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12111976-DS-22 | 21,038,247 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted with worsening cough and
shortness of breath, which we think is due to a combination of
pneumonia, asthma exacerbation and fluid overload. We started an
antibiotic called levaquin and gave you a diuretic to decrease
the fluid. Your breathing improved and you did not have any
episodes of ventricular tachycardia while you were here.
While you were on water pills, your electrolyte levels changed
rapidly. While your body re-adjusts, we would like you to take
half of your Valsartan (Diovan) for the next few days and then
have your blood tests rechecked ___. You will also
start a new water pill called Furosemide (Lasix).
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ h/o CAD s/p CABG s/p posterior MI with ischemic CM EF ___
with resultant VT with multiple syncopal episodes resulting in
ICD implantion in ___, asthma, OSA, hyperlipidemia presenting
for persistent cough for nearly 2 weeks and increasing dyspnea
over the last 2 days despite treatment with steroids of asthma
flare, treated for pneumonia, volume overload, asthma
exacerbation
. | 132 | 61 |
19923506-DS-14 | 21,528,712 | ACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks.
___ 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.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without changing positions.
BRACE: You have been given a brace. This brace should be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
WOUND: Remove the external dressing in 2 days. If your incision
is draining, cover it with a new dry sterile dressing. If it is
dry then you may leave the incision open to air. Once the
incision is completely dry, (usually ___ days after the
operation) you may shower. Do not soak the incision in a bath or
pool until fully healed. If the incision starts draining at any
time after surgery, cover it with a sterile dressing. Please
call the office.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
MEDICATIONS: You should resume taking your normal home
medications. Refrain from NSAIDs immediately post operatively.
You have also been given Additional Medications to control your
post-operative pain. Please allow our office 72 hours for refill
of narcotic prescriptions. Please plan ahead. You can either
have them mailed to your home or pick them up at ___
___, ___. We are not able
to call or fax narcotic prescriptions to your pharmacy. In
addition, per practice policy, we only prescribe pain
medications for 90 days from the date of surgery. | ___ presented to the ___ emergency department on
___ from her rehabilitation facility with fever, back pain
and leukocytosis and decreased hct. CT scan of her thoracic
spine revealed loss of fixation of the thoracic instrumentation
from prior revision fusion on ___. She was taken to the
operating room on ___ for emergency incision and drainage,
removal of instrumentation, and washout of posterior wound. A
wound vac was placed at the time of surgery. Refer to the
dictated operative note for further details. The surgery was
performed without complication, the patient tolerated the
procedure well, and was transferred to the PACU in a stable
condition. TEDs/pneumoboots were used for postoperative DVT
prophylaxis. Intravenous antibiotics were started in the
emergency department and continued postoperatively. Urine
culture was positive for pseudomonas. Intra-operative cultures
were negative. She was closely monitored for signs of infection
postoperatively. Initially, postoperative pain was controlled
with a PCA. Diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
___ remained in halo and traction to 20lbs. She was
also fitted for CTLSO brace for when out of bed. The wound vac
and hemovac were removed on post-operative day three. Infectious
disease was consulted and recommends continuing parenteral
antibiotics, specifically vancomycin and cefepime for about 6
weeks. PICC line placement was consented for and placed on ___.
Traction was discontinued on ___ and she was placed back in
halo vest. She will remain in halo vest for about 3 months. On
the day of discharge she was tolerating oral pain medication,
urinating without difficulty, and tolerating regular diet. | 271 | 268 |
11566352-DS-4 | 20,029,805 | -You should keep your left lower extremity elevated when you are
not dangling or walking (you may use pillows at home) to help
with swelling and drainage.
-You should walk around utilizing your crutches and not bearing
any weight on your left leg.
-Report any change in color of your flap area including
increased redness and/or any dusky or darkened appearance to Dr.
___.
-use gauze, as needed, to help absorb any drainage from flap.
-Your left lower extremity should be wrapped with clean ace wrap
daily from your foot to just under your knee and you should wear
your posterior boot/splint.
-Your left forearm dressing should be changed daily; apply
xeroform to graft area, then gauze fluffs and then wrap with ace
wrap.
-You may shower but cover your thigh donor site and your left
forearm skin graft site with plastic wrap/bag to shield from
moisture. You may leave your left lower extremity flap/repair
site open to let warm water run over it. Pat dry with soft towel
and re-apply ace wrap. No tub baths until directed by Dr. ___.
-Leave your graft donor site open to air to dry out.
-You may continue to dangle and walk around according to the
protocol which you started in the hospital. On ___, you
may advance to 1 hour dangles, three times per day. Continue
this for a few days then advance to 90 minutes, three times per
day. You should dangle a maximum of 90 minutes three times/day.
Continue with the 90 minutes three times/day until further
instructed by Dr. ___ at your first follow up appointment.
.
Diet/Activity:
1. You may resume your regular diet.
2. Avoid heavy lifting and do not engage in strenuous activity
until instructed by Dr. ___.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you. | The patient was admitted to ___ service after a motorcycle
crash where he sustained an open tib-fib fracture, bilateral
first rib fractures and pneumomediastinum. His left lower
extremity fracture was determined to be a grade 3 open left
tibia-fibula fracture and patient was taken to the OR on ___
by Orthopedic service for washout and debridement of open
fracture with application of multiplanar external fixator and
wound VAC to anterior left lower extremity wound defect.
Plastic surgery was consulted on ___ for flap coverage
planning to left lower extremity (LLE) wound defect. On
___, the patient returned to the OR with both Orthopedics
and Plastics services. Orthopedics began with washout and
debridement of LLE wound, removal of external fixator with open
reduction and internal fixation left bimalleolar ankle fracture
with internal fixation and Intramedullary (IM) nail left tibia
with insertion of antibiotic cement delivery device. Plastics
then did a radial forearm free flap reconstruction to LLE wound
defect and placed a split thickness skin graft to left forearm
donor site. Patient tolerated all of these procedures very
well. Patient was admitted to Plastic surgery service and placed
on bedrest for 5 days after the final surgery with close
monitoring of free flap to LLE. He received Toradol x 3 days
post-operatively and then transitioned to 121.5mg of ASA QD as
part of a free flap anticoagulation protocol. On POD#5, all
surgical dressings were removed and flap remained warm, pink and
viable. All LLE incisions remained patent and without signs of
infection. Patient's LLE was maintained in a pre-fabricated
posterior support splint for the remainder of his stay and he
was discharged home with same. Left forearm incision and skin
graft sites were patent and without signs of infection or
breakdown. Left thigh donor site remained open to air to dry.
Patient began a LLE dangle protocol three times a day on POD#5
with incremental increases in dangle times each day as part of
flap dependency training. The LLE free flap tolerated dangle
challenges well.
.
Neuro: Post-operatively, the patient's pain was managed with a
dilaudid PCA and/or IV pain medications with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: The patient was given IV fluids during pre-op periods of
NPO and directly post-operatively until tolerating oral intake.
His diet was advanced when appropriate, which was tolerated
well. He was started on a bowel regimen to maintain bowel
movements. Patient was commenced on Flomax PO for urinary
retention post-operatively. Patient able to void freely and
without difficulty during the remainder of admission. Intake
and output were closely monitored.
.
ID: Post-operatively, the patient was given 3 doses of IV
cefazolin and then IV gentamicin was added on ___.
Gentamicin was discontinued on ___ and patient was
maintained on cefazolin (and then keflex) alone until ___.
The patient's temperature was closely watched for signs of
infection.
.
Prophylaxis: The patient received subcutaneous heparin during a
portion of this stay and was transitioned to Lovenox prior to
discharge for purposes of teaching self lovenox injections.
Patient was discharged home with 2 weeks of lovenox therapy.
.
At the time of discharge on HD#12, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating with crutches and non wt bearing on LLE, voiding
without assistance, and pain was well controlled. All incisions
were clean and intact without signs of infection or breakdown.
LLE flap site remained pink, warm and viable. LLE was
maintained in pre-fab posterior splint with ace wrap to just
below knee. Left forearm skin graft site was healthy and pink
with 100% take. | 558 | 648 |
15674134-DS-4 | 21,195,450 | Dear Ms. ___,
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call ___ with any
questions or concerns. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* Since you have steri-strips, leave them on. They will fall off
on their own or be removed during your followup visit.
* If you have staples, they will be removed at your follow-up
visit.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
Constipation:
* Drink ___ liters of water every day.
* Incorporate 20 to 35 grams of fiber into your daily diet to
maintain normal bowel function. Examples of high fiber foods
include:
Whole grain breads, Bran cereal, Prune juice, Fresh fruits and
vegetables, Dried fruits such as dried apricots and prunes,
Legumes, Nuts/seeds.
* Take Colace stool softener ___ times daily.
* Use Dulcolax suppository daily as needed.
* Take Miralax laxative powder daily as needed.
* Stop constipation medications if you are having loose stools
or diarrhea.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | On ___, Ms. ___ presented to the emergency room with RLQ
pain, hypotension and vaginal posting. She had a positive
pregnancy test and ultrasound imaging concerning for
hemoperitoneum and ruptured ectopic pregnancy. An HG of 8900 was
noted and no intrauterine pregnancy.
She received IV resuscitation and 3 units of red cells and in
the ER and was taken urgently to the operating room. She
underwent an operative laproscopy, evacuation of hemoperitoneum,
and right salpingectomy for ruptured ectopic. Please see the
operative report for full details. Her pre-operative HCT was
36.8. Patient received 2 additional units of packed red blood
cells intra-operatively, for a total of 5 units. EBL was 4000cc.
PACU HCT was stable at 36.5. Her coagulation factors were
trended and were stable.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with IV toradol. Her diet was
advanced without difficulty, and she was transitioned to PO
oxycodone, ibuprofen, and Tylenol. On post-operative day 1, her
urine output was adequate, so her foley was removed, and she
voided spontaneously.
She expressed significant tearfulness regarding these events and
pregnancy loss. Patient was seen by Social Work during her
admission. She will have outpatient followup with this service.
She was discharged to home with outpatient followup in one week. | 296 | 211 |
15195922-DS-9 | 29,089,742 | Querida ___,
Fuiste ___ hospital ___ a tus dificultades al
producir ___ en ___
___ demostraron un ___
___ de
___ y movimiento.
___, tus signos vitales demostraron ___
___ saturacion de oxygeno. ___ de tus pulmones no
demostraron un coagulo como ___ oxigenacion. Por
lo tanto, es muy propable ___ to ___ oxigenacion sea en
___ de Ebstein. ___
piernas no demostro ___. Sin
embargo, ___ anticonceptiva, ___ comenzaste
a tomar recientemente, es probable ___
___ a formar un coagulo. Este coagulo ___
___ cardiaco. | ___ y/o R-handed F with hx of Ebstein anomaly with ASD, WPW
syndrome s/p unsuccessful ablation in ___ presenting with acute
onset dysarthria, word-finding difficulty and R-sided weakness
with MRI notable for L caudate/putamen stroke. Cardiac workup
revealed arrhythmia with ASD/PFO due to known abnormalities,
likely cardioembolic source of clot. Started on anticoagulation
with heparin, now transitioned to coumadin with lovenox bridge.
#Neuro: Admission neurologic exam was notable for dysarthric
speech, word-finding difficulty, R-facial asymmetry and R-sided
weakness. MRI was notable for L caudate/putamen stroke, likely
of embolic etiology in the setting of recently started OCP. TTE
and ___ studies were done without clear source of embolism, and
coagulation panel was unremarkable. Patient was started on
heparin drip and transitioned to coumadin with lovenox bridge
upon discharge. Patient was also evaluated by cardiology as
below. ___ and speech and language consults were obtained,
which recommended outpatient follow-up. Symptoms were monitored
daily with improvement in ___ language fluency, dysarthria
and weakness throughout the course of admission. Upon discharge,
patient could speak in ___ word ___ sentences, had mild
persistent asymmetry of the lower R facial musculature and mild
dysarthria.
#CV: Patient underwent TTE for evaluation of possible
cardioembolic source and delineation of congenital anomaly.
Ebstein's anomaly with ASD was confirmed. EKG was consistent
with ___ syndrome. Patient was found to be
hypoxic to 89% on 6L O2, raising the concern for pulmonary
embolism. CTPA was negative for PE. Patient was evaluated by
both the cardiology service and the ___ Adult Congenital
Heart Disease service to evaluate chronic versus acute onset
hypoxemia. Both services felt that her hypoxemia was
physiologic given the extent of her shunting and that there was
likely no worsening of her defect, but that cardiac surgery
should be pursued in the near future. O2 supplementation was
stopped given physiologic shunting. Patient's O2 saturation
ranged between 82-93%/RA without any evidence of cyanosis,
tachypnea or dyspnea. Patient was started on heparin and
transitioned to coumadin with lovenox bridge.
#Resp: Patient was kept on continuous O2 monitoring. Had a desat
to the los ___ while in the shower with associated cyanosis,
which was thought to be vasovagal. No PE on CTPA. Her O2 sats
remained in the mid-high ___ on room air.
#FEN: Patient was maintained on cardiac healthy diet.
#HEME: Started on anticoagulation with heparin, now transitioned
to coumadin with lovenox bridge. | 87 | 392 |
13299965-DS-16 | 29,978,163 | Dear Ms. ___,
You came to ___ with a fast heart rate that caused
palpitations. It improved with starting a new medication called
verapamil. Please followup with your outpatient doctors.
It was a pleasure taking care of you.
Your ___ medical team | ___ with history of rheumatic fever, paroxysmal atrial
fibrillation, type 2 diabetes mellitus, hypertension,
hyperlipidemia who presented with shortness of breath and
palpitations. She was found to be in an SVT by paramedics and
converted to sinus with adenosine. She was started on verapamil
as an inpatient and tolerated it well. She was discharged home
with continued services.
# Supraventricular tachycardia: Arrived to the hospital in NSR
following the adenosine. Unclear precipitant. EKG without
ischemic changes and serially negative troponin. No signs or
symptoms of infection. She appeared euvolemic on exam. She was
started on verapamil 120 mg daily with good effect, HRs in the
___ and no additional episodes of SVT. TSH was slightly low but
free T4 was normal. She was discharged with no antiocoagulation
for embolic prevention in the setting of underlying paroxysmal
atrial fibrillation given recent chronic subdural hematoma and
multiple recent falls; this risk-benefit trade-off was discussed
with daughter and patient.
# Hypertension: Antihypertensives discontinued during last
admission in setting of orthostasis and recent fall in favor of
verapamil.
# Recent subdural hematoma: Patient was recently admitted for
fall with headstrike, imaging showed chronic subdural hematoma.
Will follow-up with ___ clinic.
# Hyperthyroidism: Continued methimazole. TSH was low (0.22) but
free T4 was ultimately normal. Recommend rechecking with PCP at
followup.
# Gait instability: 8 falls in the last year. None since last
discharge. Has a walker, but per her daughter does not always
use. Very important to patient to remain independent. She was
discharged home with continued services. | 40 | 250 |
10148145-DS-7 | 21,346,827 | You were admitted to the ___ on ___ for a wound
dehiscence. You received IV antibiotics and placement of an
irrigating wound vacuum and were seen by Dr. ___
recommended antibiotic and wound vac therapy initially.
However, given the depth of your wound, you were taken to the
operating room on ___ for irrigation and debridement of your
wound and placement of an incisional vac. Postoperatively you
were restarted on antibiotics and an infectious disease consult
was placed. They recommended an antibiotic course scheduled to
end on ___. The incisional vac was changed on the day of
discharge and replaced with a new vac sponge. This will be
changed again by the KCI representative on ___ and based on
the appearance of the wound at that time will likely stay in
place until ___. | ___ was admitted to the ___ on ___ from
___ for concern of wound dehiscence and infection
from his prior urgent L1-L3
laminectomies, L2-3 diskectomy on ___ for cauda equina
syndrome.
On ___, he was started on IV cefazolin and received placement
of a ___ irrigating wound vacuum which he tolerated well. He
did not complain of any subjective fevers, chills, or sweats and
his WBC was within normal limits. He remained stable overnight.
On ___, he reported tolerating the wound vac well. He was eager
to return to rehab but per Dr. ___ was asked to remain
in house on antibiotics and with a vac change scheduled for ___
where he could also be examined by Dr. ___.
On ___, he continued to tolerate the wound vac and was
neurologically stable. He remained afebrile without any WBC.
On ___, the wound vac was changed and the patient
continued to do well.
On ___, in the early morning the team was notified that
WoundVac dressing was leaking. Upon inspection, the foam was
found to be intact, and the dressing wasreinforced.
On ___, the patient's neurological and motor exam remained
stable. The team changed the wound-vac dressing with Dr.
___ changed ___ irrigation fluid from saline
to Dakins ___.
On ___, the patient continued to do well and was without fever
or complaint. The WoundVac dressing maintained a good seal.
On ___ the patient remained neurologically stable. His
wound vac remained in place and he was preparing for surgery on
___.
On ___ the patient was taken to the operating room and
underwent a Lumbar Wound Revision. His case was uncomplicated
and he was extubated in the OR and recovered in the PACU. He was
transferred to the floor when stable. He was placed on
vancomycin, cefepime, and flagyl for antibiotic coverage pending
an ID consult.
On ___, the patient continued to be stable on the floor with a
stable neurological exam. He was seen by ID who recommended
vancomycin, ceftazidime, and flagyl while awaiting culture
speciation.
The patient continued to remain stable in house from on ___ and
___ where he continued on vancomycin, ceftazidime, and flagyl.
He did have a run of ventricular tachycardia on ___, lytes and
a formal EKG were obtained that were unremarkable.
The patient was discharged in stable condition on ___. He
was discharged on Vancomycin 1500 mg q8h and ertapenem 1g q24h
both until ___. The patient's incisional vac was changed on
the day of discharge. This vac will be changed by the Prevena
___ Wound Nurse ___ cell: ___ on ___.
Per the infectious disease team, there was no need for ID follow
up at this time. However, the infectious disease team at ___
will continue to monitor the final speciation of his wound
cultures and will notify the team at ___ should any
antibiotic changes be necessary.
This plan was discussed with the patient prior to discharge and
the patient expressed understanding. He will call to schedule a
two week follow up with Dr. ___. | 136 | 495 |
11511467-DS-16 | 28,499,471 | Resume your normal medications and begin new medications as
directed.
· You may be instructed by your doctor to take one ___ a
day and/or Plavix. If so, do not take any other products that
have aspirin in them. If you are unsure of what products contain
Aspirin, as your pharmacist or call our office.
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
When to Call Your Doctor at ___ for:
· 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 | ___, Patient was admitted to the floor after being evaluated
in the emergency department. He was started on Plavix and
aspirin. Stroke neurology was consulted and recommended an
ophthalmology consult as well as an MRI/MRA to evaluate for
stroke.
On ___ Mr. ___ had visual field testing which demonstrated
the presence of a left homonymous hemianopsia. On ___ he
underwent MRI/MRA which showed subacute right temporal,
bilateral occipital infarcts right greater than left. It was
felt that the strokes were possibly a result of dehydration in
the setting of exertion.
On ___ he remained neurologically stable and at the time of
discharge he was tolerating a regular diet, ambulating without
difficulty, afebrile with stable vital signs. He will follow up
as an outpatient to complete his work up with a TTE and follow
up with Dr. ___ in ___ weeks in clinic. | 145 | 142 |
15320664-DS-9 | 28,635,381 | Dear Ms. ___,
You were admitted for abdominal pain in the setting of a likely
ruptured kidney cyst. We treated you with pain medications.
Follow up is scheduled at your PCP ___ (should you wish to
keep this appointment) and the nephrology and GI offices will
call you to schedule follow up as well.
It was a pleasure taking care of you.
Sincerely,
Your ___ team | Ms. ___ is a ___ female with PMH polycystic kidney
disease w/ polycystic liver, chronic abdominal pain who
presented with 1 day of abdominal pain and fever.
#Abdominal pain/fever: Likely due to cyst rupture, as symptoms
are similar to prior flares of her polycystic kidney/liver
disease and she has no other signs or symptoms of infection.
Held off on antibiotics. Spoke to urology consult on the phone
who said that the patient has an appointment in 2 weeks and can
follow up as an outpatient for decortication; nothing to do in
the meantime to prepare for this clinic visit, and would not do
decortication while the patient is having a cyst rupture. Fever
downtrended by second day of admission. Continued home
oxycontin. Given IV dilaudid while vomiting, changed to PO by
second day of admission. Also gave Tylenol, though patient
reported that this had no effect. Patient reported being back to
her baseline chronic level of abdominal pain. Her home oxycontin
is for her neck pain. She requested dilaudid on discharge. I
discussed with her that she needs an overall pain management
plan with her outpatient providers and dilaudid is not a good
long term option, especially now that she is back to her
baseline level of pain. We agreed to a very short course to help
bridge her to her next PCP appointment, which has been scheduled
for early next week. Also continued home promethazine and
prochlorperazine | 62 | 237 |
12426098-DS-24 | 21,387,177 | Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because you
were having confusion and were incontinence. You had many
normal studies (normal electrolytes, urinalysis, head imaging,
etc.) without apparent reversible causes of your confusion and
you were discharged to rehab. Best of luck to you in your
future health.
Please take all medications as prescribed, attend all doctors
___ as ___, and talk to a doctor if you have any
questions or concerns.
Sincerely,
Your ___ Care Team | ___ yo M PMHx atherosclerosis, DM, B12 deficiency, and EtOH abuse
presented with acute on chronic delirium. He had a full
delirium workup negative for reversible etiologies along with
MRI Brain showing chronic small vessel ischemia and he was
discharged to rehab
# Delirium / Dementia: Patient presents with relatively new
onset memory loss per family. Per report it seems it may be
waxing/waning so unclear if current status represents dementia
versus delirium, possibly combination of both. He was scheduled
to have a cognitive neurology appointment but was unable to make
as outpatient. Per family (___), patient had had a
question of mild memory impairment over the summer (and was thus
referred for neuropsychological evaluation, previously
relatively independent in ADLs, went to bank, took daily walks,
did own cooking, however ___ drinks/day). Only over the last 7
days has he had significant decompensation (urinary and bowel
incontinence, wandering hallways of his apartment complex
because he didnt remember where he lived, forgetful and not
himself, hygiene and upkeep poor, apartment unclean). History
and physical exam otherwise unremarkable except for somonolence
and disorientation.
Differential included electrolyte abnormalities or uremia (none
noted), infection (normal vitals and WBC), hepatic
encephalopathy (LFTs normal, no cirrhosis stigmata), UTI (clean
UA), intracranial process (CT/MRI show no acute process),
ethanol withdrawal or Wernicke's encephalopathy ___ drinks per
day, scoring minimally on CIWA, no improvement with
thiamine/folate/MVI), normal pressure hydrocephalus (no
characteristic gait, no evidence on imaging, variably continent
therefore likely functional), thyroid disease (normal TSH),
neurosyphilis (RPR negative, no other signs of tertiary
syphilis), and B12 deficiency (had been refusing shots as
outpatient but B12 within normal limits, no evidence of
neuropathy, on high dose oral cobalamin). MRI/CT Brain showed
chronic small vessel disease without acute disease process
making vascular dementia more likely. Epilepsy/post-ictal state
and meningeal process were considered but felt to be unlikely
given lack of clinical signs/symptoms and stable clinical and
mental status. Throughout his time, patient remained oriented
to person and hospital only and never knew date. He was given
thiamine/folate/B12 supplementation. Physical Therapy
recommended ___ rehab and he will see outpatient cognitive
neurology to continue workup of his delirium.
#Urinary Incontinence: Patient with reported new urinary
incontinence, likely relate to dementia/delirium process as
above. No signs of hydrocephalus concerning for normal pressure
hydrocephalus. No back pain or other focal neurological deficits
concerning for spinal cord pathology. No signs of UTI based on
UA. Patient was intermittently using toilet, so this was felt
to reflect functional pathology in the setting of dementia/AMS.
# Hypertension: Hypertensive on arrival to floor in setting of
missing home anti-hypertensives; continued on home lisinopril
and added HCTZ.
# Acute Kidney Injur: On ___, noted to have Cr 1.3 from
baseline 1. Patient has elevated BUN/Cr likely prerenal with
dehydration in setting of low PO intake. Patient was repleted
with IV fluids and his discharge Cr was 1.3.
# EtOH Use: Per HCP, patient drank at least ___ drinks per day.
As an inpatient, he was started on folate, thiamine, MVI for
nutrition support and concern for ___'s encephalopathy and
was monitored on CIWA scale for >48 hours; patient only scored
for confusion and the scale was discontinued.
# DMII: Poorly controlled and kept on insulin sliding scale as
inpatient as well as diabetic heart-healthy diet.
# B12 deficiency: Continue home dose ___ units B12 daily with
B12 level being WNL
# HLD: Chronic stable issue continued on home simvastatin.
# Code: Full Code confirmed with HCP
# Emergency Contact: HCP/daughter-in-law ___
___ or grandson ___ ___
# ___: ___
# Transitional Issues
- Continue dementia workup (consider LP/EEG); ___ cognitive
neurology
- Continue high-dose oral B12 therapy to minimize further
worsening of cognition
- Minimize access to ethanol
- Control vascular dementia risk factors (HTN, DM)
- Given CKD and baseline Cr 1.0-1.3, regularly evaluate
continuation of metformin for diabetes control given risk of
lactic acidosis | 90 | 644 |
12354194-DS-21 | 25,822,088 | Dear Ms. ___,
You were admitted to the hospital because you had sudden onset
lower back pain and weakness and your primary care physician
asked you to go to the Emergency Department. While in the
hospital you had a fever and developed confusion. All causes of
infection were ruled out and your mental status improved. It is
possible that you had a condition that causes inflammation of
the surrounding layer of the heart called "pericarditis." You
were without symptoms for this however and we did not treat you.
For your back pain and weakness it will be important for you to
continue with physical therapy and to follow up in clinic with
your appointments below.
We held your lasix on discharge because you were dehydrated. It
is very important that you weigh yourself every morning and call
your doctor if your weight goes up more than 3 lbs. If you start
to notice that you are gaining weight and your legs are getting
swollen, then you should restart your lasix (furosemide).
It is very important that you have your labs drawn at Dr. ___
office on ___. Dr. ___ will follow up these
results and adjust your coumadin dosing if needed.
It was a pleasure being involved in your care.
Your ___ Team | ___ with a PMH of RA, Nephrotic syndrome, hypertension and renal
vein thrombosis on coumdin who presented yesterday to the ED
with low back pain found to have fevers, EKG consistent with
pericarditis, and developed transient somnolence in ED and so
was transferred to MICU for concern of bacterial meningitis.
# Pericarditis: Patient presented with chest pain at home that
has now resolved. On arrival to ED patient was without chest
pain but did have diffuse ST segment elevation with mild PR
depressions. Etiology ___ be secondary to rheumatoid arthritis
vs. idiopathic vs. viral. Per rheumatology it is unlikely that
pericarditis is secondary to RA definitively. Also a possibility
that patient had a viral pericarditis though denies prodromal
viral symptoms prior to admission including fever, chills,
rhinorrhea, and cough. Echocardiogram was also reassuring
without evidence of pericardial effusion. She was not treated
with on NSAIDs/colchicine due to ___ and known membranous
nephropathy.
# Fever/Altered mental status:
Patient with RA/Nephrotic Syndrome on chronic corticosteroids
and azathioprine presented with back pain and difficulty with
ambulation and was found to have fevers. Differential includes
CNS/Spine source (ruled-out by MRI and exam, no meningeal signs,
no delirium or focal neurological deficits), cardiac
inflammatory source (can develop fever in setting of
pericarditis), pulmonary (no dyspnea/cough, normal CXR), urinary
source (incontinence but no dysuria and UA unremarkable), skin
source (no signs/symptoms). Infectious work-up was negative for
an acute process. There was concern that patient had meningitis
given encephalopathy and fevers, however given her rapid
improvement and resolution of fevers/AMS her antibiotics were
discontinued. Ultimately her fever ___ have been attributable to
her pericarditis though resolved this hospital course.
# Lower Back Pain with associated lower extremity subjective
weakness:
The ___ lower back pain and weakness that brought her to
the hospital was ultimately felt to be secondary to possible
dehydration and spinal stenosis symptoms. MRI imaging of her C,
T, and L-spine was completed. Patient was noted to have multiple
levels of foraminal narrowing and degenerative changes. Ortho
spine assessed patient and noted that the findings did not
warrant any surgical intervention. The ___ neurologic exam
also remained intact while in the hospital. Ultimately it was
determined that after ___ assessment patient could be discharged
home with continued physical therapy sessions and outpatient
spine clinic follow up.
# ___:
Patient came to hospital with normal renal function but
developed ___ during course of ED stay. Her losartan and
furosemide were held initially and she was given gentle IVF and
her Cr normalized. Chem-7 should be checked on ___ to assess
renal function.
# Membranous Nephropathy with renal vein thrombosis: Chronic
stable issue stable proteinuria and on prophylactic warfarin
post-renal vein thrombosis. She was maintained on prednisone
5mg and azathioprine 50mg TID as well as warfarin for post-renal
vein thrombosis prophylaxis and omeprazole for GIB ppx. INR
should be checked on ___ and warfarin dose adjusted
appropriately. INR was supratherapeutic on admission and
warfarin dose decreased to 4 mg from 6 mg. Goal INR of ___.
# HFpEF: Held furosemide in setting of ___. Patient remained
euvolemic on exam. It was felt that daily weights should be
monitored on discharge and if weight increased > 3 lbs then
furosemide should be restarted at 80 mg BID.
# HTN: Chronic stable issue continued on amlodipine. Losartan
was initially held secondary to ___ but restarted prior to
discharge.
# Asthma: Patient remained without wheezing or cough this
hospital course. Home inhaler regimen continued.
#Incidental Imaging Findings:
Right kidney larger than the left, better assessed on the prior
CT abdomen study. Adnexal cyst noted on both sides on the
localizing images series 3, image 6, the larger 1 on the left
measuring 2.2 x 2.9 cm. | 211 | 613 |
13506053-DS-16 | 25,163,349 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please
follow your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- NWB RUE. ROMAT in ex fix.
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Add tramadol as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter andmay be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- No chemical anticoagulation needed
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
For patients discharged with external fixators in place, the
initial dressing may have Xeroform wrapped at the pin site with
surrounding gauze.
Often, the Xeroform is used in the immediate post-op phase to
allow for control of the bleeding. The Xeroform can be removed
___ days after surgery.
If the pin sites are clean and dry, keep them open to air. If
they are still draining slightly, cover with clean dry gauze
until draining stops.
If they need to be cleaned, use ___ strength Hydrogen Peroxide
with a Q-tip to the site.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a elbow fracture-dislocation and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for closed reduction and hinged external
fixation, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with OT who determined that
discharge to home with family support was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the operative extremity, and does not require DVT
prophylaxis on discharge. 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. | 598 | 255 |
15701011-DS-6 | 24,777,231 | Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with dissolvable sutures underneath
the skin and glue. You do not need suture removal.
Please keep your incision dry for 48 hours after surgery.
