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10964464-DS-21 | 22,015,797 | 1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
7. SWELLING: Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. You may wrap the knee with an ace bandage
for added compression. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
8. ANTICOAGULATION: Please continue your Lovenox 60 mg twice
daily for four (4) weeks to help prevent deep vein thrombosis
(blood clots).
9. WOUND CARE: Please keep dry sterile dressing in place until
follow-up visit next week with the Plastics team on ___. You
have 1 JP drain in place, which should remain in place until
your follow up with the Plastic Surgery & Reconstruction team.
All questions and concerns regarding wound care should be
directed to their office. See follow up appointment information
below.
10. ___ (once at home): Home ___, daily dressing changes and
wound checks as instructed by Plastics Surgery & Reconstruction
team.
11. ACTIVITY: Toe touch weight bearing on the operative
extremity. Two crutches or walker. Knee immobilizer in place at
all times. NO ROM. No strenuous exercise or heavy lifting until
follow up appointment.
12. PICC CARE: Per protocol
13. WEEKLY LABS: draw on ___ and send result to ID RNs
at: ___ R.N.s at ___.
- CBC/DIFF
- CPK
- CHEM 7
- LFTS
- ESR/CRP
**All questions regarding outpatient parenteral antibiotics
should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
Current OPAT regimen
Daptomycin 750 mg IV Q24H
Duration of OPAT regimen
Start date: ___
Stop date: ___
Physical Therapy:
***No Range of Motion LLE, knee immobilizer in place at all
times locked in extension***
Toe touch weight bearing LLE
Mobilize frequently***
Treatments Frequency:
**Stage 3 necrotic pressure ulcer of left buttock, s/p sharp
excisional debridement x2. Please perform daily dressing changes
as below.
Site: Left glut
Description: Type/Etiology/Stage: Unstageable pressure injury
Size: 4.2(L)x4.2(W)x2.0(D)cm, no tunneling or undermining. Wound
bed: 50% black/soft eschar and 50% pink/white mix tissue. No
fluctuance in wound bed. Wound edges: Unattached Exudate: Small
serosang Odor: None detected Periwound tissue: Partial thickness
opening extending from ___ o'clock position extending approx.
1cm otherwise blanching erythema. No warmth. Wound Pain: Mild
discomfort with cleansing, palpation
Care: s/p x2 bedside sharp debridement ___ and ___ with
general surgery team Topical therapy: Normal saline to cleanse
wound. Pat the tissue dry with dry gauze. Apply THIN layer of
criticaid clear barrier ointment to periwound skin (to protect)
Apply santyl ointment (nickel thick) to wound bed Gently pack
wound with BARELY MOISTENED (with normal saline) 2x2 gauze
Secure with pink hy tape (Manf #20) Change dressing daily.
Support surface: Mighty Air mattress in place
Turn and reposition every ___ hours and prn off affected area
Heels off bed surface at all times Waffle Boots ( x )
If OOB, limit sit time to one hour at a time and
Sit on a pressure redistribution cushion-
ROHO ( x ) Obtain from ___
OR ___ air full length chair cushion ( x) (Obtain from ___
Elevate ___ sitting.
Moisturize B/L ___ and feet, intact skin only BID with Sooth
And Cool Ointment.
*Dressing changes daily* -
Normal saline to cleanse wound.
Pat the tissue dry with dry gauze.
Apply THIN layer of criticaid clear barrier ointment to
periwound skin (to protect)
Apply santyl ointment (nickel thick) to wound bed
Gently pack wound with BARELY MOISTENED (with normal saline)
2x2 gauze
Secure with pink hy tape.
Change dressing daily.
Incontinence care:
Please avoid chucks under patient.
Cleanse area with commercial foam cleanser and soft disposable
cloth.
Apply THIN layer of criticaid clear barrier ointment daily and
every third cleansing.
Can use large softsorb to wick away liquid stool
Change daily and as needed.
**Please leave knee dressing and JP drain x1 in place until
follow up visit in clinic on ___, record output q4H** | The patient was admitted to the Orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics. | 917 | 44 |
13086509-DS-19 | 26,601,834 | Dear Mr. ___,
It was a pleasure taking care of ___ while ___ were hospitalized
at the ___ were transferred here because
your dialysis graft was not able to be accessed. ___ underwent
an imaging procedure called a fistulogram so that our
interventional radiologists could determine whether there was in
fact flow through your dialysis graft. When they discovered that
there was no flow because of a clot, they were able to perform a
procedure called a thrombectomy to remove the clot. The
thrombectomy was successful and the flow through your graft was
confirmed when ___ received hemodialysis on ___.
Your dialysis session went very well. Our nephrologists
recommended that ___ start vitamins called nephrocaps for
patients on hemodialysis. ___ may also need to start a
medication called erythropoietin with hemodialysis so to help
___ produce red blood cells.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ASSESSMENT & PLAN: ___ yo male with history of ESRD s/p failed
kidney transplant now on HD (MWF), DM, and HTN presenting with
pain and swelling at graft site with likely thrombosed AV graft.
#Thrombosed AV graft: The patient came to the hospital
complaining of pain and tenderness at the site after restarting
dialysis for approximately one month. Recent balloon dilatation
two weeks ago for narrowing was noted. He has had succesful
hemodialysis since but unsuccessful on ___. In the emergency
department, initial vital signs were 98.1 71 199/84 16 100% on
RA. The transplant consult service suggested admission to
medicine, as did the renal consult service (transplant surgery
following) and either interventional radiology the following day
or AV Care in ___ He was given labetalol for elevated BP's
with repeat BP 177/80. The patient was admitted to medicine and
the following day received a fistulogram in ___ followed by
successful thrombectomy. Afterwards, good flow with appropriate
bruit and thrill at graft site confirmed by renal
fellow/attending. Hemodialysis was done successfully, confirming
graft viability
#ESRD status post failed transplant now on HD: The patient was
stable in terms of electrolytes without any signs of volume
overload or uremia. As described above, he did well on
hemodialysis status post thrombectomy. His tacrolimus level was
found to be low. He was continued on his sevelamer,
multivitamin, tacrolimus, and leuflonamide. He was started on
nephrocaps per renal recommendations.
#HTN: losartan and labetalol were continued with good effect.
#DM: lantus with a humalog insulin sliding scale were continued
with good effect. | 152 | 259 |
18186075-DS-12 | 24,395,600 | Dear Miss ___,
It was a pleasure to care for you at the ___
___. You were admitted for an intermittently very
slow heart rate causing you to have neurologic symptoms. We
believe that this slow heart rate likely caused you to fall,
precipitating your arm fracture. While here, you had a pacemaker
placed to maintain a normal heart rate. You were seen by
Orthopaedics who recommended a sling for your arm, but no
operative management. We prescribed you a lidocaine patch to
control your back pain.
Please see below for your medications and appointments. Thank
you for allowing us to participate in your care. | ___ PMHx macular generation (legally blind), HTN, HL, RBBB with
LAFB concerning for infranodal conduction disorder who presented
with recurrent episodes of altered states of consciousness in
the setting of sinus pauses, now s/p PPM placement.
# Diminished Responsiveness d/t complete heart block: Multiple
events in the past several months with stiffening, LOC,
preceeded by an aura and followed by ___ hours of confusion.
Accompanied by weeks of SOB, fatigue and anorexia. No focal
deficits on neurologic exam except bilateral upgoing toes.
Neurologic imaging unrevealing for cause. While here, she was on
both cardiac telemetry and EEG. She had a typical event WITHOUT
EEG correlate, but WITH 4 second pause on tele. Thus, her
episodes most likely represent bradyarrythmia with brain
hypoperfusion leading to myoclonus and seizure-like movements,
and not primary epilepsy. She was tranferred to the cardiology
service for pacemaker placement after an unwitnessed fall ___
with HR ___ and EKG showing 3:1 conduction block. She had
placemaker placed ___ without complication. She was treated
with vancomycin for 48 hrs after pacemaker placement and keflex
x1 day.
# Lt ulnar fracture: due to fall. Orthopedics was consulted and
recommended orthoplast ulnar gutter splint. Physical therapy and
occupational therapy was consulted.
# Atrial flutter: Pt was noted to have atrial flutter on
telemetry. She was started on rivaroxaban 15mg daily.
# Hypertension: Intermittently off beta-blocker while
bradycardia was managed as above, restarted after pacemaker
placement. Pt was discharged on metoprolol tartrate 12.5mg bid.
# Hyperlipidemia: Continued home dose statin.
# Wheezing/Shortness of Breath: Continued Fluticasone-Salmeterol
Diskus (250/50) with albuterol and ipratropium Q6h as needed.
Discharged on Advair and albuterol PRN. | 104 | 269 |
19353792-DS-18 | 21,353,363 | You were admitted to the hospital with appendicitis requiring an
operation to remove your appendix. You are being treated with a
course of antibiotics that you will need to complete as
directed.
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep 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.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites. | She was admitted to the Acute Care Surgery team and under CT
imaging of her abdomen and pelvis showing thickening of the
appendiceal wall with surrounding stranding and a small amount
of fluid in the tip consistent with appendicitis. She was
consented, prepped and taken to the operating room for
laporascopic appendectomy. There were no complications. She was
continued on IV Cipro and Flagyl postoperatively. Her diet was
advanced to regular and she was able to tolerate solids without
difficulty. The antibiotics were also changed to oral form and
were recommended to be continued for another 7 days after
discharge. Her pain was well controlled with po pain
medications.
Her PCP was contacted for questions pertaining to
anticoagulation given her history of PE in ___ and no further
anticoagulation was indicated at this time. She was placed on
subcutaneous Heparin tid during her stay.
She was discharged to home with instructions for follow up with
her PCP and in the Acute Care Surgery Clinic. | 295 | 164 |
18307935-DS-15 | 22,053,124 | Dear Mr. ___,
You were admitted to ___ for migration of your G-tube site and
pain around G-tube site. You were seen by the surgery team who
decided to take you to the OR and replace the G Tube as well as
create a stomach osteomy. You had electrolyte abnormalities
which improved with IV fluids. You had fevers and were seen by
infectious disease specialists. We used a few different
antibiotics which you had adverse reactions to. We eventually
treated you for a pnuemonia with Doxycycline (as well as for a
suspected MRSA catheter tip infection). You need to take
Doxycyline for the suspected catheter tip infection until you
see the infectious disease specialist. We do not think you had
an infection of the ICD leads (the imaging study did not suggest
that). You had substantial pain that was controlled with IV
Dilaudid. We weaned you off IV Dilauded as best as we could.
Pain Medicine could not make any specific suggestions in light
of your inability to take pills by mouth.
Of note, we recommended anticoagulation for the upper extremity
DVT. We offered injections and rectal administration of blood
thinners, however, you did not like those options. We discussed
the risk and benefits of this decision.
Transitional Issues
Please follow-up with your appointments as listed.
Please contact ___ for any issues with the IV
medications - ___.
