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14502255-DS-4 | 26,558,229 | Dear Mr. ___,
You were admitted to ___ and
underwent pigtail tube placement for a small pneumothorax and
non-operative management of your left rib fractures. You are
recovering well and are now ready for discharge. Please follow
the instructions below to continue your recovery:
Rib Fractures:
*Your injury caused left ___ 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. Please do not
drive for the next ___ weeks while taking your pain medication
*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).
Warm regards,
Your ___ Surgery Team | The patient was admitted to the Trauma Surgical Service on
___ for evaluation and treatment of left ___ rib fractures
and pneumothorax. The pneumothorax was managed with a pigtail
placement. Pigtail was initially put to suction and subsequent
chest X-rays were obtained showing a tiny apical pneumothorax
which was stable once on water seal. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 298 | 145 |
16056045-DS-17 | 20,031,138 | You were admitted to the surgery service at ___ for evaluation
of leukocytosis and fever. You were started on antibiotics and
you leukocytosis started to improve. You 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 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. | The patient s/p robotic assisted Whipple on ___ was
readmitted to the HPB Surgical Service for evaluation of fever
and leukocytosis. On admission patient was afebrile with WBC
28.6. Patient's blood and urine cultures were sent for
microbiology evaluation. Patient was started on IV Cipro/Flagyl,
made NPO with IV fluids. Abdominal CT scan revealed a dilated,
edematous pancreaticobiliary limb without bile or pancreatic
duct dilation, no definite fluid collection. On HD 2, patient's
WBC was 30.2, he remained afebrile. Abdominal US was obtained
for possible drainage or aspiration and was negative for any
organized, drainable fluid collection. Patient's diet was
advanced to regular, he was continued on antibiotics, remained
afebrile with LFTs WNL. On HD 3, patient's WBC started to
downward, antibiotics were switched to oral. Patient's urine
culture was negative and blood cultures were nothing to grow.
Patient's C.diff test was cancelled secondary to normal, formed
stool. Patient was discharged home on PO antibiotics x 14 days
total, he will repeat abdominal US on ___ and will be seen by
Dr. ___. He will also repeat his blood test.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 289 | 229 |
10675858-DS-2 | 29,932,827 | ******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
continues to be non-draining.
******WEIGHT-BEARING*******
non weight bearing right upper extremity; may bear weight
through elbow
weight bearing as tolerated bilateral lower extremity
Left lower extremity in hard soled shoe
******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 2 weeks post-operatively
Physical Therapy:
Activity: Activity: Activity as tolerated qid
Right lower extremity: Full weight bearing
Right upper extremity: Non weight bearing
Pt can weight bear throuh R elbow
Treatments Frequency:
daily dressing changes | The patient was admitted to the orthopaedic surgery service on
___ with R open tib/fib, R ulna, L P1 fractures. Patient
was taken to the operating room and underwent IMN R tibia,
fasciotomies, ORIF R ulna. Patient tolerated the procedure
without difficulty and was transferred to the PACU, then the
floor in stable condition. Pt returned to OR 2 days later for
closure of the fasciotomies. Patient tolerated the procedure
without difficulty and was transferred to the PACU, then the
floor in stable condition. Please see operative report for full
details.
Musculoskeletal: After procedure, patient's weight-bearing
status was transitioned to RUE ___, RLE WBAT, LLE WBAT.
Throughout the hospitalization, patient worked with physical
therapy and occupational therapy.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was hemodynamically stable.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: *The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on HD#, POD #***, the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The incision was clean, dry, and intact without
evidence of erythema or drainage; the extremity was NVI distally
throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. | 230 | 329 |
12288622-DS-6 | 28,069,467 | Dear Mr. ___,
You came to the hospital because you had return of the symptoms
you had during your stroke, consisting primarily of left-sided
weakness. While you were here, you were seen by our neurologists
who did not feel you had had a new stroke. We found evidence of
a urinary tract infection. We gave you antibiotics for this, and
your weakness improved. This is a phenomenon called stroke
"recrudescence," in which an infection can bring back old stroke
symptoms. Still, if you do have symptoms return, it is important
to be certain that you have not had a new stroke, and you should
return to the hospital if you have any similar symptoms.
It was a pleasure participating in your care.
Sincerely,
Your ___ Care | ___ y/o M with h/o CVA in ___ with residual left-sided
weakness, AF/hx DVT (on Coumadin), presented to ___ after
being found by his son to be confused and have left-sided
weakness, transferred to ___ for concern for acute
intracranial process given midline shift on CT (determined by
___ neurosurgery to be congenital). Found to have Klebsiella
UTI I/s/o likely BPH. Neurologic symptoms thought to be ___
recrudensence from recent strokes and improved with antibiotics.
He is being discharged to rehab to continue ___, and will
complete a 7-day course of bactrim.
#Klebsiella UTI
The patient presented to the ___ ED from ___ with a
positive urinalysis. The patient denied any dysuria, but
endorsed foul-smelling urine and polyuria at initial
presentation. WBC 11.4 on admission, downtrended to 7.4 with
treatment. He was started on Unasyn empirically in the ___ ED
(due to concern for dental abscess) and was eventually narrowed
to bactrim to complete a 7-day course.
#Midline shift
The initial concern at OSH was for intracranial bleed or mass,
however repeat ___ at ___ was read as stable from prior,
"midline shift" actually likely congenital abnormality.
#?BPH:
The patient endorses a history of urination almost every hour at
his baseline with sensation of incomplete emptying. Likely risk
factor for his UTI. Offered Flomax but patient declined.
#Weakness
Seen by neurology in ED who felt his symptoms represented
recrudescence of his stroke symptoms I/s/o UTI. His weakness
improved back to baseline within ___ hours of antibiotic
treatment. Seen by physical therapy that assessed that the
patient "remains limited by fatigue and continues to require
assistance for all mobility thus will require discharge to
___ at this time."
#Non-anion gap metabolic acidosis
On admission to the hospital, he was found to have a normal
anion gap metabolic acidosis. On history, he reported that he
had been experiencing intermittent episodes of diarrhea and
loose stools a few days prior to his admission. This resolved
prior to discharge. | 122 | 320 |
16961468-DS-10 | 23,065,307 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted to the hospital with fevers and abdominal
pain. You were found to have pancreatitis (inflammation of the
pancreas). We gave you IV fluids and placed you on bowel rest
(nothing by mouth), and your pain improved. Avoid fatty foods
or heavy meals. Abdominal pain may persist for weeks to months.
You were also found to have a urinary tract infection, for which
you will complete a 7 day course of antibiotics.
It was a pleasure being involved in your care,
Your ___ Doctors
___ CHANGES
- ___ propranolol to metoprolol XL for fast heart rate
- Decreased simvastatin dose to 40mg daily
- Stop diclofenac for now, which can cause worsening abdominal
pain | ___ with NSCLC (poorly differentiated SCC, s/p 4 cycles
___, now C1D6 on ponatinib (study drug, has received 4
doses), presenting now with fevers, malaise, and abdominal pain
most notable in RUQ, found to have acute pancreatitis.
# Acute pancreatitis - Patient had classic symptoms of
pancreatitis, elevated lipase, and CT evidence of mild
pancreatic inflammation. BISAP score was 3. RUQ negative for
cholelithiasis or cholecystitis. Reported mild ETOH use.
Ponatinib is reported to cause pancreatitis. Symptoms improved
with bowel rest, IV fluid resuscitation, and pain control with
IV toradol, then transitioned to acetaminophen/oxycodone.
Ponatinib was held. He tolerated a low residue, low fat diet,
and his pain was well controlled with oxycodone and
acetaminophen.
# Enterococcus UTI - Symptomatic, complicated (male, +SIRS).
sensitive to ampicillin. Endorsed dysuria, urinary frequency,
suprapubic discomfort. He was started on
Amoxicillin/clavulonate, D1 = ___ to complete 7 day course on
___
# SIRS/Sepsis - Resolved. Likely secondary to pancreatitis and
UTI as above. Currently afebrile, still tachycardic
# Anemia / HCT drop - Asymptomatic, has dropped from H/H ___
on admission to 9.7/27.5 on discharge. ___ have had slow GI
bleed from toradol but stools were guaiac negative prior to
starting toradol and upon discharge. Increased omeprazole from
20 to 40mg daily.
# NSCLC: Poorly differentiated SCC, s/p 4 cycles ___, on
admission, was C1D6 on ponatinib (study drug, has received 4
doses). Ponatinib was held for now as above. Continued
antiemetics. Dr. ___ oncologist, offered guidance
during this hospitalization.
# Accelerated junctional rhythm: ECG was checked ED given
concern for ACS presenting as epigastric pain, and showed
question Afib with RVR to 100s and ST depressions in V3-V5.
Repeat EKG was read as accelerated junctional rhythm. Remained
hemodynamically stable and heart rate improved with metoprolol
(replacing propranolol). Cardiac enzymes were cycled, with trop
<0.01, 0.02.
# Anion gap metabolic acidosis: ___ have been secondary to
starvation ketosis given ketones in urine and decreased PO
intake. No history of diabetes/hyperglycemia to suggest DKA,
and lactate WNL. No history of significant alcohol intake or
other ingestions, and renal function WNL. Resolved with IVF and
advancing diet.
# HTN: Slightly hypertensive during this admission with blood
pressure ranging 130-160 systolic. Held home propranolol and
started metoprolol as above for heart rate control. ___ have
hypertension in the setting of pain and infection, but if he
remains hypertensive, would recommend starting anti-hypertensive
agent as an outpatient
# HLD: Initially held simvastatin while trending LFTs. Upon
discharge, decreased dose from 80 mg daily to 40 mg daily.
# Mild COPD: Albuterol as needed.
# BPH: Continued finasteride 5 mg daily, terazosin 10 mg daily.
# GERD: Increased omeprazole to 40mg daily. | 132 | 464 |
10354409-DS-20 | 22,687,539 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you were feeling tired and short of
breath.
What happened while I was in the hospital?
- We did an ultrasound of your heart which showed that your
heart muscle is weakened.
- You had multiple procedures to help us decide which
medications would be best for your heart failure.
- We started you on medications to help your heart pump stronger
and lower your blood pressure.
What should I do after leaving the hospital?
- We have made changes to your medication list, so please make
sure to take your medications as directed. You will also need to
have close follow up with your heart doctor and your primary
care doctor. Please take your medications as listed in your
discharge summary and follow up at the listed appointments.
- Please stop taking your home labetalol
- Please start taking lisinopril, digoxin
- Please continue to take your lovenox and atorvastatin
- Please weigh yourself every day in the morning after you go to
the bathroom and before you get dressed. If your weight goes up
by more than 3 lbs please take one tablet of Lasix and please
call your heart doctor to notify them of this change.
- Please seek medical attention if you have new or concerning
symptoms or you develop swelling in your legs, abdominal
distention, or shortness of breath at night.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team | ___ years old woman from ___ with a history of HIV
on HAART, T-cell lymphoma (HTLV-1 positive, s/p 6 cycles CHOEP
last ___, hypertension, and history of CVA on Lovenox
without residual deficits who presents with fatigue, persistent
tachycardia and dyspnea found to have newly depressed EF ___.
#HFrEF:
#NON-ISCHEMIC CARDIOMYOPATHY:
Newly depressed EF ___, most likely multi-factorial related
to toxin-induced cardiomyopathy (s/p 6 cycles hydroxydaunorubin)
vs. HIV vs. tachycardia-induced as she has had persistent
resting sinus tachycardia documented since ___. She did
undergo coronary angiogram as there were questionable wall
motion abnormalities on TTE, although no evidence of CAD, making
ischemic cause unlikely. She was started initially on IV Lasix,
although relatively unresponsive to Lasix and diuresis limited
by developing ___. Right heart catheterization was preformed
showing low right sided filling pressures, PCWP 7, with CI 2.1.
Diuresis was discontinued due to low filling pressures, and she
was started on lisinopril 2.5mg and digoxin 0.125mg for
inotropic support. She was counseled on checking her weight
daily at home, and will be discharged on Lasix 20mg PRN to be
taken for weight increase > 3 lbs. Cardiac MRI was preformed
while inpatient, although results still pending at discharge.
Plan to follow up in heart failure clinic on ___. She will need
a digoxin trough level checked at that time, goal trough level
0.5-0.9 ng/mL.
#SINUS TACHYCARDIA:
Patient has had persistent resting sinus tachycardia documented
since ___. TSH and cortisol within normal limits as of
___, and hemoglobin at baseline, although she is anemic
(HgB . Most recent CTA in ___ negative for PE and low
suspicion given that patient is anti-coagulated on lovenox. Most
likely compensatory component in the setting of newly reduced
EF.
#HX EMBOLIC STROKE:
Admitted ___ for subacute embolic stroke, with symptom
resolution (difficulty speaking, slurred speech, L facial droop
and L sided neglect at that time). TTE with bubble study did
show PFO. Started on Lovenox BID. Per last oncology note, plan
to continue anticoagulation for at least a month after
chemotherapy. Lovenox was continued at discharge, along with
home atorvastatin. Plan to follow up with hematology/oncology
(Dr. ___ to determine duration of anticoagulation
treatment.
# HIV:
CD4 count ___ years ago about 500, previously undetectable viral
load for at least ___ years, with newly detectable viral load 3.3
on admission, CD4 count 282. Possibly contributing to cause of
new cardiomyopathy as above. ID consulted while inpatient with
plan to follow up as an outpatient with Dr. ___. Home Atripla
was continued.
#T-CELL LYMPHOMA:
HTLV-1 positive, s/p 6 cycles of CHOEP (last ___ without
any sign of residual disease on her PET scan on ___.
Resolution of hilar masses per most recent outpatient PET
(___). Plan initially to pursue prophylactic intrathecal
chemotherapy within the next month or two. Plan for continued
discussions between cardiology (Dr. ___ and
hematology/oncology with regards to safety and timing of further
chemotherapy as an outpatient.
#HYPERTENSION:
Discontinued home labetolol due to low cardiac index.
TRANSITIONAL ISSUES:
====================
DISCHARGE WEIGHT: 176.5lbs
DISCHARGE CR: 1.3
[ ] Please encourage patient to check daily weights at home
[ ] Home diuretic: furosemide 20mg PRN for weight gain of > 3lbs
[ ] Medications added: lisinopril 2.5mg, digoxin 0.125mg
[ ] Medications discontinued: labetalol
[ ] Repeat BMP at heart failure clinic follow up, if Cr
up-trending (>1.3) consider discontinuation of Lisinopril, as
well as dose adjustments in HAART therapy (tenofivir and
emtricitabine will need to be dose reduced)
[ ] Also, if Cr up-trending (>1.3) please discuss with
hematology/oncology discontinuation of Lovenox or alternative
anticoagulation plan
[ ] Check digoxin level at heart failure clinic follow up,
patient instructed to hold her digoxin the morning of her
appointment so that a level will be accurate, resume digoxin if
level within normal limits, hold if supratherapeutic
[ ] Please follow up results of cardiac MRI, results pending at
discharge
[ ] Follow up scheduled ___ ___
[ ] Patient has newly detectable HIV viral load, follow up with
infectious disease (Dr. ___ scheduled ___
[ ] Continued home Lovenox on discharge for history of embolic
stroke, follow up with hematology/oncology (Dr. ___ to
determine duration of anticoagulation
# CODE: full, presumed
# CONTACT: HCP: ___, son. ___ | 284 | 686 |
10386441-DS-8 | 26,725,151 | Dear Ms. ___,
It was a plesaure caring for you at ___. You were admitted to
the hospital with fevers, fatigue, and chest pain for two weeks.
Your D-Dimer was high, but a CT scan showed that you did not
have an pulmonary embolism. You had other blood tests that
showed that there is inflammation in your body, but did not
identify the cause of your symptoms. You can take naproxen for
pain, but take this with food. You had a pelvic xray that was
normal. You should see your primary care physician within two
weeks. Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Dear Ms. ___,
It was a plesaure caring for you at ___. You were admitted to
the hospital with fevers, fatigue, and chest pain for two weeks.
Your D-Dimer was high, but a CT scan showed that you did not
have an pulmonary embolism. You had other blood tests that
showed that there is inflammation in your body, but did not
identify the cause of your symptoms. You can take naproxen for
pain, but take this with food. You had a pelvic xray that was
normal. You should see your primary care physician within two
weeks. Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team | Ms. ___ presented with fevers, fatigue, and chest pain for
two weeks. She had an elevated DDimer but her CT angiogram was
negative and her ECG was normal. Her fevers and symptoms were
most suspicious for rheumatologic disease and she had an
elevated ESR/CRP. She had a pelvic xray to assess for ankylosis
spondylitis that was normal. She requires follow up with her
primary care physician within two weeks for further evaluation.
# FEVER: Patient presented with 2 weeks of intermittent fevers
and fatigue x 2 weeks. Outpatient w/u included negative negative
EBV abd lyme serologies. The symptoms were most likely c/w a
rheumatologic or CTD given the fatigue, SI tenderness, and
shoulder pain but could also be due to a viral illness. Given
normal ECG and readily reproducible chest pain, acute cardiac
process was unlikely. Infectious etiologies were also
considered. She had an elevated ESR and CRP. She had a pelvic
xray that was normal. She also had an HIV test sent that was
pending at the time of discharge and later returned negative.
She should see her primary care physician within two weeks to
consider further evaluation. She remained afebrile and
hemodynamically stable throughout her hospitalization.
# MUSCULOSKELETAL PAIN/Costochondritis: Given normal ECG and
negative CTA, PE is unlikely. DDimer is sensitive but not
specific so elevated DDimer in setting of normal CTA is
reassuring. The normal ECG and negative trops argue against
ACS. The reproducible nature of the CP is also reassuring that
this is not ACS and suggests that this is MSK in nature. She
also had sacroilitus on physical examination. She had a pelvic
xray that was normal. | 225 | 284 |
14450867-DS-7 | 24,946,007 | Dear ___ was a pleasure to take care of you at ___
___. You were brought into the hospital because you
had pauses on your heart monitor. You had a cardiac MRI done
which preliminarily showed that the right side of your heart had
worsening leak through the tricuspid valve (called tricuspid
regurgitation) and that the chambers of your heart are becoming
larger than normal. You were seen by Dr. ___ cardiac
surgery and you and your family discussed tricuspid valve repair
with cardiac surgery team.
Right and left heart catheterizations were done to evaluate
pressures in the chambers of your heart and your coronary
arteries (arteries that feed your heart) prior to your surgery.
On the preliminary report, it showed that the coronary arteries
were normal, and the pressures in your heart chambers were
little high.
You are having some cough and sputum production, but your chest
x-ray on admission did not show any pneumonia. If your cough
worsens and you have fevers greater than ___ F at home, please
see your primary care physician.
These NEW medications were started for you.
- Metoprolol succinate (Toprol XL) 25 mg by mouth daily | This is a ___ yo woman with h/o untreated polymyositis and
worsening TR who presents with one month of an intermittent
chest squeezing sensation and palpitations and worsening dyspnea
on exertion. Transtelephonic monitoring revealed episodes of
atrial tachycardia with offset pauses of up to 5.5 seconds. She
was found to have worsening RA/RV enlargement and tricuspid
regurgitation compared to cardiac MRI in ___, so she was
evaluated by cardiac surgery for tricuspid repair and after an
extended family meeting, amenable for tricuspid repair.
# Sick sinus syndrome: Patient with most recent echocardiogram
showing severe tricuspid regurgitation and enlarged RA/RV, so
was given ___ of hearts monitor. Found to have episodes of
atrial tachycardia followed offset pauses, longest of which was
5.5 seconds, so called to come to ED for evaluation. Patient
seems to be symptomatic with these pauses, though she complains
only of "squeezing" sensation in heart and warmth on top of her
head, no dizziness or lightheadedness. Denied any syncopal
episodes. She was evaluated by EP for possible pacemaker
placement, but given her severe tricuspid regurgitation, it was
thought that having her evaluated for tricuspid valve repair
with epicardial ventricular pacemaker lead placement during the
open heart surgery would be a better option. She was started on
low dose metoprolol to control her atrial tachycardia and was
monitored on telemetry.
# Presyncope: report of warmth/lightheadedness correlating with
the pause on her outpatient monitoring. Couple episodes of
similar sensation intermittently correlating with the pauses,
but patient did not have any episodes of syncope.
# Severe TR with concomitant RA/RV enlargement: Patient's
echocardiogram on ___ showed severe TR and right atrial
enlargement. Patient did not have evidence of right heart
failure on exam during this hospitalization, but did complain of
worsening DOE. She had cardiac MRI done for comparison to her
___ imaging, and it showed worsening RA/RV enlargement and
worsening tricuspid regurgitation. Family meeting with cardiac
surgery team was had and patient decided to proceed with
tricuspid valve repair after the ___. She had right
and left heart catheterization done to evaluate pressures and
coronaries of her heart prior to surgery and showed clean
coronaries and mild diastolic dysfunction. Patient and family
will contact cardiac surgery in a few weeks to schedule her
surgery.
# Cough, likely upper respiratory infection: Initially
concerning given her recent history of community acquired
pneumonia and leukocytosis to 13, but her leukocytosis resolved
on HOD#3 and WBC remained normal for the rest of
hospitalization. She continued to have cough and white sputum
production but no fevers/chills. There was no consolidation on
admission CXR, and her physical exam had rhonchi/crackles but no
decreased breath sounds or egophony. Her blood cultures were
negative and urine cultures were contaminated. She was given
cough syrup and tessalon perles for symptomatic management. Her
repeat CXR for pre-op also did not show consolidation.
# Anemia: Initially hct in high ___ but dropped to mid ___
without evidence of bleeding. Labs were checkec for possible
hemolysis but bili was normal and haptoglobin was in upper limit
of normal. Active type and screen were kept for possible need
for transfusion but her hct remained stable after initial drop.
# Thrombocytopenia: Plt stable around 140s, unclear etiology.
# Polymyositis: Rheumatology consulted and disease thought to be
very quiescent at this time with CK at 399, which is much
improved from her prior levels. CRP nl ESR only mildly elevated
at 45. Given protein in her urine, other rheumatology serologies
were sent to evaluate for lupus or other autoimmune entities
involving kidney, but other than positive ___ at 1:160 speckled
pattern (present in previous testing), all the other labs were
negative/normal (C3/C4, Anti dsDNA, Anti-La, Anti-Ro, anti RNP,
scleroderma antibody and centromere)
=================================================== | 192 | 614 |
17039252-DS-14 | 20,523,787 | You were admitted to the Trauma Service at ___, because you
had a fall on ice about 1 week before your admission, resulting
in pain on the left side of your face. You were evaluated in
___ and a bleed on the left side of your brain (left sided
subdural hematoma), a fracture of your eye socket on the left
(Left orbital wall fracture) and you were then transferred to
___ which confirmed the 2 injuries. During your admission you
were evaluated by Neurosurgery who did not think that you head
bleed need surgery. You were also evaluated by Plastics for your
Left orbital wall fracture and did not offer surgery at this
admission but would consider treating as an outpatient. You had
double vision but your nerve was not trapped. During your
admission you were diagnosed with a urinary infection and a 3
day course of antibiotic were prescribed.
Plastics clinic, appointment ___ with the Chief
Resident's clinic for re-evaluation in 2 weeks. Given your
discharge on a weekend the clinic was not available to contact.
___:
Please call ___ for a Neurosurgery follow-up
appointment with Dr. ___ in 4 weeks.
Follow-up with ophthalmology ___ weeks after discharge with Dr.
___ in ___ ___ | ___ y/o with history of glaucoma of left eye, with recent
unwitnessed fall on icy driveway X 1 week ago. She is unsure if
she sustained loss of consciousness. Was seen by PCP today for
facial swelling/ecchymosis who advised her to present to the ED
for further workup and evaluation. The patient was then
evaluated at ___ w/ imaging workup and found to have L SDH,
L orbital fracture, and L radial fx and was then transferred to
___. Pt c/o double vision, binocular, since the incident. She
reported diplopia. Neurosurgery did not think her SDH was
operative, Ophtho evaluated and suggested L eye coverage for
diplopia. Plastics suggested that they would not offer surgical
treatment for her L orbital fracture during this admission but
this will be considered during the follow-up in clinic. Tertiary
exam was uneventful. Once the patient was ambulating well,
tolerating a diet and moving her bowels she was discharged with
instructions. | 206 | 157 |
13756625-DS-15 | 21,400,587 | Dear Mr. ___,
You were admitted for abdominal pain. We did lab tests and scans
and did not see any concerning findings. Your symptoms improved
with pain medication and you were able to tolerate food. In the
future, please avoid large fatty meals, as the amount of Creon
(pancreatic enzymes) you are taking is likely not enough to help
you digest that amount of fat. We have made no changes to your
medication. | ___ yo w/pancreatic cancer presents with abdominal pain
concerning for pancreatitis. CT Abd pelv negative for concernign
features. Lipase nl. LFTs downtrending over the day. Pain likely
related to high fat intake in context of pancreatic
insufficiency. Creon dosage likely insufficient to handle fat
load from the ice cream. No lipase elevation or WBC elevation to
suggest a high degree of pancreatic inflammation, but it is
unclear to me how much pancreatic tissue is left after the
whipple. Patient wil f/u with oncology for further malignancy
management. | 72 | 87 |
12453404-DS-39 | 24,730,116 | Dear Ms ___,
It was a pleasure taking care of you at ___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted for back pain and abdominal pain
WHAT WAS DONE FOR YOU WHILE YOU WERE IN THE HOSPITAL?
- You were treated with antibiotics for a urinary tract
infection
- You had imaging of your shoulder which showed a tear in your
rotator cuff
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Do physical therapy for your shoulder to improve your pain
- You should take all of your medications as prescribed
- You should keep all your follow up appointments | ___ year old woman with history of active drug use (cocaine,
fentanyl x2), HCV cirrhosis c/b portal hypertension (ascites,
esophageal varices, HE), as well as complex ID history including
recurrent MDR UTI in setting of nephrolithiasis, MSSA
endocarditis c/b spinal osteomyelitis (___), R shoulder
osteomyelitis (___), MRSA septic arthritis c/b septic emboli to
lungs (___), panhypopitutarism, and IDDM who presented with
back and abdominal pain, malaise, and question of hemoptysis,
ultimately diagnosed with UTI in setting of known retained renal
stone. | 96 | 81 |
19035579-DS-6 | 21,295,755 | 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:
- As tolerated, weight bearing as tolerated
- Assistive devices as needed for additional support
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 81 mg daily for 4 weeks
- Continue to take the lovenox injections until follow up
- We will discuss anticoagulation going forward at your follow
up visit
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- You may change the dressing with a dry dressing every ___ days
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
Physical Therapy:
Patient may weight bear as tolerated. Assistive devices as
needed.
Treatments Frequency:
Dry dressing to surgical site every ___ days | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have compression of the femoral vasculature in the right
lower extremity and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for irrigation, debridement, and decompression of the right hip
bursa/vasculature, 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#3. 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.
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 in the RLE extremity, and will be discharged on aspirin and
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. | 318 | 259 |
19567278-DS-17 | 20,986,102 | Dear Ms. ___,
You were admitted to ___ due to severe flank and abdominal
pain. We did a CT scan that did not show any severe worsening of
your infection. We treated your pain and you felt improved so
you were discharged home.
Please make sure to keep all your follow up appointments. It
will be very important for your doctors to follow ___ closely.
We wish you all the best!
- Your ___ care team | SUMMARY: ___ with a PMH significant for poorly controlled DM
compicated by right below knee amputation and chronic left foot
ulceration recently discharged from ___ on outpatient abx for
MSSA vertebral oseomyelitis, T9-12 abcesses/phlegmon, and psoas
abscess transferred from OSH with back and abdominal pain
uncontrolled with home oxycodone. She had a CT scan performed
which did not show any progression of infection. She improved
with PO medications and was discharged home with plan for close
follow up. | 73 | 79 |
19966115-DS-17 | 26,417,465 | Dear Mr. ___,
You were admitted to the hospital after you experienced a few
weeks of worsening confusion and weakness at home. It was
noticed that you had purulent drainage from your Foley catheter,
so your Foley was changed. Your urine was tested and it appeared
you had evidence of another urinary tract infection (bacteria
growing in your bladder). Because of this we have treated you
with an antibiotic course (this will continue through evening of
___
As you know, your cancer is ongoing, and in the year since your
last oncology appointment, it is likely that your cancer has
progressed and will eventually cause you more symptoms and
continue to contribute to a decline in your health. There was
ongoing discussion with your family about the importance of
clarifying your wishes regarding what you would want done in the
event of a health care emergency. It is likely that as your
cancer gets worse, you will move more toward end of life care.
As you have stated your wishes, you elected to have "everything
done" in the event that your heart should give way or your lungs
have difficulty breathing. The last thing we would want to do
would be to expose you to a traumatic experience, like a cardiac
resuscitation (with the possibility of broken ribs) or
intubation, if the experience were not something you would wish
and there were little chance of meaningful recovery. There is a
decent chance that as your cancer gets worse, there may be a
medical emergency from which there can be no definitive or
meaningful recovery. Should you wish to focus on your comfort in
such a scenario, it would be very helpful to clarify this with
your family and your outpatient oncologist before any medical
emergencies happen.
Your sugars appeared to be fairly well controlled while you were
in the hospital. We have resumed your Humalog insulin at a
reduced number of units. Please monitor your blood sugar
throughout the day and ask the hospice program for assistance
should you have concerns about your sugar being too high or too
low.
We have written you for an antibiotic that we recommend you take
through ___ evening.
It was a pleasure to be involved with your care at ___!
- Your ___ Care Team | This is an ___ year old male with chronic atrial fibrillation,
___ Disease, dementia, systolic CHF, prostate cancer
with urinary retention and chronic indwelling Foley catheter
admitted with bacterial urinary tract infection, culture
showing Ecoli sensitive to Bactrim, foley changed and initiated
on antibiotics, showing clinical improvement able to be
discharged home.
# Catheter-associated bacterial UTI: Patient presented with
progressive weakness and confusion, with purulent drainage from
foley on initial exam. His foley catheter was exchanged and
cultures growing >100k cfu E coli, resistant to ceftazidime,
sensitive to meropenem and bactrim. Patient transitioned to
Bactrim and was able to be discharged (last day bactrim planned
for ___
# Atelectasis - Patient admission chest xray raising concern for
RLL process pneumonitis vs. atelectasis vs. pneumonia. On
admission exam, lungs clear, no hypoxia or other respiratory
findings. Pneumonia or atelectasis were felt to be unlikely
given his reassuring clinical picture. He was monitored
without development of respirator findings.