Please avoid swimming for two weeks.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
for 2 weeks.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs. | Ms. ___ was admitted to the Neurosurgery service on ___ due
to concerns, as exhibited on MRI, of a spinal cord lesion at the
C5-C6 level. She was admitted to the inpatient ward and kept
NPO, given IV fluids overnight in preparation for an operative
intervention on her cervical spine. Surgical intervention was
discussed on ___. Dr ___ surgery's risks and
benefits and the patient consented to surgery. Surgery was moved
to ___ because of OR scheduling/ timing. The patient was kept
inpatient in preparation for surgery. On ___ Ms. ___ remains
neurologically intact with the exception of motor strength 4-
bilat tricep and 4+ right quad/hamstring. Ms. ___ was
consented for the OR and will be NPO for planned C6 corpectomy
and C5-C7 fusion on ___.
On ___, the patient was taken to the OR for her scheduled
procedure, which she tolerated well. Please see the operative
report for further details. Post-operatively, the patient was
recovered in the PACU and transferred to the inpatient ward for
further management and observation. Her pain was controlled with
narcotic and non-narcotic analgesics. On ___ her JP drain was
discontinued and her pain was controlled. She was ambulating
independently. | 229 | 198 |
14660168-DS-5 | 29,242,521 | Dear ___,
___ was a pleasure to take care of you at ___
___. You were admitted for weakness and
lightheadedness. The most likely cause of your slow decline is
long term steroid use. We treated your weakness and
lightheadedness with IV fluids, vitamin supplementation and a
medication to increase your blood pressure (fludrocortisone). We
decreased your dose of prednisone to 2.5 mg daily. You are now
safe to go home.
Please take your medications as prescribed and follow up with
the appointments listed below.
The following changes were made to your medications:
DECREASED prednisone to 2.5mg daily
STOPPED atenolol because you blood pressure was low
STARTED fludrocortisone to increase your blood pressure
STARTED B12 for B12 deficiency
STARTED multivitamin for supplementation
STARTED potassium supplement because fludrocortisone lowers your
potassium | ___ yo female with a past medical history of pemphigus, on long
term corticosteroids, with recent functional decline of
uncertain etiology.
# Functional decline: The patient and her family report a rapid
functional decline starting 4 months prior to the patient's
hospitalization. The patient was referred to the ___ emergency
department by a member of the housestaff who was caring for her
husband on the ___. The patient has a history of chronic
steroid use for pemphigus (prednisone 12.5 mg QOD x years, with
higher doses in the past), although the disease has been
inactive for many years. The patient's overall past medical
history is concerning for iatrogenic ___ syndrome
evidenced by cataracts, glaucoma, psychiatric disturbances,
proximal weakness/wasting (CK 15), glucose intolerance (A1C
6.4), recent infections (dental abscess, pneumonia),
osteoporosis c/b vertebral fractures and skin thinning. Her more
recent problems stem from treatment of a dental abscess. While
undergoing treatment for the abscess her corticosteroids were
stopped. She was re-evaluated by her PCP who diagnosed her with
adrenal insufficiency. She was started on cortisone acetate 5 mg
BID and fludrocortisone. She subsequently developed severe
hypokalemia and a more rapid physical decline including
substantial weight loss. Her major complaints include weakness,
decreased appetite and fatigue. She had no focal neurologic
findings. She was able to stand from a seated position. Her B12
was found to be low and she was started on supplementation. TSH
was normal (1.2) as was AM cortisol (15). The patient's albumin
was 3.7. MMSE score ___. She was found to be orthostatic. The
patient also admitted to depression given her current physical
state and her husband's illness. Overall her presentation was
consistent with iatrogenic ___ and mineralocorticoid
deficiency. She was discharged on prednisone 2.5 mg daily and
fludrocortisone 0.1 mg daily. Potassium supplementation was
provided as well. The patient should undergo diagnostic and age
appropriate cancer screening due to her significant weight loss.
Treatment for depression should be considered as well.
# GERD/ulcer prophylaxis: Stable. The patient was continued on
omeprazole while hospitalized. The need for a PPI should be
reassessed if the patient is fully tapered off of
corticosteroids.
# Glaucoma: Stable. The patient was continued on brimonidine eye
drops.
# Diabetes mellitus: The patient's diabetes was most likely
induced by her long term corticosteroid use. Her A1C was 6.4%.
She was given sliding scale insulin while hospitalized.
Rapaglinide was continued at discharge.
TRANSITIONAL ISSUES
*******************
1. PCP follow up
2. Taper prednisone and fludrocortisone as appropriate
3. Please check CBC, Chem 10 on ___
4. Diagnostic and age appropriate cancer screening recommended
5. Consider treatment for depression | 121 | 421 |
19369340-DS-19 | 22,890,848 | You were admitted to the hospital with severe L1-L2 spinal
stenosis. You were offered surgery but declined and requested to
wait until after the holiday.
Activity
You must wear your brace at all times when out of bed. You may
apply your brace sitting at the edge of the bed. You do not need
to sleep with it on.
You must wear your brace while showering.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
until cleared by your
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs. | On ___ the patient presented to an OSH for back pain and fecal
incontinence and was transferred to ___ for further evaluation
after an MRI was obtained and was consistent with lumbar
stenosis with complete effacement of CSF at L1-2, and
retrolisthesis of L1 on L2. The patient was admitted to the
Neurosurgery service and was admitted to the floor for further
care and evaluation.
On ___ the patient had flexion and extension films done which
demonstrated that the patient has extrusion of the left L5
pedicle screw beyond the anterior margin
of the vertebral body. There are degenerative changes with loss
of intervertebral disc height at multiple levels. There is
retrolisthesis of L1 over L2 which measures 5 mm on flexion and
10 mm on extension. This constitutes abnormal motion. She
remained neurologically intact with paresthesias to her right
knee although stated this has been stable since she had a knee
replacement ___ years ago, and also endorsed paresthesias from the
lateral aspect of her left knee to left distal great toe. Her
dexamethasone regimen was discontinued.
On ___ surgery was offered to patient who declined until after
___. TLSO brace ordered. ___ consult placed.
On ___ the patient's exam remained neurologically stable. Her
pain was well controlled. Surgery was again offered but was
declined by the patient as she requested to wait until after the
holiday. She was seen by ___ while wearing the TLSO brace and was
recommended for home ___. She was discharged in stable condition. | 228 | 252 |
19480277-DS-20 | 24,044,009 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | Patient was admitted to the cardiac surgery service and was
taken urgently to the cath lab for drainage of pericardial
effusion that was causing tamponade physiology.
He tolearted the proceedure well. A pericardial drain was placed
for drianage of approximately 620cc of bloody drainage. He was
transferred to the CVICU for monitoring. During his stay in the
ICU he was hypertensive and medications were adjusted. He had
episodes of rapid afib and was bolused with amiodarone and
continued on amiodarone taper. He was resumed on coumadin
therapy. His pericardial drain was removed on POD#1. He remained
HD stable. TTE was obtained at discharge which was unchnaged
from previous per report.
He was cleared for discharge to home on POD# 2 All f/u
appointments arranged. | 132 | 123 |
18514858-DS-5 | 21,318,101 | Dear Mr. ___:
It was a pleasure taking care of you at ___
___. You came to the hospital for fatigue and shortness of
breath. You were found in atrial flutter, which is an irregular
rhythm of the heart that increases your heart rate. You also
presented an exacerbation of your heart failure, an acute injury
of the kidney and liver, and a urinary tract infection.
You were given medication to slow your heart beat, and were put
on diuretics to decrease fluid retention. You also received IV
antibiotics for your urinary tract infection. You responded
adequately, and were then transitioned to your regular oral
medication.
You will be sent home with a new medication for your heart,
digoxin 0.0625 mg daily and an antibiotic to take for two days
(cefpodozime). Your home metformin has been suspended since you
had an adverse drug reaction. You will continue to take the rest
of your medications as usual.
Please remember to take your medications, follow a healthy diet
and go to your cardiologist on the scheduled date. Weigh
yourself every morning, call MD if weight goes up more than 3
lbs.
Once again it has been a pleasure taking care of you.
Sincerely,
Your ___ team. | ___ y/o M with a PMH of paroxysmal a. flutter on eliquis,
constrictive pericarditis, ischemic cardiomyopathy (LVEF 40%),
type 2 DM and HTN who presents with SOB and fatigue and is
diagnosed with atrial flutter with RVR, acute on chronic sCHF,
___, ALF and urinary tract infection.
ACTIVE ISSUES
# Atrial flutter: Patient with PMH of paroxysmal afib, is
admitted with atrial flutter with a RVR of 114. Patient was
given a loading dose of digoxin 0.125 mg PO/NG Q6H (2 Doses),
and was then mantained on digoxin 0.0625mg PO QD and metoprolol
tartrate 25mg PO Q6H. Patient's HR around ___ with
medication, asymptomatic. Will be kept on that dose of digoxin,
and will receive metoprolol succinate 100mg QD. Has indication
for anticoagulation, is receiving apixaban 2.5 mg PO/NG BID.
# Acute on chronic sCHF: Patient with PMH of ischemic
cardiomyopathy with an LVEF 40%. At admission the PE was
suggestive of mild fluid overload (JVP elevated to jaw,
billateral crackles and +1 edema in BLE). However, due to
constrictive pericarditis, diuresis was managed with caution. He
received lasix IV bolus of 20 mg and was then transitioned back
to home dose of furosemide 20mg PO QD. His discharge weight is
68kg (down from 70.5 at admission).
# Metabolic acidosis high anion gap/ Lactic acidosis: At
admission lactate was 4.3 and patient had a high anion gap that
peaked at 28. The lactic acidosis was attributed to
hypoperfusion and/or metformin overdose. The patient has shown
slow downtrend throughout hospitalization. Last lactate= 3.2.
# ___: Patient admitted with Cr: 1.6. (Baseline ___. Probably
secondary to hypoperfusion. Peaked at 1.8. At discharge 1.4.
# Acute liver failure: There was evidence of transaminitis since
admission, with ALT 374 AST 377. There was also an increase in
INR up to 2.9 and the patient was not oriented (possible grade I
hepatic encephalitis). The lab values downtrended slowly with
medications and patient's mental status improved.
# UTI: Urine culture was positive for PROTEUS MIRABILIS
>100,000 ORGANISMS/ML. The patient did not report any symptoms.
He received ceftriaxone 1g Q24H for 5 days and will be sent home
with cefpodoxime 100 mg Q12h for 2 days.
# Disposition: On ___, the patient reported to the team that
he adamantly wished to be discharged home. His providers had
been working on getting rehab placement, and occupational
therapy had recommended either home with 24-hour supervision or
rehab placement. Given the patient's insistence, the risks and
benefits of going home without adequately supervision were
explained to his daughter, ___. Risks included
potentially life threatening falls and his impaired ability to
call for help appropriately. Attempts were made to discuss the
patient's care with the patient, but his grandson, who was by
the bedside, was incredibly rude to the care team and
particularly to the ___ interpreter; he refused to step out
of the patient's room when asked.
CHRONIC ISSUES
# CAD: Evidence of CAD on past stress test. No current CP.
Patient was kept on Atorvastatin 20 mg PO/NG QPM
# Type II DM: had been receiving metformin at home. HPI
suggested metformin toxicity, so patient was kept on an insulin
sliding scale. Fingersticks in 150s-200s. Patient will be
discharged without metformin, shoulf F/U diabetes treatment with
PCP. A1C 8.0%
# Dyslipidemia: Will be kept on Atorvastatin 20 mg PO/NG QPM
# Depression: Will be kept on Paroxetine 10 mg PO/NG DAILY
# FEN: Heart-Healthy diet | 199 | 562 |
14699427-DS-42 | 25,706,926 | You came to the hospital with 1. a severe migraine headache, 2.
pain of your right knee, and 3. diarrhea.
1. We treated your migraine with pain medication and anti-nausea
medication, as well as IV fluids. Please continue your
outpatient treatment of migraines, including lamotrigine for
migraine prevention. You may take the anti-nausea medicine
(zofran) by mouth if you continue to have nausea. Take pain
medications for your headaches as recommended by your primary
care doctor.
2. We took an x-ray of your R knee which was normal. We asked
our orthopedics colleagues to evaluate your knee, and in
consultation with your outpatient orthopedist decided not to tap
the small amount of fluid in your knee. They felt your knee was
stable and was very unlikely to be infected. However, you have
an appointment with your orthopedist Dr. ___ on ___
below), and you should follow-up with him regarding your knee
infection that happened in ___.
3. Your diarrhea might have been by the IV antibiotics you
received for your infected knee. All of your stool studies in
the hospital were negative. Please follow-up with your primary
care doctor regarding your diarrhea, especially if it persists.
If your diarrhea worsens, please make sure you are able to
hydrate yourself adequately, and seek medical attention. | Ms. ___ is a ___ year old woman with hx of right total knee
replacement, recently hospitalized at ___ for knee
infection s/p washout, s/p one month course of IV antibiotics,
admitted for one week of non-bloody diarrhea and migraine.
#Migraine: The patient's migraine improved with IV fluids, IV
zofran, and IV dilaudid 3 mg q2H prn pain. She briefly reported
nausa and emesis during this time, which resolved on its own.
The day prior to discharge, patient started to feel better.
#Diarrhea: This spontaneously improved upon admission such that
she had no bowel movements on HD1, one bowel movement on HD2,
and no bowel movements on HD 3. C diff repeated at ___ was
negative. All stool studies were negative: fecal culture,
campylobacter culture, ova and parasites, and fecal culture r/o
E coli. CT abd and pelvis was also reassuring.
#R knee: Noted to have mild effusion on exam, but patient had
full ROM and was able to ambulate. This was evaluated by ortho,
who in consultation with her home orthopedist decided not to tap
her knee. The patient was told by her orthopedist to take
warfarin for 6 weeks after the washout (to end ___, but it
was noted that her INR was subtherapeutic (1.1). Because it
would take her longer than this time to become therapeutic on
coumadin, in consultation with pharmacy, she was given enoxparin
30 mg BID SC for DVT ppx. She was discharged with 3 more doses
of enoxaparin.
#Asthma: stable and asymptomatic during hospitalization. We
continue home flovent and wrote for albuterol nebulizers PRN,
which she did not require. | 212 | 264 |
11770362-DS-9 | 21,806,627 | Dear Mr. ___,
You were admitted to ___ with lightheadedness and low blood
pressure. You were found to have bacteria in your urine and were
initially treated for a urinary tract infection; however, the
culture showed that the urine was likely contaminated and since
you had no other evidence of infection your antibiotics were
stopped. Your labs and blood pressure were consistent with
dehydration, which may be related to your recent chemotherapy,
so you received IV fluids. Your blood pressure and
lightheadedness improved with fluids. Please follow up with your
outpatient doctors as below.
If you have fevers, chills, or feel very unwell, please return
the ED.
It was a pleasure caring for you,
Your ___ Care Team | ___ yo man PMH C5-C6 paraplegia, recent dx metastatic
bladdercancer now presents with lightheadedness, syncope and
bacteruria.
#Lightheadedness/hypotension: Likely ___ hypovolemia as lactate
and Na improved with IVF, with low volume potentially related to
recent chemo administration. On first day of admission, had
episode of lightheadedness with SBP 97, vitals and sx improved
in ___ with IVF. Unlikely vertigo or medication effect given no
symptoms nor signs of vestibular disturbance and per heme-onc
his chemo regimen unlikely to cause vestibular effect,
especially as sx occurred several days after treatment. CT head
to r/o metastatic disease was negative. Autonomic dysfunction is
also on the differential given paraplegia, however less likely
given hypovolemia as noted above. No evidence of active
infection at this time. Patient continued to have some
lightheadedness initially after sitting up, but this improved
over the course of his admission and he was able to sit in
wheelchair without difficulty at time of discharge.
#Bacteruria: Initial concern for UTI given sx and UA with >182
WBC and bacteria; however, 6 epis in UA and Ucx, while growing
>100K pseudomonas, also grew skin/genital flora making
contamination/colonization likely.Given paraplegia and urinary
stasis, uses condom catheter and is on tamsulosin with Bactrim
ppx as outpatient. Has had
prior tx for urinary retention and remote hx of UTI in past. No
culture data in our system but known colonization. Difficult to
fully assess sx given paraplegia, but no WBC elevation, no
fevers. Initially covered with CTX and then switched briefly to
cipro when pseudomonas speciation was released, but
sensitivities showed only intermediate sensitivity to Cipro and
patient improved even without adequate antibiotic coverage,
making colonization and not active infection even more likely.
Antibiotics stopped and patient restarted on home bactrim ppx on
discharge. ___ benefit from intermittent self-caths if retention
predisposing to UTI's (f/u with urology).
#Metastatic bladder CA: Received cisplatin/gemicitabine ___.
Followed closely by heme-onc.
#Paraplegia: No sensation or motor function below nipple line.
Cared for closely by wife who is ___.
>30 min spent on discharge coordination on day of discharge | 118 | 340 |
13764116-DS-12 | 26,842,749 | ******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: Please keep wounds clean and dry. Any suture
removal will occur at your follow-up visit.
- Keep wounds clean. ___ shower letting soap and water run over
the wound. Pat dry and cover with clean/dry dressings. Do not
submerge in hot tub, pool, ocean, lake, river, dishwater, or any
standing water.
-Keep right hand elevated above the level of the heart as much
as possible.
******WEIGHT-BEARING*******
nwb rue, finger ROM as tolerated
******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 ___.
-Antibiotics per ID _______________
*****ANTICOAGULATION******
- None
******FOLLOW-UP**********
Please follow up with Dr ___ in ___ days post-operation
for evaluation. Call ___ to schedule appointment upon
discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
Follow-up with Behavioral Health Services at ___ Women's
Hospital with ___ as scheduled.
Physical Therapy:
non-weight bearing right upper extremity, finger range of
motion as tolerated. Try to move each finger (including long
finger) through full extension and flexion 4 times a day.
Treatments Frequency:
-Keep right upper extremity elevated as much as possible.
- ___ shower daily letting soap and water run over wound. Pat
dry and replace clean, dry, bandages. | The patient was admitted to the Orthopaedic Trauma Service for
I&D of wound infection on right hand. The patient was taken to
the OR and underwent an uncomplicated I&D and removal of foreign
bodies. 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 PO pain meds. The patient
tolerated diet advancement without difficulty and made steady
progress with ___. Infectious diesease and psychiatry were
consulted
Weight bearing status: nwb rue, finger ROM as tolerated.
The patient received ___ antibiotics as well as
pneumoboots for DVT prophylaxis. The incision was clean. The
patient was discharged in stable condition with written
instructions concerning precautionary instructions and the
appropriate follow-up care. The patient will not require DVT
prophylaxis. All questions were answered prior to discharge and
the patient expressed readiness for discharge. | 289 | 154 |
14460495-DS-14 | 22,779,527 | Dear ___,
___ were admitted with headache and fever consistent with HSV
ENCEPHALITIS. ___ had a lumbar puncture at ___ that
showed inflammation and suspicion for infection. ___ were
started on broad spectrum antibiotics and acyclovir. ___ had a
MRI that showed swelling of your right temporal lobe. ___ were
transferred to ___ for further management. ___ were started on
Keppra to help prevent seizures. The bacterial cultures were
negative so ___ were taken off antibiotics. ___ were kept on the
acylovir to continue a 21 day course. ___ had an EEG that showed
slowing on the right side but no seizure activity. ___ had a
repeat MRI on ___ that was stable. ___ had a repeat LP on ___
that showed improvement in the white blood cell count. ___ were
deemed stable for discharge on ___ with home acyclovir dosing.
___ should follow up with neurology as scheduled below.
The following changes were made to your medications:
Start:
Acyclovir 800mg every 8 hours, to be completed on ___
Keppra 750mg twice a day | # Neurology: Mrs. ___ was admitted, started on acyclovir,
vancomycin, ceftriaxone, and ampicillin. She was connected to
vEEG. She stated that she had been having episodes of metallic
smells concerning for temporal lobe seizures. She was started on
keppra 750mg BID. Her EEG showed slowing in the right temporal
lobe but no epileptiform activity. It was discontinued after
24hrs. She was given toradol and tylenol #3 for pain control.
She had a normal neurological exam and was asymptomatic after
___ days of admission. She had a repeat MRI on ___ that showed
a stable right temporal lobe hyperintensity but did not have as
much contrast enhancement. She had a repeat LP done on ___ that
had an improved WBC count of 130. She was deemed stable for
discharge and to complete a 3wk course of acyclovir.
# ID: Her bacterial cultures from the initial lumbar puncture at
___ were negative. She came back HSV1 PCR positive. She was
taken off antibiotics after negative cultures and kept on
acyclovir. The rest of her viral testing was negative. The
repeat HSV is pending. | 171 | 182 |
13581631-DS-34 | 28,150,960 | Dear Mr. ___,
You were admitted to ___ after you were found to have low
blood pressure and a fast heart rate at dialysis. You were
given a medication to help slow your heart rate and keep you in
a normal rhythm. You also had a few sessions of dialysis here
to removal extra fluid. You had a repeat echocardiogram of your
heart which shows that your heart is not pumping as well as it
was a year and a half ago which is likely due to your history of
high blood pressure and dialysis.
WHAT TO DO NEXT:
- Take all of your medications as prescribed.
- Keep all of your dialysis appointments.
- Weigh yourself daily and call your doctor if your weight
increases by more than 3 pounds in one day.
- Avoid eating more than 2g of salt per day and drinking more
than 2L of fluid per day.
- Please follow up with your cardiologist and primary care
physician as scheduled for you.
Please seek immediate medical care if you develop chest pain,
trouble breathing, or pass out.
We wish you the best in health moving forward,
Your ___ Care Team | ___ year old M with PMHx ESRD secondary to chronic HTN on ___ HD,
HFpEF (___), Afib on Coumadin, COPD on home O2, who
presented with dyspnea, generalized weakness, poor apetite,
tachycardia, hypotension and productive cough initially admitted
too the MICU for presumed volume overload after missing ESRD who
was subsequently transferred to the CCU for further management
after he was found to have severe global biventricular systolic
dysfunction on TTE:
# Acute Systolic Heart Failure Exacerbation
# NSTEMI
Patient presented with dyspnea, tachycardia, and hypotension
consistent with volume overload after missing his HD session on
___ prior to admission due to tachycardia. On day of
admission, patient sent from HD to emergency room for
tachycardia. Etiology of tachycardia and hypotension thought to
be secondary to atrial fibrillation with rapid ventricular
response and dyspnea and cough thought to be secondary to volume
overload after missing dialysis. TTE on admission revealed
severe global hypokinesis with newly depressed EF 25%. After
controlling his rate with metoprolol and volume removal, patient
had a subsequent TTE with severe LV diastolic dysfunction
suggestive of restrictive cardiomyopathy and EF 30%, likely
secondary to his ESRD and HTN with low suspicion of ischemic
etiology. Patient was discharged home on Metoprolol 100mg XL
daily, ASA 81mg daily, and atorvastatin 80mg daily with
appropriate primary care and cardiology outpatient follow up.
# Hyperkalemia
# ESRD on HD (___ schedule)
Patient presented with acute hyperkalemia likely secondary to
intravascular hypovolemia as suggested by elevated cell counts)
and missed HD sessions prior to admission. Urgent ultra
filtration was performed in the ED on admission and patient
received HD two sessions on ___ and ___.
# Paroxysmal atrial fibrillation
Patient has history of cardioversions and takes warfarin and
metoprolol. Given atrial fibrillation and rapid ventricular
rates with resultant hypotension, decision was made for
amiodarone load. Patient in sinus rhthym on discharge. Patient
discharged on amiodarone 400mg BID through ___ and then
daily, Metoprolol 100mg XL daily for rate control, and warfarin
with goal INR ___.
# Transaminitis
Patient had ALT/AST elevation to 300s, which were
downtrending/stable prior to discharge. Etiology unclear,
either secondary to hepatic congestion in setting of volume
overload versus medication side effect from empiric antibiotics
given on admission given his initial undifferentiated
hypotension, tachycardia, and cough. Amiodarone also possible.
RUQ u/s obtained and unremoarkable. TSH normal. Abdominal exam
benign. His outpatient primary care provider was contacted who
will follow up for resolution outpatient.
# COPD
# OSA
Patient continued on home O2 at night in hospital. Started
Advair as patient was not on home inhaler.
# Anemia
# Thrombocytopenia
Stable in patient, presumed secondary to ESRD. Patient is s/p
on Ferumoxytol ___.
# Hyperlipidemia: Atorvastatin replaced home pravastatin.
# Peripheral neuropathy: Continued gabapentin.
# Gout: Continued home allopurinol.
# History of Recurrent Cdiff: Patient takes oral vancomycin at
home for prophylaxis. Patient did not receive vancomycin in
house as did not have prior documentation for this for pharmacy
release of medication and in-house C.difficile negative.
# BPH: Home Doxazosin recently discontinued outpatient prior to
admission in setting of hypotension.
TRANSITIONAL ISSUES
===========================
- Patient discharged with transaminitis w/ possibility of
amiodarone effect, please assess for resolution on follow up.
- Patient's newly discovered restrictive cardiomyopathy was felt
to be related to his ESRD and history of HTN. Please evaluate
for alternative causes as clinically indicated, i.e amyloidosis.
- Amiodarone load for atrial fibrillation initiated on ___ and
patient discharged on amiodarone 400mg BID on ___. He will
start amiodarone daily on ___.
- The patient was found to be C.diff negative and therefore his
PO vancomycin was stopped.
- Patient was discharged with an INR of 1.8. His warfarin dose
was decreased to 1.5mg daily given his amiodarone. His INR
should be closely followed, and adjustments made as needed for
goal INR ___.
- The patient was not started on an ___ given low blood
pressures. Please consider outpatient initiation as tolerated
in the outpatient setting.
# Code: Full, confirmed
# Communication/HCP: ___ Wife/HCP ___ (H),
___ (c); Daughter ___ is ___ contact/co-HCP
___
# DRY WEIGHT: 65kg | 189 | 708 |
18857939-DS-15 | 29,292,852 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for changes in your behavior and concern
about your temperature being a little higher than usual
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital, we found that you were
dehydrated and the salt level in your blood was too high. We
gave you fluid to fix this.
- You also had some kidney injury which was also improved by
the fluids.
- We found that your INR level was too high, so we held your
warfarin. On the day of your discharge was 3.1.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Continue to try to drink in fluids and eat soft foods as much
as possible
- Restart your Coumadin only after your INR level is less than
3.
We wish you the best!
Sincerely,
Your ___ Team | ___ female with a past medical history significant for
advanced Alzheimer's dementia with behavior disturbances,
depression, DVT on warfarin, rectovaginal fistula with sigmoid
colostomy, who is presenting from ___
with lethargy, found to have hypernatremia, leukocytosis, with
possible aspiration pneumonitis on CXR. Patient's hypernatremia
and Cr improved with hydration. Per ___ discussion with
daughter, family preferred to continue oral feeding with
soft/pureed foods despite aspiration risk at this time.
TRANSITIONAL ISSUES
====================
[] Patient is on a variety of medications. Given her age and
multiple comorbidities, she would benefit from deprescribing.
[] ___ should check INR on ___ and resume
Coumadin if in range
[] Encourage oral hydration as much as possible given patient's
risk of dehydration
[] Please follow up blood culture pending at discharge.
ACUTE ISSUES ADDRESSED
=======================
#Hypertnatremia
Patient presenting with a sodium of 153. Likely hypovolemic
hypernatremia in the setting of poor PO intake reported by
daughter. Patient was slowly repleted with NS followed by D5W
(received total of 2.5L). Na improved from 153 -> 143 on day of
discharge.
#Leukocytosis
Patient presented with white blood cell count of 12 with a
neutrophil predominance. No clear evidence of infection was
found. Chest x-ray was without consolidation but with possible
mild aspiration/atelectasis, UA without evidence of infection,
LFTs within normal limits. Flu PCR negative. UCx and BCx without
growth at time of discharge. Most likely cause of leukocytosis
is aspiration pneumonitis given aspiration risk described below.
Given lack of clear etiology, improvement in patient mental
status, and lack of fevers, no antibiotics were given.
Leukocytosis downtrended on day of discharge.
#Aspiration Risk
Speech & Swallow saw the patient and were concerned about
aspiration. Patient was initially maintained NPO. Per
conversation with daughter, patient had been doing well with 1:1
feeding and cueing at living facility. Given this, she expressed
a preference to continue feeding patient despite aspiration
risk. Patient was transitioned to pureed diet with thin liquids.
#GOC
Per last ___, pt is full code. The daughter confirmed that her
mother would want everything done to prolong her life.
___ on CKD
Per ___ records, the patient's baseline creatinine is ___.
Cr on admission was 1.5, likely in the setting of decreased PO
intake. Improved with IV fluids to 1.0.
#DVT on warfarin
Patient with DVT diagnosed in ___ on indefinite
anticoagulation. On admission, INR elevated at 3.5. Warfarin was
held with plan to recheck at ___ and restart if
within range. INR on day of discharge 3.1.
#Alzheimer's dementia
Continued home donepezil, memantine, risperidone. Held lorazepam
given concern for deliriogenic effects.
#Hypertension (Goal <150/80 given age/frailty)
Continued home atenolol
#Depression
Continued home trazodone QHS, citalopram
CORE MEASURES
#CODE: Full (confirmed w daughter, ___ in ___
#CONTACT: ___ (Daughter) Phone: ___ | 188 | 439 |
18600028-DS-36 | 26,135,329 | Dear Mr. ___,
It has been a pleasure caring for you at ___.
Why was I here?
-You were here because you had chest pain.
What was done while I was here?
-We looked in your arteries and we found that there is some
blockage but not enough to require a procedure.
-Your heart artery problem will be managed by medicines.
What should I do when I get home?
-You should follow up with your cardiologist.
-Please look at your medication list for any new meds and
changes.
We wish you the best!
Sincerely,
Your ___ Medicine Team | ___ is a ___ ear old man with paraplegia secondary to
a fall in ___, chronic pain, recent bilateral psoas abscesses
who presents with acute onset chest pain and troponin elevation.
He was found to have troponin elevation but no STE on EKG. He
was taken the cath lab for coronoary angiography on ___,
___, which showed no significant blockage, moderate ___ LAD
disease, and nothing to stent. The plan is to optimize medical
management for his CAD by starting atorvastatin 80mg, metop
succinate 25 mg, and ASA ___oes not want to take
Plavix, so he will just be on dual therapy with warfarin +
aspirin. | 88 | 107 |
15574516-DS-14 | 23,019,179 | Dear ___,
You were admitted to the Stroke Service at ___
___ after presenting with right-sided weakness. MRI
of your brain was negative for evidence of stroke. Your were
noted to have a large number of white blood cells in your urine,
suggesting the possibility of a urinary tract infection. You
had recently completed a 7 day course of Macrobid. You were
restarted on another 7 day course of Macrobid. However, you
should discuss this with the physician who manages your urinary
difficulties to see if this is the treatment he/she would like
you to have based on your prior urine culture results. A urine
culture is pending at ___ at the time of discharge. | Ms ___ was admitted to the Stroke Service at ___
___ after presenting with right-sided
weakness. MRI of her brain was negative for evidence of stroke.