Please continue IV Doxycycline until you see the infectious
disease specialist. | # G-tube migration - Patient presented with severe pain
secondary to G-tube migration. He required IV dilaudid for pain
control. Restarted TPN per nutrition recs, used home TPN
regimen with some electrolyte additives. ACS & Dr. ___
___ and performed wound exploration and sharp debridement
percutaneous endoscopic gastrostomy on ___. They replaced
the G tube and created a stomach osteomy (which will close by
secondary intention). The tubes showed good output on suction
and was eventually left to gravity with connecting bags. The
pain was then controlled with IV Dilaudid and the pt was slowly
weaned off of IV Dilaudid over a span of a week. Seen by Pain
Medicine for pain control, however, patient was unwilling to try
suggested alternatives. Pt cannot take PO medications due to
lack of intestines. Patient did not object to being sent home
without pain medications other then Fentanyl patches (cannot
send patient on IV dilaudid due to risk of overuse). Fentanyl
patches and pain control will be followed-up with the patient's
PCP. Octeotride was suggested to decrease gastric output,
howver, patient verbalized that he could maintain good
hydration. Also, electrolytes were stable s/p surgery.
# Fever / Sepsis - Patient was febrile between ___.
Met sepsis criteria based on fever, tachycardia (as high as 140,
sinus tachycardia, consistent with temperature elevation),
leukopenia, and suspected infection. Infectious disease
specialists were consulted. Ultimately, the source could not be
confirmed as there were many possible sources (outlined below).
Continued to spike fevers despite vancomycin, cefepime,
daptomycin. On ___, pt was febrile most of the day to ___,
had sinus tachycardia to the 130-140s. Gave fluid bolus, used
cooling blankets, IV tyelenol & toradol. Fevers ultimately
resolved with initiation of broad spectrum antibiotics
(linezolid, metronidazole, cefepime). Cefepime and
metronidazole were discontinued on ___. Linezolid course, ___
- ___, per ID. Lineziolid was discontinued due to
agranulocytosis and thus was switched to Doxycycline.
Doxycycline would be continued until pt is seen by ID in clinic
(treatment for MRSA catheter tip infection). Pt was afebrile on
Doxycycline except for one fever s/p surgery. At time of
discharge, patient was afebrile and had stable VS.
ANTIBIOTICS HISTORY
Vancomycin: preadmission - ___
Ciprofloxacin: ___
Fluconazole: ___
Daptomycin: ___
Cefepime: ___
Metronidazole: ___
Linezolid: ___
Doxycycline: ___- ___ Visit
# RUE DVT - pt did not adhere to lovenox therapy prescribed in
___. During this admission, RUE US showed stable clot, lovenox
was restarted during this admission, but patient refused lovenox
shots after 3 days. Heparin drip also tried but discontinued as
the patient refused a dedicated line for heparin drip. He
communicated full understanding of risks of not treating DVT.
After further discussion with patient, heparin drip was started
___. Developed increased RUE swelling ___, and repeat
RUE ultrasound showed stable DVT. At time of discharge, pt was
explained the risk and benefits of anti-coagulation. The pt
fully understood the risk of PE without anticoagulation. He was
unwilling to have daily Lovenox shots or Coumadin PR. He
persistently declined anticoagulation and is aware of the risk
of DVT's, including PE and possible death.
.
# Pancytopenia - rec'd 2U PRBCs on ___, HCT increased
appropriately from ___. He has chronic pancytopenia likely
from nutritional deficiency and repeated courses of broad
spectrum antibiotics. Got 2U PRBCs on ___ with suboptimal
response. Hemolysis labs unremarkable. However, reticulocytes
were depressed at 0.9 on ___, likely secondary to linezolid.
Linezolid was discontinued ___. The pancytopenia improved after
discontinuation of Linezolid, however, patient is still
pancytopenic likely from nutritional deficit. It has been stable
over the last 2 weeks of his admission.
.
# Catheter tip infection
He has a ___ catheter for TPN. He had a MRSA catheter tip
infection on ___ for which he had been started on
vancomycin. We continued IV vancomycin, originally planned to
complete 4 week course of vancomycin until ___. However, as he
developed fevers on ___, vancomycin was continued until ___,
at which point vancomycin was changed to daptomycin because of
concern that fevers were drug-related. Daptomycin was changed
to linezolid on ___ because fevers persisted. CBC monitored
daily because marrow suppression is an adverse effect of
linezolid. On ___, reticulocytes were low, so linezolid was
stopped and changed to doxycycline on ___ for the MRSA
catheter tip infection. Because he is TPN-dependent, he is at
risk for fungemia, but mycolytic cultures x2 were negative.
Soft tissue ultrasound was not suggestive of pocket infection or
abscess. Doxycycline was continued until ___ clinic visit
for the MRSA catheter tip infection. Discharged with IV
Doxycycline.
.
# Lactobacillus bacteremia - ___ blood culture from ___
catheter grew lactobacillus. Empirically treated with cefepime
and metronidazole ___. All other blood cultures negative.
.
# ___ urinary tract infection - He complained of dysuria on
___, UA was suggestive of UTI, so he received two days of IV
ciprofloxacin ___, which was stopped because urine cultures
grew yeast. He was treated with fluconazole for 3 days.
.
# ICD lead infection - Patient had an ICD placed ___ at ___
for Vfib arrest in ___, pocket revision ___, and partial
lead and generator removal on ___. CTS has seen and felt
that the operative risk of removal of ICD leads is too high.
PET-CT did not show increased FDG uptake suggestive of lead
infection.
.
# HCAP - CT showed LLL consolidation, treated with cefepime
___.
.
# Tooth pain - he complained of tooth pain and a recently
chipped tooth, so a panorex was done, he was seen by an oral
surgeon, who recommended no intervention for his tooth pain.
.
# Chronic urinary retention: Has atonic bladder secondary to
congenital intestinal obstruction. Renal ultrasound and PET-CT
showed hydronephrosis and large, distended bladder. Seen by
urology in-house. Required intermittent straight
catheterization for bladder decompression during this admission.
Will have f/u with Dr. ___.
.
# Hypernatremia, Hypokalemia, Metabolic Alkalosis - On
presentation, was hypernatremic, hypokalemic, and had a
metabolic alkalosis. Occurred in the setting of missing 2 days
of TPN because of repeated ED visits. Improved with 3.5L
hypotonic IV fluids. Venous blood gas consistent with pure
metabolic alkalosis. Most likely etiology is
gastrointestinal/insensible losses of free water and H+ through
the leaky G-tube. Contraction alkalosis likely also contributed
in the setting of volume depletion as he was unable to get TPN
or hydration. After initial volume resuscitation, electrolytes
normalized and were maintained with daily TPN and occassional
electrolyte replacement. Normal electrolytes at time of
discharge.
. | 234 | 1,098 |
18185480-DS-6 | 25,139,333 | Dear Ms. ___,
You were admitted to the hospital after an episode of losing
consciousness (syncope). We performed numerous tests and
determined your syncope is not related to a problem with your
heart. We believe your syncope is likely due to a common
condition known as vasovagal, where your body reacts suddenly to
changes and stressors, causing you to briefly lose
consciousness.
You were provided with a heart monitor and instructed on its
use. This is to be absolutely sure there is not any cause
related to the heart.
Because your blood pressure was high you were started on a new
blood pressure medication.
It was a pleasure taking care of you,
-Your ___ Team | Ms. ___ is a ___ F with a history of bipolar
disorder, hypertension, anxiety disorder, with multiple recent
syncopal episodes who presents following a syncopal episode.
#Syncope: Patient has had multiple episodes of syncope over last
month, with episodes occurring almost daily the week prior to
admission. Prodrome of diaphoresis in addition to a prolonged
recovery from the episodes suggest vasovagal etiology, likely in
the setting of her recent life stressors with work. Syncope
work-up for other etiologies was negative. In particular, ECHO
and carotid US showed no signs of stenosis or outflow
obstruction. EKGs showed sinus bradycardia, and patient has no
history of heart disease, palpitations, arrhythmia thus unlikely
a cardiac cause. However, she will go home with ___ of Hearts
monitoring. Patient was educated about vasovagal and encouraged
to maintain PO intake and use physical counterpressure
techniques when she feels symptoms.
#Episodic Hypertension: Patient presented with hypertensive
urgency at 170/102 on admission, with baseline at 110's/70's,
per patient. Patient has had episodic elevations in blood
pressure throughout admission, ranging from 110s-170s/70s-100s,
though has been asymptomatic. Initial elevation may have been
attributed to clonidine rebound (which she takes for night
sweats/anxiety). Clonidine was stopped and patient was started
on captopril 6.25 TID in the hospital. She was discharged on
lisinopril 5 mg daily, and will follow up with PCP for
medication titration. Given episodic elevations in blood
pressure, sweating, weight loss, there was concern for
pheochromocytoma. Urine metanephrines are pending at discharge.
#Night Sweats: Patient endorses 7 lb weight loss over past two
months with daily night sweats, dissimilar to her hot flash
symptoms. CXR normal with no signs of lung mass or TB infection.
LDH slightly elevated, though hemolyzed specimen. Patient has
had history of longstanding night sweats, often triggered but
life stressors.
#Diarrhea: Patient endorses watery diarrhea at nights every ___
days, usually attributed to stress episodes. No recent
antibiotics, exposure, no association with food, no significant
caffeine intake. During hospital stay, patient had no bowel
movements.
#Wheezing: Patient is asymptomatic, though diffuse bilateral
wheezing was heard on exam. Patient notes history of
asthma/allergies, particularly worse during this time of year.
She uses home mucinex and claritin, which successfully manages
her symptoms.
***TRANSITIONAL ISSUES***
[ ] f/u quantiferon gold due to concern for night sweats and
weight loss
[ ] f/u ___ of Hearts
[ ] f/u urine metanephrines due to concern for pheochromocytoma.
[ ] Started on lisinopril 5 mg daily, may need uptitration.
[ ] Check electrolytes at next visit due to starting lisinopril
# CODE: Full, but doesn't want to be kept alive if
neurologically not intact.
# CONTACT: ___ (private care-friend) ___ | 114 | 439 |
15141762-DS-5 | 26,216,480 | 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 one month or while taking narcotics. driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | MEDICINE COURSE:
Mr. ___ is a ___ year old male with known coronary artery
disease who was transferred from OSH for treatment of severe SOB
and DOE. CXR on admission was consistent with pulmonary edema.
He was initially admitted to the ___ service and started with
IV lasix boluses for diuresis. On hospital day 2 he syncopized
with precedent lightheadedness. He also triggered for hypoxia
with O2 sats to mid ___ on 5L NC. He was switched to a high flow
face mask and started on lasix and nitroglycerin drips. A TTE
performed that day was notable for severe regional left
ventricular systolic dysfunction with focal near-akinesis of the
septum, anterior wall, inferior wall and apex and EF of ___ (
down from 60% on Echo rom ___. He was taken to the cath lab
on hospital day 3 given progressive hypoxia and syncope. His
cath was notable for a newly occluded SVG-RCA and SVG to ramus
with significant stenosis. Aortic valve area of ~0.5-0.6cm. .