# R hilar lung cancer
# Goals of care:
Patient presented about ___ year after his initial evaluation
regarding a right lung mass, for which he been seen by oncology,
declined biopsy or additional procedures, and had received
empiric radiation therapy. Per prior documentation he
had been DNR/DNI and was currently receiving hospice care. On
this admission, family and patient reported wanting to be full
code, although they were open to further discussions, but only
in the context of requested oncology follow-up. Per discussion
with family, there was no other long-term provider who they
felt comfortable having this discussion with. Patient family's
goal was to help him regain some strength and return home. He
was set up with an oncology follow-up appointment at time of
discharge. He was continued on Acetaminophen 650 mg PO BID and
Naproxen 250 mg PO Q12H for pain.
# Systolic CHF - Continued home Lasix
# Chronic Atrial fibrillation - INR 3.3 on day of discharge;
per discussion with pharmacy, Coumadin dose adjusted to 3mg
daily; continued metoprolll
# ___ - Continued Carbidopa-Levodopa
# Diabetes type 2 - Continued home Humalog 75/25, but at reduced
dose (as below) due to low-normal fingersticks.
# GERD - Continued PPI
# Dementia - Continued QUEtiapine; patient on this
longitudinally, but given history of ___ would consider
weaning in long-term to reduce risk of worsening ___
symptoms
# BPH - continued Tamsulosin
# Dysphagia : continued Prethickened liquids | 376 | 402 |
11738050-DS-14 | 21,179,790 | Dear Ms. ___,
It was a pleasure to take care of your during this
hospitalization. You were admitted to ___
___ after you were found at your extended living
facility to have a low blood count. At ___, you were found to
have a "hematoma," or blood collection, in your buttock region.
Your blood counts were trended and remained stable.
During this admission, there was a concern that you may have a
urinary tract infection. You were initially treated with
intravenous antibiotics. However, given that you never had a
fever or elevation in white blood cell count to suggest
infection, antibiotics were stopped prior to discharge.
Instead, it is thought that your urine grew bacteria because of
your chronic foley catheter. This was removed and you were found
to be able to urinate on your own.
You are now safe to leave the hospital. Please follow-up with
your doctors and take your medications as prescribed. | ___ w/ hx of afib, schizophrenia, DVT on lovenox, s/p
laminectomy w/ new L2 compression fx, epilepsy who presents with
a gluteal hematoma.
# Gluteal Hematoma: Hct 22 from 37 in the setting of systemic
anticoagulation for prior deep venous thrombosis. At ___
scan was conducted and showed a large right gluteal hematoma.
Surgery was consulted and recommended that her hematocrit be
trended and that emergent ___ embolization be considered if she
were to become unstable. Her hematocrits were trended and
remained stable at ___. At the time of discharge Hct was
26.5.
# Bacterial colonization of urinary tract: During this
admission, the patient was initially thought to have a urinary
tract infection. Her urine culture grew Pseudomonas and
Stenotrophomonas. The patient was initially treated with
intravenous antibiotics (gentamycin then cefepime given
extensive antibiotic allergies), but they were discontinued
because the patient never developed a fever or leukocytosis to
suggest infection. Instead, it was thought that she had chronic
bacterial colonization of her urinary tract due to her chronic
indwelling foley. Her foley was removed, and the patient
successfully voided without evidence of urinary retention.
# DVT: Given that the patient was started on systemic
anticoagulation in the setting of deep venous thrombosis in
___, the patient was deemed to have completed close
to a 3 month course. In the setting of her bleeding, she was
not restarted on systemic anticoagulation, but prophylactic
subcutaneous heparin was started on ___ without
complications.
#Schizophrenia: The patient was continued on her home
perphenazine and olanzapine without complications.
#Seizure disorder: The patient was continued on her home
levetiracetam, dilantin, and ativan without complications.
#Chronic Pain: The patient was continued on her home pain
regimen (morphine CR and ___, tizanidine, prn methocarbamol,
acetaminophen, and dilaudid) without complications.
#Afib: The patient's heart rate remained well-controlled during
this admission. Given her CHADS score = 2, no systemic
anticoagulation was administered. The patient is being
discharged on prophylactic subcutaneous heparin (see above).
#Decubitus Ulcers: The patient has a history of decubitus
ulcers. Wound care was consulted during this admission and
aided in management.
#Edema: The patient's home lasix was held in the setting of her
gluteal hematoma. This was restarted at the time of discharge.
# Communication: Patient communication and medical
decision-making was condcuted with the aid of her guardians
___ ___ ___
___ ___ and case managers ___
___ ___ ___, ___ ___. | 159 | 407 |
14496767-DS-44 | 21,413,292 | Dear Mr. ___,
It was a pleasure taking care of you while you were in the
hospital.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were admitted due to electrolyte abnormalities, very high
blood pressure and high blood sugars
- You were seen by the ___ physicians who helped make insulin
adjustments to control your blood sugar. Please follow both
their long acting and short acting insulin regimen
recommendations as prescribed.
- We think your high blood pressures caused some strain on your
heart, but there is no sign of permanent damage
- We did an extensive evaluation to find a trigger for your
symptoms, but unfortunately could not find one, so we believe it
may be related to not taking any long-acting insulin at home
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Please resume your normal PD schedule
- Please follow-up with your usual outpatient providers
- ___ take your insulin injections and peritoneal insulin as
directed.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best!
- Your ___ Care Team | ___ of T1DM, ESRD s/p failed kidney transplant (___) and
pancreas transplant (___) now on PD, HTN, CAD (s/p DES to LCx
on DAPT in ___, PVD s/p b/l BKA who p/w n/v, elevated glucose,
anion gap metabolic acidosis c/f DKA.
=================
ACTIVE ISSUES
=================
# Gap Metabolic Acidosis concerning for DKA: Patient had had
multiple admissions in the past for DKA and a pattern of
non-compliance. However, patient stated he had been compliant w/
insulin at home. There were no recent illnesses or stresses that
he reported and no recent alcohol use. Upon review of
medications with ___ Diabetes specialists, however, patient
stated that he had only been taking novolog and also
intraperitoneal insulin (i.e. not taking any long-acting
insulin). On admission, patient had an anion gap metabolic
acidosis w/ glucose 341 upon arrival that uptrended to 463 in
the ED before being placed on insulin gtt. Patient was anuric,
so urine ketones were not checked. Patient was restarted on SC
insulin upon arrival to ICU floor w/ end therapy for insulin
being detemir 4U at breakfast and 6U at bedtime, novolog 5U w/
meals, novolog sliding scale w/ meals. He also will receive 18U
of novolin insulin in his PD fluid. ___ clarified his insulin
regimen prior to discharge. Patient notably had some abdominal
pain and nausea the day of discharge, but his laboratory work
was unremarkable except for mild leukocytosis.
# Hypertensive emergency, type II NSTEMI: Trop was elevated to
1.47 upon arrival, downtrended subsequently. Patient had a poor
baseline of known CAD and is s/p DES to ___ in ___. Has ESRD
but baseline trops 0.4-0.5. EKGs unchanged from prior. Most
likely demand ischemia I/s/o hypovolemia ___ DKA and/or
contribution from hypertensive emergency. Cards saw patient in
ED and said no intervention or heparin gtt at this time.
Continued home ASA/Plavix, Lipitor 80 and Coreg. Echo
demonstrated no marked changes from his prior.
# HTN Urgency/Emergency: Presented w/ sBP in 200s, improved to
170s in ED. Had a trop leak as above, thought to be possibly
demand ischemia ___ to hypertension. By the time he arrived to
the ICU, his BP had normalized. Patient stated he was not able
to keep PO meds down at home given n/v, hence the elevated BP
upon arrival. Patient just had one episode of SBP > 180 on the
day prior to his discharge, though this improved once he took
his oral home blood pressure meds.
# Anemia: Patient demonstrated a downtrending Hb from prior
without evidence of hemolysis or bleeding. He did not require
transfusion. He stated he was due for his Aranesp infusion,
which was originally to be ___. His peritoneal dialysis team
including Dr. ___ was contacted for follow-up. On review of
his CBCs, it was noted that he has had a long-standing anemia
with some predominance of myeloid precursors. Hematology
consultation as outpatient is suggested.
# Hyponatremia: likely pseudohyponatremia given elevated
glucose. Resolved w/ tx.
# ESRD on PD: s/p failed kidney and pancreas transplant. Renal
consulted to continue PD in house. Continued home sevalamir,
nephrocaps, and prednisone. He noted that after peritoneal
dialysis he had stomach pain and difficulty taking his home
meds. His outpatient nephrologist was contacted regarding
management strategies for this, such as leaving in 100cc to
prevent pain.
=================
CHRONIC ISSUES
=================
# Anemia: at baseline, monitored
# Depression: Continued home celexa and Wellbutrin
# GERD: continued home PPI
# Gastroparesis: continued home reglan
Transitional issues:
- patient notably refused ___ on discharge.
- patient has blood and peritoneal cultures that require
follow-up.
- Patient is being discharged on an insulin regimen of novolog 5
units at breakfast, lunch, and dinner, with 4 units of levemir
at breakfast and 6 units at dinner. He also injects 18 units of
novolin into 6L 1.5% peritoneal dialysis bag. He was written for
new supplies.
- Patient had ongoing presence of anemia on discharge, with Hb
downtrending from 10 to low 7s this admission. Seemed most
consistent with downtrend in the setting of inflammation, with
patient being due for his outpatient Aranesp. On review of his
CBCs, however, it was noted that he has had a long-standing
anemia with some predominance of myeloid precursors. Hematology
consultation as outpatient is suggested. Dr. ___ was
contacted re: setting up outpatient PD team to provide Aranesp.
- his abdominal pain mostly occurs toward the end of his PD
sessions; Nephrology may consider leaving residual fluid to
reduce the discomfort of the final fluid pull of his PD, as
suggested by inpatient Nephrology consultation
- Patient had slight leukocytosis on discharge labs. He should
ideally receive follow-up sets of labs including CBC within one
week.
# Communication: HCP: ___ (MOTHER)
Phone number: ___
Cell phone: ___
# Code: DNR/DNI (confirmed)
Greater than 30 minutes were spent on this patient's discharge
day management. | 175 | 791 |
13383131-DS-24 | 29,666,157 | Dear Mr. ___,
You were admitted to the hospital because of nausea and elevated
liver tests. We believe this is likely due to some type of
virus. Tests for EBV and CMV are pending and you should follow
up with your primary care doctor and kidney doctor to follow up
the results of this test.
Sincerely,
Your ___ Team | ___ M w/ T1DM s/p kidney-pancreas transplant in ___ presenting
with fever, abdominal pain, and nausea.
#Fever: One isolated temperature at home of 101.5. Afebrile
here. Given immunosuppression, covered broadly with vanc/zosyn
in the ED. Monitored overnight off antibiotics and had no repeat
fever.
#Nausea: ___ be viral gastroenteritis given fever, isolated
nausea and elevated LFTs. Symptoms resolved on admission to the
floor.
#Abdominal Pain: History consistent with dyspepsia or PUD. RUQUS
negative, lipase wnl. Begun on empiric acid suppression with
famotidine.
#Transaminitis: No elevation of bili so unlikely biliary. LFT
elevations can be seen in viral illnesses. No imaging to suggest
acute hepatic process. CMV and EBV pending at discharge. | 56 | 107 |
19328212-DS-16 | 25,068,066 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
You were admitted for bloody bowel movements.
WHAT HAPPENED IN THE HOSPITAL?
You received three blood transfusions. A colonoscopy was
performed, which showed diverticulosis, which was likely the
cause of your bleeding.
WHAT SHOULD YOU DO AT HOME?
-Please stop taking aspirin
-Please monitor your bowel movements and return to the ED in the
event of bloody ones
-Please take your stool softeners daily
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | ___ female with history of prior GIB, severe pan-colonic
diverticulosis, hemorrhoids, and obesity s/p R-en-Y gastric
bypass who presented with symptomatic, hemodynamically unstable
BRBPR presumably of diverticular origin. | 89 | 28 |
16295978-DS-8 | 24,992,760 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were admitted
because of your shortness of breath, for which you were treated
for pneumonia and heart failure exacerbation. It is very
important for you to take your medications as prescribed and
follow up with your doctors as ___ (see below for your
upcoming appointments). Please measure your weight every day
and call your primary care physician if your weight increases by
2 pounds. Please have your labs drawn on ___.
Sincerely,
Your ___ team | BRIEF SUMMARY
=============
___ w/ metastatic castrate-resistant prostate CA (on leupron),
AF (Coumadin), CAD (s/p 4vCABG), HFrEF, HTN, DM admitted w/ CAP
(completed levofloxacin) and HFrEF exacerbation, improved with
diuresis.
ACTIVE ISSUES
=============
#) ACUTE SYSTOLIC HEART FAILURE EXACERBATION:
Pt presented with shortness of breath in the setting of
decompensated systolic heart failure in the setting of diuretic
non-adherence. Workup notable for elevated proBNP and bilateral
pleural effusion thought to be secondary to heart failure
exacerbation. Received diuresis with Lasix 40mg IV BID with
improvement. Continued home metoprolol. Discharged on Lasix 40mg
PO BID. Discharge weight 89.99kg.
#) COMMUNITY-ACQUIRED PNEUMONIA
Presented with shortness of breath likely secondary to heart
failure exacerbation (as above) but concern for possible
pneumonia so treated empirically for community-acquired
pneumonia, initially with ceftriaxone and azithromycin and then
transitioned to levofloxacin (completed on ___.
#) DELIRIUM
On admission, patient with confusion likely secondary to
delirium in the setting of acute illness and improved with
management of active issues (as above).
CHRONIC ISSUES
==============
#) Metastatic Prostate Cancer: Followed by Dr. ___. Recent
visit showed his metastatic prostate cancer is progressing and
his PSA is rising. Of note, he is refractory to Zytiga and
enzalutamide. Palliative care was consulted for pain control.
#) Atrial fibrillation: continued on warfarin (adjusted
accordingly) and home metoprolol.
#) DM: held home glyburide during admission and managed with
insulin sliding scale.
#) CAD: continued home aspirin and atorvastatin
TRANSITIONAL ISSUES
===============================
#) Pt noted to have pleural effusions thought to be secondary to
heart failure during admission. Pt should follow up with
Interventional Pulmonology to determine if the effusions persist
despite diuresis, and consideration of thoracentesis.
#) Needs repeat INR checked on ___ and adjustment of
Coumadin accordingly.
#) Needs BMP checked on ___ and repletion of electrolytes
accordingly.
#) Need to monitor volume status and adjust diuretic
accordingly. Discharged on Lasix 40mg PO BID. Discharge weight
89.99kg.
#HCP/Contact: ___ (wife) ___ | 90 | 300 |
12597051-DS-13 | 25,786,052 | Mrs. ___,
___ was a pleasure caring for you during your most recent
hospitalization. You presented to the emergency department with
worsening left hip pain, weakness in both legs, and progressive
urinary incontinence. You were examined by the emergency
department doctors. ___ were collected and showed your kidney
was under stress. You were given a foley which helped restore
your kidney function to your normal baseline. While in the
emergency department, you had an x-ray of your left hip taken to
evaluate you left hip pain. It showed a left femoral neck
fracture.
You were transferred to the medicine floor, where you underwent
a MRI of your ___ to evaluate leg weakness and urinary
changes. The MRI showed fractures in two of you thoracic
vertebrae. Surgical repair of your left hip and veterbral
fractures was discussed. Your left femur fracture was surgically
repaired. Subsequently, your vertebral fractures were surgically
repaired. You were followed by the orthopaedic, thoracic,
pulmonary and neuro teams.
While on the medicine floor you were cared for and examined by
doctors and ___ frequently. Physical therapy worked with you
regularly. More ___ were collected which showed a low number of
immune proteins in your blood. You were given IVIG to correct
this. The ulcers that you presented with were kept clean and
dressed appropriately. You were seen by wound care and
dermatology. You developed a clot in your left arm near your
PICC site. Your PICC was removed. The decision was made not to
anticoagulate you because of your underlying history of ___
___ disease. The clot was stable on subsequent imaging.
You had no significant bleeds during your stay, however did
receive 1 unit of packed red blood cells after your ___
surgery to help your anemia.
You developed an episode of thrush which was treated with
antibiotic mouthwash. You managed your diabetes with insulin.
The prednisone you were taking for your Elhers Danlos syndrome
and asthma was weaned down.
On discharge, you did not have a fever. Your physical exam was
notable for intact sensation in both your legs. You had full
strength of your toes and ankles with unchanged weakness in your
knees and hips. You were discharged to a rehabilitation
facility. You have follow up scheduled with orthopedics on
___ for your left femur fracture. You will also need
follow up with Dr. ___ from ___ surgery for follow up
of your back surgeries. Please have your rehab facility assist
you in making an appointment with his office in the next 2 weeks
(phone: ___.
Again, it was a pleasure caring for you. We wish you a speedy
recovery.
Sincerely,
Your BI Medicine Team | Mrs. ___ is a ___ woman with a complicated hisotry
of Elhers-Danlos syndrome, poorly controlled T2DM, platelet
dysfunction disease, chronic pain, steroid dependent asthma, and
seizure disorder who presents with worsening left hip pain,
bilateral leg weakness, and progressive urinary incontinence
concerning for code cord. Subsequently found to have a left
proximal femur fracture s/p ORIF on ___, T7/8 vertebral
compression fractures s/p surgical stabilization on (anterior
___ posterior ___, and ___ s/p resolution. Her hospital
course was complicated by hypogammaglobulinemia s/p IVIG
infusion, stable left axillary vein thrombus around PICC line
(not put on anticoagulation give her vWF), and non-healing
sacral decubitus ulcers (present prior to admission, managed by
wound care). No significant bleeds during her hospitalization.
Her hospital course is outlined by problem below:
ACTIVE ISSUES:
# T7/T8 Compression Fractures c/b Cord Compression s/p
Anterior/Posterior Fusion: Presented with urinary incontinence,
bilateral leg weakness and poor rectal tone. Retropulsion of the
disk into the cord with no cord signal change demonstrated on
MRI ___. Symptoms concerning for cord compression, likely due
to pathologic fractures, particularly given her history of
prednisone use, DM and ED syndrome. Pt s/p anterior fusion of
T7-T9 w/ spacer and vertebroplasty on ___ and s/p posterior
fusion of T3-T12 on ___. Placed in TLSO brace for out of bed
activity. Had frequent neuro checks. Neuro exam remained stable
with no worsening of bowel incontinence, lower extremity
weakness, and lower extremity sensory loss. Pain was controlled
with a combination of Dilaudid, MScontin and Tylenol. Patient
was followed by Ortho ___, Thoracics, and Heme/Onc.
# L Femur Fracture s/p ORIF: Presented with L hip pain. Hip XR
on ___ showed L femoral neck fracture. Likely caused by trauma
with bed transfers in setting of chronic prednisone use,
baseline low-level activity, poorly controlled DM2 and obesity.
Patient s/p ORIF of left femur fracture performed on ___.
Incision site healing well. Discharged touchdown-weight bearing
LLE. Pain was controlled with a combination of Dilaudid,
MScontin and Tylenol.
# Ulcers: Presented with ulcerations around coccyx, inferior
buttucks folds, and labia. Likely precipitated by bedridden
status, poor immune function (DM, chronic prednisone),
incontinence soilage. Managed with appropriate wound care and
regular repositioning. Seen by wound care and dermatology.
# LUE thrombus: LUE U/S on ___ showed nonocclusive thrombus
within 1 of 2 left axillary veins adjacent to indwelling PICC. L
PICC lined was discontinued and a R peripheral was placed.
Repeat LUE U/S on ___ showed stable appearance of thrombus. No
additional anticoagulation was provided given increased risk of
bleeding secondary to underlying ___ disease. R
PICC line was removed.
# Anemia: Hgb downtrended to 6.5 om ___ in the setting of
having undergone posterior fusion of T3-T12 the day prior (Hgb
of 9.0 on ___ before surgery). Patient received 1u pRBCs and
her Hgb returned to baseline. Drop in Hgb likey ___ to
intraoperative bleeding and hemovac output. Her baseline HGB has
been 8.0-9.0 during this hospitalization.
# L Pleural Effusion: Developed L pleural effusion during
hospitalization. Chronic bilateral crakcles L>R and diminished L
breath sounds. Engaged in chest ___, regular incentive
spirometry, and flutter valve. Provided with intermittent
supplemental )2 up to 4L.
CHRONIC ISSUES:
# Asthma: Stable. Presented on prednisone 40 mg BID which was
weaned during hospitalization (decreased to 35mg BID on ___, to
30mg BID on ___, to 25mg BID on ___, to 20mg BID on ___, to
15mg BID on ___, to 10mg BID on ___, to 7.5mg BID on ___, to
5.0mg BID on ___. Given Ipratropium-Albuterol Nebs. Her home
doses of Flovent, Albuterol Inhaler, Flovent, Singulair, and
Theophylline were continued.
# Poorly controlled type 2 diabetes: Stable. No hypoglycemic
episodes during hospitalization. Pt was taking 30u novolog 70/30
with meals with additional ___ throuhgout the day to manage
her glucose during this hospitalization.
# Elhers-Danlos syndrome: Stable. Will require outpatient follow
up with Rheumatology.
# ___ disease: Stable. Hematologist documents "not
___ disease, but rather a intrisic bleeding
disorder that responds to DDAVP and can be treated as such. In
addition she should have platelet transfusions for larger
surgeries to help with homeostasis." Platelets and Desmopressin
were given prior to each operation.
# Seizure disorder: Stable. History of absence seizures. No
events during hospitalization. Continued home Lamotrigine.
# Depression: Stable. Continued home Cymbalta.
# Thrombocytosis: rising platelet count for past week. Up to
900s on day of discharge. Unclear etiology. likely reactive
from previous procedures and sacral decub. Recommend recheck of
platelets in one week to monitor for resolution.
# Steroid Taper: Of note patient has been on long steroid taper,
if patient is hypotensive, may be sign of adrenal insufficiency
- recommend low threshold to restart steroids. | 442 | 778 |
10610424-DS-9 | 23,750,968 | Dear Mr. ___,
You were admitted due to cough, fever, and pain in your groin. A
chest xray was performed and your cough and fever were
determined to be due to a pneumonia. The pain in your groin was
felt to be due to an infection of one of the structures in your
scrotum, the "spermatic cord." You were evaluated by surgery in
the emergency room and they did not feel that you needed any
surgical intervention at this time. We treated your pneumonia
and groin infection with antibiotics that you will continue
after you are discharged. Please avoid lifting heavy objects for
at least the next ___ days.
We wish you a speedy recovery!
- Your ___ Care Team | === SUMMARY ===
___ with no significant PMH who presented with fever, testicular
pain, and cough.
=== ACUTE ISSUES ===
# Pneumonia: Patient presented with one week of productive cough
and one day of fevers. In ED patient was tachycardic (109) and
febrile (100.4). CXR performed was consistent with atypical
pneumonia and patient was started on azithromycin and
ceftriaxone. Patient was discharged on levofloxacin 10 day
course to treat both pneumonia and vasitis.
# Vasitis: Patient presented with 1 week of discomfort with
urinating that evolved into dysuria and hematuria. Came into ED
yesterday due to acute onset non-radiating groin pain. Reported
sexual encounter prior week (MSM). Scrotal ultrasound performed
in ED ruled out testicular torsion. CTAP did not show evidence
of hernia but did show asymmetric thickening within the right
inguinal canal suggests inflammation or infection involving the
spermatic cord. UA with 98 WBC, 13 RBC, few bacteria, and
negative nitrites. Patient received IV ceftriaxone and
azithromycin per above. Additionally received IM ceftriaxone
dose in hospital and was discharged on 10 day course of
levofloxacin to treat pneumonia, possible chlamydia infection,
and vasitis in an MSM patient.
=== CHRONIC ISSUES ===
None.
=== TRANSITIONAL ISSUES ===
#Pneumonia: Patient diagnosed with atypical pneumonia and
discharged on 10d levofloxacin. Please follow up for resolution
of symptoms.
#Vasitis: Patient presented with acute onset groin pain that was
ruled out for testicular torsion and incarcerated hernia. Was
treated for inflammation of spermatic cord seen on CT-AP with IM
CTX and discharged on 10 day levofloxacin course. Was
additionally prescribed 10 pills oxycodone 5mg for pain. Please
follow up and assess for resolution of symptoms.
#Hernia: Scrotal ultrasound showed increased fat in the right
inguinal canal may represent a right inguinal hernia but no
herniation was noted on CTAP. Patient advised to avoid heavy
lifting for next ___ days at least. Please follow up and assess
for evidence of hernia.
#HIV Testing: Patient reports sexual encounter week prior. HIV
testing was not performed in hospital. Please follow up and
consider HIV testing if clinically appropriate.
Code Status: Full
HCP: None Selected | 120 | 344 |
12595991-DS-18 | 22,050,503 | Dear Ms. ___,
It was a pleasure taking part in your care at ___
___. You were admitted to the hospital
because you had respiratory distress. We found that your lungs
were reacting badly to the medication amiodarone. You received
steroids, and your lungs improved rapidly, suggesting another
possible steroid-responsive lung disease. While in hospital, you
were also seen by the cardiology team who aided in the
management of your heart medications while you were being
treated.
With therapy, your lung function improved and you were
discharged to rehab to complete recovery.
You will need to followup with pulmonology to complete the
diagnositic workup and decide on duration of therapy. You also
will followup with cardiology and orthopedics
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | PRIMARY REASON FOR HOSPITALIZATION
=================
___ y/o F with a PMHs significant for HTN, HLD, Afib on coumadin,
sCHF, cardiomyopathy with recent EF 35% and recent admission
here s/p fall with ankle fracture who presented from rehab with
respiratory distress, hypotension and likely urosepsis. She was
treated for urosepsis with ceftriaxone. Her shortness of breath
was likely amiodarone toxicity in combination with other
steroid-responsive interstitial lung process. She will require
further diagnostic workup as an outpatient with pulmonology.
Active Issues
=================
# Respiratory Distress
Patient has had severely decreased lung volumes ever since ___ on imaging. Initially she was admitted in respiratory
distress and required BIPAP in the ED; however, soon after
arrival to the MICU she was weaned to shovel mask and then nasal
cannula. Initial differential for cause was unclear and
included sepsis vs. flash pulmonary edema vs. pneumonia. She
continued to do well until ___ when she acutely
decompensated and required BIPAP once again. Etiology was
initially unclear and neurology was consulted and there was no
evidence of neuromuscular disease. She was then successfully
diuresed and was able to be weaned back to shovel mask. High
resolution CT chest on ___ showed pulmonary fibrosis
consistent with amiodarone toxicity. Thus, amiodarone was
discontinued and patient initiated on steroids. She received
high dose IV solumedrol for 2 days and improved dramatically.
Oxygen was weaned to 2L NC on transfer to the floor. Plan for
prednisone taper per Dr. ___. Vasculitis and rheumatologic
work-up was initiated and negative to date on discharge. She
will followup with pulmonology for further diagnosis and
management. Prednisone will continue at 60mg per day for 2 weeks
then taper by 10mg weekly until 20mg daily. This dose will
continue until pulmonary followup. Atovaquone for PCP
prophylaxis, omeprazole for GI prophylaxis, and Ca/VitD for BMD
loss prophylaxis were initiated prior to discharge.
# Weakness
Appears to have had a decline in overall strength from a
baseline of weakness (was able to walk a block, stand in the
shower several weeks ago) for unclear reasons, possibly due to
deconditioning in the setting of recovering from ankle fracture.
There is concern for an underlying neurological process that may
contribute to respiratory weakness; however neurology has been
consulted and does not feel there is any neuromuscular disease
contributing given that her CK nml and she has no focal
neurological deficits.
# Urosepsis
The patient was admitted from rehab with WBC of 15.6, tachypnea
and hypotension, fevers to 100.2 in the ED, ultimately requiring
pressor support and BIPAP in the ED thus meeting criteria for
septic shock. She initially had a lactate of 3.8 in the ED
which then downtrended to 2.4 after 1500cc of IVF. Source of
infection initially felt to be pna given new onset cough vs.
urinary given dirty UA in the ED. CXR done in the ED of poor
quality but could not exclude pneumonia, although R lower lobe
consolidation could represent atelectasis. She was on
norepinephrine to maintain MAP>65 and was slowly weaned of
pressors (off since ___ with gentle fluid rescuitation
given hhere severe CHF. She was empirically treated with
Vancomycine and cefepime. Urine culture eventually grew pan
sensitive E coli and she was narrowed to Ceftriaxone and
completed a 10-day course.
#Leukocytosis
Ms. ___ initially presented with leukocytosis with bandemia
in the setting of urosepsis. This resolved with abx. Her WBC
count rose while on steroids and was felt to be attributed to
this. No focal s/s of infection, no diarrhea, no fevers, and
stable VS on discharge. A followup CBC is requested after
discharge at the receiving facility, and listed on the page 1.
# Ileus vs Obstruction
Patient admitted with mild diffuse abdominal pain and
tenderness. KUB in the ED was concerning for obstruction
(although she was having bowel movements). Given initial
concern for intra-abdominal process, patient was treated with
Vanc/zosyn while in the ED. Ct abd/pelvis concerning for
obstruction vs. ileus, no free fluid. Surgery was consulted and
felt that her presentation was most consistent with ileus ___
urosepsis as above. Given low suspicion for intra-abdominal
infection and that this is likely an ileus, will not continue
zosyn. It was unclear if this was truly a new process, as she
appeared quite distended on prior recent exams and her stomach
is full on CT abd/pelvis. There was some concern for outlet
obstruction or gastroparesis. An NGT was placed for
decompresison and her symptoms improved with zofran prn nausea
medication. Eventually NGT was removed and she was transitioned
to a full diet.
# ___ on CKD
Patient admitted with Cr of 2.7 up from baseline of around
1.3-1.4. This was most likely ___ pre-renal etiology, as her cr
improved back to baseline with fluid rescusitation.
# Hyponatremia
Patient with new hyponatremia of 129 upon presentation from
prior in the low-mid ___. Given septic picture as above,
hyponatremia was most likely due to hypovolemic hyponatremia
(although differential diagnosis for hyponatremia is quite
broad) as sodium quickly returned to baseline.