Her weakness was felt to be functional in origin considering the
drift without pronation and the clear signs of give-way
weakness, but full strength with encouragement. Her UA was
notable for 86 WBC, + nitrites, and large leukocyte esterase
with only 3 epithelial cells, concerning for UTI. She had
recently completed a 7 day course of Macrobid. She was restarted
on another 7 day course of Macrobid and instructed to discuss
this with the physician who manages her urinary difficulties. A
urine culture at ___ was done and was found to be positive for
E.coli, however, further incubation showed contamination with
mixed skin/genital flora. Clinical significance of isolate(s)
was thought to be uncertain. | 120 | 141 |
14170029-DS-7 | 27,348,631 | Dear Mr. ___,
You were admitted to the ___ because of problems breathing.
Based on your history and imaging, we think you may have
aspirated, or choked, leading to an infection of your lungs.
You were started on IV antibiotics and assessed by our speech
and swallow pathologists. They felt you were having significant
problems swallowing. You should continue to be very careful
when you eat because you are at risk for aspirating which can
lead to pneumonia and even death. You are now on a modified diet
for your safety.
You were also noted to have an old bleed on the CT scan of your
head. Most of this was old, although there were some signs of a
new bleed. Please be careful on your feet, as every fall may
put you at risk for worsening bleed. You should call your
doctor immediately if you have any worsening weakness or other
concerning symptoms.
Finally, you were also noted to have decreased heart function.
Please call your doctor if you have chest pain, gain >3lb or
notice worsening swelling of your legs.
It was a pleasure taking part in your care,
Your ___ Medicine Team | ___ yo M w/ afib, COPD, moderate-severe dementia presenting with
acute respiratory failure and chest x-ray concerning for
bilateral infiltrates.
# altered mental status, progressive dementia: He was initially
intubated in ED for airway protection in the setting of altered
mental status with mixed picture of hypercarbic and hypoxic
respiratory failure. Patient's mental status continued to
improve after being called out of ICU, although he remained
altered. Per family, patient was at baseline. Dysarthric,
somewhat appropriate in responses, but not always intelligible.
Notably, pt with progressive dementia over past year.
Moderate-to-severe per FAST testing w/ PCP. Pt has HTN, smoking
hx, but normal lipid panel; possible component of vascular
dementia. Pt additionally found to have acute on chronic SDH
which could be responsible for, at least in part, his altered
state; no focal findings on neuro exam. Neurosurgery consulted;
did not feel SDHs were responsible for current presentation.
Patient was continued on home donepezil. Home melatonin was
held.
# aspiration PNA: concern given CXR opacities and acute
respiratory distress. Likely in setting of dementia. No
foreign body on CXR. Likely etiology of mixed hypercarbic and
hypoxic respiratory failure esp in setting of COPD. Could also
be CAP/aspiration given polymicrobial sputum specimen; S/S of
sputum unable to be performed given polymicrobial nature of
infxn. Legionella, MRSA, rapid viral panel negative. S/S
consulted in ICU who made patient strict NPO. Eventually was
reevaluated with video and patient was advanced to pureed/honey
diet. In reagrds to antibiotics, patient received Vanc/cefepime
(___), flagyl ___, then switched to monotherapy
with unasyn ___.
# hypoxia: The most likely cause for his respiratory failure was
an aspiration event given history of gargling and chocking in
the context of bilateral infiltrates and a history of
moderate-severe dementia. He was treated with
Vancomycin/Cefepime/Azithromycin. Emphysematous changes were
noted on CT C-spine and he was also treated with solumedrol for
a 5 day COPD exacerbation course. TTE was done which
demonstrated severe global left ventricular systolic dysfunction
(EF 20%) and regional RV systolic dysfunction. His respiratory
status improved and he was extubated on ___ prior to callout
to medicine floor.
# COPD: Wheezy on exam, hypercarbic, extensive smoking hx, CT
findings of possible interstitial lung dz suggestive of COPD. No
prior PFTs, no use of inhalers or O2 at home. Received
Albuterol/ipratropium nebs. Received a short course of azithro
(z-pak) and solumedrol (___) followed by a 4 day pred burst.
Consider PFTs/pulm f/u as outpatient.
# h/o subdural hemorrhage: For his moderate-severe dementia with
a suspected component of vascular dementia he underwent NCHCT on
admission which was negative for ICH or acute process, although
positive for likely chronic frontoparietal SDH. He did not have
a reported history of trauma or falls. Neurosurgery was
consulted and recommended no acute surgical intervention and
followed with repeat NCHCT in 6 weeks as an outpatient for
monitoring. His neurology exam was non focal. Home ASA was
continued and SQ heparin was started. He underwent speech and
swallow evaluation for aspiration.
# global systolic dysfunction: New, identified on echo.
Consider infiltrative vs toxic vs diffuse CAD. Started on 40
atorvastatin. He had no signs of volume overload. Given his
poor functional status and advanced dementia decision was made
not to pursue further work-up as an inpatient.
# HTN: Hypotensive in ED required 2L fluids with appropriate
response. Hypertensive up to SBP 170s in ICU post-extubation,
improved s/p IV hydral and labetalol. Patient's SBPs remained
150-160 while on medicine floor.
# CKD: Baseline creatinine ~1.2. Stable/better than baseline
during hospitalization.
# BPH: Foley placed in ED. Removed on xfer to floor ___.
Restarted home finasteride on medicine floor. Patient on condom
cath given urinary incontinence.
# Glaucoma: Blind in L eye. Continued home timolol, latanoprost
gtt.
#Primary prevention: continued ASA 81mg. | 200 | 633 |
19056923-DS-17 | 27,271,973 | Dear Ms. ___,
WHY WAS I ADMITTED?
-You were admitted for shortness of breath and chest pain due to
accumulation of fluid around your lungs.
WHAT WAS DONE FOR ME WHILE I WAS IN THE HOSPITAL?
-Your shortness of breath and chest pain was due to the fluid
that accumulated around your lungs which is a complication of
your liver disease.
-Our colleagues in interventional pulmonology placed a tube in
your chest to drain the fluid around your lungs which resulted
in improvement of your breathing. They removed the tube once
your breathing improved.
-Your kidney function was worse than normal for you when you
were admitted. We gave you a medication called albumin and held
your diuretics ("water pills") in order to improve your kidney
function.
- Once you kidney function improved, we gave you diuretics
("water pills") as needed to reduce any re-accumulation of fluid
around your lungs after the chest tube was removed.
-Our colleagues in interventional radiology later performed a
TIPS procedure to help decrease the pressure in your liver that
is causing fluid to accumulate in your lungs and abdomen.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed.
- Please follow up with your primary care physician ___ ___
days of discharge. Please call as soon as possible to schedule a
follow up appointment.
- Please follow up with ___ interventional radiology for your
radio-frequency ablation procedure for treatment of your liver
cancer.
- Please follow up with your specialist providers at the ___
___, with your hematologist in ___, and with
any appointments listed in this summary.
- If you haven any fever, chills, nausea, vomiting, weight gain,
increased swelling, or shortness of breath please call your PCP
or come to the emergency department.
It was a pleasure caring for you at ___.
Best Wishes,
Your ___ Care Team | Ms ___ is a ___ female with past medical history
significant for insulin-dependent diabetes mellitus and NASH
cirrhosis ___ B/C) complicated by a history of
encephalopathy, esophageal varices (status post bleed several
years ago), recurrent hepatic hydrothorax, and HCC who presents
with shortness of breath, chest pain and evidence of a right
hepatic hydrothorax.
#NASH cirrhosis ___ B/C)
#Hepatic hydrothorax
The patient has a history of NASH cirrhosis ___ B/C),
currently on the transplant list and followed by Dr. ___ as
an outpatient. Her cirrhosis has been complicated by
encephalopathy, esophageal varices (status post bleed several
years ago), recurrent hepatic hydrothorax, hyponatremia on
tolvaptan and HCC. For this admission, she presented with
shortness of breath, pleuritic chest pain, minimal ascites on
exam, found to have a large right pleural effusion on CXR,
concerning for hepatic hydrothorax. Her recurrent hydrothorax on
presentation occurred the setting of her spironolactone being
decreased from 100 mg daily to 25 mg daily secondary to
hyponatremia. While in the ED, the patient had a pigtail
placement with drainage of 1L of fluid with symptomatic
improvement. At this time her chest tube was clamped. On
admission, the patient had a MELD score of 14 and was without
any localizing signs of infection. The chest tube was removed on
___ and the patient remained stable with good O2 saturation on
room air. Her pleural fluid studies were consistent with a
pseudoexudate, most likely hepatic hydrothorax. Her home
diuretics were initially held due to creatinine increase to 1.3
from baseline of 1.0. She was given albumin 75g x2 and 25g x1.
As her creatinine returned to baseline levels, Lasix ___ IV
was started as diuretic therapy to treat her continuing
hydrothorax. An abdominal ultrasound was also obtained which
showed no lower abdominal ascites. The patient was evaluated by
interventional radiology for TIPS placement given her continued
recurrences of hydrothorax on diuretic therapy. The
interventional radiology team performed the TIPS procedure and a
right thoracentesis (draining 4 L) on ___. Following TIPS,
there was concern for ischemic hepatitis given significant
elevation in LFTs and up-trending INR, however these values
stabilized and downtrended after several days. She spiked a
fever to 100.7 F post TIPS with a mild leukocytosis, was
pan-cultured (blood cultures no growth, and no growth in urine
or sputum culture), but remained afebrile since with a normal
WBC. Following TIPS and thoracentesis, she also reported some
hemoptysis, thought to be due to epistaxis, though this
resolved. During her hospitalization, frequent CXRs were
obtained to monitor recurrence of her right hepatic hydrothorax.
Prior to discharge, the most recent CXR showed stable residual
hydrothorax. The patient was continued on rifaximin, ursodiol,
vitamin B12, and lactulose during hospitalization. On discharge
she was breathing well on RA and MELD score was 19.
# Pancytopenia
On admission, the patient had evidence of pancytopenia (WBC 2.2,
Hgb 10.8, plt 22) that was stable from prior admission. Her
pancytopenia has been persistent since her first labs recorded
in the ___ system on ___. She is followed by a
hematologist in ___, Dr. ___
(___). Per her hematologist, the patient's pancytopenia
is most likely due to her liver disease though she had at one
point considered an autoimmune process. A bone marrow biopsy was
preformed by her hematologist on ___, notable for erythroid
hyperplasia, normal number of megakaryocytes, suggesting
hypersplenism as main etiology of her cytopenia. There was no
evidence of lymphoma, MDS, or MPD (BM report from OSH placed in
chart). We trended her CBC, which showed improvement
#Coagulopathy
INR was 1.4 on admission, stable from prior admission. The
patient's coagulopathy was thought to be due to underlying liver
disease. INR remained stable around 1.4-1.7 until after the
TIPS, when it increased to 2.3 likely in the setting of lier
ischemia. However, the INR downtrended to 1.9 on discharge. | 304 | 633 |
16836795-DS-7 | 28,061,659 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- You were admitted for dysphagia and weakness.
WHAT HAPPENED IN THE HOSPITAL?
- You underwent electromyography (EMG) which was normal, meaning
that your muscles are nerves are working normally.
- Your labs including electrolyte, thyroid, adrenal, vitamins
and minerals were normal.
- Speech and swallow evaluation showed that your swallow
function appears safe and functional.
WHAT SHOULD YOU DO AT HOME?
- Advance your diet as tolerated.
- Increase your activity with physical therapy and exercise.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | BRIEF SUMMARY:
___ year-old woman with history of fatigue, weakness, and
hypophonia since ___ diagnosed with "myasthenia-like
syndrome" with negative myasthenia antibody profile, POTS,
gastroparesis, SIBO who presented to the ED with reports of
progress weakness, dyphagia, and weight loss. | 101 | 35 |
19063167-DS-18 | 21,716,338 | You were admitted to the hospital with a lower GI bleed. You
were taken to the operating room and had part of your colon
removed. You have no further evidence of bleeding and are
recovering well from the procedure. Your incisional staples will
be removed at your follow up appointment listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or dilaudid. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | Mr. ___ is a ___ with HTN, GERD, diverticulosis, and multiple
diverticular bleeds who is presenting with BRBPR, with presumed
diverticular source.
.
# BRBPR: The patient has had multiple episodes of bright red
blood per rectum, likely ___ diverticular bleeds. He was most
recently admitted on ___, during which he was transfused
3U PRBCs, with a crit 25.9 at the time of discharge.
Colonoscopy from ___ with evidence of diverticulosis of the
sigmoid, descending, and transverse colon. An EGD done on
previous admission (___), was normal with no ulcers or
other potential sources for bleeding. The patient was
discharged then represented with another episode bright red
blood per rectum. The patient was initially doing well on the
floor, but had episode of BRBPR with feeling of dizziness and
shortness of breath; was given another unit of PRBC. CTA was
not able to localize the source; showed e/o diverticulosis.
.
While in the unit, the patient was transfused for goal crit of
30, receiving 4 units PRBC. He had a tagged RBC scan which did
not show bleeding source and the patient was not taken to ___ for
embolization. Surgery was also on board, and because no
specific bleeding vessel was found, the patient was taken to the
OR on ___ for R hemicolectomy.
.
# HTN: The patient's home atenolol was held in the setting of
his GI bleed. It was restarted postoperatively when
hemodynamically stable and the patient was tolerating PO's.
.
# Back pain: The patient's home percocet was continued
preoperatively. APS was consulted for postoperative pain
management and an epidural was placed. He was also started on a
PCA. On POD#3, the epidural was removed and he was transitioned
to oral pain medications. At discharge, he reported adequate
pain control with an oral regimen.
.
# GERD: On PPI at home, was held perioperatively and restarted
on POD#2 when tolerating PO's.
Postoperatively, the patient remained stable on the surgical
floor. His intake and output was monitored. On POD#3 after
removal of the epidural, his foley catheter was removed at which
time he voided without difficulty. His vital signs were
routinely monitored and he remained afebrile and hemodynamically
stable. His hematocrit remained stable. His WBC remained normal.
His electrolytes were monitored and repleted as needed. He was
encouraged to mobilize out of bed early as tolerated, which he
was able to do independently. He was also started on SC heparin
postoperatively for DVT prophylaxis.
Initially postoperatively, he was kept NPO and given IV fluids
for hydration. A NG tube was placed intraoperatively and removed
on POD#1. On POD#2 he reported passing flatus and he was started
on clear liquids, which were slowly advanced to a regular diet.
On POD#3, he was tolerating regular food without
nausea/vomiting. He was hemodynically stable and afebrile. His
pain was adequately controlled with oral pain medication and he
was out of bed ambulating independently. He was discharged to
home with follow up scheduled in ___ clinic ___. | 799 | 506 |
16921793-DS-49 | 23,590,416 | Dear Ms. ___,
You were admitted for shortness of breath. This was likely due
to worsening of your pulmonary hypertension as well as some
excess fluid in your body. You underwent dialysis to remove
fluid and were given inhalers and were feeling better.
Please see the attached list for changes to your medications. | ___ yo woman w/a hx of HTN, HLD, ESRD s/p failed transplant on
dialysis, severe multivessel CAD and pHTN who presents acute on
chronic dyspnea on exertion.
# Shortness of breath/pulmonary HTN: patient presented with
acute on chronic dyspnea on exertion in the setting of known
moderate to severe pulmonary hypertension. EKG was unchanged
and troponins were at baseline. Repeat ECHO here showed some
progression of pulmonary artery hypertension with elevated in PA
pressures and global RV dysfunction. Patient's symptoms were
likely due to worsening of her pulmonary hypertension in the
setting of slight volume overload. Patient underwent right
heart cath on ___ to assess pulmonary hypertension and
responsiveness to vasodilators, which she failed. Pulmonary
service was consulted who recommended keeping patient close to
dry weight as possible, starting advair BID, and having close
follow-up in ___ clinic for possible IV prostacyclin therapy.
CTA thorax was also done which showed no PE or evidence of ILD.
Patient symptomatically improved after dialysis treatments and
initiation of albuterol nebulizers. Patient was also started on
isosorbide mononitrate for potential responsiveness to nitrates.
She was discharged with a prescription for albuterol nebulizer
and advair and will follow-up in ___ clinic for her pulmonary
HTN.
# CAD: multivessel disease not amenable to intervention on
previous cath in ___. Patient did not c/o chest pain,
troponins remained at baseline, EKG was unconcerning. She was
continued on metoprolol, aspirin, atorvastatin 80.
# Asthma: patient reported symptomatic improvement with
nebulizer treatments. She was given a prescription for
albuterol nebs as well as adavair.
# ESRD on HD: nephrology was consulted, patient received
dialysis as per home schedule. Patient received dialysis as
needed, next due date is 2.19.
CHRONIC ISSUES
# HTN: stable, continued metoprolol, losartan
# HLD: continued atorvastatin 80mg
# GERD: continued omeprazole
# Chronic pain: pain controlled with tylenol
# Seizure Disorder: patient reports nonconvulsive seizures.
Continued keppra 500 mg QHS and QHD ___.
# Hypothyroidism: continued levothyroxine 75 mcg
# Anxiety: continued home lorazepam 0.5 mg tablet
TRANSITIONAL ISSUES
1. Patient has close followup to discuss further workup and
therapy for her severe pulmonary hypertension, which is likely
the cause of the progressive decline in her exertional capacity.
2. Patient remained full code. | 53 | 388 |
16713571-DS-14 | 23,584,257 | Dear Ms. ___,
You presented to ___ on ___ ___ concerns of increasing
redness and drainage from your prior abdominal debridement site.
You had a CT scan and an ultrasound of your liver which were
concerning for a cecal mass and new mass on your liver. You
were admitted to the Acute Care Surgery team for further medical
evaluation.
On ___, you had a biopsy of your liver. The pathology
report showed you to have adenocarcinoma. The Medicine and
Hematology/Oncology teams are aware of your diagnosis and you
have follow-up appointments scheduled with them as an outpatient
(please see below). You also a follow-up scheduled with Dr. ___
in the ___ Care Surgery clinic.
You are now medically cleared for discharge. Please note the
following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | ___ year-old female with a history of RLQ abdominal wall
abscess/infection s/p debridement in ___, who now presented
to ___ on ___ with complaints of increased erythema and
drainage from her prior debridement site. On HD1, she had a CT
Abd/Pelvis and liver ultrasound which showed concern for
suspicious for colorectal carcinoma with hepatic metastases. She
was admitted to the Acute Care Surgery team.
On HD3, the patient underwent an ultrasound-guided targeted
liver biopsy. The finalized pathology report on ___
indicated metastatic adenocarcinoma, moderately-differentiated,
consistent with a colorectal primary. The patient was notified
of this finding, the Hematology/Oncology team was consulted and
outpatient follow-up appointments were made for the patient to
follow-up for outpatient care.
The patient was alert and oriented throughout hospitalization.
Pain was controlled with oral pain medication. The patient
remained stable from a cardiovascular standpoint; vital signs
were routinely monitored. The patient remained stable from a
pulmonary standpoint. Good pulmonary toilet, early ambulation
and incentive spirometry were encouraged throughout
hospitalization.
The patient tolerated a regular diet. The patient's intake and
output were closely monitored. The patient's fever curves were
closely watched for signs of infection.
The patient's blood counts were closely watched for signs of
bleeding, of which there were none. 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. | 420 | 280 |
19906564-DS-10 | 24,594,046 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had a severe infection of the
left knee with spread of bacteria to your bloodstream.
What happened while I was in the hospital?
- You underwent washout of the left knee and then removal of all
the joint hardware. There is now an antibiotic spacer and you
will need 6 weeks of IV antibiotics to ensure clearance of the
infection. You required brief ICU stays because of rapid heart
rates and are doing much better with additional medications.
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 AVOID weight
bearing on the left leg.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a L periprosthetic joint infection and was admitted to
the medicine service. The patient was taken to the operating
room on ___ for L TKA I+D with liner exchange by Dr. ___,
___ 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 TSICU with a hemovac
drain in place to the L knee. In the TSICU patient was
extubated, arterial line was discontinued, pressor support
weaned as appropriate. Patient developed Afib with RVR
refractory to diltiazem drip, transitioned to metoprolol and
heparin gtt with appropriate improvement in symptoms. Patient
was started on IV antibiotics of vancomycin and ceftriaxone
empirically, transitioned to ancef per culture sensitivities of
MSSA bacteremia/PJI. Pt was transferred to the medicine floor: | 169 | 156 |
16508561-DS-13 | 22,774,427 | Dear Mr. ___,
It was a pleasure caring for you at the ___
___.
WHY WAS I SEEN IN THE HOSPITAL?
-You were confused and having hallucinations.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-We treated you for alcohol withdrawal with medications through
the IV.
-You were persistently confused, and had been for some time.
Some of this was likely related to the medicines for your
withdrawal; some was likely slower and more gradual in onset.
-We ruled out reversible causes of confusion, including tests
for an infection of the brain.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Please take your medicines as prescribed.
-Please follow up with your doctors as listed below.
We wish you the best,
Your ___ Care Team | ___ year old male with a PMH significant for chronic alcohol use
disorder presented with hallucinations c/f withdrawal vs.
delirium. | 116 | 20 |
10578880-DS-8 | 22,062,774 | You were admitted to the acute care surgery service after
suffering a jaw fracture in order the Oral and Maxofacial
Surgery (OMFS) could repair your jaw. They left the following
instructions for you:
1. Take antibiotics for 1 week
2. Wash your mouth with Peridex 2x a day for 2 weeks
3. Please review jaw instructions placed in your chart.
Wound care: Do not disturb or probe the surgical area with any
objects. The sutures placed in your mouth are usually the type
that self dissolve. If you have any sutures on the skin of your
face or neck, your surgeon will remove them on the day of your
first follow up appointment. SMOKING is detrimental to healing
and will cause complications.
Bleeding: Intermittent bleeding or oozing overnight is normal.
Placing fresh gauze over the area and biting on the gauze for
___ minutes at a time may control the bleeding. If you had
nasal surgery, you may have occasional slow oozing from your
nostril for the first ___ days. Bleeding should never be severe.
If bleeding persists or is severe or uncontrollable, please call
our office immediately. If it is after normal business hours,
please come to the emergency room and request that the oral
surgery resident on call be paged.
___: Normal healing after oral surgery should be as follows:
the first ___ days after surgery, are generally the most
uncomfortable and there is usually significant swelling. After
the first week, you should be more comfortable. The remainder of
your postoperative course should be gradual, steady improvement.
If you do not see continued improvement, please call our office.
Physical activity: It is recommended that you not perform any
strenuous physical activity for a few weeks after surgery. Do
not lift any heavy loads and avoid physical sports unless you
obtain permission from your surgeon.
Swelling & Ice applications: Swelling is often associated with
surgery. Swelling can be minimized by using a cold pack, ice bag
or a bag of frozen peas wrapped in a towel, with firm
application to face and neck areas. This should be applied 20
minutes on and 20 minutes off during the first ___ days after
surgery. If you have been given medicine to control the
swelling, be sure to take it as directed.
Hot applications: Starting on the ___ or ___ day after surgery,
you may apply warm compresses to the skin over the areas of
swelling (hot water bottle wrapped in a towel, etc), for 20
minutes on and 20 min off to help soothe tender areas and help
to decrease swelling and stiffness. Please use caution when
applying ice or heat to your face as certain areas may feel numb
after surgery and extremes of temperature may cause serious
damage.
Tooth brushing: Begin your normal oral hygiene the day after
surgery. Soreness and swelling may nor permit vigorous brushing,
but please make every effort to clean your teeth with the bounds
of comfort. Any toothpaste is acceptable. Please remember that
your gums may be numb after surgery. To avoid injury to the gums
during brushing, use a child size toothbrush and brush in front
of a mirror staying only on teeth.
Mouth rinses: Keeping your mouth clean after surgery is
essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass
of warm water and gently rinse with portions of the solution,
taking 5 min to use the entire glassful. Repeat as often as you
like, but you should do this at least 4 times each day. If your
surgeon has prescribed a specific rinse, use as directed.
Showering: You may shower ___ days after surgery, but please ask
your surgeon about this. If you have any incisions on the skin
of your face or body, you should cover them with a water
resistant dressing while showering. DO NOT SOAK SURGICAL SITES.
This will avoid getting the area excessively wet. As you may
physically feel weak after surgery, initially avoid extreme hot
or cold showers, as these may cause some patients to pass out.
Also it is a good idea to make sure someone is available to
assist you in case if you may need help.
Sleeping: Please keep your head elevated while sleeping. This
will minimize swelling and discomfort and reduce pain while
allowing you to breathe more easily. One or two pillows may be
placed beneath your mattress at the head of the bed to prop the
bed into a more vertical position.
Pain: Most facial and jaw reconstructive surgery is accompanied
by some degree of discomfort. You will usually have a
prescription for pain medication. Some patients find that
stronger pain medications cause nausea, but if you precede each
pain pill with a small amount of food, chances of nausea will be
reduced. The effects of pain medications vary widely among
individuals. If you do not achieve adequate pain relief at first
you may supplement each pain pill with an analgesic such as
Tylenol or Motrin. If you find that you are taking large amounts
of pain medications at frequent intervals, please call our
office.
If your jaws are wired shut with elastics, you may have been
prescribed liquid pain medications. Please remember to rinse
your mouth after taking liquid pain medications as they can
stick to the braces and can cause gum disease and damage teeth.
Diet: Unless otherwise instructed, only a cool, clear liquid
diet is allowed for the first 24 hours after surgery. After 48
hours, you can increase to a full liquid diet, but please check
with your doctor before doing this. Avoid extreme hot and cold.
If your jaws are not wired shut, then after one week, you may be
able to gradually progress to a soft diet, but ONLY if your
surgeon instructs you to do so. It is important not to skip any
meals. If you take nourishment regularly you will feel better,
gain strength, have less discomfort and heal faster. Over the
counter meal supplements are helpful to support nutritional
needs in the first few days after surgery. A nutrition guidebook
will be given to you before you are discharged from the
hospital. Remember to rinse your mouth after any food intake,
failure to do this may cause infections and gum disease and
possible loss of teeth.
Nausea/Vomiting: Nausea is not uncommon after surgery. Sometimes
pain medications are the cause. Precede each pill with a small
amount of soft food. Taking pain pills with a large glass of
water can also reduce nausea. Try taking clear fluids and
minimizing taking pain medications, but call us if you do not
feel better. If your jaws are wired shut with elastics and you
experience nausea/vomiting, try tilting your head and neck to
one side. This will allow the vomitus to drain out of your
mouth. If you feel that you cannot safely expel the vomitus in
this manner, you can cut elastics/wires and open your mouth.
Inform our office immediately if you elect to do this. If it is
after normal business hours, please come to the emergency room
at once, and have the oral surgery on call resident paged.
___ Instructions: If you have had a bone ___ or soft tissue
___ procedure, the site where the ___ was taken from (rib,
head, mouth, skin, clavicle, hip etc) may require additional
precautions. Depending on the site of the ___ harvest, your
surgeon will instruct you regarding specific instructions for
the care of that area. If you had a bone ___ taken from your
hip, we encourage you to ambulate on the day of surgery with
assistance. It is important to start slowly and hold onto stable
structures while walking. As you progressively increase your
ambulation, the discomfort will gradually diminish. If you have
any problems with urination or with bowel movements, call our
office immediately.
Elastics: Depending on the type of surgery, you may have
elastics and/or wires placed on your braces. Before discharge
from the hospital, the doctor ___ instruct you regarding these
wires/elastics. If for any reason, the elastics or wires break,
or if you feel your bite is shifting, please call our office. | ___ year old gentleman admitted to the hospital after being
punched in the face. He was reported to have sustained an
isolated mandible fracture. He was transferred here for further
management. Upon admission, he was made NPO, given intravenous
fluids, and underwent additional imaging. On cat scan imaging
of the head he was reported to have no acute intra-cranial
injury. C-spine imaging showed no mal-alignment of the spine.
Because of his injury, he was evaluated by the Oral Maxillary
service who recommended surgery. The patient was taken to the
operating room on HD #2 where he underwent an open reduction
internal fixation of right parasymphysis fracture and a closed
reduction maximum mandibular fixation of the left subcondylar
fracture. The operative course was stable with a 50cc blood
loss ( please see operative note). The patient was extubated
after the procedure and monitored in the recovery. His
post-operative course has been stable. He has been afebrile and
his pain has been controlled with oral analgesia. He has resumed
a full liquid diet withiout any difficulty in swallowing. He
has been instructed to continue antiobiotic coverage for 1 week
and peridex rinses for 2 weeks. He will follow- up with ___
surgeons in ___. A copy of the discharge summary and
operative note were given to the patient at discharge. | 1,341 | 233 |
10884125-DS-8 | 21,961,831 | Dear Mr. ___,
It was a pleasure caring for you at ___ ___
___. You came to the hospital for alcohol
withdrawal, and requesting assistance with sobriety. During
your stay you did not require many doses of medication for
withdrawal, and you had no sign of instability or seizure.
It is important for your recovery that you work with your Social
Worker, Psychiatrist, and Psychologist to help you have a
sustained sobriety. You were given a list of locations for
possible partial programs by social work on discharge.
We have made no changes to your medications. Please follow-up
with your primary care physician as listed below.
Best of luck on your recovery and sobriety. | ___ with Hx seizure disorder, multiple traumatic injuries, EtOH
abuse, recent admission at ___ for EtOH withdrawl (d/c ___,
presents for detox.
# EtOH withdrawal: Patient requested medical detox, will plan
to seek longer-term assistance via the ___ system. He has a
social worker, psychiatrist, and psychologist that he works with
in the ___ system. Refused our social work/case management
support. He has no history of withdrawal-related seizures. Only
scored on CIWA once, the night of ___. Continued thiamine,
folic acid, and MVI.
# h/o seizure disorder: No history of EtOH withdrawl seizure.
Continued Keppra
# Back pain: Likely ___ injury from a fall. No evidence of
neurological deficit. Only mild midline tenderness. Provided
ibuprofen PRN.
# ADHD: held methylphenidate, continue propranolol
# Tobacco abuse: nicotine lozenges
# Med rec: ideally we could get his medication list from the
___, however given the holiday this was not possible
# Code: FULL | 118 | 157 |
18745490-DS-17 | 27,236,914 | Dear Ms. ___,
You were admitted for concern of carotid dissection. However, on
review of your imaging and of your symptoms, you do not have a
carotid artery dissection. It is likely an artifact on imaging.
We recommend you continue aspirin for primary prevention of
stroke and to have repeat imaging in ___ weeks.
There were no other changes to your home medications. Please
follow up with neurology after your repeat brain imaging.
Your symptoms of sensory changes are likely due to muscular neck
tension or cervical radiculopathy.
Sincerely,
Your ___ Neurology Team | She was admitted for concern of carotid artery dissection.
However history is not consistent (consists of 1 min of
difficultly gathering thoughts; lightheadedness; and
intermittent decreased LT on left side) with dissection and ___
clinical Exam was nonfocal except for physiological anisocoria
(R 2->1.5, L 2.5 to 2) and 90% decreased Lt on RUE and R face.