Right heart cath was notable for RA pressure 15, PCWP ~30,
cardiac index 1.6 consistent with cardiogenic shock. An
intra-aortic ballon pump was placed in the cath lab and he was
transferred to the CCU. In the CCU he remained on a lasix drip
and nitro drip, titrated to maintain a a CVP of ___. The nitro
gtt was weaned on hospital day 5. Isosorbide and hydralalzine
were also added for afterload reduction. The patient was weaned
from the ballon pump on hospital day 8. The lasix drip was
discontinue on hospital 9 and he was started on torsemide for
diuresis. The patient likely had progressive demand ischemia of
his myocardium secondary to re-stenosis of his grafts and
progression of his AS, leading to decreased EF and WMA and
cardiogenic shock. The patient also had progression of his AS,
now severe with Aortic Valve mean gradient = 24 mmHg. ___ 0.6 sq
cm.. His severe AS and decreased EF likely contributed his poor
CI and CO. He was evaluated BY CT surgery for aortic valve
replacement and revision of CABG, which was initially delayed to
allow to time for washout of his prasurgrel. During this time he
was also seen by the infectious disease, vascular surgery and
podiatry services for non healing ulcer of right foot.
He was started on Vancomycin and Zosyn for osteomyelitis of
foot. | 112 | 401 |
16354538-DS-16 | 26,960,224 | Dear Mr. ___,
It was a pleasure to care for you while you were hospitalized.
You were admitted to the hospital due to weakness and increased
urinary frequency. You were found to have a urinary tract
infection. You improved with treatment with IV antibiotics and
are now ready for discharge. Following discharge, you will
require another 4 days of antibiotics. Please complete the
course as prescribed.
Please follow up with Dr. ___ as planned next week.
Take care,
Your BI Care Team | ___ male with h/o CVA and glaucoma who presents with
marked weakness and AMS in the setting of a UTI.
# UTI w/ acute encephalopathy
- he was treated with IV ceftriaxone 1 gram daily x 3 doses with
rapid improvement in mental status to baseline by hospital day 1
- on hospital day 2, he continued to feel well and walked with
physical therapy with the aid of a walker and was seen to have
strength and functioning close to his baseline
- he will be discharged with Macrobid ___ bid to complete a
total 7 day course of antibiotics based on resistance profile
from urine culture
# Sinus tachycardia w/ PAC's
- tachycardic on admission, improved with 1.5 L of saline given
over 24 hours
- heart rate returned to baseline 90's-100 at discharge on qAM
metoprolol 12.5 daily
# ___ on CKD - Cr 1.9 on admission
- renal function improved to Cr 1.3 on discharge
CHRONIC/STABLE PROBLEMS
# Glaucoma - continued on eye drops and oral antiviral during
hospitalization
# BPH - continued on home tamsulosin
# CVA - continued on home ASA
Post discharge care:
- he will have home physical therapy initiated after discharge
- he will continue his other home supports with nursing/aide
- he will follow up with PCP, ___ as scheduled the
following week
Patient seen and examined on day of discharge and stable for
discharge. >30 min spent on DC planning and coordination of
care | 82 | 233 |
12151993-DS-14 | 29,716,743 | Dear Mr. ___,
You were admitted to the hospital for altered mental status
thought to be related to a UTI. You were treated with
antibiotics with some improvement. We are discharging you to
hospice to focus on improving your symptoms.
Take care, and we wish you the best.
Sincerely,
Your oncology team | ___ is a ___ man with history of colon
cancer s/p R hemicolectomy and RFA of liver met, now with
glioblastoma on treatment with bevacizumab presented with fever,
___, and AMS concerning for UTI.
1. Encephalopathy secondary to urosepsis: Alertness has been
improving, however still oriented x 0. This is likely closer to
the patient's recent baseline secondary to dementia and
glioblastoma. Patient initially presented with fever, urinary
retention, and altered mental status likely secondary to
continued issues with foley catheter/urinary retention. There
may be element of post-renal obstruction with blood
clots/bleeding leading to ___ and decreased excretion of drug
metabolites. Appears to have failed outpatient levofloxacin
therapy for previous acinetobacter UTI.
-Urine culture revealed levofloxacin resistant staph.
-Received 6 days of antibiotics, transitioned to comfort-focused
care at discharge.
-Blood Cx NGTD
-Failed voiding trial so foley was re-inserted.
2. Malnutrition: Given delirium, patient with very minimal PO
intake. Occasionally can tolerate ice cream and has been
swallowing meds with this. Despite aspiration risk, feeding for
comfort is acceptable.
3. ___: Improved. Likely elements of post-renal given urinary
retention and blood clot obstructing foley and pre-renal from
decreased PO intake in setting of encephalopathy. Improved with
foley and IVFs. Baseline 0.9-1.0
4. Agitation: Initially required restraints during acute
encephalopathic process from pulling foley. His foley was
removed with plans for straight cath to prevent him from needing
restraints to keep him from pulling his foley, but he failed
voiding trial and foley reinserted. He was continued on Zydis 10
mg QHS for agitation; additional Zydis available PRN.
Benzodiazepines were avoided as they were extremely sedating to
him.
5. Glioblastoma: S/p chemoradiation and recent bevacizumab
treatment. Decision made to no longer pursue treatment and focus
on comfort, as his overall prognosis is poor.
-If seizures, may use SL Ativan as abortive therapy | 48 | 294 |
15019807-DS-25 | 25,288,011 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
because you were found to be more confused and sleepy. You had
imaging of your chest and were found to have a pneumonia which
was treated with antibiotics and improved. You also had an
injury to your kidney which appears to be improving.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
All the best,
Your ___ Team | PRIMARY REASON FOR HOSPITALIZATION:
================================================
Mr. ___ is an ___ with a PMHx of vascular dementia, h/o
ICH, NPH s/p shunt, PE with IVC not on anticoagulation, CAD s/p
CABG and LAD stent, AFib (not on coumadin d/t falls), complete
heart block s/p pacemaker, BIBA for AMS. Found to have ___,
hyperkalemia, and developed hypotension in the ED. | 86 | 56 |
17214626-DS-23 | 21,079,179 | You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can
tolerate.
oIsometric Extension Exercise in the collar: 2x/day x ___xercises as instructed.
-Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks. You may remove the collar to take a shower. Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
-You should resume taking your normal home medications.
-You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
-Follow up:
oPlease Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
oAt the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
oWe will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
Activity: Activity: Activity as tolerated
Cervical collar: At all times
___ Goals
Time Frame: 1 week
1 - Indep state ___ spinal precautions
2 - CGA amb 100' c LRAD
3 - Tolerate high level balance test
4 - Indep supine to sit with HOB flat
Treatments Frequency:
Site: Posterior neck
Description: surgical incision
Care: asses SS of infection | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was initially
transferred to the TSICU and remained intubated for airway
protection given difficulty handling secretions. He was weaned
off the vent without difficulty and extubated on POD#1 and
subsequently transferred to the floor. TEDs/pnemoboots were used
for postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Nutrition saw the patient to
make recommendations for tube feeds, which were advanced to goal
and tolerated well by the patient. The patient was transitioned
to pain medication via G-tube. Foley was removed on POD#2.
Physical therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating tube feeds. | 497 | 177 |
17195386-DS-12 | 20,907,217 | You were hospitalized with a blockage in your bile duct due to
stones. The stones were removed by ERCP procedure. You also had
an infection in your bile ducts which is being treated with
antibiotics. It is very important that you complete the
Ciprofloxacin prescription as prescribed. | ___ yo man with a history of hypertension (not on meds),
depression, hypothyroidism now with a fullness in the head of
his pancreas, ___ lb weight loss, and biliary obstruction with
choledocolithiasis and cholangitis. There was concern for
possible malignancy given "fullness" in pancreas. Pt underwent
EUS/ERCP, during which stones were extracted from the bile duct.
There was "fullness" in the pancreas, which could be concerning
for possible malignancy, so pt underwent MRCP evaluation, final
read pending. During the hospitalization, pt was treated for
cholangitis with an acute GNR blood stream infection. He was
treated with Pip/Tazo, and then transitioned to Cipro based upon
sensitivities. He was afebrile at the time of discharge, and
will complete 10 more days of Cipro. Final culture results
remain pending.
Surgery followed throughout the hospitalization, and they plan
cholecystectomy in outpatient follow up.
# Cholangitis with biliary obstruction (choledocolithiasis)
# Pancreatic fullness - concerning for possible malignancy; MRCP
report pending
# Weight loss/malnutrition, chronic loose stool
# Acute GNR acute blood stream infection; ___ to cipro
Biliary obstruction resolved s/p ERCP with stone extraction.
Leukocytosis improving, responding to antibiotics.
- Cipro based on sensitivities; will prescribe 10 more days from
discharge.
- PCP to follow up MRCP
- Planning CCY in outpt follow up
# Possible new onset Atrial Fibrillation -
CHADS2 score = 2 (1 point for hypertension, 1 point for age)
At the time of admission, there was concern for new onset afib.
Final cardiology read of EKG from ___ shows "appears to be a
combination of occasional sinus beats
with junctional beats with retrograde P waves along with
probably some ectopic
atrial beats". His HR remained controlled throughout the
hospitalization. Consider follow up EKG as an outpatient to
clarify.
# Depression
- continued sertraline
# Cognitive impairment - may be a component of
delirium/encephalopathy but concerning re: dementia.
- follow up with PCP
# ___
- continue levothyroxine
# Glaucoma
- continue home timolol gtt
FULL CODE
VTE Prophylaxis: Pneumoboots
DISP: home. | 48 | 360 |
13287239-DS-6 | 28,390,004 | You acknowledge that you are leaving against medical advice.
You were informed about an incidental 3mm lung nodule seen on
your CT scan and the need to follow this finding up with your
PCP to make sure that it is not cancerous (your risk is very low
of cancer).
You should not take opiate pain medication as this will worsen
your gastric paresis, and risks intestinal perforation with
concurrent C. difficile infection (which you report).
Please complete your Metronidazole (Flagyl) course which you
were prescribed by another physician. Please follow up with
your PCP in person or at the very least by phone no later than
tomorrow. | ___ yo woman with prior history of gastroparesis, now with
abdominal pain, nausea, vomiting, after attempt to eat regular
solid food. She has an unconfirmed report of C. difficile
diarrhea from recent hospitalization.
# Abdominal Pain: Likely gastroparesis. GI was consulted and
recommended IV Reglan or erythromycin bth of which she has
claimed allergies to. Patient requested opiate narcotic pain
medication. She has 2 contrainidications to opiates
(gastroparesis, and presumed C. diff infection with sigmoid
stranding). I declined to give this to her. She had no
localizing signs to her abdominal pain on exam, and findings
were not consistent with pain throughout the exam. She was
afebrile, has no leukocytosis or Left shift), and UA was also
clear. She was instructed to keep NPO in hospital. She decided
to leave against medical advice, similar to her last
hospitalization.
# Nausea w/ vomiting in ER: Patient no longer nauseous on
medical ward. Received promethazine in the ED.
# C. difficile diarrhea: Uncomfirmed. Keep on contact
precautions. Will request OSH records. Continued IV Flagyl for
now. Patient left against medical advice.
# Asthma: Chronic, intermittent. Give Fluticasone 110mcg 2puff
BID for now (pulmicort not on formulary). Albuterol prn.
Patient left against medical advice.
# GERD: patient reports history of GERD for which she takes
intermittent PPI (hasn't taken in 2 weeks). As this class of
drug is associated with increased C. diff infection, I have
advised her to not restart this med without speaking first with
her PCP. Patient left against medical advice.
# Hypokalemia: 3.3 on admission. Will replete with 40mEq in
fist liter of NS
# Hypomagnesemia: 1.6 on admission. Will replete with 2mg IV now
# Incidental pulmonary nodule: 3mm. Patient with low risk
features for malignancy. I informed patient of this finding and
low risk of malignancy, and instructed her to follow-up with PCP
for further discussion and follow-up imaging as indicated.
