required to control his pain.
#) Urinary Tract Infection:
He had a UA positive for infection, initially on ceftriaxone,
later transitioned to cipro.
#) Ileus/Nausea/Vomiting:
On ___, he developed severe abd pain, with decreased bowel
sounds. KUB was unable to exclude free air but ileus was
suspected, repeat abdominal film later was concerning for SBO vs
ileus, but that afternoon he was transitioned to CMO and he was
treated symptomatically with ondansetron and enemas.
#) CMO: Patient made CMO after being unable to be weaned from
pressures, worsening nausea/vomiting symptoms, and a family
meeting with palliative care. He expressed more despondent
feelings and was refusing all care. Levophed and tele
discontinued. No further lab draws. SubQ narcotics for pain
control. Ativan PRN for anxiety, glycopyrolate PRN for
secretions.
- If he appears to decompensate: call sons cell at ___
or family line at ___ at night
#) Other Chronic Medical Issues: holding therapy given CMO | 58 | 343 |
15774521-DS-17 | 23,180,663 | Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted with concern for an issue
with your gallbladder. However, when you arrived to BID your
pain had resolved and you did not show signs of infection. Your
liver function and gallbladder function tests were normalized.
We do think you possibly had a gallbladder stone that was lodged
in your draining system, but this has since passed. An ERCP
(endoscopy) was considered but due to your heart risks it was
not needed unless emergent/urgent.
There is a chance you could develop symptoms again. If you
develop sudden pain again that lasts for >4 hours, is
accompanied by nausea/vomiting, fever, or yellowing of the skin
or eyes, please call return to the ED.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Please continue your salt restriction and current
cardiac medications. | Mr. ___ is a ___ with h/o ischemic cardiomyopathy LVEF
of 20% ___ BMS to LCX, DES to LAD, mitral valve repair/three
vessel CABG (LIMA to LAD, SVG to OM, SVG to PDA)on Plavix, pAF
on amiodarone, ___ biventricular ICD implant in ___, RA
thrombus on apixaban, drug induced liver cirrhosis, T2DM with
recent admission dc'd ___ for acute CHF exacerbation presented
from OSH for acute abd pain and concern for choledocholithiasis
or cholecystitis.
# Abdominal Pain -resolved RUQ on admission, sudden onset and
offset x3 hr.
Relieved with pain medication. No nausea, vomiting, diarrhea,
icterus. LFTs WNL which is improved from previously. CT outside
hospital with ?cystic duct stone. Imaging ?cholecystitis but the
patient has no RUQ pain, benign abd exam, eating, and no
wBc/fever. We monitored for 24 hours without any abd pain or LFT
elevation at time of discharge
- imaging second opinion by radiology however there were no
images sent from ___. Discussed with patient and due to no
further complaints would like to d/c today
- ERCP/Cards involved and no further intervention. MRI is not
FDA approved/compatible for MRCP and without any further LFT
elevation or pain it benefits to not outweigh risks for ERCP
with his heart status. He did have a recent clean cath in the
last 3 months so if euvolemic and emergent situation arises this
may be reconsidered.
___ on CKD stabe III0 resolved. - baseline 1.5-1.7. Cr 2.2 at
OSH wth Cr
1.9 then baseline 1.6 on discharge.
# CORONARIES: ___ 3v CABG (LIMA to LAD, SVG to OM, SVG to PDA)
# PUMP: EF 20%
# RHYTHM: NSR/bi-V paced
#Chronic Systolic CHF Exacerbation:
HFrEF with LVEF 20% on last TTE. Extensively followd by
Cardiology. Appreciate their evaluation.
- Metop succ 6.25 XL qd, spironolactone 12.5 qd, Lasix 120 BID
- no ACE-I/hydral as does not tolerate afterload reduction
#Cirrhosis:
Patient has liver biopsy consistent with cirrhosis with features
of drug induced injury. No encephalopathy.
- f/u with ___ for liver/heart transplant eval.
#Paroxysmal Afib/atrial tachycardia:
Patient has known paroxysmal atrial fibrillation and is ___ BiV
pacemaker placement, cardioversion on ___. ___ EP ablation.
Doing well. No indication for telemetry. Continue apixiban
# CAD ___ CABG:
LIMA to LAD, SVG to OM, SVG to PDA. LHC demonstrated stable CAD
with patent grafts in ___. No CP. Continued Plavix and
pravastatin 40mg daily.
# H/o Right Atrial Thrombus: Continued apixaban as above.
# Type II Diabetes Mellitus:
Previously discharged on glargine 25U qHS, novolog 16U
# Anemia:
Likley ___ CKD. Hgb at baseline of ___ throughout the admission.
# Back pain:
Continue oxycodone 5 q4
# DVT ppx: on apixiban
# Diet: Regular , 3g salt restriction
# Precautions: None
# Code status: DNR per patient request, extensively discussed
with
patient how he does not want any CPR and/or intubation. This may
be disagreement with his wife but was verbalized with me without
hesitation by the patient.
# Contact Wife ___ number: ___
Cell phone: ___ | 148 | 492 |
10176833-DS-6 | 20,607,200 | 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:
- TDWB RLE in unlocked ___, ROMAT
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 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right tibial plateau fx and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF right tibia with anterior
compartment release, 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
NVI distally in the right lower extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 201 | 257 |
19171754-DS-18 | 28,171,826 | Ms. ___,
It was a pleasure taking care of you this hospitalization. You
were treated for cholangitis, and you underwent ERCP and you had
a stent placed in the common bile duct. This will allow the
common bile duct to drain both from the gallbladder and the
liver better.
Your liver tests were elevated but are trending down. I have
started you on ciprofloxacin and flagyl which you should take
for a total of 7 days for treatment of cholangitis.
Please be advised, I recommend close follow-up with your
outpatient PCP you have an appointment next week with your
oncologist for follow-up of the pancreatic and biliary changes.
Thank you,
Your ___ team | ___ female with history of metastatic pancreatic cancer
on protocol ___ and recurrent cholangitis s/p stent placement
who presents with fever. | 110 | 21 |
11917055-DS-14 | 28,116,873 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for pain in your neck and
chest, and given your changes on electrocardiogram, we were
concerned for a problem with blood flow to your heart. A cardiac
catheterization was performed which showed 2 blockages in your
arteries. These were stented with 2 bare metal stents. Your
symptoms resolved and you were monitored after the procedure.
Additionally, you received 3 units of PRBCs during this
admission for a low blood count.
Please make the following changes to your medications:
START Aspirin 325mg daily
START Plavix 75mg daily
STOP Omeprazole as this can interfere with Plavix, an important
medication to prevent blood clots forming around the new drug
eluting stent.
START Ranitidine 150mg daily. This medication works similarly as
omeprazole and so has been substituted for it. | ___ M with transfusion dependent MDS and CAD s/p CABG who
presents with unstable angina in setting of anemia.
# Unstable angina: Symptoms correlate with ST depressions on EKG
that resolve with SL nitroglycerin and resolution of chest pain.
After discussion with cardiology, patient was started on IV
heparin and underwent cardiac catheterization which showed 90%
lesion of the graft to SVG-OM (90% lesion) and 90% lesion of the
jump diag graft (SVG-diag-LAD), both areas of which was stented
with BMSs. Patient was noted to have some distal embolization
during cardiac catheterization. CKMB were trended and decreased
as expected in the day s/p catheterization. Transfusions of pRBC
were administered with a goal hematocrit of >30% (patient
received 3 transfusions during admission). His aspirin was
increased from 81mg to 325 mg daily, and he was started on
plavix 75mg daily. He was not placed on a statin or ACEI given
his age and comorbidities/prognosis (MDS, likely has lung cancer
and also has a history of allergy to several statins).
# Low-grade temperature: Patient developed low-grade temperature
of 100.2 one evening 2 days prior to discharge. On infectious
review of symptoms, the patient denied SOB, abdominal pain, n/v,
diarrhea. Has had a persistent cough for months, not worse. He
was experiencing some pleuritic left shoulder pain with deep
inspiration and leaning on his left side (not associated with
exertion), however CXR was unrevealing. His exam does not reveal
source of infection (lungs are clear). Given his neutropenia and
concern for infection, he was monitored for an additional day
and was afebrile x24hrs prior to discharge. UA was negative.
Urine and blood cultures were pending/NGTD on discharge. No
sources of fever became apparent. Low grade fever may be due to
suspected malignancy. Outpatient CBC was planned to monitor this
closely.
# Anemia: Known to be tranfusion dependent MDS, but has required
more frequent transfusions lately. Total bilirubin was increased
in the setting of known Gilberts. Haptoglobin normal.
Reticulocyte count elevated at 4.9%. Patient received 3 units of
PRBCs with a goal hct in the high ___, given CAD and chest pain.
Given low grade fever, he was not transfused prior to discharge,
but outpatient CBC was planned to monitor hct level closely.
# Thrombocytopenia: Likely from MDS vs ITP. Stable at baseline
and no evidence of bleeding.
# Leukopenia: WBC ranged from 1.7-2.7. Neutrophils on the day
prior to discharge were 63%. Grnaulocyte count was 1360 this
admission, so patient was kept on neutropenic precautions.
# Lung mass: Presumed to be lung malignancy given smoking
history. ___ be contributing to worsening fatigue. Patient was
scheduled with ___ f/u on ___ (4 days from discharge). | 136 | 441 |
10781985-DS-20 | 22,939,090 | Dear Mr. ___,
.
It was a pleasure taking part in your medical care. You were in
the hospital because your kidneys were not working well. We
tried IV steroids to help your kidneys but unfortunately you
still required dialysis. You will continue to have dialysis in
rehab and then as an outpatient. You should call your
nephrologist, Dr. ___, to schedule an appointment after
discharge.
.
You also had a urinary tract infection and an infection in your
blood. We treated you with IV antibiotics. You should continue
the antibiotics to complete a 2 week course on days that you get
dialysis.
.
You were also noted to be anemic. You had a small amount of
blood in your stool so you underwent an EGD to rule out bleeding
from you upper GI tract. This showed gastritis (irritation of
the stomach) but no bleeding. You should follow up with Dr.
___ gastroenterologist, as scheduled below to discuss
repeating a colonoscopy.
.
We have made multiple changes to your medications. Please see
the updated list below.
.
Please attend the follow up doctor's appointments as scheduled
below.
.
We wish you all the best! | ___ year-old male with recurrent minimal change disease, diabetes
Type II, and hypertension here with nephrotic syndrome and
worsening ___ despite high dose prednisone therapy with minimal
response to IV solumedrol now on dialysis. Hospitalization
complicated by anemia, thrombocytopenia, UTI, bacteremia.
.
# Acute renal failure/Recurrent nephrotic syndrome: The patient
has had 2 or 3 prior episodes of nephrotic syndrome, caused by
minimal change disease, which had previously been responsive to
steroids. During this relapse of nephrotic syndrome, he was on
PO prednisone 60 mg daily for 14 days prior to being admitted,
yet he was not responding to the PO prednisone. Upon admission,
he was transitioned from PO prednisone 60 mg daily to IV
solumedrol 125 mg daily. His creatinine initially trended down
with IV solumedrol but it then reached a plateau that was
elevated at baseline at ~5 up from baseline of ~1 in ___.
Mild ATN may have contributed to ___. Because patient failed to
regain renal function on solumedrol, hemodialysis was initiated
with plans to continue on discharge. He was transitioned from
Solumedrol IV to Prednisone 60mg which he will likely require
for several months with no taper. Patient was started on
nephrocaps and low K diet. He was also treated with PPI, and
Bactrim was started for prevention of Pneumocystis pneumonia.
.
#Anemia: On admission, hct was 36.8. The patient has a history
of iron-deficiency anemia, on iron supplementation. He also has
a history of gastritis which was previously evaluated by
endoscopy. The patient had an MCV of 74 which is consistent with
microcytic anemia with a possible iron-deficient etiology. Fe
studies showed anemia of chronic disease possibly from a renal
etiology. Retic count was 0.6, indicating that a component of
the patient's anemia is caused by his kidneys not producing
enough EPO in the setting of CKD or his bone marrow not
responding to the EPO. GNR bacteremia (see below) may have also
contributed to anemia. During admission, hct trended down.
Transfusion threshold was hct 25 and he required 2 units of
pRBCs over the admission. He had guaiac positive stool x1. Given
history of gastritis, there was concern for possible UGIB. An
EGD showed that the patient has mild gastritis but no active
source of bleeding. Gastric biopsy results pending at time of
discharge. He will f/u with GI as outpatient for possible
colonoscopy and EUS to evaluate the possible lipoma in the
second part of his duodenum.
.
#Thrombocytopenia: Platelets trended down from baseline 200 to
nadir of 89. The dx included infection, HIT, hemodialysis, DIC,
TTP-HUS, and post-transfusion purpura. In setting of GNR
bacteremia and low reticulocyte count, it is likely that his
bone marrow was being suppressed. Initially, heparin sq was
held, but HIT type 2 antibody test was negative. At that time,
heparin SQ and for dialysis line were re-started. No extensive
bruising, has no hematuria, has no bloody diarrhea and normal
hemolysis labs. Normal FDP fibrinogen coagulation panel. On
d/c, platelets were 167.
.
#UTI, bacterial: U/A was indicative of infection. Urine culture
showed Klebsiella pneumoniae which was pan sensitive. At this
time, the foley was pulled. Patient was initially treated with
Cipro, but was then transitioned to cepfepime --> ceftriaxone
given bacteremia (see below).
.
#Bacteremia: On ___, blood cultures grew out GNRs, found to be
klebsiella, pan sensitive as organism in the urine. Thus,
source of bacteremia was UTI. First neg blood culture on ___.
The patient has been on ceftriaxone 1 g Q24h to treat this
infection. The patient will need to be on antibiotics to treat
his bacteremia until ___ for a 2 week course. On d/c, he will
switch from ceftriaxone to Ceftazadime per HD protocol (1g after
HD).
.
#Hypertension, benign: The patient has a history of essential
Hypertension. His increase in volume status was likely
contributing to his elevated BP as SBPs were better controlled
after dialysis sessions. Patient was well controlled on
hydralazine 25mg q6h in house, but was transitioned to
amlodipine 5mg qd as it is more feasible for him to take a daily
drug at home. Will need to continue to titrate amlodipine as
needed.
.
#Diabetes, type II, uncontrolled, without complications: Blood
glucose was difficult to control in the setting of high dose
steroids as above. Initially, he was managed with Lantus in the
morning in addition to insulin sliding scale. However, sugars
were still elevated and ___ was consulted--recommended
changing to NPH and helped with sliding scale. He will need to
f/u with ___ as outpatient as glucose will be particularly
difficult to control when prednisone is tapered.
.
#Hypercholesterolemia: Continued home simvastatin 40 mg PO
daily.
.
#GERD: Temporarily on IV PPI when ?UGIB, then transitioned back
to home omeprazole 20mg qd.
. | 187 | 783 |
13237895-DS-10 | 22,563,680 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for dizziness and lightheadedness which we
believe was caused by Benign Paroxysmal Positional Vertigo. You
were evluated by Neurology and Physical Therapy. You symptoms
improved somewhat during your stay, and it was felt that you
could be discharged home safely. Please use a walker for the
time being until your symptoms fully resolve.
Please follow up with your primary care doctor and vestibular
physical therapy.
Sincerely,
Your ___ Team | Ms. ___ presented to the ED with 7 days of intermittent and
worsening positional dizziness and lightheadedness. Her exam was
notable for positive ___ to the right which, along with
history was highly suggestive of BPPV.
ACUTE ISSUES
# Dizziness: The patient relayed a history of positional
dizziness despite fluid resuscitation as an outpatient. This was
thought to be BPPV given positional nature and ability to elicit
symptoms with ___ maneuver (by neurology). She was seen
by Neurology who recommended vestibular ___. She was seen by
physical therapy who performed an Epley Manuever with
improvement of symptoms. Posterior circulation hypoperfusion was
ruled out with a negative CTA head/neck. She was able to
tolerate PO and ambulate with a walker.
# Hyponatremia: The patient presented with a mild hyponatremia
of 131, which was thought unlikely to contribute to current
symptoms. Patient has had significant hyponatremia before and
relayed that she is on a 2L/day fluid restriction. Her current
presentation was likely hypovolemic hyponatremia as patient has
no hx of heart failure to suggest hypervolemic, and patient is
on two diuretics. Lasix was held given history that patient is
decreasing lasix as an outpatient and that her leg swelling is
improved with compression stockings. She was discharged with a
script for these. Her sodium was 133 on discharge.
# Chronic suppressive therapy for UTI: The patient is on
ciprofloxacin for chronic suppressive therapy for UTI (hx of
frequent UTIs). Patient had no current symptoms of dysuria, no
elevated wbc, or evidence of SIRS. UA only showed leuks and few
bacteria. Therefore this was deemed as asymptomatic bacteruria
and not treated with treatment doses of antibiotics, but instead
prophylactic doses were continued. Her final urine culture
resulted after discharge which showed >100K Citrobacter Koseri,
which was resistant to ciprofloxacin. Outpatient follow-up is
needed.
CHRONIC ISSUES
# DM: Stable. Outpatient glimiperide and saxagliptin held in the
inpatient setting in exchange for insulin sliding scale.
# HTN: Normotensive currently. Lasix held as above.
# CKD: Creatinine 1.0 today. Can be followed as outpatient
TRANSITIONAL ISSUES
- Please assess urinary symptoms as an outpatient given positive
culture with organisms resistant to ciprofloxacin (her current
treatment) to determine if she needs to be treated for a UTI
- consider altering prophylactic antibiotic choice since her
isolate, CItrobacter Koseri, was resistant to ciprofloxacin
- please consider avoiding fluoroquinolones in this patient as
they are more likely to cause delirium in the elderly
- please consider using an ___ for this patient with
diabetes if not contraindicated | 84 | 410 |
16522501-DS-20 | 24,987,800 | 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:
- 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.
- Short arm cast should remain on until follow up. Please keep
cast dry
ACTIVITY AND WEIGHT BEARING:
- NWB in LUE and WBAT LLE
Follow Up:
Please follow up with ___ in the orthopedic trauma
clinic ___ days post-operation for evaluation. Call
___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission and any new medications/refills.
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 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left distal radius and left hip fractures and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for ORIF of the left
distal radius and L hip, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the LLE and NWB in LUE,
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. | 299 | 246 |
11907163-DS-3 | 25,644,899 | Dear Mr. ___,
You were hospitalized due to symptoms of right-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.
Your risk factors for stroke are:
Hypertension
Hyperlipidemia
In order to prevent future strokes, we would like you to use a
heart monitor for 30 days to assess for any rhythm problems,
specifically atrial fibrillation.
Please continue taking your medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Mr. ___ is a ___ year old R-handed man with well-controlled
epilepsy, CAD s/p DES 3 months ago, HTN, HLD who presented with
acute onset right-sided weakness. Initial exam was notable for
right-sided arm/leg weakness and mild ataxia. Initial labs were
normal. ___ was negative for acute intracranial process. CTA
was notable for possible mild short segment narrowing proximal
to left MCA bifurcation, but negative for stenosis, occlusion or
aneurysm of the major vessels of the neck. Two thyroid nodules
were also identified incidentally. Thyroid ultrasound showed two
2.5 cm nodules. TSH normal at 2.3. Recommendation was for
outpatient FNA vs. 6 month repeat ultrasound.
Mr. ___ was admitted to the Neurology stroke service for a
suspected ischemic stroke. MRI head w/o contrast revealed acute
to subacute infarctions involving the left corona radiata and
left occipital lobe as well as chronic microangiopathy. Stroke
risk factors were checked, indicating HbA1c of 4.5 and LDL of
49. Echocardiogram was significant for LVH and left atrial
dilatation. Mr. ___ was evaluated by ___ who recommended
discharge to acute rehab facility given difficulties with
mobility and coordination. Neurologic exam before discharge was
significant for improved motor strength but persistent right
dysmetria.
Mr. ___ was told to continue taking his home medication,
including dual anti-platelet therapy (aspirin and Plavix) as
well as atorvastatin. He was prescribed a heart monitor for 30
days to assess for atrial fibrillation. He will follow up with
his neurologist (Dr. ___ and PCP (Dr. ___, both at ___.
--------------- | 241 | 250 |
19897675-DS-9 | 20,344,270 | Dear Mr ___,
You were admitted for worsening rash and arthritis. We feel
that the rash and arthritis are probably inflammatory (not
infectious or contagious in origin) and likely are related to an
autoimmune process. For this reason, we started you on
steroids, with significant improvement in your joint swelling.
You will need to be on prednisone 30 mg X 3 days, 20 mg X 3
days, 10 mg X 3 days, 5 mg X 3 days, then can stop. Rheumatology
will contact you regarding a follow up appointment next week. | This ___ year old female with a questionable history of psoriasis
(no psoriatic lesions were noted) presenting with polyarthritis
and palm and sole rash that was characterized as eruptive and
pustular. Dermatology saw Ms ___ and ___ that the rash
could be consistent with pustular psoriasis even though she had
no risk factors (did not start using steroids previously and has
unclear history of psoriasis). Biopsy was consistent with this
diagnosis. However, biopsy cannot distinguish between this and
keratoderma blenorrhagicum which is associated with HLA B27
seronegative spondyloarthropathies, especially reactive
arthritis. G/C and chylamydia were negative, however she did
describe a preceeding sore throat and sick contacts with fever
and sore throat and her ASO titers returned mildly positive.
Given increasing joint swelling in wrists bilaterally with no
improvement with NSAIDs, we started her on PO prednisone taper.
She will see Rheumatology as an outpatient. Plain films were
obtained of the left hand with no acute changes. She was
discharged on prednisone with significant improvement in
arthritic symptoms and synovitis and stable rash. Syphilis and
parvovirus titers returned negative. A single blood culture of
6 showed gram + organisms in clusters later identified as
coag-negative Staphylococcal species (contaminant). | 94 | 210 |
10778034-DS-16 | 28,078,318 | You were admitted to ___ Neurosurgery service for further
evaluation of your headache. Your non-contrast head CT was
stable and showed no new signs of bleeding. You were kept
overnight for observation. As you remained neurologically
stable, you are being discharged home with the following
instructions.
- As instructed by your Neurologist, do not take more than one
dose of either Fioricet or Tylenol three times during the week.
If you do, you are risk for rebound headaches.
- You are being discharged on a Medrol dosepack which could help
in diminishing your headache symptoms.
- You are also being started on Gabapentin at the recommendation
of Neurology. This is used to help treat your left facial
tingling and headaches.
- If you have any questions or concerns, you may call the
Neurosurgery office or your Neurologist. | Mr. ___ was admitted to the Neurosurgery service for further
management of his headaches. A CT head was performed while the
patient was in the ED and showed no acute hemorrhage. He was
started on steroids and gabapentin to reduce his headache pain
and left facial tingling.
On the following morning, Mr. ___ continued to have his
headache, but it was much better controlled. He was discharged
home with prescriptions for a Medrol dosepack and gabapentin.
As advised by Neurology, he was instructed to not take more than
three doses (per week) of Fioricet or Tylenol for his headaches
due to concerns of rebound headaches.
Per his discharge instructions, Mr. ___ should follow up with
Dr. ___ Dr. ___ previously
scheduled.
At the time of discharge, Mr. ___ was afebrile,
hemodynamically and neurologically intact. | 138 | 141 |
16711329-DS-7 | 29,021,886 | Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
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:
- weight bearing as tolerated 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 R femur fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for R retrograde femoral nail, 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 with 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 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. | 351 | 257 |
11057803-DS-17 | 28,345,095 | Dear Ms. ___,
You were admitted to the hospital with confusion because of a
urinary infection. This improved with antibiotics. You were also
found to have an abnormal heartbeat when you came to the ER
called "A fib." You had an echo that showed an EF of 75% with
moderately thickened mitral valve leaflets. We started you on a
blood thinner called Coumadin to prevent strokes which will be
titrated at the rehab facility.