MRI showed no acute stroke, MRA images were reviewed on rounds
and appeared to be inconclusive. Imaging seems more consistent
with artifact than with dissections, but patient was started on
aspirin 81 mg daily and Patient should have repeat CTA in ___s follow up with neurology. In terms of stroke
workup A1c 5.8, LDL pending at time of discharge.
Transitional Issues:
- Repeat CTA in ___ weeks
- outpatient PCP and neurology followup | 93 | 130 |
16619178-DS-4 | 28,279,177 | Dear Mr. ___,
You were admitted to ___ on ___ after you experienced
some nausea and an EKG showed changes concerning for heart
injury. You underwent catheterization which found a block on one
of your main arteries, so 2 stents were placed. Your heart rates
were also initially slow, but have improved with the stents
placed.
You were ordered for a Holter Monitor to monitor your heart rate
after your hospital discharge. You are able to pick up this
monitor at this hospital tomorrow (___). You should call
them at ___ before you come to find out their location
and to schedule your appointment.
You were started on Aspirin and Plavix, and it is extremely
important that you take both these medications every day.
Missing a single dose can cause a life-threatening blood clot to
form in your stent. If you experience any new chest pain,
shortness of breath, arm or jaw pain, or nausea, please contact
your physician or come to the nearest Emergency Room. You should
also notify your doctor if you feel lightheaded or dizzy as
these might be signs of your heart rate slowing down.
We wish you the best
Your ___ Care team | ASSESSMENT AND PLAN:
Patient is a ___ with PMHx of HTN and HLD who presents with
nausea, L arm pain, and EKG changes found to have an NSTEMI,
concern for inferior wall ischemia with EKG changes c/b
bradycardia and 3rd degree block.
# CORONARIES: RCa disease now s/p x2 DES ___ RCa and PDA)
# PUMP: EF of 55%
# RHYTHM: Sinus but CHB with junctional escape, post perfusion
sinus rhythm with 1st degree AV block
#THIRD DEGREE HB/BRADYCARDIA: In the ED, his initial EKG showed
complete heart block with triggered fascicular idioventricular
rhythm versus a relatively rapid His-fascicular escape in the
___. At the time he was placed on beta-blocker per ACS protocol
and junctional rhythm slowed to the ___. He went to the cath
lab, and underwent junctional rate improved to the ___ after
thrombectomy and stenting of RCA. His heart block was thus most
likely ___ AV nodal infarct in setting of RCA occlusion. EP was
consulted and no temporary pacing wire was placed with the
expectation that block would likely resolve w/reperfusion of the
AV node. Beta blockers were held, would likely benefit beta
blocker initiation as an outpatient. Patient was also asked to
follow up with outpatient Holter monitoring with Cardiology
followup. Patient was asymptomatic on discharge, ambulating
comfortably in sinus rhythm with first degree AV block and HRs
of 65-80.
# NSTEMI: On presentation had ST depressions in V2-V6 with
Trop-T 2.84. Atypical symptoms of nausea, L arm pain had
resolved prior to arrival in our ED. He was taken to the cath
lab where he was found to have RCA completely occluded. He
underwent thrombectomy and DES to ___ RCa and PDA. He
underwent Plavix and integrillin loading in ___ cath lab and was
continued on Plavix. He was started on statin, ASA, ACE. As
above metoprolol was held. Troponins were trended to peak.
# HTN: Patient switched from amlodipine to lisinopril 2.5 mg
daily.
# HLD: Rosuvastatin 20 mg daily continued
#Leukocytosis: WBC overall down from admission (15.2->10) with
no signs of infection. This was likely due to stress reaction
from NSTEMI, and resolved during the course of hospitalization. | 202 | 362 |
19736706-DS-25 | 27,722,057 | Dear Mr. ___,
WHAT BROUGHT YOU INTO THE HOSPITAL?
You were referred from clinic as a result of high blood pressure
and a headache.
WHAT DID WE DO FOR YOU IN THE HOSPITAL?
In the hospital, we checked your sodium level, and it was low
(123). We think your sodium was low as a result of the
indapamide medication. You had stopped the indapamide medication
prior to coming to the hospital. We restricted your water intake
to 1L and gave you salt tablets. Your sodium level was 131 upon
leaving the hospital.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
-You should maintain fluid restriction of 1 L at home until you
see Dr. ___.
-You should check your blood pressure prior to taking your
clonidine. You should not take your oral clonidine if your
systolic blood pressure (top number) is less than 110.
-You should follow-up with your primary care doctor, ___
on ___.
We wish you the very best. It was a pleasure taking care of you
in the hospital.
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old male with a history of resistant
hypertension, type II diabetes mellitus, obstructive sleep apnea
on continuous positive airway pressure, and chronic hyponatremia
who presented with two days of headache and elevated blood
pressure and found to have worsening hyponatremia, admitted for
further workup. | 165 | 51 |
19244673-DS-20 | 27,275,082 | Ms. ___,
You were admitted to ___ for abdominal pain. You were found to
have acute cholecystitis. Based on the duration of your symptoms
and your past medical history, it was decided that you under go
a percutaneous cholecystostomy instead of having an operation to
remove your gallbladder at this time. You tolerated the
procedure well and now you are ready to be discharged from the
hospital.
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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | The patient presented to ___ Emergency Department on ___.
Pt was evaluated by
the acute care surgery team. | 392 | 18 |
11763662-DS-16 | 23,950,332 | Mr. ___, it was a pleasure taking care of you here at ___.
You were admitted to the hospital because you were short of
breath. This was due to fluid in your lungs. We worked you up
for different causes of this problem. On echocardiogram, we
determined that your heart is enlarged and that it was not
pumping as well as it should be (we call this "heart failure").
We performed a stress test to find if there were any blockages
in the arteries, but were unable to find any. We also had you
sent for a cardiac catheterization in order to determine the
pressures in the chambers of your heart, and to look for any
hidden blockages in the vessels of your heart. We did not find
any problems in the vessels of your heart, but foudn that you
still had some extra fluid that should come out. We gave you
some more diuretics and will send you home with daily diuretic
therapy.
As we discussed, it is VERY important that you quit smoking.
This is the most important thing that you can do for your
health. Also, we think it would be best if you did not exert
yourself at work physically. We understand that part of your job
description is to restrain some patients, but we do not think it
is in your best interest to strain yourself in this way. Please
discuss with the people at your work about limiting this role.
You should weigh yourself every morning and record the result.
If your weight goes up by more than 3 pounds you should call
your cardiologist Dr. ___ this is a sign that you are
keeping extra fluid in your body.
Please speak with your primary care physician, ___,
___ a sleep study.
Here are the changes we have made to your medications:
___ taking aspirin
___ taking metoprolol
___ taking spironolactone
___ taking atorvastatin
___ taking warfarin - you will need your INR checked regularly
to determine the appropriate dosing
___ taking lovenox until instructed by Dr. ___ the
___ anti-coagulation nurses
___ taking lasix (furosemide) | Primary Reason for Hospitalization:
===================================
Mr. ___ is a ___ with no known cardiac history but many CAD
risk factors including T2DM, HTN, HLD, Obesity, smoking, who
presented with 1 month of progressive dyspnea, orthopnea due to
new onset CHF.
. | 344 | 38 |
16573505-DS-18 | 23,235,690 | You were admitted for seizures and new finding of left frontal
brain lesion.
You were started on Keppra, this medication prevents seizures,
you should continue to take this medication.
Continue your home medications
You may take tylenol as needed for headaches.
Do not take any products containing aspirin
do not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, and Ibuprofen etc.
Exercise should be limited to walking; no lifting, straining, or
excessive bending.
Clearance to drive and return to work will be addressed at your
post-operative office visit. | Mrs. ___ was admitted to the Neurosurgery service for
further work-up of her left frontal lesion. The patient was
started on Keppra for seizure prophylaxis (and likely seizure at
home prior to her presentation). Frequent neurologic checks
were ordered. Further imaging was required to assess the
intracranial lesion further. A CTA of the head and CT of the
torso were ordered. CTA revealed Hemorrhage and developmental
venous anomaly in the left frontal region
without an identifiable nidus, most consistent with underlying
cavernous
malformation or less likely AVM. CT chest/abdomen/pelvis was
negative for malignancy
On ___ Patient did not have any seizures overnight. She
remained neurologically stable. Patient will be scheduled for
the OR with Dr. ___ week. She will be contacted with the
information once the OR has been booked. She was discharged home
in stable condition. | 86 | 144 |
19861375-DS-16 | 23,725,146 | Dear Mr. ___,
You were hospitalized due to symptoms of temporary difficulty
speaking and a right facial droop resulting from an TRANSIENT
ISCHEMIC ATTACK or "TIA", a condition where a blood vessel
providing oxygen and nutrients to the brain is temporarily
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms. Fortunately, the MRI of your brain did
NOT show a NEW stroke so these symptoms likely represented a
TIA.
TIA 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:
-Blocked blood vessels in the brain due to atherosclerosis or
plaque
-High cholesterol
Please take your medications as prescribed:
-Aspirin 81mg daily, Plavix 75mg daily, Lipitor 40mg daily
Please also allow your blood pressure to run high (goal SBP
110-140, may run up to 180). Please ensure you stay hydrated and
eat a normal amount of salt, as your blood pressure dropped
slightly while standing on your day of discharge from the
hospital.
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 | Mr. ___ presented with transient right facial drop (upper motor
neuron pattern) and aphasia; symptoms resolved and MRI was
negative for new infarct. CTA and cerebral angiogram showed left
supraclinoid internal carotid artery occlusion (with filling of
the left hemisphere via pial collaterals from the left anterior
cerebral artery). Continued on aspirin, Plavix and Atorvastatin
for secondary stroke prevention. Counseled family on permissive
hypertension (goal SBP 110-140, may run up to 180) to prevent
stroke as pt is collateral dependent. Pt advised to maintain
adequate hydration and eat a normal amount of salt with his
diet.
Of note, on the day prior to discharge, pt was found to be
mildly orthostatic. He was asymptomatic with SBP 150s sitting to
130s standing. He was given IVF and then developed left armpit
pain and SBP 200s. This resolved. EKG and troponins x3 were
unremarkable. He was discharged home in stable condition (SBPs
130s-170s on day of discharge); physical therapy cleared pt for
home prior to discharge.
============================
TRANSITIONS OF CARE
============================
-Pt should have long term permissive hypertension (goal SBP
110-140, may run up to 180) to prevent stroke as pt is
collateral dependent. Pt advised to maintain adequate hydration
and eat a normal amount of salt with his diet.
-Iron studies pending at discharge for normocytic anemia. PCP to
___.
=
=
=
=
=
=
=
=
================================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
=
=
=
=
=
=
=
=
================================================================
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? () Yes (LDL = ) - (X) No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A | 334 | 438 |
13551670-DS-21 | 23,039,041 | Ms. ___,
You were admitted to ___
because you were having abdominal pain and nausea with vomiting.
You were observed while you were here and your symptoms
improved. We do not know exactly what caused your symptoms but
we do not think it is something dangerous or life-threatening.
When you go home, please follow-up with your primary care doctor
and ___ urologist.
We wish you the best,
Your ___ Care Team | ___ s/p appendectomy ___ years ago in ___ presents with
L-sided ABD pain, nausea, and vomiting. The abdominal pain was
intermittent, with periods of severe pain followed by sudden
abatement, possibly consistent with renal colic. UHCG negative.
The patient had CT ABD/PELVIS with contrast that revealed no
acute pathology, however was not optimized to evaluate for
stones. She was observed overnight with some tachycardia up to
130 at highest. She was given 1L IVF and managed symptomatically
with Zofran, Tylenol, and ranitidine. Her pain and accompanying
tachycardia resolved by the following morning at which time we
did not feel repeating a CT for stone protocol would be
worthwhile as it seems she passed the stone, if there ever was
one there. She tolerated PO diet. She was discharged in stable
condition. Unclear etiology of this episode, but would recommend
urology follow-up for evaluation of possible kidney stones. | 70 | 147 |
10750448-DS-6 | 27,741,089 | ___, we believe your severe pain in your rectum was due to
constipation. After you were disimpacted and you had the enema
you felt better. Stopping some medications and taking a fiber
every day will help prevent this from happening in future.
You were very weak and we have sent you to a rehab to become
stronger. | ___ admitted with rectal pain.
#Based on CT/exam (large amount of stool in vault and pain
reproduced on exam) Likely due to impacted stool. After
disimpaction felt better. Pain recurred and with enema several
large bowel movements. Since that point no recurrence of rectal
pain.
Start miralax. After touching base with PCP stopped ___ of her
meds that she was neither taking or intermittently.
Anti-cholinergic effect of meds for urinary incontinence might
have been culprit.
Did have intermittent epigastric/chest pain/bloating. Unclear
whether related to constipation. Did check EKG/CXR/troponin.
Improved with simethicone.
Would recommend also checking TSH in case contributing to
constipation.
# HTN - did have elevated BP in morning before taking meds.
Recommend takes ACE at night and beta blocker in morning. SBP in
160's but did not increase meds given age and wide pulse
pressure and concern about weakness and falls.
#DM - continue home metformin. glucoses reasonable
#Hyponatremia - mild. with hydration resolved from 132 -> 139
#Weakness - attributed to poor POs for some time and not getting
out of bed. ___ eval felt unsafe to go home and therefore
transfer to rehab.
# Anxiety - during hospital stay, patient became very worried
about many issues - BP, headache, abd pain and idea of going to
rehab. Per family this is baseline.
#TRANSITION
- check TSH | 56 | 212 |
10820114-DS-13 | 24,563,575 | Dear Mr. ___,
You were admitted to the hospital for high fevers, headaches,
neck pain, and overall because you were feeling unwell. We
initially placed you on several antibiotics and tested your
blood for several infections. None of these tests showed the
specific infection you may have. We also took several CT scans
of your head, neck, chest, and abdomen, none of which showed
anything concerning for infection. Because of an abnormality on
your CT head, we also got an MRI of your head and performed a
lumbar puncture, which were all reassuring. We think you had a
viral illness, from which your body is slowly recovering. | ___ with PMH HTN, h/o SVT, stage IV follicular lymphoma and
prostate CA presents wtih fevers to 102 for 2 days and neck pain
with cough.
.
#Fever and rigors - Pt presented with fevers to 102-103, and
with headache, neck pain, drenching nightsweats and poor PO
intake. Extensive infectious work-up was undertaken for
bacterial, viral, and fungal causes without any positive tests.
Headache/neck pain was not thought to be meningitis, as pt was
tender on lateral posterior neck and tender on scalp in
occipital area, without any visual disturbances. Pt was
empirically treated with vanc/unasyn, evetually on
vanc/zosyn/levofloxacin/tamiflu. Pt underwent extensive imaging
including CT head, neck, chest, abd, pelvis which were only
notable for ventriculomegaly in head. Subsequent MRI was
negative for acute hydrocephalus or other evidenec of acute
disease. As culture data returned, vanc/zosyn/tamiflu were
stopped. Pt underwent LP, for ? lymphoma in brain without any
abnormalities concerning for infection or lymphoma. Pt seemed to
defervesce spontaneously. At discharge, it is thought that pt
likely had a viral infection, which caused his illness.
.
In the setting of getting IVF for fevers and poor PO intake, pt
developed some pulm edema requiring O2, but was given 40iv lasix
with complete resolution of O2 requirement.
.
# Pancytopenia: Pt's pancytopenia is attributed to his acute
viral illness. Outpatient team may recheck CBC and consider BM
biopsy is this does not resolve within ___ weeks of discharge.
.
#Stage IV Follicular Lymphoma s/p ___ C1 D1 Bendamustine
and Rituxan ___. Pt did not receive any chemotherapy while
hospitalized.
.
#Prostate CA - ___ 6, no active treatment at this time. Pt
was continued on flomax.
.
#CKD III with mild Cr elevation (Cr 1.2 -> 1.4): Losartan was
stopped on admission due to worsening Cr and was not resumed as
pt's SBPs were in 100-120s and metoprolol was increased for SVT.
.
#Hx of SVT - Pt had episode of SVT in 130-150s which terminated
spontaneously. Pt only minimally symptomatic and HD stable.
Metoprolol was incrased from 25mg po xl to 75 po xl.
. | 106 | 334 |
19772404-DS-19 | 28,710,252 | Dear ___,
___ was a pleasure to take care of you at ___
___. You were admitted to the hospital because of
falls and difficulties with your balance. You were found to have
breast cancer that was most likely metastatic to the lung and
liver. You declined a biopsy of your liver to further
characterize the mass and evaluate you for treatment. You had a
urinary tract infection which was treated with antibiotics.
After discussion with your family and oncology doctors, you
decided to return home with hospice care.
You should also talk to your primary neurologist about your
seizure medications. The neurologist you saw here recommended
the following changes in order to reduce sedation but prevent
seizures:
- stop Phenytoin Sodium Extended 400 mg PO HS
- start Phenytoin 150mg in the morning and 200mg at bedtime | ___ with history of breast cancer (___), ovarian cancer (___),
Factor V Leiden on warfarin for history of two DVTs, and seizure
disorder with two recent falls who presented for concern of
metastatic malignancy. She was discharged home with hospice.
# Mental status changes. During admission, patient became more
restless and unable to concentrate or focus. She was
intermittently alert and oriented x3, and mental status waxed
and waned throughout the day. This was likely multifactorial and
may be related to hospital delirium, liver dysfunction due to
tumor burden, decreased clearance of sedating medications
(diazepam, narcotic pain meds), seizure disorder or possible
leptomeningeal disease (MRI negative). During admission she
developed new asterixis and abnormal lfts, most c/w greater
burden of disseminated intrahepatic disease than seen on
imaging. She was treated with lactulose with mild improvement.
No obvious infection was found. Neuro Oncology was consulted and
Dr. ___ the patient. MRI brain at OSH negative.
# Metastases to the lung and liver, new. Primary is unknown.
Based on history of breast and ovarian cancers, these are most
likely. However, given pace of disease, a more aggressive tumor
is favored. T
She was at high risk for clotting given her history of clots
and metastatic malignancy. Her warfarin was held, and she was
started on a heparin drip to prepare for liver biopsy to guide
further management. However, on day of biopsy, patient stated
she did not want any further diagnostic or therapeutic tests.
After discussion with her family, the patient changed her mind
and the biopsy was scheduled for the following day. On the day
of the rescheduled biopsy, the patient again stated she did not
was the procedure and wanted to go home. After a family
discussion, the biopsy was postponed until she felt better.
During the the rest of her admission, the goals of care changed
the biopsy was no longer pursued.
# Factor V Leiden on warfarin. She had supratherapeutic INR on
admission. INR 3.8 at OSH. INR 2.9 on admission here. Warfarin
was held. Heparin gtt was started. Liver biopsy was not
ultimately pursued. Given change in goals of care,
anticoagulation was discontinued.
# UTI. Complained of urinary frequency. She did have chief
complaint on admission of falls and balance issues. UA with
moderate bacteria, small leuks. UCx >100k pansensitive Ecoli.
She was treated with ceftriaxone 1g Q24H from ___ to ___.
Recheck of UA (given ongoing mental status changes) showed no
UTI.
# Hyponatremia. Resolved after 1L IVF. Serum and urine osm low.
Urine Na 24. Consistent with hypovolemic picture. Less
consistent with SIADH.
# Falls. This appeared to be mechanical in nature. Exam shows
full strength and mildly uncoordinated heel to shin on left. She
has intact sensation and no signs of cord compression or cauda
equina on exam. She would require MRI imaging or a bone scan to
evaluate for bony disease. Physical Therapy recommended patient
be discharged to rehab. Her goals of care changed, and she was
discharged to home with hospice.
# Seizure disorder: No seizures since ___. Continue home
phenobarbital and phenytoin. Drug levels were within normal
range.
ACCESS: ___ placed ___ and removed on ___ on discharge
EMERGENCY CONTACT:
Next of Kin: ___
Relationship: DAUGHTER
Phone: ___
Other Phone: ___
### TRANSITIONAL ISSUES ###
-Home with hospice.
-Symptomatic medications - olanzapine, morphine, scopolamine,
lidocaine patch.
-Avoid hepatically-cleared medications given ongoing
encephalopathy.
-Anticoaguation discontinued given hospice goals.
-Inpatient neurologist Dr. ___ these changes to
reduce sedation, but we will defer to outpatient neurologist:
- stop Phenytoin Sodium Extended 400 mg PO HS
- start Phenytoin 150mg in the morning and 200mg at bedtime | 135 | 613 |
14474735-DS-5 | 26,598,201 | Dear Ms. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted with shortness of breath. We feel this is due
to your known tracheal stenosis. You were closely monitored in
the ICU given your risk for airway compromise. You underwent
tracheal dilitation with the interventional pulmonologists. You
will need to follow up with the interventional pulmonologists
for a repeat bronchoscopy with posible cryo therapy or stenting
in the near future.
Sincerely,
Your ___ Team | BRIEF HOSPITAL COURSE
___ old never smoker with known idiopathic tracheal stenosis
s/p cervical tracheal resection and resconstruction in ___,
silicone stent placement and removal at least three times, last
removal ___ complicated by granulation tissue
requiring multipledebridements, who presents with progressive
dyspnea similar to prior episodes of tracheal stenosis. A CT was
performed which confirmed a diagnosis of re-stenosis. The
patient underwent flexible bronchoscopy on ___, with serial
tracheal dilations. No stent was placed. The patient with plan
to followup in the operating room in ___ days for possible
cryotherapy. Her home medications for asthma and depression were
continued. | 77 | 99 |
14746920-DS-10 | 23,694,773 | you were hospitalized with pulmonary embolisim (blood clot in
blood vessel to lungs) this is caused by period of immobility
when blood clot can form in lung or other risk factors that lead
to more clotting of blood.
it is treated with medication to thin the blood to make it less
able to clot so that with time the blood clot can break up on
its own.
the medication you are taking should be taken with food.
for the first 21 days take it twice a day (15mg tablet), then
you will be taking 20mg tablet once a day with evening meal.
you will take this medication for 6 months.
PLEASE TELL ANY DENTIST, DOCTOR, OR NURSE THAT YOU ARE ON
RIVAROXABAN BEFORE YOU HAVE ANY PROCEDURE, BIOPSY, OR SURGERY.
IT CAN CAUSE EXCESS BLEEDING FROM THOSE PROCEDURES. YOU MAY
NEED TO TAKE ANOTHER MEDICATION AS A SUBSTITUTE BEFORE SUCH
PROCEDURES IF THEY ARE NEEDED IN THE NEXT 6 MONTHS.
this medication interferes with your bodies ability to clot, so
there is risk of serious bleeding. bleeding can even be fatal
if you have head injury and bleed into brain or other trauma and
severe blood loss from gastrointestinal bleeding. please seek
medical help right away if you have bleeding from any part of
the body or feel weak, tired or out of breath
omeprazole is anti-reflux medicine over the counter | ___ with acute pulmonary embolism. This is likely cause of her
symptoms of chest pain. She also has a pattern of bronchiectasis
on CT chest, but describes a chronic unchanged cough and is
without fever or worsened breathing.
#PE
The most notable risk factor for PE is airplane travel but that
was over 2 months ago. She flew from ___ to ___ 2 months
ago and then spent 8 hours in a car driving to ___ 8 days
before admission. Immediate work up for inheritable
hypercoagulable states would not change immediate management.
Since she has not had colonoscopy before, she should undergo
colon cancer screening in future. No clinical evidence of
right heart strain so no echo performed. | 231 | 122 |
13310560-DS-23 | 20,500,300 | Dear Mr. ___,
You were admitted to ___ for
management of sepsis and bacteremia with a possible endovascular
graft infection. You were monitored and treated conservatively
with intravenous antibiotics. You have now recovered from your
infection and are ready to be discharged. Please follow the
instructions below to continue your recovery:
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
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 healing and recovery
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Continue your intravenous antibiotic for 6 weeks, as
instructed
Follow your discharge medication instructions
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
CALL THE OFFICE FOR: ___
A sudden increase in pain that is not controlled with pain
medication
Temperature greater than 100.5F for 24 hours | Mr. ___ is a ___ year old male with a history of advanced
dementia who was found down at home with a fever and abdominal
tenderness and brought to ___. His trauma
work up included a CT abdomen/pelvis which showed inflammation
and stranding around the left iliac artery at site of prior
external iliac to femoral bypass graft.
He was transferred to ___ in
___ and admitted to the vascular surgery service. His home
xarelto was initially held due to concern for possible bleed. He
was started on broad spectrum intravenous antibiotics and was
eventually narrowed to nafcillin when his cultures resulted
positive for MSSA. Repeat CTA of his abdomen/pelvis was stable.
He had a transesophageal echocardiogram which was negative for
signs of infection of his artificial mitral valve or pacemaker
leads. A right upper extremity PICC line was placed for
long-term intravenous antibiotics. His Xarelto was restarted on
___.
He was able to tolerate a regular diet, get out of bed and
ambulate without assistance, void without issues, and pain was
controlled on oral medications alone. He was deemed ready for
discharge, and was given the appropriate discharge and follow-up
instructions. | 276 | 192 |
14968931-DS-3 | 24,807,222 | Dear Mr ___,
It was a pleasure taking care of you here at ___
___. You were admitted to the hospital
because you were coughing up blood. This improved when your
blood thinner was stopped. The underlying cause is the cancer in
your lungs. For now we will keep your blood thinner on hold.
You were also evaluated for the cancer in your brain and spine.
You were given steroids to help with the swelling around the
tumor. We are working on arrangements for radiation for this. | PRIMARY REASON FOR HOSPITALIZATION:
====================================
Mr ___ is a ___ yo M with metastatic renal cell carcinoma with
progressive disease on nivolumab, who was admitted with
headache, dyaarthria
and hemoptysis. | 85 | 28 |
13475033-DS-105 | 22,307,389 | Dear Mr. ___,
It was our pleasure taking care of you at the ___
___!
WHAT BROUGHT YOU TO THE HOSPITAL?
- You were having recurrent nausea and vomiting after eating.
WHAT HAPPENED IN THE HOSPITAL?
- The Cardiologists saw you in the Emergency Department. They do
not think the nausea and vomiting were related to your cardiac
issues. However, they do think you would benefit from a stress
test in the future.
- Our Gastroenterologists saw you for your nausea and vomiting
with meals.
- You underwent a CT scan of the abdomen and pelvis, which did
not show any significant abnormality.
- Overall, the reason for your nausea and vomiting could not be
determined; there is some concern that it may be related to your
digoxin. You will need to come back for an
esophagogastroduodenoscopy (EGD), which is when a special camera
is inserted down the esophagus to examine your stomach and small
bowel. This will help determine the cause of your
nausea/vomiting with eating.
- You were given medications to treat your nausea and vomiting,
which helped you eat without vomiting. This can be taken as
needed.
- You underwent dialysis based on your regular schedule.
WHAT SHOULD YOU DO ONCE YOU GO HOME?
- Please take your medications as prescribed and attend your
doctor's appointments.
Please DO NOT TAKE your digoxin.
- Please follow up with the Gastroenterologists. You can call
___ to make a follow-up appointment for the EGD.
- Please follow up with the Cardiologists for a repeat stress
test.
We wish you all the best!
Your ___ Care Team | ===================
PATIENT SUMMARY
===================
___ with severe CAD (CTO mid-LCx since ___, repeated PCI to RCA
for ___ stenosis, last POBA ___, CVA (left
periventricular subcortical infarct post cath ___, HTN, HLD,
AF not on anticoagulation, ESRD on HD
MWF, who presents with a several-day history of nausea and
vomiting associated with food intake. Of note, he had been just
admitted to Cardiology for the same presentation. At that time,
the etiology of his nausea/vomiting was unclear. During this
admission, GI was consulted. CT A/P was obtained, which did not
show evidence of gastric outlet obstruction or other significant
abnormality. The patient was able to tolerate PO intake with PRN
antiemetic zofran. He was discharged home with plan for
outpatient GI follow up and EGD.
===================
TRANSITIONAL ISSUES
===================
[] The patient will need outpatient GI follow up with EGD for
workup of his anorexia and nausea/vomiting. This is being
arranged through GI office.
[] Cardiology recommended a stress test, ideally with exercise
MIBI, although most likely will be a pharmacological stress
(patient reports he is unable to exercise).
===================
ACUTE ISSUES
===================
#Anorexia
#Nausea, vomiting
Patient presented with a 2-month history of anorexia and a
several-day history of nausea/vomiting that occurs immediately
after eating. Denies any abdominal pain, diarrhea, hematemesis,
dysphagia, or early satiety. He stated that certain foods, e.g.
oatmeal and cornmeal, trigger this, while he is able to tolerate
other foods, including eggs and bagels. He endorsed a 20-lbs
weight loss during the past two months, though ___ records do
not show a significant weight change. The etiology remains
unclear. GI was consulted. CT A/P did not show evidence of
gastric outlet obstruction though on review with Radiology, did
show significant calcifications of his celiac artery and SMA.
However, chronic mesenteric ischemia was felt to be unlikely
given the lack of pain. Other differential for his presentation
includes persistent digoxin effect; worsening metaplastic
changes of esophagus (though no dysphagia), worsening PUD
(though no abdominal pain); worsening ___
ulcers vs. progressive intrusion of hiatal hernia. By ___, the
patient was able to tolerate multiple meals without emesis, and
as such it was felt to be reasonable to discharge the patient
home with outpatient gastroenterology follow-up and EGD. He was
also provided with PO Zofran 4 mg q8H PRN nausea. QTc 360.
# Coronary artery disease
# Elevated troponin to 0.15, which downtrended to 0.14. EKG
without acute ischemic changes; changes were thought to be c/w
dignoxin. He did not have any chest pain this admission.
Cardiology recommended stress testing with exercise v. pharm
mibi.
===================
CHRONIC ISSUES
===================
#End-stage renal disease on hemodialysis
Received hemodialysis per his usual ___ schedule.
#CODE: Full, presumed
#CONTACT: ___, ___ | 254 | 424 |
12143610-DS-21 | 23,782,435 | Dear Mr. ___,
You were admitted to ___ after a fall where you suffered a
fracture of your right hip joint. You were seen by our
orthopaedic surgeons who felt that you should be able to recover
without surgery as long as you follow the precautions below.
While in the hospital you developed issues with your kidney
function. You had an ultrasound of your kidneys which showed no
obstruction. You were given IV fluids with stabilization of your
kidney function.
It is important that you follow the instructions below and
followup with your orthopaedic doctors in order to aide your
recovery.
ORTHOPAEDIC INSTRUCTIONS:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing right leg
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 30mg daily for 2 weeks | HOSPITAL COURSE:
============================
___ with HTN, CKD, BPH, dementia with multiple recent falls who
presnted with right acetabular fracture in the setting of a
fall, mangaging non-operatively, hospitalization complicated by
acute on chronic kidney injury.
# Right Acetabular Fracture: Traumatic in setting of recurrent
falls and known osteoporosis. Seen by orthopaedics who feel that
fracture can be managed non-operatively. Specifically they feel
that joint is currently set in a way as to facilitate healing
with touch down weight bearing status on the Right Lower
extremity and that surgical intervention would not result is a
shorter duration of recovery or greater short term mobility.
# Recurrent Falls/Dementia: Long standing history of falls.
Thought to be related to underlying dementia and deconditioning.