# Code: Full
# DVT prophy: SC Heparin TID | 107 | 330 |
13903530-DS-47 | 29,444,514 | Mr. ___,
You were hospitalized with signs of alcohol withdrawal. You
were treated with phenobarbital and this has been very helpful
for managing your withdrawal. It is very important to avoid any
further alcohol use. If you feel like you're going to drink
alcohol again, please call your doctor ___. Alcohol use is
causing multiple medical problems including electrolyte
abnormalities, low blood counts, abnormal liver function tests.
Please talk with your social workers as well and consider
outpatient rehabilitation programs if possible.
You were found to have multiple lab abnormalities including
severely low magnesium, potassium and phosphorus. You were
given IV and oral supplements of these and they have improved.
I have recommended that your PCP's office recheck these labs at
your visit on ___ to make sure they do not become too low
again. It is important to stay well hydrated and eat regularly.
Your liver function tests were elevated but an ultrasound showed
no abnormalities (including no obstruction) in your liver or
bile ducts. These tests are all improving, likely due to not
drinking alcohol. I recommend having these rechecked as well.
You have chronically low blood counts, which were very low on
admission. You had a low white blood cell count and especially
concerning, was a low neutrophil count. Fortunately your blood
counts are improved since admission and again likely due to not
drinking alcohol. Please have your blood counts checked again.
If you have any signs of bleeding, it is critical to have your
counts rechecked.
It was a pleasure to take care of you here at ___ and we wish
you good health and recovery. | Mr. ___ is a ___ male with ETOH abuse with recurrent
alcohol withdrawal, alcoholic cirrhosis, hepatitis C, bipolar
disorder, homelessness, history of multiple
prior falls and hospitalizations who presented to the ED with
alcohol intoxication. He was found to have severe hypokalemia
and hypomagnesemia. He has been trying to decrease alcohol
intake and presented with signs of alcohol withdrawal. He was
loaded
with Phenobarbital in the ED. He was not having significant
signs of withdrawal at discharge. His LFTs are improving and
had no evidence of biliary obstruction on ultrasound. He
hypokalemia and hypophosphatemia have resolved, and
hypomagnesemia is nearly resolved. | 281 | 103 |
16690433-DS-19 | 29,871,430 | Dear Ms. ___,
.
You were admitted to the gynecologic oncology service after
presenting with a small bowel obstruction. While you were in the
hospital we stopped your diet entirely to give your bowels rest
and controlled your abdominal pain with pain medications. We
then gradually advanced your diet. You have recovered well, and
the team feels that you are safe to be discharged home. Please
continue to self-regulate your diet and follow the
recommendations provided to you by Nutrition for a low residue
diet.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Call your doctor at ___ for:
* fever > 100.4
* severe abdominal pain
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
* onset of any concerning symptoms | Ms. ___ is a ___ woman with recurrent ovarian cancer on
chemotherapy admitted to the gyn-oncology service with SBO with
concern for malignant obstruction.
Abdominal/pelvic CT on arrival revealed SBO transition in the
RLQ concerning for malignant obstruction and peritoneal
carcinomatosis. She was made NPO, started on IV fluids and given
IV zofran, ativan, and pepcid for nausea. Her pain was
controlled with IV morphine. Over the week her diet was slowly
advanced and she was transitioned to PO pain meds.
On hospital day #4 she was tolerating a regular diet without
nausea, emesis, and pain was controlled on oral medications. She
was discharged home in stable condition with appropriate
outpatient follow-up scheduled. | 149 | 115 |
17025507-DS-7 | 26,441,418 | Dear Ms. ___,
Thank you for coming to ___ for your care. Please read the
following directions carefully:
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had fevers and
confusion while you were at home
- We were concerned you had an infection that involves your
brain and spinal cord.
WHAT WAS DONE FOR ME WHILE I WAS HERE?
- You had several tests including a spinal tap and an MRI. These
unfortunately did not show exactly what bacteria or virus could
be causing your symptoms
- We gave you a course of antibiotics through an IV to treat
several possible causes of these kinds of infections
WHAT DO I NEED TO DO AFTER I LEAVE THE HOSPITAL?
- The medications you were taking before you came to the
hospital have not been changed. They are listed below as well
- Please keep your appointments as listed below
- If you develop new fevers, confusion, or any other concerning
symptoms, please seek urgent medical attention
We wish you the best with your health!
- Your ___ care team | =======
SUMMARY
=======
Ms. ___ is a ___ year old female with past medical history
notable for multiple myeloma, with recent admission due to
concerns for HSV-2 aseptic meningitis, readmitted due to fevers
and confusion at home. Her repeat infectious workup was largely
unremarkable (including negative HSV-2 CSF PCR) except for
persistent, although decreased, lymphocytes in her CSF. She was
treated empirically with a 10d course of vancomycin, cefepime,
ampicillin, and acyclovir for possible HSV-2 meningitis, and
other possible bacterial causes. Her hospital course was
unremarkable.
==============
ACUTE PROBLEMS
==============
#Altered mental status
#Fevers
Recent discharge for presumed aseptic HSV-2 meningits, as
patient had presented at that time with similar symptoms of AMS
and fevers, with CSF PCR notable for low-level positive HSV-2.
She had at that time received both a full IV acyclovir course as
well as PO valacyclovir in the outpatient setting. She was
subsequently readmitted after several days due to similar
symptoms. Of note, her initial fever of T 101.6 in the ED had
defervesced prior to initiation of antimicrobial agents.
Presumptive diagnosis of HSV-2 aseptic meningitis vs Malloret's
meningitis vs undertreated viral/bacterial etiology that was not
adequately covered during last admission. Infectious workup
largely unremarkable - CSF PCR for this admit was negative for
HSV-2, although did demonstrate lymphocytes. She ultimately
received a total of 10 days of vancomycin, cefepime, ampicillin,
and acyclovir for empiric coverage of possible undertreated
viral and bacterial causes.
================
CHRONIC PROBLEMS
================
#Multiple Myeloma
She had not been taking her pomalyst on admission per outpatient
oncology direction. This was not continued while inpatient as
well. She had normal quantitative Ig levels during this
admission.
# CODE: Full (presumed)
# EMERGENCY CONTACT:
Name of health care proxy: ___
___: daughter
Phone number: ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. | 174 | 341 |
12742846-DS-9 | 27,247,454 | Dear. Ms ___,
You were admitted for evaluation of your headache. It was
different from your previous headaches associated with
pseudotumor, was bad throughout the day (regardless of
cough/laugh) and was associated with neck pain, upper back
numbness, and right more than left hand numbness. After thorough
evaluation, we feel that your headache may now be primarily
secondary to you Chiari malformation. We performed a cervical
spine MRI during your stay to make sure your symptoms were not
from spinal compression from any other etiology - this exam was
remarkable only for your low lying cerebellar tonsils consistent
with Chiari malformation. You will follow up with Neurosurgery
for further Chiari evaluation, MRI CSF CINE flow study, and for
discussion of neurosurgical evaluation. | Ms ___ headaches were different from her previous
headaches associated with pseudotumor. This headache was bad
throughout the day (regardless of cough/laugh) and was
associated with neck pain, upper back numbness, and right more
than left hand numbness. her headache was thought to be
primarily related to her Chiari malformation. We performed a
cervical spine MRI during the stay given her C5/6 distribution
numbness and also given her left lower extremity mild proximal
weakness and spasticity. This exam was remarkable for low lying
cerebellar tonsils consistent with Chiari malformation and also
for mild disc bulge at C5/6 that abutted the cord but without
cord signal change and with open canal. Ms. ___ will follow
up with Neurosurgery for further Chiari evaluation, MRI CSF CINE
flow study, and for discussion of neurosurgical evaluation. | 121 | 132 |
16439081-DS-16 | 22,048,538 | Discharge Instructions
Brain Hemorrhage without Surgery
Activity
· We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your ___ 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 should hold Eliquis until follow up with neurosurgery in 1
month with a repeat head CT.
· ***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication for a through ___, then stop. It is important that
you take this medication consistently and on time.
· You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating, and
remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· Constipation is common. Be sure to drink plenty of fluids and
eat a ___ diet. If you are taking narcotics (prescription
pain medications), try an ___ 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 | #Subdural hematoma:
Patient was admitted to the neurosurgical ICU under Dr.
___ on ___ s/p fall with TBI. Repeat head CT showed
stable 1.4cm left subdural hematoma without mass effect/midline
shift, and no new areas of hemorrhage. Eliquis was held (see
below) and she was given 4 units FFP for reversal. She was
started on Keppra for seizure prophylaxis, to be continued for 1
week. She remained neurologically intact. She was transferred to
the floor on ___ and continued to be stable.
#Afib:
Eliquis was held on admission given intracranial hemorrhage. HR
controlled with home metoprolol. Cardiology was consulted, who
agreed with holding anticoagulation until safe from a
neurosurgical perspective. Patient was instructed to hold
Eliquis for 1 month, until follow up with Dr. ___
a repeat head ___ of Hearts monitor was also recommended
for evaluation of arrhythmia that could have lead to fall
(although unlikely given that likely vagal from inducing
vomiting). She will follow up with her outpatient cardiologist,
Dr. ___ discharge.
#Toe pain
L foot/toe pain from fall. ___ was negative for fracture.
Recommended rest, ice, elevation.
#Renal
Renal transplant team followed while inpatient. She was
continued on home medications and Tacrolimus level was
monitored. Renal function at baseline. She also has recurrent
UTIs and was continued on Cipro (completed ___.
She was instructed to follow up on ___ for routine labs.
#DISPO
She was cleared by ___ for discharge home with home ___ on ___.
Tertiary survey was completed by ___ with no further injuries
noted. At time of discharge pain was well controlled, she was
tolerating PO diet without nausea or vomiting, she was
ambulating, and voiding. Discharge instructions were reviewed
with patient and daughter (translated) and all questions were
answered. | 457 | 287 |
19663491-DS-5 | 21,765,130 | You were admitted with pneumonia and infected fluid in your
lung. You had this drained with a chest tube and you were
started on antibiotics. Based on the results of type of
bacteria, you will require 4 weeks of intravenous antibiotics.
You will need to follow up with infectious disease doctors to
make sure you continue to have improvement.
You were found to be slightly weak from your long
hospitalization. You were discharged to rehab so you could get
your antibiotics and improve your strength. | ___ with HIV on HARRT (CD4 count of 800), HCV (failed
treatment), history of IVDU on methadone, who presented with
dyspnea and was found to have pneumonia and empyema. He was
treated with antibiotics and had a chest tube placed. The
cultures from the sputum and pleural fluid returned and he was
switched to IV cefepime and PO flagyl for a 4 week course. ID
will follow as an outpatient.
# Pneumonia with empyema: He had hypoxemia, pneumonia and a
large empyema on chest CT. He was initially started on
vancomycin, cefepime, and levofloxacin. Interventional
pulmonology placed a chest tube on ___. The effusion was
loculated and required tPA and ___ injections. The results of
the pleural effusion cultures were strep milleri species. Sputum
cultures grew Beta streptococcus group C, enterobacter
aerogenes, acinetobacter baumannii complex, haemophilus
influenza and beta lactamase negative (see results secontion).