# ___
At home patient is on Aspirin, Lisinopril, Spironolactone and
Torsemide. Medications were initially held due to septic
picture, but were restarted and well tolerated.
# Afib on coumadin
Patient known to have afib and is on coumadin at home. Home
medications include coumadin, amiodarone and metoprolol. Home
dose metoprolol was initially held due to sepsis. INR elevated
upon admission, so coumadin was initially held. As above,
amiodarone was stopped on ___ given concerning for toxicity
leading to pulmonary fibrosis and metoprolol restarted on ___,
with dose increased. She remained A-V paced thereafter.
# L ankle fracture
Patient was recently admitted here under orthopedics for a L
ankle fracture s/p fall which was managed non-surgically.
Orthopedics saw her while she was hospitalized. She had repeat
imaging and a cast was placed on ___. She will need follow-up
with Dr. ___.
# Insomnia
Will continue home dose zolpidem with careful holding
parameters.
TRANSITIONS IN CARE
=====================
Communication: Patient, and husband- ___ ___
Code Status: DNI but okay to rescusitate, continue to discuss
Prednisone will continue at 60mg per day for 2 weeks then taper
by 10mg weekly until 20mg daily. This dose will continue until
pulmonary followup.
Followup will be with pulmonology, cardiology, orthopedics, and
primary care
CBC and Chem-10 to be checked the day following discharge from
the hospital | 128 | 1,040 |
13548972-DS-18 | 20,719,078 | Ms. ___,
It was a pleasure participating in your care at ___. You were
admitted because you were more tired and had more seizures. We
found that you had an aspiration pneumonia. We treated you with
antibiotics. You also underwent speech and swallow evaluation,
which showed you are at risk for aspiration and we changed your
diet to pureed with thin liquid. We will also arrange home
visiting nurse to evaluate your ability to swallow at home.
We made the following changes to your medications:
STARTED Augmentin (last day ___ | ___ y/o female with PMHx cerebral palsy (non-verbal at baseline),
seizure d/o (baseline ___ who presents with lethargy and
increased seizure activity, found to have consolidation on CXR
concerning for aspiration PNA.
# Pneumonia - Consolidation on CXR concerning for pneumonia,
likely aspiration given patient's history of CP and seizures.
Sister reports patient has seizures with oral stimulation.
Initially started on Unasyn, then transitioned to Augmentin
after S&S evaluation. Patient initially required 3LNC, but
rapidly improved to O2sat in the mid ___ on RA. Speech and
swallow eval showed concern for aspiration due to seizure
activity during evaluation and weak oral musculature.
Recommended pureed diet with thin liquids. Per S&S team,
patient has similar risk of aspiration with either thin or thick
liquids. Family not considering PEG or G-tube as an option.
Therefore, final recommendations are pureed food with thin
liquids without further S&S eval. Patient to complete 7-day
course antibiotics, last day ___.
# Decreased MS/Increased seizures - Baseline up to 10
seizures/day, manifested as arm jerking and blank stare x ___
seconds. Phenobarb level is 31 in the therapeutic range.
Electrolytes wnl with exception of slightly increased potassium.
Infection most likely etiology of increased seizure activity.
Labs do show evidence of dehydration as well with creatinine and
BUN elevated and ratio > 20. TSH normal. Seizure activities
decreased to baseline after treatment of infection. Seen by
Neurology Consult in the ED and they are in agreement with plan
for treatment of pneumonia.
# Pancytopenia - Has chronic macrocytic anemia, likely ___
phenobarbital. This admission also had thrombocytopenia and
leukopenia. Has intermittently been thrombocytopenic before,
although not to this extent. No signs of bleeding/bruising
currently. Pancytopenia could be a reaction to bone marrow
suppression due to infection. Hematology evaluated smear, saw
atypical lymphocytes c/w infection, no schistocytes, no abnormal
RBC morphology except some hypochromacia. Patient was
transiently neutropenic on ___, but ANC increased to 1200 on the
day of discharge (___). Platelet also to ___ from nadir of ___.
Plan to have ___ re-draw labs on ___ and fax to Dr. ___
___ follow up. Expect counts to improve as infection is being
treated. B12, folate wnl, iron panel all normal, but retic
count low.
# Hyperkalemia - mildly hyperkalemic on admission- repeat on the
next day was 4.3.
# Hypothyroidism - Continued levothyroxine, check TSH as above
# Patient remained DNR/DNI throughout admission, confirmed with
family - mother and sister.
# Transitional issues:
- Aspiration PNA- last day of Augmentin ___.
- Pancytopenia- all lines recovering on the day of discharge.
Plan to have ___ draw CBC with diff on ___, to be faxed to and
followed by Dr. ___.
- Aspiration risk- S&S evaluation showed aspiration risk,
recommended pureed diet with thin liquids. Plan to have ___
repeat swallow eval at home. | 92 | 490 |
17716301-DS-12 | 21,544,901 | Posterior Cervical Fusion
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Cervical Collar / Neck Brace: You need to wear the brace at all
times until your follow-up appointment which should be in 2
weeks. You may remove the collar for hygiene. Limit your motion
of your neck while the collar is off.
Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision
is completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Call the office at that time.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Dispo to Spinal Cord Rehab
Neuro:Continue to Monitor Weakness, Pain/Anxiety Mgmt, C-collar
___ weeks
CV:Vertebral Artery Thrombosis: ASA 81mg Daily
Pulm:Trach-Wean as Tolerated, pulmonary toilet, PMV
GI:Bowel Regimen
Nutrition:TF's Jevity 1.5 60cc/hr goal, monitor for re-feeding
syndrome
Renal:St Cath Regimen
MSK:Cont to monitor RUE strength. Episode of decreased BI
strength on ___ but improved
Physical Therapy:
C-Collar at all times X ___ weeks
Frequent Repositioning
TEDS when OOB
Aggressive Skin Care
Trach Care/Collar Hygiene
Bowel/Bladder Program
___ Care: Patient Education, Therapeutic Activities, Functional
Mobility Training, Balance Training, Continuous Pulse Oximetry,
Neuromuscular Re-education
OT Care:ADL Re-training, Cognitive Re-training, Delirium
prevention/treatment, Balance and mobility Re-training,
Patient/Caregiver ___
___:
Wound Care: If the incision is draining cover it with a new
sterile dressing. If it is dry then you can leave the incision
open to the air. Once the incision is completely dry (usually
___ days after the operation) you may leave it open to air. Do
not soak the incision in water. If the incision starts draining
at anytime after surgery, do not get the incision wet. Call the
office at that time.
Trach/PEG Care
Aggressive Skin Care and Prevention Measures/Frequent
Repositioning | Brief ___ Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the
___ in stable condition. TEDs/pnemoboots/SC Heparin were used
for postoperative DVT prophylaxis. Intravenous antibiotics were
continued postop per standard protocol. Initial postop pain was
controlled with oral and iv pain medication. Standard Spinal
Cord Injury Bowel Program. Trach and PEG was done on ___.
The patient subsequently developed fevers to 103 on ___. A CXR
noted on ___ a LLL consolidation/infiltrate and started on
Vancomycin/Cefepime on ___. The patient was then switched to
PO Levofloxacin 750mg Daily for a 5 day course on ___. The
patient has been afebrile for 48 hours with a stable WBC's.
Physical Therapy, Occupational Therapy, Spiritual Services, and
Social Work were utilized for help with his care and coping
during hospitalization.
Neurology was consulted initially for ? left vertebral artery
dissection. Per Neurology: It was not entirely clear whether
there was a true dissection or an in situ vessel narrowing;
however, further imaging would not change management. Neurology
recommended to take ASA 81mg for stroke prevention.
OMFS was also initially consulted for loose fractured fragment
of anterior mandible that would need to be fixated. The segment
was reduced into place with the aid of
two 24 gauge bridle wires by interconnecting the fractured
segment to non-fractured segments of the mandible and splint
placement. There is a strict non-chew diet with anterior
mandible segment for four weeks in place.
Dispo Planning:Discharge to Acute Spinal Cord Rehab from TICU
DAILY EVENTS: ___: s/p OR with ortho/spine, admitted to TICU.
CT max/face: No evidence of acute facial bone fracture. Sinus
disease as described above. Front lower teeth noted to be loose.
MR C-spine: no further c-spine compression. L subclavian line
placement. On neo, then norepi for goal MAP >85. CTA neck: There
is non visualization of the left vertebral artery (V2 and V3
segments) with reconstitution of the left vertebral artery at
the V4 level (series 2, image 199) most likely due to a
dissection and thrombosis. The bilateral carotid arteries and
right vertebral artery are patent. The basilar artery is patent.
Exam: shrugs shoulders, able to flex right UE at elbow.
sensation above nipples. ___ motor LUE and b/l ___. Appropriate
and following commands when given breaks from sedation. Pain
well controlled with prn dilaudid, Tylenol.
___: Weaned to extubate and extubated in the morning. Failed
extubation as he couldn't cough up secretions and re-intubated
via awake nasal fiberoptic. CT Sinus revealed labial mandibular
alveolar ridge fracture involving ___ ___. OMFS c/s, stated
no acute intervention, but should be splinted. Will evaluate
splint once clear extubation plan is known. OG Tube unable to be
passed, likely secondary to laryngeal edema. DHT may have to be
placed via ___ guidance. BAIR hugger started as patient was
hypothermic. Neurology c/s to help manage vertebral artery
dissection.
___: levophed d/c'ed, steroids d/c'ed, pt remained intubated,
additional attempts at NGT/OGT/dobhoff failed, called ___ but
can't place dobhoff on ___, could do tomorrow (order is in),
plan for trach/peg ___. D/c'ed steroids per spine. Spine drain
d/c'ed. OMFS placed temporary splint on lower teeth, needs more
permanent splint once ETT out
___: Patient with intermittent desats to high ___ on PS.
Cancelled ___ guided OG/NG tube given trach/PEG tomorrow. Rehab
screen initiation discussed with CM.
___: Trach and PEG placed in OR. OMFS to re-wire mandibular
splint this AM.
___: OMFS re-wired mandibular splint in pm, but it fell off.
They will have their attending come look and determine if they
need to go to OR for this. will need to be on strict non-chew
diet x 4 wks. Accepted to ___ rehab. Discussion/updates
with family at bedside. TF started, tolerating well. foley
d/c'd, st cath instead. a line and cvl d/c'd. started gabapentin
for pain. no trach mask trials yet. c/o tightness everywhere in
am, given Ativan.
___: Re-wired by ___. ___ will set up follow up. No further
intervention planned at this time from their stand point.
Patient did spike a fever overnight with increased sputum
production. Chest x-ray is unremarkable. Bronchoscopy performed
and BAL sample obtained.
___: Patient spiked fever at 2200 at 101.7F. Cultures ordered
yesterday night so no further cultures ordered. Tylenol given.
___: Tol 4 hrs spont vent, then requested to be put back on
rate-control for comfort, but was satting well. Pulls TVs of
350-400 on his own, gets 500 on rate-control. bilateral LENIs
negative. Family asking to speak with spine surgery before
discharge to rehab. My ICU updated, family's questions answered.
Febrile to 102.6 in pm.
___: Patient found to have ulcer at the inferior aspect of
trach site. Wound culture sent and patient started on Keflex.
This is likely source of fever at this time. Evaluated by ACS
who removed sutures from trach collar. Patient spikes a fever
overnight but has not had any significant change clinically.
Planned for discharge to ___ on ___.
___ - continues to spike fever ___. CBC uptrending.
Decision made not to send to rehab. CT Abd/Pelvis showed
collapse left lower lobe vs. infiltrate. no intraabdominal
pathology. Bronch performed, revealed thick mucous plugs in left
upper and lower lobes. Suctioned and BAL sent. Started on
Vanc/Cef for broad spectrum coverage.
___ - febrile again overnight. blood cultures, urine
culture sent. not tolerating pressure support well. kept on rate
throughout most of the day and evening.
___: Patient afebrile throughout day. Vancomycin increased to
1500mg Q12h given low vancomycin level.
___: Fever/WBC increase likely secondary to tracheobronchitis.
Switch Vanc/Cef to Levoflox to complete 8 day course total. D/c
to rehab. Insurance screening. | 327 | 967 |
16514111-DS-33 | 20,671,643 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
-You were admitted because you were feeling short of breath
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were found to have fluid on your lungs. This was felt to
be due to your heart failure, where your heart does not pump
hard enough and fluid backs up into your lungs.
- You were given a diuretic medication through the IV to help
get the fluid out.
- You also had low blood counts so you received a blood
transfusion. This was probably caused by your kidney disease.
- You improved considerably and were ready to leave the
hospital.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Take all of your medications as prescribed (listed below).
Your torsemide dose is 100 mg twice a day and your Cyclosporine
dose is 75mg twice a day
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs. Your discharge weight is 170
lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ care team | Mr. ___ is a ___ year old male with a significant past medical
history of HFrEF, HTN, CKD, hepatitis C and ___ s/p liver
transplant in ___, who presented with several weeks of dyspnea
and RLE swelling.
# Acute on chronic HFrEF exacerbation: The etiology of this
patient's heart failure is non-ischemic per his outside medical
records. He presented with a progressive 10 kg weight gain
despite a recent increase in his home Torsemide dose (60mg to
140mg). The etiology of his likely exacerbation is unclear. In
addition, his renal function appeared stable from his baseline
and reports good urine output. He denies any symptoms to suggest
an ischemic or arrhythmogenic etiology. His exam was also
notable for an absence of a murmur, to suggest worsening
valvular disease. He was diuresed with IV Lasix 160 BID. His
ECHO showed preserved EF without much acute change from last
Atrius ECHO. His weight went down 8 lbs. He symptomatically
improved. He is being discharged Torsemide 100 mg BID.
Nephrology team followed inpatient, with suggestion to consider
metolazone as outpatient. He had good diuresis with torsemide
dosing as above. Continued home carvedilol for B-blockade.
# Normocytic anemia: The patient had a reduced Hb to 6.7 on
admission, which is down from his baseline of ___. The likely
etiology of his anemia is uncertain, however this could be
related to his CKD. He was Guaiac negative in the ED and denies
any melena or hematochezia. He only reports mild epistaxis. He
could also have a component of iron deficiency anemia. He
received a blood transfusion with an appropriate increase in his
Hb. His CT abdomen/pelvis did not show a retroperitoneal
hematoma or bleed. He is relatively iron deficient given CKD,
with plan for outpatient iron to be arranged by renal team.
Consider outpatient colonoscopy given overall downtrending iron
deficiency anemia.
# CKD: The patient's Cr appears to be at baseline on admission.
He currently has a fistula in place, however he is not currently
receiving HD. Renal was consulted this admission and closely
monitored his volume status. He will follow up with them as an
outpatient, and if there are any acute changes in weight, HD
will be considered. He was continued on home Calcitriol and his
Sodium bicarbonate was held in the setting of his volume status.
His sodium bicarbonate was resumed on discharge.
# Hepatitis C and HCC s/p liver transplant ___: The patient is
currently doing well without any signs of infection or
rejection. His LFTs were within normal limits throughout his
hospitalization. There is no evidence to suggest this is a
source of his volume overload. He was continued on Cyclosporine,
with dose adjustments, and continued on his home
Sulfameth/Trimethoprim SS 1 TAB PO DAILY and Mycophenolate
Mofetil 500 mg PO BID. Please note his cyclosporine dosing was
changed to **** | 246 | 468 |
10996799-DS-20 | 27,194,950 | Miss ___,
Thank you for allowing us at ___ to take part in your care.
You were admitted due to difficulty breathing and abnormal
sugars. You were treated for these. We are also treating you for
suspected pneumonia with Levofloxacin from ___
You were also started on lisinopril daily for your blood
pressures.
We also noticed you were on a lot of sedating medications, like
ativan, and oxycodone. We recommend you cut back on these. You
are being discharged on lisinopril due to elevated pressures
while here. Follow up with your PCP after discharge in ___ days.
Thank you,
Your ___ team | ___ with a PMHx of asthma (baseline PF ~250), allergic
rhinitis, OSA (on CPAP), chronic sinusitis, DM, depression, who
presented with fever, chills, wheezing, dyspnea, headache. She
was found to have an asthma exacerbation.
# Asthma exacerbation. Trigger may be weather change vs. related
to infection. No definite source of infection seen on ___.
However given symptomatic fevers and chills and cough prior to
presentation pneumonia couldn't be ruled out given chest xray
was equivocal. She was started on levofloxacin 750mg, 5 day
course (day ___. Patient was treated with 40mg oral
steroids and albuterol nebs/ipratropium nebs advair and
azithromycin while in the ED.
# DM. Poorly controlled, likely due to getting half NPH in ED
w/breakfast in AM and steroids. Takes metformin at home and
states she takes no other ISS. ___ on ___ ___ were
downtrending after 10 U and then again 8 U. Much improved prior
to discharge at 149
## TRANSITIONAL ISSUES:
- Patient on too many sedating medications in the outpatient
setting. Consider reducing/ weaning them. Patient informed of
risks of sedating medications with OSA and encouraged to
maintain absolute adherence to CPAP use when sleeping and to
discuss absolute need of these medications with her prescribing
physicians
- On levofloxacin ___ - ___
- Lisinopril started due to elevated pressures
- f/u with PCP | 98 | 214 |
18751336-DS-2 | 26,078,601 | You were admitted for increased confusion. This was likely
related to dehydration, and changes in your blood (called
hyponatremia). We made sure that your heart was not the cause
of your symptoms, and there was no evidence for a stroke.
.
We treated you with fluids through the veins, and this helped
you improve. Please note that we have not changed any of your
medications. Make sure that you eat and drink enough to stay
hydrated. | SUMMARY: ___ year old woman with depression and cognitive
disorder NOS admitted from home after home ___ services
expressed concern regarding the patient's safety, found to be
hypovolemic with abnormal electrolytes and off baseline mental
status.
.
# Hypovolemic hyponatremia: Improved with IV normal saline.
Most likely secondary to decreased oral intake. Other causes of
change in mental status were ruled out with head CT, serial
cardiac enzymes, and urine analysis.
.
# Safety concern: By report of the ___, there is concern for
the patient's well being at home, in the setting of her usual
caretaker being out of town. Discussed with case management,
social work, and home ___ in addition to contacting the primary
care-giver who is currently on vacation in ___ to
ensure safe discharge plan.
.
# Depressive and cognitive disorder: At baseline is AAO x1
(name) and able to recognize only close friends/family members.
She is able to ambulate and use a commode, she is able to eat
and drink. She is maintained on a cocktail of psychotropic
medications, which were not changed on this admission, with the
exception of holding haldol.
.
# Expanded sella: Seen on CT head read. In an ___ year old
patient, this may be age related. She has no obvious endocrine
abnormalities (hyponatremia more likely explained by
hypovolemia). Given her age and co-morbidities, no further
inpatient work-up will be performed, and consideration of a
follow-up CT scan as an outpatient in several months may be
indicated.
.
# DM: held home anti-hypoglycemics in favor of sliding scale
insulin in-house
# HTN: Continued home lisinopril
# Intermittent tachycardia: Chronic. Tachycardia on admission
resolved with fluids.
.
==== | 77 | 277 |
16604920-DS-25 | 21,347,002 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted after a CT found showed
increasing size of the abscesses in your liver. We changed your
antibiotics course and you underwent a liver biopsy. While not
quite all tests are back from the biopsy, the pathology showed a
healing abscess, but no micro-organisms were found. We will need
to keep you on IV zosyn and fluconazole at least until you
follow up with your infectious disease doctors next week.
Sincerely,
Your ___ Care Team | PRINCIPLE REASON FOR ADMISSION:
___ PMH of PE (lovenox), Anxiety, AML (in complete remission,
undergoing consolidation with high dose ara-C), who was recently
admitted for neutropenic fever found to have hepatic
microabscesses, admitttd with increasing size of hepatic lesions
despite ___ntibiosis initially changed
to vancomycin, pip/tazo, micafungin; later changed micafungin to
fluconazole. She underwent liver biopsy on ___. Surgical
pathology is consistent with resolving abscess, although
microbiologic studies to date have been negative aside from
positive B-Glucan. Plan to continue empiric IV zosyn with po
fluconazole was made and she will follow up with ID to determine
final abx course.
Etiology of her abscess is unclear, which will make
determination
of abx course difficult. Given imaging findings and positive
glucan (and since it worsened despite ertapenem) favor possible
hepato-splenic candidiasis. afebrile with normal LFTs, and
appears to be healing. Favor continue broad GNR/anaerobic
coverage with pip/tazo and fluconazole for candidiasis. Will
need
likely prolonged treatment of at least two weeks. Will arrange
home services and ID follow up next week. Otherwise she had
developed moderate neutropenia which improved
after initiating treatment as above. Likely related to resolving
abscess.
# Hepatic microabscesses:
Etiology of abscesses remains unclear. Grew in size despite 2
weeks of ertapenem as outpatient. No significant fevers and no
liver test abnormalities. Antibiosis initially changed to
vancomycin, pip/tazo, micafungin; later changed micafungin to
fluconazole. She underwent liver biopsy on ___. Surgical
pathology is consistent with resolving abscess, although
microbiologic studies to date have been negative aside from
positive B-Glucan. Plan to continue empiric IV zosyn with po
fluconazole was made and she will follow up with ID to determine
final abx course.
- ___ remaining infectious studies
- ___ flow cytometry on liver sample
- Con't pip-tazo/fluconazole; D1 effectively ___.
- ___ in ___ clinic next week for final abx course
# Neutropenia: Admitted with mild neutropenia. ___ eventually
dropped to 750 on ___ before recovering prior to discharge.
Potentially medication induced vs effect of infectious abscess.
#Hx of PE: Lovenox was held prior to liver biopsy. Of note, she
was not maintained on heparin gtt due to patients firm desire to
avoid PIV, lack of additional IV access, and asympomtatic nature
after >3 months of anticoagulation. She was restarted on
therapeutic following biopsy without incident.
#Hx of AML in remission
Continued acyclovir ppx. Flow cytometry was sent on liver biopsy
specimen. Will need to follow up with Dr. ___ week
(either ___ or ___ for further treatment planning.
# Vaginal spotting:
Noted on admission. Likely due to delayed Lupron dosing.
Resolved.
#Anxiety
Continued escitalopram
# Anemia in malignancy
Stable to improving sp consolidation chemotherapy
# Billing: >30 minutes spent coordinating and executing this
discharge plan | 88 | 420 |
13507696-DS-4 | 26,524,954 | You have undergone the following operation: POSTERIOR Lumbar
Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___ 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound. | ___ woman who presents with acute on chronic severe neck
and low back pain. Previous films have identified a
pseudarthrosis and she elects to undergo revision spine surgery.
She was initially admitted to medicine for the initial workup
but was transfered to the Spine service post-op. Please see
Operative Note for procedure in detail.
Post-operatively she was given antibiotics and pain medication.
A pain service consult was obtained and recommendations
followed. A hemovac drain was placed intra-operatively and this
was removed POD 2. Her bladder catheter was removed POD 3 and
her diet was advanced without difficulty. She was able to work
with physical therapy for strength and balance. She was
discharged in good condition and will follow up in the
Orthopaedic Spine clinic. | 345 | 133 |
18390348-DS-21 | 23,817,868 | Dear Mr. ___,
You were admitted to ___ for coughing up blood. We performed a
CT scan which showed fluid in your lungs and widening of your
airways. We were concerned you may have tuberculosis and
performed several test which indicate that you do not. A
bronchoscopy was perfomed which showed no active bleeding with
some residual blood. There was a blood clot in a small airway
branch, which the team had difficulty removing. Interventional
Pulmonology will contact you regarding possible further
evaluation of the blood clot. | # HEMOPTYSIS: Hemodynamically stable on admission. Started
suddenly 1 day prior to admission and he had 2 episodes.
Differential diagnosis included lung cancer/brochoalveolar
malignancy/esophageal cancer (60 pack year smoking history, yet
no weight loss or dysphagia), TB (immigrated from ___ ___ yrs
ago, last travel to ___ ___ years ago. However, no fever, no
leukocytosis, no hilar adenopathy), bronchiectasis, PNA (again
no fever or leukocytosis), PE (negative CTA, WELLS 1), ___
___ varices ___ drinks per night, yet no wretching
or vomiting). CTA w RUL ground glass opacity concerning for
alveolar hemorrhage vs atypical infection vs bacterial
infection, with no evidence of PE, no mass. Per radiology, more
likely hemmorhage rather than infection, enlarged bronchial
arteries possibly amenable to ___ embolization. He remained
stable with no additional episodes and therefore did not go for
embolization. Patient was not started on antibioitcs on
admission as he was afebrile with no leukocytosis. Sputum for
acid fast x 3 were sent and were all negative. Pulmonology was
consulted and recommended a bronchoscopy which showed no active
bleeding but some residual blood. A large clot was blocking
smaller airways and they were unable to remove it. No lesions or
masses were seen. Pulmonology will set up outpatient follow up
with patient. Cytology from lavage is still pending at
discharge. Episode thought to most likely be from vascular
malformation and or bronchiectasis in setting of pending
cytology.
# ALCOHOL ABUSE: Patient endorsed drinking ___ drinks per day.
He scored 0 repeatedly on CIWA and did not require
benzodiazapines. He was given thiamine, folate, MVI daily. He
was prescribed a Rx at discharge for these
================================================== | 86 | 269 |
19134963-DS-15 | 26,659,729 | Ms. ___,
It was a pleasure taking part in your care. You were admitted to
___ with influenza and pneumonia. You were given IV fluids and
were treated with Tamiflu (you will need 5 days of treatment)
and levofloxacin (you will also need 5 days of treatment with
this medication). At the time of discharge your symptoms were
greatly improved.
If you develop any worsening symptoms of increased fever,
worsening body aches, worsening cough, or lethargy, please call
your PCP to be evaluated or return to the ___ ER.
Meds:
- Start Tamiflu 75mg by mouth, twice a day for 3.5 days (evening
dose tonight, then 3 days)
- Start levofloxacin 750mg by mouth daily for 3 more days | Ms ___ is a ___ female with an insignificant past medical
history presenting with 24 hours of cough, shortness of breath
wth radiographic evidence of a RML PNA.
#. PNA: She had symptoms of influenza with fevers, myalgias, and
cough for approximately ___ days prior to admission. She was
initially observed in the ED and was given 5 liters of IV fluids
overnight. She was then admitted for further observation. She
tested positive for influenza and her chest x-ray showed a right
middle lobe pneumonia. She was treated with Tamiflu 75mg BID for
5 days and levofloxacin 750mg PO daily for 5 days. Her CURB-65
was 0. After a night of monitoring and treatment her symptoms
were greatly improved.
She was a college student living with other students. She was
told that she should wear a mask for 5 days from the onset of
symptoms of from her last fever. She was also told that her
friends should be screened for symptoms or be evaluated for
treatment. | 119 | 171 |
12331149-DS-12 | 23,136,354 | Dear Mr. ___,
You were transferred to ___ after you suffered a fall and
injured your left kidney. Imaging showed that you had a hematoma
as well as urine leaking around the left kidney. You also had a
left sided 10th rib fracture. To help your symptoms and address
the fluid collection, the urology service took you to the
operating room and placed a stent in your left ureter (which
drains urine from the kidney to bladder). After this your
symptoms improved greatly. You also had a foley catheter placed
while you were in the operating room. This should remain in
place until you follow up with urology. You will need to call
___ to schedule an appointment in about one week
(___). You have also been prescribed a new medication called
tamsulosin to avoid urinary retention. Please take 1 tablet each
evening. Continuation of this medication will be discussed at
your urology follow up. During your hospitalization, your labs
were monitored closely and showed improving renal function and
stable blood counts. You were started on all your home
medications and were tolerating a full diet prior to discharge.
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.
It was a pleasure taking care of you,
Your ___ Surgery Team | Mr. ___ is a ___ with h/o vfib arrest s/p AICD placement
(___), prior MI, and HLD who presented to ___ as a transfer
from an OSH with CT findings of left renal laceration and a
retroperitoneal hematoma after a mechanical fall. Fall is likely
mechanical as patient tripped over a snow bank without any
pre-syncopal symptoms, head strike, or loss of consciousness.
Given degree of renal injury, he was transferred to ___ for
further evaluation. On arrival, patient was afebrile and
hemodynamically stable with Hct of 32 (35 at OSH 5 hours prior),
unremarkable FAST examination, and UA demonstrating gross
hematuria. Given findings, the patient was admitted for
observation and serial Hct in the setting of a known RP
hematoma. On admission patient had a repeat CT abdomen pelvis
that was notable for multiple wedge-shaped left renal cortical
lacerations extending into the renal pelvis (grade IV injury),
with associated extravasation from the renal calyces. There was
also note of a nondisplaced fracture in the lateral aspect of
the left 10th rib. Patient was admitted to the acute surgical
service and was kept NPO on IVF, with targeted pain management.
Aspirin was held. Urology was consulted and recommended
conservative management with close monitoring of post residual
volumes. On ___, a repeat CT abdomen pelvis was ordered and
demonstrated expansion of the left perirenal collection with
contrast from the renal calyces. Given these findings both
interventional radiology and urology were consulted to discuss
management options. Ultimately the patient went to the OR on
___ for cystoscopy with left ureteral stent placement.
Patient also had a foley catheter placed at that time. There
were no adverse events in the operating room; please see the
operative note for details. Pt was taken to the PACU until
stable, then transferred to the ward again for observation. On
return to the floor subcutaneous heparin was started for DVT
prophylaxis and the patient was started on a regular diet which
he tolerated well. Creatinine on admission was 1.3/1.4, but
downtrended to 1.0 on the day of discharge.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
TRANSITIONAL ISSUES
===================
[]Left Renal laceration/urine extravasation: Patient had foley
placed on ___. This is to stay in place for a minimum of 1
week. Patient should be seen in ___ clinic for evaluation
prior to foley removal. He has been provided the number to
schedule an appointment ___ | 418 | 434 |
14644494-DS-21 | 26,770,930 | Dear Ms. ___,
You were admitted after an un-witnessed fall at home. Imaging
showed that you did not have any head bleeds. It also showed
that you did not have any acute fracture of your spine or
pelvis.
It is still unclear what caused your fall. Your known aortic
stenosis could have been a cause. We are aware that you were
recently evaluated for a potential trans-catheter aortic valve
repair in the future. However, you and your family agreed that
you will not elect to perform this procedure at this time.