Evaluated by Neurology in the past with concern for NPH though
no formal diangosis. Infectious workup negative during admission
# Acute on Chronic Kidney Injury: Creatinine on admission 2.3
and has been stable since. Baseline creatinine 1.8. CK not
signficantly elevated. No hydronephrosis seen on renal US. FeNa
2.5% suggestive of renal sodium wasting and likely ATN.
Creatinine downtrending on discharge.
# Hypertension: On lisinopril, labetolol, and amlodipine at
home, but lisinopril was held on admission in setting of ___. In
absence of lisinopril, he was noted to be more hypertensive
especially in the mornings that was thought be exacerbated by
pain and anxiety. During admission, labetalol was from 200mg BID
to ___ TID and amlodipine increased from 2.5mg to 5mg daily
with goal BP <150/90. Restart lisinopril as an outpatient
pending stability in renal function.
# Troponinemia: Patient has reported history of CAD, though
history unclear. CK initially elevated in setting of fall with
unclear duration of immobility, CK-MB index was normal. The
patient was asymptomatic without chest pain or dyspnea, EKG with
LBBB block but no Sgarbossa criteria thus thought not to reflect
active ischemia. Troponin continued to elevate in the absence of
ischemia thought to reflect decreased renal clearance with low
grade troponin leak from hypertension. He was continued on
aspirin.
CHRONIC ISSUES:
# BPH: Followed by Dr. ___ Urology. Continue tamsulosin and
recently started finasteride.
# Hypothyroidism: TSH was elevated in acute illness but free T4
normal. Was continued on levothyroxine.
# Iron deficiency anemia: Hct stable during admission. Started
ferrous sulfate daily.
# Muscle spasms: continued pramipexole.
# Osteoporosis: continued calcium and vitamin D
TRANSITIONAL:
- Touch down weight bearing on the right lower extremity for two
months.
- Followup with Dr. ___ in 2 weeks for repeat imaging
- Enoxaparin for ___ weeks at least. Course to be determined as
outpatient with Dr. ___ Orthopaedics.
- Please discuss with Dr. ___ lisinopril pending
stablity in renal function.
- Pain control with acteaminophen 650mg PO QID, tramadol 25mg PO
q12h:PRN pain, and oxycodone 2.5mg PO daily:prn 30min prior to
___. Ensure ongoing bowel regimen to prevent constipation.
- Continue calcium and vitamin D
- consider starting memantine as an outpatient
CORE MEASURES:
# Diet: pureed/thin liquid diet
# PPX: Enoxaparin
# CODE: DNR/DNI
# CONTACT/HCP: ___ (Wife): ___ or
___ | 235 | 487 |
18870126-DS-13 | 20,022,198 | Mr. ___,
You were seen at ___ for Dialysis. You had your dialysis
session in the hospital and you are scheduled for repeat
dialysis on ___.
Best Wishes,
Your ___ Team | Brief Hospital Course:
___ year old male with PMH of HTN, HLD and ESRD on ___, Th, ___
HD who presented to the ED with volume overload and hyperkalemia
(7.2) in the setting of missed HD. The patient had been
traveling abroad and did not arrange for HD upon return. He
presented to his prior HD center who did not have room for him
and instructed him to go to the ED. Prior to his presentation,
his last HD session was in the ___ on ___. Upon
arrival to the ED, the dialysis/renal team was consulted and the
patient was admitted for bedside HD. EKG on admission unchanged
from prior. Patient complained of mild SOB but denied any
nausea, vomiting, or abdominal pain His K improved from 7.2 on
arrival to 4.0 three hours after HD was completed. It was
arranged for him to have his next session at ___ in
___ on ___ at 5:00pm and the patient was discharged
home following his session.
Of note, the patient was hypertensive to SBPs 200 upon admission
in the setting of volume overload. His pressures improved to
SBPs 140s with dialysis. In addition, the patient's HgB 8.1
which is lower than expected than someone with CKD on EPO
(baseline appears to be ~9). No signs of active bleed and
patient HD stable. Would consider further work-up as an
out-patient. | 28 | 228 |
15335971-DS-8 | 28,690,238 | Dear Mr. ___,
It was a pleasure to be a part of your care team at ___
___. You were admitted to the hospital
because your blood count was very low. You had an endoscopy,
which showed some ulcers in your stomach, which is probably
where the bleeding was from. You should continue to take a new
medication called pantoprazole, which will help to heal your
stomach. We also think that you should be tested for a bacteria
called H. pylori which can cause these ulcers, and that you
should have another endoscopy in 2 months to see if these ulcers
are healing.
Please see below for your medications.
Again, it was very nice to meet you, and we wish you the best.
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ gentleman with a past medical
history of ___ disease, prostate cancer, and high blood
pressure presents with 2 weeks of subacute and worsening fatigue
and dyspnea on exertion, likely ___ anemia from GI bleed.
========================= | 124 | 40 |
12612324-DS-16 | 27,302,404 | You were admitted for an infection of the gallbladder duct
(cholangitis) related to your gallbladder cancer causing a
blockage. You previously had a stent put in for this, and on
this admission had another procedure (ERCP) to help open up this
blockage. You have been on antibiotics for this infection and
will be given a prescription to continue for several more days
at home. | ASSESSEMENT & PLAN: ___ yo w/Klatskin tumor diagnosed ___
presents with worsening abdominal pain and fever secondary to
cholangitis.
#Cholangitis
The patient was admitted to the medicine service and was given
IV fluids, nothing by mouth, with antiemetics and narcotics as
needed. She was given Zosyn empirically and was afebrile. She
was taken to the ERCP suite on the morning of ___ which had the
following impression:
A metal stent placed in the biliary duct was found in the major
papilla just inside the bile duct. Cannulation of the biliary
duct was successful and deep with a balloon catheter. There
were small filling defects inside the metal stent at the biliary
tree. The common hepatic duct above the metal stent and the left
and right hepatic ducts were normal. No discrete stricture was
noted. Normal intrahepatics.
Several balloon sweeps were performed. Small amount of
debris/sludge was extracted successfully using a balloon. Final
cholangiogram showed no filling defects.
Given the patient symptoms and the early obstruction of the
recent placed metal stent, a decision was made to place a 5cm by
___ double pig tail biliary stent inside the metal stent.
Excellent flow of bile was noted.
.
The patient returned to the floor and advanced to a full diet
with no problems by the following day. She will be discharged
home on PO cipro/flagyl to complete a 7 day course.
#Gallbladder carcinoma - patient has an appointment to see Dr.
___ on ___ to discuss treatment options
#falls at home: pt admitted from rehab. seen by ___, okay to go
home with home ___ and 24h family support
# 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 ___ | 64 | 304 |
16446532-DS-25 | 25,456,833 | Dear Mr. ___,
You were admitted to ___ for
evaluation of arm pain. We found that your arm had started
bleeding again. You had procedures by the plastic surgery team
to help stop this bleeding. During your hospitalization, we also
stopped your warfarin to help control your bleeding. This was
restarted before you left, and your INR was 2.3. Please recheck
your inr on ___
You should follow up with your primary care doctor after you
leave. Please call him to set up an appointment this week. You
should also follow up with Dr. ___, a plastic surgeon.
Please call him at ___ to set up an appointment this
week.
When you leave, you should take 1.5mg of warfarin each day. You
should check your INR on ___. We also decreased your
dose of torsemide.
It was a pleasure to help care for you during this
hospitalization, and we wish you all the best in the future.
Sincerely,
Your ___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ y.o. ___ gentleman with HTN, CAD s/p 3v CABG
in ___, MVR w/ mechanical valve, Afib on coumadin s/p ICD,
systolic cardiomyopathy LVEF 40% ___, and ___
Disease as well as recent admission to the ___ service ___
- ___ for acute sCHF exacerbation and negative work-up for
cardiac sarcoidosis with RH catheterization, c/b development of
compartment syndrome ___ at cath site requiring fasciotomy and
skin graft ___, who presented with significant bleeding from
graft site and increased swelling.
#Right arm bleeding: On presentation, pt with significant
bleeding and swelling from graft site in the setting of
supratherpeutic INR. In the emergency department, pt was
evaluated by plastic surgery who performed bedside drainage of
Right arm hematoma. Post-procedurally, pt was admitted to ___,
where his warfarin was held and his INR was reversed with
vitamin K. Pt was bridged with heparin when he became
subtherapeutic. TTE did not show any thrombi on the mitral
valve. Pt underwent Right arm exploration and evacuation by hand
surgery on ___, which showed good hemostasis. Notably, pt
was found to have difficulty closing his Right hand
post-procedurally, although perfusion of the hand otherwise
appeared normal. He was restarted on warfarin with heparin
bridge. INR became therapeutic on ___, and pt was
discharged with a plan to follow up with ___ of plastic
surgery. Of note, pt was also discharged with a plan to obtain
occupational therapy as an outpatient.
#sCHF: Pt appeared to be euvolemic on exam. Pt's torsemide was
decreased to 10mg Qday this hospitalization, and he remained
roughly euvolemic on this dose. | 169 | 259 |
19867135-DS-13 | 21,097,459 | Discharge Instructions
Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
- You may restart your Aspirin on ___ and may restart your
Coumadin on ___.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | ___ was admitted to the hospital from the emergency
room after signs and symptoms and imaging were consistent with
an intraventricular hemorrhage. He was observed in the hospital
with frequent neuro checks as well as repeat imaging to assess
for worsening symptoms of which there were none. His headache
was improving, he was ambulating on his own, and remained stable
clinically throughout his hospitalization.
___ was consulted while he was inpatient and titrated and
adjusted his diabetes medications accordingly and made
recommendations for his home regimen.
___ was consulted and saw him on ___. They recommended home
upon discharge after ___ more visits.
He was discharged on ___. At the time of discharge he was
ambulating with assistance, voiding independently, tolerating PO
diet and pain meds, and his vital signs were stable.
He will restart his Aspirin on ___ and will restart his
coumadin on ___.
He should follow up with his PCP regarding diabetes and otitis
media. Patient will follow up with Dr. ___ on ___. | 417 | 168 |
17047928-DS-21 | 26,055,200 | 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.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body. | The patient was transferred to ___ from an OSH with a
non-contrast CT head demonstrating a small left parafalcine
subdural hematoma without shift. The patient was admitted to
neurosurgery on ___ for close monitoring. A repeat non-contrast
CT head was performed on ___, which demonstrated a stable SDH.
The patient remained neurologically stable and her home
medications were restarted on the morning of ___. Physical
therapy was consulted and worked with the patient. They
recomended discharging the patient back to her assisted living
facility with continued ___. It was recommended the patient
change her home environment to have a commode at bedside, but
the patient refused this change.
On ___, the patient was discharged to her assisted living
facility with continued physical therapy. On discharge, she was
tolerating a regular diet, her pain was well controlled, she was
voiding, and was neurologically stable. | 126 | 143 |
13566153-DS-10 | 21,375,734 | Ms. ___,
You were admitted to the hospital with shortness of breath for 2
months with concern that your symptoms could be due to
tuberculosis. A chest xray showed some consolidation in the
right upper lobe which may be due to an old infection. You had
a ppd placed which was negative, making it very unlikely that
you had been exposed to tuberculosis in the past.
We have given you an albuterol inhaler to use as needed for
shortness of breath. You will need to have a repeat chest x-ray
in ___ weeks to ensure that your x-ray has improved. You will
also need to have lung function tests to help us determine why
your breathing has been difficult | ___ year old homeless woman who was admitted with cough, night
sweats and chills accompanied by RUL infiltrate on CXR.
# Dyspnea: Patient's dyspnea was felt to be secondary to an
upper respiratory URI with associated bronchospasm, which was
relieved with Albuterol. Although an infiltrate was noted on
CXR, this was likely an old pneumonia for which patient was
already treated. In addition, she was afebrile without
leukocytosis or hypoxia during entire hospitalization, making an
acute process less likely, especially she had already been
treated with a full antibiotic course. There was initial
suspicion for active tuberculosis with fever and night sweats,
but this was felt to be clinically unlikely based on history,
physical and radiographic appearance of the infiltrate. Due to
risk factors for acquiring latent TB, a ppd was planted and
returned negative, which also reinforced low clinical concern
for tuberculosis. Patient was discharged with prescription for
albuterol. She should have further evaluation for suspected
reactive airway disease vs. asthma with outpt PFTs. She should
also have repeat CXR in ___ weeks to assess for interval
resolution of RUL infiltrate. If infiltrate persists or
symptoms worsen, would recommend further evaluation with CT
chest and consideration of outpt Pulmonary evaluation.
# Tobacco dependence: While in hospital, patient maintained on
nicotine patch prn. Upon discharge, patient continued on
patches with follow up arranged with PCP for continued
management.
# Psychosocial concerns: Patient reports difficulty finding
housing and stress caring for her young son with significant
social support structures. She was seen by social work while in
the hospital who recommended case management services through
___ Health or a community mental health agency. The patient
was given information on how to obtain these services and will
follow up as outpatient. | 123 | 294 |
19085099-DS-8 | 25,609,387 | Mr. ___,
It was a pleasure taking care of you here at ___
___. You were brought to the hospital by
ambulance after the unfortunate accident where you where hit by
another car and then bumped into a tree. You were evaluated in
the Emergency Department and thoroughly examined for
life-threatening injuries. Upon physical examination and imaging
studies, we only found a laceration to your head. Fortunately,
no major intracranial or neck injuries were found. You were kept
in the hospital overnight for further workup regarding the
possibility that you may have passed-out prior to the accident,
a sign that could sometimes mean something is wrong with your
heart or the vessels in your neck. For this reason, the medicine
team evaluated and determined that it was unlikely this
happened, and deemed suitable for you to go home.
Instructions:
1. Please resume all your home medications.
2. You may take tylenol or NSAIDs for pain if need be.
3. Please follow-up with your primary care provider for ___
routine medical checkup. Your creatinine levels were found to be
borderline high, a finding that should be known by your PCP.
4. Please call our office or come to the emergency department in
case:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
5. Wound Care: You may shower, no tub baths or swimming.
If there is clear drainage from your cut, cover with clean, dry
gauze. Please call the doctor if you have increased pain,
swelling, redness, or drainage from the incision sites. | Mr ___ arrived at our institution brought in by ambulance
after a motor vehicle collision as an unrestrained driver
against a tree at low-moderate speed, reportedly losing
consciousness. Basic trauma protocol was activated upon his
arrival to the emergency department. Physical exam and imaging
studies performed, namely CT of the head and neck, were within
normal limits but to a right frontoparietal scalp laceration
with an underlying subgaleal hematoma. This was repaired
successfully with nylon sutures shortly after arrival.
Patient was admitted for observation overnight. Given no
recollection of the accident or what led to it, an internal
medicine consult was requested for proper workup of a possible
syncopal episode. After thorough evaluation, they deemed
unlikely that patient had syncopated prior to the event. All
tests performed, including ECG, telemetry, and blood work were
reassuring. It was later reported by one of the family members
that the police report had stated that another car had been
involved in the accident, leading to Mr ___ collision
with a tree. No further medical workup was required and he was
cleared from that standpoint. A tertiary survey done 24 hours
after admission failed to reveal other injuries.
On discharge, patient was doing remarkably well. He was afebrile
with stable vital signs. His pain was minimal and
well-controlled, and he was tolerating a regular diet,
ambulating and voiding without assistance. Patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. | 349 | 242 |
14486034-DS-16 | 22,031,949 | Dear Ms. ___,
You were admitted to ___ for observation after presenting to
the ED with a low grade fever, abdominal pain, and headache
several days following your parathyroidectomy. Your labs were
reviewed and cultures from your blood and urine and pending, all
of which are normal to date.
Please resume all of your regular home medications, unless
specifically advised not to take a particular medication.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.
Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site. You may shower and wash incisions with a mild
soap and warm water. Avoid swimming and baths until cleared by
your surgeon. Gently pat the area dry. You have a neck incision
with steri-strips in place, do not remove the steri-strips, they
will fall off on their own.
Thank you for allowing us to participate in your care. We look
forward to seeing you at your follow-up visit. | Mrs. ___ is a ___ year old woman with LRRT who presents with
postoperative fever. She was admitted for observation. Nl WBC.
Negative UA (UCx contaminated). Negative BCx while in house.
Noted some abdominal discomfort that resolved with
maalox/lidocaine. Wound did not seem to be source of
bacteremia. Renal transplant was consulted and agreed with
observation, thinking that she has no localizing signs, and her
story, particularly with sick contacts, best fits a viral
etiology for her fever. She did have thrush, but it did not
contribute to her fevers. Mild elevation in T resolved by HD2.
The patient was discharged home 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. | 172 | 141 |
17922352-DS-16 | 22,829,999 | Dear Mr. ___,
You were admitted to ___ due to throat pain and lesions on
your tongue. You were treated with antifungal medication called
fluconazole and a medication called valacyclovir. We sent off a
number of tests and a biopsy that were still in process at time
of discharge.
- Please follow up below as recommended with your doctors: call
Dr. ___ to have an appointment in the next week.
- Please continue taking valacyclovir as prescribed for 3 weeks.
Take all of the prescription even if you are feeling better.
- We restarted your sirolimus at 1mg daily. Please get your
level checked at 5pm on ___. Otherwise continue
the rest of your medications.
- You will be called at home with follow-up appointments to see
Infectious Disease.
- Your tongue sutures can be removed on ___. Any healthcare
provider can take the stitches out.
- You already have an appointment to see Dermatology in a few
weeks.
We wish you all the best!
- Your ___ care team | ___ h/o ESRD ___ diabetic nephropathy s/p LURT ___ on
MMF/sirolimus, IDDM, ___ of left ear s/p Mohs in ___, NSTEMI
who presents with sore throat, found to have ulcerations and
white plaque on exam. | 163 | 36 |
18739340-DS-7 | 28,654,776 | -You had a foley catheter in place while in the hospital so you
may expect intermittent amounhts of small blood in the urine. If
foley remains upon discharge, please care as instructed by
nursing staff.
-The hematoma at the penis will resolve over the next few to
several weeks. Try and elevate penis as much as possible and lay
down when possible rather than sitting.
-You may experience some pain associated with spasm/fullness of
your penis and scrotum; This is normal. Take the narcotic pain
medication as prescribed if additional pain relief is needed.
-Do not lift anything heavier than a phone book (10 pounds)
-Resume all of your pre-admission medications, except HOLD
aspirin and NSAIDS (motrin, ibuprofen, etc) until you see your
urologist in followup
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place (if left with catheter) you should
not engage in strenuous activity
- Absoultely no sexual activity of any sort until cleared by
urologist in follow up
Apply dressing as follows:
- Once daily remove prior dressing by unwrapping gauze.
- Can shower at this time. Let water drip gently over penis and
pat dry afterwards. No baths until area heals
- Reapply small square of xeroform or petroleum gauze over skin
defect. Wrap ___ of kerlex gauze around penile shaft, applying
gentle compression to penis. Ensure gauze encompasses up to the
head of the penis but does not block urethral opening. | The patient was admitted from the emergency department after an
evening of observation to Dr. ___ service for
hematoma management and monitoring.
The ED checked the patient's hematocrit which was completely
stable upon admission and through his time of stay. The ED
managed the patient overnight with IV dilaudid and a compresion
dressing. The patient was extremely sedated and required
catheterization with Foley urethral catheter likely from
significant narcotic doses and significant compressive dressing.
On the AM of HD1, this dressing was removed and a liquified
hematoma was evacuated from the left side of the patient's
penis. The dressing was replaced with a sterile gauze dressing
and some minor spotting persisted. He was converted to oral pain
medications and given tylenol as needed. Penile edema and
echymoses were stable and edema was decreasing by time of
discharge. At discharge, patient's pain was controlled with oral
pain medications, he was tolerating regular diet, he was
ambulating without assistance, and voiding without difficulty -
a retrograde uretherogram showed no defect in the urethra
(patient had reported some question of pneumaturia). Skin at
hematoma site was stable and did not appear infected. Specific
instructions about wound care were given in addition to home ___
were prescribed. This was also included in this discharge
summary.
Pt should call to arrange/confirm your follow-up appointment AND
if you have any urological questions. | 326 | 225 |
19616613-DS-11 | 28,204,724 | Dear Mr. ___,
It was a pleasure treating you at ___
___. You were admitted with concern for recent fevers and
abdominal pain in the setting of your known pancreatic cancer.
Your abdominal pain was evaluated via an endoscopic procedure
which unfortunately showed advancement of your cancer. After
discussion with you, your family, and your outpatient provider,
the decision was made to admit you to hospice care at a
rehabilitation facility.
We wish you the best going forward,
Your ___ team | ___ M with DM2, obesity, OSA, HCV/EtOH cirrhosis, recent
diagnosis of pancreatic adenocarcenoma (___) and cholangitis
s/p ERCP (___) with stent placement found to have presumed
cholangitis and multisystem organ failure in the setting of
overwhelming sepsis. Given his poor prognosis, the patient was
transitioned to comfort measure and discharged on hospice.
#) PANCREATIC ADENOCARCINOMA: Stage III/IV based on T4 tumor
size (tumor encases celiac vessels and is >4cm) and +LNs seen on
imaging, but full formal staging has not yet taken place. When
it became clear that PTBD would not be placed due to patient's
persistent decompensation, patient and family decided to
transition to hospice.
#) SEPSIS: Patient was admitted with chills, confusion and
malaise along with worsening abdominal pain ___ in
severity), nausea, poor PO intake and jaundice concerning for
cholangitis. He was started on IV vancomycin and pip/tazo upon
admission. ERCP was significant for malignant-appearing
strictures as well- unfortunately ERCP revealed blockage of
biliary drainage with no possible endoscopic intervention. PTBD
scheduled ___ was deferred in the setting of continued
decompensation. Pip/tazo was d/c on ___. Of note, blood
cultures from admission were consistent with strep viridans and
subsequent blood cultures from ___ were consistent with gram
negative rods, presumably from GI source. Patient was started on
meropenem on ___ for concern of sepsis in the setting of
fever, tachycardia, and respiratory distress while awaiting
PTBD. Interventional radiology subsequently concluded that
patient is longer candidate for PTBD due to respiratory issues
and concern for instability under anesthesia. Antibiotics were
discontinued upon transitioned to comfort measures.
#) RESPIRATORY DISTRESS: While in the PACU awaiting PTBD on
___, patient developed tachycardia and increasing respiratory
distress with increasing O2 requirements to 10L facemask. The
operation was held and he transferred to the MICU. Symptoms were
presumably from sepsis and PE. Patient was initially restarted
on heparin gtt at lower goal but this was discontinued within
___ given worsening coagulopathy.
#) PULMONARY EMBOLUS: On ___ CTA C/A/P showed acute PE
bilaterally in lobar and segmental branches for which patient
was started on heparin gtt. Heparin gtt was discontinued
midnight prior to anticipated PTBD on ___. Heparin gtt was
briefly restarted on heparin gtt at lower goal the evening that
procedure was deferred but this was again within 12h given
worsening coagulopathy.
#) HEPATITIS C/ETOH CIRRHOSIS: Peritoneal fluid studies are not
consistent with SBP. Scheduled for liver bx with ___ but
deferring in setting of acute illness. SAAG>1.1 suggesting
likely secondary to portal hypertension.
# Communication: HCP:Brother/HCP ___ (___)
# Code: DNR/DNI | 78 | 420 |
11194776-DS-28 | 22,897,186 | Dear Ms. ___,
It was a pleasure taking care of you in the hospital.
WHAT BROUGHT YOU INTO THE HOSPITAL?
You came into the hospital with chest pain.
WHAT DID WE DO FOR YOU IN THE HOSPITAL?
We ordered labs and examined you and felt that there was no
cardiac cause for your chest pain. We think that your chest pain
is musculoskeletal in nature.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
-You can take diclofenac sodium topical gel for the chest pain.
-You should follow-up with your primary care physician in two
weeks.
-Weigh yourself every morning, call a physician if your weight
goes up 3 lbs in one day or 5 lbs in one week.
Sincerely,
Your ___ Team | Ms. ___ is a ___ woman with ESRD (on HD MWF), NASH
cirrhosis (EGD ___ (-)varices, (+)GAVE & portal HTN
gastropathy), history of GIB (EGD ___ (+)antral erosions &
AVMs), CAD s/p CABG (LIMA to LAD and SVG to PDA ___, pAF
(not on anticoagulation), HFpEF, T2DM, who presented with
non-pleuritic chest pain and is admitted for workup and
management of chest pain. Most likely etiology is
musculoskeletal given reproducibility on exam.
# Chest pain.
Given that the pain is reproducible on exam, most likely
musculoskeletal in nature. Trop 0.04x2, CKMB2. Does not seem to
be cardiac chest pain given that it is non-exertional, no
radiation, and no associated nausea or diaphoresis. Does not
need nuclear stress test at this time. The patient can follow-up
with outpatient cardiologist if pain has new exertional
component. Can treat pain with diclofenac sodium topical gel
post-discharge.
# ESRD on HD.
ESRD ___ to T2DM. On HD since ___ - MWF. Had HD w/ 1L UF on
___.
- Continued Calcium Acetate 1334 mg PO tid with meals
- Continued Hectorol 11 mcg IV q HD
- Continued vitamin D 1000 units daily
# CAD s/p CABG. Continued ASA, metop, imdur, statin.
# History Afib (not on anticoagulation ___ GIB). CHADS2VASC 5.
Continued metop. Currently in sinus.
# DMII. ISS while in hospital.
# Anemia: Multifactorial - anemia of renal disease, known GI
bleeding. Hgb 8.3 on admission. Hgb 8.6 on discharge, no signs
of bleeding.
- Continued Venofer 50 mg IV q ___
- Continued Epogen 8000 units q HD
# HTN: Normotensive
- Continued Amlodipine 10 mg, Isosorbide mononitrate ER 30 mg,
Metoprolol succinate XL 150 mg
# Nutrition: Low Na, Low K, Low P diet, water restriction to
1.5L per day. Nephrocaps 1 CAP daily.
# NASH Cirrhosis (MELD-Na 23) - Patient does not have a history
of varices. No clinical e/o decompensation. Patient follows with
Dr. ___.
# Asthma
- Continued home albuterol, fluticasone inhalers.
# Depression
- Continued home paroxetine.
# GERD.
- Continued pantoprazole. | 111 | 324 |
13294123-DS-25 | 26,698,099 | Dear Mr. ___,
You were admitted to the hospital because of shortness of breath
and diarrhea. Your shortness of breath was because of pneumonia,
which was treated with antibiotics. Your diarrhea was due to a
recurrence of an infection called C. difficile. Your C. diff was
also treated with antibiotics (vancomycin and flagyl).
While here you also continued to receive radiation for your lung
cancer.
Physical therapy also worked with you while you were here to
help improve your strength.
Your pneumonia and your C. diff improved, so you were discharged
home.
The following medications were added:
- Vancomycin 120mg every 6 hours (last day is ___
- Flagyl 500mg every 8 hours (last day is ___
Thank you for choosing ___ for your healthcare needs. It was a
pleasure caring for you.
Sincerely,
Your ___ Team | Mr. ___ is a ___ with Stage II SCC of the lung who
presented with HCAP and recurrent C. diff infection. He
continued to receive radiation while inpatient. For his HCAP he
was treated with a 7d course of antibiotics (cefepime,
transitioned to augmentin). His C. diff was treated with PO
vancomycin and PO flagyl. He was also having right sided chest
wall pain, associated with swallowing. Rad-onc felt this was
most likely a side effect of his radiation. This was managed
with Oxycodone and a lidocaine patch. ___ also worked with him
while he was here and felt he was strong enough to go home and
did not require ___ rehab. He developed neutropenia during
his hospitalization, likely due to recent chemotherapy. He was
treated with neupogen with normalization of his white blood cell
count.
He developed volume overload while in the hospital, as his home
torsemide was held due to his C. Diff infection. He was treated
with IV Lasix and then transitioned back to his home torsemide.
He developed a mild ___ so his torsemide dose was decreased to
20mg. With this dose, his Cr returned to baseline. Please
continue to assess his volume status and adjust the dose of
torsemide as an outpatient.
Pt's HIV markers were checked as inpatient. His Viral load was
63 copies/mL. His CD4 count was low (64) but his percentage was
normal (32%) so the low CD4 count likely was due to his
leukopenia rather than his HIV burden, so he does not need PCP
___. His CD4 count should be rechecked at a follow-up
appointment once his white count has normalized.
#Acute on chronic respiratory failure secondary to HCAP.
The patient has SCC of the lung and is on 2L NC at home, however
he developed an increasing oxygen requirement and cough. CTA
chest on ___ showed opacities in R lung base that "could
represent pneumonia in the right clinical setting". Because the
patient had an increased O2 requirement, a worsening cough, and
was just discharged from the hospital on ___, he was treated
for HCAP. He was initially started on cefepime, and completed
his 7d course with augmentin. His O2 requirement improved, and
he was actually able to be on room air at times with O2 sat >
93%. He went home on oxygen as he was still intermittently
requiring up to 2L.
#Recurrent C. diff.
The patient had recurrent C. diff which was treated initially
with PO vanc. It was not improving, likely because he was being
treated for HCAP at the same time, so he was started on IV
flagyl. Prior to discharge his diarrhea had decreased in
frequency but was still more than his baseline. Because he has
had recurrent episodes of C. diff, he was set up with an
outpatient appointment with ID to discuss the possibility of
fecal transplant. He was discharged on PO vanc and PO flagyl to
complete a full 14d course from the day he finished the
augmentin for his HCAP.
#Odynophagia.
The patient was complaining of R sided chest wall pain
associated with swallowing. He had a recent endoscopy which
showed esophagitis, which is consistent with his long standing
GERD treated with ranitidine; however, this is not consistent
with R sided chest pain. He had no evidence of oral thrush on
exam; however, he could have had esophageal thrush so he was
treated empirically with nystatin with no improvement in his
symptoms. Rad/onc felt that even though his radiation was
directed at his L chest, this pain could be a side effect of the
radiation. He was treated with oxycodone 15mg PRN and a
lidocaine patch with some improvement of his symptoms. He was
discharged home on this regimen.
#Neutropenia.
Attributed to the ___ he got on ___ and his radiation
therapy. He was given neupogen, which was stopped when his ___
recovered.
#Pitting sacral and lower extremity edema.
The patient's home torsemide was held because he was having >10
loose bowel movements/day from his C.diff infection. He
developed pitting sacral and lower extremity edema. He was
diuresed with IV Lasix and wore TEDS. Prior to discharge he was
restarted on his home torsemide 40mg, but was feeling
lightheaded and had SBP <100. For that reason he was discharged
on half his home dose (Torsemide 20mg).
#HIV.
Pt's HIV markers were checked as inpatient. His Viral load was
63 copies/mL. His CD4 count was low (64) but his percentage was
normal (32%) so the low CD4 count likely was due to his
leukopenia rather than his HIV burden, so he does not need PCP
___. He was continued on his home HIV regimen of
Darunivr, Truvada, Ritonavir.
#Stage II lung squamous cell carcinoma.
Started cycle 2 ___ taxol ___. Continued to receive
daily radiation as an inpatient.
#L foot and ankle swelling.