It was a pleasure to take care of you,
Your ___ team | ___ hx Htn, HLD, OP, rheumatic heart disease and remote hx
breast
ca presents with confusion and inability to get up, found to
have
a UTI as well as new onset AFib with RVR.
#Encephalopathy, poor mobility
#Urinary Tract Infection - Coagulase negative Staph
: Patient admitted with altered mental status thought to be
secondary to progressive, chronic dementia and cognitive
impairment with an acute encephalopathy secondary to her urinary
tract infection. She lives at home alone and has had a poor PO
intake lately
-Treated with ceftriaxone (___)
-Grew staph coagulase negative bacteria in her UA
-d/c on Augmentin (___) to complete a 7 day course
-plan to discharge patient to rehab facility to improve her
functional mobility
#New onset AFib with RVR: In the ED, patient had HRs in the 160s
and an EKG with ischemic changes. Her troponins were negative
and her HR improved to the 100s-110s with fluids. Initially, son
and family reluctant to start anticoagulation in the setting of
altered mental status but anticoagulation with Coumadin was
started on ___. CHADSVASC 4. Coumadin was used as patient with
valvular atrial fibrillation. Patient with difficult to control
HRs in the 130s-150s intermittently and metoprolol was
uptitrated until she was discharged with metoprolol 37.5 mg
every 6 hours.
-transition to 75 mg PO every 12 hours if BP>110/60
-patient has been asymptomatic with her high HRs.
-held ASA 81 mg daily in the setting of starting AC, but can be
restarted with primary care physician
-___ further evidence of a myocardial infarction
-TTE done that showed thickened mitral valves, EF>65%
-Lipids, A1C, and TSH normal.
******Please check INR three times a week on: ___
to titrate Coumadin. Patient currently taking 2.5 mg daily with
an INR of 1.1; goal INR ___
#Hypoxia - Patient with lower oxygen saturations between 92-94%
on RA. Patient carries no formal diagnosis of COPD however her
smoking history and lung exam are consistent with what seems to
be COPD. XRAY did not show any consolidation to suggest
pneumonia. Oxygen saturations remained stable.. Doubt any acute
CHF,
although she has some trace ___ swelling clinically she looks
euvolemic presently
#Hypertension/HLD
-continued losartan 50 mg PO daily
-continued Atorvastatin 10 mg daily at bedtime
#Osteoporosis - reportedly Rx forteo (teriperatide) and has been
non compliant with this, not sure if she is taking it.
Compression fracture in thoracic spine noticed as indicental
finding on CXR and related to pain with movement
- Vitamin D deficiency is new Dx, replace with 50K units q
___
- PTH
#Anxiety/depression - not formally listed in her history and son
does not confirm these, but she takes sertraline and Xanax at
home. C/w sertraline 50 mg daily. Hold Xanax ___ some confusion.
#Question of urinary incontinence - takes oxybuytynin at home,
held in the hospital secondary to concern of anticholinergic
effects.
#Code Status: Full
#Communication - patient's son ___ ___.
DISCONTINUED MEDICATIONS:
Alprazolam 0.25 mg PO TID PRN anxiety
NEW MEDICATIONS
Acetaminophen 1000 mg PO TID PRN for mild-moderate pain, fevers
Albuterol Neb q6h PRN for wheezing/shortness of breath
Amoxicillin-Clavulanic Acid ___ mg every 12 hours x 3 more doses
- end on ___
Metoprolol tartrate 37.5 mg every 6 hours - CAN CHANGE TO 75 mg
every 12 hours if blood pressure is greater than 110/60
Vitamin D 50,000 units PO once a week
Warfarin 2.5 mg daily at 4PM
HELD MEDICATIONS - follow up with your primary care physician
-___ 81 mg daily
-oxybutynin chloride 5 mg daily
CONTINUE THESE MEDICATIONS:
Atorvastatin 10 mg at bedtime
Losartan 50 mg daily
Sertraline 50 mg daily
Clobetasol 0.05% solution BID to scalp | 87 | 575 |
19670384-DS-56 | 22,898,422 | Dear Ms. ___,
You were admitted to the hospital because you were having chest
pain and shortness of breath. Our tests for blood clots and
heart attacks were all normal. Your pain improved, and we felt
it was safe to be discharged and follow up with your
cardiologists for a possible echocardiogram or stress test.
Please call your cardiologist and make an appointment in the
next few weeks for an echocardiogram or stress test. Please also
get your standing kidney labs checked on ___ or ___ at
your usual site; they will be forwarded to your kidney doctor.
Your dose of Prograf was decreased from 2mg twice a day to 1.5
mg twice a day based on your blood levels.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team | HOSPITAL COURSE
===============
___ yo F with PMH CAD/NSTEMI, FSGN s/p renal txp in ___ (acute
rejection ___, DVT/PE on Coumadin until ___ (stopped ___
hemarthrosis), TIA and 2 lacunar strokes, HTN, HL presented as
OSH transfer from OSH with chest pain and dyspnea on exertion.
Was empirically started on heparin, but V/Q scan and CTA
negative for PE or dissection. Troponin negative x3 with no EKG
changes. Pain decreased but still present at time of discharge,
patient advised to follow up outpatient with cardiologist for
possible echo or stress test. Creatinine bumped from 1.8 to 2.3
on discharge in setting of CTA; patient to have labs checked
___ or ___ with results followed up by transplant
nephrology.
ACTIVE ISSUES
=============
# Chest pain
Patient presenting with chest pain consistent with previous PE.
Low clinical suspicion for dissection. Patient with history of
MIs but pain not consistent, trops negative x 2, and no EKG
changes. Both V/Q scan and CTA negative for PE, so stopped
empiric heparin gtt on ___. Will f/u with cardiology
outpatient for possible stress test.
# Acute kidney injury
Creatinine 2.3 on ___ from 1.8 day prior, likely in response
to contrast on ___ CTA. 1L NS on ___ to hydrate; patient to
have labs checked ___ or ___ with results followed up by
transplant nephrology.
# ESRD s/p renal transplant: Admission Cr of 1.8 from a baseline
of 1.8-2.0. Patient took double dose of immunosuppression on
___, so pending levels readjusted doses as below.
- Prograf was decreased from 2mg twice a day to 1.5 mg twice a
day based on levels.
- Continued sirolimus 1 mg PO daily
CHRONIC ISSUES
==============
# CHF: Patient w/new CHF last admission (TTE with ejection
fraction 51% and wall motion abnormalities). Continued
furosemide 40 mg daily.
# HTN: Continued home amlodipine.
# CAD with h/o NSTEMI: Continued home metoprolol, ASA,
clopidogrel, atorvastatin.
# GERD: Continued PPI.
# GOUT: Continued febuxostat
TRANSITIONAL ISSUES
===================
[] Prograf was decreased from 2mg twice a day to 1.5 mg twice a
day based on levels.
[] Patient to call cardiologist ___ and make an
appointment in the next few weeks for an echocardiogram or
stress test.
[] Patient to get usual kidney labs checked on ___ or ___
due to Cr 2.3 on discharge, to be followed up by transplant
nephrologist | 137 | 366 |
18407883-DS-4 | 26,426,109 | Dear Ms. ___,
You came to ___ for abdominal pain, and you were treated with
antibiotics for a urine infection (which we think was the cause
of your pain). We will discharge you home with a course of
cefpodoxime (antibiotics) for your urine infection. You also
talked to a member of a home hospice team but declined their
program at this time.
Please see below for your medications and antibiotics. | ___ with hx. severe AS, DM, stage III CKD, HTN,
hyperthyroidism, anemia who presents with c/o abdominal pain,
found to have urinary tract infection. Chart review revealed
patient clearly expressed DNR/DNI and outpatient notes have
documented desire to not pursue surgery for known severe AS. She
was treated for UTI, and blood and urine cultures were followed.
Hospice care was introduced to the patient and her family (since
she has refused care for severe AS and thus has a life-limiting
illness); however, they ultimately declined and she was
discharged home.
--ACUTE--
# Urinary tract infection:
P/w abd pain, found to have grossly positive UA, likely
representing urinary tract infection. She was treated with
ceftriaxone; blood and urine cultures were sent. She was
transitioned to cefpodoxime for a total 7d course. BCX are
pending; urine cultures grew E.coli (resistant only to cipro)
and Klebsiella (intermediate resistance to nitrofurantoin).
# Abdominal pain:
Pt presented with epigastric and left lower quadrant abdominal
pain, resolved after 2 hours, without associated fevers, nausea,
vomiting, cough, shortness of breath, chest pain, loose stools,
urinary symptoms, or new rash. She describes the pain as a
'twinge' in her belly after eating that resolved on its own.
Denies constipation or diarrhea. CT abdomen pelvis showed Large
hiatal hernia, large ventral hernia containing small bowel and
mesentery, with no evidence of incarceration, enlarged uterus
containing a partially calcified mass, likely a fibroid, and a
heterogeneous right adnexal mass measuring 3.2 x 2.4 cm
concerning for possible ovarian mass. However, none of these
findings could explain her new discomfort, which was ultimately
attributed to her UTI and resolved with abx as above.
# Fever:
Maximal temperature in the ED was 102.6 rectally, likely
reflecting urinary tract infection in the absence of other
localizing signs or symptoms of infection. In the hospital, she
had the occasional temperature of 100.4 but continued to improve
on abx for UTI. No fevers at time of discharge.
--CHRONIC--
# critical AS:
S/p admission at ___ ___ for respiratory failure thought due
to AS. TTE ___ showed ___ 0.9. Per outpatient record,
patient declined transcuaneous valve and/or surgical
intervention and would rather 'die at home' where she is happy.
Did not appear volume overloaded during hospitalization. Volume
status was closely monitored and home
antihypertensives/diuretics held.
# HTN: continue metoprolol, hold lisinopril
# CKD: patient with Cr 1.3 on admission, last value in OMR is
1.3 ___, up from 1.0 in ___. ACEI/diuretic held.
Meds renally dosed.
# Normocytic anemia: Hct of 29 on admission which per OMR as it
recent baseline, etiology possibly due to CKD vs nutrient
deficiency. Hct was trended but given goals of care was not
investigated further, as active bleeding not suspected.
# DM: diet controlled, ISS in house
# Graves disease: continue methimazole
--TRANSITIONAL--
1. Radiographic findings - can consider workup but this should
be judiciously pursued given clearly stated goals of care
# Incidentalomas: Large hiatal hernia; large ventral hernia
containing small bowel and mesentery, with no evidence of
incarceration; enlarged uterus containing a partially calcified
mass, likely a fibroid; heterogeneous right adnexal mass
measuring 3.2 x 2.4 cm concerning for ovarian mass.
# LUL nodule: noted on CXR, recommending CT scan for further
investigation
- CT chest as outpatient (transitional issue)
2. Final blood cultures can be followed up in OMR.
3. patient's lisinopril and furosemide were held on admission,
she remained normotensive and euvolemic, recommend considering
restarting per PCP ___
4. consider referral to home hospice again once patient ready
5. to complete a 7d course antibiotics for complicated UTI
(cefpodoxime) | 72 | 584 |
15394622-DS-20 | 20,379,301 | Continue to take the Flomax as directed and do not take the
terazosin until you see your PCP. Continue to drink and eat
adequately. It is important to stay hydrated.
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.
.
General Discharge Instructions:
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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*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. | After being admitted to the ___ surgical service, Mr. ___
was appropriately resuscitated and had labs drawn which were
notable for a crit of 28.6. His other laboratory values were
within normal limits. He had blood and urine cultures taken
which are negative to date and an EKG which was unchanged from
previous. His terazosin was held but was continued on other
home meds. He did not have any further episodes of syncope or
near syncope while an inpatient. He tolerated a regular diet
during his stay. His vital signs were routinely monitored. He
was started on flomax for urinary difficulty (to replace the
terazosin). He was voiding without difficulty on discharge. | 348 | 122 |
15655656-DS-21 | 24,564,688 | ******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*******
Partial weight bearing right lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 4 weeks post-operatively.
******FOLLOW-UP**********
Please follow up with Dr ___ in 14 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.
Physical Therapy:
partial weight bearing RLE
Treatments Frequency:
physical therapy | The patient was admitted to the Orthopaedic Trauma Service for
repair of a right distal femur fracture. The patient was taken
to the OR and underwent an uncomplicated 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: partial weight bearing RLE.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. | 216 | 172 |
10001667-DS-10 | 22,672,901 | Dear Ms. ___,
You were hospitalized due to symptoms of slurred speech due to
concern for an ACUTE ISCHEMIC STROKE, a condition where a blood
vessel providing oxygen and nutrients to the brain is blocked by
a clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms. However, the MRI of your brain did not show
evidence of stroke or TIA. Your symptoms could have been related
to blood pressure, dehydration, alcohol use, or a combination of
these factors.
We are changing your medications as follows:
Increase apixaban to 2.5mg twice daily
Start Vitamin B12 daily supplement
Please take your other medications as prescribed.
Please follow up with your primary care physician as listed
below. You should also follow up with your cardiologist as you
were noted to have occasional pauses on cardiac monitoring.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, please pay attention to
the sudden onset and persistence of these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | Ms. ___ is a ___ year old female with AFib on Eliquis, CHF,
HLD, HTN who presented w/ sudden onset dysarthria, abnormal arm
movements, and poor balance (walker at baseline). NIHSS 1 for
slurred speech at OSH. There, a CTA head and neck was completed,
and there was concern for left M2 branch attenuation concerning
for stenosis or occlusion, and she was subsequently transferred
for consideration of thrombectomy but NIHSS 0 on arrival so she
was not deemed a candidate. She was admitted to the Neurology
stroke service for further evaluation of possible TIA vs stroke.
No further symptoms noted during admission. MRI head w/o
contrast were without evidence of stroke. Reports recent
echocardiogram per outpatient PCP/cardiologist, reported as no
acute findings and so this was not repeated. She mentioned
concern about worsening memory, but able to perform ADLs w/
meals/cleaning provided by ALF (moved 10 months ago); it appears
there has been no acute change. She was taking apixiban 2.5mg
once daily (unclear why as this is a BID medication), and so her
dose was increased to 2.5mg BID (she was not a candidate for 5mg
BID due to her age and weight). She was started on atorvastatin
for her hyperlipidemia (LDL 126). EP cardiology was consulted
for frequent sinus pauses noted on telemetry that persisted
despite holding home atenolol, recommending discontinuing home
digoxin and close cardiology ___. Discharged to home w/
___ & ___ and close PCP ___.
#Transient slurred speech and instability, c/f TIA
- ___ consult - cleared for home with home services
- Started on atorvastatin for HLD and increased home apixaban to
therapeutic level
- ___ with stroke neurology after discharge | 248 | 273 |
10745635-DS-5 | 27,183,970 | Dear Ms. ___,
It was a pleasure taking care of you!
You were admitted with poor kidney function and started on
hemodialysis through your left brachiocephalic fistula placed in
___. You tolerated 3 sessions of HD well and will
continue HD as an outpatient at ___ Dialysis ___
beginning ___ at 3pm.
You were also noted to have very low calcium which is likely due
to poor vitamin D absorption because of your kidney disease. You
were given IV calcium with improvement in your calcium level.
You calcium will continue to be corrected at dialysis.
You also had elevated blood pressure during this admission,
likely due to excess fluid prior to hemodialysis. Your doxazosin
was increased during this admission. Your blood pressure
improved with increased doxazosin and hemodialysis. Your HCTZ
(hydrochlorathiazide) was stopped as this is not effective given
your kidney function.
While here, you were noted to lack immunity to hepatitis B. You
were given the first of three vaccines here. You will need to
follow-up with your primary doctor for the second vaccine in 1
month and the third vaccine in 6 months.
Your ___ Team | ___ w/ DM1 and worsening kidney disease now presenting with GFR
and symptoms (pruritis, swelling, SOB) consistent with ESRD here
for initiation of dialyis.
#ESRD: Patient with CKD likely ___ diabetes here with GFR of 9,
leg swelling, dyspnea on exertion and symptoms of pruritis
suggestive of uremia. Patient evaluated by transplant surgery
who gave the ok to use left upper extremity fistula. Patient
started on dialysis on ___ with additional sessions on ___
and ___. Given concern that fistula was difficult to access at
___ session, LUE ultrasound performed on ___ with read
pending at discharge. Hepatitis serologies showed patient was
not hepatitis B immune and patient was given first immunization
in Hep B series on day of discharge and PPD was planted and was
negative. Patient was continued on home sevelamer and started on
nephrocaps as well as 3 days of aluminum hydroxide. Calcitriol
was stopped as patient on doxercalciferon with dialysis.
# Hypocalcemia: Patient admitted with calcium of 6.2 (corrected
to about 6.5 with albumin). Patient was asymptomatic without
Chvostek's sign and with normal Qtc on EKG. Attempted to correct
with HD however without good effect and patient treated with
calcium gluconate with improvement of calcium to 7.5 on ___
(corrected to 7.8). Patient continued on calcitriol during
hospitalization and this was stopped prior to discharge with
plan for correction of calcium and vitamin D via HD.
# Hypertension: Patient hypertensive on arrival to 180s,
improved with home carvedilol, HCTZ, losartan, doxazosin and
lasix. Patient with recurrent hypertension to 203/64 on ___
with improved to systolic pressures of 140s with evening
carvedilol. Patient with recurrent hypertension to SBP of 200s
thought to be due to volume overload and ineffectiveness of HCTZ
with ESRD. HCTZ stopped and doxazosin increased to 4mg BID on
___. With increased doxazosin and 1.5L off at HD on day of
discharge, blood pressures improved to 130s-160s/60s prior to
discharge. Patient may need down titration of blood pressure
meds as fluid status improves with HD.
#Anemia: Patient with hematocrit ranging ___ (just below
previous baseline in ___ of this year. Normocytic anemia likely
related to low erythropoetin in setting of end stage renal
disease. Patient started on epo with HD on ___ along with iron
supplementation through dialysate. Anemia stable during
admission and patient asymptomatic.
#Petechial rash: Patient developed petechial rash over bilateral
arms to just above elbows bilaterally without any itching or
pain. Rash did not spread, and was slowly improving after
initiation of HD. Rash was thought to be due to uremic platelets
in the setting of ESRD.
# Diabetes, Type I: Patient was initially continued on home
lantus with an insulin sliding scale however, sugars poorly
controlled on initial insulin sliding scale with sugars ranging
170s-340s. On hospital day 4, patient returned to ___ counting
with carb ratio 10:1 and lower dose of sliding scale insulin
with improvement in sugars to 150s-250s prior to discharge.
# Hyperlipidemia: Patient continued on home simvastatin while
inpatient.
# Dysthymic Disorder: Continued on home bupropion and sertraline
while admitted.
# Code Status: Full Code
# Health Care Proxy: ___, sister,
-- | 184 | 518 |
11161241-DS-17 | 22,432,004 | You were admitted for feeling dizzy. Because you took an extra
dose of your blood pressure medication, this made your blood
pressure low. When you were straining to have a bowel movement,
your blood pressure was low enough to cause your symptoms.
Please make sure to get a pill-box from your pharmacy as we
discussed. Taking incorrect medication can be very dangerous,
and a pill-box can help keep track of which medications you
should take and when. One thing to consider is to have two
pillboxes, one for the morning, and one for the evening to help
prevent getting confused.
Please note the following medication changes:
-Please DO NOT TAKE your lisinopril-hydrochlorothiazide (blood
pressure medicine) today. You can restart this medicine
tomorrow, ___.
-We have not changed any of your other medications | SUMMARY: ___ year old man with history of hypertension presents
with postural dizziness and orthostatic hypotension in the
emergency room.
.
# Orthostatic hypotension: Secondary to taking additional doses
of anti-hypertensives by accident. His initial episode of
dizziness at home developed in setting of high vagal tone while
attempting to force a bowel movement. Was given 2.5L of normal
saline IV, and instructed to obtain a pill-box for medications,
counseled on the dangers of excess medication use, and
discharged after orthostasis and symptoms resolved.
.
# ___: From hypoperfusion and extra dose of ACE-I/diuretic,
improved back to baseline creatinine of 1.1-1.2 with IVF.
.
# Depression: Citalopram was continued, this medication was felt
to be unlikely cause of his orthostasis.
# Hyperlipidemia: continued statin
# Pulmonary nodule: Follow-up CT in 6 months is recommended
.
==== | 130 | 135 |
15960846-DS-12 | 24,385,232 | You were admitted to ___ with abdominal pain and bowel
prolapsing out of your colostomy. You were taken urgently to the
operating room for repair of the bowel. Five days after your
operation, you developed a fascial dehiscence and had bowels
protruding from your incision. This required you be taken back
urgently to the operating room for repair. You have tolerated
these procedures well.
Your blood and urine cultures were positive for bacterial
growth, and you have completed a course of antibiotics to treat
this.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
**You will go home with the Foley Catheter in place. Your
urologist should remove this in clinic in ___ days time. | On ___ ACS was consulted for prolapsed bowel on Mr. ___.
He was taken to the operating room for exploratory laparotomy,
LOA, sigmoidectomy and end-colostomy formation. After a brief
stay in the PACU, he was re-admitted to the surgical floor.
His post-operative course was complicated by sustained
tachycardia greater than 140, for which he received valium. His
abdomen was distended and a foley catheter was placed. He
continued to have a distended abdomen, and on POD#4 he was noted
to be dry heaving. He was found to be febrile to 102.3, and
blood and urine cultures were taken. After three failed
attempts to straight cath the patient, an 18 ___ Coude
catheter was placed. After foley placement, he vomited one time
and remained distended.
On POD#5 he eviscerated on the floor, and was taken back to the
OR for repair of fascial dehiscence. An NG tube was placed in
the OR, and his blood cultures grew GNRs, so he was started on
Meropenem.
On ___, his bowel function returned and the NG tube was
removed.
On ___, significant sanguineous drainage was noted from the
middle aspect of the wound, and two staples were removed. The
underlying fascia was noted to be intact, and an old hematoma
was evacuated. After a few more episodes of emesis, the patient
began tolerating full liquids, and final a regular diet. His
pain was well controlled. He was discharged back to his group
home with ___ for foley care and wound care. He will be seen in
clinic for follow up. | 404 | 268 |
13675932-DS-20 | 23,148,914 | CALL THE OFFICE FOR: ___
- Sudden onset of chest pain, abdominal pain, back pain,
neck pain, jaw pain or left or right arm pain.
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move, use or feel your arm
or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours | Patient presented to ___ ___ 11:45pm from outside hospital
for suspected aortic dissection. Imaging from outside hospital
revealed a type B aortic dissection. Patient was stable on
admission and was admitted to CVICU for strict BP monitoring,
placed on IV labetolol/nitro for SBP goal of <120, DBP<90.
___: patient denies any chest pain; however, reports left
shoulder pain that resolved within next few hours. Patient
downgraded from CVICU to floor for observation
___: increased omeprazole for presumed ulcer
___: pt stable in CVICU, sent back to VICU
___: CP improved
___: CP correlating with BP increasing
___: hydralazine prn often, labetolol increased to 200TID
___: Cards Consult, CP non cardiac, rather d/t aortic IMH
___: minimal chest pain
___: Cr stablized at 1.2, baseline 1.2, CTa done, no change,
sent home with specific instructions with dosing and adherance
to BP medications. Visiting nurse for ___ few days for BP checks. | 90 | 141 |
14526750-DS-16 | 22,748,459 | Dear Ms. ___,
You came to the hospital because your blood count was low. It
improved after getting blood. You had bleeding into your hip
after your surgery. This can happen sometimes. It was likely
made worse by the lovenox given to you to help prevent blood
clots. You are no longer taking that medicine, so it is very
important to keep intermittent compression on your legs and move
as much as you can at rehab.