It was a pleasure taking care of you!
Sincerely,
Your ___ Team | ___ y/o F with history of severe AS and cerebral amyloid
angiopathy who presents with syncope.
#Syncope: Given lack of history, difficult to tell if
mechanical, orthostatic, arryhthmogenic or structural cause of
syncope. No sign of infection. UA negative. Patient had recently
been evaluated for TAVR (deemed high risk for SAVR) for known
severe AS. However, both the patient and her daughter remain
hesitant to pursue TAVR at this time. While hospitalized, no
events on telemetry, orthostatics borderline without clear
symptoms (SBP 170->151). Aortic stenosis potential cause but
given the lack of other symptoms (angina, dyspnea, CHF) it was
decided with the patient and her daughter that it was not worth
pursuing TAVR at this time when the true cause of fall is very
unclear. She was discharged to rehab with the plan to bridge to
an ALF with home services (currently lives alone with no
services).
#Cerebral Angiopathy/Dementia: Very severe memory dysfunction.
Cannot remember hour to hour. However, still very functional and
pleasant. Had one episode of agitation while here and required a
PRN dose of olanzapine 2.5mg.
#Depression/Insomnia: Continued home fluoxetine
#Constipation: Continued senna/miralax
#Hypothyroidism: continued levothyroxine 25mcg daily | 99 | 188 |
16700747-DS-10 | 23,053,804 | Dear ___,
It was a pleasure taking care of you at ___
___. You were admitted for visual changes worsening
in the past week with blurry vision, halos around lights, and
sensitivity to light. You also had a lump on the left side of
your head that was causing you sharp pain and pressure. A CT
scan of your head with contrast did not show any concerning
findings in your head, and the mass on the side of your head is
likely a sebaceous cyst, and is unchanged from your last CT scan
on ___. Lumbar puncture, MRI brain scan, and visual evoked
potentials were normal, which rules out infectious or
inflammatory neurologic causes of your visual changes such as
optic neuritis. Your vision improved while you were here, and
was ___ at discharge. Additionally, it is likely your visual
changes are partially related to your cataracts, and you were
given outpatient opthalmology follow up.
It is important that you take all medications as perscribed, and
keep all of your follow up appointments. | The pt is a ___ year-old woman with PMHx of bipolar disorder,
HTN, HL and prior cervical spinal surgery who presented with
bilaterally blurred vision for the past week and head pain
associated with a soft tissue mass on the L side.
# NEURO: The patient presented with a reportedly rapid
deterioration of vision in the week prior to admission, with
vision ___ b/l on admission. However, when we tried the
patient with her glasses (which she initially refused and said
they didnt help), she improved to ___ b/l. Opthalmology exam
on admission showed no evidence of retinal or papillary disease,
no glaucoma, but did note bilateral cataracts. Temporal
arteritis was clinically unlikely given no true history of jaw
claudication, location of head pain associated with soft tissue
mass on the side of head, and unrevealing optho exam (showed
only cataracts), and good temporal artery pulse without
nodularity along the artery. The patient's reported history of
rapidly worsening vision was concerning for possible bilateral
optic neuritis. The patient got a head CT with and without
contrast which showed no acute intracranial process. LP showed
benign CSF and culture were negative at discharge. MRI was
preformed once we confirmed with neurosurgery that her prior
spinal surgery metal was MRI compatible, and did not show
evidence of optic neuritis or MS. ___ evoked potentials
showed no abnormality. Since there was no evidence of
inflammatory or infectious process in the CNS which could be
causing the visual changes, the patient with discharged with
outpatient ophthalmology follow up.
# HEAD MASS: The patient originally complained that her head
mass had been growing in the recent weeks - months and was
causing increased pain. However, CT head showed likely sebaceous
cyst in the area, unchanged from ___. Additionally,
outpatient PCP notes noted the mass several months ago. This, it
was felt that there was no urgent issues with the mass and
further managment was deferred to her PCP.
# PSYCH: H/o bipolar disorder. When the patient was admitted she
said she was somewhat "down" but denied suicidal ideation. She
has regular outpatient psych treatment. Home medications were
continued during admission.
# CARDS: Continue antihypertensives (HCTZ, lisiopril,
amlodipine) and simvastatin
# PPx:SQH | 171 | 362 |
12156365-DS-9 | 24,378,629 | Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
after a motor vehicle crash and found to have multiple injuries
including fractures in your neck, back, pelvis, and nasal bone.
You were seen by the orthopedic and orthopedic spine team who
recommend management of your neck, back, and pelvic fractures
non-operatively. For your neck fracture, please continue to wear
your hard cervical spine at all times. No lifting, twisting, or
bending until cleared by the orthopedic teams. You may walk and
be full weight bearing on your legs. You had a catheter placed
for urine because you were not able to empty your bladder on
your own. A urine test showed an infection and therefore you
were given antibiotics. You should follow up in the ___
clinic to have a voiding trial. Please keep the foley catheter
in place until your appointment.
You were seen and evaluated by the physical and occupation
therapists who recommend discharge to rehab to continue your
recovery. You are now ready to be discharged to rehab with 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. | Ms. ___ is a ___ yo F who sustained a ___ yo F who was admitted
to the Emergency department after a reported rollover motor
vehicle crash. Unknown loss of consciousness. Given mild
dementia at baseline, accurate history was difficult to obtain.
CT head, neck, torso, showed unstable C2 fracture and a chronic
C1 fracture, and pelvic rami fracture. She was given IV
antibiotics and tetanus shot prior to transfer.
Orthopedic spine surgery consulted and type III odontoid
fracture with extension into the left lateral mass diagnosed.
Recommended non-operative management in hard ___ collar.
Orthopedic surgery consulted for pelvic fracture and
non-operative management was recommended and she was cleared for
full weight bearing.
Neuro: The patient was alert and oriented throughout
hospitalization although did have waxing and waning periods of
confusion. Geriatric medicine was consulted to assist in
managing dementia symptoms. Pain was managed with standing
Tylenol and low dose oxycodone. Narcotics were limited as much
as possible.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was given a regular diet which she
tolerated well without difficulty. Patient's intake and output
were closely monitored. On HD2 foley catheter was placed for
urinary retention and she failed voiding trial x2. Urology was
consulted and recommended holding home oxybutynin dose and
outpatient follow up for voiding trial and further urodynamic
studies as needed.
ID: The patient's fever curves were closely watched for signs of
infection. On HD7 patient had abdominal pain and loose stool.
C.diff sample sent and positive. She was therefore started on
oral flagyl and her abdominal pain resolved.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Rehab stay anticipated <30 days. | 397 | 388 |
16018707-DS-7 | 21,343,475 | Posterior Cervical Fusion
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit in a car or chair for more than~45 minutes without
getting up and walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Cervical Collar / Neck Brace:You need to wear
the brace at all times until your follow-up appointment which
should be in 2 weeks.You may remove the collar to take a
shower.Limit your motion of your neck while the collar is
off.Place the collar back on your neck immediately after the
shower.
Wound Care: Please keep the incision covered
with a dry dressing on until your follow up appointment. Do not
soak the incision in a bath or pool.If the incision starts
draining at anytime after surgery,do not get the incision
wet.Call the office at that time.If you have an incision on your
hip please follow the same instructions in terms of wound care.
You should resume taking your normal home
medications
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in narcotic
prescriptions (oxycontin,oxycodone,percocet) to the pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
At the 2-week visit we will check your
incision,take baseline x rays and answer any questions.
We will then see you at 6 weeks from the day of
the operation.At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit,drainage from your wound,or have any questions.
Opthamology and Plastics teams were consulted for her Orbital
wall fracture and bilateral nasal bone fractures respectively.
***She will require sinus precautions per (HOB elevated to 30
degrees, no blowing nose and no drinking from a straw)
-She will require plastics surgery outpatient follow up for
nasal bone fractures
Per Plastic Surgery Note:
She may follow up with plastic surgery in a week with Dr. ___
___ to discuss next steps and possible need for operative
repair of nasal bone fracture.
Plastic Surgery/Dr. ___: ___
Fax: ___
-She will also follow up with her primary ophthalmologist on
discharge for her orbital wall fracture.
Per Ophthalmology Consult Note:
Large R orbital floor fracture and opacified maxillary sinus
No evidence of globe injury or retrobulbar hematoma
Assessment:
___ presenting s/p fall with R inferior orbital floor fracture.
She has full EOMs and her ophthalmic exam is otherwise
unremarkable. There are no signs of intraocular trauma.
Recommendations/follow-up:
1. Fracture management per plastic surgery
2. Follow up with primary ophthalmologist on discharge.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
c-collar at all times; may remove for hygiene.
Treatments Frequency:
Please keep a dry dressing over the incision on until your
follow up appointmen.Do not soak the incision in a bath or
pool.If the incision starts draining at anytime after surgery,do
not get the incision wet.Call the office at that time. | Ms. ___ is a ___ y/o F who initially presented to OSH s/p
mechanical fall where she was found down. At the OSH she was
found to have a comminuted
right inferior orbital wall fracture with blood in the sinus,
slight injury, with displacement of the inferior rectus muscle
as well as nasal fractures. Also labs were notable for mild
rhabdo. She was transferred to ___ for further care. The
patient reported burning pain in her bilateral hands as well as
weakness. Ortho ___ was consulted and recommended MRI T and L
___. The patient remained in a hard cervical collar. Ortho
___ diagnosed the patient with central cord syndrome s/p
hyperextension injury to the cervical ___. Plan was to take
the patient to the OR for C3-C7 laminectomy and C3-T1 posterior
instrumented fusion.
Ophthalmology evaluated the patient's right eye orbital wall
fracture and there was no evidence of intraocular trauma.
Plastic Surgery was consulted for nasal bone fractures and no
immediate surgical intervention was warranted. It was
recommended she follow-up in clinic with Dr. ___ in
approximately ___ weeks to discuss next steps and possible need
for operative repair.
CK was monitored and downtrended.
On HD2, the patient was taken to the OR with Ortho ___ and
underwent C3-C7 Laminectomy; C3-T1 Fusion on ___.
Patient was admitted to the ___ ___ Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.
Post op course is complicated by acute blood loss anemia, pain
and persists with upper extremity weakness and pain. She was
treated with 2 units PRBC's for her blood loss anemia.
Opthamology and Plastics teams were consulted for her Orbital
wall fracture and nasal fractures. She will require sinus
precautions (HOB>30 degrees, no blowing nose, no drinking from a
straw) per plastics team and outpatient follow up. She will also
follow up with her primary ophthalmologist on discharge.
Hospital course was otherwise unremarkable.On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet. | 743 | 416 |
11593376-DS-17 | 22,169,123 | Dear Mr. ___:
You were admitted to ___ for evaluation of your confusion.
There was no infection that we found to cause this. You were
seen by our psychiatrists who felt that you would be served best
by living in a facility with closer supervision.
It was a pleasure to care for you!
Your ___ Team | Mr ___ is a ___ yo M with psychiatric history and ETOH abuse
with progressive mental decline over past ___ yr presenting to ED
for psych eval/social services. Per cognitive neurology,
decline is most likely ___ alcoholic dementia. | 55 | 39 |
15692648-DS-17 | 22,461,446 | Dear Ms. ___,
It was a pleasure looking after you. As you know, you were
admitted with very low platelet counts. You received steroids
(intravenous dexamethasone) for a total of 4 days during the
hospitalization. The platelet count is at the ___ range. The
cause of the low platelets is, at present, unclear. This may be
due to a recent viral infection, medications (particularly from
one of the recent antibiotics) or simply idiopathic. You have a
close follow-up with the ___ clinic in 2 days to
determine whether there should be additional treatments for the
low platelet count.
There is no need for additional medications. You may
continue with the medications you were previously prescribed
(obviously, no antibiotics for now). If there is any signs of
bleeding (gastrointestinal, lightheadedness, headache), then
please contact your primary care doctor or go to the
urgent/emergency room for further evaluation.
Again, it was a pleasure. We wish you good health!
Your ___ Team | Hospital Course: Ms. ___ is a ___ h/o HTN, tob dependence,
recent sinusitis (rx'd with abx) presenting with acute
thrombocytopenia (nadir 3K). No signs of bleeding,
hemodynamically stable. | 185 | 29 |
16003661-DS-28 | 25,299,480 | You were admitted to the hospital for a small bowel obstruction.
We managed you conservatively with an NG tube, bowel rest, and
medications to move your bowels. Over time, your bowels started
to move and were able to tolerate a regular diet.
Return to the emergency department if you are unable to move
your bowels, are not passing gas, your abdominal pain worsens,
are unable to tolerate foods/liquids.
Continue to take any medications you were taking prior to coming
to the hospital. You will need to follow up with your PCP. An
appointment has been made for you (see below). | Mrs. ___ was admitted to the inpatient ward under the
Acute Care Surgery service on ___ for further management of
her small bowel obstruction. Her KUB on admission showed
several dilated loops with paucity of colonic gas concerning for
a small bowel obstruction. She was kept NPO and given IV fluids
until her bowel function returned. She was given IV narcotic
and non-narcotic pain medications. Daily electrolyte levels
were checked and repleted (if necessary) while she was NPO.
Because her bowel obstruction hadn't cleared and she was still
having nausea, a ___ tube was inserted on hospital day
3.
On hospital day 6, Mrs. ___ began to pass flatus and show
signs of returning bowel function. She was slowly started on a
regular diet, which she tolerated well. At the same time, she
was resumed on her home medications. Her bronchodilator therapy
and COPD regiment was also initiated, while her supplemental
oxygen was discontinued. She was given an aggressive bowel
regimen to assist in facilitation of a bowel movement, which she
later achieved.
At the time of discharge, Mrs. ___ was hemodynamically
stable, afebrile, and in no acute distress. She was tolerating
a regular diet, voiding without issue and ambulating with
minimal assistance. Since she has no pain at this time, no
prescriptions for discharge were necessary and she will resume
all her prior home medications. A follow-up appointment with
her PCP has been provided. Mrs. ___ is being discharged
to her group home via a chair car. | 102 | 263 |
14723419-DS-5 | 20,366,611 | Mr. ___, it was a pleasure to participate in your care
while you were at ___. You came to the hospital because you
experienced some shortness of breath. We found that this
symptom was due to a collection of fluid around your lung which
is a complication of cirrhosis.
The fluid around your lung was drained and you were safe to be
discharged home.
You are being discharged on increased doses of your water pills
(lasix & spironolactone). You will need to have your bloodwork
checked ___ days after you are discharged to make sure there are
no problems on these increased doses. | ___ with HCV/EtOH cirrhosis c/b hepatic hydrothorax presents
with recurrent R. pleural effusion likely hepatic hydrothorax.
#R pleural effusion, likely hepatic hydrothorax: Pt presented
with shortness of breath and R pleural effusion on imaging, most
likely hepatic hydrothorax, thought due to non-compliance with
low salt diet and progression of PVT. Had a thoracentesis with
pigtail catheter placement on ___, with 5.5L of output.
Catheter was removed ___. Lasix was increased to 80mg po
bid, and spironolactone was increased to 200mg daily. Pt
improved clinically, with decreased shortness of breath. Serial
CXR showed decreased size of the R pleural effusion.
Interventional radiology was consulted, and they felt pt could
potentially undergo TIPS if indicated despite PVT; this was not
pursued given improvement on increased doses of diuretics.
Interventional pulmonology felt there was no role for
pleurodesis, even if other therapies failed. Pleural fluid
culture showed no growth as of ___.
#Ascites: Worsening ascites over several days likely
multifactorial in the setting of SBP, dietary indescretion, and
PVT occlusion. Patient with >250PMN in ascitic fluid in ED;
however, likely due to bloody tap given absence of other
signs/sx and high hct in fluid (21). Pt had no h/o of prior
peritonitis. Ceftriaxone was started in the ED but discontinued
after the patient was admitted. Fluid culture showed no growth
as of ___. Pt on high dose diuretics as per above.
#Chronic PVT: CT showed evidence of completely occluded PVT as
compared to partial occlusion on imaging earlier this year.
Patient stopped taking coumadin prior to hernia repair and never
restarted. PVT likely predisposing to worsening ascites and
hydrothorax. Pt was not restarted on coumadin, as it was not
indicated for his chronic PVT.
#H/o hepatic encephalopathy: Pt showed no evidence of confusion
or encephalopathy during admission. Was continued on rifaximin
and lactulose.
#H/o variceal bleed: Hct remained stable.
#HCV/EtOH cirrhosis: Pt is currently being evaluated for
transplant. Otherwise, as per above.
#CKD: Cr remained stable and at baseline. | 105 | 327 |
14068632-DS-4 | 22,400,442 | Dear Mr. ___,
You were hospitalized due to symptoms of leg weakness resulting
from an ACUTE ISCHEMIC SPINAL STROKE, a condition where a blood
providing oxygen and nutrients to the spine is decreased.
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:
Aortic dissection
Atrial fibrillation
Diabetes
Hyperlipidemia
Hypertension
We are changing your medications as follows:
We started you on Apixaban and Diltiazam
We stopped your Aspirin
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician.
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 ___ man with history of atrial
fibrillation and ___ aortic dissection s/p graft in
___ who presented with tearing chest pain, SOB, and bilateral
lower extremity weakness, concerning for spinal cord infarction
secondary to dissection. Exam notable for bilateral lower
extremity weakness R>L with diminished sensation to pinprick
consistent with anterior spinal cord syndrome. MRI notable for
spinal cord infarct spanning C5/C6 to T12 which is consistent
with the deficits of the corticospinal and spinothalamic tracts
at and beyond these levels. Additionally, patient demonstrates
weakness of the L hand, etiology is likely secondary to a
separate central cord syndrome related to canal narrowing as
identified on cervical MRI with small posterior disc buldges at
the level of C3-C6. He was initially managed in ICU with lumbar
drain and then eventually transferred to NIMU s/p removal. | 203 | 141 |
16236902-DS-2 | 28,165,994 | Ms. ___
___ presented to the hospital because of confusion. We
performed imaging of your brain and ___ were found to have a
very small stroke in a region on the left side of your brain
that is important in memory. We think that ___ will recover
your memory functions over the next few weeks. We have started
___ on aspirin 81 mg daily and atorvastatin 40 mg daily to help
reduce your risk of having another stroke. ___ will need to ask
your primary care physician for ___ referral to follow up with a
neurologist.
We have prescribed ___ a two week course of pregabalin for
management of the pain ___ are having because of your recent
shingles infection. If ___ need more of this medication beyond
this please reach out to your primary care provider.
Thank ___ for allowing us to care for ___.
___ Neurology | Ms. ___ is a ___ left-handed woman with a past medical
history of one lifetime grand mal seizure, discoid lupus,
depression, anxiety, migraine, psoriasis who presents with
significant retrograde amnesia. Exam on presentation otherwise
nonfocal with no other abnormalities. She had an MRI of the
brain which revealed a small left hippocampal stroke. We
performed a CTA head and neck which did not show severe
atherosclerosis. TTE did not reveal LV embolus. Telemetry has
been without abnormal rhythms. We have initiated
hypercoagulability work-up. She will need two weeks of cardiac
monitoring as an outpatient, which she will need to discuss with
her PCP to arrange. We have started her on aspirin 81 mg daily
and atorvastatin 40 mg daily for secondary stroke prevention.
She had 48 hours of EEG which were normal. She had bland CSF
studies.
She has evidence of a recent shingles infection. She was
complaining of parasthesias in the affected area. We have
prescribed her a two week course of pregabalin. She can request
additional medication from her primary physician if needed. We
have not made any other changes in her home medications. | 153 | 186 |
13524625-DS-14 | 21,188,503 | 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. | Ms. ___ is a ___ y/o F who was admitted to the neurosurgery
service s/p fall without LOC. Imaging studies revealed a left
subarachnoid hemorrhage in the sylvian fissure. She was admitted
for monitoring as well as a syncopal work-up. Urinalysis and
culture was negative for an infectious process. Cardiac enzymes
were negative. On ___, she underwent a CTA which showed a
2-mm left PCOM aneurysm versus infundibulum. No neurosurgical
procedure was required.
The patient underwent a repeat head CT on ___ which was stable
from her prior exam. During her inpatient stay, she was
hemodynamically and neurologically stable. Her pain was treated
with narcotic and non-narcotic analgesics.
In terms of her syncope work-up, a carotid ultrasound showed
less than 40% ICA stenosis bilaterally. An ECG showed a heart
rate of 70 in sinus rhythm with possible left ventricular
hypertrophy. An echocardiogram was obtained prior to the
patient's discharge, but a formal read was not available. The
imaging was suboptimal due to poor windows and the patient's
body habitus.
Ms. ___ was discharged on ___. She was instructed to
contact the ___ clinic for a follow-up appointment in
four weeks with a non-contrast head CT prior to her appointment. | 67 | 212 |
12408912-DS-18 | 22,562,143 | Dear Mr. ___,
You were admitted to ___
because you were having trouble breathing. You were connected to
a breathing machine (ventilator) to help you breath. You were
also give a breathing tube through your neck (tracheostomy) and
a feeding tube in your belly (PEG tube). While you were here,
you were found to have an infection in your lungs (pneumonia),
and you were started on antibiotics. | ___ with advanced NSCLC s/p multiple IP procedures with
palliative stenting and COPD who presents with acute hypercarbic
respiratory failure.
#Acute hypercarbic respiratory failure requiring tracheostomy:
Patient was intubated in the setting of his respiratory failure.
The respiratory failure is was caused by his non-small cell lung
cancer, which causes narrowed airways and risk of
obstruction/mucous plugging. Throughout his hospitalization, he
had mucous plugs plus copious secretions. He also underwent
multiple bronchoscopies to clear out the mucous/secretions.
After he had been intubated for one week with unsuccessful vent
weaning, he underwent a trach/PEG procedure on ___. He was
gradually weaned from the ventilator and was tolerating PSV as
of ___, tolerating trach mask as of ___ (including overnight),
and using speech valve as of ___. On the floor he was able to
work with physical therapy and continued tolerating his speaking
valve.
#Pneumonia:
The patient was treated with an 8 day course of vancomycin and
ceftriaxone for ventilator associated pneumonia, exacerbated by
a post-obstructive picture from his non-small cell lung cancer.
A sputum culture was also obtained that was positive for
stenotrophomonas, and he was treated for 7 days with Bactrim.
After that course was finished, he had another fever. He was
started on vancomycin and zosyn on ___. This was narrowed again
to Bactrim on ___ when sputum culture again grew
Stenotrophomonas; he completed a ___nemia:
The patient was found to have anemia, likely secondary to anemia
of chronic disease. During this hospitalization, he was
transfused a total of 2 units packed red blood cells. H&H stable
for many days prior to discharge.
# Hyperkalemia: Pt had recurrent episodes of hyperkalemia
requiring treatment. Renal was consulted and they felt this was
a side effect of Bactrim. This has resolved now that he is off
this medication.
# Abdominal Pain and constipation:
Pt has been having intermittent abdominal pain on exam. CT A/P
performed showed ? of intermittent intesussception, although
clinically his pain is greatly relieved when he has a bowel
movement, so it is likely related to constipation. He is
discharged with numerous PRN laxatives and will need these
titrated to ensure he has regular BMs.
# Cancer-related pain
He has been started on standing dilaudid with additional doses
PRN.
# Prostate Abnormality on CT:
Patient likely has metastatic prostate cancer with PSA of 69 and
lytic bone lesions. This is unlikely to be life limiting given
the advanced state of his lung cancer and he is on no treatment
for this.
#Protein-calorie malnutrition
Patient is cachectic in the setting of his cancer. He is on
continuous nepro tube feeds at 50 mL/hr per PEG tube.
# Advanced Non-small cell lung cancer:
#GOALS OF CARE
This patient has terminal cancer with life expectancy is likely
less than ___ months. He is unable to communicate well s/p
trach, he is largely bedbound due to deconditioning and advanced
cancer and has cancer related pain; quality of life appears to
be minimal. He is not a candidate for chemotherapy or radiation.
His primary lesion encases major airways and errodes into the
right atrium, suggesting he is at ongoing risk for sudden death
with PEA arrest from various irreversible and unsurvivable
causes (massive exsanguination, tamponade, etc.).
It is the belief of his guardian and of this author that his
full code status is medically inappropriate and far more likely
to cause him suffering than to prolong life. Unfortunately, his
guardian does not have the legal authority to change his code
status and the patient does not have the capacity to make this
decision himself. A lawyer at the ___
___ is petitioning the court to expand the powers of his
guardian ___ from The Arc of
___, ___. This hearing is on or around
___. The attorney at ___ (___) will
continue to follow the case and offer support if needed, but
they are not the primary party making the petition.
TRANSITIONAL ISSUES
- Continue ___ and speech therapy to maintain his ability to move
and communicate independently.
- Adjust PO dilaudid as needed for pain
- Adjust bowel regimen as needed for one BM daily (constipation
causes him significant abdominal pain)
- Continue to follow the legal petition for the guardian to be
able to change code status. | 66 | 701 |
19076225-DS-13 | 21,136,805 | Discharge Instructions
Brain Tumor
Surgery
You underwent surgery to remove a brain lesion from your
brain.
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 have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. 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 experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | ___ year old female presents with headaches found to have a 1.7cm
by 1.9cm cystic mass. She was transferred to ___ from an OSH
for further care and evaluation by the Neurosurgery Team. She
was admitted to the Neuro ICU.
#Right Craniotomy for Tumor Resection: The patient was taken to
the OR and underwent a right craniotomy for tumor resection. She
remained intubated post operatively and was taken immediately to
CT scan for a post-operative NCHCT which demonstrated
improvement of hydrocephalus and SAH and small amount of
hemorrhage in the resection bed. She was loaded with 1 gram of
Keppra in the OR and continued on 500mg BID. She was on
dexamethasone, and urine output was monitored q1h and serum
osmolality, sodiums and specific gravity was monitored q6h. A
post-operative MRI was ordered and that showed some residual
tumor. She remained stable over the remaining few days and was
transferred to the ___ on ___. She continues to have a
waxing and waning exam and got a Head CT due to lethargy on
___ and ___, both of which were stable. On ___ the
patient was brighter on AM exam and her labs were closely
monitored. She was ordered for ___ and OT, who recommend rehab at
discharge. Sutures and staples were removed on POD#13 as
incision was clean, dry and well healed.
ENDOCRINE - patient was closely followed by Endocrinology for
the following:
#DI: The patient has been on DI watch with frequent serum sodium
and UA checks. On ___ she was hypernatremic to the 158 with
increased serum osmolarity and decreased urine spec gravity. She
was given DDAVP with good effect. She was instructed to drink
to thirst with goal of 1 liter a day. On ___ her sodium was
down to 137 from 147 and on repeat check later in the day down
to 133, likely SIADH, and 1.2L fluid restriction was initiated.
On ___ the patients sodium had normalized to 138 and she
continued to drink to thirst. Her serum sodium and urine labs
were monitored closely every six hours. Overnight on ___ she
met criteria for DI, and was given 1mcg of DDAVP with good
effect. The patient urine output, Sodium, and Specific Gravity
continued to wax and wane. She received DDAVP on ___ with good
effect. Endocrine continued to follow and recommended having
her drink to thirst with goal of 600cc every 4 hours. Labs
checks were relaxed to Q 8 on ___ and ___. Starting on
___ patient was given standing DDAVP 10mcg intranasal daily at
9pm.
#Panhypopituitarism: Preop labs showed low LH (low suggesting
hypogonadism), low cortisol (suggesting secondary adrenal
insufficiency), low Prolactin (suggesting pituitary hypofunction
___ mass effect), and low FT4 (suggesting central
hypothyroidism). She was given 100 mg IV hydrocortisone
intraoperativly and started on Decadron 4q6 postop and tapered
to 2mg BID.
#Leukocytosis
Patient was noted to have persistent elevated white blood cell
count. She was afebrile. Urine and Blood cultures were negative.
CXR was negative for acute infection process. ___ Doppler US were
negative for DVT. Leukocytosis is possibility related to
dexamethasone and taper of this medication was started. | 419 | 528 |
18991843-DS-38 | 26,102,972 | Ms. ___,
It was a pleasure caring for you during your most recent
hospitalization. You were admitted with concern for a blood
stream infection and possible infection of your port. Upon
further examination of the culture and the port, the bacteria
was thought to be a contaminent. You were initially given
antibiotics but that was stopped after just a few doses.
We had the podiatrists come and see your left foot. Your foot
did not appear infected at this time. There is concern that
your blood flow may be limited which may make the surgical site
difficult to heal. You should see a vascular doctor ___
for ___ to have more of a work-up to possibly help improve
blood flow.
Please continue to keep all of your weight from the front
portion of your left foot. You are allowed to place weight on
the heel of your left foot only. Continue to do daily dressing
changes. Finally, please continue to weigh yourself daily. If
your weight increases by 2 or 3 pounds, call your cardiologist
immediately.
We wish you a speedy recovery and all the best,
Your ___ Care Team | BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ female with
a PMH of autoimmune hemolytic anemia on prednisone, diastolic
heart failure (recent exacerbation ___, ESRD s/p renal
transplant on sirolimus, and recent left hallux amputation
(___) who presented with positive blood cultures drawn off
of her accessed port at clinic. Her blood cultures eventually
grew coag negative staph bacteremia. Given her hx. of
immunocompromise, she was initially started on vancomycin with
vanc locks. The infectious disease doctors were ___. Pt.
remained afebrile, without a leukocytosis, without further
evidence of growth on cultures. As such, this blood cx. was
thought to be a contaminant. Pt. was discontinued off
vancomycin. Pt's Hgb was noted to trend down from 8 to 6. She
was transfused two units of specially matched blood from the
___ Cross given her extensive history of blood
antibodies. She was discharged with close outpatient follow-up.
ACTIVE ISSUES
==============
# Coag Negative Staph Bacteremia: Pt's port was mismanaged at
rehab facility. Port was left accessed with old needle in
place. As such, pt. had outpatient blood cultures with returned
initially with gram positive cocci. For concern for bacteremia,
pt. was admitted for further work-up. Given immunosuppression,
pt. was started on daptomycin (given hx. of VRE colonization)
and later transitioned to IV vanc with vanc locks per ID
consultation. Blood cultures later turned coag negative staph.
This was thought to be a contaminant as no other blood cultures
returned positive. She lacked any infectious symptoms on
admission. Podiatry was consulted who felt that her healing
left hallux amputation site was without infection. She was
discharged off antibiotics.