Minimal swelling on exam without history of trauma, no evidence
of infection. CTA negative for PE and negative ___ for
acute DVT.
#CAD. Continued home ASA, statin
#COPD. Continued home tiotropium and albuterol neb prn
#Depression. Continued quetiapine and venlafaxine.
#GERD. Continued home ranitidine
#Subclavian Stenosis. Noted during previous admission. BPs
softer
in L arm, so BP only checked in R arm. | 130 | 850 |
14535070-DS-28 | 23,650,723 | Ms. ___,
You were admitted due to increasing back pain.
Further workup did not show that your myeloma is worsening. We
gave you some pain medications and your pain has relatively
improved. We also did not find any infectious cause for your
back pain.
We plan to discharge you today because overall you are doing
well. We are concerned however about your lack of suitable
housing. Our social worker has been helping you with this issue.
Please follow up with the department of transitional assistance
as advised for emergency shelter.
Take all of your medications as prescribed.
Please refer below for your outpatient appointments with Dr.
___.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team | ASSESSMENT AND PLAN:
___ yo female with a history of multiple myeloma/plasmacytoma who
is admitted with increasing back pain.
#Transaminitis: Noted on ___, slight elevation of ALT/AST. T
bili
normal. Unclear etiology, possibly medication-induced but not
taking much medication now. No abdominal discomfort or fever on
exam. Will monitor closely outpatient.
#Constipation: Had 2 bowel movements this morning. Likely as a
result of opioids given in the setting of back pain. Added
miralax and dulcolax to stool regimen in the past 2 days,
continues with Colace and Senna BID. Now controlled on oxycodone
prn, off oxycontin. Monitoring closely
#Multiple Myeloma/Plasmacytoma/Back Pain:
- Plasmacytoma seen on MRI
- Consulted neurosurgery to see possible interventions that will
help alleviate pain - for now no surgical intervention indicated
per their recs
-PET Scan on ___ showed that the rim of the left sacral lesion
demonstrates borderline increased FDG uptake, possibly due to
bony remodeling/inflammation, without clear focal area of
differentially increased FDG uptake for biopsy target but
otherwise no focus of FDG avid disease. Therefore, no need for
sacral biopsy in addition to Rad ONC evaluation. We offered
patient biopsy of the lesion at the rim as above but patient
refused.
- PRN oxycodone
- uptitrated oxycontin to 10mg q8 over the weekend, used 80mg
total oxycodone in prns/restarted Neurontin 300mg TID on ___
however, discontinued ___ due to AMS/Syncope
- Consider palliative care consult if pain uncontrolled - has
been stable.
- Holding off BM bx as most recent disease markers on ___ are
stable, patient has refused in the past but will defer to
outpatient provider, Dr. ___ she needs procedure done
- ___ consult, rec encourage frequent mobility and maximize
independence in ADLs. Assist of 1 for ambulation and transfers
out of bed to chair 3x/day with a SC.
#Lightheadedness/AMS: Resolved. Likely related to NPO status in
addition to pain medications. Obtained blood cultures ___ to
rule
out infectious process, NTD. Head CT ___ - ruled out acute bleed
or infarct. Now on regular diet, received 1L NS while NPO, will
continue to monitor closely
#Coping: Patient has minimal social support. Son was in ___
custody for 47 days per her report. Daughter is very supportive
but patient reports that she is not able to live with her at the
current apartment. Has financial constraints. On section 8 but
not able to find any suitable housing for now. Consulted ___ for
support. Shelter arrangements in process. Consider family
meeting
with daughter prior to discharge today. Has missed appointments
with Dr. ___ as she was afraid of potential interventions she
will receive at the clinic. She is very anxious about bone
marrow
biopsy and/or needle sticks.
#Anxiety: Regarding healthcare and procedures. continue on
Ativan
prn
#FEN:
- Electrolytes per oncology scales
- Regular diet
#BOWEL REGIMEN:
- Colace/Senna BID + Miralax
#DVT PROPHYLAXIS:
- Heparin 5000 units SC BID, hold if plts < 50K
#ACCESS:
- Peripheral IV
#Disposition: BMT for now, expected discharge post symptomatic
improvement
#Code status: full | 113 | 439 |
11874107-DS-15 | 23,718,976 | Dear ___,
You were hospitalized due to symptoms of difficulty with speech
and writing 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.
We are changing your medications as follows:
-START aspirin 81 mg daily
-START Plavix 75 mg daily
-START atorvastatin 40 mg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | ___ with no significant PMH who presented to the ED as a
transfer
from ___ after a transient episode of word finding difficulties,
initially concerned for TIA. Had been considered a candidate for
tPA via telestroke, but tPA not administered due to significant
improvement in symptoms. Patient was loaded with aspirin and
Plavix. Upon transfer, the patient reported that her speech was
back to baseline without any residual deficits. MRI head showed
acute to subacute punctate left superior frontal gyrus and
corona radiata probable infarcts without evidence of hemorrhagic
transformation. TTE showed no evidence of source of cardiac
embolus. A1c was found to be 5.5 and LDL 102. Patient remained
in her baseline functional status and was discharged home safely
with ongoing aspirin and atorvastatin and a 30-day course of
Plavix. | 241 | 130 |
10568382-DS-6 | 26,143,957 | Dear Mr. ___,
You came in with pain in your back and ribs. We found that you
were having a pain crisis from sickle cell. We treated you with
IV fluids and pain medication.
At home please make sure to stay well hydrated. You can take
Tylenol for pain. If your pain is not relieved by Tylenol you
can take oxycodone as needed. Please do not drive after taking
oxycodone, as this medication can make you drowsy.
We also found that had a pneumonia. We treated you with
antibiotics. You will need to take antibiotics for two more days
after leaving the hospital (last day ___.
Please see below for your follow up appointments.
It was a pleasure taking care of you, and we are happy that
you're feeling better! | Mr. ___ is a ___ male with a past medical history
notable for severe AS and sickle cell disease who presented with
an acute pain crisis in setting of possible community acquired
pneumonia. | 125 | 33 |
17979567-DS-7 | 23,034,148 | Dear Mr. ___,
It was a pleasure to take care of you during your recent
admission at ___. You came in
with the flu and we treated you for that. Once you were getting
better you unfortunately developed an infection in your
bloodstream that may have originated in your abdomen. We treated
you for that too and drained the fluid from your abdomen a
couple of times. Your kidney have suffered a little in the
process of fighting these infections and they should hopefully
get better over time. Also, you may eventually feel strong
enough to go through the TIPS so you won't need fluid taps that
often. We have placed a feeding tube to improve your nutrition
which is the first step to get stronger.
We wish you a quick recovery,
Your ___ Team | ___ w/cirrhosis (presumed NASH), pancreatic neuroendocrine tumor
metastatic to liver, coronary artery disease, presents with
weakness and fatigue, found to be influenza positive. | 133 | 24 |
17134675-DS-26 | 25,316,404 | Dear Ms. ___,
You were admitted to ___ for evaluation of your wound. You
were found to have an abscess in your abdomen/pelvis and
underwent a procedure to drain your abscess. You required a
brief stay in the intensive care unit, and are now ready to go
back to your rehabilitation facility. Please follow the
instructions below to help with your continued recovery:
- Your nutritional status was found to be suboptimal during your
hospital stay. You should try to increase the amount you eat and
drink, including adding ensure or similar supplemental nutrition
shakes.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation. | Briefly, Ms. ___ was admitted to ___ on ___ for
evaluation of a developing abdominal infection. She underwent a
right flank exploration with surgical drainage of an
abdominopelvic abscess on ___, please see operative note for
details. She was admitted to the ICU postoperatively for a
persistent pressor requirement and for close monitoring, please
see daily ICU notes for details. She was transferred to the
floor and her NGT placed post-operatively was removed. Her home
warfarin was restarted and she was noted to be malnourished on
clinical and laboratory exam; she was offered a PEG tube after
failing to take in adequate PO, but refused. Her home
medications were restarted when she was stable, and she had a
Foley catheter during her hospitalization secondary to
persistent post-operative labial swelling and perineal skin
irritiaton. On ___, she was found to be medically stable for
return to rehab. She was discharged in stable condition with
instructions to follow up with her PCP and in ___ clinic.
Hospital Issues
# Abdominal abscess - s/p open I&D, ___ placed ___
be removed at time of clinic visit, abx course completed
(vanc/ceftazidime).
# Malnutrition - pt appears chronically malnourished, will
require supplemental nutrition via Dobhoff vs PEG vs improved PO
intake
# Heel ulcer - Pt has chronic heel ulcers that will require
outpatient podiatry follow up for potential debridement.
# DVT - restart warfarin, INR monitoring continued | 501 | 230 |
12329543-DS-16 | 24,144,400 | Dear Ms. ___,
It was a pleasure caring for you at ___ ___
___. We are pleased to have been a part of your
transition to home hospice and comfort focused care. We have
adjusted your medications to mimimize those that are
uncessessary and to maximize your ongoing comfort. Please feel
free to contact your hospice service for any of your needs
regarding pain, nausea, or any other symptoms that concern you. | Ms. ___ is a very pleasant ___ yo F with metastatic breast
cancer (spine, liver, cranium) s/p numerous chemo regimens
(letrozole, taxol, capecitabine, doxol, eribulin) and XRT with
progressive disease who has had worsening episodes of confusion
over the last few weeks. During this admission, she was in her
nadir from recent Eribulin and was treated with empiric
antibiotics for neutropenic fever. She also required a
temporary Foley for urinary retentionm. Both of these had
resolved by day of discharge.
The patient may have leptomeningeal involvement of her cancer.
LP was deferred, and patient made the decision to transition to
___ Focused Care with Home Hospice, living with her
children. The goals of care and medications were transitioned
accordingly and patient was set up for home hospice prior to
discharge in good condition, mentating and ambulating well. | 73 | 141 |
11365932-DS-25 | 25,045,569 | You are being discharged from ___
___. It was a pleasure taking care of you. You were
admitted to the hospital for evaluation of pus in your urine and
bloody stools. While you were here it was discovered the the
pelvic abscess was draining into your bladder. You were put on
the right antibiotics and seen by the surgeons, kidney doctors,
infectious disease doctors. ___ was felt you needed to be
started on hemodialysis so we placed a hemodialysis line and
removed your PD line. You also were given a PICC line so we
could give you long term antibiotics. A drain was also placed
in the abscess and a Foley catheter was placed and needs to
remain in place at the time of discharge. You will have follow
up with all your specialists.
Please see the medication list for a detailed list of your
medications and any changes that were made. | ASSESSMENT & PLAN: ___ y/o F w/ PMH of lithium-induced ESRD on
PD, hemorrhoids, tracheal stenosis, and hypertension recently
discharged on ___ after transplant surg admit for
diverticulitis (treated conservatively w/ levo flagyl), and then
subsequently admitted for UTI and treated with meropenum who
presents with blood in BM, and a concerning CT scan for fistula
now s/p drain placement.
# Pelvic Abscess with enterovesicular fistula: s/p drain
placement Currently draining purulent material. Cultures with
polymicrobial infection as well as ___ albicans growing from
abscess. Per surgery, no colectomy during this hospitalization,
will need to follow up as outpatient. Her Foley continued to
drain pus and given the fistula between the abscess and the dome
of the bladder urology was consulted and they felt that the
Foley needed to stay in long term and that with the foley in
place and the pigtail drain, the fistulous tract should resolve
on its own. Given her pelvic abscess, PD was contraindicated.
An HD line was tunelled in the patient's right chest wall and
PICC line was placed on the right as well. The patient went for
surgical removal of her PD catheter and the surgical sites were
healing well at the time of discharge. For antiobiotics of her
infection, she was placed on meropenem and fluconazole. She was
also kept on PO flagyl for her c. diff and she will need to
continue the flagyl for 14 days after the last dose of her other
abx. She will have follow up with ID, Urology, Colorectal
surgery for further management of her abscess. The patient was
discharged home with her sister caring for her.
# ESRD on Dialysis: Ms. ___ was on PD on arrival, but given
her abscess PD was held. She was going to need long term
management of this abscess and so an HD line was placed and she
was started on Hemodialysis. PPD was negative and hep
serologies were sent. She tolerated HD well. PD catheter was
removed and she tolerated the procedure well without
complications. In addition, the renal team was following her
and we started sevelamer 800mg PO TID w/ meals. She otherwise
did very well from a renal standpoint. As changes in the
management of her Dialysis evolved, I constantly updated her
outpatient nephrologist so that he was up to date on the plan
upon discharge. In addition, we started vein preservation on
the LUE and mapping for possible AV fistula vs. graft was done
prior to discharge.
# RUE swelling: RUE swelling was noticed while she was in the OR
having her PD catheter removed. It was initially thought to be
___ blood pressure cuff on that arm, but it did not resolve on
arrival to the floor. She had no erythema or pain in the arm,
but given she had a PICC line and HD line on the right she was
sent for RUE dopplers that was negative for DVT. Unclear why
she was having edema and it will need to be followed in the
outpatient setting.
# UTI: Patient has a history of a fairly sensitive E. Coli in
the past, but required treatment with meropenam because of
allergies. Mixed flora in urine likely realted to fistula. See
abx and management of abscess and fistula as above.
# Guiaic Positive Stool: Patient is reported as having guiaic
positive brown stool. Etiologies include hemmorhoids, which the
patient has a known history of, as well as diverticulitis. HCT
is currently at baseline with the patient remaining
hemodynamically stable. Hct was stable throughout most of her
hospital stay.
# Hyponatremia: Patient appears to be euvolemic, could be
secondary to SIADH. Resovled without significant intervention.
# Macrocytic Anemia: At baseline. Iron studies in ___
suggest ACI.
# C. Diff: Patient was 1 day short of completing an antibiotic
course for c. dif. will continue flagyl for now given on other
abx as well. See above for plan for c. diff management.
Essentially flagyl will be continued for 14 days after
discontinuation of other abx.
# Rash: Appeared to be a fixed drug reaction. The area was
marked and despite not changing any of her medications, the rash
improved. At the time of discharge it was not present.
# PSYCH: Continued home meds:
- Fluoxetine 20 mg PO DAILY
- Lithium Carbonate 150 mg PO BID
- OLANZapine 10 mg PO BID
- Lorazepam 1 mg PO QHS:PRN insomina
- OLANZapine 5 mg PO ASDIR
. | 159 | 765 |
17212434-DS-19 | 25,255,898 | Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted with dyspnea on exertion. A
chest x ray did not show any infection or fluid collection. You
will need to go home with oxygen. You were also seen by
palliative care who recommended diet modifications to try to
increase your weight.
Medication changes:
Please start home oxygen to maintain saturation >92%
START senna an dcolace as needed for constipation
START cyanocobalamin (vitamin B-12) for deficiency
START dexamethasone 2 mg daily to help with your appetite and
energy
START levothyroxine 12.5 micrograms ___ tab) daily
START multivitamin to supplement diet
STOP axitinib
STOP lisinopril | Mr. ___ is a ___ year old man with metastatic renal cell
carcinoma who presented with shortness of breath and overall
weakness, unclear etiology.
#. Fatigue/failure to thrive: Patient presented with worsening
failure to thrive and fatigue over past months. Etiology
unclear, however likely multifactorial secondary to
chemotherapy, deconditioning and hypothyroidism. It is not
clear this is related to progression of disease as his last CT
scan showed improvement in metastatic RCC. TSH elevated with
normal T4 and low T3 so patient started on levothyroxine 12.5 mg
daily. B12 was low on admission so patient was given IM
repletion while here and started on PO supplement on discharge.
Cortisol was normal. Patient was seen by palliative care and
nutrition. Nutrition recommended supplements. Dexamethasone 2 mg
daily was started per palliative care recommendations. An MRI
brain was done to rule out metastatic disease and this was
negative. Patient was gently hydrated with NS at 100 cc/hr.
Axitinib was held as this may be causing some of symptoms, could
consider restarting as outpatient. Citalopram was continued for
depression.
#. Shortness of Breath: Patietn complained of dsypnea on
exertion. Given oncology history there is concern for pulmonary
embolism; however his sats are 100% on room air and he is not
tachycardic. Hypothyroidism may be contributing. Likely he is
deconditioned from weight loss and overall decline. Exam and
chest x-ray were not not concerning for CHF or PNA. Patient
was saturating well and comfortable on room air at rest, however
desaturated with ambulation. It was difficult to assess whether
this was a true desaturation or a poor measurement. Patient was
discharged with home oxygen.
#. Metastatic RCC: Patient responding to Axitinib based on last
CT scan on ___, however functional status as declined. Pain
was adequately controlled with ___ regimen. Axitinib was held
as it may have been contributing to symptoms or overall decline.
Patient was seen by palliative care and started on
dexamethasone.
#. BPH: Continued flomax, finasteride. | 100 | 333 |
11754422-DS-3 | 21,552,929 | You were admitted for presyncope (dizziness). You already had
workup as outpatient which was unrevealing. During hospitalized
telemetry only revealed rate controlled atrial fibrillation.
Cardiology consult was called and they felt the presyncopal
episode was unlikely to be cardiac. We think the original
episode was either due to urinary infection or urinary retention
from enlarged prostate.
Antibiotics were started to treat for possible urinary infection
and will be continued for 7 days total.
Flomax was stopped due to decrease in blood pressure. We decided
to discontinue all blood pressure meds except for Coreg and your
goal systolic blood pressure is 140s-170s.
You had some trauma from attempts to insert Foley catheter, and
warfarin was stopped so bleeding can be controlled. Urology was
consulted for hematuria and felt catheter placement was an
option, but you were urinating alright and declined catheter
placement.
Please do not restart warfarin until you've discussed with your
primary doctor. Follow up with your PCP, ___, and your
cardiologist within the next ___ weeks. You will need a repeat
CBC (blood count) drawn early this week. | Mr. ___ was admitted for presyncope.
#Presyncope:
Telemetry showed only rate-controlled atrial fibrillation.
Cardiology was consulted and given recent extensive cardiac
workup, they felt this episode was unlikely to be cardiac in
origin. TTE was repeated was stable. The most likely cause of
presyncope was either UTI or urinary retention. Urinalysis and
culture were unable to be performed the first day due to foley
trauma with significant hematuria.
#Hematuria, urinary retention, BPH, acute blood loss anemia:
He developed hematuria after traumatic attempts at placing Foley
in the ED. Warfarin was held and initial INR was 2.5.. Urology
was consulted and offered foley, but the patient and his family
refused citing infection risk. Upon discussion with family, it
was agreed to hold warfarin until hematuria resolves and restart
warfarin as an outpatient. The patient endorsed significant
prostate symptoms and started on Flomax but developed
orthostatic hypotension so it was stopped. PVRs improved to
150s. He was not having difficulty urinating at the time of
discharge and urine was non-bloody. Last INR was 1.4 on
___ and hemoglobin was 8.6 on discharge, down from
admission.
#Hypertension:
Amlodipine was stopped due to the patient feeling lower
extremity weakness while on it. Flomax was started for BPH but
he developed relative hypotension, so it was stopped. His BP
was noted to be labile. Due to concern that this was
contributing to presyncope, decision was made to discontinue all
blood pressure meds except for Coreg. His goal systolic blood
pressure was 140s-170s.
#Possible urinary tract infection:
Ceftriaxone were started empirically to treat for possible
urinary infection, given his urinary difficulty earlier in his
hospital course. Urine cultures were negative. He was afebrile
without leukocytosis. He was discharged on Cefpodoxime (renally
dosed) to be completed on ___, for total of 7 days.
#Transition of care issues: I spoke with Dr. ___ by phone
prior to discharge on ___ regarding plan. The patient has
follow up scheduled with his PCP and cardiologist later this
month. He was discharged with ___ services (___).
- Once hematuria has resolved, discuss restarting warfarin.
- Patient was given order for a CBC to be drawn around
___ to assess for worsening anemia.
- Recommend urology referral if persistent hematuria or
difficulty urinating.
- Consider restarting Amlodipine if HTN not adequately
controlled.
Check if applies: [ X ] Mr. ___ is clinically stable for
discharge today. The total time spent today on discharge
planning, counseling and coordination of care today was greater
than 30 minutes. | 185 | 421 |
10352268-DS-2 | 28,386,581 | You came in with a pneumonia due to an obstruction of your
airways caused by the lung cancer. You had a stent placed and
this helped clear the obstruction.
We are sending you home with hospice services to make sure you
have the best quality of life moving forwards.
Please return if you have intractable pain or symptoms not
relieved by medications.
It was a pleasure taking care of you at ___ ___
___. | Ms. ___ is a ___ woman with a history of newly
diagnosed stage IV non small cell lung cancer with metastases to
the adrenals, severe aortic stenosis (area 0.8cm2), HLD, and HTN
who presented from clinic with 3 weeks of shortness of breath,
cough, weakness and was initially admitted to the ICU with
hypoxemia and hypotension, now stable after IP stenting for
post-obstructive pna and subsequently tx'ed to the floor.
# SEPTIC SHOCK
# POST-OBSTRUCTIVE PNA
# LEFT BRONCHUS LESION
The patient presented with cough, shortness of breath, and
evidence of pneumonia on CXR. She was also hypotensive d/t
septic shock and required pressors briefly in the FICU. She was
started on Vancomycin and Zosyn for post-obstructive pneumonia.
CT scan revealed an enlarged left mainstem bronchus tumor. This
was removed by interventional pulmonology via rigid bronchoscopy
in the OR on ___. A pulmonary stent was placed to maintain the
patency of the airway. The patient was given BID mucomist and
saline treatments per pulmonology recommendations. Her
breathing and pna improved significantly post-procedure. Her
abx were narrowed to PO levaquin for completion of 5 day course
on discharge.
# HYPONATREMIA
The patient was noted to hyponatremic on arrival based on the
review of baseline Atrius records that revealed a sodium level
that varied between 129-131. Her current presentation was
thought to be likely SIADH in the setting of her lung cancer,
with possible component of hypovolemia. Na stable/improved at
135 on dischare.
# METASTATIC LUNG CANCER
# GOC
A CT chest on admission showed likely tumor necrosis and slight
increase in size of suprarenal metastases, unchanged mediastinal
lymphadenopathy, and an unchanged 4mm pulmonary nodule. It also
revealed an occlusive left main stem bronchus tumor that was
removed with subsequent placement of a pulmonary stent on ___
by interventional pulmonology. On ___, the patient expressed a
desire to go home with hospice care. After goals of care
conversation with family, HCP, and Atrius oncologist it was
decided not to pursue any further tests/treatments per patient's
wishes. Pt was discharged with home hospice services.
# ADRENAL ISUFFICEINCY
Pt was started on empiric stress dose steroids in the ICU due to
hypotension and known adrenal metastases as well as recent
dexamethasone use. She was discharged to complete 2-week
hydrocortisone taper
# AORTIC STENOSIS: Severe on ___ TTE. She appeared euvolemic
on discharge.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care. | 72 | 399 |
15528352-DS-23 | 24,302,308 | Dear Ms. ___,
It was a pleasure taking care of you at ___!
You were admitted for difficulty breathing and low oxygen
levels. You had a breathing tube in the ICU, and received
antibiotics for a pneumonia, steroids to treat the COPD flare,
and diuretics (water pills) to remove fluid out of the lungs.
Your lungs improved with this treatment, and eventually
transferred to the regular medicine floor where you continued to
do well. Your heart was initially in an abnormal rhythm, but you
were started on some medicines and your heart is now in a normal
rhythm.
The most important thing you can do when you leave the hospital
is to quit smoking. I have provided you with nicotine patches,
please obtain the nicotine gum and use in the way we discussed.
Please get the flu vaccine and pneumonia vaccines with your
primary care physician when you next see him/her. Otherwise, use
your inhalers and other medicines as prescribed. Lastly, please
see your cardiologist given the abnormal heart rhythm.
We wish you the best of health,
Your ___ Care Team | ___ woman with a history of CAD with prior missed MI
___, no intervention), COPD, rectal cancer s/p chemoradiation
and low anterior resection, and breast cancer s/p lumpectomy who
was initially admitted to the CCU for multifactorial respiratory
failure requiring intubation in setting of acute pulmonary
edema, pneumonia, and COPD. Course further notable for new
wide-complex tachycardia, most likely to be atrial fibrillation
with aberrancy. | 176 | 67 |
17420619-DS-23 | 26,096,088 | Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for low sodium levels.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You were treated with a medicine called albumin to help
improve your sodium levels.
- An imaging study of your liver showed a new, small mass in the
right side of your liver. This will require re-evaluation in ___
months.
- You were maintained a sodium and fluid-restricted diet to
improve your sodium levels.
- Your diuretic medication dose was adjusted.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Weight yourself daily. Call your liver doctor if your weight
increases by more than 3 pounds.
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ year old man with history of alcoholic
cirrhosis MELD 30 listed for transplant with several recent
admissions for volume overload, gout, hypertension, GAD,
bilateral avascular hip necrosis, subdural hematoma who
presented to the ED for abnormal outpatient labs (hyponatremic
to 127). This was likely due to confusion over his diuretic
regimen after recent discharge from ___ on ___.
___ was given albumin and IV lasix and serum sodium improved. ___
was discharged on a regimen of torsemide 80g BID. | 155 | 84 |
11881853-DS-19 | 20,415,003 | Dear ___,
You were admitted to the hospital for shortness of breath. You
were treated for a pneumonia with antibiotics.
While you were in the hospital, we managed your abdominal
distension supportively by supporting your symptoms of nausea
and pain. A G tube was placed to help with your abdominal
distention.
Please follow up with your PCP and Dr ___
(oncologist) as scheduled.
It was a pleasure taking care of you,
Your ___ Team | ___ with h/o metastatic GB adenoCA with peritoneal spread c/b
recent duodenal perforation s/p surgical repair, chronic bowel
obstruction with NGT, COPD, and CAD who presents from hospice
with SOB and persistent bowel obstruction, and inability to
manage symptoms at home.
Discharged home with home hospice.
# GOC: Patient has metastatic Gallbladder adenocarcinoma and
given limited functional status, is not a candidate for systemic
therapies. She is well known to palliative care service from
her recent admission and notably on last admission patient
expressed desire to be comfortable at home. Pt was recently
discharged tp home hospice as DNR/DNI/DNH. However, patient
became short of breath prior to admission, and EMS was called.
Her code status was reversed in ED and confirmed Full Code in
the ICU with HCP present. After speaking with daughter and HCP
on initial transfer to the floor, they stated they felt like
they were "forced" into DNR/DNI status. Palliative care was
reconsulted during admission. Had family meeting with Dr
___, patient and HCP on ___. Agreed on
DNR/DNI. A palliative venting G tube was placed by ___ ___.
Patient and family agreed on discharge to home with home
hospice.
# Sepsis ___ likely HCAP/Aspiration PNA: Patient admitted with
worsened SOB, tachycardia, leukocytosis and procalcitonin > 2.
Patinet with recent prolonged hospitalization with prior
HCAP/aspiration. Unfortunately, no micro data was obtained at
OSH prior to antibiosis. CXR here on admission consistent with
LLL PNA. She also has severe ileus / obstruction and bowel
translocation is possible.
She was initially given vancomycin, ceftazidime, flagyl
(___). Vancomycin was discontinued on ___. Antibiotics
were continued through ___. Blood cultures were negative.
# Bowel obstruction: Patient admitted with abdominal distension
in the setting of known malignancy, recurrent/chronic bowel
obstruction, and anasarca. On MICU transfer to floors, patient
reporting flatus and small BMs. Her NGT was to suction during
admission. Of note, patient came in with NGT from home hospice
for nausea and pain control. Her exlap stables were removed on
___. NGT was placed to low suction and patient remained NPO. A
venting G tube was placed by ___ ___. She was started on
octreotide.
# Tachycardia: Patient initially in ICU with HR110-120s which
persisted on initial floor transfer. The etiology of this
tachycardia was attributed to malnutrition / emaciation vs
metastatic cancer vs sepsis. HR on last DC summary was
documented as 106. Because patient is immobilized with cancer,
pulmonary embolism is on the differential, however ___ & ___
CTA was negative for PE. Patient was placed on telemetry
monitoring.
# Anemia of Chronic Disease: Hb on admission 6.2 and patient
received 1U PRBCs with greater than appropriate response.
# Non Gap Metabolic Acidosis: Patient admitted with metabolic
acidosis likely secondary to PPI usage, with also starvation
ketosis. Lactate normal, only trace ketonuria. Minimal uremia.
Significant respiratory compensation with pCO2 ~20. She was
continued on mIVF D51/2NS @75.
CHRONIC ISSUES
# Gallbladder Cancer: Widely metastatic. Last chemo (palliative)
___. She received oxycodone for pain control
# COPD: On nebs
# Hypertension: Held anti-hypertensives due to sepsis
TRANSITIONAL ISSUES:
====================
- Dr ___ be palliative care oncologist
- Home with ___' ___
- CODE: full at time of transfer home, but hospice intends to
discuss w patient
- CONTACT:
Name of health care proxy: ___
___: granddaughter
Cell phone: ___ | 70 | 554 |
16594085-DS-12 | 26,679,521 | Dear Mr. ___,
It was a privilege to care for you at the ___
___. You were admitted for worsening leg pain and
swelling in the setting of a recently found thigh mass. While
you were here, you were transitioned to a new blood thinner at
the recommendation of our clot experts. You also underwent a
biopsy of the thigh mass for pathology which is suggestive of
sarcoma.
You were also found to have a fracture of the area below your
left knee. You were seen by orthopedic oncology who recommended
a surgery to help with pain and stability in that leg.
You are now being discharged to rehab in order to work on your
strength and coordination. Please take all medications as
prescribed and follow up with all appointments as detailed
below.
We wish you the best.
Sincerely,
Your ___ Team | Mr. ___ is a ___ male with history of remote prostate
Ca, HTN, and CKD who presents with worsening LLE swelling in the
context of SFA DVT secondary to compressive left thigh mass that
failed to improve with outpatient apixaban.
# Left lower leg edema and pain, secondary to:
# Left SFA DVT
--Recently diagnosed with SFA DVT approximately two weeks
ago and started on apixaban. DVT likely secondary to local vein
compression by thigh mass (as detailed below). Repeat U/S
without essentially unchanged size of clot. Per heme, likely
does not represent clot failure, though preference for lovenox
at this time rather than resumption of apixaban. Patient started
on lovenox 60mg BID (slightly dose reduced for CKD). He then he
developed hyperkalemia, so decision was made by Heme to switch
back to apixaban, which he tolerated well. He was transitioned
to a heparin gtt in anticipation of surgery as below and then
restarted on apixaban 2.5 mg BID post-procedurally.
# Left tibial plateau fracture
--Continued to have severe left lower leg pain, worse with
bearing weight, despite therapeutic anticoagulation and
increasing multi-modal pain medication regimen, prompting
further imaging of the leg. X-rays of the leg showed a
non-displaced left tibial plateau fracture which most likely
pathologic and not traumatic. Knee immobilizer placed for
comfort. Given inability to bear weight due to pain and risk of
worsening fracture limiting quality of life, ortho-onc
recommended limited surgery to stabilize knee which was done on
___, which patient tolerated well. Intraoperative biopsies
taken were pending at time of discharge, but preliminary
pathology report suggestive of high grade sarcoma, as previously
suspected.