It was a pleasure caring for you and we wish you the best,
Your ___ Team | Ms. ___ is a ___ woman with history of HTN,
hypothyroidism, anemia, CKD, recent mechanical fall with left
hip fracture s/p ORIF (___) on enoxaparin presenting from rehab
with anemia noted on routine lab work. | 89 | 35 |
10789227-DS-15 | 29,382,611 | You were admitted to the hospital after a fall in which you
sustained right sided rib fractures and a small collapse of your
right lung. Your vital signs have been stable and you are
preparing for discharge to a rehabilitation center to help
further regain your strength and mobility. You are being
discharged with the following instructions:
Your injury caused right sided_rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
In addition to the rib fracture recommendations, I have included
the following instructions:
You experience new chest pain, pressure, squeezing or tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed. | ___ year old female admitted to the hospital after a mechanical
fall in which she sustained right sided ___ rib fractures and a
small right pneumothorax. She was transferred here for medical
management. Upon admission, the patient was made NPO, given
intravenous fluids, and underwent imaging. Cat scan imaging of
the head and c-spine showed no acute fractures. Additional
imaging of the chest and pelvis showed a small right apical
pneumothorax, 13x8 mm nodule left lower lobe and a 0.7 cm lesion
in left hepatic lobe. These findings will need further
investigation.
During the patient's hospitalization, her vital signs remained
stable and she was afebrile. She was instructed in the use of
the incentive spirometer. Her rib pain was controlled with oral
analgesia. She was tolerating a regular diet and voiding without
difficulty. She was evaluated by physical therapy and
recommendations made for discharge to a rehabilitation facility.
The patient was discharged on HD #5 in stable condition.
(telephone conversation with NP at facility for need to review
current medications) | 456 | 181 |
19340580-DS-8 | 23,671,635 | Dear ___,
It was a pleasure to care for you here at ___
___. You were admitted on ___ for abdominal
pain and found to have a urinary tract infection. You were
treated with antibiotics. You will need to continue to take this
medication until it is finished (last day is ___.
Additionally, your tacrolimus dose was changed. It is very
important that you have your tacrolimus level checked at a lab
in 1-week (have the lab fax these results to ___.
It is also very important you be seen by the ___
here at ___. Please see below for scheduled appointment. | PRIMARY REASON FOR HOSPITALIZATION:
============================================
___ y/o ___ only female with history of renal
transplant (cadaveric, thought to be due to SLE nephritis, done
in ___ ___ who presents with RLQ pain and SCr mildly
elevated above baseline. | 99 | 36 |
19396772-DS-13 | 23,551,433 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
- weakness
- worsening symptoms of your connective tissue disorder
What was done for you in the hospital:
- We gave you high dose steroids and IVIG to help treat your
connective tissue disorder.
- We performed a stress test to test your heart function - this
showed it was in good condition
- We gave you a medication (Lasix) to help remove extra fluid
from your body received from the IVIG. With this your breathing
improved.
- You were evaluated by the rheumatology team who will continue
to see you as an outpatient.
What you should do after you leave the hospital:
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your doctor to discuss or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team | ___ woman with history of mixed connective tissue
disorder and scleroderma overlap (myositis, Raynaud's,
telangiectasia, sclerodactyly, positive ___, U1 RNP and CCP
antibodies), and hypothyroidism who presented with myalgia and
generalized weakness most consistent with mixed connective
tissue disorder flare / myositis.
# MIXED CONNECTIVE TISSUE DISORDER FLARE / MYOSITIS
Initially presented for worsening weakness, myalgias and
difficulty ambulating after recent viral infection most
consistent with MCTD / myositis flare. Previously treated with
MTX, plaquenil, azathioprine, most recently on MMF and
prednisone 20 mg. During this admission she was treated with
high dose Solumedrol (1000 mg x3 days) after which was
transitioned to prednisone 60 mg. Further received IVIG 2g x2
(split doses). Symptoms of weakness and myalgias did not
immediately improve, however labs were notable for steady
downtrend of CK. She was discharged with plan to continue higher
dose prednisone and MMF with close outpatient rheumatology
follow up for further management.
# ELEVATED TROPONIN
Initial workup notable for elevated troponin (peak 0.29) with
CK-MB index >5%. No ischemic EKG changes or symptoms concerning
for ACS. Overall thought most likely due to be related to
myositis flare. TTE unchanged from prior. Obtained pMIBI which
demonstrated normal myocardial perfusion.
# ELEVATED TRANSAMINASES
Lab workup notable for mild though persistently abnormal LFTs,
ongoing for several months prior to this admission. RUQUS
without obvious pathology. Prior hepatitis serologies negative,
negative anti-smooth and AMA antibodies. Currently on MMF though
abnormal LFTs predate this medication. No other obvious
hepatotoxic medications. Overall thought most likely related to
connective tissue disorder. Anti-LK pending at time of
discharge.
# VOLUME OVERLOAD
Mildly hypoxic with evidence of volume overload following IVIG
administration. Improved with intermittent diuresis and was
euvolemic by time of discharge. No need for home maintenance
diuretic.
# DIAPHORETIC EPISODES
Reported intermittent episodes of diaphoresis. Unclear etiology
though temporal association with MMF points towards medication
side effect. Immunosuppressed but no other focal signs of
infection. Blood cultures negative.
# ORAL CANDIDIASIS
Noted on exam in setting of chronic steroids. No odynophagia and
so unlikely to have esophageal involvement. Started 14-day
course oral nystatin.
# MACROCYTIC ANEMIA
Most likely due to MMF. B12/folate were normal.
# BORDERLINE QTc
In setting of chronic amitryptilin and fluoxetine. QTc prior to
discharge was 415.
# LIKELY MILD SCLERODERMA ASSOCIATED LUNG DISSEASE
Per prior records has mild PHTN based on right heart cath. Prior
PFTs notable for reduced FVC and DLCO. No acute respiratory
symptoms and with stable O2. Rheumatology planning for regular
monitoring of PFTs with annual CT chest.
# DYSPHAGIA
Noted to have mild-moderate symptoms of dysphagia which
typically worsen with myositis flares. Normal endoscopy and
biopsy ___. Per speech/swallow, she may benefit from a repeat
video swallow study and esophagram to evaluate for
MCTD-associated esophageal dysmotility if not improved with
flare treatment.
# LEFT HIP BURSITIS
Reports ongoing left hip pain ever since a mechanical fall ___
months prior to admission. X-ray with evidence of degenerative
changes. Clinically most consistent with bursitis. Consider
outpatient steroid injection if persistent pain.
# STEROID INDUCED HYPERGLYCEMIA:
Patient was kept on insulin sliding scale while inpatient. Did
not require insulin on discharge
# FIBROMYALGIA
Continued on amitriptyline 10 mg PO/NG QHS and fluoxetine 40 mg
PO/NG DAILY
# BONE HEALTH
Continuing alendronate 70 mg for prophylaxis of steroid induced
osteoporosis. Continued vitamin D.
# HYPOTHYROIDISM
Continued levothyroxine Sodium 100 mcg PO/NG DAILY
# ANXIETY
Continued alprazolam 0.25 mg PO/NG TID:PRN | 228 | 554 |
10156886-DS-18 | 24,201,568 | You were hospitalized for fatigue, altered mental status
(confusion), and hypercalcemia (elevated calcium levels). The
high calcium is likely the cause of the fatigue and confusion.
Also, your blood sodium level was low. You were treated with
intravenous fluids and your symptoms and calcium improved.
Additionally, CT of the head and abdomen were unrevealing other
than progressing cancer in the liver. MRI of the brain was
normal. Because the current chemotherapy is not working, you
will be changed to a new chemotherapy medication called
everolimus (Afinitor), which has been ordered and should arrive
in approximately one week. In the meantime, you should continue
the previous chemotherapy axitinib. You have also been set up
for home IV fluids to maintain a low calcium level. You were
started on calcitonin a nasal spray to help bring your calcium
levels down. This should be used sparingly as it does not
continue to work long-term (>1 week). You can use it when you
suspect the calcium levels are elevated (worsening
fatigue/weakness, confusion, or confirmed high calcium on blood
work). You will need to continue monthly denosumab (Xgeva)
injections in the clinic.
While you were hospitalized, you were evaluated by a
nutritionist. The following recommendations were made by the
nutritionist:
1. Please start drinking Ensure Plus three times per day.
2. Please continue eating and drinking as much as possible. | ___ man with HTN and metastatic renal cell CA admitted for
weakness, altered mental status, and hypercalcemia. Mental
status and calcium improved with IV hydration.
.
# Weakness/metabolic encephalopathy: Likely due to hypercalcemia
given history of waxing and waning course coinciding with
calcium correction. Calcium and mental status have improved
during this admission and he and his wife feel that he is ready
and would be safe for discharge. Lactulose started, but no
evidence of hepatic encephalopathy - no asterixis, normal
ammonia level. AM cortisol normal. Corrected calcium as
outlined below.
- Blood cultures PENDING.
.
# Hypercalcemia: Due to renal cell carcinoma mets. PTH <6.
Allergic to bisphosphonates. IV fluids given with plan to
continue this at home. Denosumab will be given as an
outpatient, due to insurance issues limiting in-patient use.
Started calcitonin PRN, but not continuous consider
tachyphylaxis.
.
# Renal cell carcinoma: Continued axitinib until everolimus
(Afinitor) arrives (already ordered, but can take a week to come
in). Progressed through gemcitabine/sunitinib and now axitinib.
Anti-emetics PRN.
.
# Anemia: Chronic, mild, stable.
.
# Leukocytosis: No evidence for infection. Likely due to
malignancy. U/A negative.
- Blood cultures PENDING.
.
# Abnormal LFTs: Due to liver mets. Hepatitis serologies
negative. Stable.
.
# Hypothyroidism: Normal T4. TSH mildly elevated 4.6, low T3,
normal free T4. Started low-dose levothyroxine.
.
# Hyponatremia: High Una 116 consistent with SIADH, probably
exacerbated by poor PO intake. Stable on IV normal saline.
.
# FEN: Regular diet. Continued outpatient dronabinol for
anorexia/wght loss. IV fluids; continued IV fluids at home.
Repleted hypophosphatemia.
.
# DVT PPx: Heparin SC.
.
# GI PPx: H2 blocker. Bowel regimen.
.
# Pain (neck/chest/abdomen): Due to cancer. Acetaminophen
(limited doses considering LFT abnormalities). Tramadol PRN.
.
# IV access: Peripheral IV. ___ placed ___ for home IV
hydration.
.
# Precautions: None.
.
# CODE: FULL.
.
TRANSITIONAL ISSUES:
- F/U BLOOD CULTURES.
- Denosumab to be given as outpatient.
- Chemotherapy to be changed from axitinib to everolimus as
outpatient. | 234 | 327 |
18459172-DS-6 | 26,446,197 | Dear Mr ___,
It was a pleasure taking care of you at ___
___. You came to the hospital because your liver
abscess grew out bacteria. You were started on IV antibiotics
and had a "PICC" (a semi-permanent IV) placed. You will be
discharged on IV antibiotics to be continued for at least 3
weeks. You will need a repeat Ultrasound in 3 weeks to evaluate
the abscess. You should keep the drain in place until then (care
instructions below).
Please follow up at your appointments as scheduled.
We wish you the best!
~your ___ team
___ 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).
-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 bag or bulb frequently. Record the
output daily. You should have a nurse doing this for you.
-You may shower; wash the area gently with warm, soapy water.
-Keep the insertion site clean and dry otherwise.
-Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
-If you drain stops putting out any fluid, please have the ___
call Interventional Radiology at ___ at ___ and page
___. This is the Radiology fellow on call who can assist you.
-A ultrasound should be scheduled for you in 3 weeks. We will
review the ultrasound and determine if the collection has
resolved, if so we will pull the drain at this time. | Patient is a ___ with a PMHx of cholecystitis s/p
cholecystectomy and liver lesion s/p ___ drainage and JP drain
placement ___, admitted for IV antibiotics for GNRs growing in
drainage fluid.
#Hepatic abscess: Unclear etiology of abscess. Given prior
presence of hepatic cyst and recent instrumentation, likely
superinfection as a complication of cholecystectomy. Fluid from
JP drain grew Pan-sensitive E coli. He was initially started on
zosyn then transitioned to IV CTX via ___, which should be
continued for at least 3 weeks. He will be followed by the ___
___ clinic and should have a repeat liver Ultrasound in 3
weeks. JP drain should remain in place until repeat imaging. CT
abdomen on ___ showed drain in good position with decreased
size of fluid collection.
# Pain control: Spinal stimulator in place. Continued on home
pain regimen and started on bowel regimen for opiate induced
constipation
# Anemia: Patient had new diagnosis of anemia at last
hospitalization. No prior labs available for comparison. He had
no evidence of active bleed and Hgb within range of prior
hospitalization. Fe studies from prior admission consistent with
AOCD. H/H stable this admission.
# COPD: Continued home spiriva | 247 | 200 |
18260067-DS-29 | 22,336,117 | Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service for treatment of your Right
foot Infection. You had samples of your bone obtained for
pathology evaluation. The results revealed an infection in your
bone for which you will need to receive at least 6 weeks of IV
antibiotics. You were given IV antibiotics and your ulceration
was treated while in the hospital. You are being discharged home
with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your R foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE. | The patient was admitted to the podiatric surgery service from
the ED on ___ for a R foot infection. Bedside micro obtained
and sent for evaluation. On ___ bedside deep bone and tissue
samples were taken and sent.
The patient remained afebrile with stable vital signs; pain was
well controlled oral pain medication on a PRN basis. The
patient remained stable from both a cardiovascular and pulmonary
standpoint. She was placed on vancomycin, ciprofloxacin, and
flagyl while hospitalized and discharged home on the same. Her
intake and output were closely monitored and noted to be
adequtae. The patient received subcutaneous heparin throughout
admission; early and frequent ambulation were strongly
encouraged. She was evaluated by ___ who determined she was ok to
go home and did not require rehab.
The patient was subsequently discharged to home on HD 7 with 6
weeks of IV antibiotics. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 449 | 165 |
11623625-DS-8 | 20,179,956 | Dear Ms. ___,
You were hospitalized due to symptoms of nausea and gait
instability 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:
Elevated cholesterol (Chol 239, LDL 166)
We are changing your medications as follows:
Begin Atorvastatin
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 | Ms. ___ was admitted to the Neurology service for headache,
nausea and gait instability. MRI showed a left cerebellar
infarct.
CTA head and neck showed: 1. No right internal carotid stenosis
by NASCET criteria. Mild calcified plaque at the right external
artery origin.
2. Mild mixed plaque in the proximal left internal carotid
artery with approximately 15 percent stenosis by NASCET
criteria.
3. Occlusion of the right vertebral artery distal to the C4-C5
level.
4. No evidence for left vertebral artery stenosis.
_________________________________
Transitional Issues
- Begin Atorvastatin
__________________________________
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?
() Yes - () No
4. LDL documented? (x) Yes (LDL =166) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - () 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 follow-up) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - () N/A | 259 | 312 |
11261398-DS-12 | 26,615,732 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
after you had some shortness of breath after your EGD procedure.
You received a paracentesis in the Emergency Department to
remove fluid from your belly. We also gave you a diuretic during
your stay in the hospital. Your symptoms improved and we
discharged you home.
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team | Mr. ___ is a ___ (speaks ___ but conversational in
___ with PMH HTN, DMII, hx ETOH abuse, recent diagnosis of
pancreatic ca (not yet on chemo), and newly diagnosed cirrhosis
with ascites s/p therapeutic para on ___ who presents from
the PACU after experiencing shortness of breath and abdominal
distention after extubation after an EGD. Transferred to ED and
then to medicine.
#Shortness of breath: patient experienced shortness of breath
after extubation. Likely hypoxia in the setting of anesthesia
with significant edema/ascites as a contributing factor. Patient
received a 4-L paracentesis in the ED and was admitted for
further diuresis. Upon arrival to the floor, asymptomatic and
satting 96% on ra with no evidence of crackles on exam. CXR did
show a small pleural effusion. Patient began diuresis on ___:
as he strongly wished to return home that day, he received po
lasix 40 mg and 100 mg spironolactone to begin diuresis and was
discharged on these medications.
#Alcoholic cirrhosis complicated by ascites and edema:
___ class C, MELD 6 at admission. Received a 4L tap upon
arrival in the ED. Had 3+ pitting edema in ___. EGD on ___
did not show any varices. No evidence of SBP from peritoneal
fluid analysis. Diuresed per above.
# Hypertension: held home Hctz pending more aggressive diuresis.
Continued metoprolol.
# Dyslipidemia: continued home ezetimibe
# Diabetes mellitus, type 2: on home metformin. Held while in
house, ISS
#Pancreatic adenocarcinoma: Diagnosed via CT on ___,
underwent MRCP in ___ on ___ at which time a common
bile duct stricture was identified within the pancreatic head.
Dr. ___ ERCP and identified portal gastropathy. A
plastic stent was deployed across the 2.5 cm stricture within
the pancreatic head. Brushings demonstrated adenocarcinoma. Not
yet on treatment, has an initial appointment with Dr. ___ in
Heme-onc on ___.
#CODE: Full
#CONTACT: Sister ___: ___ | 69 | 318 |
13805137-DS-6 | 22,152,943 | 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:
- 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:
- WBAT
Physical Therapy:
WBAT
Treatment Frequency:
daily DSD | The patient was taken to the operating room on ___ for L hip
hemiarthroplasty, which the patient tolerated well (for full
details please see the separately dictated operative report).
The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
The Medicine Team was consulted for persistent, asymptomatic
tachycardia, which resolved with blood transfusion.
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 WBAT in the affected 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. | 121 | 215 |
18166516-DS-5 | 21,152,582 | You were admitted with headache. Your lumbar puncture did not
show evidence of cancer cells in the fluid surrounding the
brain. It is not clear what is causing the headaches at this
point, but we do not think there are cancer cells around the
brain causing them and therefore we would not recommend
radiation treatment to the brain at this time. You do have some
cancer in the skull, which could be pressing on the brain or
blood vessels in some areas of the head and causing the
headaches.
For pain, we decided on the following regimen:
Take the following meds NO MATTER WHAT:
Gabapentin and methadone
ADDITIONAL MEDS TO TAKE WHEN YOUR PAIN GETS WORSE:
If you have more pain during the day, take ___ (can take up
to 2 tabs, three times a day - so total of 6 tabs) or dilaudid.
Dilaudid you can take ___ mg (recommend taking at least 6) every
___ hours as needed for additional pain.
We STOPPED your morphine. Use dilaudid now when you would have
taken the morphine before.
Because you are taking the ___ use Tylenol because
the ___ has Tylenol in it too.
FOR NAUSEA:
For your nausea, take metoclopramide up to 4 times a day as
needed if you need it for nausea, and if you are having a lot of
nausea just take the metoclopramide three times a day no matter
what to prevent it. and if needed low doses of Ativan can make
you sleepy but would be fine to use.
IN CASE OF EMERGENCIES WHEN YOU ARE TOO NAUSEATED TO TAKE PILLS:
** in emergency when you are too nauseated to take a pill, we
have sent you with a prescription for ondansetron (also called
Zofran) which can be dissolved under the tongue | Ms. ___ is a ___ female with history of ER/PR+
metastatic breast adenocarcinoma to the liver, vertebrae, lung,
pleural fluid, calvarium, and palate s/p recent XRT to C1-T2 and
palliative taxol now on capecitabine as well as
Lupron/AI who presents with headache and nausea.
# Headache/Nausea
Pt presented with severe headache and nausea after bending down.
Her MRI brain showed new areas of right frontal and left
frontoparietal hyperintensity suspicious for leptomeningeal
metastasis, multiple stable calvarial mets measuring up to 1.5cm
in the right occipital bone with destruction of the inner table,
with probably underlying dural involvement. Her CSF cytology
however was negative for malignant cells. Radiation oncology
felt that in the context of negative cytology WBRT was not
indicated and that there was no one skull based lesion that
merited targeted radiation, though she does have right sided
lesion which is larger than the other which could be considered
for radiation should her headaches fail to improve further in
the next 2 weeks. Dr. ___ neuro oncology was following and
also felt that in absence of positive cytology intrathecal
chemotherapy was not indicated. It was his opinion that likely
her skull based mets were causing her headaches. Overall her
headaches improved but remained an issue at the time of
discharge. She was initially started on high dose steroids but
when CSF came back negative these were tapered.
She will continue her home methadone and gabapentin as she was
taking. Celebrex was started inpatient but this was not covered
by her insurance and was discontinued at time of discharge. She
did well with hydromorphone combined with ___ for control
of her headaches that allowed her to be functional without
oversedation. Continue home prn reglan for nausea and Ativan
if needed though cautious using Ativan and dilaudid together as
pt had a reaction "was loopy" earlier this year when using both
at once though we did not see this during this admission. We
also minimized Zofran as she had bradycardia during this
admission. The differential includes spontaneous CSF
rupture/leak which would be expected to self-resolve however
opening pressure was not low (26) which argues against this.
There was nothing to suggest bacterial/infectious etiology such
as meningitis as she never had fever or leukocytosis or
meningismus. Her CSF had 0 WBC and 0 polys. There was a report
of GPR on CSF which was felt to be corynebacteria and given
absence of any clinical sx/signs of bacterial meningitis, this
was felt to be skin contaminant. Discussed w/ micro lab and they
were in agreement.
She was concerned about recurrence of severe nausea and pain at
home preventing her from taking pills in an acute situation, so
she was sent home with some liquid dilaudid and prn ODT Zofran
to be reserved for these rare situations.
# Metastatic ER/PR+ Breast adenocarcinoma: Mets to liver,
vertebrae, pleural fluid, calavarium, palate. She had initial
ER+/PR+/EGFR- left breast cancer in ___, then recurrence on
right breast ___. She is currently on capecitabine. cont
letrozole but holding capecitabine per Dr. ___ she
___ likely resume this as outpatient.
# Shortness of Breath/Pleural effusions: Stable. Denies dyspnea
at this time and comfortable off oxygen during conversations and
ambulating the floor frequently. S/p right sided pleurodesis
earlier this year. Supplemental O2 prn comfort but she is
ambulating without it and comfortable
# PICC-Associated Right Upper Extremity DVT - Recently finished
course of apixiban
# Bradycardia - HR 45-70s, pt asymptomatic, but did have
prolonged periods with HR in ___ which was new for her.
Bradycardia likely vasovagally mediated w/
headache and nausea or from some element of ICP, vs from
narcotics. Lytes
WNL, EKG and CEs reassuring, no chest pain, no e/o heart block,
and serial EKGs without prolonged QTC (mid ___, stable)
despite multiple QTC prolonging meds. Ultimately Zofran was
discontinued with some mild improvement in her bradycardia. Her
methadone was continued with prn reglan for nausea but no other
QTc prolonging meds.
# H/o ___ White - reported per pt. No
SVT/tachyarrhytymia this admit, at home intermittently
occurs(last in ___ w/ post LP headache) uses vagal maneuvers
EMERGENCY CONTACT HCP: ___ (husband/HCP) ___
Greater than 30 minutes were spent in planning and execution of
this discharge. | 290 | 693 |
10507603-DS-17 | 22,786,097 | You were admitted for left groin pain which most likely occurred
from a kidney stone which passed quickly while you were in the
hospital. You were found to have a blood stream infection most
likely from acute urinary obstruction causing bacteria to move
from your urinary system into the blood. You were treated with
an antibiotic and will continue for a total 2 week course. | ___ yo women with HTN, COPD, CAD, CKD who developed severe left
groin/lower abdominal pain beginning ___ at about ___ with
nausea and vomiting most likely ___ movement of small kidney
stone through urinary system now bacteremic with proteus
#Proteus blood stream infection: Likely ___ acute urinary
obstruction from small kidney stone. Pt was not septic, did not
spike a fever. She appeared extremely healthy for having GNR
blood stream infection. She was initially started on CTX.