# Autoimmune hemolytic anemia with exacerbation: Pt. is known
to have autoimmune hemolytic anemia, s/p splenectomy, on chronic
prednisone. Her H/H downtrended on admission. She remained
hemodynamically stable. After speaking with blood bank, a
sample of the pt's blood was sent to the ___ Cross. 2
units of matched blood were found. She received 2 units of
pRBCs without issue. Her H/H remained stable. Her hemolysis
labs were noted to be near their usual baseline or improved.
# Hyponatremia: Pt. noted to have hyponatremia. On further
evaluation, it seems pt. had some nausea, vomiting, and poor PO
intake in the several days leading up to hospitalization. This
in addition to her diuretic therapy likely resulted in
hypovolemic hyponatremia. Diuretics temporarily held and PO
intake improved. Hyponatremia slowly resolved with improved PO
intake and diuretics were resumed.
# ___ on CKD: Pt. with increased creatinine to 2.2 from 1.5.
Likely pre-renal azotemia as pt. improved as she reached
euvolemia.
# Peripheral Vascular Disease complicated by Left Hallux
Arterial Ulceration/Gangrene status-post Left Peroneal Artery
Angioplasty and Left Hallux Amputation: Pt. with amputation on
___. Podiatry evaluated the site and felt that there was no
active infection on admission. Also was felt that her wound
would likely not heal without improved arterial supply to the
foot. Pt. was encouraged to present to her already scheduled
outpatient vascular work-up. She was continued on atorvastatin
and clopidogrel.
#HTN: Pt. with some low-normal BPs on admission. As such, her
hydralazine was decreased to 25mg PO TID.
CHRONIC ISSUES
================
#Diastolic Heart Failure: Pt's torsemide were temporarily held
given hypovolemia but were later resumed. Discharge weight
below.
# Type II Diabetes Mellitus: ISS while in house.
# Atrial Fibrillation / Atrial Flutter status-post Atrial
Appendage Ligation: Pt. not candidate for warfarin given
previous life-threatening GI bleeds in the past. She was
continued on metoprolol for rate control.
TRANSITIONAL ISSUES
=======================
# Discharge Weight: 58.2kg
# Repeat Blood Cultures: Per ID, pt. should have repeat blood
cultures off port in ___ days from ___ to ensure no further
growth of coag negative staph.
# Wound Dressing: Continue daily wet to dry dressing changes
# Repeat Labs: Pt. should have repeat CBC and Chem 7 to check
for worsening anemia and hyponatremia ___ days following
discharge.
# Recent Amputation: Pt. should be non weight bearing on left
forefoot. She can be full weight bearing on left heel. When
walking, she should use forefoot offloading shoe.
# Nonhealing foot: Podiatry evaluated her foot on
hospitalization. no concern for infection at this time. There is
continued concern that the blood supply to her left foot is
limited. She should follow-up with vascular as scheduled.
# Port Care: Port should be deaccessed at this time. She will
require a port flush ___ weeks from ___.
# BP Regimen: Hydralazine reduced from 50 TID to 25 TID at
discharge as pt's BP was within normal limits in the setting of
averaging ___ doses of 50mg hydralazine a day during her
hospital stay.
# Code: Full, confirmed
# Emergency Contact: Emergency contact is ___
(daughter, HCP) @ ___ | 195 | 805 |
14998555-DS-19 | 21,686,984 | -Please also refer to the instructions provided to you by the
Ostomy nurse specialist that details the required care and
management of your Urostomy
-You will be sent home with Visiting Nurse ___
services to facilitate your transition to home care of your
urostomy
-Resume your pre-admission/home medications except as noted.
Always call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor
-___ you have been prescribed IBUPROFEN, please note that you may
take this in addition to the prescribed NARCOTIC pain
medications and/or tylenol. FIRST, alternate Tylenol
(acetaminophen) and Ibuprofen for pain control.
-REPLACE the Tylenol with the prescribed narcotic if the
narcotic is combined with Tylenol (examples include brand names
___, Tylenol #3 w/ codeine and their generic
equivalents). ALWAYS discuss your medications (especially when
using narcotics or new medications) use with the pharmacist when
you first retrieve your prescription if you have any questions.
Use the narcotic pain medication for break-through pain that is
>4 on the pain scale.
-The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 4 grams (from
ALL sources) PER DAY and remember that the prescribed narcotic
pain medication may also contain Tylenol (acetaminophen) so this
needs to be considered when monitoring your daily dose and
maximum.
-If you are taking Ibuprofen (Brand names include ___
this should always be taken with food. If you develop stomach
pain or note black stool, stop the Ibuprofen.
-Please do NOT drive, operate dangerous machinery, or consume
alcohol while taking narcotic pain medications.
-Do NOT drive and until you are cleared to resume such
activities by your PCP or urologist. You may be a passenger
-Colace may have 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. | Mr ___ was admitted to Dr. ___ service on ___
with the above history. At ___ he had a CT which
showed bilateral mild hydronephrosis,
which is to be expected, and was otherwise unremarkable. His
labs were notable for a wbc of 34, elevated LFTs and UA
concerning for infection. In the ___ ED he was seen with wbc now
elevated to 64. He was afebrile but his leukocytosis and loose
stools were felt to be concerning for c. dificile colitis and he
was started on broad spectrum antibiotics including coverage for
c dificile with PO flagyl as well as cefepime and vancomycin.
On HD2 formal ID consult was obtained. He had initial
difficulties having a bowel movement and thus c. dificile
amplification assay was unable to be performed however urine and
blood cultures remained negative so empiric treatment for c.
dificile was continued. ACS were consulted and recommended
serial KUB to assess for risk of toxic megacolon, this was done
and was normal.
On HD3 ID recommended taking off cefepime and vancomycin which
was done. His WBC continued to trend down. He complained of
slight dizziness and nausea which was self limited.
On HD4, complained of some right lower extremity pain. Given
recent surgery lower extremity venous ultrasounds were obtained
to rule out DVT and were negative. Repeat KUB showed some
colonic dilation which was within normal limits per radiology.
WBC continued to downtrend .
On HD5 c. dificile assay was resulted and was negative. Urine
and blood cultures remained negative. Discussed with ID consult
team and given lack of other source and clinical scenario there
was high suspiscion for c. dificile colitis. He was clinically
improved with WBC down to 16 and trending down, he was afebrile
with normal exam. As a result it was recommended to continue
empiric course of treatment for c. dificile colitis to consist
of 14 days of PO vancomycin.
At the time of discharge on HD5 the wound was healing well with
no evidence of erythema, swelling, or purulent drainage. His
drain was removed and his scrotal edema, which was monitored
daily, was markedly improved. The ostomy was perfused and
patent. Follow up appointments were discussed and the patient
was discharged home with previously arranged visiting nurse
services to be continued. | 297 | 377 |
19588182-DS-18 | 21,472,953 | Mr ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our institution
after undergoing a procedure to clear an occlusion in your right
lower extremity that was causing you pain. After a brief
hospital stay and successful recovery, we now feel comfortable
discharging you home, provided you follow these recommendations.
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty Discharge Instructions
MEDICATION:
Take new medications as instructed: Coumadin and Lovenox
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for 1
week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room. | Mr ___ presented with a 3-day history of right lower
extremity claudication. Imaging studies performed at outside
hospital were consistent with right popliteal artery occlusion,
for which purpose he max started on a heparin drip and
transferred to our institution for further evaluation and
management. Decision was made to take the patient to the
operating room for angiography/angioplasty. Findings were
consistent with right popliteal artery occlusion with distal
reconstitution of anterior and posterior tibial arteries. A
___ catheter was placed and initiation of lysis was
performed (see Operative Note for further details). Patient was
taken back to the ward after a brief uneventful stay in the
PACU. After overnight lysis, he was taken back to the operating
room for lysis check. A patent popliteal artery with 2-vessel
runoff through AT and ___ confirmed success of the lysis
treatment. All hardware was removed. A ___ Perclose was
placed for hemostasis, and the patient returned to the floor
after a brief PACU stay. Heparin drip was continued and warfarin
therapy started.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed appropriately with oral
medications. A noticeable improvement in pain was reported after
the procedure. CV: The patient remained stable from a
cardiovascular standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. Findings on CT consistent
with non-opacified vessels in right lower lobe were concerning
-even with low suspicion- for pulmonary embolism. Given
patient's reassuring clinical status, further studies were not
pursued. GI/GU/FEN: The patient's diet was advanced sequentially
to a regular diet, which was well tolerated. Patient's intake
and output were closely monitored. Urine output on POD#1 from
initial surgery was noted to be grossly bloody, which was
attributed to the recent administration of thrombolytics. Given
persistence of hematuria, a Urology consult was requested on
POD#2 and heparin drip was discontinued. Recommendation was made
to start continuous bladder irrigation overnight, urine analysis
and cytology, as well as a CT urography (refer to Reports for
details). Findings were reassuring, although an unusual density
within the bladder (likely a clot) prompted recommendation for
outpatient follow-up. Hematuria cleared and CBI was stopped
after overnight treatment. Three-way Foley catheter was removed
and patient voided with no issues. ID: The patient's fever
curves were closely watched for signs of infection, of which
there were none. HEME: The patient's blood counts were closely
watched for signs of bleeding, of which there were none.
Prophylaxis: The patient was started on warfarin on POD#1 of the
second procedure and bridging with enoxaparin was initiated.
Arrangements were made prior to discharge for anticoagulation
management.
At the time of discharge, Mr ___ was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 375 | 495 |
19624082-DS-25 | 28,409,180 | Dear Mr. ___, it was a pleasure taking care of you during
your hospitalization at ___. You were admitted with fevers,
headaches, muscle aches and found to have a viral infection
called CMV. You were seen by our infectious disease team who
recommended IV Ganciclovir as treatment. You will continue IV
ganciclovir for at least two more weeks. You are scheduled to
follow up with infectious disease doctors on ___ for
further management. As part of your treatment, you should have
your labs checked on ___. | ___ with sarcoidosis (on cellcept, pred on admission) and Hep C
cirrhosis (genotype 3), Childs C MELD 14, presented with fevers
and pancytopenia, found to have primary CMV infection.
# febrile neutropenia: ___ CMV (107,000 on admission dropping to
70,900 by discharge) plus MMF in combination with ribavirin
causing anemia. We ruled out Lyme, EBV, Parvo B19, underlying
hematolgical disorders, C.diff, and full respiratory panel was
negative. UA negative. Fevers likely ___ CMV itself. Cefepime
stopped as blood cultures were consistently negative.
-increased Pred from 5 to 10 for evidence of adrenal fatigue.
-conted ganciclovir IV (will need a total of 2 weeks treatment)
-PICC line and discharge with OPAT follow up on ___. ID will
assess length of treatment based on CMV viral load.
-restarted ribavirin at low dose 200mg daily after stopping soon
after admission for anemia and evidence of hemolysis, a known
side effect of Ribavirin.
# Pancytopenia: Likely ___ CMV plus MMF in combination with
ribavirin causing anemia Fevers likely ___ CMV itself. Improved
on ganciclovir.
-contd to hold MMF
-monitored clinically
#Back Pain - Patient has complained of non-localizing back back
for several days. He can recount a specific day last week where
he pulled a muscle in his back after twisting while lifting a
heavy bag. He does experience some occasional pins and needles.
Abscess unlikely; presentation consistent with acute pinched
nerve.
- monitored for changes in physical exam--none.
# HCV/Sarcoid/EtOH Cirrhosis: Well-compensated of recent, though
has a history of decompensation with ascites, hepatic
encephalopathy. His last liver ultrasound from ___
did not show any focal liver lesion. Last endoscopy was done in
___ and showed grade 1 varices for which he is on
propranolol. Currently, MELD 8, ___ class B without
evidence of decompensation by hepatic encephalopathy, GI
bleeding, or SBP.
- Continued home lactulose and rifaximin
- Held beta-blocker in the setting of potential infection
- Held diuretics in the setting of potential
infection/hypovolemia
# HCV: Genotype 3. Currently on treatment with sofosbuvir and
ribavirin, the latter of which was decreased in dose given
anemia requiring transfusion. Will continue current treatment,
but discuss decreasing/changing given pancytopenia per above
- Continue HCV treatment with sofosbuvir 400mg daily; will
supply while he is inpatient.
- RESTARTING ribavirin at 200mg daily; started holding original
dose of 600 DAILY on ___. Went 3 days without Ribavirin.
# Sarcoid: Complicated by hypercalcemia, hepatic cholestasis,
lung involvement. Currently on immunosuppressive regimen of
prednisone, cellcept.
- Will continue to hold MMF (his pulmonologist agrees) in light
of suppressed bone marrow. Counts increasing.
- per pulm and rheum, can hold mmf indefinitely at this point,
as his Sarcoid is mild.
- Continue home prednisone 5mg daily, though he will temporarily
need a 10mg dose while he fights his CMV infection
- Continued home Bactrim infection ppx | 89 | 459 |
11361793-DS-6 | 22,052,211 | Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to ___ for a bone
infection involving your right heel and the lower half of your
right leg. You received IV antibiotics while you were here and
you were taken to the operating room for debridement of your
right heel ulcer by podiatry. The podiatrists found that your
bone infection was more extensive than previously thought and
recommended a below the knee amputation of your right leg. Your
amputation was done by the vascular surgeons.
You will need to continue IV antibiotics after your surgery. A
special IV line was placed ___ your left upper arm so you could
continue to receive these antibiotics. These will continue
through ___.
DIVISION OF VASCULAR AND ENDOVASCULAR SURGERY
AMPUTATION DISCHARGE INSTRUCTIONS
ACTIVITY:
On the side of your amputation you are non weight bearing for
___ weeks.
You should keep this amputation site elevated when ever
possible.
You may use the opposite foot for transfers and pivots.
No driving until cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
Sutures / Staples may have been removed before discharge. If
they are not, an appointment will be made for you to return for
staple removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap ___ the shower.
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which ___ turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE FOR: ___
Bleeding, redness of, or drainage from your foot wound
New pain, numbness or discoloration of the skin on the
effected foot
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site. | ___ PMHx ___ s/p L TMA (___), s/p R hallux partial amputation
(___), s/p R heel debridement (___), s/p R partial
calcenectomy (___) now presents with R calcaneus draining
purulent material with radiographic findings c/w chronic
osteomyeltitis now s/p R calcaneal debridement and R BKA. | 380 | 45 |
18944791-DS-15 | 20,409,923 | Mr. ___,
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management of
your toxic ingestion, seizure and recent fall with head bleeding
and skull fracture. You were also found to have a pneumonia and
were treated with oral antibiotics with improvement ___ your
breathing. Your confusion and balance issues improved during
your hospital stay and we are hopeful that these issues continue
to improve. YOU ARE NOT PERMITTED TO OPERATE A ___ FOR 6-MONTHS FOLLOWING YOUR SEIZURE EVENT.
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 ___ 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. | The patient was admitted on ___ from the emergency department
to the SICU following a seizure after ingesting an unknown
substance. A CT showed subdural, subarachnoid, punctate
hemorrhage and a basal skull fracture. He was loaded with
dilantin and sedated with fentanyl and versed. Initial
toxicology labs obtained were negative for any identifiable
substances. A repeat non-contrast head CT showed a stable bleed.
Toxicology was consulted and recommended aggressive hydration,
sedation and normothermia. Profolol was started as a sedative
agent. His labs were reflective fo a rising creatinine kinase as
well as elevated LFT's. The patient consistently became febrile
to 102 when sedation was weaned for neuro exams.
___: The patient remained sedated and maintained a goal urine
output of 100-140cc of urine an hour. He was afebrile. When
sedation was weaned, he followed commands intermittently. He
also experienced vigorous shaking off sedation. He was
thrombocytopenis down to 82 after a platelet cound of 171 on
admission. Heparin was held and labwork for DIC were sent.
Fibrinogen returned at 444.
___, the patient was started on EEG for question of seizures.
His NG output was bilious coffee grounds for which he was
started on protonix. Sputum cultures grew out gram negative rods
and cipro was started. A chest x-ray showed a new right base
consolidation and patient with MSSA pneumonia but without
pleural effusion and mild vascular congestion. Patient continued
to be sedated with wean on ___ and ___.
Patient was extubated on ___ and was originally placed on 15L
NRB. Was changed to face tent mask later that day. Bedside
ultrasound showed impressive consolidation of right lung base
but minimal pleural effusion. Patient was weaned to ___ NC and
had gradual improvement of his respiratory status. Antibiotics
were changed to nafcillin, ciprofloxacin, and flagyl but then
narrowed to PO clindamycin. Patient had poor IV access and a
right EJ was placed. Patient continued to have good urine output
and the foley catheter and IV fluids were stopped. Patient was
afebrile for 2 days before transfer to the floor. The issue of
withdrawing from school was mentioned the patient and patient's
family and will be something they will discuss to determine
patient's future course. Clinically and radiographically,
pneumonia improved before transferring to the floor on ___.
On the floor, Patient was continued on a 10 day course of PO
clindamycin for MSSA pneumonia. Patient remained neurologically
stable. As the seizures ___ the ED were felt to be provoked by
ingestion of a toxic substance, and patient had remained seizure
free following his admission, Neurology felt that phenytoin
could be discontinued, although the Patient was instructed not
to drive for 6 mos. Pt's skull fracture and
SDH/SAH/post-concussive syndrome remained stable, and Patient
was instructed to follow-up with Neurosurgery ___ 4 weeks
following his discharge. Patient initially had significant
muscle pain secondary to rhabdomyolysis, which improved over his
hospitalization. His CK continued to trend downwards. Patient's
thrombocytopenia continued to improve and his platelet count was
within normal limits on the day of discharge. The results of
several toxicology studies remained pending at the time of
discharge. | 228 | 519 |
10237425-DS-9 | 20,193,910 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You came in because of fever and low blood
pressure. The source of your infection is likely the ___
excision site. We treated you with IV antibiotics, and we will
continue to treat you with oral antibiotics for a total of 10
days (___). We are glad to see your infection is
improving.
We hope your muscle strain improves. We will let your PCP know
that ___ would be beneficial. Please follow up with your PCP, the
appointment is listed below. | ___ Y/o man with hx Hypertension, hyperlipidemia presenting with
fevers, with elevated lactate to 2.1, hypotension on
presentation meeting criteria for severe sepsis.
#Fever: Cellulitis at recent skin surgery site of excision of
basal cell carcinoma:
I also think he may have had viral prodrome with high fever and
lab changes detailed below. Patient initially presented with ___
SIRS criteria (fever, tachycardia) with elevated lactic acid and
Cr. Sources of infection include cellulitis from recent ___
excision site on Lt shoulder vs transient bacteremia ___
procedure. Other etiologies to considered included PNA, UTI,
cholangitis given hyperbilirubinemia, gastroenteritis given
diarrhea, and viral infection. CXR and UA were negative for
infection. Cholangitis was thought to be less likely as patient
was not having any abdominal pain. Furthermore, RUQ U/S was
reassuring. Empirically started on vancomycin and zosyn. Zosyn
was later discontinued as it was thought cellulitis was the most
likely source. Patient's blood pressure responded to IVF
resuscitation. Patient discharged on Bactrim, he will be treated
for a full 10 day course (___).
# Transaminitis: Present since ___. RUQ US showing fatty liver,
although cannot rule out hepatic firbosis and cirrhosis. DDx
includes NAFL, cirrhosis, vs statin use. Hepatology serologies
were negative. Patient does not have signs of cirrhosis on
physical exam. ___ consider hepatology follow as an outpatient
for further workup.
# Hyperbilirubinemia: New onset, indirect > direct, indicating
hemolysis vs ___'s syndrome. Reticulocyte count,
haptoglobin, and peripheral smear inconsistent with hemolysis.
Peripheral smear showed no schistocytes, no spherocytes, some
Burr cells (? liver disease), and neutrophils. Patient's Tbili
trended down during hospitalization.
# Thrombocytopenia: Seems to be chronic, however trending down
now. New downtrend may be ___ infection, liver disease, vs
antibiotics. Platelets remained stable.
# Anemia: Iron studies consistent with anemia of chronic
disease. H/H were stable.
# ARF: Cr elevated to 1.7 at ___. Baseline is 1.0
in ___. Etiology likely pre-renal. Patient s/p 3L NS. Cr back
at baseline.
# HTN: Atenolol was help in setting of severe sepsis. Patient to
continue atenolol on discharge.
# Hypercholesterolemia: Atorvastatin held in setting of LFT
elevation. Re-started upon discharge.
# CAD s/p MI
- Continue aspirin.
# BCC x ___ s/p excision
- Daily dressing change
- Suture removal 2 weeks from procedure (___)
- Continue to f/u with Dr ___ | 93 | 393 |
17876390-DS-12 | 28,699,990 | Ms. ___,
You were hospitalized with diarrhea and confusion. You may have
had an infection which caused the diarrhea and confusion. We
gave you lactulose and rifaximin which helped clear the
confusion. We did not find any other evidence of infection: no
bacteria in your blood or urine. Please follow up with your PCP
and hepatologist Dr. ___.
It was a pleasure taking care of you!
Your ___ team | ___ yo F with NASH cirrhosis (Childs B) c/b ascites and hepatic
encephalopathy who presents with acute hepatic encephalopathy in
setting of recent profuse diarrhea. | 70 | 25 |
12953072-DS-22 | 20,165,640 | Dear Mr. ___,
It was a pleasure taking care of ___ at ___. ___ were
admitted with abdominal pain and diarrhea. ___ were seen by GI
specialists and underwent testing including a colonoscopy. ___
tests were concerning for a new diagnosis of inflammatory bowel
disease. ___ were started on steroids and improved. ___ are
now ready for discharge on a slow prednisone taper:
- Take prednisone 40mg once a day (8 pills) ___, THEN
- Take prednisone 35mg once a day (7 pills) from ___ until
___, THEN
- Take prednisone 30mg once a day (6 pills) until your GI
appointment with Dr. ___
___ were also started on insulin for your diabetes. This type
is called ___. ___ should inject ___ Units with Breakfast and
60 Units with Dinner
As your prednisone dose changes ___ will need to change your
insulin dose:
- When at prednisone 35mg: change to 70/30 100 units with
breakfast, 50 units with dinner
- When at prednisone 30mg: change to 70/30 90 units with
breakfast, 40 units with dinner
At your upcoming appointment, Dr. ___ will help manage
your insulin and discuss with ___ regarding seeing a diabetes
specialist. If ___ have questions about your insulin between
now and then, please call Dr. ___ saw ___ as an
inpatient) at ___.
As we discussed your ultrasound showed a small gallbladder
polyp. The radiologist recommends ___ have a repeat ultrasound
in ___ year to make sure it has not changed size. We have
communicated this to your primary care doctor as well. | ___ year old male with past medical history of DM2, GERD, recent
hospital stay for Cdiff colitis discharged ___ readmitted
___ with worsening diarrhea, status post colonoscopy with
significant colitis, biopsy concerning for inflammatory bowel
disease, now status post initiation of steroids with
improvement, course complicated by transaminitis, resolving,
able to be discharged home on steroids and new insulin regimen
# Inflammatory Bowel Disease with acute flare complicated by
diarrhea - patient admitted with diarrhea and abdominal pain in
setting of recent hospital stay for similar that had been
attributed to ___; repeat cdiff testing was negative, as was
infectious diarrhea workup, which prompted additional workup in
including colonoscopy and EGD that showed colitis, biopsies
demonstrating signs of chronic colitis thought to be consistent
with new diagnosis of inflammatory bowel disease. Patient was
started on steroid pulse with improvement in stool frequency
(>12/day to 6/day) and inflammatory markers (CRP 40 to 10).
Quant gold negative, hepatitis serologies revealed he will need
outpatient vaccinations. VIP peptide pending at discharge.
Discharged on prednisone taper, with plan to decrease 5mg every
week, and hold at 30mg daily until his GI follow-up on ___.
# Diabetes type 2 with hyperglycemia - patient with poorly
controlled fingersticks as outpatient on metformin and
sulfonylurea (A1c 10). In setting of above steroid pulse,
patient developed worsening hyperglycemia requiring initiation
of insulin. Patient seen by ___ consult, and after trials of
several different regimens, was maintained on a 70/30 regimen
with good control. Patient instructed on adminsitration, seen
by ___ educator. Patient given clear instructions for how to
adjust insulin regimen with prednisone taper. Verbal signout
given to PCP who agreed with plan. Ensured insurance coverage
and discharged with 70/30 kwikpen. Given above diarrhea, opted
not to restart home metformin until stools completely
normalized.
# Transaminitis - course complicated transaminitis, peaking at
ALT 98 AST 69 before trending down. Patient workup included an
ultrasound that showed steatosis--patient may benefit from
hepatology referral. ___, AMA, ___ all negative. Suspect
underlying cause was steroids in combination with acute illness,
on top of underlying steatosis. At discharge ALT 76 AST 38.
Would consider rechecking at follow-up to ensure resolution.
# Gallbladder polyp - seen on ultrasound; recommmended for ___
year follow-up
# Hypertension - continued lisinopril
# GERD - continued PPI
# Hyperlipidemia - continued statin
# Asthma - continued advair
Transitional Issues
- Newly started on prednisone for new diagnosis of inflammatory
bowel disease; discharged on 40mg prednisone daily, to decrease
5mg every week, hold at 30mg daily until GI follow-up
- Novolog 70/30: 120 units at breakfast, 60 units at dinner; per
___ insulin should be tapered with prednisone as follows:
When at prednisone 35mg, change to 70/30 100 units with
breakfast, 50 units with dinner; when at prednisone 30mg,
change to 70/30 90 units with breakfast, 40 units with dinner.
- Incidentally found to have 3mm gallbladder polyp. Per
radiology, a ___ follow-up ultrasound may be performed to
assess stability.
- RUQ ultrasound showed steatosis--patient may benefit from
hepatology referral | 259 | 514 |
14744896-DS-16 | 25,994,591 | You were admitted to ___ after stabbing yourself with a
foreign body and were taken to the operating room for an
exploratory laparotomy and suturing of enterotomy and placement
of drain. Your post operative course was complicated by a blood
stream infection. You also have developed a fistula, which is a
tract from your intestines out through your skin. You should
continue to pouch with an ostomy appliance this while there is
stool coming out however it may close up eventually.
Incidentally, it was noted that you have an active hepatitis C
infection, and the liver doctors recommend ___ treatment
for this at an outpatient Liver clinic.
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.
Please change your dressings over the right lower abdominal
wound daily. Apply moist gauze and place a dry gauze on top and
secure the dressing with tape. | Mr. ___ was admitted to the trauma team after a suicide
attempt. He was taken to the operating room to repair the
enterotomy. The patient tolerated the procedure well and was
transferred to the floor for close monitoring. Urology was
consulted for insertion of styrofoam into penis and they
recommend a cystoscopy as an outpatient, although the patient
had no further urological complaints during the hospitalization.
Incidentally the patient was noted to be hepatitis C positive
with high viral count. Hepatology was consulted who recommended
outpatient follow-up. IV ciprofloxacin and flagyl were started
postoperatively as there was open bowel in the abdomen for 24
hours. Post operative day four the patient was advancing his
diet and was able to tolerate PO medication. A PICC line was
placed post operative day 7 for antibiotics. Post operative day
8 the wound was opened and packed. Post op day 9 the patient was
febrile to 102 a fever work up was done and a CT scan showed a
___ fistula through transverse colon to midline. He
was started on vanc and zosyn and then per Infectious Disease
recs, changed to ceftriaxone and PO flagyl. The following day
the patient became febrile again and started growing GPC's from
the PICC. The PICC was removed, and the patient remained
afebrile throughout the hospitalization after the PICC was
removed. The patient also received a TEE to rule out
endocarditis. The echo was normal. Pyschiatry was also involved
in the patients care at this point to evaluate the patient.
Blood cultures grew out S. viridans, and infectious disease was
able to make final recommendations on antibiotics which included
1 gm IV Ceftriaxone Q24H ___ - ___ 750 mg PO
levofloxacin QD ___ - ___ 500 mg PO flagyl Q8H
___ - ___. The patient self discontinued his IV access
2 days before switching from ceftriaxone to levofloxacin. The
levofloxacin was started early. The patient was afebrile,
tolerating a diet, voiding and pain was under control prior to
discharge. The midline fistula was managed with an ostomy pouch
and output had been slowing down. | 351 | 347 |
13965647-DS-14 | 27,027,514 | Wound Care: You can get the **right** 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.
Do not remove the splint from the **left** hand. keep the splint
dry at all times.
******WEIGHT-BEARING*******
non-weight bearing bilateral upper extremities.
you may use your right hand for daily acitivities, but do not
bear weight on this hand
******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******
- None | The patient was admitted to the Orthopaedic Trauma Service for
repair of bilateral distal radius fractures. The patient was
taken to the OR and underwent an uncomplicated open reduction
internal fixation bilateral wrists. 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 ___.
The patient was transfused 0 units of blood for acute blood loss
anemia.
Weight bearing status: nonweightbearing bilateral upper
extremities.
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. All questions were answered
prior to discharge and the patient expressed readiness for
discharge. | 166 | 156 |
14036445-DS-16 | 27,241,340 | You were admitted for evaluation of abdominal pain and nausea
and diarrhea. You were found to have an infection and started on
antibiotic therapy (Cipro and flagyl) for which your GI team
would like you to continue for likely 4 weeks. In addition, you
will need to take PO vancomycin for concern of recurrent C.diff.
You should follow-up with your PCP and GI teams on discharge. | SUMMARY/ASSESSMENT: ___ year old M with a PMH of Crohn's disease
(___), polio (shorter R leg), CAD s/p 1 stent who presents
with ___ days of abdominal cramping and loose, nonbloody stools,
now improved. C.diff positive overnight. | 66 | 35 |
10331875-DS-14 | 25,252,109 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
=================================
- You were admitted because you were not behaving as you
typically do and we noted that you were having weakness in your
legs concerning for a worsening of the infection in your spine.
What happened while I was in the hospital?
====================================
- You had an MRI scan of your spine, which showed that the
infection in your back which you received treatment for in the
past had not resolved and was likely the cause of your symptoms.
You underwent spine surgery to drain this fluid collection and
remove infected tissue.
- You were started on IV antibiotics to treat a chronic
infection in the bones of your spine.
- You resumed taking the study medication for your melanoma
- You were fitted with a brace to protect your back when
sitting up or moving.
What should I do after leaving the hospital?