# Thigh mass:
# Metastatic sarcoma:
# Goals of care:
Recent MRI demonstrated large soft tissue mass in the left thigh
encircling the superficial femoral vessels with associated
femoral vein thrombosis (as above) with radiographic features
highly concerning for sarcoma. S/p biopsy on ___ and staging CT
on ___ that demonstrated lung nodules. First biopsy results
were non-diagnostic due to majority of cells being necrotic.
Another biopsy was performed, this time of the enlarged left
inguinal lymph node (rather than the thigh mass itself), and the
results showed likely sarcoma (final stains pending). PET-CT was
performed and revealed known disease in thigh/along vessels up
to iliac and pulmonary nodules as well as possible small focus
in spine. He was seen by oncology who recommended against
chemotherapy. He was evaluated by radiation oncology who said
they would continue to follow his course and consider palliative
radiation therapy depending upon the final pathology results,
with radiation commencing no sooner than 2 weeks following his
orthopedic surgery (i.e. no sooner than ___. After
discussion with palliative care, he was transitioned to DNR/DNI.
# Hyperkalemia: developed while on heparin/LMWH despite holding
his home lisinopril -HCTZ. Improved initially w/ stopping
heparin/LMWH, then worsened again, suspect from lack of bowel
movements. Improved after bowel regimen produced multiple BMs.
# Constipation: likely multifactorial from opioids, pain, and
lack of mobility from severe LLE pain. Improved with aggressive
bowel regimen.
I spent > 30 minutes of time on discharge planning and in face
to face encounter with patient and family
TRANSITIONAL ISSUES:
====================
[ ] Intraoperative biopsies from ___ suggestive of high grade
sarcoma. Finalized path expected ___. Pt will need hemonc
follow up and radiation oncology follow up for palliative
radiation therapy planning. Appointments pending at time of
discharge
[ ] Pt underwent ORIF on ___ with ortho oncology which he
tolerated well. He is scheduled for follow up in their clinic
for post operative check and staple removal
[ ] Post operative pain controlled with oxycodone 10 mg q6h at
first. Down titrated to 5 mg q6h on ___ as pain better
controlled. Continue to adjust pain meds as needed
[ ] Please continue apixaban 2.5 mg BID for recently diagnosed
LLE DVT
[ ] Patient found to be anemic to 7.1 on ___. Likely
multifactorial from iron deficiency anemia, anemia of chronic
disease, mild bleeding post operatively and dilutional from
fluid administration. Received IV iron on ___ and 1 unit pRBC on
day of discharge. Please continue PO iron supplementation | 140 | 692 |
19396692-DS-19 | 29,512,458 | Dear Mr. ___,
It was a priviliege to care for you at the ___
___. You were admitted for treatment of a severe
urinary tract infection caused by a stone blocking your kidney
from draining properly. You required placement of a PCN tube to
drain the kidney and will need several more days of IV
antibiotic to treat the bacterial infection. After your
infection is treated, you will need to have a procedure with the
urologist to remove the stone and then the PCN tube can be
removed.
You had some episodes of not wanting to eat or interact in the
setting of being sick in the hospital and missing some
medications, and this improved with assistance of our psychiatry
team and restarting some home medications.
Please continue to take all medications as prescribed and follow
up with all appointments as detailed below.
We wish you the best!
Sincerely,
Your ___ team | Mr. ___ is a ___ male PMHx schizoaffective disorder
and BPH who was admitted with urosepsis in setting of
obstructing ureteral stone, s/p R. PCN by ___.
# Complicated UTI:
# Obstructing Nephrolithiasis:
# Acute kidney injury (resolved):
Presented with fever, leukocytosis, and flank pain all c/w
urosepsis. CT abdomen and pelvis noted 11 mm obstructing stone
near the left ureteropelvic junction. He underwent PCN
placement by ___ with resultant improvement in renal function to
baseline. Urine culture growing both MDR E.coli and Proteus,
both sensitive to meropenem. He completed total 10 day course of
antibiotics following his PCN repositioning on ___. With
regards to his PCN, this will remain in place until he has
definitive management of his obstructing kidney stone with
interventional radiology, in the ___ Building at ___
___ at 12:30p
# Toxic-metabolic encephalopathy:
# Schizoaffective disorder:
Hospital course complicated by both agitation and hypoactive
delirium secondary to acute infection and known schizoaffective
disorder. While markedly somnolent, all psychiatric medications
were initially held and the psychiatry team was consulted to
guide safe resumption of his regimen. Plan at discharge is to
hold scheduled benzodiazepines, continue Effexor/ valproate, and
continue uptitrating Clozaril by 50 mg daily. Dose on day of
discharge (___) should be 275 mg of Clozaril.
TRANSITIONAL ISSUES:
==================
[] Ensure that patient follows up with interventional radiology
after completion of antibiotics for replacement of perc
nephrostomy tube (___). Patient should follow up with
Urology upon discharge here at ___ for incomplete emptying
likely due to BPH- Dr. ___: office (___) ___ at 3:15 pm. ___ ___ floor.
[] Psychiatric regimen on discharge has changed; see med rec.
Plan at discharge is to hold scheduled benzodiazepines, continue
Effexor/ valproate, and continue uptitrating Clozaril by 50 mg
daily. Dose on day of discharge (___) should be 275 mg of
Clozaril.
>30 min spent on discharge planning | 150 | 311 |
12637088-DS-15 | 23,335,591 | Dear Ms. ___,
It was a pleasure taking care of you during this admission. You
were admitted from a rehab facility on ___ after developing an
upper GI bleed. You were on coumadin after your knee surgery
which likely contributed to the bleeding. You were admitted to
the ICU and received blood transfusions. Multiple endoscopies
were completed that showed ulcers at the gastro-esophageal
junction. They were ablated to try to stop the bleeding. In
addition, interventional radiology embolized the left gastric
artery to stop the bleeding. The procedures were successful and
your bledding resolved. You were transferred out of the ICU once
you were stabilized. You did well without further bleeding. Your
hematocrit remained stable. Another endoscopy was performed to
examine the stomach, and it showed no bleeding.
While in the ICU you received IV fluids and blood products,
which caused significant swelling. You are being treated with
lasix to get some of the fluid off. Your electrolytes will need
to be monitored every other day while on this medication.
In addition, you are being treated for septic arthritis in the
right knee. You had a right knee washout during a previous
admission on ___. You will need to be on long-term IV
antibiotics for that infection until ___. You will be
getting the antibiotics through your PICC line. | Primary Reason for Admission: ___ y/o woman with recent R knee
septic arthritis, cellulitis and severe sepsis on Coumadin
presenting with hematemesis and hypotension.
. | 217 | 26 |
18553055-DS-33 | 25,986,478 | Dear Mr. ___,
You were admitted to ___ due to
chest discomfort. You were found to have a dangerously high
potassium and so you were admitted to the ICU. The treatment for
this high potassium is dialysis. However, your dialysis fistula
is non functioning correctly, and you were unable to undergo
dialysis successfully. We wanted to place a dialysis line into
your vein to give you dialysis, but you refused. We
alternatively were interested in completing a short session of
dialysis but you also refused this. The plan was to have the
dialysis fistula evaluated by our interventional radiologists.
However, you refused and wanted to go home to your regular
dialysis unit. We called your dialysis unit who is unable to
take you today. We are very concerned about you leaving and it
is against medical advice. We think there is a high risk of
sudden death and you may not feel any symptoms prior to death,
which is very worrisome. You vocalized that you were ok with
this risk, and repeated back that you were willing to take on
the risk of dying suddenly. You also refused medication called
kayexalate which helps remove potassium by having a bowel
movement. Although you refused this medication here, please
consider taking this once you leave. We have called it into your
pharmacy for you.
Please return to the hospital as soon as you are amenable. You
need dialysis and you need your dialysis fistula clot fixed.
We wish you the best in health.
Sincerely,
Your ___ care team | ___ hx ESRD on ___ HD, PE in ___, mechanical MVR on Coumadin,
CAD, HTN who presented from HD w/chest discomfort after R sided
fistula clotted, found to be hyperkalemic w/K>8.
#Hyperkalemia:
Presented from HD w/chest discomfort after R sided fistula
clotted, found to be hyperkalemic w/K >8. Mr. ___ was
admitted to the ICU given hyperkalemia. It was felt that his K+
8.7 on admission was too high risk for immediate AVF clot
thrombectomy. He received 10units regular insulin, 1g Calcium
Gluconate, 25mg Dextrose x 2. He adamantly refused HD line
placement for urgent HD. Given this, HD was attempted via AVF
and he did undergo HD for 2 hours. This was unable to be
completed due to poor flow. K+ did improve to 5.7 but increased
to 7.1 on ___. This is concerning for recirculation with
ineffective removal of potassium. This potential issue was
brought up last week when patient admitted for subtherapeutic
INR, needing IV heparin (persistent high potassium values during
the admission). Patient otherwise denies this as being a problem
and insists this relates to our particular dialysis machines
and/or the way we access his fistula, denying problems with his
potassium outside of admissions to ___. Plan was to perform
urgent dialysis to lower K and then pursue thrombectomy with ___.
However, patient chose to leave AMA on morning of ___.
Patient repeatedly and very clearly told that there is high
concern for sudden death at home with current level of
potassium, particularly with inability to dialyze until ___.
He can clearly verbalize this concern, but wishes to go home
regardless. He is aware that lethal arrhythmia can develop at
home with absolutely no warning and no ability to have time to
call ___. We did discuss that compliance with medical
recommendations are important part of transplant evaluation and
selection.
# ESRD on HD MWF:
BUN 87, Creatinine 15.2 on admission. No evidence of volume
overload or uremia. As above, only tolerated HD for two hours
and adamantly refused temporarily HD line. Continued home
selevamer and calcium acetate.
#HFrEF:
TTE on ___ showed moderately-to-severely depressed systolic
function secondary to global contractile dysfunction and
dyssynchrony w/LVEF 30%. Continued metoprolol, atorvastatin,
aspirin.
# History of PE:
Diagnosed in ___. Therapeutic on Coumadin. continued
warfarin.
# Hypertension:
continued home metoprolol.
TRANSITIONAL ISSUES:
- patient requires K+ check as soon as possible. Last K+ 7.1 on
discharge
- patient requires AVF thrombectomy.
- full code
- HCP: ___ Relationship: Friend; Phone number:
___ | 253 | 415 |
19915727-DS-13 | 22,326,711 | Dear ___,
It was a pleasure taking care of you at ___ in ___. You
were readmitted for pain in your right lower leg with new
swelling. We performed an ultrasound of your right lower leg,
which did not show a clot, but revealed a nodule that was hard
to characterize, but may have been a resolving pool of blood or
an infection or leukemia. We decided to obtain an MRI of your
right lower leg to further characterize the lesion. Since you
were feeling better, and ready to go home, we discussed that you
could leave after the MRI with the plan that if anything
abnormal was seen on the MRI that required you to return to
___, that we would contact you and you would return. | A/P:
___ year old female who is s/p 7+3 for NPM1+ FLT3+ AML presenting
with persistent right lower extremity pain and swelling.
# Right lower extremity pain: Pt presents with right lower
extremity pain, which is not a DVT. Based on US findings, may be
consistent with hematoma, given flow characteristics. ___ denies
any fevers, chills. While pt has pulm nodules, given lack of
other infectious sx, would not think that nodules in leg
represents fungal process. Also would consider whether this
represents leukemic involvement. Given recent neutropenia and
abnormal findings, will obtain MRI RLE to furhter characterize
the lesion. As pt is reliable and egaer to return home and does
not clinically appear to have evidence of significant leg
pain/tenderness or other evidnece pathology, that would be
worrisome for other emergent processes (e/g/ fasciitis), will DC
pt with MRI final read pending with plan to call pt and ask her
to return should MRI of RLE reveal issues that require urgent
intervention such as biopsy.
.
# AML with normal cytogenetics NPM1+, FLT3+: Day 14 BM negative.
BM from day ___ is pending.
.
# Pulm nodules: Was noted on prior CT which was suspected to be
possible infection (questionably fungal) - bronchoscopy was
considered on prior admission however was not performed because
patient decided against procedure. Pt will continue voriconazole
for treatment of presumed fungal infection with plan to check
B-glucan and galactomannan.
.
# Migraines: Pt may take tylenol prn, though advised not to take
standing adn to check temperature prior to taking tylenol.
.
# Anxiety: Patient is understandably very emotional and gets
easily worked up. Pt was continued on lorazepam 0.5mg PO q4h prn
.
#Asthma - albuterol nebs prn
TRANSITION ISSUES
# check beta d glucan and galactomannan from ___ and beta D
glucan on ___
# follow-up on pulm nodules with repeat CT in 2 weeks
# follow-up on RLE MRI results
# f/u BM biopsy to assess for CR1 | 127 | 316 |
14918161-DS-16 | 20,006,447 | Dear Ms. ___,
You were admitted to the hospital with abdominal pain and found
to have an infection in your gallbladder. You were taken to the
operating room and had your gallbladder removed
laparoscopically. You tolerated the procedure well 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. | Patient is a ___ year old female with past medical history of
type I diabetes, depression, and atrial fibrillation not on
anti-coagulation who presents to the ED with complaints of
abdominal pain, nausea with concerns for clinical cholecystitis.
Imaging was completed following arrival which demonstrated
cholelithiasis without ultrasound evidence of acute
cholecystitis. Therefore acute care surgery was consulted for
evaluation and management.
She was then taken to the operating room and underwent
laparoscopic cholecystectomy on ___. (Please see operative
report for details of this procedure). She tolerated the
procedure well, was extubated upon completion, and was
subsequently taken to the PACU for recovery.
Once pain was well controlled, and the patient experienced a
return of bowel function, her diet was advanced as tolerated.
During this hospitalization, the patient voided without
difficulty and ambulated early and frequently. The patient
became hypoglycemic and the ___ Diabetes inpatient service
adjusted her insulin regimen which she tolerated well. An
appointment was made for her on ___ at 1:00PM at the
___ Diabetes ___ to re-evaluate the new insulin regimen.
The patient was adherent with respiratory toilet and incentive
spirometry and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well. She was
afebrile and her vital signs were stable. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and her pain was well controlled. The patient was
discharged home without services. Discharge teaching was
completed and follow-up instructions were reviewed with reported
understanding and agreement. | 740 | 263 |
17697737-DS-22 | 27,898,068 | Dear Mr. ___,
It was a pleasure caring for you while you were admitted to the
hospital. You were admitted because you were found to have a low
blood count. You were treated with multiple blood transfusions.
There was concern that you may be bleeding from your
gastrointestinal tract and you were evaluated by the
gastroenterology team. They felt that you did not need an urgent
procedure and recommended that you start a new medication called
omeprazole. You were monitored overnight on the oncology service
and your blood counts remained stable.
.
The following changes have been made to your medication regimen:
Please START taking
- omeprazole 40 mg twice daily
.
Please STOP taking
- ranitidine
- ibuprofen
.
Please take the rest of your medications as prescribed and
follow up with your doctors as ___.
. | ___ with ___ stage IV (brain met s/p resection and
cyberknife) s/p C1 of carboplatin gemcitabine on ___ who
presented to clinic with fatigue found to have a HCT of 17 now
s/p ICU stay with 5 units PRBCs.
.
# GASTROINTESTINAL BLEEDING - Patient had guaiac positive stool
in the ED (confirmed by ___ physician) with an unsuccessful
nasogastric lavage. There was initial concern for upper
gastrointestinal bleeding given his hematocrit of 17% (10% drop
since ___ - though that was after transfusion for a
hematocrit of 23% on ___. Patient has been taking Ibuprofen
for headache while on steroids, which could predispose the
patient to gastritis among other issues. Patient does report
history of polyps on colonoscopy ___ prior and has known
diverticular disease, which could be a source for lower GI
bleeding. We initiated a Protonix infusion following a bolus and
consulted the GI specialists. He was maintained NPO with plans
for endoscopy, however HCT stabilized and he remained
hemodynamically stable without evidence of frank melana or
hematochezia. He received 5 units of packed red cells on
admission for his hematocrit of 17%. His HCT stabilized between
24 and 25. Given risks associated with intervention and the lack
of evidence for acute bleeding the decision was made to
empirically treat with PPI without endoscopy. The protonix gtt
was changed to IV BID and then omeprazole 40 mg po BID. His INR
was elevated likely in the setting malnutrition and he was given
1 unit of PRBC and vitamin K. Patient was monitored overnight
and continued to remain stable. He was discharged with plans to
avoid NSAIDS and with a prescription for a PPI.
.
# SEVERE MICROCYTIC ANEMIA - Patient has unclear hematocrit
baseline and has known anemia with recent hematocrit of 23%
following recent transfusion in ___ clinic.
Chronic GI bleeding, marrow suppression given his underlying
malignancy vs. marrow suppressive therapy could be contributing.
We monitored his hematocrit serially and transfused as needed.
.
# METASTATIC NON-SMALL CELL LUNG CANCER - The patient is
status-post resection and cyberknife of brain metastatsis and
first cycle of chemotherapy. He was continued on his Keppra
dosing for seizure prophylaxis and oxycontin and oxycodone for
pain. The patient was evaluated by the palliative care team.
Patient decided at this time he is interested in full aggressive
care including CPR and intubation but not prolonged intubation.
Once he feels that he is declining and nearing death, he says
that he will likely choose to die without resuscitation but is
not at that point now. Patient was discharged with plans for
home visiting care (minimal services at this time) and potential
bridge to hospice should that be decided as the next step.
Patient has plans to follow up with his outpatient oncologist
next week and issues of goals of care will be discussed during
that visit.
.
# SINUS TACHYCARDIA - On reviewing his record, patient's
baseline heart rate has been in the 110-120s (lowest HR recorded
in clinic was 112), except for a single EKG from ___
documenting a rate of 80 bpm. Unclear etiology likely ___
anemia. Patient continued to have sinus tachycardia despite
blood tranfusions and IVF making hypovolemia less likely. Had
CTA chest on ___ which was negative for PE and patient
remained in no respiratory distress, without pleuritic chest
pain, and maintained oxygen saturations in the ___ on room air.
LENIs were negative for DVT. Also, likely component of
overlying anxiety.
.
# ASTHMA, COPD - Patient denies history of COPD, however given
his smoking history, this was likely. Patient did not appear to
be in exacerbation during admission. He was treated with
albuterol nebulizer treatments as needed.
.
# FEVERS - Patient had reported temperature of 99.2F in the ED,
and was given Cefepime for unclear source. The patient does have
stable and chronic non-productive cough, but his CXR did not
appear to demonstrate pneumonia. An infectious work-up was
performed with reassuring blood and urine cultures.
. | 136 | 652 |
10323492-DS-20 | 24,179,340 | Dear Ms. ___,
.
It is always a pleasure to take care of you and we are glad you
are feeling improved and ready to go home. You were admitted to
the gynecology oncology service for management of a small bowel
obstruction. You were managed conservatively with antiemetics,
pain medications, and an NG tube. You had return of bowel
function and your diet was advanced. You have recovered well and
the team feels that you are safe to be discharged home. Please
follow the instructions:
.
* Take a stool softener to prevent constipation. You were
prescribed Colace. If you continue to feel constipated and have
not had a bowel movement within 48hrs of leaving the hospital
you can take a gentle laxative such as milk of magnesium.
* Do not take more than 4000mg acetaminophen (tylenol) in 24
hrs.
* Please continue a low residual diet (avoid high-fiber foods,
like whole-grain breads and cereals, nuts, seeds, raw or dried
fruits, and vegetables). If symptoms resume such as pain and
cramping, please resume low residual diet and call office.
* It is safe to walk up stairs.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | Ms. ___ was admitted to the gyn/onc service with an SBO.
Given her symptoms were similar to prior recent presentations
and she had no peritoneal signs on examination, imaging was
referred. An NGT was placed for bowel rest/decompression in the
ED. Her white blood cell count was noted to be elevated, but
there was no clinical evidence of infection (normal exam,
normal lactate). A repeat CBC on hospital day 1 showed a normal
WBC
She was managed conservatively during her admission with an NG
tube.
On hospital day 3, she began noticing more stool and gas in her
ostomy. She had minimal residual on an NGT clamp trial. Her NGT
was removed and her diet was
advanced without issue. On hospital day #3 she was tolerating a
regular
diet. She was discharged home in stable condition with
outpatient follow-up planned. | 201 | 146 |
10402073-DS-11 | 20,966,440 | Dear Ms. ___,
You were admitted to ___ for
evaluation of speech disturbance and weakness on your right
side. CT and MRI scans of your head and neck showed that your
symptoms were due to a stroke. It is likely that your stroke was
due to a blood clot arising from your atrial fibrillation, so we
started you on a blood thinner (apixaban/Eliquis) to reduce your
risk of future strokes.
Please follow up with your primary care provider within one week
of discharge from your acute rehabilitation facility. Please
also follow up with a neurologist within the next ___ months;
your primary care provider can help refer you to a neurologist.
It was a pleasure taking care of you at ___.
Sincerely,
Neurology at ___ | Ms. ___ is an ___ woman with history notable for
atrial fibrillation (not on anticoagulation), HFpEF, and
___ transferred from ___ after presenting with
aphasia and right face, arm, and leg weakness, found to have
multifocal L MCA ischemic infarcts. Thrombolytics not
administered due to presentation outside the tPA window, and CT
imaging of the head and neck otherwise negative for large vessel
occlusion amenable to thrombectomy. Mechanism of infarction
accordingly most likely atrial fibrillation not on
anticoagulation, which, per discussion with Ms. ___ PCP,
was due to patient preference. Accordingly, anticoagulation
initiated with apixaban to reduce risk of future strokes, along
with low-intensity atorvastatin therapy given likely
cardioembolic mechanism and low atherosclerotic burden on
imaging.
Hospital course complicated by non-fluent aphasia and
dysarthria, for which SLP evaluation recommended modified diet.
TRANSITIONAL ISSUES
1. Continued SLP evaluation and advancement of diet as
indicated.
2. Thyroid ultrasound to evaluate incidentally-noted left
thyroid nodule.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = 85) - () No
5. Intensive statin therapy administered? () Yes - (x) No [Low
atherosclerotic burden and cardioembolic mechanism of stroke]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? () Yes - (x) No [Low
atherosclerotic burden and cardioembolic mechanism of stroke]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
35 minutes were spent on discharge. | 120 | 379 |
14398235-DS-10 | 29,059,867 | Dear ___,
___ were admitted to the hospital with abdominal pain and
underwent a procedure called an ERCP, which found that ___ had
obstruction of your bile ducts causing the pain, and the
obstruction was relieved. After the procedure, ___ had
temporary inflammation of your pancreas, causing additional
abdominal pain, which resolved with IV fluids and gradual
advancement of your diet. ___ were also treated with
antibiotics to reduce the risk of infection after the procedure.
Do not take aspirin, Plavix, Coumadin, NSAIDs (e.g. Advil,
Motrin, Aleve, ibuprofen, etc.), or other anticoagulant
medications for 2 more days.
Please follow-up in ___ surgery clinic (as scheduled below) to
be evaluated for removal of your gallbladder to reduce the risk
of having recurrence of the problem that brought ___ to the
hospital (bile duct obstruction from gallstones).
It was a pleasure caring for ___ while ___ were in the hospital
and we wish ___ a full and speedy recovery.
Sincerely,
The ___ Medicine Team | Ms. ___ is a ___ y/o F w/lymphoma, C. diff presents with
abdominal pain due to biliary obstruction now s/p ERCP with
sphincterotomy on ___, but with recurrent abdominal pain with
improving LFTs but newly elevated lipase most likely due to
post-ERCP pancreatitis, which subsequently resolved with
conservative measures (NPO, IVF, pain control). On the day of
discharge, her lipase had normalized and she was tolerating a
normal diet with no abdominal pain. Regarding her biliary
obstrcution ___ choledocholithiasis, the patient will follow-up
with surgery as an outpatient to discuss possible
cholecystectomy, as she did not want to pursue any surgical
intervention during this hospitalization. She will complete 5
days of oral ciprofloxacin for ppx per ERCP team recs. She was
advised to avoid aspirin, plavix, NSAIDs, coumadin and other
anticoagulant medications for 5 days following her procedure.
She was otherwise continued on her home medications during
hospitalization.
Time in care: 45 minutes in patient care, patient counseling,
care coordination and other discharge-related activities on the
day of discharge. | 158 | 172 |
16121370-DS-18 | 20,244,610 | Dear Ms. ___,
You came to the hospital because you had abdominal pain, right
sided weakness and difficulty speaking. You had imaging which
showed a large bleeding stroke in the left side of your brain.
You also had a possible stroke or mass on the right side of your
brain.
For your bleeding stroke, we controlled your blood pressure to
prevent more bleeding. Neurosurgery saw you and recommended no
surgery as the bleed was too large.
You also had blood work which showed your had inflammation of
your pancreas. We tested you for common causes of pancreas
inflammation which were all negative. The pancreas inflammation
may have been caused by a medication or supplement. For your
pancreatitis, you were given fluids and you improved.
Because of your stroke, you were not able to swallow and a
feeding tube was placed to help your get nutrition.
Now that you are leaving the hospital, you will go to rehab
where you will continue to work with physical therapy. You will
need to have repeat imaging of your pancreas in 2 weeks. Then,
in about 1 month you will repeat imaging of your brain to see if
the mass on the right side of your brain has changed.
Please take all of your medicines as prescribed and follow up
with your doctors as listed below.
We wish you the best!
___ Neurology | Ms. ___ is an ___ year old woman with history of hypertension
who presented with abdominal pain, vomiting, confusion, aphasia
and right sided weakness found to have left fronto-temporal ICH
complicated by hematoma expansion and respiratory failure.
#Left IPH
#Right anterior temporal ischemia with hemorrhagic conversion
vs. mass
She developed acute onset confusion, aphasia and right sided
weakness. Her exam was notable for left gaze deviation, right
facial droop, RUE w/d in plane of bed and RLE with dense plegia.
She had a NCHCT with left fronto-temporal IPH and right anterior
temporal hypodensity. She was intubated in the emergency
department given increasing somnolence. She had LFTs which were
elevated (~400) with elevated lipase (~1800) and was admitted to
the medicine ICU. She had increasing somnolence and serial NCHCT
with expansion of her hematoma without increased midline shift.
She was transferred to neuro ICU. SBP goal <150 and did not
require standing antihypertensives. Her 48 hour NCHCT showed
overall stable hemorrhage and subq heparin was resumed. In terms
of etiology, given her preceding months of abdominal symptoms,
weight loss and an area of hemorrhage and area of hypodensity,
suspicion for malignancy was high. She underwent MRI/MRA which
showed left fronto-temporal IPH without evidence of contrast
enhancement or abnormal vascularity as well as an area in right
temporal anterior lobe with contrast enhancement suspicious of
underlying malignancy. She had a CT Torso with and without
contrast which showed no evidence of malignancy but did show
pancreatitis. GI was consulted who recommended MRCP in ___ weeks
to assess for underlying malignancy after inflammation has
resolved. Alternative etiologies for her IPH were ischemic
hemorrhagic conversion, but TTE negative for thrombus and LENIs
negative as well. CAA vs. hypertensive etiologies were also
considered, but she had no persistent hypertension and no other
findings suggestive of CAA on MRI. In the neuro ICU, her mental
status improved and she was alert, but not following commands
with global aphasia. She was subsequently extubated on ___. She
was transferred to the neurology ward service where she
continued to improve. She had PEG placed ___. She remained
stable from neuro perspective. On discharge, she was alert with
improving aphasia, able to speak short phrases softly in ___
and able to follow simple commands in ___. She will have
follow-up with neurology and repeat MRI with and without
contrast of brain to assess left IPH and possible right anterior
temporal mass, amyloid.
#Acute on Chronic Abdominal Pain
#Pancreatitis
Family reported weeks to months of abdominal complaints. She was
scheduled for endoscopy as outpatient. Prior to presentation she
had acute worsening of her abdominal pain and vomiting. LFTs
were elevated (400-600s), lipase was elevated to 1800sand tbili
to 1.6. She had CT Torso which showed pancreatitis. She was
treated with aggressive fluids for 48 hrs and her liver enzymes
normalized. She had no evidence of gallstones, no history of
etoh, normal ANCA, triglycerides and calcium. She does however
take statin, celocoxib and supplements, all of which have been
linked to pancreatitis. These medications were stopped. There
was also suspicion for pancreatic malignancy given her history
of chronic abdominal issues and 20 lb weight loss. Given
inflammation in the setting of pancreatitis, GI recommended MRCP
which was performed but not completed due to chest pain (EKG
unremarkable) and anxiety. No pancreatic abnormality detected on
this limited study. Given the study limitations, she was
scheduled for an outpatient EUS and GI follow-up prior to
discharge.
#Hypoxic respiratory failure
She arrived to ED on NRB and was intubated in the setting of
somnolence and inability to protect her airway. She was
extubated on ___ and required face tent. She had rhonchorous
breath sounds and evidence of pulmonary edema on CXR. She was
treated with duonebs, albuterol, chest ___ and suctioning. She
was given Lasix 10 mg x1 on ___ with improvement in her
respiratory status. She was redosed with Lasix 20 mg x1 on ___
and subsequently was sating well on RA. She did not require
further dieresis throughout her course.
#UTI
Had fever to 103 on ___, UCx revealed pan sensitive E. coli. She
was treated with CTX for ___. She then had foul
smelling urine on ___ and UA was obtained which had many WBC
and leuk esterase. UCx showed E. coli sensitive to CTX. She was
started on CTX with 7 day course (___).
#Dysphagia
She had PEG placement ___ without complication. TFs resumed
1200 on ___. Nepro used given hyperkalemia and ___.
#Urinary retention
She had urinary retention requires Q6H straight caths throughout
her hospital course. Given some vaginal irritation and skin
breakdown, foley was replaced. Please do void trial at rehab.
#Hyponatremia
She developed Na from 128-130. Urine lytes suggestive of SIADH.
FWF were decreased and she was started on salt tabs 1 g TID. Her
Na normalized. Then on ___ she again developed hyponatremia.
Repeat urine lytes on ___ still suggestive of SIADH. TSH was
rechecked day prior and was 18. Endocrine recommended increasing
levothyroxine. FWF was decreased and Na trended upward. Na 134
at time of discharge.
#Hypothyroidism
She missed 3 days of levothyroxine on admission given patient
aphasia and family obtaining med list. TSH 12 on ___, 8 on
___, 18 on ___. Levothyroxine 100 mcg daily increased to 125
mcg on ___ and 150 mcg on ___. She should have repeat TFTs ___
weeks after discharge.
#DVT
She was grabbing at left leg at times and therefore a lower
extremity ultrasound was done on ___ which showed non occlusive
right popliteal thrombus and occlusive peroneal vein thrombus.