Sensitivities returned demonstrating sensitivity to
ciprofloxacin. The pt has a documented cipro allergy but on
futher discussion, it was determined this was not a true allergy
and she was monitored while on this medication with no incident.
She will complete a 2 week course.
#Left hydronephrosis, hydroureter, and calcyceal rupture: Pt
presented with left groin and abdominal pain. The etiology of
her intial presentation is unclear but is consistent with
passage of a small calculus that was not seen on intial CT. The
fact that the patient's pain resolved quickly is c/w spontaneous
stone passage. Given the
patient's long time smoking hx, interval imaging is needed to
ensure resolution of left hydronephrosis given that intial CT
was done without IV contrast. Urology saw the pt and recommended
urine cytology as an outpt (given smoking history). She will
have urology follow up.
# ? Aspiration: CT scan demonstrated left base airspace opacity.
She had no symptoms of pneumonia. This finding may be from
aspiration when she vomited.
# CAD s/p stent x 3: Continued home regimen of daily aspirin,
QOD plavix, statin, losartan.
# ___ on CKD: Likely from being dry in the setting of infection.
Possible from left sided obstruction in the setting of CKD.
Improvement after gentle IVF and presumed passing of stone.
Given improving renal function at the time of discharge, she was
instructed to have repeat Cr checked 2 days after discharge to
determine if cipro dosing will need to be change (results will
be sent to her PCPs office).
# COPD: Not active. Not on inhalers
# Hypertension off meds now per son
# ___
# Hypothyroidism: Levothyroxine
# Moderate AS: Asymptomatic. Avoided aggressive IVF | 67 | 360 |
14747467-DS-18 | 22,963,287 | Dear Mr. ___,
It was a priviliege to care for you at the ___
___. You were admitted with back and leg pain and
found to have muscle inflammation that is likely a side effect
of your statin medication. We held this medication and you
received IV fluid hydration to improve your kidney injury. You
were seen by our physical therapist, who recommended that you go
to rehab to get stronger.
You ate quite a few bananas and your potassium was a little
high, so we held your blood pressure medication at discharge,
this can be restarted as an outpatient.
Please continue to take all medications as prescribed and follow
up with all appointments as detailed below.
We wish you the best!
Sincerely,
Your ___ team | Mr. ___ is a ___ male with HTN/HLD, DMII, CKD,
dementia, and COPD who presented to the ED with four days of
back and lower extremity pain with ambulation, found to have
rhabdomyolysis thought secondary to statin, as well as ___ and
___ in setting of rhabdomyolysis.
# Acute on Chronic Renal insufficiency
# Rhabdomyolysis
# Concern for statin-induced myopathy
Patient presents with several days of leg and lower back pain
and noted to have ___, CK > 8K, and moderate "blood" on dipstick
urinalysis (but only 1 RBC on microscopic exam). Overall
consistent with rhabdomyolysis. Patient without any recent
excessive activity and while carries a history of dementia,
lives at home with several family members and has not had any
prolonged periods of being down. Treated with aggressive IVF
with improvement of renal function to baseline (Cr from peak 2.6
to 1.8-1.9 on discharge, on review of prior labs appears recent
baseline around 1.8-1.9 per PCP ___ as well as improvement of
CK from ___ to 1769. Statin discontinued indefinitely.
# ___: Both AST/ALT elevated in 100-200 range, suspect
in setting of rhabdomylosis and muscle release of AST/ALT. On
discharge ALT 141, AST 144, AP 89, Tbili 0.6. RUQ U/S obtained
___ with no evidence of cholelithiasis or acute cholecystitis,
normal hepatic parenchyma, no intrahepatic or extrahepatic
biliary dilatation. Consider recheck at PCP follow up.
# Back pain:
# Leg pain:
Suspect related to rhabdo as above. Patient notes a history of
"arthritis" that is likely OA as no documentation of
rheumatologic condition in chart. Patient seen by ___ who
recommended rehab.
# HTN: Lisinopril initially held in setting of ___, later held
as had borderline K up to 5.4, was 5.0 at time of discharge.
Upon review appears that patient was eating many bananas which
may have contributed. Would recheck ___ and if still stable,
consider restart of home lisinopril.
# HLD: Discontinued statin as above.
# hx of DM2: Diet controlled. SSI while inpatient.
# COPD: Continued home Spiriva, received albuterol PRN while in
patient.
# Positive ___: Patient with 1:80 ___ titer, which can be seen
in
20% of healthy individuals, currently without other complaints
such as joint pains, rash, systemic symptoms.
TRANSITIONAL ISSUES:
====================
[] Statin discontinued indefinitely given rhabdomyolysis
[] Cr on discharge 1.9, K 5.0 (baseline Cr around 1.8-1.9 per
PCP ___ lisinopril on hold at this time given fluctuating K
in setting of possible dietary choices. Please recheck by ___,
and consider resume lisinopril should repeat labs be stable. At
this time please also CK and LFT to ensure continued downtrend.
[] Note patient still with daily coughing episodes in setting of
known COPD, no PFTs available, may consider as outpatient +/-
uptitration of inhaler regimen pending GOLD staging
[] Due for 2nd dose of shingles vaccine (presumably received
shingrix, last ___ per OMR)
#CODE: Full
#CONTACT: Daughter ___ ___ | 123 | 461 |
14321890-DS-19 | 26,898,621 | Dear Ms. ___,
It was a pleasure taking care of you! You were admitted to the
inpatient oncology service at ___
___ diarrhea. We think your diarrhea is related to your
ipilimumab and started you on steroids for this. You had a
procedure to look at your colon called a sigmoidoscopy. Biopsies
for this were taken which showed colitis (inflammation of your
colon). Please continue to take steroids as prescribed until you
see your oncologist. Thank you for allowing us to participate in
your care! | ___ with metastatic melanoma on ipilimumab with 5 days of
worsening diarrhea.
#diarrhea: Ddx ipilimumab-related colitis (started on prednisone
in ED), infectious etiology (e.g. cdiff, though no recent abx,
abd exam benign, lactate wnl). Patient was started empirically
on PO steroids for presumed ipilimumab colitis in the emergency
room. Stool cultures and C Diff negative. ___ Flex sig with
erythema of the rectum, sigmoid and distal descending colon.
Biopsies consistent with colilitis, CMV negative, likely
ipilimumab-associated. Had episode of possible BRBPR ___ which
appeared more like orange-red tinged stool, no blood upon
wiping, no recurrent episodes. Hct stable, with no associated
symptoms. Unable to recall any red-orange colored foods. Unable
to obtain stool guiaic prior to discharge home. Patient was
started on PRN loperimide and continued on steroids. She had
improvement of her symptoms on this regimen and was able to
tolerate PO without any nausea or cramping. She is to continue
prednisione 60mg until seen by her oncologist for follow up.
#dyspnea: Reported subacutely worsening DOE on admission,
thought to be related to known metastatic disease, possibly
exacerbated by poor PO intake/dehydration due to her diarrhea.
Her symptoms improved on admission and the patient was able to
ambulate without difficulty at the time of discharge.
#hyponatremia: thought to be secondary to hypovolemia, improved
with IVF.
#Onc: outpatient oncology team notified of admission and updated
on daily events.
#BPAD: cont home meds seroquel and valproic acid
#h/o anxiety: continued on home clonazepam
#HL: continued home statin
Transitional issues
# f/u final blood cultures.
# Discharged on 60mg prednisone daily, to continue on this
regimen until seen by her oncologist
# Given PRN loperamide for diarrhea
# Had red-tinged stools on ___, unable to obtain stool guiaic
prior to discharge. No further episodes in the hospital. If
bloody BM do not improve, consider performing complete
colonoscopy as an outpatient | 85 | 301 |
19902791-DS-9 | 27,957,067 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were not feeling well and
had an infection on your arm.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were also given insulin for your high blood sugar levels.
You met with the ___ diabetes experts, who came up with a
plan for managing your diabetes. You were given IV antibiotics
for your infection that had spread to your blood and discharged
on PO antibiotics.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please measure your blood sugars at home while on metformin.
If your sugars are > 200, please administer insulin as
recommended (lantus 35U in the morning as well as Humalog per
the sliding scale provided to you)
- Please go to your ___ appointment at ___
- Please see your PCP to ___ on your medical conditions
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | ___ year-old-female with hx R-sided breast cancer metastatic to
nodes s/p total mastectomy (tamoxifen currently on hold), HTN,
HLD, HFrEF (EF 40% in ___, poorly-controlled DM presenting
with R forearm cellulitis, sepsis, and DKA, with course c/b CoNS
in blood, likely contaminant.
# R forearm cellulitis:
# CoNS in 1 of 2 bottles:
# Sepsis:
P/w sepsis ___ to R forearm cellulitis without purulence with
low suspicion for osteomyelitis or necrotizing fasciitis given
unremarkable Xray of humerus, forearm, hand and RUE U/s with no
e/o DVT. Improved with Vanc/Zosyn and then transition to PO
antibx, subsequently
re-broadened to Vanc/CTX prior to MICU callout given GPCs in 1
of 2 bottles drawn in ED. BCx speciated to CoNS, likely a
contaminant, with subsequent BCx NGTD. Given improvement in her
cellulitis, she was transitioned to PO Keflex/doxycycline on ___
to complete a 10-day course through ___.
# Diabetic ketoacidosis:
# Uncontrolled diabetes mellitus:
A1c 7.2% ___, up to 13.3% on admission for DKA, likely in
setting of infection and metformin non-adherence (had confused
metoprolol and metformin). DKA resolved, and sugars improved on
lantus 35u qAM/15u qPM with Humalog 8u qAC + SS. Ms. ___ is
reluctant to start insulin, hoping for improvement in her
diabetes with metformin alone. In discussion with ___, she
has agreed to discharge on metformin 500mg BID, along with
lantus and humalog insulin pens. She will check her fingersticks
before meals. If sugar is >200, she has agreed to administer
lantus 35u qAM with a humalog sliding scale beginning with 8u
for fingerstick >200. She was provided a glucometer, lancets,
and test strips prior to discharge and received teaching from
the ___, nursing, and nutrition. She was instructed
on identifying and managing hypoglycemia as well. She will f/u
with ___ endocrinology and with her PCP ___ ___.
# Acute on chronic thrombocytopenia:
Plt have ___ slowly downtrending over the last year or so. Was
recently seen by heme/onc (Dr. ___ on ___ who attributed
thrombocytopenia to tamoxifen (now on hold since ___ in setting
of likely initiation of aromastase inhibitor). W/u notable for
CMV IgM/IgG positivity, but CMV VL was negative. HIV negative.
No e/o DIC. Plt were uptrending at discharge (from 106 on ___ to
132 on ___ with no e/o bleeding.
# HFrEF (EF 40% in ___:
# HTN:
# Risk factors for CAD:
EF 40% on stress echo ___ with e/o prior inferior MI without
inducible ischemia. Received IVF iso sepsis and DKA, but no e/o
volume overload during admission. Continued home Toprol and half
dose of home losartan (25mg daily in place of home 50mg daily).
___ benefit from outpatient cardiology f/u and addition of
low-dose ASA and a statin, which were deferred to PCP.
# R-sided breast cancer metastatic to nodes s/p total
mastectomy:
Tamoxifen on hold since ___, with plan for initiation of AI.
She will f/u with her outpatient oncologist, Dr. ___,
___ discharge.
TRANSITIONAL ISSUES
===================
[ ] F/u BCx, pending at discharge
[ ] ___ diabetes management and insulin titration
[ ] Insulin plan as above: discharged on metformin 500mg BID
with plan to dose lantus 35u qAM for AM fingerstick >200 and
humalog SS beginning with 8u for pre-prandial fingerstick >200
[ ] ABx with cephalexin/doxycycline x 10 days to complete ___
[ ] Reduced losartan to 25mg qd from 50mg. Titrate as needed
[ ] Consider starting moderate intensity statin and ASA for
primary prevention given ASCVD risk >10%. ___ benefit from
outpatient cardiology f/u.
[ ] Further ___ deferred to outpatient
hematology/oncology | 190 | 560 |
10089199-DS-21 | 27,816,056 | You were admitted to ___ with abdominal pain after some
alcohol consumption and fast food consumption. Your acute pain
went away with bowel rest and time.
You were seen by the GI doctors who ___ that your underlying
Crohn's disease was not adequately treated with your present
regimen of medication and they advised that we start you on
budesonide daily. | SUMMARY/ASSESSMENT: Ms. ___ is a ___ female with the
past medical history and findings noted above who presented with
abdominal pain, likely related to dietary indiscretion, but on a
background of likely persistently active Crohn's disease.
#Abdominal pain
#Crohn's disease with proximal terminal ileitis
The pt p/w ___ pain, quite rapid onset, no
nausea/vomiting/diarrhea/melena/hematochezia. CT shows her known
Crohn's disease which is active in the terminal ileum. Her
acute symptoms resolved with bowel rest, and antibiotics were
stopped. Her acute symptoms were not felt to represent a flare
of her Crohn's disease, but rather a reaction to the dietary
indiscretions.
In regards to her Crohn's disease, her imaging remains unchanged
since ___ despite treatment with stellara at increasing
dose, so the GI consult advised start of budesonide and follow
up regarding changes in her chronic treatment for Crohn's.
#Asthma
Currently asymptomatic, usually seasonal.
- she was treated with Duonebs PRN
# GYN
OCPs continued | 62 | 149 |
12432370-DS-15 | 25,275,495 | Dear ___,
___ was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
You were not eating well and you had lost a lot of weight.
WHAT HAPPENED WHILE YOU WERE HERE?
You had imaging of your head that showed a brain tumor and
swelling. We gave you medication to help reduce the swelling and
prevent seizures.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- You are being discharged to a ___ facility where the
doctors and ___ continue to make sure you are
comfortable.
Sincerely,
Your ___ Team | ___ with a PMH of ___ disease,dementia, NIDDM, CVA,
meningioma who p/w sub-acute weight loss and increased lethargy,
found on imaging to have significant edema with evidence of
midline shift secondary to expanding meningioma.
ACTIVE ISSUES
=============
# Encephalopathy
# Meningioma
Patient initially presented with failure to thrive and weight
loss with altered mental status. She had CT in the ED which
showed a new 6 mm mid-line shift as compared with imaging done
___. Per family discussion at the time of admission no
neurosurgical intervention was indicated, nor was it within the
patient's goals of care. Patient was started on Dexamethasone
4mg BID and was subsequently increased to 4mg QID the second day
of admission. Neuro onc consulted and recommended MRI which
showed worsening likely infiltrative process causing edema and
midline shift, no evidence of an acute stroke. Patient was also
started on Keppra for seizure prophylaxis given history of
unresponsive episodes at her nursing facility. Given location of
her meningioma, it was felt very likely that patient would have
some element of seizure activity on EEG. No e/o infection on
labs, no significant electrolyte/LFT/BMP abnormalities from
baseline. Per neuro-onc, given already present cerebral edema,
radiation therapy was not an option for treatment. Given the
patient's poor prognosis, progressive cerebral edema and midline
shift, and limited medical therapies, GOC conversion with family
on ___ led to decision to transition the patient to comfort
measures while still continuing on dexamethasone and Keppra for
comfort. Patient was discharged to inpatient hospice.
#HTN
Blood pressure progressively increased throughout her admission,
as high as 202/68 on ___. Started on hydralazine 10 TID with
some improvement in BP to SBPs 140s-160s. Concerning for early
signs of herniation with associated bradycardia to HR ___.
#Nutrition
Initially started on diet as patient presented with failure to
thrive and significant sub-acute weight loss. Speech and swallow
consulted and recommended NPO due to aspiration risk. Per goals
of care discussion with the family, diet was liberalized to food
for comfort on ___.
#Hypoxia
Patient had O2 requirement of 2L on first day of admission and
was noted to be intermittently tachypneic to as high as the ___.
She needed up to 4L during her admission but CXR revealed no
acute findings. Speech and swallow team evaluated for concern
for aspiration risk, made NPO, but per above restarted comfort
feeding on ___. She continued to be tachypneic at the time of
discharge but was saturating well on room air.
Transitional Issues
======================
[]Continue on PO Dexamethasone 4mg q6 hr, Keppra 500mg BID as
able if patient swallowing and able to take PO.
[]Continue IV dilaudid PRN for pain. | 90 | 430 |
18652620-DS-17 | 29,318,549 | Dear Ms. ___,
Thank you for choosing ___ as your site of care!
Why was I admitted to the hospital?
You were admitted to the hospital because of back pain and
because you had a stone that was in your urinary system.
What was done for me while I was in the hospital?
You had a renal ultrasound and a CT scan which showed a stone.
Your kidney showed some dilation, but this is mild.
You received IV fluids and IV antibiotics and your pain
resolved.
We discussed the imaging with our Urology team who felt that the
stone will likely pass on its own.
What should I do when I go home?
Please continue to take your antibiotics for the next 5 days.
You will be contacted by the Urology office to be seen in
clinic.
It is very important you take your seizure medication every day.
If you notice worsening abdominal pain or fever, please return
to the emergency department.
You should drink 2.5L of water every day.
Please call your primary care provider to be seen within the
next 7 days.
We wish you the best! | PATIENT SUMMARY FOR ADMISSION:
Ms. ___ is a ___ year old female with history including
seizure disorder and nephrolithiasis who presented with left
flank pain and was admitted for management of left UVJ stone who
was discharged once symptomatically improved. | 174 | 39 |
14288592-DS-21 | 28,152,964 | Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management of
your fatigue, weakness, and unintential weight loss and
persistent, chronic diarrhea. Laboratory evaluation revealed you
had life-threatening hypercalcemia and acute kidney injury
(acute renal failure) which was treated aggressively with IV
hydration. You were treated with medications to lower your
calcium and further laboratory studies and imaging were obtained
to determine the source of your elevated calcium. You had an
upper and lower endocscopy performed which showed no evidence of
malignancy, just some microscopic colitis. You had an extensive
work-up started to rule out malignancy, and your chest imaging
showed a right-sided lung nodule. All of your other laboratory
work was reassuring. Your nutrition remains a concern, and you
should consider follow-up with a Nutritionist regarding these
issues. You will follow-up with your primary care physician, an
___, your Renal and GI physicians.
.
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.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
START: Budesonide 3 grams by mouth daily
START: Pamidronate 90 mg IV every 7-days at the Pheresis IV
infusion clinic for hypercalcemia treatment. Your primary care
physician ___ help coordinate this.
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: Calcium supplement
DISCONTINUE: Vitamin D supplement
DISCONTINUE: Triamterene-Hydrochlorothiazide
DISCONTINUE: Gabapentin
DISCONTINUE: Citalopram
DISCONTINUE: Cholestyramine-Aspartame
DISCONTINUE: Prochlorperazine
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above. | ___ with a PMH significant for temporal arteritis (biopsy-proven
___, three episodes of transient right eye blindness,
previously on Prednisone), Osteopenia, HTN, HLD, hypothyroidism,
hyperparathyroidism, sciatica, peripheral neuropathy, s/p
cholecystectomy (with bile salt diarrhea) who presents as a
direct admission from her PCP office given concerns for
unintentional 15-lbs weight loss, persistent nausea and anorexia
found to have acute renal insufficiency
.
# UNINTENTIONAL WEIGHT LOSS, POOR PO INTAKE - The patient
presented with a vague constellation of symptoms, specifically
an unintentional weight loss of roughly 15-lbs over the course
of ___ years (146 to 125-lbs) with decreased interest in food
and poor PO intake rather than early satiety. She denied
abdominal pain. She has persistent nausea and some emesis
episodes that are non-bloody. She denies fevers or chills, has
had no sick contacts and or recent URI symptoms. Possible
etiologies included: endocrinopathy (hyperthyroidism, diabetes,
adrenal insufficiency) vs. gastrointestinal disorders (anorexia,
without abdominal pain, denies early satiety; no dysphagia,
odynophagia or dysmotility - consider malabsorption or chronic
infectious diarrhea given leukocytosis; unlikely obstruction)
vs. inflammatory bowel disease (no history of UC or Crohn, no
bloody diarrhea, no abdominal pain) vs. occult malignancy
(reassuring age-appropriate screening and negative stool guaiac,
but significant hypercalcemia makes this more likely) vs.
substance abuse concerns (denied by patient; daughters note
prior heavy alcohol use) vs. medication-effect.
.
We consulted Gastroenterology and, along with serologic studies,
they recommended EGD and colonoscopy which was performed on
___ and showed only grade I internal hemorrhoids and scoped
to the hepatic flexure; otherwise normal colon. There was
microscopic evidence of microscopic colitis (lymphocytic
variant) and she was started on Budenoside 3 mg PO daily and
will follow-up with her GI physician. Her EGD showed a small
hiatal hernia, but no other abnormality. She has also had
age-appropriate screening - normal colonoscopy (___),
mammography in ___ BI-RADS 1 and negative for malignancy. Her
TSH was 4.0, random cortisol level was reassuring. We sent stool
studies which were negative and reassuring (including Giardia,
C.diff toxin negative). Fecal fat assessment was ordered to rule
out a malabsorptive picture of diarrhea and was pending at
discharge. A urine and serum toxicology screen was negative. Her
nutritional status was impaired - her albumin 3.2 and iron
studies compatible with a mild component of anemia of chronic
disease. We asked the Nutritionists to evaluate her and we
supplemented her diet with oral Ensure shakes with meals and she
steadily improved. Her weight was closely monitored.
.
The unintentional weight loss and anorexia with nausea was all
attributed to her severe hypercalcemia and likely underlying
malignancy (see below). Her chronic diarrhea was attributed to
her microscopic colitis.
.
# HYPERCALCEMIA - On the patient's initial evaluation her serum
calcium was 8.8-8.9 in ___, with hypocalcemia in the 7.7 range
in ___ and was last checked at 7.4 in ___ - this admission her
calcium was initially drawn at 17.9 (correction for albumin of
3.2 would be 18.4) with phosphorus of 2.6. Her creatinine
baseline was 0.8-0.9 (and has trended upward from 1.1 to 1.7 and
on presentation was in the 2.2-2.3 range). She initially
presentated with fatigue, weight loss (anorexia and nausea),
mild abdominal discomfort, mental clouding and neuropsychiatric
complaints all fitting with the serum calcium measurement; no
PTH had been measured previously. Possible etiologies included:
primary hyperparathyroidism vs. hypervitaminosis with vitamin D
vs. malignancy (most probable) vs. milk-alkali syndrome vs. bone
resorptive issues (Paget disease, immobilization, vitamin A
overuse); with that said, serum calcium values > 13 mg/dL are
more concerning for malignancy and her serum calcium was > 18
mg/dL this admission. Nephrology was consulted early and
assisted with management of her acute renal failure and
hypercalcemia. She was initially treated with aggressive IV
fluid resuscitation - a goal of 6L (received 1L NS x 1 in the
ED, ran NS @ 200 cc/hr for goal UOP 100-150 cc/hr) was achieved.
Following these fluids, we switched her to maintenance fluid
with Lasix 20 mg IV BID to follow. She also received Calcitonin
100 units SC Q12 hours for 2-days and was dosed a
bisphosphonate, specifically Pamidronate 60 mg IV (received
___. The IV bisphosphonate medication should be dosed every
___ months. Her labs revealed a PTH ___, a TSH of 4.0, vitamin
D-25 and 1,25 levels were pending, UPEP was negative and SPEP
was negative. We serially trended her calcium and phosphorus
levels and monitored her electrolytes. She was maintained on
telemetry and her electrolytes were optimized. Her Foley
catheter was removed without issue following her re-hydration;
it had been placed for urine output monitoring. We also stopped
Lasix and allowed her to maintain PO hydration for 24-hours
prior to discharge, with good effect. We discontinued her
Calcium, Vitamin D and Hydrochlorothiazide medication given her
hypercalcemia. Her calcium maintained in the ___ mg/dL range
prior to discharge and will be followed as an outpatient.