He improved with treatment and drainage and his chest tube was
pulled on ___. He was seen by infectious disease specialists
who recommended a 4 week course of cefepime and flagyl. He will
need to continue this until ___ (and will need to be seen
by ID prior to discontinuation). A picc line was placed. He
should not be discharged from rehab with the ___ as he is at
risk of IVDU. After completion of his antibiotics this should be
removed. At the time of discharge he was on 1L NC.
# Opioid dependence: He takes 91mg of methadone per day (Habit
OPAC on ___.). He was continued on methadone 90mg per day.
He is at risk of abuse of the PICC. This should be removed prior
to discharge. He is also getting oxycodone as needed for pain.
# Chronic CO2 retention: Likely secondary to COPD or obesity
hypoventilation syndrome. He has been relatively stable with NC
and has not required positive pressure ventilation. This should
be evaluated further after discharge. He was treated with PRN
nebulizers.
# Hyponatremia: He had hyponatremia. Initially he was treated
with IVF with some improvement in his sodium. However, the urine
lytes were suggestive of SIADH. Thus, he was put on a fluid
restriction. However, the patient was unhappy with this and
refused to comply. His Na was stable at 132 without treatment.
Sodium should be checked a couple of times per week to make sure
it is stable at rehab.
# HIV: His most recent CD4 count is 875 with a viral load of
2422. He should be continued on truvada and kaletra.
# Hypertension: He was continue on amlodipine BID. Blood
pressures largely controlled.
# Anxiety: He was continued on his clonazepam.
# Constipation: he was writted for a bowel regimen
# Asthma: stable, continued on inhalers. | 84 | 443 |
15398865-DS-10 | 24,208,509 | Dear Mr. ___,
================================
WHY DID YOU COME TO THE HOSPITAL?
================================
- For evaluation of swelling in your legs and abdomen
=====================================
WHAT WAS DONE FOR YOU DURING YOUR STAY?
=====================================
- You were diagnosed with cirrhosis of the liver, which in your
case is related to alcohol use. This led to the fluid build up
in your belly.
- It was found that your heart does not pump as strong as it
should (called heart failure), which also led to the fluid
building up.
- The extra fluid was removed by giving you medications to
increase urination ("water pills"/"diuretics") and by draining
the fluid directly from your belly with a needle
("paracentesis") twice
- A scope was done of the tube leading to your gut (esophagus)
using a camera ("EGD") and did NOT see any large veins
("varices") that were at risk of bleeding.
- A nutritionist developed a high protein-low salt meal plan to
help rebuild muscle mass and keep the fluid off.
==============================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
==============================================
- Stop drinking alcohol completely, even 1 drink is too many.
- Take all the medications as prescribed (see below)
- Follow up on ___ with your primary care physician's
office
- Follow up in liver clinic with Dr. ___ as below
- Follow up in cardiology clinic (see below)
- Weigh yourself everyday and let you primary doctor know if
your weight goes up by more than 3 pounds in 2 days.
- Make sure to drink an Ensure with breakfast, lunch, and dinner
everyday.
- Eat no more than 2g of salt every day
- Use the rolling walker to get around and if you ever feel
dizzy or lightheaded, seek medical attention immediately
It was a pleasure taking care of you during your stay!
Sincerely,
Your ___ team | SUMMARY:
Mr. ___ is a ___ year old male who had not seen an MD in
over ___ years prior to his presentation with volume overload
which was eventually diagnosed as decompensated alcohol-induced
cirrhosis. Patient had 48.5 lbs of fluid removed via a
combination of multiple large volume paracentesis and diuretics,
and further diuresis was limited by orthostasis, for which
midodrine therapy was initiated. A screening EGD showed no
gastro-esophageal varices. He did not display any signs of
hepatic encephalopathy. He had obvious protein-energy
malnutrition, for which Ensure Enlive with breakfast, lunch, and
dinner was recommended.
Given his elevated BNP on admission, an echocardiogram was
ordered which showed an EF of 35-40% with diffuse LV
dysfunction, suggesting a global cardiomyopathic process such as
alcohol cardiomyopathy. Cardiology evaluated patient and
deferred catheterization and recommended an outpatient
ischemic/viability workup with possibily a cardiac MRI. Given
his lack of elevated JVP, we tried to initiate beta blocker
therapy but coreg 3.125 BID was poorly tolerated as he developed
symptomatic orthostasis. | 292 | 167 |
12569430-DS-18 | 20,687,251 | ******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. Always remove your bivalve cast when taking
a shower, do not get it wet. You may continue dry sterile
dressings with ABD pad to the wound, and wrap with kerlix or ace
wrap. No baths or swimming for at least 4 weeks. Any stitches
or staples that need to be removed will be taken out at your
2-week follow up appointment. No dressing is needed if wound
continued to be non-draining.
******WEIGHT-BEARING*******
Right lower extremity: Non-weight bearing in splint
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
******FOLLOW-UP**********
Please follow up with ___ in ___ days
post-operation for evaluation and staple/suture removal. Call
___ to schedule appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills. | The patient was admitted to the Orthopaedic Trauma Service for
repair of a right trimalleolar ankle fracture. The patient was
taken to the OR and underwent an uncomplicated open reduction
internal fixation right trimalleolar ankle fracture without
fixation of the posterior malleolus. The patient tolerated the
procedure without complications and was transferred to the PACU
in stable condition. Please see operative report for details.
Post operatively pain was controlled with a PCA with a
transition to PO pain meds once tolerating POs. The patient
tolerated diet advancement without difficulty and made steady
progress with ___.
Weight bearing status: Right lower extremity non-weight bearing
The patient received ___ antibiotics as well as
Lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge home and the patient expressed
readiness for discharge. | 253 | 187 |
13975682-DS-14 | 20,910,806 | Dear Ms. ___,
It was a pleasure taking care of you during your
hospitalization at ___. You
were admitted after becoming ill at your home. On arrival to
the hospital you were found to be very dehydrated with a very
high blood sugar. Because of this you were initially admitted
to the medical intensive care unit. You improved and were moved
to regular medical floor. To continue to regain your strength
you will now be discharged to a rehab facility. We wish you
luck in your continued recovery! | Ms. ___ is a ___ yo F with history of type 2 diabetes, atrial
fibrillation, diastolic heart failure and CAD who was found down
in her home. Patient was found to have HONK with elevated
lactic acidosis, initially admitted to the MICU. | 98 | 44 |
18895472-DS-7 | 24,194,598 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
Why you were admitted to the hospital:
- You were having abdominal pain, particularly with eating
- You were diagnosed with gallstones, which are likely causing
your pain
What happened while you were here:
- Surgery was deferred due to a high risk of complications
- You were treated medically and your pain slowly improved
- Additionally, work up showed that you have cirrhosis, which is
scarring of the liver
- Several tests were sent to find out the cause of the scarring,
many of which were still pending at discharge
What you should do once you return home:
- Please continue taking your medications as prescribed
- Please follow up with the appointments outlined below.
Specifically, you should see your primary care provider, ___ liver
doctor, and the diabetes doctor
- If you do not wish to attend the ___ appointment, please
call your endocrinologist to schedule an appointment within ___
weeks
- You should decrease the dose of the cyclobenzaprine and
sumatriptan given the new diagnosis of cirrhosis
We wish you the best.
Sincerely,
Your ___ Care team | Ms. ___ is a ___ y/o female with a history of DM type II,
HTN, HLD, GERD and NASH who presented with abdominal pain
concerning for biliary colic, found to have cholelithiasis
without cholecystitis or choledocholithiasis. Surgery evaluated
and deferred given high surgical risk. She was managed medically
with improvement in her pain. Additionally, imaging showed a new
diagnosis of cirrhosis, etiology remains unclear but likely ___
NASH. | 183 | 69 |
17691344-DS-5 | 29,788,340 | You were admitted to ___ for a recurrence of atrial
fibrillation and hyperthyroidism related to thyroiditis as shown
by thyroid scan.
Continue all of your medications with the following changes:
- Start Apixaban (Eliquis) 5mg twice a day. This medication is
a blood thinner that prevents blood clots from forming in your
heart due to atrial fibrillation.
- Stop aspirin and levothyroxine.
- Increase Metoprolol Succinate to 25mg twice a day. This is to
keep your heart rate under control.
You did not have a cardioversion to get you back in a normal
heart rhythm because the Electrophysiology doctors ___ your
___ function back to normal prior to attempting a
cardioversion.
If you have any urgent questions that are related to your
recovery from your medical issues or are experiencing any
symptoms that are concerning to you and you think you may need
to return to the hospital, please call the ___ HeartLine at
___ to speak to a cardiologist or cardiac nurse
practitioner.
It has been a pleasure to have participated in your care and we
wish you the best with your health!
Your ___ Cardiac Care Team | Assessment: Ms. ___ is a ___ year old female with a h/o
hypothyroidism (on home levothyroxine 50mcg daily), pAF (on
flecainide and metoprolol) and AT who presented to ED ___
with palpitations and dyspnea since ___ at 1500. She was
found to be in AF on EKG with HR 110bpm with no ischemic
changes.
Trop negative. TSH <0.01, T4 15. She is not on home
anticoagulation therefore a heparin gtt was started in ED for
possible TEE/DCCV today, ___. | 196 | 73 |
17075739-DS-22 | 21,966,244 | Mr. ___,
It was a pleasure taking care of you at the ___
___ ___. You were admitted for pneumonia and
because you were not behaving as your usual self. You were
treated with antibiotics and your pneumonia resolved. You
received a lot of fluids while in the hospital which caused
fluid build up in and around your lungs. We treated this with
medication which made you urinate all the excess fluid.
Please continue to take all your medication as prescribed.
Weigh yourself every morning, if weight goes up more than 3 lbs
please increase your lasix from 40mg once a day to 40mg every 12
hours (twice a day). | ___ M h/o SBO s/p SBR, AVR on coumadin, CHF, DM, paranoid
schizophrenia, transferred from nursing home with
confusion/agitation and abdominal distention complicated by
acute decompensated dCHF and pulmonary edema. | 112 | 30 |
14904554-DS-15 | 27,433,052 | Dear Mr. ___,
It was a pleasure taking part in your care during your admission
to ___. As you know, you were
admitted for chest pain. A study of the blood vessels that
supply your heart (cardiac catheterization) showed stable
blockages of a few vessels, and no intervention was felt to be
necessary. Though it is clear that you did not suffer a heart
attack, it is less clear what might have caused your chest pain.
However, if you have severe pain again, you should immediately
return to the emergency department for evaluation.
No changes were made to your medications. | BRIEF HOSPITAL COURSE:
====================
___ year old man with h/o CAD (s/p 2 x stents to RCA and LCX in
___ and recurrent CP in ___ with moderate CAD noted
throughout and mod single vessel disease of LAD) and heavy
tobacco use who presented w/ chest pain concerning for ACS
ACTIVE ISSUES
====================
1. CHEST PAIN
Given his known hx of CAD, pt's severe chest pain on admission
was concerning for unstable angina. Though his EKG did not show
any clear e/o ischemia and his cardiac biomarkers were negative,
he was treated empirically for ACS w/ ASA, Atorvastatin 80 and
Fondaparinux. Aortic Dissection was considered given the
"tearing quality" of his chest pain but his mediastinum was not
widened on CXR, and his vital signs remained stable. Chest pain
was initially treated with IV dilaudid and a nitroglycerin drip,
but pt became hypotensive requiring IVF, so the nitroglycerin
was discontinued, and further pain control was achieved with IV
Dilaudid alone. Notably, pain relented soon after being
transferred to the medicine ward.