She was hemodynamically stable and sating well on RA. She was
felt to be too high risk given her IPH for high dose IV heparin
or systemic anticoagulation. ___ was consulted who recommend IVC
filter placement which was done on ___ without complications. | 227 | 948 |
19449006-DS-18 | 29,935,618 | You were admitted to the hospital abdominal pain. You underwent
a cat scan of the abdomen and you were found to have
appendicitis. You were taken to the opertating room to have
your appendix removed. You are recovery nicely from the surgery
and you are preparing for discharge home with the following
instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound | The patient was admitted to the acute care service with
abdominal pain. Upon admission, she was made NPO, given
intravenous fluids, and underwent imaging. On cat scan of the
abdomen she was reported to have a dilated, fluid filled
appendix suggestive of appendicitis. Because of these findings,
she was taken to the operating room for a laparoscopic
appendectomy.
The operative course was stable with minimal blood loss. She
was extubated after the procedure and monitored in the recovery
room. During the post-operative course, she reported a headache
which resolved with fioricet and toradol. She was started on
clear liquids and advanced to a regular diet.
She was discharged on POD #1 with stable vital signs.
Appointments were made for follow-up with the acute care service
and with her primary care provider;
******
Of note: finding on cat scan of abdomen:
2cm right adrenal nodule, new from ___ is incompletely
characterized, but
likely represents an adenoma. Further evaluation with adrenal
protocol CT, or
MRI could be considered;
Patient was informed of these findings and recommendation made
for follow-up with primary care provider. Copy of report given
to patient. | 831 | 197 |
15303862-DS-20 | 28,826,906 | Dear Mr. ___,
It was a pleasure taking care of you at ___!
Why was I admitted to the hospital?
- You were having left knee pain concerning for an infection of
your knee replacement
What happened while I was in the hospital?
- You underwent surgery to have the infection drained from your
knee.
- You received antibiotics for your infection
- Excess fluid was removed from your body with diuretics
- Your fevers eventually improved after a second wash out of
your knee
What should I do when I get home from the hospital?
- Be sure to continue to take your antibiotics for a total of 6
weeks; you will have a visiting nurse that is going to help you
with this
- Make sure to have your labs checked while you are taking
antibiotics
- Please go to all of your follow-up appointments with the
infectious disease doctors, orthopedic surgeons, liver doctor,
and your primary care doctor
- Make sure to take your new diuretic every day; please weight
yourself in the mornings before eating and taking your
medications; if your weight increases by 3 pounds in one day or
5 pounds in one week, please call your liver doctor
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
- If you have fevers, chills, worsening knee pain, increased
wound drainage, leg swelling, problems breathing, or generally
feel unwell, please call your doctor or go to the emergency room
Sincerely,
Your ___ Treatment Team | SUMMARY
========
Mr. ___ is a ___ male with history of hep C (Harvoni
with SVR ___ cirrhosis complicated by varices, ascities and
hepatic encephalopathy, who presented to an outside hospital on
___ with worsening left knee pain, was found to have septic
knee arthritis complicated by septic shock s/p I&D and drain on
___ with repeat washout on ___, with course complicated by
volume overload and ___, now improving.
ACTIVE ISSUES
==============
# Septic arthritis
# Group B Strep Bacteremia (blood stream infection)
Patient presented with knee pain found to have septic knee
arthritis complicated by septic shock and group B strep
bacteremia status post I&D and liner exchange on ___ with
improvement in his blood pressures and lactate. Drain removed on
___. Blood cultures grew group B strep and bacillus species,
per ID bacillus species is thought to be a contaminant.
Initially placed on vancomycin/cefepime/Flagyl for concern of
polymicrobial infection then narrowed to ceftriaxone 2g daily
for 6 weeks. He underwent repeat L knee washout on ___ in
the setting of recurrent fevers. TTE was without evidence of
endocarditis. The infection is thought to be due to potentially
gut translocation in the setting of cirrhosis. ___ assessed the
patient and recommended home with ___.
# Intermittent fevers
# Tachycardia
Onset ___ while on Ceftriaxone, added vancomycin, broadened to
cefepime on ___. Pt continued to spike through broad spectrum
ABX despite negative work up and the absence of localizing
infectious symptoms. PICC line inserted on ___. UA is
negative and blood cultures remained negative. CXR was negative
for pneumonia. Repeat arthrocentesis demonstrated neutrophilic
predominance concerning for ongoing infection of joint. Patient
underwent repeat washout with ortho on ___. Patient
defervesced and has been afebrile for >48 hours at time of
discharge. He will continue ceftriaxone 2gm daily for 6 weeks
(last day ___.
# Volume overload
# Shortness of breath
Dyspneic at baseline following ?VATS procedure ___ years ago.
Baseline weight per patient 233 pounds, presented at standing
weight of 268. Ongoing volume issues due to need for transfusion
of blood products for anemia. Diuresed with Lasix drip, to
weight 235 pounds. He will be discharged on torsemide 40mg.
# Hep C cirrhosis (Childs C, MELD 24 on admission)
Complicated by ascites, varices, hepatic encephalopathy and GI
bleed in the past due to gastric ulcers. Not currently listed
for transplant.
- HE: history of frequent hospitalizations due to hepatic
encephalopathy. Patient has been AOx3 without asterixis.
Continued home rifaxamin & lactulose TID
- Ascites: discharged on torsemide 40mg PO daily
- SBP: Will require cipro ppx for life after rx with ceftriaxone
- Esophageal varices - last EGD reportedly in ___
though report unavailable. Discharged on home propranolol
- Thrombocytopenia: In the setting of infection and liver
disease/splenomegaly. Patient received multiple transfusions of
platelets in perioperative period.
- HCV - treated in ___ with SVR
# PICC Associated Nonocclusive thrombus
Duplex ultrasound obtained to evaluate for blood clot as cause
of ongoing fevers. Non occlusive thrombus identified in right
basilic vein adjacent to the intraluminal catheter. PICC
continued to be functional. Thrombus not felt to be source of
fevers. Elected against anticoagulation of thrombus given size,
provocation of PICC and underlying coagulopathy and cirrhosis.
#Nephrolithiasis
During fever workup, a CT abdomen with contrast was performed on
___ which demonstrated a 5 mm obstructing stone in the right
mid ureter with moderate upstream
hydroureteronephrosis. Patient denying urinary symptoms or pain.
Felt to be an incidental finding and not the source of fevers.
# Anemia:
Hgb 9.5 on presentation, downtrended to 6.6 while in hospital in
setting of multiple procedures. No other source of bleeding.
Felt in part to be related to polyphlebotomy. Patient received 3
units of pRBC over hospital course. Hgb on discharge 7.9.
#Leukopenia
As low as 2.9 during hospitalization. Patient on multiple
antibiotics that were felt to be potential culprits (Cipro,
vancomycin). Improving with transition back to ceftriaxone, was
3.7 on discharge.
# ___
Baseline creatinine 0.9-1.1, initially presenting to ___
___
with a creatinine of 2.5. Creatinine then trended down to 1.1.
Had second insult in setting of supratherapuetic vancomycin.
Improved to 1.2 at time of discharge.
CHRONIC ISSUES
# Hypertension: Held home propranolol while in house due to
sepsis.
# Hypothyroidism: Continued home levothyroxine. | 293 | 689 |
14471841-DS-9 | 23,782,019 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for abdominal
bloating. Initially there was a concern that you may have a
bowel obstruction, but a CT scan showed that you do not. It did
show that you had some fluid building up in your belly, and you
had some of this fluid removed which resulted in improvement of
your symptoms. You met with Dr. ___ discussed that your
liver cancer and your hepatitis C cirrhosis are progressing, and
that treatment with chemotherapy is not likely to help. We
discussed that getting an abdominal catheter may help you drain
fluid regularly to help with your bloating, but that these
catheters are generally only put in for patients who are on
hospice care. You indicated that you would like to get a second
opinion from Cancer Treatment Centers of ___. As such we did
not put in the catheter. Your bloating symptoms may return, in
which case we would need to consider a repeat procedure to
remove fluid. | Mr. ___ is a ___ year old male with a history of HCV, EtOH
cirrhosis complicated by ___ on chemotherapy who presented to
the ED for abdominal discomfort with possible SBO, worsening
metastatic disease, worsening ascites, severe constipation.
Abdominal Bloating associated with mild pain with low grade
fever. no SBO on CT scan. improved with paracentesis ___ but
symptoms returned the following day. discussed indwelling
catheter to allow frequent drainage of ascites. this would
normally be done in a hospice setting, but Mr. ___ now
indicates that he is not ready for hospice and wants to get a
second opinion. as such, plan for catheter cancelled. he has
some small fluid pockets on US but no urgent indication for
paracentesis at this time.
# HCV and EtOH cirrhosis complicated by HCC. MELD 22. Missed
recent chemo x2 out of difficulty getting to clinic. No clear
evidence of hepatic encephalopathy. Not on diuretics or
lactulose. did not tolerate taking lactulose in the past due to
diarrhea even at small doses. He was seen by the liver service
with recommendation to start rifaximin. He was also started on
aldactone to help with ascites management. His primary
oncologist Dr. ___ spoke with the patient ___ regarding his
poor prognosis (months) and that further chemotherapy will not
help him. He is upset but understands. He plans to seek another
opinion from Cancer Treatment Centers of ___.
# coagulopathy - likely from liver disease. He received vitamin
K 5mg PO x 3 days with little benefit, suggesting coagulopathy
due to liver synthetic function
# 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 ___ | 177 | 290 |
15568392-DS-13 | 20,851,661 | Dear Ms. ___,
You were transferred to ___ after a cardiac arrest after
falling into water. We think this happened because you had a
seizure. You were intubated at ___ and
then transferred here. Here, you became more and more awake and
were extubated on ___. You were monitored on EEG for seizure,
and while we didn't capture any seizure activity, we did decide
to start you on Zonisamide 100mg daily because we think you had
a seizure while taking Dilantin. You also had an MRI, which was
normal except for a 6mm meningioma unchanged from your most
recent MRI in ___. You were also treated for possible
aspiration pneumonia since you fell in water. We stopped IV
antibiotics before your discharge, and you should continue
taking oral antibiotics for 4 more days. You should follow up
with Dr. ___ as an outpatient for more changes to your seizure
medications, and with your primary care physician. You cannot
drive until you are seizure free for at least 6 months. You
should not swim or bathe unsupervised because of the risk of
having a seizure.
If you experience any new concerning symptoms (listed below)
please contact your primary care doctor for follow up or present
to the ED.
It was a pleasure taking care of you and we wish you the best!
Sincerely,
Your ___ Neurology Team | ___ is a ___ year old woman with PMH of seizure disorder
with witnessed fall into pool, face down in water for several
minutes, found to be without pulse with CPR initiated followed
by coughing up water, with ROSC, intubated at ___ transferred to
___ for further care.
# S/p cardiac arrest:
# Respiratory failure:
On arrival to the MICU was following all commands, though when
weaned to pressure support took increasingly smaller tidal
volumes and eventually apneic so kept intubated overnight on
CMV. Extubated in the AM ___. without complications. Since
mental status intact on arrival, was not cooled but kept
normothermic at 36 C. Etiology of arrest thought to be hypoxemia
from being down in pool. Initiating event causing fall into pool
thought to be seizure. TTE WNL. Repeat chest imaging on ___
demonstrated a possible RLL infiltrate. This in the setting of
increased green sputum production and rising leukocytosis
prompted the initiation of Zosyn on ___ for PNA.
Anti-pseudomonal coverage was chosen given history of water
ingestion. Her leukocytosis resolved, and she had no fevers, and
CXR showed no pneumonia, and clinically she did not have
symptoms. Prior to discharge, ___ was switched to Augmentin
875mg BID for 4 more days to complete a ___erebral edema seen on non-contrast head CT:
Seen on 2 serial CTs, though not seen significantly on
subsequent MRI. Per neurology consult, level of edema did not
correlate with intact mental status exam. MRI performed to
evaluate venous sinus thrombosis as etiology, which was not
seen. Small meningioma was noted incidentally.
# Seizures
___ did not have any missed doses of medications, so she was
continued on her home Dilantin. The night before her seizure and
cardiac arrest she had not taken her ativan and hadn't slept
well, so it was thought that sleep deprivation may have been a
provoking factor. Zonisamide 100mg daily was added, with plan to
increase to 200mg daily after 2 weeks. She was continued on
cvEEG, and had no seizures captured. She was continued on Ativan
QHS for sleep, which she should continue until follow up. She
has follow up with Dr. ___ outpatient epileptologist.
#Hypothyroidism
She was continued on her home levothyroxine 88mcg daily
#Depression, anxiety
She was continued on her home citalopram 40mg daily, baclofen
10mg TID, and lorazepam 1mg PO QHS PRN insomnia. | 223 | 381 |
10674024-DS-3 | 24,846,770 | You were admitted to the hospital for treatment for an infected
seroma. Your wounds required incision and drainage as well as ___
drain placement. Please follow these discharge instructions: | ___ PMHx morbid obesity s/p gastric bypass with significant
weight loss s/p abdominoplasty with panniculectomy at ___
___ (___) p/w abdominal abscess.
# Sepsis: On admission, pt meets ___ SIRS criteria (leukocytosis
and tachycardia). She also has a presumed source (abdominal
wound). She also had hypotension that was fluid responsive.
# Infected Seroma: Pt s/p recent abdominal surgery. She has had
increased abdominal pain and girth over the last several days.
She now has a leukocytosis, tachycardia, and mild hypotension.
Imaging from ___ is suggestive of an infectious
intraabdominal collection. Plastic surgery saw the pt ___ the ED
and recommended medical management with IV antibiotics and ___
drainage of collection. ___ drained 100 cc's of pus from her
left-sided collection, wound swab growing MRSA, pigtail left ___
place. Her antibiotics were narrowed to vancomycin alone, PICC
was placed given difficult access. She received Oxycodone 2.5 mg
PO Q4H PRN pain. She was called out to the plastic surgery
service. Given that she continued to have pain ___ her RLQ, a
bedside I&D was performed. She tolerated this procedure well and
her exam continued to improve. ID recommended 1 week of IV
vancomycin followed by 1 week of Bactrim PO which was ordered.
# S/p Gastric Bypass: Continued tums, B12, MVI, calcitriol
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled. She
was discharged home with ___ services. | 29 | 253 |
15551558-DS-10 | 25,449,611 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
***Has right groin staples that need to be discontinued in 2
weeks | She was admitted on ___ and was taken emergently to the
operating room. She underwent emergent Ascending Aorta
replacement with CABG x 1 with Dr. ___. Please see operative
note for full details. She tolerated the procedure well and was
transferred to the ___ in stable condition for recovery and
invasive monitoring.
She weaned from sedation on POD#1 but she was slow to wake. She
was arrousable but she required aggressive diuresis with a Lasix
drip and was extubated on POD#4. She had tube feeds through a
dobhoff tube which was very difficult to place and required ___.
Her chest tubes and wires were discontinued in the first few
days postop. She was weaned from inotropic and vasopressor
support. Beta blocker was initiated and she was diuresed toward
his preoperative weight. She had an elevated WBC and grew
Citerobacter on a BAL. She was treated with Ceftazadime and
Levofloxacin. Levofloxacin is to continue until ___ to complete
course of antibiotics for PNA. She remained hemodynamically
stable and was transferred to the telemetry floor for further
recovery. As PO intake increased, TFs and DHT discontinued.
Encourage oral intake/free water with rising Na. She received SC
Heparin for DVT prophylaxis. Wound care consult evaluated
sternal and right groin wounds. Initially draining serous -
which resolved. Softsorb applied to sternal wound to minimize
irritation with good effect. She was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 17 she required maximum assistance
for mobility, the wound was healing, and pain was controlled
with Tylenol only. She was discharged to ___
___ in good condition with appropriate follow up instructions. | 129 | 284 |
11644818-DS-21 | 29,782,315 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were instructed to come to the hospital by orthopedic
surgery due to persistent right leg cellulitis.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated with IV antibiotics for an infection in your
leg
- The Infectious disease specialists evaluated you and believed
that some of the redness and skin changes in your leg are due to
poor blood supply, rather than infection. They recommended that
you stop the IV antibiotics and that you could go home with
continued oral antibiotics.
- You were found to have a urinary tract infection, which was
treated with an oral antibiotic.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and ___
with your appointments as listed below.
-You should watch for any signs of infection, including fevers,
chills, worsening redness or pain in your leg, and drainage of
pus.
-You should follow up with a vascular surgeon to evaluate the
blood supply to your leg.
We wish you the best!
Sincerely,
Your ___ Team | Mr. ___ is a ___ with history of sick sinus syndrome s/p
pacemaker, R ankle fracture s/p ORIF with hardware placement,
presenting with persistent RLE cellulitis x2 months.
ACTIVE ISSUES
=============
#Non-purulent RLE Cellulitis
Patient presented to ___ in early ___ for a
pneumonia, and was found to have RLE cellulitis, which was
treated
initially with IV vancomycin, CTX, and azithromycin, and he was
discharged on PO doxycycline. Course was extended due to
insufficient response, and cephalexin was added on ___.
Presenting here due to persistent cellulitis, due to concern
from
orthopedics given ongoing infection and plan for possible
further
surgical intervention to right ankle. Patient was afebrile, and
hemodynamically stable, and there is no evidence of involvement
of the underlying joint or hardware. However, given the
persistence of the infection and the possibility for seeding the
ankle hardware or cardiac pacemaker, pt was treated initially
with IV
antibiotics. Patient was seen by infectious disease, felt that
some of his skin changes were more consistent with peripheral
vascular disease (likely mixed arterial and venous), and
therefore recommended discontinuing IV antibiotics and
completing a course of cephalexin (end ___. Blood cultures
were pending. CRP elevated at 10.9/ESR 46. Recommended
outpatient vascular surgery evaluation, which was discussed with
pt and his wife prior to discharge home.
#Normocytic anemia
Most recent hemoglobin in ___ was 10.6. Hemoglobin on admission
7.9. Iron studies consistent with anemia of chronic
inflammation.
#Complicated UTI
Urinalysis in the ED was significant for pyuria and bacteria.
Patient also reports increased frequency of urination. Urine
cultures grew KLEBSIELLA PNEUMONIAE >100,000 CFU/mL;
sensitivities reported after discharge revealed highly resistant
(carbapenem resistant, sensitive only to amikacin). Discussed
with ID, RNs, and environmental services for appropriate room
cleaning. Pt and his wife notified by phone; given lack of
dysuria, reasonable to defer further treatment of UTI vs
asymptomatic bacteruria. Received one dose of CTX in the ED, and
initially treated with PO Ciprofloxacin 500 mg BID, neither of
which were active against highly resistant Klebsiella.
Chronic Issues
==============
# Chronic low back pain
Tylenol ___ mg every 8 hours as needed
# SSS s/p cardiac pacemaker (per patient, about ___ years ago)
# CODE: full (presumed)
# CONTACT: ___ H: ___ c: ___
TRANSITIONAL ISSUES
===================
- On course of cephalexin 500 mg four times a day through ___
for cellulitis. It is unclear how much of his current findings
are due to infection vs peripheral vascular disease.
- Will need follow up with vascular surgery for question of
peripheral vascular disease
- Urine sensitivities for Klebsiella resulted after patient was
already discharged. Resistant to nearly all antibiotics
(intermediate sensitivity to meropenem, and sensitive to
amkikacin). Patient was only having very minor urinary symptoms
(just frequency) so the risks of treating outweigh the benefits.
However, should he develop more significant urinary symptoms or
become septic, this will be a very difficult organism to treat.
[x ] The patient is safe to discharge today, and I spent [ ]
<30min; [x ] >30min in discharge day management services. | 199 | 479 |
11372885-DS-12 | 28,092,681 | It was a pleasure participating in your care at ___. You were
admitted to the hospital for likely lung infection. Please
continue the prescribed antibiotics.
Otherwise, it is very important that you take all of your usual
home medications as directed in your discharge paperwork. | Ms. ___ is a ___ year old female with history of Hodgkin's
Lymphoma, status post chemo and SCT in ___, residual radiation
pneumonitis who presents with cough and shortness of breath x1
week, noted to be tachycardic with lactic acidosis in the ED.
She was admitted to the MICU and her lactate resolved and
symptoms improved with IV fluids and treatment for community
acquired pneumonia.
# Community acquired pneumonia: She did have WBC to 15 with
mild fevers and productive cough/sputum production. We decided
to treat with levofloxcain 750 mg daily x 7 days because of her
history of radiation damage and bronchiectasis. Other likely
etiologies are a viral URI/bronchitis in the setting of her sick
contacts at school with associated reactive airway disease,
especially given her normal CXR. She was continued on her home
fluticasone inhaler and albuterol inhaler. She did recieve 40
mg of prednisone in the ED but this was not continued.
# Tachycardia: Could be in setting of infection, though pt
reports very good PO fluid intake. She says she has been
running a "high" heart rate in the ___ over recent months
at baseline and this is confirmed in prior clinic notes.
Pulmonary embolus was considered but her Ddimer in the 200s
makes this less likely. No evidence of effusion/tamponade on ED
bedside echo. No recent levothryoxine dose changes. We sent an
email to her outpatient PCP making them aware that this was an
ongoing issue and they may want to pursue cardiac work-up
including echo and stress since she has potential for
radiation-induced CAD or heart failure.
# Lactic acidosis: Unclear why her lactate persisted greater
than 4 despite 3L NS in the absence of a significant infectious
process. BP is normal on the floor. No abdominal pain or other
localizing symptoms. It did resolve the following morning.
# Hypothyroidism: Continued home levothyroxine 75 mcg daily. | 44 | 329 |
15048951-DS-18 | 27,313,759 | Dear Mr. ___,
Why was I here?
- You were admitted to the hospital because you were found to be
intoxicated with alcohol and there was concern that you might
have alcohol withdrawal and seizures.
What was done for me here?
- You received a medication that reduced your chance of having a
seizure and helped to manage the symptoms of alcohol withdrawal.
- We also provided you with important vitamins and started
medications to help your liver disease
What should I do when I go home?
- We recommend that you follow-up at the ___
___ and ask for a case manager there.
- We recommend that you follow-up with your primary care
provider ___ 1 week.
Please call your doctor if you have any changes in body
temperature (fevers, chills), heart palpitations, tremors,
seizures, hallucinations, or any chest pain or shortness of
breath.
It was a pleasure taking care of you! We wish you the best of
luck.
Your ___ Inpatient Care Team | ___ man with a h/o alcohol abuse complicated by withdrawal
seizing episodes in the past, cirrhosis ___ EtOH and HCV with
varices, who was brought in by EMS after being found down. On
arrival, patient was minimally responsive and noted to have an
EtOH level of 433. He initially received 2 mg IV Ativan, but due
to persistent tachycardia with minimal responsiveness, he was
admitted to the MICU. On arrival to the MICU, he was arousable,
but generally refused to engage in conversation. He received a
phenobarbital loading dose, but was not continued on maintenance
dosing due to his cirrhosis and stabilization of his symptoms.
He had a transient fever, which was felt to be due to aspiration
pneumonitis vs ETOH withdrawal, which resolved without
antibiotics. He was transferred to the floor on ___, where
he remained without signs of alcohol withdrawal. He was seen by
SW; at discharge plan for made for the patient to follow-up at
the ___ where he could be set up with a
case manager. He also expressed interest in following up with
his PCP in order to be connected to Behavioral Health Services.
#ETOH withdrawal.
#Tachycardia.
Prior discharge summary notes history of withdrawal seizures
which patient denies. On arrival in MICU, patient was
tachycardic, tremulous, and nauseous concerning for onset of
withdrawal. Serum ETOH 433 on arrival to ED, with elevated
lactate to 2.4 (suspect type B lactic acidosis). Received 2 mg
Ativan in ED and was reportedly somnolent. Mental status
improved on assessment in MICU and patient received reduced
phenobarbital load to 5 mg/kg which he tolerated to good effect.
He received high dose Thiamine, folate, and multivitamin.
The patient was transferred to the floor on ___ and
remained clinically stable. He did not exhibit any signs or
symptoms of acute alcohol withdrawal and did not require any
additional lorazepam (written for 1 mg q4 PRN per ___
protocol). He was continued on Thiamine, multivitamin, folate.
He was seen by ___ and expressed interest in programs for
Behavioral Health and substance use recovery and was provided
with relevant resources. At discharge, a plan was made for the
patient to follow-up at ___ where he can
be set up with a case manager, as well as with his primary care
provider, who was informed about his admission.
#Acute Hypoxemic Respiratory Failure
Patient noted to desaturate and had oxygen requirement in the
MICU. This was likely due to sedation. It resolved prior to
discharge.
#Fever.
Temperature to 101.6F in ED. Mild leukocytosis on admission,
which normalized later. CXR with b/l lower lobe opacities
favoring atelectasis rather than infection. UA negative for
infection. Antibiotics were deferred given hemodynamic stability
and low suspicion for infection.
On the floor, the patient spiked a fever again to 101.7 the
night of ___. UCx was clear and repeat CXR did not demonstrate
pulmonary process suggestive of pneumonia. The etiology was
thought to be most likely temperature fluctuations in setting of
withdrawal. The patient remained afebrile throughout the morning
on the day of discharge. He was given return precautions to
re-present to care if he developed more concerning respiratory
symptoms
#Hyponatremia: Na 131 on ___, drop from 139, together with
lower blood pressures (systolics <100) was noted. This was
thought to be most likely hypovolemic hyponatremia. The patient
was treated with IVF and increased PO intake and his blood
pressures increased to systolics >110 prior to d/c.
#Cirrhosis
#Esophageal varices.
#Hx ___ tear.
Received Nadolol and Lactulose on prior admissions, though does
not take these medications as an outpatient. In ___ EGD
showed 2 cords of grade II varices seen in the lower esophagus.
He was restarted on Pantoprazole, Lactulose, and Nadolol while
inpatient.
#Coagulopathy: Presented with an admission INR of 1.8. This did
not respond to Vitamin K challenge, so likely primarily due to
liver disease.
#Anemia of chronic disease: His hemoglobin was low on admission
but similar to prior values in our system. Likely due to marrow
dysfunction from alcohol and cirrhosis, and there was no
evidence of active blood loss.
====================== | 157 | 660 |
11722906-DS-31 | 21,082,524 | Dear Mr. ___,
Thank you for choosing to receive your care at ___. You were
admitted with dizziness and chest pressure. You were evaluated
by neurology and underwent an MRI scan of your head, which did
not reveal any concerning cause of your dizziness. You were also
evaluated extensively with nuclear and treadmill stress testing
of your heart, which did not reveal any heart disease. You also
had a rapid heart rate, with no concerning cause such as repeat
clots in your lungs or heart disease. We think that your
dizziness, fast heart rate, and chest pressure is likely related
to anxiety and possibly panic attacks. You were seen by
psychiatry, and started on two medications to help treat your
anxiety and panic attacks.
You were noted to have fluctuating INRs during this admission.
You were continued on your Coumadin while in hospital, and are
being discharged with lovenox injections to keep your blood
thinned while your Coumadin reaches a therapeutic level again.
We wish you the best with your ongoing recovery.
Sincerely,
your ___ care team | ___ year old with history of UC s/p total proctocolectomy and
ileoanal pouch, ankylosing spondylitis, type 2 DM, DVT, and
recent admission ___ to ___ where he was found to have BPPV and
a LLL PE started on Coumadin now presenting with dizziness since
discharge and chest pressure for one day, found to be
tachycardic with an elevated lactate.
# Dizziness:
Patient reporting new onset dizziness, described as feeling his
pulse in his head and his vision beating side to side. Pt was
given a diagnosis of BPPV at last admission, however his
symptoms are not consistent with this finding. On exam, e/o
decreased proprioception on exam w/ nystagmus laterally on
prolonged upward gaze. Workup for seropositive autoimmune
disorder negative so far: RF<3, ___ neg. CRP 2.5, sed rate 6.
B12 503. Cu nl. Vit E low. RPR nl. CT head did not demonstrate
an acute process. MRI head with no gross abnormalities. Thought
most likely to be a multifactorial peripheral cause (planter
neuropathy), with additional strong component of anxiety.
Improved with Ativan. Started on Vit E 400u/day and citalopram
0.25mg BID. Should follow up with remaining labs sent by neuro
at f/u appointment with Dr. ___ should also be referred
to psychiatry from PCP ___ (per psychiatry recommendations,
as they think this is the fastest mechanism for him) for ongoing
treatment of anxiety. Also has f/u appointment w/ ENT ___
at ___.
# Chest pressure, shortness of breath:
Pt presents with chest pain/discomfort on deep inspiration. EKG
demonstrated non-specific T-wave inversions, but troponin was
negative x 2 so ACS ruled out. TTE ___ demonstrated normal LV
function, slightly dilated RV, PASP unable to be estimated. BNP
low (unreliable given his adiposity); overall, CHF exacerbation
unlikely. New tachycardia and pleuritic nature of pain c/f
repeat PE, but CTA negative and patient on coumadin. Trial of
naproxen ineffective at controlling pain, suggesting
pericarditis less likely. Nitro effective at pain control,
suggesting angina; However, exercise stress test without
inducible ischemia, angina, or echo abnormalities and nuclear
stress test without any abnormalities. Seen by psychiatry, who
think symptoms may be ___ anxiety attacks. Patient was on
longstanding metoprolol, which was held this admission for
dizziness and may be exacerbating anxiety and tachycardia.
Restarted metoprolol, and started Clonazepam 0.25mg BID, with
some improvement in symptoms. Instructed in relaxation
techniques as well.
# Pulmonary embolism: Pt presents with INR 3.3 and known PE
diminished in size without evidence of new PE. Subsequently
became subtherapeutic after holding for supratherapeutic INR.
Transitioned from coumadin to apixiban 10mg BID, but had
hematuria so converted back to Coumadin. Started on heparin GTT.
Patient triggered ___ for tachycardia, c/f possible repeat PE
in the setting of subtherapeutic Coumadin and heparin, but no HD
instability so decision was made not to pursue CT angio and to
continue treatment with lovenox as a bridge to heparin moving
forward.
# Hematuria: Pt presents with UA demonstrating large amounts of
blood. He was noted to have gross hematuria during his recent
admission with negative initial workup. He had a repeat episode
of hematuria after starting apixiban. Urology was consulted
during last admission and plan was for urology follow up as
outpatient cystoscopy. Outpatient follow up planned on ___.
# Ankylosing spondylitis: Pt denies worsening symptoms, however
states that he did notice some hand and feet swelling a few days
ago that resolved. Continued home gabapentin,
methylprednisolone, oxycodone PRN. ESR and CRP WNL.
# Hypertension: Restarted metoprolol as above
# Depression, recent SI: Pt denies SI/HI. Continued home
venlafaxine.
# UC: Pt reports some blood in stool following apixiban, but no
other abdominal pain or active symptoms. Deferred humira to
outpatient.
# Diabetes, likely steroid induced: HISS in house, not on any
medications at home.
# Low testosterone: Held home testosterone in house
TRANSITIONAL ISSUES
===================
-Should get close psychiatry follow-up for ongoing management of
anxiety (both pharmacologic and non-pharmacologic).
-f/u pending labs, including anti-GAD and anti-gliaden
-recheck INR ___, adjust warfarin dosing accordingly;
should instruct patient to stop lovenox. PCP to coordinate with
___.
- Patient with hematuria currently in the process of workup;
needs outpatient cystoscopy
# CONTACT: ___ (sister) ___
# CODE STATUS: Full code | 177 | 708 |
Subsets and Splits