.
We began the work-up for a malignancy this admission, given her
extreme hypercalcemia (milk alkali syndrome and
hypervitaminosis-D were considered) - the most likely etiologies
being multiple myeloma vs. lymphoma vs. solid tumor malignancy
with production of PTHrp. Her work-up for myeloma was
unrevealing with a negative UPEP and SPEP, and her free kappa
and gamma light chain analysis was pending at the time of
discharge. A CT of the chest showed a right lung nodule which
was suspicious for malignancy with a left-sided smaller lesion
as well (see radiology read). She will likely need biopsy of one
of these lesions for tissue diagnosis, given the concern for a
bronchogenic carcinoma. Given her smoking history and
unintentional weight loss, this was the most likely diagnosis,
but her recombinant PTH was still pending at discharge. A CT
abdomen and pelvis was also obtained for staging, and the final
read was pending at the time of discharge - but this
preliminarily showed a non-obstructing renal stone and some
retroperitoneal nodes.
.
# PERSISTENT DIARRHEA - The patient has had persistent diarrhea
for several days to weeks that has been watery, occasionally
formed and non-bloody with no abdominal pain or features of
early satiety. She has a remote history of bile salt diarrhea
reported following cholecystectomy without relief after
cholestyramine therapy. She was admitted with leukocytosis to 14
(neutrophilia), and was afebrile nonetheless. She denied recent
sick contacts, had no recent URI symptoms, and no recent travel
or antibiotics. Possible etiologies included inflammatory bowel
disease (stools were non-bloody) vs. irritable bowel syndrome
vs. functional diarrhea (possible given no abdominal pain but
exclusionary diagnosis) vs. microscopic colitis vs.
malabsorption (denied pale, greasy, voluminous, foul-smelling
stools; we considered lactose intolerance or chronic pancreatic
insufficiency, as well as celiac disease) vs.
post-cholecystectomy diarrhea (performed ___ vs. chronic
infections (C. difficile, Aeromonas, Plesiomonas, Campylobacter,
Giardia, Amebae, Cryptosporidium, Whipple's disease, and
Cyclospora) vs. medication effects. Gastroenterology was
consulted and recommended an extensive work-up. The patient had
negative ova & parasite culture, a negative C.diff toxin,
negative stool studies for bacteria and Giardia. Immune-mediated
work-up showed no immunoglobulin deficits and tTG-IgA for celiac
was negative. An EGD and colonoscopy was performed and did show
evidence of microscopic colitis which was treated with
Budenoside 3 mg PO daily and this should be monitored by her GI
physician. Her fecal fat qualitative assessment was pending at
the time of discharge.
.
# ACUTE RENAL FAILURE - She presented with acute renal
insufficiency with a creatinine of 2.2-2.3 with a baseline of
0.9-1.0 and with no prior chronic renal insuffiency. The patient
also presented with an acute hypokalemic, hypochloremic
metabolic alkalosis, attributed to contraction from volume
depletion. On exam, she was noted to have volume depletion and
dehydration given her nutritional status. A U/A showed trace
protein (although her protein/creatinine ratio was elevated at
34.3) and she received 1L NS x 1 in the ED. Her FeNA was 1% on
admission. We consulted Nephrology given her hypercalcemia and
acute renal insufficiency. Her UPEP and SPEP were negative for
___ proteins or M-spike, respectively. Her creatinine
dramatically improved with hydration from 2.2 to 1.7-1.8 prior
to discharge. This will be monitored as an outpatient. A Foley
catheter had been placed initially and was discontinued when she
tolerated oral hydration. She voided without issues. A urine
culture was negative for growth this admission. Lastly, we
avoided all nephrotoxins (discontinued her Gabapentin) and
renally dosed all medications.
.
# LEUKOCYTOSIS - She presented with a WBC to ___ with a
neutrophil predominance (N83.2 L13.1 M3.2 E0.3 B0.2, no
bandemia); without fevers or chills and without systemic
symptoms of infection (no dysuria, no URI or cough symptoms)
with the exception of chronic diarrheal concerns. Of note, she
stopped oral systemic steroids in ___ and during her treatment
period had a leukocytosis in the ___ range. Other etiologies
considered included: hematologic or solid malignancy vs.
medication-induced (not on steroids) vs. hypercalcemia. There
were no indications for antibiotics and in the end, an
exhaustive infectious work-up only revealed microscopic colitis.
The colitis, along with a potential malignancy, was the most
likely etiology of her leukocytosis. A CXR was negative, U/A was
reassuring, and urine and blood cultures along with stools
studies were all negative and reassuring. She remained afebrile
and her leukocytosis improved to 14 prior to discharge.
.
# TEMPORAL ARTERITIS, POLYMYALGIA RHEUMATICA - Has a history of
biopsy-proven giant cell arteritis in ___, with three
episodes of transient right eye blindness; previously on
Prednisone, but not within the last 6-months. No recurrence of
symptoms and managed by Dr. ___ from ___
with last follow-up in ___. This admission, she had no evidence
of vision changes or PMR flare.
.
# OSTEOPENIA, BONE METABOLISM - She was diagnosed on BMD imaging
in ___ with no vertebral or pathologic fractures of note; and
had been maintained on Calcium carbonate-Vitamin D3 500 (1250
mg/200 units) PO daily - no longer on chronic steroids for
temporal arteritis - had left partial hip arthroplasty for left
hip OA in ___. Given her above issues with hypercalcemia, we
discontinued her Vitamin D and calcium supplementation.
.
# PERIPHERAL NEUROPATHY - The patient has a chronic diagnosis
with evidence of peripheral neuropathy in the lower extremities;
etiologies included vitamin B12 vs. folate deficiency vs.
alcohol-induced (prior heavy history of abuse, denies current
use) vs. medications vs. chronic malnutrition vs. diabetic
neuropathy (HbA1c 5.9% in ___ vs. hypercalcemia issues.
This admission her HbA1c was normal, her vitamin-B12 - 1352,
folate - > 10 and she was maintained on a Multivitamin 1 tab PO
daily, Thiamine 100 mg PO daily and Folate 1 mg PO daily. Again,
we discontinued Gabapentin for now given renal insufficiency and
concern for mental status changes and recent somnolence, per her
daughters. We did not resume this medication.
.
# HYPERTENSION - The patient is normotensive and she has been
well-controlled on Triamterene-Hydrochlorothiazide 37.5-25 mg PO
daily; prior PCP visits note systolic BP in the 100-120 mmHg
range. We discontinued her potassium-sparring diuretic and
thiazide diuretic given her renal insufficiency and electrolyte
abnormalities.
.
# HYPERLIPIDEMIA - in ___, FLP showing cholesterol was 127,
Trig 99, HDL 65, LDL 42 - she has been maintained on Simvastatin
20 mg PO daily and we continued this medication.
.
# SCIATICA - She had no evidence of active back pain complaints;
not currently on narcotic medications; Tylenol ___ mg PO Q6H
PRN pain was administered as needed and we monitored her
neurologic exam.
. | 369 | 1,867 |
18067599-DS-8 | 24,372,008 | Dear Mr. ___, It was a pleasure taking care of you during
your stay at ___. You were
admitted for lower extremity weakness with falls. You received
an MRI which showed that your cancer has probably spread to your
spine; however, the imaging did not show definite signs of
spinal cord compression. The spine surgeons examined you and
reviewed your records, and did not feel you would benefit from
surgery at this time. You were seen by physical therapy, who
felt you could benefit from rehabilitation services as an
outpatient. You were sent home in good condition. Your
follow-up appointments are listed below. | Pt admitted for progressive leg weakness and loss of sensation
following a fall. In the ED pt tachycardic to 99, VS otherwise
stable. Pt received ativan, morphine, and also empiric
dexamethasone for concern for compression. Pt denied urinary
symptoms. CT head and C-spine negative for fracture or bleed.
MRI performed due to concern for spinal compression, imaging
complicated by motion artifact. Pt was seen by neuro-oncology
who did felt that pt's exam was reassuring, no additional
imaging under anaesthesia necessary. Pt did display a metastasic
lesion at T10, but w/ little evidence that this was the cause of
his symptoms, more likely osteoarthritis or musculoskeletal
pain. Per outpatient oncology notes, pt is undergoing evaluation
for cyberknife therapy, and recent scans show little disease
progression -- no systemic therapy indicated. Pt was treated w/
ibuprofen, and also w/ oxycodone and morphine for breakthrough
pain. His symptoms resolved w/ little intervention, and he was
discharged in improved condition to follow up with his PCP and
primary oncologist. | 104 | 165 |
17862236-DS-26 | 26,604,678 | Dear Mr. ___,
You were seen at ___ for fevers
and for chest pain. Your fevers were ultimately felt to be due
to an infection of your skin/fat tissue (called "cellulitis").
You were initially treated with broad IV antibiotics but these
were adjusted to oral antibiotics with the input of infectious
disease. You will continue these antibiotics (cephalexin) for 7
days after you are discharged (end ___.
For your chest pain, you underwent a cardiac catheterization
early in your admission to determine if there was a blockage in
the arteries to your heart.
What should you do when you leave the hospital?
- Please follow up with the appointments we have arranged.
- Please continue cephalexin (an antibiotic) until ___.
- Please discontinue your gemfibrozil due to the
drug-interaction with atorvastatin.
- There were no other major medication changes. Please continue
taking your Plavix.
It was a pleasure taking care of you at ___.
Sincerely,
Your ___ care team | Mr. ___ is a ___ y/o man with a PMH of CAD s/p
multiple PCI, PVD s/p R BKA/L ___ toe amputation, stroke, HTN,
HLD, T2DM, chronic pain who has been admitted with NSTEMI in the
setting of sepsis from skin and soft tissue infection.
# CORONARIES: Diffuse 3VD, L dominant, complex lesions in ___
LAD
(bifurcation lesion with a diffusely diseased restenotic diag),
distal LAD, ostial ramus intermedius and moderate disease in the
dominant AV groove CX into the LPDA. Underwent PCA to LAD this
admission (see below)
# PUMP: LVEF >55%
# RHYTHM: NSR
# NSTEMI: Patient presented with chest pain in the setting of
sepsis. EKG showed NSR, rate of 105, ST depressions in V4/V5,
with TWI in V1/V2, Q-wave in III. Trops initially 0.13 with CKMB
21. Patient initially underwent cardiac catheterization on
hospital day 1 which showed diffuse multivessel CAD. No
intervention was performed due to diffuse disease and ongoing
fevers (see below). He was planned for medical management with
nitro gtt for chest pain symptom relief as well as Plavix,
metoprolol, aspirin 81, atorvastatin 80 mg qHS. ACEi was
initially held due to hypotension (although ultimately resumed
over hospital course). However, troponins continued to rise and
patient again developed chest pain on ___ that was responsive
to SL nitro. He was placed on heparin gtt and isordil for chest
pain control. He was taken back to the cath lab on ___, and
received a drug-eluting stent to proximal LAD, and balloon
angioplasty of D1 ostium and lower pole branch of ramus
intermedius. Please review OMR for the catheterization reports.
# Severe sepsis secondary to cellulitis: Patient initially
febrile, with leukocytosis, borderline hypotension and
tachycardia. Source appears to be left foot with warmth and
erythema. No evident ulceration or erosion. Dopplerable DP
pulses. No evidence of trauma, though neuropathy and severe
peripheral vascular disease does place him at high risk for
SSTI. Given his recent hospitalizations and diabetes, patient
was initially covered broadly, including with MRSA and
Pseudomonal coverage. He does not have any cough or evidence of
PNA on CXR or evidence of UTI. He was initiated on vancomycin
1000 mg IV q8h and zosyn with panculture. Given concern for
osteomyelitis of foot, case discussed with vascular, podiatry,
and infectious diseases and decision was made that there was low
suspicion for osteomyelitis, and no MRI was necessary.
Ultimately, he defervesced and improved clinically in <24 hours
and it was felt that the source of infection was cellulitis. He
was narrowed to cephalexin and will complete a course ending
___.
#HEART FAILURE WITH PRESERVED EJECTION FRACTION. Noted to have
elevated LVEDP on catheterization. No dyspnea, PND, orthopnea at
this time to suggest significant decompensation. Given concern
for sepsis, he did not undergo diuresis initially. TTE this
admission showed mild regional left ventricular systolic
dysfunction c/w CAD in mid to distal LAD territory. EF 45-50%. | 152 | 474 |
12829586-DS-20 | 23,223,744 | 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:
- RLE WBAT
- LLE WBAT w/ posterior hip precautions
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left hip dislocation (and underwent closed reduction
in the ED, please see note for full details) and a right femoral
shaft fracture and was admitted to the orthopedic surgery
service.
The patient was seen and evaluated by ACS who continued to
follow for a tertiary survey. Please see their note for full
details.
The patient was taken to the operating room on ___ for
right femoral shaft retrograde 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 <<>> 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
RLE WBAT and LLE WBAT w/ posterior hip precautions, 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. | 272 | 299 |
19376468-DS-8 | 26,630,438 | Discharge Instructions:
Traumatic Brain Injury
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.
You make take a shower 3 days after surgery.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
**Please DO NOT take your ___ for at least one month
following your injury. Please follow-up with your PCP/Prescriber
regarding this important medication change. At your follow up
appointment with Dr. ___ your ___ will be
discussed.
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 symptoms after traumatic
brain injury. Headaches can be long-lasting.
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.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
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 | #TBI; Acute SDH
___ female on ___ admitted in the early morning of
___ s/p a mechanical fall overnight. NCHCT at OSH showed an
acute parafalcine SDH for which she was transferred to ___ for
Neurosurgical evaluation. At OSH, her INR was 1.8 and she
received K-Centra. Upon presentation to the ___ ED, her
___ was held with plans to hold for one month. She received
Vitamin K for a repeat INR of 1.5, after which her INR was 1.3.
She was found to be neurologically intact, and was admitted to
the floor for observation. She was started on Keppra 500mg BID
for one-week for seizure prophylaxis. Repeat NCHCT 6-hours after
her original scan was stable. She remained neurologically intact
and her pain well-controlled with oral medications, oxycodone
was added to medication regimen due to complaints of headaches
worse with movement. Patient's INR was 1.1 on ___. Patient
continued to remain neurologically intact. ___ evaluated the
patient on ___ and recommended discharge home without services.
On ___ patient without complaints of increased headaches,
lightheadedness, dizziness, or any other neurological
complaints. Patient ambulating without difficulty to a from the
restroom.
#Trauma
Upon admission, her left knee was found to be edematous. XR at
OSH had been negative. ACS was consulted for tertiary survey and
stated full traumatic workup was negative without additional
injuries.
#Diabetes
The patient was ordered for her home diabetes medications upon
admission and she was covered with an Insulin sliding scale
AC/HS PRN.
#BRPPR
In the ED, the patient was noted to have one episode of a small
amount of BRBPR. A CBC was repeated and was stable. Her CBC was
monitored daily and she was ordered for stool guaiacs. Patient
reports history of hemorrhoids for which she notes BRBPR
occasionally, she states she has a scheduled appointment with
her PCP regarding this issue as well as complaints of diarrhea.
Patient without diarrhea while inpatient.
#Disposition
Patient was evaluated by physical therapy on ___ and
recommended for home discharge without services. Patient was
discharged to home on ___. Patient given all follow up
instructions and prescriptions. Patient to follow up with PCP
next week regarding left forehead laceration as well as her
complaints of diarrhea and BRBPR. Patient to follow up with Dr.
___ in ___ weeks with CTH, patient will continue to hold
___ until this appointment with Dr. ___. | 550 | 388 |
16595729-DS-14 | 29,064,764 | Mr. ___,
You were admitted for your chest pain and management of bleeding
of vessels in your stomach due to your liver disease. You were
initially managed in the ICU for difficulty breathing and found
to have worsening heart failure and need for blood transfusions.
After you were stabilized and transferred to the medicine
floors, you had your procedure to stop the vessels in the
stomach from bleeding.
You are to continue your medications as shown below and
follow-up with your appointments listed. If you have pain,
swelling, purulence at the incision site or in your abdomen, you
should return to the hospital immediately. If you have recurring
chest pain, shortness of breath, severe fatigue/weakness, you
should return to the hospital immediately.
We wish you the best,
Your ___ team | BRIEF SUMMARY
=============
___ year old male with history of Hep C cirrhosis s/p Harvoni c/b
varices s/p TIPS ___ after admission for variceal bleed,
presenting with anemia, NSTEMI, and decompensated CHF.
ACTIVE ISSUES
=============
#Acute on chronic CHF exacerbation:
The patient was recently admitted with NSTEMI in the setting of
GIB. At that time, he was initiated on statin, but ASA was held
in the setting of GIB. No beta blocker due to history of severe
bradycardia from them. He was scheduled to follow-up with
cardiology for further work-up (stress vs. cath), however he
represented with anemia and a NSTEMI. Cardiology was consulted
as an inpatient and the patient was managed in a similar
fashion. He was started on ASA 81mg, heparin gtt was held due to
concern for risk of variceal hemorrhage pending EGD, and beta
blocker held due to risk of bradycardia. He was continued on
high dose statin. On ___ due to worsening tachypnea, shortness
of breath, patient transferred to the MICU for nitro gtt, TTE,
further diuresis and possible BIPAP. In the MICU, he was started
on captopril and uptitrated to lisinopril 40 mg. Home
hydralazine was started. He was diuresed with IV Lasix boluses
up to 60 mg BID with good effect. Repeat TTE showed mildly
depressed EF 45-50%.
# Type II NSTEMI/Chest Discomfort: Likely ___ hypertensive
emergency with some EKG changes with ST depressions and TWI.
Repeat EKGs have improved. CTA negative for PE. We continued
aspirin 81, atorva 80. We held his beta blocker in the setting
of bradycardia to ___. It was deemed that he not need his
metoprolol. Patient was also not candidate a for cath lab given
bleeding.
#Anemia: The patient presented with subacute to acute H/H drop
since prior admission. Given history of GIB and questionable
history of coffee ground emesis, there was a concern for UGIB.
However, clinical history does not support GIB as the sole
etiology of his anemia; TIPS should have decompressed gastric
varices, which are grade I and should not be bleeding at any
rate. Luminal GI bleed unlikely to cause this degree of Hgb drop
given no significant bloody output. CTA negative for RP bleed,
however notable for persistent esophageal and gastric varices as
well as ascites. Given concern for variceal hemorrhage he was
started on PPI and octreotide gtt as well as Ceftriaxone for GIB
in a cirrhotic patient. His H/H stabilized and he was
transferred to the floor. Due to concern for coronary ischemia
in the context of anemia, he was transfused 2 units of blood on
___, 1 on ___ and 1 on ___. His octreotide was stopped
given that he was hemodynamically stable and he completed 7 days
of ceftriaxone. Pt underwent ___ embolectomy without
complications, incisino site was clean/dry with stabilizing H/H
after procedure. | 127 | 461 |
18622438-DS-18 | 26,463,795 | Dear Mr ___,
You presented to ___ because your doctor
referred you here to discuss the possibility of liver
transplant.
While in the hospital, you were found to have severe liver and
kidney disease.
-You were treated with albumin.
-You had a number of labs drawn to make sure you don't have an
infection.
-You were seen by the nutrition specialist to help you decide
what kind of food is best for you.
-You were informed that a liver transplant would require blood
transfusions; however, you declined transfusions given your
beliefs.
-You have decided to pursue hospice care at this point.
After you leave the hospital, it is important that you continue
taking your medications as prescribed. Make sure you follow up
with your doctors in ___.
We wish you the best,
Your ___ medicine team | ___ with alcoholic cirrhosis and DMII presented with
decompensated liver failure and MELDNa36, referred from ___
for evaluation of liver transplant.
ACUTE ISSUES:
==============
# Goals of care
# Liver transplantation need due to Alcoholic cirrhosis
Since patient refused blood transfusions, it is unlikely that
any surgeon would agree to perform a liver transplant. ___ was
discussed by our transplant committee, who felt ___ was not an
appropriate candidate to be transplanted here due to his refusal
to take blood products. ___ understands that ___ would likely die
without a transplant, but expresses the preference to go home.
___ was not interested in further management of his acute
decompensated hepatitis given there was limited further
intervention to change his overall course without transplant- ___
reports ___ would rather spend the remaining time ___ has left at
home.
# Alcoholic Cirrhosis
Patient presented in liver failure with MELDNa36 and Child Class
C. ___ had failed to improve with steroids and sphincterotomy for
alleged cholodocholithiasis at OSH. Sober x 2.5 months. Used to
drink ___ gallon of rum daily. Complicated situation as patient
is a Jehovah's Witness and refuses blood products. Workup
initiated included ___, AMA, SMA, hepatitis A IgM, hepatitis A
Ab, hepatitis B SAg, hepatitis B cAb, hepatitis B SAb, hepatitis
B viral load, hepatitis C Ab, hepatitis C viral load, IgG, IgA,
IgM, iron, ferritin, TIBC, CMV, EBV, HSV, HIV, A1c, utox,
ethanol. RUQUS showed cirrhosis. Diagnostic paracentesis showed
no SBP. Nutrition was consulted to teach patient about low
sodium, high protein diet. ___ was treated with lactulose and
rifaximin. Results of workup were largely negative for non-EtOH
etiologies and comorbidities.
___ 01:25AM BLOOD calTIBC-153* ___ Ferritn-1273*
TRF-118*
___ 01:25AM BLOOD %HbA1c-5.9 eAG-123
___ 01:25AM BLOOD TSH-4.2
___ 01:25AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
IgM HBc-NEG IgM HAV-NEG
___ 01:25AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 01:25AM BLOOD ___
___ 01:25AM BLOOD IgG-982 IgA-679* IgM-160
___ 01:25AM BLOOD HIV Ab-NEG
___ 01:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:25AM BLOOD HCV Ab-NEG
___ 01:25AM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT
___ 10:19PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ Blood (EBV) ___ VIRUS VCA-IgG
AB-NEGATIVE; ___ VIRUS EBNA IgG AB-NEGATIVE;
___ VIRUS VCA-IgM AB-NEGATIVE
___ Blood (CMV AB) CMV IgG ANTIBODY-NEGATIVE;
CMV IgM ANTIBODY-NEGATIVE
The patient was informed that a liver transplant would require
blood transfusions. However, ___ stated that as a ___s
Witness, ___ refuses blood transfusions. ___ expresses
understanding that ___ would likely die without a liver
transplant. States that ___ wants to go home to live out the
remainder of his days.
# ___: Patient presented with creatinine elevated to 2.7. This
was suspected due to HRS, with a possible component of ATN as
well. ___ received albumin challenge 100g x3 days with some
improvement in creatinine to 2.1.
# Ascites
Underwent therapeutic paracentesis, draining 4.5L of ascitic
fluid on ___. No evidence of SBP on tap x2.
# Nutrition
Nutrition was consulted to educate patient on low salt diet;
however, nutrition team expressed concern that patient does not
want to follow low salt diet even though ___ has received such
education in the past. ___ was offered a tube placement for tube
feeds; however, ___ declined, preferring to go home and eat what
___ likes in his remaining time.
# Macrocytic Anemia: Likely ___ alcohol. Retic elevated 5.4, TSH
normal, B12 elevated.
# Thrombocytopenia: I/s/o cirrhosis, splenomegaly. Continued to
monitor.
# Hyponatremia: suspected to be related to ___.
Improved with albumin.