Given his hx of extensive CAD, he was continued on Fondaparinux
anticoagulation pending cardiac catheterization, which revealed
stable coronary artery disease, not requiring percutaneous
coronary intervention, and no e/o vasospasm. LAD with proximal
tubular 40% stenosis; mid-LAD 50% lesion between S1/D1 and
S2/D2; first diagonal with 50% lesion proximally; 45% stenosis
proximally in the long modest caliber fourth obtuse marginal;
patent stent in the major fifth obtuse marginal/LPL; RCA with
20% proximal stenosis and 20% distal stenosis; PDA with diffuse
plaquing to 40%. Given concern for aortic dissection he had
supravalvular aortography done in the catheterization lab which
did not show any e/o dissection.
Initiation of isosorbide mononitrate or caclium channel blocker
was considered, but his blood pressure (90s-100s systolic) did
not permit during this admission. Since the findings on cardiac
catheterization did not require any intervention, he was
informed of the importance of managing his risk factors for CAD.
Specifically, the team spent much time with the pt educating him
regarding the risks of smoking, and potential methods for
quitting.
He was discharged chest pain-free in stable condition, w/
appropriate follow up appointments. He was instructed to
continue Aspirin 81mg daily. | 99 | 354 |
13480587-DS-21 | 22,935,144 | You were admitted to the hospital with right lower quadrant pain
and were found to have 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 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. | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed acute appendicitis, no
drainable fluid collection or extraluminal air. WBC was elevated
at 15. The patient underwent laparoscopic appendectomy, which
went well without complication (reader referred to the Operative
Note for details). After a brief, uneventful stay in the PACU,
the patient arrived on the floor tolerating clear liquids, on IV
fluids, and PO/IV analgesia for pain control. The patient was
hemodynamically stable.
.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. He was noted to have a high
post void residual and was given a dose of Tamsulosin. During
this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. ___ was consulted to help manage the
patient's juvenile diabetes, for which he was on an insulin pump
for. During the hospitalization, the patient's blood sugars were
well controlled.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 738 | 260 |
14309697-DS-28 | 21,896,854 | Dear Ms. ___,
It was a pleasure caring for you during your admission to ___
___. As you know, you came in with
chest pain. Your EKG and blood tests did not show evidence of a
heart attack and your pain improved.
During your stay, your blood pressure was very high, and we
increased your labetolol to three times per day. We did not make
any other changes to your medications. Please call your doctor
right away if you feel lightheaded or dizzy, or if you have
chest pain or a racing heart beat again.
Please weigh yourself every morning and call your doctor if
weight goes up more than 3 lbs. Once again, it was a pleasure
caring for you and we wish you the best,
Sincerely,
Your Medical Team | Ms. ___ is a ___ with known CAD who developed sharp left
sided chest pain at HD that felt different than her prior
anginal symptoms but did respond to SL NTG x 1. She was
transferred to ___, where three sets of cardiac enzymes were
at baseline and EKG showed no acute ischemic changes. Last
stress test was ___ and showed no symptoms or EKG changes.
There were WMA's at rest but no inducible ischemia.
She underwent HD. During HD, chest pain briefly recurred, then
resolved again. It is unclear what caused pain, as it was not
reproducible to suggest classic MSK pain, and she did not have
reflux or other GI symptoms to suggest clear GI etiology.
Given lack of acute EKG changes or enzyme elevation, patient
will follow-up as an outpatient with Cardiologist Dr. ___.
Please consider utility of repeat outpatient stress test at next
visit.
During stay, patient was persistently hypertensive to high
170's, even after HD, which diuresed her to just below dry
weight. Labetolol was increased from BID to TID, and blood
pressure will be rechecked at HD session tomorrow.
# Chest pain: Patient with acute onset of sharp, stabbing chest
pain unlike prior history of stable angina which resolved with
single dose of nitro. While pain could certainly represent
unstable angina, does not meet criteria for NSTEMI given trops
at baseline (likely elevated chronically due to CKD). Three sets
of cardiac enzymes were negative. EKG showed no acute ischemic
changes. We continued her aspirin, statin, and beta blocker.
# Hypertension: baseline HTN with SBPs 140s-160s per patient.
She remained persistently hypertensive here with SBPS in the
170s, even after dialysis to dry weight. We increased her
labetolol 300 mg BID to TID.
# ESRD: Low phos, low K diet. She received dialysis on ___.
# Diabetes: Type II, currently off of insulin and oral agents
given symptomatic on medications with hypoglycemia. We
maintained her on a conservative ISS while in house.
#CAD s/p MI, BMS, with dCHF: EG 55% in ___. We continued
aspirin and simvastatin.
# Peripheral Vascular Disease: Continued aspirin
# HLD: Continued simvastatin
# Depression/Anxiety: Continued ___ Mirtazapine
#Seasonal Allergies: Continued home loratadine
TRANSITIONAL ISSUES
- Follow-up with Dr. ___ consideration of outpatient
stress test
- Monitor BP on increased dose of labetolol (next BP check
tomorrow, ___, at HD)
-Consider d/c plavix (not clear indication given remote h/o bare
metal stent) | 131 | 412 |
17650265-DS-9 | 24,473,978 | It was a pleasure caring for you at ___. You were admitted
with nausea and vomiting. You underwent testing that did not
show signs of a serious infection. Your symptoms improved--you
most likely had a "stomach bug" (viral gastroenteritis).
While you were here, you were also dizzy. This is likely the
result of a condition called "benign paroxysmal positional
vertigo". This may be a result of your recent viral infection.
It should resolve over time--in the meantime, we recommended
using a medication called meclizine to treat your symptoms. You
were seen by a physical therapist who recommended that you
continue to see a physical therapist to help you with these
symptoms.
You have improved and are now ready for discharge | This is a ___ year old female with past medical history of
developmental delay, type 2 diabetes, bipolar disorder admitted
___ with abdominal pain, nausea and vomiting secondary to a
viral gastroenteritis, course complicated by a peripheral
vertigo (potentially BPPV), GI symptoms treated conservatively
and now tolerating a regular diet, vertigo symptoms improving
with meclizine and maneuvers, ready for discharge home with
close PCP ___ and outpatient physical therapy.
# Viral Gastroenteritis / Abdominal Pain / Nausea / Dehydration
- patient admitted with abdominal pain with nausea, vomiting and
diarrhea x 1 day; CT abd/pelvis without focal process; labs
notable only for mildly elevated lactate (resolved with fluid
resuscitation) and elevated lipase (less than 3x the upper limit
of normal). Patient rapidly improved with conservative
management, most consistent with viral gastroenteritis (and not
acute pancreatitis).
# Peripheral Vertigo - patient reported onset of symptoms around
time of her GI symptoms above-reported sensation of room
spinning, worse with changing of position; no tinnitus or
hearing deficit; no focal neuro findings; no orthostasis and did
not improve with volume repletion. Given onset with viral
infection felt to be possible related peripheral vertigo versus
potential BPPV. Symptoms resolved with trial of PO meclizine
treatment. Patient was seen by physical therapy for maneuvers,
who recommended outpatient ___ ___. At time of discharge,
patient was safely ambulating.
# Type 2 Diabetes with neurologic complications - continued home
oral glimepiride, Invokana, liraglutide, metformin. Continued
home gabapentin.
# Bipolar disorder - continued oxcarbazepine
# Hyperlipidemia - continued statin, ASA
# GERD - continued PPI
# Hypertension - continued lisinopril
TRANSITIONAL ISSUES
- Discharged home
- Contact - Legal Guardian ___ ___ - all
medical details relayed to her
- Discharged on trial of meclizine--given prescription for 1
weeks supply to get her to upcoming PCP ___
< 30 minutes spent on this discharge. | 128 | 304 |
16731886-DS-16 | 28,737,427 | You were admitted with difficulty walking. You were seen by
physical therapy and they recommended a rolling walker and
continued physical therapy at home.
MRI of the brain showed several very tiny "specks" that the
radiologist thought could be old tiny strokes, but nothing new
or "acute" that would explain your recent symptoms. | ASSESSMENT AND PLAN: ___ yo with recent GI illness and
dehydration presents with difficulty ambulating and general
weakness
Ataxia/Weakness: improved, likely ___ dehydration and possible
component of UTI, no focal neuro symptoms
- change macrobid to cipro based on prior culture data and
multiple allergies will have to monitor closely for medication
induced delerium
- consult ___
- f/u urine culture
Bladder Cancer:chronic hydronephrosis of R ureter
- monitor renal function
HTN: poorly controlled, not on home meds
- start HCTZ and lisinopril
COPD: no acute exacerbation, not on home meds
Dyslipidemia: cont home meds
FEN: gen diet
PPX: heparin
ACCESS: piv
FULL CODE: presumed
CONTACT: daughter
DISPO: medicine, pending above
___, ___
signed electronically | 52 | 105 |
19075045-DS-22 | 25,729,260 | Dear Mr. ___,
It was a pleasure to be part of your care at ___.
You were admitted to the hospital because you were having
difficulty breathing and were having leg swelling, which were
concerning for a heart failure exacerbation. This heart failure
exacerbation was likely exacerbated by an episode of atrial
fibrillation.
You were treated with diuretics to help get rid of the extra
fluid that you had accumulated as a result of your heart failure
and with a medicine to help your heart beat more efficiently.
In the hospital you received a cardioversion to help return your
heart back to a normal rhythm. Your home beta-blocker
(carvedilol) was stopped. You were not re-started on a
beta-blocker because your blood pressure was low. Your heart
remained in a normal rhythm for most of your stay, however at
the end it converted back to an irregular rhythm. You underwent
a second cardioversion on ___.
Your diuretic Lasix was switched to torsemide 40 mg, which you
should take twice a day.
If you experience any worsening difficulty breathing or
accumulation of swelling in your legs, please contact your
doctor.
Please monitor your INR daily and call the result in to your
PCP, ___ (___).
We wish you the best,
Your ___ Team | Mr. ___ is a ___ year-old gentleman with HFpEF, CKD, AF on
warfarin, s/p PPM for sick sinus who presented with dyspnea on
exertion and significant edema consistent with a diastolic HF
exacerbation, with concern for recurrent atrial fibrillation as
precipitating factor.
#Acutely Decompensated Heart Failure With Preserved Ejection
Fraction: LVEF = 50%. Unclear precipitant given non-ischemic EKG
with TnT elevation in proportion to renal dysfunction and no
history of medication non-compliance or dietary indiscretion. Pt
in atrial fibrillation, possibly contributing to exacerbation,
though his rates were generally in the ___ to 110s. On admission
he was significantly volume overloaded with 3+ pitting edema to
thighs and sacrum. Admission weight was 86.9 kg compared to
discharge weight of 88.2 on ___ (although the latter likely
did NOT represent his true dry weight). He was started on lasix
gtt upon admission and titrated up to 20 mg/h. He was resistant
to diuresis and dobutamine gtt 2.5 was added on ___. With
inotropic support he diuresed effectively. Patient was
cardioverted x2 from AF into NSR (see below). A pyrophosphate
scan performed on ___ to r/o amyloidosis as the etiology of his
heart failure but this was negative. Given his mod-severe TR and
MR on prior TTE (___), and the need for dobutamine to
diurese, a right heart cath (___) was performed to evaluate for
RV dysfunction and the possibility of high output heart failure
in the setting of a known right femoral AV fistula (iatrogenic
from prior caths at that site). The RHC revealed normal right
and left heart filling pressures and normal cardiac output (no
evidence of high output state). The patient was successfully
weaned off dobutamine following the cessation of Lasix and
cardioversion. He was transitioned to torsemide 40mg BID and
remained euvolemic on PO diuretics at discharge.