====================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Please continue your IV antibiotics until ___
- You need weekly labs drawn and sent to the infectious disease
clinic.
- Your urinary catheter should be removed on ___
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team | Patient Summary Statement for Admission:
================================
Mr. ___ is a ___ with history of stage IIIC metastatic
melanoma (with renal and right-sided ilioinguinal metastases)
status post chemotherapy, immunotherapy, and cyberknife,
currently on study drug LOXO-101 (TRK inhibitor); NASH cirrhosis
complicated by hepatic encephalopathy, esophageal varices, and
ascites; with multiple recent admissions notably for
Enterobacter bacteremia/spinal osteomyelitis requiring IV
Cefepime, complicated by C. difficile colitis. ___ presented with
altered mental status and found to have worsening
osteomyelitis/diskitis with compression fractures, for which ___
underwent surgical washout and was admitted to medicine for
further management. | 249 | 91 |
12289074-DS-18 | 23,635,485 | Dear ___,
You were admitted to ___ because you were having chest pain
and were found to be having a myocardial infarction (heart
attack) which required care in the cardiac intensive care unit.
You had 3 stents placed to treat your heart attack. In order to
prevent clots from forming on these stents you were started on
two new medictions: Aspirin and Plavix. You were also started on
a medication called Atorvastatin to decrease your risk of future
heart attacks.
While you were here you developed severe confusion. This may
have been due to an acute stress reaction or a parasite
infection. You were treated for the parasite infection with
antibiotics. Your confusion resolved and you were eager to
return ___.
Please attend your follow up appointments as listed below.
Thank you for choosing ___ for your healthcare.
Sincerely,
your ___ Team | Mr. ___ is a ___ PMH notable for diabetes and ESRD on
HD who presented with chest pain and found to be having a STEMI
so he was admitted to the CCU. Cardiac cath showed 3 vessel
disease so there was no intervention done, he was returned to
the CCU with an IABP, and he was planned for CABG. The morning
he was supposed to go for CABG he developed global amnesia, MRI
was performed and showed bilateral cortical infarcts (possibly
old), so CABG was cancelled and he underwent high risk PCI with
placement of 3 DES. He was discharged on aspirin, Plavix and
atorvastatin.
#AMS/GLOBAL AMNESIA: patient with AMS and global amnesia w/
psychomotor slowing since ___ AM, patient unable to explain why
he is in hospital/his name/where he is from. Etiology unclear.
Patient w/ b/l small cortical infarct on MRI, however per neuro,
likely does not explain patient's clinical presentation. EEG w/
no e/o seizure activity, CT head negative for acute intracranial
abnormalities. Psych consulted who felt that patient's
presentation most c/w hypoactive delirium in setting of acute
illness/hospitalization. Per family has history of depression
and possible hallucinations. Blood and Urine Cx negative.
Patient was started on amantadine with slight improvement of
psychomotor slowing. Per psych this could also be an acute
stress reaction, and if that is the case it will likely improve
slowly over time. Patient w/ hx positive toxocara Ab, however
per ID, unlikely that toxocara would cause amnesia.
Cysticercosis Ab came back negative, Toxocara Ab positive, so
started on 5d course of albendazole 400mg BID. His global
amnesia resolved completely prior to discharge.
#STEMI: Patient presented w/ ___KG showing STEMI
with anterior ST elevation in V1 and V2 with STD and TWI in
V4-V6, I and aVL, trops w/ peak to 0.28. Patient underwent
cardiac cath which showed 3VD, and was planned to have CABG.
IABP placed to maximize coronary flow, removed shortly due to
development of abdominal pain (described below). However, on day
prior to scheduled CABG, patient developed acute onset amnesia
(described above) and CABG was deferred. TTE w/ LVEF ~45%,
mildly reduced global left ventricular systolic function with
regional hypokinesis of the distal septum and apex. Patient was
treated w/ heparin gtt until he returned to cardiac cath w/
placement of 3 DES. Patient discharged on ASA, Plavix, and
atorvastatin. He was not discharge on a beta blocker because of
his orthostatic hypotension. Due to the holiday We were not able
to discharge him on ticagrelor which would require
prior-authorization and contacting his insurance (both closed on
___). Please transition him to ticagrelor as an
outpatient. Ticagrelor has less interaction with INH and is
preferred given his history of stroke during admission.
#FEVERS: Unclear etiology. The patient developed fevers >100.4
after he was transferred to the floor. CXR, UA were not
consistent with signs of infection. UCx and BCx were negative.
His Toxocara Ab was positive and cystercicosis Ab was negative,
so with ID following he was treated empirically for Toxocara
with a 5d course of albendazole. He was afebrile for several
days prior to discharge.
#ABDOMINAL PAIN AND DIARRHEA: During hospital course, patient
developed severe abdominal pain w/ elevated lactate, likely ___
bowel ischemia iso balloon pump. Balloon pumped removed w/
resolution abdominal pain. Guiac negative. C. diff negative.
#ORTHOSTATIC HYPOTENSION: Patient developed orthostatic
hypotension that was noticed after he was transferred to the
floor and started working with ___. The differential included
medication effect (metoprolol), fluid shifts with HD,
hypovolemia vs ANS dysfunction iso poorly controlled DM. He was
given intermittent IVF boluses and was run even at HD but
remained orthostatic so his metoprolol was stopped and he was
started on midodrine 5mg TID. Prior to discharge his orthostatic
hypotension improved, but he was still mildly orthostatic.
# BILATERAL CORTICAL INFARCTS: TTE negative for any vegetations.
Possibly cholesterol emboli following cath. ___ have been
contributing to AMS/amnesia as above. It is also possible that
these are old and were not new this admission.
# TRANSAMINITIS: Unclear etiology. ID was consulted to see
whether this could be caused by his INH therapy and they felt it
was unlikely to be the cause. His transaminitis gradually
resolved throughout this admission.
# RETINAL HEMORRHAGES: These were seen on MRI so optho was
consulted. Per records at ___ had recent optho surgery and
has known retinal hemorrhages and retinal proliferation from DM.
He is legally blind.
# ESRD: Receives dialysis M, W, F. No electrolyte abnormalities
or significant acidosis during hospitalization. Continued ___
calcitriol, calcium acetate, sodium bicarbonate.
#ANEMIA: Stable. Likely iso ESRD.
#DIABETES: Not currently on any glycemic agents or insulin. He
was put on a HISS while in the hospital.
#LATENT TB: Asymptomatic, not active. Continued ___ isoniazid
___ mg daily with vitamin B6 | 136 | 790 |
10353397-DS-12 | 23,569,343 | Dear Ms ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for worsening shortness of breath.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have fluid reaccumulating around your lung.
This is related to your cancer.
- The interventional pulmonary team placed a catheter into your
chest to drain the fluid around the lung.
- You were evaluated by physical therapy, who recommended rehab
to help you regain your strength.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old woman with history of hypertension,
anemia and metastatic renal cell carcinoma diagnosed in ___ by mediastinal lymph node biopsy with known metastases to
lung, bone, mediastinal/hilar and periaortic lymph nodes s/p
initiation of treatment with Nivolumab/Zometa (C1D1 ___ who
presents with dyspnea due to recurrent malignant pleural
effusion. She underwent placement of a PleurX catheter with IP
and was discharged to rehab. | 125 | 70 |
12084946-DS-4 | 23,544,647 | Dear Mr. ___,
It was a pleasure taking care of you at ___!
You were admitted to the ICU for having difficulty breathing and
requiring a large amount of oxygen. Your chest imaging was
concerning for increased fluid in your lungs. The kidney doctors
did ___ and took out the extra fluid, and your
breathing got better. We did an ultrasound of your heart that
showed it is a bit stiff, but otherwise beating well. You will
continue dialysis as an outpatient. You are scheduled to see
your pulmonologist in ___, please make every effort to make
that appointment.
We wish you the best of health,
Your ___ Care Team | BRIEF HOSPITAL COURSE
=====================
___ male with a history of ESRD on dialysis, diabetes,
hypertension, hyperlipidemia, restrictive lung disease who
presented to the ED with acute onset dyspnea, found to have SBP
elevated to the 200's with evidence of volume overload on CXR
without clear inciting factor.
ACUTE ISSUES
===========
#Volume overload
#Dyspnea:
Patient presented with significant volume overload with SBPs
elevated to the 200's and CXR demonstrating worsening pulmonary
edema. Unclear what precipitated hypervolemia. Patient aware of
volume restriction and undergoing dialysis 3x week without
changes to regimen or medications. Patient noting stable BPs as
outpatient
making flash pulmonary edema less likely; however, patient with
unstable BPs since admission. No recent echo in OMR so CHF
possible. Also possible that patient was slowly gaining weight
that was missed because of gastroparesis (volume overloaded with
dry weight decreasing). Patient was placed on BiPAP in the ED
and initiated on a nitro drip. Renal was consulted for emergent
ultrafiltration in the setting of hypervolemia with compromised
respiratory status. Patient responded well with successful
titration of O2 down to home 3L O2 NC with good saturations and
d/c of nitro drip with some improvement in BPs. Repeat blood gas
was without evidence of hypercarbia. TTE demonstrated mild LVH
with normal LV systolic function. No obvious
valvular pathology or pathologic flow identified. CT Chest was
obtained in setting of restrictive lung disease with possible
contribution to dyspnea and no CT for ___ years. CT chest
demonstrated no significant change in moderately extensive areas
of round atelectasis in each lung. widespread pleural plaques
suggesting sequela of prior asbestos exposure. No evidence for
coinciding or superimposed asbestos
related interstitial lung disease. Also, a new mosaic pattern of
attenuation which can be seen with parenchymal abnormalities
including scroll vascular congestion, inflammatory types of
pneumonitis, atypical infectious processes, or air trapping
associated with small airways disease. And finally, newly
apparent right lobe thyroid nodule, measuring up to 25 mm.
#Hypertension: Patient with SBPs to the 200's on arrival to the
ED, likely in the setting of volume overload. Patient on home
regimen of clonidine BID, amlodipine daily with BP's
well-controlled, without recent changes to medication regimen.
Per Patient, BP's measured during dialysis run around 120's
systolic, but can drop to SBP 90's. Patient stating that he
adheres to BP regimen and that he took both clonidine and
amlodipine the AM of presentation. Patient placed on nitro drip
in ED with improvement in SBP to 140-150's. Patient without
headache, lightheadedness, visual changes, chest pain throughout
ICU course. Previously with SOB but resolved after initiation of
nitro drip and after ultrafiltration. BPs continued to be
intermittently elevated in ICU with systolic BPs to the 170's
and patient asymptomatic.
#Leukocytosis: Patient with elevated white count to ~16. Likely
stress response in the setting of dyspnea with resolution to
11.2 in the ICU. CXR without evidence of infection. However,
with significant underlying lung disease, difficult to discern
new opacities. Chest CT obtained which demonstrated no
significant change from prior. Patient remained without evidence
of infection throughout ICU stay.
#Elevated troponin: Troponin in ED slightly elevated to 0.04
(around baseline in past) in the s/o renal disease. EKG without
changes concerning for ischemia. Repeat troponin slightly
elevated to 0.06, but not outside patient's baseline elevation
per review of OMR. Patient asymptomatic. TTE obtained which
demonstrasted normal LV function.
CORE MEASURES
=============
# Code Status: Full code
# Emergency Contact: Sister
# ___
# Disposition: HOME | 108 | 562 |
15461634-DS-33 | 25,055,877 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
You had redness, swelling, and pus on your right lower leg that
is consistent with an infection called cellulitis.
What did you receive in the hospital?
You were seen by the Infectious Disease team and received an
antibiotic called Bactrim, after one day your leg already looked
better. You will continue taking the Bactrim at home for 5 more
days.
What should you do once you leave the hospital?
- Please take your medications as prescribed and go to your
future appointments which are listed below.
We wish you all the ___!
- Your ___ Care Team | ___ is a ___ w PMH notable for AF on Xarelto, morbid
obesity, previous admission for vertebral discitis/osteomyelitis
___ obstructive nephrolithiasis and klebsiella bacteremia (s/p
ureteral stent), OSA (not adherent to CPAP), OA s/p b/l knee
replacement, hypothyroidism, and multiple abdominal surgeries
who presented with ___ erythema concerning for cellulitis, now
resolving on Bactrim. | 110 | 54 |
15760105-DS-22 | 27,201,334 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
Why you were admitted to the hospital:
- You were having confusion and somnolence
What happened while you were here:
- Imaging of your head showed that your known lymphoma had
spread to the area around the brain.
- You were treated with high dose chemotherapy and monitored for
several days.
- Your confusion improved and you were discharged to a
rehabilitation facility.
What you should do once your return home:
- Please continue taking your medications and follow up at the
appointments outlined below
- Please call clinic or return to the emergency for a fever
(temp >100.4)
Sincerely,
Your ___ Care Team | PATIENT SUMMARY:
================
Mr. ___ is a ___ y/o male with a hx of DLBCL s/p 6 cycles of
da-R-EPOCH (c6d1 ___ as well as CAD, HTN, HLD, HBV and
cavernous sinus thrombosis who presented with AMS, imaging with
new intracranial lesions c/w CNS Lymphoma. | 111 | 43 |
18368667-DS-14 | 29,423,017 | Dear Ms. ___,
You came to the ___ Emergency Department from your dialysis
center due to redness and swelling of your left forearm AV graft
site, and you were admitted to Transplant Surgery service for
further observation and evaluation.
While here, you remained afebrile and hemodynamically stable. We
continued you on IV antibiotics during hemodialysis, which you
received today prior to discharge.
You are now being discharged back to your living facility, and
will continue to get your antibiotics through dialysis. You will
need to follow-up with Dr. ___ week, please follow the
instructions below to make an appointment.
Thank you for allowing us to participate in your care. | Ms. ___ presented to ___ from dialysis on ___ after she
was noted to have worsening erythema and swelling of her left
forearm fistula site. Vancomycin and gentamicin had been started
___ when the erythema was first noted, and continued with HD
through her R HD catheter.
In the ED, ultrasound was ordered and transplant surgery team
was consulted. Ultrasound of the left forearm showed normal
flow in the graft, as well as a collection measuring up to 2.5
cm surrounding the graft consistent with hematoma or thrombosed
pseudoaneurysm however a superinfection could not be excluded.
She was subsequently admitted to the ___ Surgical Service
where she was monitored and continued on vancomycin and
gentamicin with HD which was performed on ___ via the HD
catheter. The patient remained afebrile and hemodynamically
stable on the floor, without any worsening or spread of the area
of erythema.
Blood cultures from the dialysis center and those drawn on this
admission have been negative to date, and she is now being
discharged back to her living facility with plans to continue
antibiotics with hemodialysis.
TRANSITIONAL ISSUES
===================
-Discharge back to ___ in ___ where she resides
-Continue vancomycin and gentamicin during HD
-HD through R HD catheter only, do not use AV fistula in L
forearm
-Please continue to monitor erythema of L forearm as well as
around HD catheter
-Patient needs an appointment for follow-up with Dr. ___
___ week | 107 | 234 |
19110490-DS-4 | 25,379,069 | Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with staples- you must wait until after
they are removed to wash your hair. You may shower before this
time using a shower cap to cover your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
Fever greater than or equal to 101.5° F. | The patient was admitted from the emergency department to the
neurosurgery floor on ___. Mr. ___ was taken to
the operating room on the ___ and underwent a left
craniotomy and removal of tumor. He tolerated the procedure well
and was extubated in the operating room. He was transferred to
the Neuro ICU
post-operatively. She underwent a post-operative non-contrast
head CT which showed expected post-operative changes. He was
kept intubated and sedated overnight.
On ___, The patient was weaned off sedation in the morning. The
patient was written for a decadron wean. Neurology and radiology
and medical oncology were consulted. He had a CT of his torso
which showed suprahilar mass in the left upper lobe with
pathologic enlargement of hilar and mediastinal lymph nodes
concerning for primary lung malignancy with nodal metastases.
No evidence of distant metastatic disease in the abdomen or
pelvis. Endotracheal tube with the tip 14 mm above the carina
and should be retracted for appropriate positioning.
As well as a post operative MRI which showed status post left
frontal craniotomy with resection of dominant left frontal mass.
There is, however, thick nodular enhancement in the surgical
bed, which raises suspicion for residual tumor. Additionally,
right inferior temporal enhancing lesion and the right
retromandibular trigone lesion are also again noted and raises
suspicious for metastatic disease. Again noted is vasogenic
edema within the surgical bed with a stable 9mm rightward shift
of midline structures. Post-surgical changes include a small
left subdural hematoma, hemorrhage within the surgical bed, and
small amount of hemorrhage layering posteriorly within the
occipital horns of lateral ventricles as well as within the
fourth ventricle.
On ___, The patient was extubated in morning and tolerated
extubation well. The patient was mobilized out of bed to chair
and exhibited an improved exam. On exam, the patient moved all
extremities slowly antigravity to command. He moved his right
upper extremity less than his left upperextremity. Eyes were
open spontaneously. Pupils were equal and reactive. On ___ he
was transferred to the SDU where he was monitored over the
weekend. On ___ he remained stable and was discharged to rehab. | 259 | 367 |
15330347-DS-11 | 24,699,643 | Dear Ms. ___,
It has been a pleasure taking part in your care during your
hospitalization.
Why you were admitted to the hospital:
===================================================
- You were admitted to the hospital because you were short of
breath and having chest pressure.
What happened during your hospitalization:
===================================================
- A number of tests were performed which were reassuring for
your heart not having further injury
- You were found to have extra fluid in your lungs contributing
to your shortness of breath. You were given a medication to help
you urinate out the extra fluid, and your breathing and chest
discomfort improved.
- You were found to have an abnormal heart rhythm called atrial
fibrillation. For this, you should continue to take Coumadin,
which you are already taking, and we increased your dose of
metoprolol.
What you should do at home:
===================================================
- Please take all of your medications as prescribed. The dose of
your metoprolol was increased as described below.
- Follow up at the appointments as listed below.
- Please weigh yourself every morning, and call the doctor if
your weight goes up more than 3 lbs. in one day or 5 lbs. in one
week. This may indicate extra fluid in your body.
- Should you notice any new or concerning symptoms, please seek
urgent medical care.
We wish you the best!
- Your ___ Care team | ___ woman with PMHx notable for recent anterior STEMI in
___ (LAD occluded mid at origin of large diag --> crossed
s/p PCI to mLAD, LCx with 80% mid, ramus with 80% proximal
disease, RCA occluded with collateral), HFrEF (LVEF 30%,
akinetic and aneurysmal, possible mural apical thrombus, on
warfarin) admitted for worsening exertional dyspnea and chest
pressure most likely due to acute CHF exacerbation and newly
discovered a-fib vs. a-flutter. She improved rapidly with one
dose of IV Lasix and had stable HRs on increased dose of
metoprolol succinate.
# ATRIAL FIBRILLATION vs FLUTTER
# POSSIBLE MURAL THROMBUS
A-fib/flutter newly discovered on telemetry during this
admission in setting of recent STEMI and HFrEF, with well
controlled rates overall. Likely related to recently discovered
(possible) apical mural thrombus during last admission. INR
sub-therapeutic on admission and so patient was initially
bridged on heparin gtt until therapeutic. Home metoprolol dose
was increased from 12.5mg daily to 50mg daily (succinate)
# DYSPNEA / MILD HYPOXEMIA
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE
Presented with worsening exertional dyspnea with new oxygen
requirement, most likely from acute heart failure exacerbation
in setting of reduced EF and recent STEMI. BNP 8800 upon
arrival, reportedly with JVD elevation upon cardiology
evaluation in ED but appeared euvolemic at time of discharge
without further diuresis aside from initial day. Also with newly
discovered paroxysmal atrial fibrillation likely contributing.
Less concerned for ACS
given mild troponin elevation is down-trending with flat MB and
more likely residual from recent STEMI. Would expect much more
profound symptoms and EKG changes if in-stent thrombosis, and
patient has been adherent to anti-platelet medications. Symptoms
resolved and on room air following modest diuresis.
# CHEST PRESSURE
# CAD s/p RECENT ANTERIOR STEMI
Recently with DES to LAD for STEMI with re-presentation
including sub-sternal chest pressure. EKG with interval
improvement and down-trending troponin, negative MB. Overall low
concern for acute thrombosis. Symptoms completely resolved with
treatment of presumed CHF exacerbation. Metoprolol succinate was
increased per above. Continued statin, aspirin, Plavix.
# OSTEOPOROSIS
- held alendronate while inpatient | 212 | 331 |
12088836-DS-8 | 25,142,199 | Dear ___,
You were hospitalized due to symptoms of left sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure
High cholesterol
Atrial Fibrillation
Coronary Artery Disease
We are changing your medications as follows:
Please continue taking Atorvastatin 20mg every evening
Please continue taking Eliquis 5mg twice daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
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. ___ was admitted to the Neuro ICU after undergoing
successful mechanical thrombectomy where TICI III reperfusion
was obtained at 1431, 2h11m after LKW time. Her deficits rapidly
improved. She was antigravity but still neglecting minutes after
thrombectomy. On arrival to the ICU she had L field cut,
prominent L facial droop, subtle neglect, and 4 to 4+ strength
throughout her L hemibody. by the morning of ___ her facial
droop had significantly improved, her field cut had resolved,
and her strength was somewhat improved. MRI showed only small
area of infarction at the R putamen and border of the internal
capsule, as well as 3 other punctate areas of cortical infarct,
2 in the L parietal lobe and 1 in the L frontal lobe.
Etiology was felt likely cardioembolic given distribution of
infarcts (bilateral anterior circulation infarcts, M1 thrombus.
She was treated with permissive hypertension to 180/105 per
routine post-tPA guidelines. She was mobilized and had interval
CT at 24 hours post-tPA. She was started on aspirin, and
continued on home atorvastatin 20 mg qpm (LDL 70). A1c was 5.9.
TSH was normal. She was subsequently transferred to the
Neurology Floor.
While on the floor, she was monitored on telemetry with evidence
of atrial fibrillation with rapid ventricular response. She was
restarted on her home metoprolol and after discussion with
family it was decided to start on anticoagulation therapy with
Eliquis 5mg twice daily. She underwent an Echocardiogram which
showed some mild CAD but no intracardiac thrombus or septal
defect. She was evaluated by ___ and recommended for acute
rehab. | 243 | 261 |
18106039-DS-21 | 22,207,024 | Dear Ms. ___,
You came to the hospital because you were having problems
opening and moving your left eye. We imaged your brain with an
MRI which showed worsening of your previous brain abnormality.
We performed a lumbar puncture and sent out basic studies which
did not show evidence of acute infection. We sent fluid for more
extensive studies which is pending. Depending on these results
we will develop a plan of treatment. You will need to follow up
in the ___ clinic to discuss the possibility of a
biopsy (taking a piece of the abnormal tissue for diagnosis). We
did not make any medication changes.
It has been a pleasure caring for you,
Your ___ Neurology team | ___ year old woman with history of diabetes, hypertension, and
left subdural collection, presenting with subacute progressive
painless complete left ophthalmoplegia consistent with multiple
cranial neuropathies.
Neurologic exam notable for complete LT ptosis, unreactive pupil
at 3mm, inability to move the LT eye in any direction of gaze,
consistent with complete III, IV, and VI nerve palsies.
Laboratory studies from prior admission reviewed notable for
positive quantiferon gold and AChR antibodies which are of
unclear significance. MRI ___, with contrast showed interval
worsening of her extra-axial dural thickening, contrast
enhancement with involvement of the left tentorium, posterior
falx, extending into the left anteromedial middle cranial fossa.
There is also involvement of the left cavernous sinus and
encroachment on the lateral wall cavernous sinus, proximal third
cranial nerve within cavernous sinus, and cisternal segment of
the fifth cranial nerve. Labs notable for elevated CRP of 13.2,
ESR of 48, negative Sjogrens antibodies, Hepatitis panel, ___,
Lyme PCR, and RPR. SPEP and UPEP pending. Lumbar puncture was
performed and notable for glucose 94, protein of 50, WBC 3 (95%
lymphocytic), RBC 2, CSF was sent for Cytology, flow cytometry
and a large hold was saved. Neurosurgery team was consulted to
assess for the possibility of biopsy and will follow her as an
outpatient. Rheumatology recommended sending IgG subclasses
1,2,3,4, cyclic citrullinated peptide antibody which are
pending. The question of empiric treatment with steroids was
raised, however this was held given the possibility of biopsy.
Etiology unclear, but given the painless, subacute, and
progressive nature of her symptoms concerns are for
inflammatory, granulomatous, autoimmune, or neoplastic process.
After neuroradiology discussion differential includes
sarcoidosis, histiocytosis, mycobacteria infection, IGD4-related
disease, and idiopathic focal pachymeningitis. She will
follow-up with neurosurgery for consideration of biopsy
depending on LP results.
Transitional Issues:
====================
#NO MEDICATION CHANGES
[] Follow-up with neurosurgery
[] Follow-up LP/serum labs pending | 117 | 304 |
11601011-DS-15 | 29,085,030 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were seen in the hospital becuase of your
right flank pain and your left flank pain. You were found to
have a clot in both your right and left arms. We treated this
with a medication called lovenox. We also started an
anti-clotting medication called coumadin, also known as
warfarin. You will take this for 3 months, and you can ___
with your PCP for management.
For your right flank pain, we consulted a pain management team
who made recommendations to optimize your pain control in the
hospital. We also set you up to follow up in their clinic for
chronic control.
Thank you for involving us in your medical care.
Your ___ team. | ___ M with h/o spina bifida, chronic hydronephrsis w/
neurogenic bladder s/p ileal conduit urinary diversion, HTN and
recent discharge ___ for management of MDR E. Coli UTI on
ertapenem, returning with right flank pain and left arm pain
#Right flank pain: this is a chronic issue since last admission,
when he was discharged with ___ pain. Since this is the primary
cause of his readmissions, an extensive discussion regarding his
care was begun. The patient reported that he left his prior care
at ___ due to a frustration with not
receiving pain medications and for his dissatisfaction with
readmission for pain. He reported that he took nothing at home
when he is not in pain but has a lot of difficulty controlling
his flares. At baseline, he says that he can be comfortable
without oxycodone. At the time of previous discharge (___), he
had received oxycodone 10 mg q4h PRN. However, he reports that
he did not fill this prescription yet, and so was not taking
oxycodone at home. His pain regimen during this hospitalization
included: Initial dilaudid 1 mg IV in the ED x1 on ___ and
x1 on ___, dilaudid 0.5 mg IV q4h on ___, Throughout admission
he received: tylenol 1 g q8h standing, gabapentin 300 mg BID and
600 mg qHS, oxycodone 10 mg q4h, increasing to 15 mg q4h on
___, lidocaine patch, tizanidine 4 mg qHS starting ___.
A pain management team was consulted, and the plan to use
dilaudid IV during the initial admission with transition to po
was determined. In addition, records were obtained from
___ to see his history of hospital visits,
which included an average of about ___ monthly visits for right
flank pain. The treatment plan varied with each visit and per
patient and records, there was nothing consistent that worked
for pain management. Per records from ___ narcotic
registry, the patient has not filled a significant number of
prescriptions for oxycodone. He does take them intermittently,
consistent with his history of right flank pain flares.
Ultimately, we coordinated care for him to see a chronic pain
specialist at ___, where he is planned for follow up. Upon
discharge, he had not required dilaudid IV for >24 hours and had
not required any PRN medication overnight. The patient was
satisfied with his oral regimen and wanted to "get back to a
normal life".
#Left arm pain: The patient had a bilteral upper extremity
ultrasound in the ED which showed bilateral DVTs. The left
upper extremity clot was associated with his midline, although
the midline remained patent. Anticoagulation with lovenox
1mg/kg BID and coumadin 5 mg was started on ___. His INR
increased to 1.2 by the time of discharge on ___, but given
the short course of therapy, dose was not adjusted. He was
planned for follow up the morning after discharge with the
___ pharmacy clinic @ ___ for
warfarin management and he was written a prescription for INR
draw for that day (___). Given subtherapeutic INR at time of
discharge, he received a prescription to continue lovenox until
his PCP ___. He is projected to stay on coumadin for at
least 3 months. His left midline was kept in place throughout
admission.
#MDR E. Coli and Klebsella UTI: he was kept on carbapenem
coverage with meropenem 500 mg q6h (ertapenem not available on
formulary). He was discharged on the same ertapenem as per
initial plan for a total of 14 day course (___). | 127 | 577 |
16442091-DS-6 | 20,054,838 | Dear Mr. ___,
You were admitted to the hospital with jaundice (yellowing of
the skin). You were found to have gallstones in your gallbladder
and your common bile duct causing your jaundice. You underwent
an ERCP for removal of the common bile duct stones. Following
your ERCP, you were seen by the surgery team with plan for
cholecystectomy (gallbladder removal). This will be done as an
outpatient and is scheduled for ___ as below.
Your bilirubin is still elevated which raises the possibility of
ongoing gallstones in your bile duct. You were started on
ciprofloxacin to prevent infection until you have your surgery.
You will follow-up with a new primary care doctor here who will
check labs on ___ to ensure your bilirubin is continuing to
down trend.
On your initial CT scan, you were noted to have a pulmonary
nodule. Please discuss a dedicated CT scan of your chest with
your primary care doctor after discharge.
It was a pleasure taking care of you,
Your ___ Care Team | Mr. ___ is a ___ man with no significant past medical
history who initially presented to an outside hospital with
abdominal pain and jaundice, found to have cholelithiasis and
hyperbilirubinemia, transferred to ___ for ERCP. | 167 | 35 |
18709932-DS-22 | 26,539,251 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You came in with chest pain and shortness of
breath. We attempted to perform 2 stress tests but you declined
both times. Your symptoms improved soon after admission. We
strongly suggest you avoid the outdoors while it is hot and stay
in a coool environment.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs. | Patient is an ___ ___ speaking male with a history of CAD
s/p CABG, aortic stenosis s/p AVR who presented with chest pain
and shortness of breath starting at rest morning ___ being
admitted for nuclear stress test after attempt in the ED was not
successful.