#DMII
Continued lantus, ISS
#CODE: Full with limited trial
#CONTACT:
Name of health care proxy: ___
Phone number: ___
TRANSITIONAL ISSUES
[ ] Furosemide and spironolactone held in the setting of
improving ___. Would revisit utility of these medications for
symptomatic relief moving forward in discussion with hospice
services.
[ ] Patient reports ___ has hospice services set up. ___ is being
discharged with visiting nurse as ___ bridge to hospice.
[ ] Patient is advised to go to regular appointments with his
primary care doctor (___) and gastroenterologist (Dr
___. | 128 | 642 |
19648992-DS-19 | 27,165,500 | Dear Mr ___,
It was a pleasure having you here at the ___ ___
___. You were admitted here after you were having
chest pain and an episode of feeling lightheaded. A stress test
done here was equivocal. We feel your lightheadedness was an
adverse reaction after your exercise stress test. We
discontinued your plavix and started you on a medication for
blood pressure called labetalol. Please keep your follow up
appointments below.
We wish you the very best
Your ___ medical team | ___ w/ hx of CAD s/p LCx stent ___, prostate CA managed w/
active surveillance, HLD p/w back/chest pain & weakness,
equivocal stress test being admitted for unwitnessed syncopal
episode.
#SYNCOPAL EPISODE: Patient did not lose consciousness.
Unwitnessed. No events on tele. Patient likely had vasovagal
event after exercising in stress test. No hx of urinary
incontinence or confusion to suggest seizure. No diuresis/bleed
to suggest orthostasis. Normal fingertsick glucose levels and
TSH 2.6. Patient was asymptomatic throughout hospital stay on
floor.
#CHEST PAIN: Patient originally came in for chest pain.
Equivocal stress test in ED. Ruled out for MI. EKG shows no
ischemic changes. Plavix was discontinued as it has been a year
since stensts placed. Pain actually around top of shoulder
blade and reproducible on palpation. Labetalol was added to
medical regimen given very high heart rate during stress test.
Patient was continued on aspirin and atorvastatin.
#HLD:
-continued atorvastatin | 86 | 160 |
11478384-DS-15 | 23,546,220 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-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.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place. | Mr ___ was admitted to Dr ___ for nephrolithiasis
management with a known right ureteral stone and acute kidney
injury, he subsequently underwent cystoscopy, right
ureteroscopy, laser litrhotripsy of right UVJ stone, right
ureteric stent placement, biopsy of incidental bladder tumor at
left ureteric orifice, left ureteric stent palcement and left
retrograde pyelogram
He tolerated the procedure well and recovered in the PACU before
transfer to the general surgical floor. See the dictated
operative note for full details. Overnight, the patient was
hydrated with intravenous fluids and received appropriate
perioperative prophylactic antibiotics. On POD1, BMP was checked
and revealed creatinine down to 1.5.
Intravenous fluids and Flomax were given to help facilitate
passage of stones. At discharge on POD1, patients pain was
controlled with oral pain medications, tolerating regular diet,
ambulating without assistance, and voiding without difficulty.
Patient was explicitly advised to follow up as directed as the
indwelling ureteral stent must be removed and or exchanged and
he | 351 | 160 |
13484393-DS-6 | 25,057,192 | It was a pleasure taking care of you during your hospitalization
at ___.
You were hospitalized with constipation secondary to opioid use
for pain control. You were given an agressive bowel regimen
during this admission and had bowel movements. Upon discharge,
take a daily bowel regimen, including senna, colace, and
FiberCon. If you do not have a bowel movement after 2 days,
please use medications like bisacodyl, magnesium citrate. If you
do not have a bowel movement after 3 days, try a fleets enema
(can be purchased over the counter. If you still do not have a
bowel movement after these attempts, please see medical
attention.
Keep all hospital follow-up appointments. They are listed below.
We have made adjustments to your pain medication regimen. STOP
taking dilaudid for pain control. Instead use tramadol every ___s increased doses of gabapentin. Continue taking
MS ___ morphine) you were doing previously.
Continue taking cyclobenzaprine as needed for back muscle
spasms. | Patient is a ___ F s/p spinanl fusion ___ p/w
constipation and inability to tolerate POs who had bowel
movements after aggressive bowel regimen and then able to
tolerate oral diet.
# Constipation: Attributed to narcotic use for post-operative
pain control as well as iron supplementation for anemia. Patient
was given a soaps-suds enema as well as aggressive bowel regimen
with resultant bowel movement. Patient had 2 bowel movements
through the admission and was tolerating POs through day
___. In her discharge paper work she was instructed to
take a daily bowel regimen of senna, colace, and fiber
supplement daily. If she had not had a bowel movement in 2 days
then she was instructed to use magnesium citrate or bisacodyl,
and if still no bowel movement, then to try a Fleets enema. The
patient was instructed to seek medical attention if she did not
have a bowel movement in 4 days or if she had symptoms secondary
to constipation.
# Post-operative pain control: Patient's home pain medication
regimen of MS ___ and PRN dilaudid were discontinued on
admission. She was swithced to scheduled tramadol, increased
gabapentin dosing, and cyclobenzaprine TID: PRN. IV morphine was
available as needed for breakthrough pain. Upon discharge,
patient was instructed to continue MS ___ 15mg BID with
scheduled Ultram as well as increased gabapentin as an
outpatient as well as continuing Flexril PRN as an outpatient.
She was instructed to stop taking dialudid for breakthrough
pain.
# Nausea/vomiting: Prior to presentation and upon presentation,
patient was unable to tolerate orals which was attributed to
constipation. IV ativan was available as needed for nausea; IV
zofran was avoided as medication could also cause constipation.
Patient was able to tolerate oral diet upon discharge.
# Anemia: Patient attributes anemia to blood donation;
supplemented as an outpatient. Hematocrit remained stable
through hospital admission. Discharged patient with instructions
to decrease frequency of ferrous sulfate
# Thrombocytosis: Likely reactive. Trended through the
admission.
# s/p spinal surgery: Orthopaedic surgery evaluated the patient
in the ED. Per patient report, ortho stated that the incision
site looked good. Orthopaedic surgery followed the patient
through the hospital course with plan to keep outpatient
surgical follow-up as previously scheduled. | 157 | 370 |
10358580-DS-20 | 27,307,471 | Ms. ___ was admitted to the ___ Neurology Wards for new onset
fever and breathing difficulties. She received some gentle
suctioning which relieved her tachypnea in the ED. We found a
urinary tract infection, and she received one dose of treatment
with ceftriaxone. She sustained an allergic reaction to this
medication, with stridor, facial and tongue swelling, and she
was switched to other agents. Ultimately, she was transitioned
to AZTREONAM, based on the pattern of sensitivies. Blood
cultures grew out skin contaminants. She needs to remain on
AZTREONAM until ___. A PICC line was placed.
A NCHCT done in the ED showed no new hemorrhage, but a
combination of old strokes of various ages. While in the
hospital, she was maintained on the remainder of her
medications. Her son, ___, was updated on the day of
discharge. | Ms. ___ was admitted to the ___ Neurology Wards for new onset
fever and breathing difficulties. She lives in an elderly home
and was to at first be transferred to ___ (from where
she had originally been discharged few days prior following the
discovery of a large new stroke). In the ED, she received some
gentle suctioning which relieved her tachypnea in the ED. Labs
showed a WBC of 9.5 and a urinary tract infection, and she
received one dose of treatment with ceftriaxone. She sustained
an allergic reaction to this medication, with stridor, facial
and tongue swelling. A repeat CXR was no different from the
admission CXR, and simply showed "pulmonary vascular
engorgement". Her presumed anaphylactic reaction was addressed
aggressively with the administration of nebulizer treatments and
one dose of methylprednisolone and diphenhydramine.
She was switched to bactrim DS for a few days, but then her
urine culture sensitivities identified the growth of Proteus
that was resistant to multiple agents including bactrim and
cephalosporins. Given her allergy and the sensitivity results,
we discussed with ID team and she was switched to AZTREONAM. A
repeat UA was checked while on this medication and showed little
by way of signs of UTI. The last dose of this medication should
be on ___. For the delivery of long term antibiotics, a
PICC line was placed. Of note, blood cultures drawn at the time
of ED visit grew out GPCs, and so she was initiated on
vancomycin. However, these returned as coagulase negative staph,
and so the patient's vancomycin was discontinued.
A NCHCT done in the ED showed no new hemorrhage, but a
combination of old strokes of various ages. While in the
hospital, she was maintained on the remainder of her
medications. We obtained further history from her son that she
had been previously on warfarin and aspirin, but this caused
difficulties with epistaxis and serious cutaneous bruising. She
had been actually off of aspirin prior to her most recent
stroke, and had recently been started. From the neurological
perspective, given her recent stroke, active atrial fibrillation
and previous history of bleeding, we decided on continuing an
antiplatelet agent. Her son, ___, was updated on the day of
discharge and he agreed with this plan.
While in house, she sustained no further allergic reactions. She
had one episode of AF RVR which improved with beta blockade. Her
HR on discharge was in the 90-110 range, and so she was started
on a low dose of metoprolol for rate control. Her blood sugars
remained on the higher side (200-270) while in house, likely
related to the administration of dextrose containing agents
(aztreonam), her current infection (UTI) and non-diabetic TF
administration. The latter was switched to Glucerna 1.0 one day
prior to discharge.
Transitional issues:
- Please have the patient follow up with Dr. ___ the
___ of Stroke Neurology. We defer the remainder of her
medical care to the physicians at her facility. | 137 | 491 |
15131736-DS-21 | 28,033,478 | Dear Ms. ___,
It has been a pleasure taking care of you at ___. You were
admitted to the hospital because your nursing home was concerned
for a change in your mental status. In the Emergency Department,
you were found to have low oxygen levels, which required placing
a breathing tube. We also found that you kidney was injured. You
were treated in the Medical Intensive Care Unit briefly and then
on the general medicine unit. Your breathing improved and we
were able to remove the breathing tube. Your kidney injury also
resolved with fluids through an IV. We were also initially
concerned that you might have another urinary tract infection.
Because of this, you were briefly started on antibiotics.
However, your mental status improved and you had no signs of
infection and we were able to stop the antibiotics and remove
the larger IV (PICC) in your arm. Your mental status and
confusion improved during your hospital stay. We think that your
low oxygen levels and confusion occured from a little
dehydration that caused kidney injury. This kidney injury may
have then caused some build-up of your pain medications in your
body. This can cause both low oxygen levels and confusion.
Please take all of your medications as directed and follow up
with your doctor. Weigh yourself every morning, call MD if
weight goes up more than 3 lbs.
It has been a pleasure taking care of you and we wish you all
the best.
Best,
Your ___ care team | ___ with severe COPD, diastolic heart failure, obstructive sleep
apnea, obesity hypoventilation syndrome who was transferred to
the hospital from rehab facility for altered mental status,
found to be in respiratory acidosis and hypoxemia with profound
agitation requiring sedation and intubation. She was extubated
on ___ (HD#1) w/o complication. She refused to wear her CPAP
mask at night. Initial UA consistent with UTI, for which she was
started on empiric meropenem. ___ of 3.0 on admission rapidly
resolved to baseline of 1.3 on ___.
Active Issues
# Hypoxic respiratory failure
Multifactorial in nature. Has COPD, chronic diastolic CHF, and
OSA. Likely contributions from exacerbation of ___ w/ mild
pulmonary edema in setting of reduced torsemide dose upon last
discharge, as well as accumulation of opioid metabolites in
setting of reduced CrCl. Her pre-intubation gas reflected
acute-on-chronic respiratory acidosis, and her post-intubation
gas was much improved. Additionally, she was agitated and
non-complaint with home O2, worsening her hypoxia. She was
extubated ___ without complication. Post-extubation she was
intermittently confused but at her baseline per collateral
conversations. Per conversation with ___ staff, Mrs
___ is extremely ___ with oxygen at her facility, and
refuses to wear her CPAP at night. She was subsequently
transferred to the medicine ward where hypoxia continued to
improve and she was titrated to home O2 (2L NC). She did refuse
CPAP on the floor but had no recurrent hypoxia.
# Encephalopathy
Likely secondary hypercarbia with pre-intubation ABG reflecting
acute respiratoy acidosis. Other contributors include
accumulation of opioid metabolites in setting of acute kidney
injury which is all exacerbated by baseline dementia. Negative
CT Head in ED. Opioids were held during hospitalization and
mental status improved to baseline. She was ultimately
discharged on a reduced dose and frequency of opioids.
# Recent UTI
She has a history of MDR E.coli UTI treated with ertapenam,
course ended ___. Urinalysis on admission had 98 WBCs for
which she was started on empiric meropenem. However, UA
difficult to interpret in setting of recent UTI and UCx grew
yeast. Antibiotics were stopped on ___. Patient remained
asymptomatic, afebrile, and with no leukocytosis. PICC line from
previous admission removed ___.
# Acute Kidney Injury
Cr 3.3 on admission (baseline 1.0-1.2). Likely due to
exacerbation of diastolic CHF in setting of reduced torsemide
dose from last admission (from 80 to 40mg qday at last
admission). CXR on admission revealed mild increase in pulmonary
edema / pulmonary vascular markings. FeUrea consistent with
pre-renal etiology. ___ also be exacerbated by dehydration
secondary to decreased PO intake in the setting of AMS. Improved
with one time furosemide administation and careful IVF.
Lisinopril initially held and Cr downtrended. Cr 0.9 on ___.
Lisinopril restarted on ___. Toresmide restarted on ___.
# Acute on chronic diastolic heart failure
As described above, she has mild pulmonary edema concerning for
exacerbation of CHF. She was diuresed and restarted on home
torsemide.
# Right shin ulcer
She has a 7x8cm ulcer s/p skin graft earlier in ___. Patient is
on MS contin at nursing home due to pain from ulcer. During
hospitalization, pain was controlled on acetaminophen alone.
Narcotics held for reasons described above (concern for
accumulation in setting of decreased CrCl leading to AMS). Wound
care was consulted who recommended applying Soothe and Cool skin
conditioner to intact dry skin, covering wound with melgisorb ag
sheet followed by softsorb. Secure with Kling and change daily.
CHRONIC ISSUES
# COPD, OSA, obesity hypoventilation syndrome
Patient not on home CPAP and refused several offerings during
hospitalization. Patient was maintained on home
Fluticasone-Salmeterol, Tiatroprium, standing albuterol inhaler,
and albuterol neb PRN, ipratropium-albuterol PRN.
# Persistent Atrial Fibrillation
Patient with afib not on home anticoagulation, without clear
documentation why. Home metoprolol 25mg BID continued.
# History of bradycardia
Patient had intermittent episodes of bradycardia while
sleeping, likely due to OSA. She was not symptomatic.
TRANSITIONAL ISSUES
- Consider change in pain regimen. Buildup for morphine
metabolites may have contributed to presentation. Pain was
managed with acetaminophen during hospitalization, and therefore
would suggest pain control with non-opiate medications or
judicious use of opiate medication. She was discharged on lower
dose of oxycodone. MS ___ was discontinued.
- Patient with atrial fibrillation, but not on anticoagulation
for unclear reasons. Please address the need as an outpatient.
- Please have daily wound care for RLE ulcer.
- Please encourage CPAP at night and supplemental O2 use. Given
her severe COPD it is important that her SaO2 be maintained at
90-92%. She does not need to be higher than this.
- EMERGENCY CONTACT: From ___ records ___ Healthcare:
___, contact ___ (friend) ___,
___ (?Granddaughter, unclear relation) ___,
___ (brother) ___, ___ (?Sister
in law): ___
- CODE STATUS: FULL (Confirmed) | 246 | 763 |
16207152-DS-6 | 21,508,893 | Dear Ms ___,
You were admitted to the hospital due to a globe laceration of
your left eye due to a fall. The laceration was surgically
repaired and you are ready for discharge home. Please follow up
with the ophthalmologist as scheduled tomorrow. Please also
schedule a follow up with Dr ___ a week. For pain
control, please use tylenol as needed but do not exceed 3 grams
per day. I have also prescribed you another pain medication
named ___ which is a non-narcotic. It is sometimes sedating
so, be mindful. If you have any questions or concerns after
discharge please call me.
Best,
___, MD | ___ s/p mechanical fall with truama resulting in OS globe
rupture. She was admitted for observation following emergent
surgical repair.
# Globe Rupture:
She underwent emergent surgery with ophthalmology to repair
ruptured globe. She tolerated the surgery well. She was seen in
___ clinic the following morning and it was recommended that
she did not need further systemic antibiotics and she was
discharged on topical antibiotics, topical prednisolone, and
atropine drops to the L eye. She will see Dr ___ day
following discharge to be re-evaluated. Her pain was managed
with tylenol and tramadol prn.
# Anxiety/Hypertension:
She will continue to take her home propranolol on discharge.
# Constipation:
Senna/Colace | 106 | 107 |
15438777-DS-5 | 28,919,345 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were diagnosed with a heart rhythm called "atrial
fibrillation"
- You had fluid in your lungs that was giving you shortness of
breath, likely a result of high blood pressure and the atrial
fibrillation.
What was done while I was in the hospital?
- We gave you medications to help remove extra fluid off your
body, which helped your breathing
- You were started on a medication to slow your heart rate
called "diltiazem"
- You had a "cardioversion" which was a procedure under
anesthesia to shock your heart back into a normal rhythm.
- You were started on a blood thinner called "pradaxa" (the
generic name is ___.
- You were seen by neurologists who believed it was safe for
you to take the pradaxa even with your history of a bleed in
your brain
What should I do when I go home?
- It is very important that you take your pradaxa and
diltiazem.
- Please go to your scheduled appointment with your
cardiologist, Dr. ___. You will be called with an appointment
for follow up.
- If you have chest pain or shortness of breath, please tell
your primary doctor or go to the emergency room.
Best wishes,
Your ___ team | ___ with h/o HTN, HLD, IPH in ___, presenting with new onset AF
and heart failure, started on pradaxa, diltiazem and underwent
TEE cardioversion ___, which was uncomplicated but did place
her in an atrial tachycardia rhythm with HR in the ___.
-CORONARIES: unknown
-PUMP: EF 67%
-RHYTHM: AFib
#Atrial Fibrillation s/p Cardioversion
Presented with rapid rates to 160s, hemodynamically stable but
symptomatic. No evidence of infection, ischemia, or PE. TSH WNL.
TTE with normal systolic function, mild MR, mild pulm HTN. She
was initially placed on a dilt gtt then transitioned to
diltiazem long acting with good rate control. Given her history
of IPH, Neurology consulted, her images from ___ from ___ were
obtained and reviewed, and they agreed with anticoagulation. She
was started on pradaxa for the possibility of using a reversal
agent if ever necessary. She underwent TEE CV ___, found to go
into atrial tachycardia with HR in low 90-100s. She should
continue her diltiazem 120 mg ER and pradaxa 150 mg BID until
follow up with Dr. ___
#HFpEF
Patient presented with PND, orthopnea, and elevated JVP and
proBNP 1625 consistent with new heart failure. Potential
etiologies include tachycardiomyopathy, alcohol (drank heavily
the weekend prior to symptoms developing), HTN (well controlled
but ran out of BP meds several days PTA). Likely also triggered
by onset of AFib
as above. TTE showed EF 67% with mild/mod MR. ___ was given IV
Lasix up to 40 mg, diuresed from 208.1 lbs to 204.6 lbs on
discharge.
-discharge weight 204.6 lbs.
#HISTORY OF INTRAPARENCHYMAL HEMORRHAGE
#HYPERTENSION
No residual deficits. BP well controlled per ___ notes on
current regimen. She ran out of antihypertensives several days
prior to admission. Her home BP meds were initially held and
resumed as tolerated. She remained normotensive during her
admission with some BP measurements in the 140s.
-resume home HCTZ and lisinopril | 235 | 294 |
10424641-DS-16 | 20,612,539 | Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
-You were concerned about your back pain and fevers
What did you receive in the hospital?
-We tested your blood and urine, and you were found to have a
kidney and blood infection. We began antibiotic therapy, and you
responded appropriately.
-You were constipated which may have contributed to your pain.
We gave you laxatives which resolved your constipation and some
of your pain.
-You had high sugars (glucose) in your blood, and we discovered
you have diabetes. Fortunately, your sugar levels are only
mildly elevated and may be managed initially with behavioral
changes.
What should you do once you leave the hospital?
-You should continue taking your antibiotic, ciprofloxacin,
everyday until ___ (last two doses will be taken on
___.
-You should follow up with your primary care physician as
scheduled below. Please speak with your primary care physician
regarding your new diagnosis of diabetes.
-Make sure you continue to hydrate well, roughly 1.5L of water
everyday. Please drink more water if you happen to exercise.
-We did not make any other changes to your home medication
regimen.
NEW MEDICATIONS:
================
-Ciprofloxacin 500mg 1 tab by mouth twice a day (last doses on
___
STOPPED MEDICATIONS:
====================
NONE
CHANGED MEDICATION DOSING TO:
=============================
NONE | ___ w/ COPD and asthma who presents with several day history of
fevers, chills, nausea/vomiting/myalgias and was found to have
bilateral pyelonephritis on CT. Patient was placed on
ceftriazone empirically and urine cultures came back with E.
coli, sensitive to ceftriaxone and ciprofloxacin. One blood
culture on ___ revealed E coli, also sensitive to
ceftriaxone and ciprofloxacin, likely a translocation from her
pyelonephritis. Her symptoms continued to improve with
antibiotic therapy.
She was constipated but began having bowel movements with a
bowel regimen. She initially had an elevated glucose and was
found to be diabetic (a1c 6.5%). Patient's glucose trended down
as her infection was treated. On day of discharge, patient was
transitioned to PO ciprofloxacin to complete a 14 day antibiotic
course to cover both her pyelonephritis and bacteremia (presumed
first day of negative blood culture ___ while antibiotic
therapy). She will complete antibiotic therapy on ___. | 216 | 149 |
17224874-DS-6 | 21,240,603 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were
hospitalized in the neurology wards to investigate further the
cause for your recent increase in seizure events. During your >
24 hour stay here, you did not have any typical events. We
continued your home medications, and we obtained an EEG and MRI
of your brain. Your EEG did not identify any seizures or obvious
epileptiform discharges. The brain MRI also did not identify any
significant abnormalities.
We discussed the various options. At this time you have an
appointment to see Drs ___ in the Department
of Neurology at ___. We tried to increase your KEPPRA from
1000mg twice daily to 1500mg twice daily, but this caused
problems with somnolence/drowsiness. Instead, we will add
another anti-seizure medication, with the goal of ultimately
discontinuing the keppra in the long term. There were no other
medication changes made today.
Do keep your follow up appointment with our neurology
department and your primary care doctor here at . We would also
like to obtain an AMBULATORY EEG (one where EEG leads are placed
and you are able to go home). To arrange this, please call ___ (the order for this test has already been placed).
Do not hesitate to contact us with questions or comments ___, ask for Dr. ___. | ___ was admitted to the ___ neurology service under the
supervision of Dr. ___. We obtained further
history. He explained that he had two types of spells: one where
he is staring and difficult to "snap out of" for ___ minutes at
times, and the second is where he has a generalized convulsion.
He had been more of the latter events recently. His only risk
factor for epilepsy is the recent head trauma, and prior work up
at another neurologist's office had identified a normal MRI and
EEG (PER REPORT of patient). He also explained that he initially
started LEV 500mg BID, which was then uptitrated to 750mg BID.
He was admitted and we repeated an extended routine EEG and
obtained our own MRI with and without contrast under epilepsy
protocols, and neither identified any obvious foci of
epileptogenicity. His MRI did not identify any changes
concerning for significant prior head trauma, such as focal
encephalomalacia, prior contusions or extensive FLAIR changes.