Admission weight: 86.9 kg
Discharge weight: 66.3 kg
#Atrial fibrillation with normal ventricular rates: HRs ___
in the hospital, and pt was asymptomatic. Pt previously on
dofetilide but this was discontinued prior to admission ___
renal failure. He was admitted on carvedilol but beta blockers
were discontinued during this admission for hypotension. INR was
therapeutic at 2.3 on admission. He was placed on heparin gtt
for better anticoagulation control in preparation for
cardioversion and cath, and then bridged back to warfarin, again
with a therapeutic INR on discharge. The patient was amiodarone
loaded and then cardioverted on ___. He maintained NSR for
several days but then on ___ he had recurrence of his atrial
fibrillation. He was continued on Amiodarone 200 mg PO/NG DAILY
and re-cardioverted on ___. At time of this second
cardioversion his rhythm pre-shock was actually atrial flutter
with 2:1 block (rather than atrial fibrillation). Post-shock on
___ he, again, was in normal sinus rhythm. EP recommended
continuing amiodarone 200mg PO qday (no change in
anti-arrhythmic therapy). Discharged on a warfarin dose of 7.5mg
daily with an INR of 2.8. He monitors his own INR at home and
calls in the results to his PCP who manages his warfarin dosing.
#Valvulopathies: moderate to severe MR and TR noted on TTE in
___ in the setting of significant volume overload. It is
less likely this represents a primary structural event but
rather was secondary to dilation of the valvular rings while
overloaded given the normal filling pressures observed on right
heart cath when dry. A follow-up TTE while dry could be
performed as an outpatient if warranted.
#Acute on Chronic Kidney Disease, Stage 4: Pt was on dialysis
through ___ and ___ subsequent to an episode of ATN
precipitated by volume overload after L shoulder arthropathy.
His last HD was ___ and the HD line was removed ___. as it was
no longer needed. He was able to diurese effectively on lasix
gtt with inotropic support and then on PO diuretic after the
dobutamine was discontinued. Cr prior to shoulder surgery and
ATN was 0.9-1.1, Cr in house ranged from 2.5-3.2, with most
values prior to discharge between 2.8 and 3.2. His renal
function changed little during diuresis, with his Cr hovering
around 3, and this likely represents a new baseline for him. He
will follow up with nephrology as an outpatient for ongoing
management.
CHRONIC ISSUES:
================
# Coronary artery disease s/p CABG: No chest discomfort or
angina equivalent was noted with no ischemic changes seen on
EKG. TnT elevation in proportion with renal dysfunction. Pt
was transitioned to rosuvastatin 20mg PO QPM and continued on
aspirin 81 mg daily. All beta blockers were discontinued ___
hypotension and not needed for rate control (nor for heart
failure since he has preserved EF).
# Diabetes Mellitus Type 2, controlled: Recent A1c 6.8%, and
patient has stopped using glargine--uses a carbohydrate scale at
home. Humalog sliding scale while in hospital and at discharge.
# Macrocytic anemia/Thrombocytopenia: Chronic, followed by Dr.
___. Platelets are lower than usual without use of
antibiotics, previously thought to be the culprit. SPEP was
normal in ___. He had gastric bypass in ___ with resulting
iron and B12 def and is on monthly B12 injections. Retic 2.7.
Normal B12, folate, LDH, hapto. Light chains assay w/ high free
kappa and lambda but with normal K:L ratio. TSH normal. MMA wnl.
___ recommended the initiation of EPO for Hgb < 9, which may be
started as an outpatient. The patient will follow-up with Dr.
___ discharge.
# GERD: Pt was continued on pantoprazole | 205 | 897 |
19213219-DS-16 | 22,096,154 | Dear Ms. ___,
It has been a pleasure taking part in your care during your
hospitalization. You were admitted to ___
___ for an exacerbation of heart failure, with weight
gain and swelling despite an increase of your dose of lasix.
Please continue to take your home medications. Please follow up
with the appointments as described below. Weigh yourself every
morning, call your doctor if your weight goes up more than 3 lbs
in one day or more than 5 lbs in one week.
Again, it has been a pleasure taking part in your care and we
wish you the best. | ___ w/ h/o moderate-severe PAH (presumed idiopathic, but also w/
h/o COPD, OSA, and hypoxemia), as well as diastolic CHF,
presents for persistent edema, fatigue, and dyspnea despite
increasing doses of oral diuretics; also found to have ___.
# Acute on chronic diastolic, biventricular CHF: Pt. w/
diastolic left-sided CHF as well as severe PAH (idiopathic vs.
___ hypoxia). She has had progressive volume overload despite
escalating doses of PO Lasix. It is possible that she is not
absorbing PO Lasix consistently due to gut edema. Patient
diuresed initially with IV lasix, transitioned to PO torsemide,
and euvolemic with dry weight of 75.1kg at discharge. Continued
home sildenafil and macitentan for PAH. Started low dose
metoprolol. Continued lisinopril. Discontinued lasix and started
torsemide.
# ___: Cr 2.0, up from baseline of 0.7. Given her overall
clinical presentation, this is likely due to renal venous
congestion w/ decompensated right heart failure. Creatinine
improved somewhat with diuresis to 1.7 at discharge.
# Macrocytic anemia: 9.8 from baseline of 11.8. No evidence of
active bleeding. B12 and folate were normal.
#Gout: Patient complained of right foot pain on ___, improved
with colchicine x1. ___ right foot pain resolved, but new
left ankle pain, now somewhat improved with repeat dose of
colchicine. Patient able to ambulate with ___ and with RN.
# COPD: stable. Continue home bronchodilators
# A-fib: rate within target range with metoprolol 25mg daily.
INR sub-therapeutic at 1.3 at the time of discharge. She
received one increased dose of 3mg on ___ and was discharged
on 2.5mg daily. | 99 | 263 |
16455598-DS-19 | 25,112,435 | These steps can help you recover after your procedure.
DO drink plenty of water to flush out the bladder.
DO avoid straining during a bowel movement. Eat
fiber-containing foods and avoid foods that can cause
constipation. Ask your doctor if you should take a laxative if
you do become constipated.
Don't take blood-thinning medications until your doctor says
it's OK.
Don't do any strenuous activity, such as heavy lifting, for
four to six weeks or until your doctor says it's OK.
Don't have sex. You'll likely be able to resume sexual
activity in about four to six weeks.
Don't drive until your doctor says it's OK. ___, you can
drive once your catheter is removed and you're no longer taking
prescription pain medications.
You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve. You may
have clear or yellow urine that periodically turns pink/red
throughout the healing process. Generally, the discoloration of
the urine is OK unless it transitions from ___,
___ Aid to a very dark, thick or like tomato juice
color
Resume your pre-admission/home medications EXCEPT as noted.
You should ALWAYS call to inform, review and discuss any
medication changes and your post-operative course with your
primary care team.
Unless otherwise advised, blood thinning medications like
ASPIRIN should be held until the urine has been clear/yellow for
at least three days. Your medication reconciliation will note
if you may resume aspirin or prescription blood thinners (like
Coumadin (warfarin), Xarelto, Lovenox, etc.)
-an ointment like bacitracin/Neosporin or "triple antibiotic"
ointment is recommended for comfort at urethral meatus where the
foley catheter inserts. Apply the ointment for comfort ___ x
daily if needed.
If needed, you will be prescribed an antibiotic to continue
after discharge or save until your Foley catheter is removed
(called a trial of void or void trial).
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 it is available
over-the-counter
AVOID STRAINING for bowel movements as this may stir up
bleeding. Avoid constipating foods for ___ weeks, and drink
plenty of fluids to keep hydrated
No vigorous physical activity or sports for 4 weeks or until
otherwise advised
Do not lift anything heavier than a phone book (10 pounds) or
participate in high intensity physical activity (which includes
intercourse) for a minimum of four weeks or until you are
cleared by your Urologist in follow-up
Acetaminophen (Tylenol) should be your first-line pain
medication. A narcotic pain medication may also be prescribed
for breakthrough or moderate pain.
The maximum daily Tylenol/Acetaminophen dose is 3 grams from
ALL sources.
Do not drive or drink alcohol while taking narcotics and do
not operate dangerous machinery. | Mr. ___ was admitted to urology with hematuria and clot
retention and underwent cystoscopy, evacuation of clot and
fulguration of prostate bed. No concerning intraoperative events
occurred; please see dictated operative note for details. He
patient received ___ antibiotic prophylaxis.
Patient's postoperative course was uncomplicated. He received
intravenous antibiotics and
continuous bladder irrigation overnight. On POD1 the CBI was
discontinued and his Foley was removed after active voiding
trial and post void residuals were checked. His urine was clear
yellow and without clots. He remained a-febrile throughout his
hospital stay. At discharge, the patient's pain well controlled
with oral pain medications, tolerating regular diet, ambulating
without assistance, and voiding without difficulty. He is given
pyridium and oral pain medications on discharge and explicit
instructions to follow up in clinic. | 497 | 130 |
15134226-DS-26 | 25,043,005 | Dear Mr. ___,
It was a pleasure treating you at the ___
___. You were admitted because of your high potassium
level and abnormal kidney function lab markers. In the emergency
department, you were given fluids and admitted overnight for
further monitoring of your electrolyte balance. In the morning,
your kidney function and potassium level (along with other
electrolytes) improved. We continued your fluids while holding
your lisinopril. Afternoon labs returned with continued
improvement and you were discharged to ___ with with your
PCP.
***PLEASE USE LAB SCRIPT TO HAVE BLOOD DRAWN ___, LABS SHOULD
BE FAXED TO ___ ___ ___
STOP:
-- Lisinopril until you see your PCP or ___
HOLD:
-- Warfarin, while taking Lovenox per Dr. ___ your ___
Fissure Procedure
Best of Health,
Your ___ Team | Mr. ___ is a ___ y/o man with a hx of a flutter (on coumadin,
recently stopped for upcoming surgery), CAD c/b STEMI s/p BMS,
IE of AV s/p AVR with ___ porcine valve replacement,
pulmonary hypternsion, HTN, OSA not on CPAP who presented to our
hospital for concerning lab finding of hyperkalemia and ___. He
had bloodwork in the ED which showed a downtrend in potassium.
He was given IVF and monitored overnight. Repeat blood work in
the AM and ___ showed downtrending potassium and creatinine. He
was then discharged to outpatient follow up with his PCP.