# Coronary artery disease: s/p 1-vessel CABG.: In the ED,
troponins were negative x2 and EKG was at baseline (atrial paced
at 60 with LBBB). Patient did not tolerate initial stress test
due to agitation but read states that the patient probably had
uniform tracer uptake in the stress and rest images throughout
the left ventricular myocardium in the setting of soft tissue
attenuation. He was admitted for a repeat study. At time of
admission he denies any chest pain, shortness of breath,
lightheadedness, or dizziness and did not have any over course
of admission. Following weekend, a repeat nuclear stress was
attempted but patient said he did not want to have one and
refused to cooperate with study. He was discharged given
resolution of symptoms and reassuring work up with negative
cardiobiomarkers and unchanged EKG. He was continued on home
aspirin, statin, and atenalol.
# Aortic stenosis: s/p AVR with a ___ tissue valve
on ___. Clinically the patient appeared evolemic. this
admission No need for diuresis. He will need a follow up TTE as
an outpatient to for valve surveillance. TTT showed EF of ___
initially following valve replacement. He was continued on home
lasix 20mg daily. Lisinopril 5mg daily was added to his regimen
this admission.
# Pleural thickening noted on CXR: Radioogy recommends chest CT
if there are no prior filmd for comparison to document stability
of these findings. Per radiology, this does not need to be done
on an urgent basis. | 72 | 290 |
12931342-DS-17 | 27,603,056 | Ms. ___,
You were admitted with left leg pain found to have a left bone
mass and lesions in your lungs concerning for cancer. You had a
bone biopsy ___, which will determine the diagnosis and the
plan. Please follow up these results with your PCP who will
send you to the appropriate doctors.
You were started on pain medications with improvement in your
pain. Please talk to your PCP if your pain is not manageable.
It was a pleasure taking care of you.
-Your ___ team | ___ h/o progressive & disabling left hip and weight loss with
imaging concerning for osteosarcoma admitted for expedited work
up.
1. Severe left leg pain with large lucent lesion of the left
proximal femur
-In combination with systemic symptoms and radiographic
findings, bone lesion is concerning for primary malignancy of
bone. However, given h/o lung cancer it is possible this is
metastatic. s/p ___ biopsy ___. Orthopedic oncology
sawa patient recommending weight bearing as tolerated (WBAT)
with walker to alleviate some pain. She will follow up with
orthopedics next week to discuss biopsy results; if this is
primary bone cancer ___ cannot manage
this and she will need to get her care at ___. Recommend
radiation oncology referral pending biopsy results. Pain
medication was titrated and well-controlled on oxycontin 10mg
BID with oxycodone ___ Q6 hours PRN with acetaminophen and
lidocaine patch. Discharge with bowel regimen and home ___.
2. Lung lesions h/o adenocarcinoma of the lung
-s/p right lower lobectomy ___ found to have Stage Ib T2NxM0
invasive moderately differentiated adenocarcinoma of the lung.
Question whether lung lesions are metastatic lung vs bone and
will await bone biopsy prior to lung biopsy. If she has a
primary bone malignancy will need to obtain lung biopsy. If lung
and bone lesions are metastatic lung cancer she can return to
her previous oncologist Dr. ___ at ___
___.
3. Orthostatic hypotension and dizziness
-Patient may have multiple causes of dizziness including
orthostatic hypotension, secondary to pain, or in setting of
intracranial process (brain mets). Dizziness does not seem to
correlate with oxycodone. Patient was only able to tolerate
limited MRI (without contrast) that did not show acute
intracranial process. Orthostatic hypotension resolved with
holding antihypertensives and giving IV fluids. At time of
discharge dizziness resolved. Recommended taking her time when
changing positions.
4. Anemia
-Suspect due to malignancy. Continue to monitor.
5. Constipation
-Likely in setting of narcotics started on bowel regimen.
Stressed the importance of continuing a bowel regimen to prevent
opioid-induced constipation.
6. Uterine Fibroid
-Initially seen on MRI hip concerning for fibroids, and
radiology recommending pelvic ultrasound. CT pelvis confirms
uterine fibroid and no further workup indicated at this time.
7. Right Renal cyst
-Initially seen on MRI hip concerning for renal cyst, and
radiology recommending renal ultrasound. CT pelvis confirms
renal cyst and no further workup indicated at this time.
8. Insomnia and anxiety
-Insomnia and anxiety are resulting in increased pain, which we
discussed. She required ___ prior to MRIs and procedures. | 90 | 427 |
12637088-DS-16 | 23,418,411 | Dear Ms. ___,
You were admitted from rehab on ___ for fevers. You were on
the antibiotic Vancomycin at rehab, and on admission you were
put on broad-spectrum antibiotics. Due to pain in your right
knee and your recent joint space infection, orthopedics drew
fluid from the joint. Analysis of that fluid showed inflammation
that was suspicious for an infection. On ___ the orthopedics
team washed out the right knee, removed the hardware from your
knee replacement, and placed intra-joint antibiotics for a
persistent septic joint. You will need to be on IV antibiotics
for 8 weeks for this joint infection. A long-term IV, A PICC,
was placed on ___ in order for you to get antibiotics at
rehab. | ___ with h/o HTN, RA with recent admissions for severe sepsis
with R septic knee and UGIB ___ GE junction ulcer presenting
with fever, due to R septic knee s/p washout, removal of
hardware, and abx spacer | 118 | 37 |
16367461-DS-9 | 29,736,987 | Dear Mr. ___,
You were admitted to the hospital because of Alcohol
intoxification. You were monitored while you were here for signs
of withdrawal and we gave you medication to treat your
withdrawal symptoms. While you were here you were also seen by
the psychiatry team. You have had some difficulty with alcohol
detox in the past, and it is very likely that depression is
contributing to this. You completed treatment for active alcohol
withdrawal and now you will be going to a treatment facility for
your depression. | Mr. ___ is a ___ year old male with a history of EtOH abuse
for ___ years complicated by DT and withdrawal seizures,
discharged from detox 5 days prior to admission, who presented
to the ED with EtOH intoxification.
# EtOH Abuse: Patient was stable on arrival to MICU. Serum tox
screen was positive for benzos; serum EtOH was 253. He placed on
CIWA protocol with Diazepam. He was given thiamine, folic acid
and multivitamins, and IV fluid resuscitation. He remained
stable and was transferred to the medicine floor on HD1. While
on the medicine floor he remained clinically stable, requiring
___ doses of diazepam throughout his 3 days on the medical ward.
He expressed a desire to go to detox. He was evaluated by
psychiatry for qualification for dual diagnosis program. He
stopped scoring and no longer required his CIWA scale. His
diazepam and CIWA scale were discontinued because he was no
longer in active withdrawal.
# ?GI bleed. Patient reported black bowel movements at home; in
the ED patient's stools were guiaic negative. Differential
included ___ tear vs gastritis vs esophageal ulcer,
PUD. He had evidence of gastritis on EGD 1 month prior. Boerhave
syndrome felt unlikely given no mediastinal widening on CXR, and
lack of deep cervical or subcutaneous emphysema. He was typed
and screened, 2 large-bore IVs were placed, and he received 40
mg pantoprazole BID. He was transferred to the MICU
hemodynamically stable and had no further episodes of bleeding.
He remained hemodynamically stable on the medicine floor with no
episodes of bleeding. His H/H remained stable and was 14.6/41.7
on discharge.
# Abdominal pain: Patient complained of vague abdominal pain,
thought likely secondary to ongoing hepatitis C/inflammation.
Per his history he has had RUQ abdominal pain for several months
and it has been unchanged in severity and quality. He had a
cholecystecomy in ___ for chronic cholecystitis. Pancreatitis
unlikely given lipase of 45. He has a history of hepatitis C
treated at ___ with 6 months of Ribavirin/IFN. His liver
enzymes were persistently elevated during his hospitalization
with ALT>AST suggesting ongoing viral hepatitis. Hepatitis
serology was negative for Hepatitis B Antigen, Hepatitis B core,
and positive for Hepatitis B antibody. Hepatitis C viral load is
pending.
# Shaking: Mr. ___ endorsed shaking of his arms, thought to
be pseudoseizure vs malingering: Felt highly unlikely to be
genuine seizure activity given inconsistent presentation, lack
of post-ictal state, resolution with distractability, purposeful
movements during episode. No evidence of hypoglycemia or active
infection. He was monitored throughout the hospital stay with
no events concerning for acute neurological pathology.
# HCV: Likely this was contracted from IVDA. This was treated at
___ with 6 mo Ribavirin/IFN. LFTs suggestive of ongoing liver
inflammation, showing a pattern inconsistent with EtOH
hepatitis. HCV viral load is pending. HBV serologies sent, which
were positive for HbsAb, and negative for Hepatitis Antigen and
Core as above, so patient was vaccinated. LFTs downtrended
slightly during ICU stay.
# Narcotic abuse: Mr. ___ endorses IVDU most recently ___ years
ago. However he had dilated pupils on presentation to ICU. He
had a negative Utox but the assay does not detect oxycodone. It
was thought possible that he was withdrawing from an opiate as
well. He was monitored throughout his hospital stay; aside from
abdominal pain, he showed no signs or symptoms opiate
withdrawal. | 88 | 558 |
18519675-DS-11 | 25,709,465 | Dear Mr. ___,
It was a pleasure taking care of you.
Why you were admitted?
- You were admitted because you were having worsening chest
pain.
What we did for you?
- Your pain is likely due to a musculoskeletal reason. Your EKG
and cardiac enzymes were reassuring. You had a scan to look at
your lungs and there was no evidence of a clot in your lungs.
- You were given IV Lasix to help urinate extra fluid.
What should you do when you leave the hospital?
- Please continue taking Lasix 80mg daily. Please weigh
yourself everyday. If your weight is increasing, please call
your cardiologist as you may require an additional dose of
Lasix.
- Please take all your medications as prescribed.
- Please attend your follow up appointments. Your kidney
function needs to be re-checked at your next outpatient
appointment.
- You can continue taking pain medications to help with the
pain. | ___ with history of diastolic CHF, recent mechanical aortic
valve re-do and CABG in ___, AFib, and Mobitz I heart block
now with PPM who presents from home with pleuritic chest pain
#Chest Pain
Pleuritic chest pain 3 weeks after CABG concerning for potential
PE. Was found to have subtherapeutic INR as outpatient. He had a
VQ scan which showed low probability for PE. Trops downtrending
on admission, EKG reassuring. His chest pain is likely secondary
to a musculoskeletal etiology as the pain is very much
reproducible on palpation and is localized to a specific spot on
the left upper chest. His chest pain improved greatly and was
manageable with oxycodone.
___:
Admission Cr 1.7 from discharge value of 1.1. Appears volume
overloaded. Endorses good appetite. Volume overload was an issue
since discharge, and it seems patient may have been taking
inappropriately low dose of Lasix (40mg BID). He was given 60mg
IV Lasix with effect and his Cr downtrended to 1.6 the following
day. He was discharged on 80mg PO Lasix with follow up Cr as
outpatient.
#Acute on chronic diastolic CHF:
EF estimated 45-50% on echo post-CABG and ___ ___. Appears
volume overload with pedal edema although denies
dyspnea/orthopnea. Likely etiology of olverload is insufficient
Lasix dosing. As above, given 60mg IV Lasix and discharged on
80mg PO Lasix. He was instructed to weigh himself daily and
contact cardiologist if weight is increasing.
#Aortic stenosis, s/p mechanical ___ (On-X)
Briefly on heparin gtt. INR level was 2.4 on discharge.
#AFib:
Continued patient on metoprolol for rate control. He was given
9mg warfarin daily while inpatient. INR level was 2.4 on
discharge.
#DM: Continued on home insulin: glargine 28u qam, then Humalog
___ with meals.
#HLD: Continued on atorvastatin
#GERD: Continued home omeprezole
#BPH: Continued finasteride, tamsulosin
TRANSITIONAL ISSUES
[] Please repeat Bun/Cr and K as outpatient.
[] Suspect chest pain is musculoskeletal in etiology. Patient
discharged with extra 10 pills of oxycodone 5mg. Please assist
with pain management
[] Please adjust Lasix dose PRN. Discharged on Lasix 80mg PO.
[] Discharge weight: 104.3 kg
[] Decreased potassium 20meq PO BID to daily. Consider
increasing back to BID if potassium level is low
[] Consider PPM interrogation as outpatient and increasing rate. | 153 | 358 |
16185969-DS-12 | 22,288,095 | You were admitted to ___ with severe joint pain due to a gout
flare. You were treated with steroids and other
anti-inflammatory medications with improvement. The physical
therapy doctors ___ and recommended you go to rehab to
continue to get better prior to returning home. You are being
discharged on a steroid taper. You will follow-up with the
Rheumatology doctors in ___. We wish you a full and
expeditious recovery. | ___ y/o M w/ HTN and gout who has developed subacute, progressive
joint pain and swelling in a polyarticular distribution in
setting of stopping colchicine shortly prior to initial onset of
symptoms. Right knee joint fluid crystal analysis consistent
with gout flare. Imaging also concerning for possible
underlying CPPD disease.
.
# Polyarticular gout flare - improving with steroid regimen
- Likely trigger was stopping colchicine.
- s/p solumedrol 40 mg IV x1 on ___, prednisone 40 mg PO on ___
and ___, solumedrol 40 mg IV on ___, solumedrol 30 mg IV on ___,
prednisone 30 mg PO on ___.
- Prednisone taper plan: 30 ___ stop
- Colchicine 0.6 mg PO daily (renal function stable)
- Pain control w/ Tylenol standing and oxycodone PRN
- There were no signs of active infection, no abx given, blood
cultures were no growth (final), and joint fluid culture (right
knee) remain no growth to date as of the day of discharge..
- XR of right ___ MTP to eval for erosive joint disease done per
Rheumatology recs: no evidence of erosive joint disease.
- TSH, iron studies, and alk phos were unremarkable, not
suggestive of other causes of CPPD disease.
- ___ had no record of patient's report allopurinol allergy;
further testing can be considered as an outpatient at discretion
of Dr. ___
- ___ clinic follow-up has been arranged for ___ at
2:00 ___ w/ Dr. ___
.
# ___ - mild, resolved
- Slight elevation in Cr after admission, possibly due to an
element of dehydration and NSAID administration in ED
- Expect he will tolerate colchicine without adverse renal
consequences, as he has taken it for many years prior to it
being recently discontinued
.
# Ulnar neuropathy - chronic, progressive, right affected more
than left
- Continued home B12/folate, though he has not responded to this
treatment.
- Rheumatology felt this was possibly due to claw toe deformity
- Rheumatology recommended that the patient follow-up with
outpatient Podiatry for eval of possible intervention on claw
toe deformity. I have discussed this issue with the patient and
his family at length, and the patient is reticent to pursue
potential surgical interventions, but I encouraged him to
discuss risks/benefits with his primary care physician and
consider podiatry evaluation as an outpatient.
.
# HTN - continued home Losartan
.
# DVT ppx - heparin subQ
.
# Time spent - 45 minutes spent on discharge-related activities
on the day of discharge. | 74 | 387 |
19265652-DS-33 | 24,073,740 | You admitted to hospital with low blood glucose and elevated
elevated blood pressure. Your low blood glucose was due to
taking too much insulin. Your elevated blood blood pressure was
likely secondary to not taking your chronic antihypertensives.
Your blood glucose was stable on the current insulin regimen.
Your blood pressure also normalized after restarting her home
antihypertensives. You underwent dialysis on ___. You
were discharged after dialysis with the plan to follow-up with
your PCP. | ___ male with the complete past medical history
including type 1 diabetes, end-stage renal disease on
hemodialysis, seizure, hypertension who was admitted admitted
with acute encephalopathy in the setting of hyperglycemia and
accelerated hypertension likely secondary to medication
mismanagement.
Type 1 diabetes
Hyperglycemia
-Per most recent discharge summary, patient was discharged on 15
units of Lantus daily. He reports taking 25 units of Lantus
daily despite recent adjustment to his home insulin regimen. He
will continue on his Humalog 6units baseline with sliding scale
3 times daily with meals. Hypertension
Hypertension
-Continue home Coreg, losartan, clonidine patch
ESRD on HD
-Underwent HD on ___ | 81 | 100 |
13907635-DS-22 | 26,719,843 | You were admitted after suffering a fracture of your right upper
arm while at a rehab facility. You were seen by orthopedic
surgery and given a brace to help the arm heal. You had an MRI
of the arm which suggested that there may have been a myeloma
lesion in the bone which weakened it and caused it to break
easily. You were seen by radiation oncology and given treatment
to the arm to help it heal. You received morphine for pain
control with good effect. | The patient was admitted for her R humerus fracture. She had
pain control with morphine IV ___ and only required doses a
few times per day. She was sometimes slightly confused after
receiving pain medications but otherwise coherent. She was seen
by orthopedic surgery and radiation oncology. Given her advanced
age and comorbidities, there was concern that surgical fixation
may lead to a long and uncertain recovery. It was decided she
would be treated with radiation to the fracture site and given a
chance to heal on her own. She received 8 Gy in one fraction on
___. On admission she had acute on chronic renal failure
which resolved to her baseline (Cr ___ with IV fluid
hydration. For her multiple myeloma, she had not been on
systemic treatment recently other than dexamethasone which was
started when she was admitted for spinal cord compression in
___. her paraproteins were rechecked and her kappa/lambda
ratio has increased only slightly from ___, while
immunoglobulins show stable IgA level with worsening reciprocal
suppression of IgG and IgM. Despite only small changes in her
paraproteins, she may need systemic treatment given her new
fracture. She will follow up with her primary hematologist to
discuss further care. Imaging studies here also redemonstrated a
chest nodule which needs to be followed up with dedicated chest
CT if clinically warranted.
# Dispo:
[x] Discharge documentation reviewed, pt is stable for
discharge.
[x] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min.
____________________________________
___, MD, pager ___ | 86 | 255 |
13274134-DS-15 | 24,195,598 | You were admitted to the hospital after a fall and fracture of
your left iliac bone and left humerus. You were seen by ortho
who recommended pain control and no surgical intervention. You
will have follow-up with the orthopedist in ___ weeks.
Also, you were found to have a mild anemia. This may be due to
the bruising after the fall, however, you should have a repeat
blood check with a primary doctor and ___ screening colonoscopy to
ensure no polyps/cancer. | This is a ___ yo F with h/o osteoporosis who presents after a
fall and is found to have an iliac wing and proximal humerus
fracture admitted for pain control.
1. Iliac wing fracture/Humerus fracture: Sustained after a
mechanical fall. She was evaluated by ortho who recommended
weight bearing and ROM as tolerated, pain control, and
outpatient follow-up. Her pain was controlled with PO dilaudid,
ibuprofen, and tylenol. She was also told to take a stool
regimen to prevent constipation. She worked with ___ who cleared
her for discharge with use of a walker. She was told to take
Vitamin D and calcium to help with bone strength, but she also
needs to establish with a PCP/endocrinologist for DEXA and
bisphosphonate initiation.
2. Anemia: Normocytic. No recent baseline. No evidence of
bleeding, except for hematomas after fall. The patient will need
repeat Hct check as an outpatient as well as screening
colonoscopy.
3. Anxiety: Continued sertraline
4. HTN: The patient had low-normal BP here and, therefore,
lisinopril will not be restarted on discharge.
5. HLD: Statin
# CODE STATUS: Full
# CONTACT: ___ (friend) ___ | 81 | 184 |
10990167-DS-20 | 25,677,010 | 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:
- Flat foot TDWB in RLE
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
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 right femoral ___ and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for revision ORIF of right femur,
removal of hardware and placement of an antibiotic spacer, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable. She was seen by infectious disease, who evaluated
her and recommended nafcillin IV antibiotic therapy for
management of her leg infection.
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
flat foot TDWB and neuro intact in the right lower extremity,
and will be discharged on lovenox for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge | 269 | 288 |
18196137-DS-16 | 21,031,755 | Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted after a fall
What was done for me while I was in the hospital?
- You were found to have some bleeding in your brain
- You were seen by the neurosurgeons who recommended close
monitoring, no surgery
- We gave you a water pill since we felt you had a lot of fluid
What should I do when I leave the hospital?
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) for 7 days after discharge.
You may resume your Eliquis in 7 days.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. 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
Sincerely,
Your ___ Care Team | This is a ___ year old female with ___ notable for AFib on
apixaban presenting as transfer from ___
following a fall with headstrike, noted to have intraparenchymal
hemorrhage, transferred for neurosurgical evaluation and then
transferred to the medicine service and managed conservatively
per neurosurgery
recs. | 612 | 45 |
19926727-DS-28 | 29,182,633 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why was I seen in the hospital?
You were feeling unwell after your scheduled session of
dialysis.
Some of the people caring for you worried about your blood
counts.
What happened while I was in the hospital?
You received a blood transfusion.
We checked your blood counts. These were stable.
-You did not have any more dizziness.
-We checked your diarrhea for signs of an infectious diarrhea
("C. diff"); this test showed that you do have C. diff, and you
were started on treatment which you should continue for 2 weeks
total.
You received your scheduled session of hemodialysis on ___.
What should I do when I leave the hospital?
-Please follow up with your primary care doctor as previously
scheduled.
-Please see your diabetes doctor at ___ to discuss whether or
not you need to start insulin.
We wish you the best,
Your ___ Care Team | Mr. ___ is a ___ gentleman with ESRD (on HD MWF),
chronic anemia, BPD, who was admitted from his outpatient
dialysis center due to dizziness and weakness during dialysis,
concerning for recurrent anemia. His hemoglobin stable was on
arrival. He received 1u PRBC transfusion which improved his
symptoms, and he did not have any further dizziness. | 148 | 56 |
17282935-DS-20 | 21,687,422 | It was a pleasure caring for you during your stay at ___
___. You were sent to the hospital from
your nursing home with pneumonia, low oxygen levels, and
confusion. Your blood pressure dropped in the Emergency
Department, and you were admitted to the Medical Intensive Care
Unit (MICU). Your breathing worsened and you became
increasingly confused, so you had to be intubated and placed on
a ventilator. While on the ventilator, you had bronchoscopy and
a large amount of mucous blocking your airways was removed.
Cultures from the mucous grew a type of bacteria called MRSA
(Methicillin Resistant Staph Aureus). Your antibiotics were
narrowed to Vancomycin, which covers this bacteria well, and
your breathing slowly improved. You were able to have the
breathing tube taken out and be transferred out of the MICU.
You also developed worsening diarrhea during your stay and stool
testing came back positive for a bacterium called Clostridium
difficile (C.diff). You were initially treated with
Metronidazole (Flagyl) for this infection, but then switched to
oral Vancomycin, which works differently than the IV Vancomycin
for your pneumonia.
Imaging during your stay showed evidence of cirrhosis, likely
from chronic Hepatitis C infection. This can decrease your
bodies ability to clear medications, and may have contributed to
your confusion and lethargy on admission. Because of your liver
disease and confusion on admission, the doses of several of your
medications were adjusted.
You will need to complete a treatment course of Vancomycin IV
for your MRSA pneumonia. This should be given at your dialysis
sessions, with your last dose on ___. You will also
need to complete a total 14 day antibiotic course for Cdiff.
This will be completed in another 10 days on ___.
You should follow up with your outpatient providers soon after
discharge. You indicated that you have already been in contact
with your nephrologist and have arranged for dialysis tomorrow. | The patient is a ___ year old female with ESRD on HD (MWF),
cirrhosis on imaging, HCV infection, and chronic low back pain
on opioids who presented with lethargy found to have pneumonia. | 325 | 33 |
18819985-DS-13 | 21,867,027 | You were hospitalized at ___ following several episodes
very concerning for seizures. While in the hospital, you were
managed by the neurology service. You underwent EEG, which did
not clearly reveal seizures. Your brain MRI did not show any
specific abnormality to explain your seizures. However,
seizures are a clinical diagnosis, and based on the description
of the events, your doctors ___ it was necessary to start you
on an anti-seizure medication Keppra.
While in the hospital, you saw ___ Diabetes, who recommended
starting Lantus (a type of insulin you can take once daily) to
help control your diabetes. You were also seen by the diabetes
educator to help address your diabetes. | # Seizures: Patient was admitted to the general neurology
service. Infectious evaluation was benign. Metabolic
evaluation was notable for hyperglycemia (mostly in the 200s.
While in some situations this can precipitate seizures, this was
not felt high enough to cause her seizure activity and likely
represents her glucose baseline. She was started on Extended
EEG to evaluate for inctal/interictal activity. She was started
on Keppra for seizure control, which was 750mg PO BID on
discharge. Social work was consulted for diagnosis coping and
to aid in access to medical care. Prelim read of her EEG (as
previously noted)- no seizure or epileptiform activity, but L
intermittent temporal slowing seen. MRI was done, and revealed
non-specific white matter changes, but without a clear epileptic
focus. The most likely etiology of her seizures is due to
longstand neurologic changes from microvascualr disease in
setting of her hypertension and diabetes. She was felt to be
safe for discharge with outpatient follow-up. She was
counselled on Mass law regarding inability to drive for a
minimum of 6 months following a seizure.
# DM T2: A1C in ___ was 11.4, with surgars ranging initially
during this hospitalization from 150s-low 300s. Endocrinology
was consulted and recommended initiation of Lantus 10u QAM.
Diabetes educator was consulted and saw the patient prior to
discharge.
----------
Transitional Issues
- Neuro: TO follow up on outpatient basis for likely new
diagnosis of epilepsy
- Endocrine- to f/u at ___.
- Insurance- SW saw patient and is working towards helping her
acquire better coverage through ___. | 116 | 266 |
17238411-DS-3 | 22,035,977 | Dear Mr. ___,
It was a pleasure caring for you at ___. You were transferred
from ___ for further evaluation of a pleural
effusion after your radiofrequency ablation proceedure. After
extensive discussion with interventional radiology and with Dr.
___ was determined that the pleural effusion is an
expected side effect of your procedure. The effusion was also
relatively small, making it more difficult to tap and increasing
the risk of complications from the tap. Your oxygenation also
improved during your hospital stay and you were able to walk
without experiencing a significant decrease in your oxygenation.
Please call your primary care provider or go to the emergency
department if you experience worsening shortness of breath or
fever.
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team | ___ is a ___ year old man with right lower lung
adenocarcinoma s/p RFA ___, not currently on chemotherapy,
and a remote PMH of prostate cancer with positive margins
treated with prostatectomy and adjuvant radiation who p/w
fatigue x1 day, findings of apical pneumothorax, pleural
effusion, question of PNA on CXR at ___, transferred to
___ for evaluation of diagnostic/therapeutic tap at request of
family members and ___.
# Pleural effusion: initially diagnosed at ___ with
apical PTX, pleural effusion based on radiologic findings,
cough, and fatigue/malaise. VS stable, WBC normal. Consulted ___
who report these changes are known complications of RFA and that
as pt afebrile, no concern for pna. Also effusion small so
difficult to tap. His outpt oncologist (Dr. ___ agreed,
thus thoracentesis was deferred. UA normal. By last day in
hospital oxygenation 97%, better than baseline on RA. Pt also
able to walk without experiencing significant decrease in
oxygenation. Family updated frequently. Note that no PTX noted
on repeat CXR's at ___.
# Fatigue: pt presented with fatigue, ___ noted that this was in
great part the family's impetus to bring pt to ___
___. By day of discharge pt had greatly improved, was
smiling and more happily interactive with staff. Consider
fatigue most likely secondary to depression, also
post-procedural fatigue. No other localizing signs/symptoms of
infection on h&p. Pt receiving adqueate treatment of lung
cancer.
# Depression: pt reported he is tired by frequent hospital
visits and inability to function as he has in the past. On
admission he endorsed passive suicidal ideation, did not repeat
this line of conversation during subsequent days of admission.
Currently treated with paroxetine. Defered management of
depression to outpt.
# CODE STATUS: presumed full, pt could make up mind during this
admission. | 125 | 294 |
16918051-DS-6 | 22,359,670 | Dear Mr. ___,
You were hospitalized due to symptoms of slurred speech and left
facial droop. These were found on CT and MRI to be resulting
from both an acute hemorrhagic, as well as an ACUTE ISCHEMIC
STROKE. An ischemic stroke is a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The hemorrhagic stroke happened very close to your
previous left sided stroke.
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.
We assessed your blood cholesterol, sugar, as well as your blood
pressure. We found your blood sugar to be stable but elevated so
we have continued with your oral medications. We have found your
cholesterol well controlled so we have continued you on your
home medication. You had an ultrasound of your heart which was
improved from the previous ones. We have resumed your home
aspirin after holding it briefly during this admission.
We are not changing your medications.
Instructions:
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 | ICU COURSE:
Mr. ___ was admitted to the neurology ICU on ___ after
presenting with dysarthria and left facial droop and was found
to have a new left parietal hypodensity with intralesionsal
hemorrhage.
On admission to ICU, he was continued on home medications, blood
pressure was kept under 140 with prn hydralazine. MRI brain
showed an acute right frontal cortical-subcortical stroke and a
left parieto-occipital hemorrhage. It was unclear if pt had
hemorrhagic transformation of an initially ischemic stroke or
whether there was an underlying lesion in the left
parieto-occipital area. His exam remained unchanged and he was
transferred to the floor on ___. | 340 | 102 |
12385857-DS-52 | 28,690,046 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- you had a decrease in your kidney function from prior contrast
and decreased oral intake
WHAT HAPPENED TO ME IN THE HOSPITAL?
- you received IV fluids
- erythromycin was started to help with your nausea
- your kidney function slowly recovered
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Continue to drink water (of if you have to apple juice), try
to take crackers or a small snack with this throughout the day
- If you have fever, productive cough, shortness of breath
please call your primary care provider as your gastroparesis
means you are higher risk of pneumonia.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ y/o male with a history of CKD, CAD s/p
NSTEMI (___), known infrarenal aortic dissection, NSCLC s/p
XRT, chronic pancreatitis, DM2 c/b neuropathy, retinopathy,
nephropathy, and gastropathy, chronic pain and medication
non-compliance sent by PCP for admission ___ worsening kidney
function (CR 2.9) suspected from contrast induced nephropathy
and ongoing symptoms of gastroparesis which improved with home
regimen as well as initiation of erythromycin. While here
hydralazine and nitrates were started for blood pressure
control. | 137 | 81 |
16102281-DS-18 | 27,448,561 | Dear Mr. ___,
You were admitted to the Internal Medicine service at ___
___ on ___ regarding management of
your recent confusion and fall. Your medical evaluation was
reassuring and we attribute your recent fainting and confusional
state to medication changes and low blood sugar, which improved
with titration of your medications in discussion with your
outpatient providers.
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. | Mr. ___ is ___ with h/o paranoid schizophrenia, CAD, DM,
chronic headaches, and autonomic dysfunction who was found down.