We empirically increased his LEV to 1500mg BID in order to
obtain better seizure control. He refused his second dose of
1500mg LEV because he felt that he would be quite sleepy on this
higher dose. He claimed to have quite a bit of knowledge
regarding anticonvulsant medications given his job as a ___
___, but later he reported to us that he WAS in school
for that temporarily, but now currently lives at home as he is
trying to transfer from one ___ branch to another.
On his second hospital night, he did report an event where in
the middle of the night, he woke up and "didn't know what just
happened". He couldn't clarify further. He just felt weird.
We ultimately provided him a choice. He could either remain in
the hospital for another ___ hours of continuous EEG
monitoring to better clarify these events. OR, we could attempt
to add a third medication with the understanding that LEV could
eventually come off. He preferred this plan, and we agreed that
an ambulatory EEG would be sufficient. We started oxcarbazepine
at 150mg BID, and he agreed to continue his current dose of
levetiracetam and topiramate. | 232 | 360 |
17227240-DS-2 | 27,558,357 | You were admitted to the surgery service at ___ for surgical
resection of your pancreatic mass. You have done well in the
post operative period and are now safe to return home to
complete your recovery with the following instructions:
.
Please call Dr. ___ office at ___ if you have any
questions or concerns.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | The patient with newly diagnosed pancreatic head mass was
admitted to the Surgical Oncology Service on ___ for
elective Whipple procedure. On ___, the patient underwent
classic pancreaticoduodenectomy (Whipple) and open
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
NPO with an NG tube, on IV fluids, with a foley catheter and a
JP drain in place, and epidural catheter for pain control. The
patient was hemodynamically stable.
The ___ hospital course was uneventful and followed the
___ Clinical Pathway without deviation. Post-operative pain
was initially well controlled with epidural catheter, which was
converted to oral pain medication when tolerating clear liquids.
The NG tube was discontinued on POD# 2, and the foley catheter
discontinued at midnight of POD#4. The patient subsequently
voided without problem. The patient was started on sips of
clears on POD# 2, which was progressively advanced as tolerated
to a regular diet by POD# 6. JP amylase was sent in the evening
of POD#6; the JP was discontinued on POD#7 as the output and
amylase level were low.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated.
At the time of discharge on ___, 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. | 202 | 308 |
16410756-DS-13 | 21,918,789 | Dear Ms. ___,
It was a pleasure participating in your care here at ___
___. You came to us with shortness of
breath and chest pain. You got a CXR which showed a small
reaccumulation of your left sided pleural effusion and
pneumothorax. You were evaluated by interventional pulmonology
who recommended treatment with nebulizers but no repeat drainage
of your effusion. You were provided copies of your cytology
results from your previous pleural drainages which were negative
for cancer cells.
You also had a cardiac ECHO done which showed reduced heart
function and some wall motion abnormality. You had a subsequent
nuclear stress test which showed normal perfusion of your heart.
We started you on metoprolol succinate XL 25 daily and
Lisinopril 5mg daily to help control your blood pressure,
hypertension and heart disease. We stopped your triamterene/HCTZ
pill and your potassium supplement because they are no longer
needed. We also reduced your aspirin dose to 81 mg to prevent
increased risk of bleeding.
We also stopped your simvastatin and started you on atorvastatin
40mg daily to help further reduce your risk of cholesterol build
up in your arteries.
We understand that you will be leaving for vacation and you
should take a scale with you and weigh yourself daily. If your
weight increases by more than 3 lbs and/or you become increasing
short of breath please notify an MD immediately. Please fill
Lasix prescription prior to your departure. ___ MD assessment
he or she can decide if you will need to take your Lasix
medication.
Please continue taking your medications as prescribed and attend
all of your follow up appointment as scheduled below.
Thank you for choosing ___ for your healthcare needs.
Sincerely,
Your ___ Team | This is a ___ year old woman with a PMH significant for COPD and
asthma, as well as recent admission to ___ at the end of
___ for left-sided hydropneumothorax, who presents with
recurrence of left-sided pleural effusion.
ACTIVE ISSUES
# Left pleural hydropneumothroax: Patient with known left sided
pleural effusion. Previously admitted at the end of ___, where work up showed pleural fluid consistent with
nonspecific exudate; microbiology showed 1 colony of coagulase-
negative Staph, which is likely a contaminant. Cytology was
negative for malignancy. Underwent thoracentesis on ___ in ___
clinic with drainage of 600 cc of serous fluid, again negative
for malignancy. Presents with mild reaccumulation of pleural
effusion and small pneumothorax on this admission. Evaluated by
interventional pulmonology on this admission and they decided
that there was no need for further intervention at this time.
Patient safe to fly 2 weeks after thoracentesis, per last IP
note (___). Continued tiotropium and albuterol. Ambulatory
saturation was >95% during admission. Discharged on her home
tiotropium and albuterol.
# Heart failure with preserved ejection fraction: Patient
presented with chest pain and SOB over the last few days.
Unclear if it was associated with exertion or other triggers but
likely multifactorial but given reaccumulating pleural effusion
underwent cardic work up. Trponin was negative x2, and EKG
without ischemic changes. ECHO showed wall motion abnormality
and EF 40% but pharmacologic nuclear stress test with EF 56% and
normal wall motion. Cardiology was consulted and recommended
metoprolol succinate 25 XL daily and lisinopril 5mg daily both
of which were started during admission. Her home ASA 81 was
continued and she was discharged with plan for cardiology
referral as she was leaving for 1 month on vacation ___ with
children and ___). Given discrepancy between EFs on ECHO and
nuclear stress would recommend repeat ECHO after cardiology
follow up. Discharged with lasix prescription to be used as
instructed by MD if weight greater than 3 lbs and increasingly
SOB. Received 20mg IV lasix during admission.
CHRONIC ISSUES
# HYPOTHYROIDISM: Patient's TSH was elevated but Free T4 was
normal. Home levothyroxine, 125 mcg daily was continued.
Recommend repeat TSH and T4 in 6 weeks.
# ASTHMA: continued home albuterol inhaler PRN
# HYPERTENSION: stopped home triamterene/HCTZ, 37.5/25 mg,
replaced with metop and lisinopril as above.
# GERD: continued home pantoprazole, 40 mg daily
# HYPERLIPIDEMIA: continued home simvastatin, 20 mg every
evening
# CAROTID STENOSIS: home aspirin 325 reduced to 81 | 278 | 418 |
13778013-DS-10 | 20,076,759 | Dear Ms. ___,
You were evaluated for evidence of biliary blockage causing
fevers, pancreatitis and abdominal pain. Your symptoms and lab
abnormalities have improved. There was no evidence of a
gallstone causing these symptoms, though it may be that a
gallstone was present and passed on its own. Unfortunately this
is impossible now to prove at this point. Less likely
possibilities that are related to dysfunction of the sphincter
allowing passage from the bile duct or stricture of the biliary
duct. The situation will require monitoring for symptoms return
and follow up with Dr. ___ in ___ weeks.
Please pick up your radiology CD on the ___ floor of the
___ building when you leave the hospital.
Please see below for medicines and followup.
It was a pleasure caring for you and we wish you the best,
Your ___ Team | Ms. ___ is a ___ with hx of HTN, NIDDM2,
hypothyroidism, s/p CCY ___ (Dr. ___ for gallstone
pancreatitis who presented with 3 days of abdominal pain, nausea
and vomiting, found to have likely recurrent gallstone
pancreatitis. She underwent EUS ___ after MRCP showed moderate
to severe dilatation of the CBD with persistent narrowing of the
intersphincteric segment of the CBD. EUS was normal appearing,
did not show any stones or sludge. Differential included passed
biliary stone vs SOD Type 1 dysfunction, less likely biliary
stricture. | 135 | 87 |
10922531-DS-14 | 24,821,365 | Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were hospitalized
for nausea.
You did not spike any fevers and your white blood cell count,
which can be a marker of infection, was normal, so it is very
unlikely that your nausea is caused by an infection that needs
to be treated. You got an abdominal cat-scan, which did not show
an acute process that might be causing your nausea. There was a
small mass seen in your pancreas which was too small to be
causing your nausea and does not need to be monitor as per the
gastroenterologists.
You were treated with anti-nausea medications and your symptoms
improved.
We recommend that you follow up with a gastrointestinal
specialist to further investigate the cause of your nausea. They
may decide to do an upper endoscopy.
Take Care,
Your ___ Team. | ___ with h/o HFpEF, asthma, pleural effusions s/p thoracentesis
c/b PTX s/p TPC, CAD s/p DES to RCA, HTN, HLD, a-fib on eliquis,
nephrolithiasis s/p several lithotripsies, presents to ED with
nausea and dry heaving for 3 weeks.
ACTIVE ISSUES
=============
# Nausea: Etiology unclear, most likely psychosomatic ___
anxiety. Patient confirms feeling generalized anxiety, though
this seems chronic, thus unclear why there would be an acute
exacerbation in the last 3 weeks. Less likely gastroenteritis
(no leukocytosis as well as course unchanged over 3 weeks),
biliary colic (no post-prandial sx), gastroparesis (no DM),
nephrolithiasis (no urinary sx, flank pain, or hydronephrosis),
esophageal spasm/Zenker's (no dysphagia). CT A/P ___ did show
IPMN new since CT A/P ___, and IPMNs can present with
nonspecific sx such as nausea, vomiting, and abdominal pain
however, GI was consulted and felt it was too small to be
causing sx and denied need for MRCP. As Zofran seemed not to
help in the past, reglan was trialed with good effect. Blood and
urine cultures were pending on discharge. We got in touch with
the patient's PCP, who recommended EGD as an outpatient to
exonerate esophagitis/PUD as his last EGD was ___ year ago.
# Pleural effusions: Pt has known recurrent pleural effusions,
previously exudative ISO chronic aspiration. CXR ___ shows
interval development of left pleural effusion and unchanged
right effusion. Given that pt has no leukocytosis, fever or
worsening respiratory symptoms, IP consult was deferred to outpt
(he has f/u appts scheduled). Given possibility that worsening
of left effusion is transudative ISO known HFpEF, home Lasix
dose was increased from 20 mg QD to 20 mg BID. Patient should
follow up with his PCP regarding his respiratory status, and if
needed, PCP can coordinate an IP appointment.
# HFpEF: Patient denied any acute worsening of SOB, however had
interval increase in left pleural effusion and appeared mildly
volume overloaded on exam. Given that he was saturating well on
room air, no active diuresis was pursued. We did however
increase his home Lasix to 20 mg BID, as above.
# HTN: Patient was hypertensive to 160s-170s. He had recently
been started on amlodipine 5 mg daily by PCP. In-house, patient
was increased to 10 mg amlodipine daily and started on labetolol
100 mg BID: PRN. Discharge BP was still in the 160s, thus
consider adding additional agent as an outpatient.
# Fat stranding on R. renal pelvis and R. ureter: Seen
incidentally on abdomen/pelvis CT ___. Given that no
hydronephrosis was seen and the patient denied any dysuria,
suspicion low for large obstructive nephrolithiasis. Patient is
followed by ___ urology and should follow up with them at the
next appointment. | 146 | 440 |
18532084-DS-16 | 28,629,646 | Dear Mr. ___,
You came to the hospital because you had chest pain. There was
concern that this chest pain may have been due to you not having
adequate blood flow to your heart. At the hospital, you
underwent a stress test that showed that your heart had mild
ischemia (a condition where the heart has pain because of
inadequate blood flow). It is important for you to take
medicines to protect your heart, lower your blood pressure, and
decrease cholesterol, but at this time you do not need any
stents placed in your heart. As a result we are sending you
home, with follow up with your primary care provider. We ask
that you call and cancel your appointment for your
echocardiogram as listed below as you had one in the hospital.
We wish you all the best!
-Your ___ Care Team | ___ yo M with a h/o HTN and SS anemia c/b iron overload and DCMP
(EF 50%, ___ who p/w exertional CP. Patient of note had pain
while power waking, and has had off and on pain for years,
thought to be ___ dilated cardiomyopathy and possible heart
strain. He had two negative troponins, EKG indicative of stable
LVH, and a stress echo that showed: "average functional exercise
capacity. Equivocal ECG changes with possible 2D
echocardiographic evidence of inducible ishemia at achieved
workload (single vessel CAD). Normal hemodynamic response to
exercise. Mild mitral regurgitation at rest." He was treated
medically for optimization of his coronary artery disease.
BRIEF HOSPITAL COURSE BY ISSUES
=================================
CHEST PAIN: Patient presented with exertional chest pain,
resolved with rest and EKG notable for LVH and ___ in V4-V6 that
are likely repolarization changes. By time he arrived to floor
chest pain da resolved at rest and exertiob. Given the dynamic
nature of these changes and the ongoing stable CP since prior to
___, team felt this likely represented strain related changes
in the setting of HF and possible microvascular dysfunction
(given absence of epicardial CAD in ___. Last cath in ___
without CAD. His risk factors is HTN. Lipid panel checked in
___ was appropriate. Since chest pain has been off and non,
now EKG changes concderning for ischemia, negative trop, and
lack of fevers, low of hypovolemia on exam. ACS, acute chest
were considered less likely. He had ECHO stress that showed
possible echocardiographic evidence of inducible ishemia at
achieved workload (single vessel CAD). AS a result he was d/ced
with medical management of CAD with aspirin and atorvastatin.
TRANSITIONAL ISSUES
================================
-Patient d/ced with medical management of his CAD seen on ECHO
with 81 mg ASA, metoprolol 25 XL and atorvastatin 40 mg
-Pt instructed to d/c upcoming ECHO appointment as he had one
done in hospital | 141 | 311 |
15151397-DS-7 | 29,000,190 | Dear Mr. ___,
You were admitted to ___ on ___ for chest discomfort. You
were subsequently diagnosed with a condition called
'perimyocarditis', which refers to inflammation in the heart and
the sac that surrounds the heart. This is usually a benign
condition that resolves spontaneously, although you should avoid
strenuous activity (including sports such as basketball) at
least until you are seen in follow up by Dr. ___.
We have prescribed ibuprofen which you should take as directed
for the next ___ days for your chest discomfort. Additionally,
you should take another medication called 'colchicine' for the
next 3 months. You should continue to take this medication for
this duration even in the absence of chest pain as it reduces
your risk of recurrence of this condition.
It was a pleasure to take care of you during your hospital stay.
Sincerely,
Your ___ Team | ___ year old male w/ ADHD p/w chest pain and elevated troponin,
diagnosed with myopericarditis.
# Myopericarditis: Patient presented with substernal chest pain,
elevated troponin to 1.24 and CK-MB of 87, and EKG changes (ST
elevations in II, III, aVF, IV-VI). Endorses recent viral
illness. No risk factors for STEMI. No CXR findings. ECHO
negative for effusion or wall motion abnormalities. Diagnosed
with myopericarditis secondary to viral infection. Repeat
troponin 10 hours later was 1.08 and CK-MB was 83. No arrhythmia
identified on telemetry overnight. Denies illicit drug use with
the exception of frequent marijuana use, and serum toxicology
screen was negative. Treated with ibuprofen 600mg q8h and
colchicine 0.6 BID. He will continue these medications as an
outpatient for 2 weeks and 3 months respectively. Patient
cautioned not to resume strenuous exercise until advised by
cardiology in follow up.
# Elevated AST and Lipase: Pt has elevated AST>ALT, lipase.
Denies heavy drinking. Elevation may be secondary to
perimyocarditis rather than liver source. Would recommend
repeating LFTs in 3 months to ensure resolution.
=== TRANSITIONAL ISSUES ===
# Myopericarditis:
- Follow up with Dr. ___ in 3 weeks.
- PCP follow up within 10 days.
- 2 weeks of ibuprofen for symptomatic relief.
- 3 months of colchicine to reduce risk of disease recurrence.
- He is discharged with a Rx for 1 month of colchicine. He will
require refills to complete his 3 month course when he sees his
PCP
# ___ AST and lipase:
- Recommend repeating these labs in 3 months to ensure
resolution | 139 | 247 |
16855430-DS-40 | 26,729,976 | Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted for shortness of breath, low
blood sugar and confusion. You were diagnosed with the flu.
You were found to have too much fluid in your lungs, so you were
given medications to reduce the fluid in your body. Your
symptoms improved and you will be discharged to a rehab
facility.
We wish you a quick recovery. | ___ woman with a PMH of DM II, stage 3 CKD, afib on
warfarin, gout, HTN, HL, HIT, and recurrent c.diff who was
admitted to ___ with SOB, hypoglycemia and altered mental
status. She was found to have pulmonary edema and influenza.
#Acute decompensated diastolic CHF. She had respiratory distress
upon arrival and was given positive pressure ventilation which
helped her significantly. Her BNP was extremely elevated
consistent with a heart failure exacerbation. She was diuresed
with increasing doses of lasix and her O2 requirement was
weaned. She required Lasix 200mg BID with metolazone to achieve
adequate diuresis. An echocardiogram was performed on ___ and
showed: Normal left ventricular cavity size with low normal
global systolic function, moderate pulmonary artery systolic
hypertension, right ventricular cavity enlargement with free
wall hypokinesis, mild mitral regurgitation and increased PCWP.
She was below her dry weight on discharge and was discharged on
a slightly higher dose of Torsemide. Discharge weight 150.4lbs.
#Influenza pneumonia- Influenza A returned positive on her
second hospital day. She was treated with a 5 day course of
Tamiflu.
# Acute renal failure on CKD: Admission Cr 2.2 (baseline of 2.4
but fluctuates). Her Creatinine peaked at 3.6 and improved with
diuresis. Creatnine 2.0 at discharge.
# RECURRENT C.DIFF: Recently on imipenem for a urinary tract
infection. Fever and elevated WBC count could be contributing.
Patient was started on an oral vancomycin taper as outlined
below:
vanco 125 Q8H for 7 days (changeover ___
vanco 125 Q12H for 7 days
vanco 125 Q24H for 7 days
vanco 125 Q48H for 4 doses
vanco 125 Q72H for 3 doses then stop | 75 | 262 |
18083755-DS-24 | 26,475,380 | Dear Ms. ___,
You were admitted to ___ due to fluid that accumulated around
your heart and made it difficult for your heart to function
well. The fluid was removed with a needle and a drain was
briefly placed in your chest. You became confused in the
intensive care unit and needed to be intubated to perform a
lumbar puncture. Fortunately, there was no infection in your
brain. Your heart rhythm converted to atrial fibrillation
during your hospitalization likely due to the stress of being
sick and the inflammation around your heart. We scheduled you
for cardioversion on ___ to try and convert you back to a
regular rhythm. We started you on a new medication for the
inflammation around your heart called colchicine. You will need
to follow up with your primary care doctor, ___,
and your rheumatologist. You will also need to see a neurologist
for cognitive testing.
We enjoyed providing your care at ___,
-Your ___ team | ___ y/o woman w/ afib on xarelto, bradyarrhythmia s/p PPM
___, GPA s/p tx, admitted with tamponade s/p drainage in ED.
#)Cardiac Tamponade: Patient admitted with pericardial effusion
and tamponade physiology. She responded well to emergent
pericardiocentesis in ED. A drain was placed with bloody output
(Hct 12). Cultures and cytology were negative. Etiology of
tamponade was unclear given patient's complex medical history
but ultimately thought to be secondary to viral infection.
Drain was pulled two days after admission and follow up TTEs
showed trace pericardial effusion. Patient continued to have
pleuritic chest pain and colchicine 0.6 mg daily was started, to
be continued for 6 monthes.
#) Altered Mental Status: The day following admission, patient
had hallucinations and was extremely agitated. She recently had
VZV infection so HSV encephalitis considered as possible cause
for acute onset mental status change. Patient given haldol PRN
as needed for agitation but was still combative and psychotic.
Patient needed to be sedated and intubated in order to obtain
LP. CT scan w/o acute changes of signs of ICP. LP was
ultimately unremarkable. The patient was extubated the following
day. Over the next two days, she returned to baseline mental
status.
#)Afib: Patient with history of pAfib on rivaroxaban, also with
rhythm and fate
control on Fleicanide and metoprolol. She was continued on
flecainide, rivoroxaban initially held in setting of
coagulopathy, metoprolol initially held due to tamponade and
hypotension. Patient was monitored on telemetry and was in
atrial fibrillation during this admission (NSR prior to
admission). Cardioversion planned for week after discharge.
Rivoroxaban restarted when stabilized and transferred out of
CCU.
#)Coagulopathy: Patient came in with elevated INR/coagulapathy
of unknown etiology. She was not on warfarin and did not appear
to have clinical signs of hepatic dysfunction. Rivaroxaban was
held initially due to ongoing bloody pericardial fluid output.
#)SSS s/p pacemaker placement: PPM placed 4 months PTA for SSS.
Pacer was interrogated and appeared to be functioning properly.
#)Lung nodule: Pt had incidental finding of new LLL nodule on
OSH CT abd/pelv. She does not have any recent weight loss but
does have risk factors such as smoking and chronic inflammation
of her lungs ___ infection and GPA. CT at ___ showed nodule
consistent with granulomatous process.
#)Hyponatremia: Patient with hyponatremia on admission, which is
new compared to prior data in system from ___. Urine sodium
and osmolarity not consistent with SIADH. Ultimately, her
hyponatremia was thought likely due to poor nutrition.
Electrolytes were followed with hyponatremia improving during
admission.
#)Anemia: Low Hgb of 8.9 appeared new compared to recent H&H on
___. CBCs trended with stable Hgb. Hemolysis panel was
unremarkable. TIBC normal, ferritin elevated c/w anemia of
chronic disease.
#)GPA: Patient with GPA, well managed on AZA. Recent labs did
not show elevated inflammatory markers. GPA was not an active
issue during admission.
#)HTN: In the setting of tamponade, antihypertensives initially
held. Patient restarted on home metoprolol and HCTZ with good
control of BP.
TRANSITIONAL ISSUES
-proteinuria- patient with urine protein:Ct of 0.3. This will
need to be followed up by her PCP.
-patient started on colchicine 0.6 daily for pericarditis which
will need to be continued for 6 months
-patient with agitation and hallucinations while in CCU with CT
showing frontal lobe atrophy. She will need neurocognitive
testing as an outpatient. | 162 | 566 |
17082938-DS-19 | 20,709,091 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You came to the
hosptial becuase of a Crohn's Flare. A cat scan done in the
emergency department showed inflammation in your small
intestine. We drew blood cultures and took stool samples to rule
out infectious causes of your bowel inflammation - these were
still pending at the time of discharge. You were treated with
steroids and antibiotics through your veins, which improved your
symptoms. You were discharged on steroids and antibiotics by
mouth.
Please call your gastroenterologist to make an outpatient
appointment with him as soon as possible. We were unable to
make an appointment for you over the weekend.
MEDICATION CHANGES:
START budesonide 9mg daily x 10 days
START ciprofloxacin 500 mg by mouth twice a day for 10 days
START flagyl 500 mg by mouth three times a day for x 10 days | ___ with h/o Crohn's disease, here with Crohn's flare
refractory to 2 weeks of PO prednisone. | 148 | 17 |
15565666-DS-17 | 26,285,748 | Ms ___ it was pleasure caring for you during your stay at
___. You were admitted with mouth and throat pain related to
side effects of chemotherapy and radiation treatment. You were
treated with supportive measures including pain medications and
IV hydration. You were also treated with antifungal for yeast
infection of mouth and esophagus. You developed fever and were
found to have a pneumonia which was treated with antibiotics.
You should continue the levofloxacin for pneumonia through ___.
Please also continue the fluconazole through ___ then stop both
of these medications.
if you ahve worsening cough or sputum please call Dr. ___
___.
You ___ eating a lot so we haven't been having you take the
metformin. When your appetite/ability to eat returns please
check your blood sugars and if they are elevated you will need
to rsetart this
Hold your aspirin for now your blood platelets were low. When
you see Dr. ___ ask him when it is ok to restart that.
Increasing your lisinopril to 20mg daily. Started a new med for
appetite and depression called mirtazapine.
Don't restart your simvastatin until ___, it can interact with
fluconazole. Fluconazole finishes ___ so you can start the
simvastatin again on ___.
Please follow up with your PCP in the next ___ weeks. | ___ yo female with a history of squamous cell carcinoma of the
tongue base who is admitted with odynophagia, PO intolerance due
to mucositis/radiation esophagitis, course complicated by
progressive anemia and development of pneumonia.
#Mucositis/Radiation esophagitis: Decreased PO intake due to
odynophagia. improving, taking pills better, but still liquids
and soft solids. Contd supportive care w/ MM, topical lidocaine
added Carafate QID. Prn Zofran/Compazine for nausea. Contd
adaptic dressing daily for external neck radiation burns +
aquaphor. IVF DCd and pt was tolerating PO somewhat better at
the time of discharge.
#Pneumonia - ___ noted she had worsening cough, CXR consistent
with pneumonia and pt had fever, LL infiltrate. possible
aspiration of oral secretion in setting of
odynophagia/esophagitis. resp status stable on RA. started
ceftriaxone ___. narrowed to PO levoflox ___ but pt reported
no significant improvement so broadened to cefepime (no longer
febrile but developed neutropenia). was given 1x neupogen w/
improvement in WBC count. She was narrowed to CTX while in house
but due to copays insurance it was cheaper to finish course of
cefepime at home, she will complete course through ___. Sputum
grew sparse MSSA pan sensitive, and it was felt cefepime/CTX had
good enough MSSA coverage but also important to cover gram
negatives commonly seen w/ HCAP in her case, and MSSA growth
only sparse.
#Anemia - stable. no overt clinical symptoms, gradually
declining ___ chemorads/inflammatory block, nothing to suggest
bleeding though drop is quite significant over the past month.
Received 1u on ___ with appropriate
bump. INR was 1.2 on ___. No melena/hematochezia, ferritin
elevated c/w inflammatory block.
# Thrombocytopenia - stable. also like ly ___ marrow suppression
from cchemo/rads, trend mirrors that of anemia. Low suspicion
for HIT as drop a bit rapid for such, and not convincingly
consistently <50% of baseline. No e/o bleeding. Plts improving
by DC.
# Hypokalemia - repleted, stable. No diarrhea/vomiting, likely
due to poor po intake
#Candidiasis - thrush and possible ___ esophagitis given
odynophagia. Cont empiric fluc and hold statin to avoid
interaction. QTC trended and remained WNL. Extended fluc course
to go through the end of antibiotic course (through ___ given
pt reported yeast infections every time on antibiotics in the
past.
#Acute on chronic pain - ___ fibromyalgia/RA exacerbated due to
above issues. Continued home lyrica, escitalopram, oxycontin
(reduced to 20 q8) and PRN oxycodone.
# Depression/decreased appetite - likely ___ situational illness
and diagnoses, SW following. Started low dose mirtazapine pt
reports she has card for medical marijuana she uses at home.
#Squamous Cell Carcinoma of Tongue Base: Recently completed
radiation and chemotherapy with cisplatin. F/u w/ RT and
oncology as ___. The node in her right neck remains firm, her
___ oncologist was notified. In the future salvage surgical
removal could be considered.
#DM: Held home metformin. Due to decreased PO intake pt may no
longer need for now, but should resume when po intake improves.
#HTN/HLD: BP elevated SBP up to 180. Increased home lisinopril
from 10mg to 20mg daily. held aspirin for now given
thrombocytopenia, pt will f/u with pcp and ___ providers about
restart pending PLT trend
#Insomnia/Anxiety - contd home nortriptyline, held temazepam | 212 | 518 |
11908889-DS-21 | 25,990,945 | Dear Mr. ___,
You were admitted for a pneumonia. You were placed on IV
antibiotics initially, did well, and were transitioned to an
oral antibiotic on which you are still doing well and will stop
tomorrow.
Continue all your medications with the following changes:
-Continue aspirin 121.5mg daily until ___ (plastic surgery)
-start verapamil 240mg SR daily
-Continue Coumadin at normal dose and have ___ check INR in the
next day or two
-continue levaquin until tomorrow
-try Tylenol ___ every 8 hours first
-tramadol ___ every 8 hours as needed for pain
-stop morphine
-stop Chlorthalidone until seen by your cardiologist
You were transferred to the cardiology service for a pacemaker
for symptomatic pauses. The pacemaker was placed and you
converted to sinus rhythm shortly before your procedure. Follow
up with Device Clinic in one week.
Because you have intermittent shortness of breath with exertion,
you can discuss with your cardiologist if perhaps this is due to
episodes of atrial fibrillation, or if you need a repeat stress
test eventually.
You also appear to have iron deficiency anemia; you should
consider starting iron supplementation with your primary care
physician, as well as undergo a colonoscopy to look for a source
of GI bleeding.
Please follow up with your plastic surgeons as directed and your
PCP in one month.
Finally, please have your ___ draw your blood on ___ or
___ for an INR check, sending the results to the ___
___ clinic as they usually do. ***have the ___ get
your SODIUM drawn as well.
We wish you all the best,
Your ___ Care Team | ___ man with a history of AF, depression, COPD, SCC scalp s/p
recent flap, presents with HAP.
# Sepsis: resolving
# Hospital acquired pneumonia
# hypoxemic respiratory failure:
Pulmonary infiltrate and findings, started on vancomycin
(___), cefepime (___), azithromycin
(___), narrowed to levofloxacin on ___. Received IVF for
sepsis. Microbiology of sputum was invalid due to extensive
contamination with upper respiratory secretions however finished
5 day course of levofloxacin (ends ___
# RUE infiltration: with fluid resuscitation, patient had
infiltration of RUE. Mildly symptomatic, resolved with
elevation. Had PICC placed given inability to use LUE, pulled
prior to discharge.
# Squamous cell carcinoma s/p resection and rotator flap
surgery. Evaluated by plastics who found no issues. Per their
recommendation, left scalp flap open to air, and daily
xeroform/4x4 gauze/kerlex/ACE wrap to L forearm graft, splint
for left forearm. He was continued on home ASA 121.5mg x4
weeks(ends around ___.
# LUE flap: unfortunately patient had a blood draw on RUE, which
is contraindicated post operatively. An incident report was
filed and apologies were expressed to patient and wife.
# AF: resumed anticoagulation as outpatient just prior to
admission with ok from plastics. His verapamil was fractionated,
and when one dose was held once for hypotension he had a brief
asymptomatic episode of RVR. He was noted to be symptomatic from
the fibrillation, so consideration can be made for a rhythm
control strategy.
# r/o SSS: had episodes during last admission that were
questionable for sick sinus syndrome, and during this admission
was noted to have symptomatic 4s pauses, for which he was
transferred to EP and received a pacemaker on ___.
# episode of chest pressure: morning of ___ had 15 minutes of
non-exertional chest pressure. Ruled out for MI, was able to
exert himself thereafter without any symptoms. Patient noted
that he had DOE recently. Received gentle diuresis with
improvement using furosemide 20mg IV x1. Can consider stress
test as outpatient.
# Aortic Stenosis: s/p tissue valve
# TIA v CVA: residual mild L weakness/numbness
- cont ASA, atorvastatin as above
- BP control as below
# HTN: held home chlorthalidone given sepsis, but continued home
lisinopril and verapamil. Had asymptomatic BPs in ___ on HD 1,
so lisinopril was stopped and he received IVF as above with
resolution. He is discharged on lisinopril and verapamil.
Chlorthalidone was held on discharge due to rise in creatinine
# Chronic Obstructive Pulmonary Disease: continued home meds
(with Advair in place of non-formulary ___.
# Depression: continued home venlafaxine, mirtazapine.
Add on creatinine was elevated at 1.7 (from 1.2 the day before.)
Results were reviewed with wife over the phone who is a ___.
Told to make sure ___ gets INR, sodium and repeat creatinine
tomorrow and to send results to PCP | 251 | 450 |
17160678-DS-6 | 26,011,997 | 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:
- 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.
- Air cast boot must be worn until follow up appointment unless
otherwise instructed
- TLSO brace to be worn at all times when out of bed
ACTIVITY AND WEIGHT BEARING:
Left lower extremit: weight bearing as tolerated in air cast
boot | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an open left tibia/fibular fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for irrigation and debridement and
fixation of the left tibia with an intramedullary nail, 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.
On the morning of POD#1, the patient was complaining of back
pain. He reported that he has chronic back pain, but the back
pain appeared to be worse since the accident. At that time,
L-spine plain films were ordered and showed a L2 compression
fracture. The orthopaedic spine team was consulted and
recommended a TLSO brace to be worn at all times while out of
bed. The patient will follow-up in the ___ in 2 weeks.
The patient worked with ___ who determined that discharge with
home ___ was appropriate.
The patient was also seen by the neurology team as an inpatient
for concerns of post-concussive syndrome. It was unclear whether
the patient had a concussion following his accident, but he was
experiencing an intermittent headache, nausea, and confusion at
times. These symptoms were thought to likely be secondary to his
recent trauma, surgery, and use of heavy pain medications and
less likely due to a concussion. The symptoms were monitored and
improved over the hospitalization. He will follow-up with the
neurology team as needed as an outpatient. 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 weight bearing as tolerated in the
left lower 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. | 180 | 405 |
14888615-DS-18 | 26,697,007 | Dear Ms. ___,
It was a pleasure participating in your care at ___
___. You were admitted because of lab work
showing that your blood counts were low and your kidneys were
not functioning as well as they normally do. The blood work
here suggested that you might have been a little dehydrated
before coming in to the hospital and the kidneys were working at
their baseline after you drank plenty of fluids. You will be
given a prescription to have your labs checked tomorrow
(___) at ___. Your transplant coordinator will
receive these results and inform you if there is anything
concerning.
Your appointment with Dr. ___ has been rescheduled for
___. If you have any conflicts with this appointment please
call to reschedule.
We wish you the best.
Sincerely,
Your ___ Team | Ms. ___ is a ___ s/p OLT in ___ for HCV Cirrhosis now
complicated by recurrent HCV infection s/p TIPS in ___ for
refractory ascites who presents for concern of abnormal labs
(low HCT and elevated Cr) in setting of recent spinal surgery on
___. | 135 | 46 |
14130048-DS-30 | 26,438,757 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You presented with abdominal pain and dehydration,
which we treated with IV fluids. You were seen by the Thoracic
surgery team, who felt your G-J tube was in the correction
position. A CT scan of your abdomen did not show any
abnormalities to explain your pain. We changed your tube feeds
while you were here. Your pain improved, and we felt you were
stable for discharge. You were also found to have a urinary
tract infection and were treated with antibiotics.
You were also found to have a urinary tract infection, which we
treated with antibiotics. | #) ABDOMINAL PAIN: Appears to be acute on chronic. Likely
multifactorial. Differential includes discomfort related to her
GJ tube placement, her periumbilical hernia, vs. some infectious
process. Does not appear to be an overlying cellulitis given
lack of erythema, but patient is tender at the GJ tube site.
Given history of diarrhea x 2, could also be gastroenteritis.
However, patient chronically complains of this type of pain
since her GJ tube placement in ___, which has especially
worsened and persisted since her tube was found to be dislodged
last ___ and was re-placed this ___ PTA. Pain is also
apparently unrelated to tube feed rate, but becomes acutely
worse upon movement. PUD confirmed on recent EGD likely
contributing to her abdominal pain. CT abdomen negative for
acute intraabdominal process and verified correct placement of
GJ tube. Amylase and lipase negative. C. diff negative. Stool
cultures ordered but patient did not have a stool before
leaving.
Patient urgently requests to go home on Day 4 of admission.
Despite encouragement to stay and explanation of the risks of
discharge, pt adamant that she needs to go home for professional
reasons. ___ with pt's PCP ___ for tomorrow AM
and pt given prescriptions for new tube feeds and bactrim.
#) ENTEROBACVTER URINARY TRACT INFECTION: Urine culture positive
for enterobacter sensitive to bactrim. Less concerned for
pyelonephritis given lack of fever, leukocytosis. DC'd vanco on
___
- Gave 7d bactrim course. | 116 | 250 |
15409416-DS-6 | 29,618,349 | Dear Ms. ___,
You were admitted to the gynecology service for monitoring of
your abdominal pain. You have recovered well and the team
believes you are ready to be discharged home. Please call
___ with any questions or concerns. Please follow the
instructions below.
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your follow-up appointment.
* You may eat a regular diet.
* You may walk up and down stairs.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* light-headedness or dizziness
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | Ms. ___ is a ___ yo woman who presented with LLQ pain most
suggestive of left ovarian cyst rupture. However, given the
patient's history of intermittent pain and enlarged left ovary
on pelvic ultrasound concerning for intermittent ovarian
torsion, she was admitted for observation with plan for
diagnostic laparoscopy if pain returned.
Upon admission she was made NPO and started on IVF. Her serial
exams were repeatedly negative and her pain did not return
overnight. She was subseqeuntly started on a regular diet the
following morning. Shortly after she developed epigastric pain,
which resolved upon starting pepcid and tums with instruction to
continue use on discharge.
*) Papulomacular rash: Patient devevloped a rash shortly after
her presentation to the ___, likely due to IV morphine. She was
treated with benadryl and hydrocortisone cream for symptomatic
releif. Her rash remained stable on day on discharge with
instruction to continue use of benadryl and hydrocortisone cream
and to avoid morphine in the future.
By hospital day #2, patient's pain had resolved, she was
voiding, ambulating and tolerating a regular diet. She was
discharged home in a stable condition with instruction to
follow-up in the gynecology clinic. | 132 | 204 |
18404315-DS-28 | 25,292,138 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Dr. ___,
___ was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because you were constipated.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given antibiotics for a possible gastrointestinal
infection.
- You were given medication to help move your bowels.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Follow up with your primary care doctor.
- Follow up with your gastroenterologist.
We wish you the best!
Sincerely,
Your ___ Team | ADMISSION
=========
___ year old lady with complex past medical history of
breast/uterine/ ovarian cancer (+BRCA 1) s/p chemoradiation
___, bilateral salpingo-oophorectomy and a hysterectomy in ___
with history of radiation colitis, multiple psychiatric
diagnoses including PTSD, ADHD, delusional disorder, depression,
borderline personality disorder, and dissociative identity
disorder who resented to the emergency department as a transfer
from urgent care for concern for colitis in the setting of
abdominal pain.
ACUTE ISSUES
============
#Ischemic Colitis
#Concern for Infectious Colitis
#Opiate Induced Constipation
Patient has previous history of biopsy proven ischmemic colitis.
She was admitted due to several weeks of constipation, after
failing Senna and a tap water enema at home. A CT of the abdomen
showed prominent fecal loading throughout the ascending and
transverse colon, likely secondary to colitis in the distal
descending colon and sigmoid colon, most likely reflecting
infectious or inflammatory colitis. Mesenteric vessels were well
opacified. She was admitted with a leukocytosis concerning for
infectious colitis initially treated with Ciprofloxacin/Flagyl
which was transitioned to Augmentin with resolution of
leukocytosis. Stool cultures were pending at time of discharge.
She was given Magnesium Citrate and responded with a large
volume bowel movement on her second hospital day, reassuring
that she did not have a mechanical obstruction. GI was
consulted, and felt this was likely multifactorial due to
history of radiation colitis and narcotic induced constipation.
She had ___ further episodes of BRBPR or hematemesis, her abdomen
remained distended and tender but not peritoneal. She likely was
missing/skipping doses of laxative, compounded by her methadone
use, leading to her recent constipation and hospitalization. Per
discussion with GI, she will not require outpatient mu
antagonist as she was able to stool with Magnesium Citrate.
However, she should be on a stable bowel regimen with a rescue
plan of Magnesium Citrate for >2 days without bowel movements as
outpatient. She will follow up with a motility specialist.
# ___
Patient had ___ that was likely pre-renal due to diarrhea,
which resolved with IV Fluids
# Hematemesis
She reported an episode of hematochezia prior to
hospitalization. Her EGD from prior admission showed evidence of
gastritis. This was felt to be likely due to ___ tear,
nausea and abdominal pain. She had ___ further episodes of
hematemesis and her hemoglobin/hematocrit was stable at
discharge. | 112 | 370 |
17217183-DS-19 | 20,516,571 | 1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. ANTICOAGULATION: Please continue your Lovenox for four (4)
weeks to help prevent deep vein thrombosis (blood clots). If
you were taking aspirin prior to your surgery, it is OK to
continue at your previous dose while taking this medication.
___ STOCKINGS x 6 WEEKS.
8. ___ (once at home): Home ___.
9. ACTIVITY: Weight bearing as tolerated on the operative
extremity; KNEE IMMOBILIZER at all times for 4 weeks - may come
out of knee immobilizer only for showering and for range of
motion with physical therapy. STRICT Posterior precautions. No
strenuous exercise or heavy lifting. Mobilize frequently
Physical Therapy:
WBAT LLE in knee immobilizer at all times, except for shower or
for ROM with Physical Therapy, x4 WEEKS
Treatment Frequency:
none | The patient was admitted to the Orthopaedic Arthroplasty
surgical service on ___ following closed reduction in the ED of
dislocated L total hip arthroplasty. Patient admitted for pain
control and Physical Therapy; uneventful hospital coruse.
N: Pain appropriately controlled with PO pain medications.
CV: Vital signs were routinely monitored; the patient remained
hemodynamically stable.
P: There were no pulmonary issues.
GI: The patient tolerated a regular diet.
GU: Foley catheter was removed once admitted; voided without
issues postoperatively. Home lisinopril continued.
ID: No issues.
Heme: The patient received lovenox for DVT prophylaxis; she will
complete the 4 week lovenox course started after her initial
arthroplasty surgeyr.
MSk: The patient was made weight-bearing as tolerated on the
operative extremity with posterior precautions; she will remain
in a knee immobilizer at all times for 4 weeks, only to come out
for showers and range of motion with Physical Therapy.
At the time of discharge, the patient was afebrile with stable
vital signs and good pain control; the operative extremity was
neurovascularly intact. The patient will follow-up in
___ clinic. | 343 | 169 |
18068560-DS-13 | 28,597,811 | Dear Mr. ___,
You are were admitted to ___ after you had a stent replaced.
You had a fast heart rate and due to low blood pressures, you
were watched and treated in the intensive care unit.
Your heart rate was fast due to a condition called atrial
fibrillation, which is not a new diagnosis for you. Your heart
rates were fast and blood pressure low, likely due to an
infection. We gave you IV fluids and antibiotics. You improved.
We started a new heart medication called diltiazem to slow your
heart rate and increased your home dose of metoprolol.
You will need to continue to take the antibiotics through
___.
Please make sure to follow-up with your oncologist (cancer
doctor) as well as the GI doctors. | ___ y M with new diagnosis of pancreatic mass as well as new
diagnosis of squamous cell carcinoma, admitted from ERCP with
fever, hypotension, tachycardia concerning for cholangitis.
# Cholangitis: 1 day of fever/chills at home several days prior
to presentation, elevated Tbili, puss seen draining for CBD
during procedure today. Good flow through CBD after stent
replacement. He remained hemodynamically stable upon arrival to
___. His LFTs improved throughout his course. Initially
received zosyn, which was then narrowed to unasyn. He was
transitioned to augmenten for a total antibiotic course of 10
days. He will follow-up with ERCP as an outpatient.
# Afib with RVR: first occured during a prior admission for
sepsis, recurred during admission in ___ for ERCP/stent
placement. At that time, he was discharged home on 200 metop.
CHADs score 2, anticoagulation had been discussed but pt
declined during admission in ___. Non-elevated troponin. He
was discharged on 300 metop succ daily, as well as diltiazem 120
daily. He was also started on aspirin 81 daily, and will discuss
anticoagulation with outpt providers.
# Squamous cell cancer: metastatic including to pancreas.
Diagnosed ___. Followed by thoracic team in conjunction
with Dr. ___ now following with oncology in
___. Had planned to start chemo on ___, which will be
delayed in setting of acute infection. Has follow-up in place.
# COPD: continued on home meds | 123 | 229 |
10217041-DS-13 | 21,082,885 | discharge instructions
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Daily dressing changes and ex pin site wound care by ___
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated right lower extremity, Touch down
weight bearing left lower extremity
Physical Therapy:
Weight bearing as tolerated right lower extremity
Touch down weight bearing left lower extremity
Treatments Frequency:
Daily ex pin site wound drssing changes and cleaning | The patient presented as a direct admit to the orthopedic
surgery service after experiencing some fevers, chills, and
noting some increasing drainage from her right ex-fix pin site
while at ___ for rehab. The patient was taken to the
operating room on ___ for removal of pelvic ex-fix, 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
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home with services 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 weight bearing as tolerated in the
right lower extremity, and touch down weight bearing in the left
lower extremity. 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. | 103 | 231 |
17207507-DS-16 | 29,558,911 | Dear Ms ___,
It was a pleasure taking care of you during your stay at ___
___. You were transferred her for
concern regarding the integrity of you AAA repair site based on
images obtained from the outside hospital. Review of your
imaging by the vascular team did not show any evidence of leak
and you were clinically stable without signs or symptoms of
bleeding. In addition, while in the emergency department, you
were experiencing some shortness of breath. You were given
inhalers which improved your symptoms and you were transferred
to the medical floor to be observed overnight. In the morning
your breathing continued to improve and you had no fevers,
chills or cough. Please continue your home medications for your
COPD and return to the hospital if you have any shortness of
breath, dizziness, fainting, blood in your stool, nausea,
vomiting, or chest pain.
Best Wishes,
Your ___ Team | ___ with COPD, anxiety, and descending aortic aneurysm s/p
recent repair who was transferred from ___ for vascular
w/u after CT scan c/f possible extravasation from thoracic AAA.
Once transferred and imaging reviewed by the vascular team, it
was determined that there was no endoleak, however, patient was
noted to be hypoxic to 89% in the ED and was therefore admitted
overnight for evaluation of dyspnea.
#Hypoxia:
Upon transfer to ___, the patient was feeling SOB with O2 sat
89%. No increased cough, sputum production, fevers, chills, or
chest pain. CTA from OSH showed no evidence of PE. CXR showed
hyperinflated lungs consistent with COPD, but no evidence of
intrathoracic process. The patient was given a nebulizer in ED,
with improvement of O2 sats to 98% on RA. She was transferred to
the floor for observation overnight. She remained on room air
and was breathing comfortably without wheezes on exam. No
evidence of desaturation with ambulation. She was continued on
her home COPD inhalers (Albuterol and Spiriva) with plans to
follow-up with her out-patient pulmonologist.
#AAA s/p repair in ___:
Patient was initially transferred to ___ when CTA imaging from
OSH concerning for possible extravasation from thoracic AAA. Per
vascular team, there is no evidence of leak on CTA and patient
was HD stable with no signs/symptoms of bleeding on exam
(baseline anemia stable, no leukocytosis or fever, abdominal
incision and examination reassuring). There was no indication
for intervention and the patient will follow-up with the
vascular team as an out-patient.
#Anemia:
The patient has baseline anemia with HgB ___. Her H/H remained
stable during her hospitalization (HgB=10.6) with no evidence of
bleeding.
#?UTI
UA at outside hospital was concerning for UTI. She received
Levaquin 500mg once prior to transfer. Repeat UA at ___
benign. Patient denied urinary symptoms and UCx showed <10,000
bacteria. Therefore, antibiotics were discontinued.
#HTN
Continued home metoprolol and lisinopril.
#Anxiety
Continued home buproprion and ativan
#HLD
Continued home statin | 150 | 333 |
Subsets and Splits