# Fall: The patient was found down. Ddx of fall inclues known
autonomic dysfunction and orthostasis, hypoglycemia (given
recent low BS readings), mechanical given parkinsonism, vs
cardiac. The patient does have significant cardiac history but
denying any chest pain, trops negative x 2 and EKG without
ischemic changes. Tele was without events. Orthostatics were
positive (known autonomic dysfunction). Fludrocortisone was
confirmed with PCP and was ___. ___ saw the patient in
house. Vitamin D was found to be low so repletion dose was
started.
# Wandering from home / dementia: the patient was getting 24
hour care from his grandson, however, wandered away from home
when left for a few hours. Talked with the patient and grandson
about the ___ to going to rehab vs long term care unit,
however, both strongly preferred that the patient stay at home.
The grandson said he could assure 24 hour care. Case management
helped set up increased home services.
# HTN: BP's stable in house. The patient was continued on
fludrocortisone.
# DM: recent low ___ at home. Lantus dose was decreased by more
than 50%, and oral hypoglycemic agents were DCed. ___ were stable
in house in the ___.
# h/o headaches: cont topamax
# CAD s/p DES and CABG ___: con't ASA, Plavix, and simvastatin
- unclear indication to continue plavix at this time, will defer
to PCP +/- cardiology decision if the patient should continue
plavix in the future
# CKD: baseline creat mid 1s, creat on admission 1.5, which
trended down during admission.
# schizophrenia: Per psychiatrist, the patient was psychotic in
___ when she switched him to Zyprexa and off other
antipsychotic meds. Since that time Zyprexa has fallen off his
med list for unknown reasons. She recommended restarting Zyprexa
at a low dose of 2.5 mg at night, and follow up outpatient with
psychiatrist. Continued home citalopram. Diazepam was down
titrated in the hospital and then DCed due to patient somnolence
during the daytime. Per the psychiatrist, he had previously been
on a higher dose, and was down titrated a few months ago prior
to this as well.
# Parkinsonism: thought to be ___ antipsychotic meds. Cont
amantidine.
# GERD: cont simethicone, ranitidine
# HEALTH CARE PROXY: ___ (daughter in law)
___, grandson ___, home phone
___
# CODE STATUS: full code
TRANSITIONAL ISSUES
- follow up with PCP
- follow up with psychiatry for further titration of psych meds
- unclear indication to continue plavix at this time, will defer
to PCP +/- cardiology decision if the patient should continue
plavix in the future
- continue to monitor ___ and titrate insulin as needed | 201 | 451 |
15752034-DS-2 | 26,958,907 | ACTIVITY
* AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next ___ weeks.
* If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having internal bleeding from your
liver or spleen injury.
* AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least ___ days unless
otherwise instructed by the MD/NP/PA.
WOUND CARE
You have an open wound
The dressing needs to be changed and packed every day with wet
to dry dressing
You also have staples at your midline incision - this will be
addressed at your follow up appointment | Mr. ___ is a ___ gentleman who was transferred to ___
from ___ after he presented to ___ with a single stab
wound to his right upper abdominal quadrant/right flank region.
He received 2u of blood at ___ and was urgently transferred
to ___ for further management. Upon arrival, GCS was 15,
E-FAST was positive in the RUQ, so he was taken to the operating
room emergently for an exploratory laparotomy. Intraoperative
course was notable for evacuation of 600 cc of clotted blood,
and a single traumatic injury to segment 6 of his liver that was
hemostatic. Abdominal washout and exploration was negative for
any other acute injuries. He did not receive any additional
blood. He was extubated at the conclusion of the case, off of
all pressors, and was transferred to the TSICU for postoperative
care.
NEURO: While intubated, he was kept sedated. His pain was
controlled first with dilaudid PCA which was transitioned to
pills when he was tolerating a diet. His pain was otherwise
well-controlled. On the floor, his pain was managed with po
oxycodone, with which he was discharged.
CARDIOVASCULAR: He was closely monitored postoperatively in the
intensive care unit. He remained hemodynamically stable
throughout his hospitalization.
PULMONARY: He was successfully extubated postoperatively and
transitioned to nasal cannula. This was weaned and he was given
and taught how to use incentive spirometer and mobilized early
to prevent atelectasis.
ABDOMINAL/GI: He underwent exploratory laparotomy and the right
upper quadrant stab wound was kept open and packed with
moist-to-dry dressings. He was started on a diet early which was
advanced as tolerated once he had bowel function.
RENAL: A foley catheter was placed intraoperatively for urine
output monitoring. This was removed at earliest possibility.
HEME: Postoperatively, his hematocrit levels were closely
monitored and remained stable. He was subsequently started on
subcutaneous heparin for DVT prophylaxis.
Upon discharge, Mr. ___ was doing well, afebrile, and
hemodynamically stable and within normal limits. He received
discharge instructions and teaching, along with follow up
instructions. He verbalizes agreement and understanding of
discharge plans. | 121 | 335 |
18570906-DS-8 | 22,708,230 | Dear Mr. ___,
It was a privilege to take care of you at ___.
WHY WAS I IN THE HOSPITAL?
- You nearly passed out and had chest pain. Your eye doctor
found that you had an irregular heart rhythm ("atrial
fibrillation" or "a-fib") and your heart was beating very fast.
Thus, you were sent to the hospital.
WHAT WAS DONE FOR ME IN THE HOSPITAL?
- You were started on medications to control the fast heart rate
- You were also given medications to manage your blood pressure,
as it was very high
- You were evaluated for causes of the irregular rhythm
-- Infections can sometimes cause stress to the heart, causing
afib. You were given antibiotics for a possible urinary tract
infection.
-- You got an ultrasound of your heart ("transthoracic
echocardiogram" or "TTE" or "echo") which showed some changes
you should discuss with your primary care doctor and your heart
doctor
- Your heart went back into normal rhythm
- The risks and benefits of starting a blood thinner to reduce
your risk of stroke was discussed, but you opted to discuss this
further with a cardiologist before making a decision
WHAT SHOULD I DO AFTER THE HOSPITAL?
- You should follow up with your primary care doctor at the ___
within a week.
- You should follow up with your eye doctor as soon as possible.
We called your eye doctor to let them know you'd be discharged
so they can arrange an appointment for you.
- You should follow up with a heart doctor ("cardiologist") at
the ___.
- Please discuss starting a blood thinner to reduce the risk of
stroke with your cardiologist.
- You should have a repeat echocardiogram in 6 months to check
your dilated aorta. Your cardiologist or primary care physician
can arrange this.
- You should call the lung doctor at the ___ for an appointment
to evaluate your breathing.
We wish you the best!
Your ___ Care Team | Mr. ___ is an ___ old man with a history of urinary
retention, urethra stricture s/p dilation (___), recurrent
UTIs, bioprosthetic aortic valve replacement (___), HTN,
smoking, lung nodules, and underlying mood disorder who
presented to ___ from an outpatient visit with near-syncope
and new-onset atrial fibrillation with rapid ventricular
response. | 310 | 51 |
13776292-DS-16 | 20,864,687 | You presented to the hospital with jaundice, fever and chills
consistent with cholangitis. You were treated with antibiotics
and the signs of infection resolved. You underwent endoscopy to
attempt to open the obstruction to the drainage of bile, but the
narrowing was too severe. You then underwent radiology guided
placement of biliary drains, which were exchanged as an
inpatient and then removed. For your underlying pancreatic
cancer, which is the cause of the cholangitis, you were
evaluated by the Oncologists and the Surgical Oncologists, and
you will need to start chemotherapy as an outpt. The surgeons
also did a diagnostic laparoscopy to look for spread of cancer.
You also had a port device placed at the same time in
anticipation for use by chemotherapy. You will be discharged
home on by mouth pain medications and a medication regimen to
prevent constipation.
.
You will need to take your medications as listed below. Please
note that opiate medications can cause excessive sedation.
Please do not use before driving, using machinery, or with
alcohol.
.
Please f/u with your doctors as listed below.
.
Medication changes:
1) tylenol ___ mg three times a day to be used for pain
2) bisacodyl 10 daily as needed for constipation
3) docusate 100 twice a day
4) nicotine patch 21 mg daily (21 mg/day) for 6 weeks, followed
by step 2 (14 mg/day) for 2 weeks; finish with step 3 (7 mg/day)
for 2 weeks
5) MS ___ 30 mg Q12H for pain
6) oxycodone 5 mg Q4H prn pain
7) polyethylene glycol 17 g daily prn for constipation
8) senna 8.6 twice a day for constipation
9) zofran 4 mg Q8H prn nausea | This is a ___ yo M with a PMHx of locally advanced pancreatic
adenocarcinoma s/p ERCP X2 with deferment of ___, who now
p/w RUQ pain worrisome for cholangitis and is now s/p placement
of PTC
.
## Cholangitis and biliary stricture
Cholangitis is likely secondary to biliary stricture ___ to
pancreatic adenocarcinoma. Pt has been noted in the past to
have CBD dilatation on abd CT s/p ERCP x 2. As a result pt
underwent ERCP but unable to cannulate CBD, so then underwent ___
guided placement of percutaneous drains with good improvement in
his bilirubin. He was placed initially on Zosyn, then
transitioned to Augmentin after his drains were capped with good
effect. He was given a about 2 weeks of antibiotics. ___
internalized his drains with a metal stent 1 cm past he
bifurcation successfully, with improvement in his bilirubin.
However, he continued to have pain at his residual R PTC drain.
Thus, the decision was made to take the patient back down to ___
on ___ for removal of both his R PTC, and L PTC drain. He
tolerated the procedure well and his LFT's were downtrending
after the procedure. ___ followed the patient and were ok with
discharge.
.
## MALIGNANT NEOPLASM, PANCREAS
Initially diagnosed earlier this year and treated with ERCP and
stenting only due to insurance reasons. He has moved to ___ for
further care. Repeat CT here confirmed pancreatic mass with
vascular involvement. EUS with biopsy confirmed the dx of
adenoCA of pancreas. CA ___ was elevated in the ___. Per
Surgery, given vascular involvement of tumor, he is not a
resection / Whipple candidate at this time, and recommend neo
adjuvant chemo/XRT. At the time of his EUS, he also underwent
fiducial placement for anticipated chemo. He then underwent
diagnostic laparoscopy with peritoneal washings and port
placement for anticipated chemo. Peritoneal washing results
were negative. He was seen by Medical Oncology and has outpt
f/u scheduled with Dr. ___, as well as Dr. ___.
The seriousness of his condition was emphasized to the patient.
He was encouraged to make a decision regarding the location of
his treatment as soon as possible. I informed the patient that
this medical condition would likely shorten his life. He said
he understood and would try and expedite his decision. Please
note, the patient continually refused his SC heparin despite
information about the risks and benefits of this therapy.
.
##PAIN, ABDOMINAL-EPIGASTRIC
Lipase elevated to 382 concerning for pancreatitis. He was
initially treated with supportive care, then transitioned to
opiate therapy. He was started on Oxycontin and Oxycodone for
breakthrough. The sedative effects were explained, to avoid
with alcohol driving/machinery. The patient was asked to call
his pharmacy to check to see if these medications were covered.
On ___ the nursing staff called the pharmacy and they
indicated that oxycontin would not be covered. As a result, his
regimen was changed to MSIR and MSContin. The patient did not
tolerate the MSIR and thus he was sent out on MSContin and
oxycodone. He was encouraged to establish care with a provider
where he would receive his cancer treatment so they could
continue to titrate his pain regimen. The patient was also
placed on Tylenol TID and a bowel regimen.
.
# CONSTIPATION
The patient was informed of the side effects of narcotics
including constipation. He understood but intermittently
refused his bowel regimen.
.
# Transitional Issues:
-Follow up with Dr. ___ Hem/Onc the day of discharge and
Dr. ___ the surgery team in ___ weeks
-Follow up LFT's and CBC in 1 week | 277 | 620 |
10913302-DS-33 | 23,831,315 | Dear Mr ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
You were in the hospital because you had a fever at home.
What happened to me while I was in the hospital?
We gave you antibiotics to treat an infection.
What should I do when I leave the hospital?
You should continue to take your medications and go to your
doctor's appointments as scheduled. Weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
Best wishes,
Your ___ team | Mr. ___ is a ___ man with a history of
recurrent AML following matched unrelated allogeneic transplant
with Cytoxan and TBI conditioning ___, currently in
remission but with severe scleroderma second to
steroid-refractory GvHD who presents from home with complaints
of fever and weakness. Although a chest x-ray, blood cultures
and urine cultures did not indicate infection, patient has had
multiple courses of antibiotics in the past for pseudomonas
susceptible to ceftazidime. Accordingly, ceftazidime was
continued for ___s an outpatient Mr. ___ and his
primary oncologist will discuss next steps in treating GvHD.
# Fever. Remained afebrile during admission. Unclear etiology as
he had no localizing symptoms other than nausea. Dull RUQ pain
resolved shortly after admission. CXR unremarkable. Most likely
source of infection would be chronic lower extremity wounds,
which have previously grown GPCs and Pseudomonas. Abdominal u/s
obtained due to complaints of RUQ pain, showed only biliary
sludge, no cholecystitis. Flu PCR negative. Blood, urine
cultures were negative. Initially started on Vancomycin and
Ceftazidime. Vancomycin stopped ___ given no blood culture
growth for 48 hrs. Ceftazidime was continued, based on prior
cultures, for ___nding ___.
# Compression fractures.
# Pain.
Patient with compression fractures noted on CT lumbar spine from
___, with marked osteopenia noted on imaging. Patient is high
risk for pathological fracture given steroid use and relative
inactivity. Continued oxycontin and oxycodone for pain control,
with IV Dilaudid for dressing changes. On ___, pt requested
evaluation by chronic pain service to try to decrease opioid
usage. Per their recommendations, Oxycontin was decreased from
30mg BID to 20mg BID, Oxycodone decreased to ___ Q4H, and
Gabapentin increased from 600mg TID to ___ TID.
# AML: No evidence for recurrent leukemia. Continued Atovaquone
for PCP prophylaxis along with Acyclovir, Azithromycin, and
Posaconazole (dose decreased with interactions with Sirolimus).
# Chronic Extensive GVHD: Has manifested as skin, liver, mouth,
eyes and lungs, with possible BOOP in past. Continued issues
with sclerodermic skin changes. Currently on sirolimus and
prednisone 20mg daily. Ruxolitinib discontinued during last
hospitalization as it was felt to be of little benefit. Has
trialed numerous medications in past, including enbrel, gleevec,
sprycel, low dose IL-2 injections, cellcept, Treg DLI infusion,
and Abatacept. He was maintained on Prednisone and Sirolimus
during admission.
# Extensive lower extremity wounds. Patient with significant
ulcerated lower extremity skin wounds with previous
superinfection with Streptococcus and Pseudomonas. Follows with
Dr. ___ here at ___ as well as Dr. ___ at ___. Home
Cipro/Amoxacillin held due to Vancomycin and Ceftazidime, but
resumed prior to discharge. He was followed by the wound care
team during admission, and received daily dressing changes.
# Systolic CHF: TTE during hospitalization on ___ showing newly
depressed EF of 35% with possible hypokinesis of the
inferoseptal and inferior walls from the base to mid-ventricle,
also with elevated NT-pBNP at that time. Was started on
metoprolol at that time, with plans to start ACE inhibitor and
uptitrate metoprolol if persistent LV function on cMRI. Recent
cMRI showed mild systolic dysfunction, small pericardial
effusion but no evidence of pericardial constriction. Metoprolol
was continued during this admission.
# Hypothyroidism. TSH recently check and found to be low at
0.06, but free T4 normal. TFTs were re-checked and showed free
T4 to be low, so Levothyroxine dose was increased from 88mcg
daily to 100mcg daily.
# Depression. Seen by psychiatry consult service on ___, who
recommended increase Venlafaxine dose, as well as continuation
of outpatient psych follow up. Venlafaxine increased to 75mg qAM
and 37.5mg qPM.
TRANSITIONAL ISSUES
=======================
[ ] ___ will see patient at home
[ ] Increased Levothyroxine to 100mcg daily.
[ ] Decreased Oxycontin to 20mg BID, and Oxycodone to ___
Q4H PRN pain.
[ ] Increased Gabapentin 900mg TID.
[ ] Patient is to START Ruxolitinib Study Med 5 mg PO BID on
___ upon arrival to home.
# CODE: Full Code
# EMERGENCY CONTACT HCP: ___ (fiancee/HCP)
___ | 84 | 639 |
13665841-DS-16 | 23,670,219 | ACDF:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
Swallowing: Difficulty swallowing is not
uncommon after this type of surgery. This should resolve over
time. Please take small bites and eat slowly. Removing the
collar while eating can be helpful however, please limit your
movement of your neck if you remove your collar while eating.
Cervical Collar / Neck Brace: You have been
given a collar. You may remove the collar to take a shower or
eat. Limit your motion of your neck while the collar is off.
You should wear the collar when walking, especially in public
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in narcotic (oxycontin,
oxycodone, percocet) prescriptions to the pharmacy. In
addition, we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment for 2 weeks after
the day of your operation if this has not been done already.
At the 2-week visit we will check your incision, take baseline x
rays and answer any questions.
We will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
-You should not lift anything greater than 10 lbs for 2 weeks.
You will be more comfortable if you do not sit in a car or chair
for more than ~45 minutes without getting up and walking around.
-___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
Treatments Frequency:
Remove the dressing in 2 days. If the incision is draining
cover it with a new sterile dressing. If it is dry then you can
leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Call the office at that time. If you have
an incision on your hip please follow the same instructions in
terms of wound care. | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#0. Physical therapy
was consulted for mobilization OOB to ambulate. Hospital course
was otherwise unremarkable. On the day of discharge the patient
was afebrile with stable vital signs, comfortable on oral pain
control and tolerating a regular diet. | 775 | 130 |
13758408-DS-15 | 29,118,730 | Dear Mr. ___,
It was our pleasure caring for you at ___
___. You were admitted to the hospital with a large
blood clot in your left leg. We looked for evidence of a blood
clot in your right leg and did not find any. It appears as
though a small piece of the blood clot has broken off and lodged
in your lungs, a condition called pulmonary embolism.
Fortunately, you are not having severe symptoms from this. We
started you on a blood thinner medication called Warfarin, also
called Coumadin. While the levels of this drug build up to
therapeutic levels in your body, you will need to take another
blood thinner called Lovenox that you inject twice daily. You
will need to ___ with your primary care physician for
further testing to find out why you had this blood clot.
Be sure to keep your left leg tightly wrapped from the foot all
the way up to the groin with an ace bandage. This is important
to prevent ___ syndrome, a painful consequence of
having a blood clot in the leg. Also, keep your leg elevated on
2 pillows while sleeping, and keep it elevated this way for at
least 2 - 3 hours every day.
Thank you for allowing us to participate in your care. | Mr. ___ is a ___ y/o male with a past medical history of
anxiety who presented to ___ Urgent Care with hematuria and
LLE swelling and was found to have an extensive LLE DVT. | 226 | 36 |
16387284-DS-18 | 22,490,708 | Dear Ms. ___,
You were admitted to the hospital because you had pain in your
left shoulder and neck. This occurred because you had a blockage
of one of the blood vessels that was placed during your surgery.
A stent was placed in your original blood vessel to restore
blood flow. You felt well after the procedure.
You will need to take a medication called clopidogrel/Plavix to
keep your new stent open. It is very important that you take
this medication, as well as aspirin, every day. You will follow
up with your usual doctors.
___ was a pleasure taking care of you during your stay.
- Your ___ Team | Ms. ___ is a ___ yo woman with h/o MI s/p 2v CABG ___ who
presented with left shoulder and neck pain and found to have
NSTEMI. Troponin peaked at 0.48. She underwent cath which showed
failure of vein graft to RCA. Drug eluting stent was placed in
her native RCA with good restoration of flow. She was started on
clopidogrel. She will follow up with her usual doctors.
# NSTEMI:
The patient presented with left-sided chest pain radiating to
the left upper scapula and left arm. EKG not localizing. She was
found to have elevated troponin which peaked at 0.48. She
underwent cath which showed failure of vein graft to RCA. Drug
eluting stent was placed in her native RCA with good restoration
of flow. She was started on clopidogrel. She will follow up with
her usual doctors. | 107 | 138 |
17096041-DS-17 | 24,581,169 | Dear Mr. ___,
It was a pleasure taking care of you during your admission to
___. You came into the hospital
because you were found down. We found that you had a bleed in
your brain. You had brain surgery to help to stop the bleeding.
During your hospitalization you had a second bleed in your brain
and required a breathing tube for a long period of time so you
had a tracheostomy and a feeding tube placed. You were treated
for 2 pneumonias, an infection in your GI tract (c difficile),
fast heart rate (atrial fibrillation with rapid ventricular
response), and delirium (altered mental status).
You worked with physical therapy and we determined you were
ready to continue further treatment at ___.
Please continue to take your medications as prescribed and
follow up with your physicians as recommended below.
Be well and take care.
Sincerely,
Your ___ Care Team | Hospital summary:
___ year old male with past medical history of ___, atrial
fibrillation on sotalol/Coumadin prior to admission, PVD, HTN,
hypothyroidism presenting s/p fall with left intraparenchymal
hemorrhage requiring urgent surgery for left craniotomy with
evacuation on ___. Since surgery, has undergone placement
of tracheostomy and PEG tube on ___ for persistent
ventilator dependence. No further surgical issues and hemorrhage
deemed stable via serial imaging. However, when he was started
on an heparin gtt for AFib on ___, he was noted to have a small
increase in a left subdural hematoma on repeat head CT ___ so
heparin was stopped. Course further complicated by A fib with
RVR. He completed a course of vanc/cefepime for enterococcus in
urine and GNR in sputum, however, on ___ patient again had
respiratory decompensation and was treated with ceftriaxone for
a pan-sensitive Klebsiella pneumonia which grew from sputum on
___ to ___. Also found to have C diff infection on ___ and
started on PO vancomycin and IV metronidazole. Metronidazole was
stopped on ___. Plan to continue PO vancomycin for 2 weeks
after stopping ceftriaxone (final day of PO vancomycin planned
for ___. Final week of hospital course characterized by
intermittent agitation due to multifactorial delirium (recent
intracranial hemorrhages, multiple hospital acquired infections,
prolonged ICU stay), requiring Seroquel and soft mittens to
prevent pulling at lines and tracheostomy tube. He had multiple
episodes of rapid atrial fibrillation, treated with metoprolol
tartrate, amiodarone, and digoxin. | 145 | 242 |
13569254-DS-3 | 26,301,274 | You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well but
were found to have a stone remaining. You then had an ERCP to
remove that stone and are now being discharged home to continue
your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | Ms. ___ presented with ___ and elevated LFTs.
She underwent an MRCP which did not show any evidence of
choledocholithiasis. She was started on IV unasyn and underwent
a laparoscopic cholecystectomy on ___. She tolerated the
procedure well. However, she was noted postop to have
persistently elevated Tbili. She was scheduled to undego an ERCP
on ___ and the procedure was started but aborted due to food
noted in her stomach and concern for aspiration. She then
underwent a repeat ERCP on ___ with CBD stone removal and
sphincterotomy performed. After this procedure, her Tbili began
to downtrend. She was tolerating a regular diet, ambulating,
voiding and pain controlled with oral pain medications. She was
discharged home with appropriate followup instructions. | 734 | 122 |
12318755-DS-15 | 21,677,409 | Mr. ___,
You were admitted to ___ after having infected bone removed
from your toe. After the surgery we are treating you with a few
more days of antibiotics to ensure the infection is resolved.
You should follow up with podiatry in clinic. | # L TOE OSTEOMYELITIS
# DIABETIC FOOT ULCER: presented with a L toe diabetic ulcer and
osteomyelitis, ___ s/p debridement of L hallux and IPJ resection.
Per podiatry team, OR
findings point towards source control. In light of this, will
complete 5-day course of linezolid and ciprofloxacin based on
isolation of strep (likely the main pathogen) on operative
cultures and pseudomonas on previous swab. Will follow up with
podiatry on ___. Will have home ___ and nursing. He may leave
dressing intact until follow-up.
[]F/u OR micro/path
[]Heel touch only left foot in surgical shoe
[]Keep dressing clean, dry, and intact,
CHRONIC DIASTOLIC HEART FAILUE
HYPOKALEMIA: remained euvolemic. Will resume home maintenance
torsemide and potassium replacement on discharge.
ATRIAL FIBRILLATION WITH SLOW VENTRICULAR RESPONSE ON COUMADIN
CHA2DS2 SCORE= 4 NOT ON NODAL AGENTS: Originally held warfarin
due to supratherapeutic INR. INR 2.5 on ___. Restarting at 2.5
mg daily rather than alternating 2.5/5. Patient to have INR
followed for further adjustments.
CHRONIC KIDNEY DISEASE STAGE V
ANEMIA of CHRONIC DISEASE: Continued home medications. Patient
takes Procrit on ___. He is opposed to blood transfusions.
Mr. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes. | 42 | 210 |
16544722-DS-26 | 25,517,348 | Dear Mr. ___,
It was a pleasure being part of your care at ___. You were
admitted to the hospital due to abdominal pain. You were found
to have acute rejection of your transplanted kidney, which was
caused by missing medications. Your medications were adjusted
and your symptoms improved. You were seen by the transplant
surgeons for consideration of removing your kidney, which may
need to be done if your rejection continues.
After discharge, it is very important for you to keep taking
your medications. Please also follow up with your outpatient
doctors.
___ was a pleasure being part of your care.
Sincerely,
Your ___ Team | Mr. ___ is a ___ with HIV (on HAART, CD4>700 on ___ and
undetectable viral load), ESRD (on HD ___ since ___, s/p
failed renal transplant, on prednisone), T2DM, HTN and colostomy
(placed after anal resection), now presenting with abdominal
pain concerning for graft rejection.
# Acute allograft rejection:
He had RLQ abdominal pain with imaging findings concerning for
acute allograft rejection. CT shows stranding, transplant
ultrasound shows elevated resistive indices. UA without evidence
of UTI. Rejection was likely precipitated by missing prednisone
doses. He was started on prednisone 60mg with improvement of
symptoms. He will be discharged on prednisone taper as described
below. He was given Tylenol, ibuprofen and hydromorphone PO for
pain control; he did not require PRN pain medications in the day
prior to discharge. Transplant surgery evaluated him for
possible explant, and determined that there was no acute
indication to explant the kidney at this time.
# ESRD on HD (Stage V CKD, s/p DDRT in ___ w/chronic allograft
glomerulopathy - ___. Sevelamer was increased to 2400
TID w/ meals for hyperphosphatemia. He received HD on ___.
Continued calcitriol and nephrocaps.
# HTN: Hypertensive upon admission as did not take HTN meds
during the past week. Continued Amlodipine, Labetalol and
losartan with adequate blood pressure control.
# Type 2 Diabetes:
Patient with history of diabetes and on home glargine. A1C 6.8%
likely doesn't reflect true glycemic control given not adherent
to steroids, and also likely reduced RBC life span. Continued
glargine and insulin sliding scale. | 102 | 245 |
12648465-DS-25 | 25,685,722 | You were admitted to the hospital with abdominal pain and weight
loss. You underwent an EGD notable for esophagitis and
gastritis. Biopsies were taken and showed yeast infection. You
were continued on your home medications with the addition of
cholestyramine and ultram for pain control. You will need to
follow-up with ___ as an outpatient for ongoing evaluation
and treatment.
Per your PCP's request, a colonoscopy was performed while you
were in the hospital given difficulty with completing the prep
as an outpatient. This went well, there were a few small polyps,
and you will likely be due for another colonoscopy in ___ years.
You were noted to have a small infection in the labial that was
treated with ___ baths.
Please see below for your follow up appointments and
medications. | ___ w/PMH of gastric bypass, multiple prior abdominal surgeries,
s/p complete reversal of her gastric bypass, CCY, esophageal
candidiasis, opiate abuse, HTN, and DVT/PE p/w epigastric
abdominal pain and nausea.
# Epigastric abdominal pain/nausea: Pt with recent h/o
esophageal candidiasis s/p treatment. Now with post prandial
epigastric pain and odynophagia. EGD notable for esophagitis and
gastritis; biopsies taken and showed persistent ___. She was
continued on her home PPI and sucralfate with the addition of
cholestyramine and started on PO fluconazole. She did not
tolerate cholestyramine. Given ongoing pain, while in house she
was evaluated by the bariatric surgery team who did not think
that surgical intervention would improve bile reflux. She was
also seen by the pain management team who recommended outpatient
nerve block given concern for nerve entrapment at surgical site
and continued use of tramadol PRN. She will need outpatient
follow-up with ___ further evaluation and treatment.
Fluconazole will finish on ___.
# Leukopenia- Noted on previous admissions as well. Resolved
without intervention.
# Malnutrition: due to odynophagia. PO intake improved
significantly following treatment for esophagitis.
CHRONIC ISSUES
# DVT/PE- Difficulty obtaining a therapeutic INR as an
outpatient over the past year. Patient was continued on
therapeutic lovenox alone during her hospitalization and
coumadin was held at discharge given concerns for patient's
medication compliance and insight into how to adjust warfarin
dosages. She has follow-up with ___ further
consideration of the risks and benefits of continued
anticoagulation.
# anxiety/depression: continued home meds (reconciled with
outpatient psych provider) and weaned clonazepam 0.5/wk per
their recs. Quetiapine was halved while inpt due to interaction
with fluconazole but should be restarted at home dose when
fluconazole course is completed.
# Medication Reconciliation: Patient has recently filled
prescriptions at three different pharmacies and reported
different doses and frequencies for several medications than
those noted in OMR. Medications discussed with patient's PCP,
___, and outpatient nurse. Gabapentin was stopped,
Seroquel was continued at 100mg qAM and 300mg qPM (but decreased
when fluconazole was started due to interaction), and Klonipin
was continued at 0.5mg qAM and 2mg qPM (tapered to 1.5 mg after
1 week per outpt psychiatrist). She was instructed to choose one
pharmacy to fill all of her prescriptions at to limit confusion
in the future. She will need close outpatient follow-up with her
PCP and psychiatrist for further titration of her psychiatric
medications.
# hx narcotics abuse: pt was continued on home ___. Pain
management was discussed with ___ provider who
preferred not to dc the patient on ultram, however given ongoing
pain and pain consult recommendations, this was continued. | 129 | 427 |
Subsets and Splits