___--
The patient was discharged from our hospital in ___ for
melena of unclear etiology, at the time of discharge his lasix
and lisinopril which had been d/c'd for the admission were
restarted. Because of his improved leg edema, lasix was
discontinued by one of his outpatient physicians. The patient
reports increasing his potassium intake with orange juice
because he thought he was previously low. He went to his PCP ___
___ and was found to have a K of 5.9 with repeat testing on
___ up to 6.8. There was also a change of 1.56->1.93 in his
creatinine over that time (at previous discharge in ___, as
1.3). he was admitted to the floors and given IVF (2 L NS @ 150
mL/hr). His labs improved during admission, from ED: Creatinine
2.0, K 5.4-->AM Crea 1.6, K ___ Crea 1.2, K 5.3. The
patient was discharged to ___ with PCP on ___.
He should have a CBC and CHEM7
(Na/K/Cl/Bicarb/BUN/Creat/Glucose) drawn ___ and faxed to his
PCP's office ___.
TRANSITIONAL ISSUES
-Patient told to start lovenox for anticoagulation (while
holding Warfarin) on discharge per recommendation of his
cardiologist for upcoming colorectal surgery for anal fissure.
-Patient to have labs drawn ___ to be faxed to PCP for
___ lisinporil during visit and told to stop at home for the
time being, please discuss restarting with PCP/cardiologist | 122 | 320 |
12709878-DS-10 | 20,892,543 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
-You were admitted to the hospital because you were found to
have a high calcium level in your blood.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You got IV fluids to help lower the calcium in your blood. When
you were not on IV fluids, the calcium level went back up.
-You were seen by the endocrinology team, who believe the high
calcium level is due to an issue with your parathyroid gland
(the gland that controls calcium levels in your blood).
-You were seen by the endocrine surgery team, who recommended
surgery to remove the parathyroid glands.
You were taken to the OR on ___ for a right upper
parathyroidectomy with Dr. ___. You tolerated this
procedure well and recovered uneventfully. You were discharged
home once you were eating, on oral medications, walking, and
completing daily activities per normal.
MEDICATIONS:
For pain medication you may take acetaminophen (Tylenol) or
ibuprofen (Motrin). You requested a recovery without opioid
analgesics and achieved appropriate pain control without them
postoperatively. You may restart all your usual home
medications.
SYMPTOMS OF LOW CALCIUM:
If you develop tingling or numbness around your mouth,
fingertips or legs, this may be a sign of a low calcium and you
should call our office. If you develop severe symptoms, please
go to emergency room.
WOUND CARE:
You may shower normally starting tonight. Allow warm soapy water
to run over the wound, rinse and pat dry gently. There is no
need to keep a dressing over the wound. Do not apply creams or
ointments. Do not submerge the wound in a swimming pool or bath
until cleared at your follow up visit. Do not pull off the steri
strip tapes--these will fall off by themselves over the next ___
weeks.
DIET:
You may resume your regular home diet without restriction. You
should stick to foods that do not upset your stomach. You
may need to start with small meals first and may not feel very
hungry at first. This will improve over time. You may supplement
your diet with protein shakes as needed if you do not feel you
are taking in enough nutrition.
ACTIVITY:
You may resume all of your normal home activities, except for
straining or lifting heavy weight. We recommend you resume
walking, exercise, bathing, per your normal regimen.
WARNING SIGNS:
You should contact our clinic or return to the ED immediately if
you experience any of the following signs or symptoms:
Fever above 101.5
Worsening pain
Worsening GI upset, nausea/vomiting, diarrhea
Change in the appearance of your incision, or redness, swelling,
or change in drainage from your incision
Any other symptoms that concern you
You can contact our clinic at any time with questions or
concerns. You should be seen in our clinic for follow up
following your discharge from the hospital.
Best wishes,
Your ___ Care Team | ___ with PMH of microcytic anemia who presents from PCP at
___ for evaluation of incidental finding of
hypercalcemia. Likely primary hyperparathyroidism given elevated
PTH and enlarged parathyroid glands on imaging. Underwent
parathyroidectomy on ___. | 469 | 35 |
11081679-DS-21 | 29,631,728 | To Whom It ___ Concern,
Mrs. ___ was hospitalized due to symptoms of right sided
weakness and difficulty with speech resulting from an ACUTE
ISCHEMIC STROKE, a condition where a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
After family meeting on ___ at 2pm, decision was made to
employ comfort measures only and further intervention was
withheld. Patient passed peacefully on ___ at 9PM, with son
at bedside. | ASSESSMENT AND PLAN:
___ year-old right-handed woman wit a fib on pradaxa, HTN, HLD,
and history of GI bleed on coumadin who presents to us with
dense right hemiparesis. Found on head CT to have a large MCA
stroke/ left carotid occlusion.
# Neuro: Held home pradaxa. Assessed vascular risk factors:
HbA1c (6.1%) and lipid panel (LDL 112). Patient underwent
MRI/MRA which showed hemorrhagic conversion involving deep gray
and white matter structures and some IVH components with
associated subfalcine herniation. Initially continued Aspirin,
which was held on ___ given hemorrhagic conversion. Repeat
Head CT showed stable hemorrhage. Patient became comfort measure
only on ___ after discussion with family members and
further interventions held.
# Cardiovascular: We rule-out MI with repeat cardiac enzymes
which showed negative troponins. Held home antihypertensives.
Patient placed on telemetry, which was discontinued once patient
became comfort measures only.
# Pulmonary: CXR revealed cardiomegaly, enlarged pulmonary
arteries, pulmonary edema and Right lower lobe consolidation
consistent with pneumonia. Started on antibiotic treatment for
pneumonia, which was discontinued once decision was made for
comfort emasures only.
# FEN: Patient with significant difficulty with NG placement so
NPO on IVF. Found to have hiatal hernia confirmed on CT
chest/abdomen/pelvis. Initially plan had been to place PEG for
long term feeding plan. However, after family meeting, plan
became comfort measures only and PEG placement was cancelled.
Withdrew IVF.
# Social: On ___ around 2pm, discussion with family
regarding goals of care determined that patient should be
comfort measure only. Palliative care team was consulted and
recommended IV Morphine for pain, Ativan po for
anxiety/agitation, Tylenol PR for fever/chills, Atropine SL
drops for excessive secretions and Lasix for comfort with
shortness of breath. Other interventions were withheld. Around
9PM, patient passed peacefully, cause of death likely
cardiopulmonary arrest. | 111 | 293 |
10639069-DS-20 | 28,711,371 | Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you were having diarrhea, vomiting,
and your blood pressure was low
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were diagnosed with gastroenteritis, a problem caused by a
bacteria or virus
- You were started on antibiotics for possible bacteria and
given IV fluids
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team | ====================
PATIENT SUMMARY:
====================
___ ___ speaking male with a history of mixed
connective tissue disease with features of Sjogren's, systemic
sclerosis (sclerodactyly and achalasia s/p endoscopic myotomy)
and SLE with class V membranous nephritis, who presented with
abdominal pain and N/V, found to have likely gastroenteritis as
per CT.
====================
TRANSITIONAL ISSUES:
====================
[ ] Ciprofloxacin and Flagyl - 7 day course to be completed
___
[ ] Please follow up stool cultures
[ ] Please follow up blood cultures - no growth to date
[ ] Restarted home lisinopril at discharge given resolution of
___
[ ] Discharge Cr 0.8
[ ] Noted to have sinus bradycardia to 40-50s while in hospital,
asx. Can consider further workup as needed as this does not
appear to be his baseline
#CODE: presumed full
#CONTACT: ___, Phone: ___
============ | 123 | 132 |
19771489-DS-9 | 29,062,877 | INSTRUCTIONS AFTER HAND SURGERY:
- You were in the hospital for hand 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:
- Nonweight bearing right upper extremity, OK for finger range
of motion as taught by the occupational therapist
MEDICATIONS
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 121.5 daily for 4 weeks
WOUND CARE:
- Dressing should remain on at all times. Do not remove. Do not
get wet. You may shower. No baths or swimming for at least 4
weeks.
- Splint must be left on until follow up appointment unless
otherwise instructed
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
-Please follow up with Dr. ___ in the Hand Surgery Clinic
for post-operative evaluation. You have an appointment scheduled
for ___ at 11AM in ___.
___
___
-Please follow up with your primary care doctor regarding this
admission within ___ weeks for any new medications/refills. | Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have right hand table saw injury and was admitted to the hand
surgery service. The patient was taken to the operating room on
___ for fixation of hand fractures and revascularization,
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 OT was appropriate. The hospital course
is notable for:
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
nonweight bearing in the right extremity, and will be discharged
on aspirin 121.5mg daily for DVT prophylaxis. The patient will
follow up with Dr. ___ per routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. | 305 | 270 |
16644295-DS-12 | 26,049,615 | Dear Ms. ___,
You were admitted to ___
because you fell and fractured your spine. You had an MRI of
your spine that showed a compression fracture of your spine but
did not show any acute compression of your spinal cord. You were
seen by the Orthopedic Spine team, who did not think you needed
surgery. While you were here you got confused, which we think
was caused by pain medications that you took. We also found that
you had low vitamin B12, so we started you on supplementation
that you should continue to take at home. Before you left you
were fitted with a brace for your back that you should use when
you are up walking. You will have a follow-up appointment with
your primary care doctor (___) and the Orthopedic Spine
clinic. It was a pleasure participating in your care - we wish
you all the best.
Sincerely,
Your ___ Medicine Team | Ms. ___ is a ___ F with PMHx notable for osteopenia,
HTN, CKD stage III, multiple recent falls with cognitive decline
per family who presented as transfer from OSH for evaluation of
bowel and urinary incontinence over ___ days after a fall, found
to have L1 compression fracture on MRI being managed
non-operatively, subsequently developed AMS.
# L1 compression fracture with retropulsion: Circumstances
around fall, including exact timing, remain unclear. Per family
patient lives alone and has been falling frequently lately. Pt
did not seek care immediately, likely due to baseline cognitive
dysfunction. Pt initially sought care at ___ for symptoms of
bowel and bladder incontinence. She was transferred to ___
given concern for cord compression. Initial exam did not reveal
any acute neurological changes. MRI here revealed acute on
chronic L1 compression fracture without evidence of compression
of cord to explain her symptoms. Pt has history of osteopenia,
which likely predisposed her to fracture. She was evaluated by
the Orthopedic Spine team, who recommended non-operative
management. She was fitted with a Jewitt brace for spine
stabilization to wear with ambulation. She was evaluated by ___
and OT, who recommended SNF for further recovery. If medication
is needed for pain prefer tylenol given AMS likely caused by
narcotic pain medication. Pt will need to follow up with Ortho
Spine clinic ___ weeks after discharge. Vitamin D and
multivitamin should be continued.
# Toxic metabolic encephalopathy: Pt's family reports
progressive cognitive decline over the past year. She continues
to lives alone, however has had several recent falls as above.
Initial exam after admission to medicine was consistent with
acute delirium given lack of orientation, attention and
concentration. Her symptoms were most likely caused by narcotic
pain medication given urine tox positive for opiates and/or
hospital setting on baseline dementia. Infectious work-up
negative. CT head revealed no acute intracranial abnormality.
She was found to be Vitamin B12 deficit, however this is not
likely to explain the acute change. TSH was normal. She required
Zyprexa in ED and additional 5mg PO on AM of ___ for
agitation, none thereafter. Over the next several days pt's
mental status gradually cleared. Prior to discharge she was
alert and oriented x 3 and able to form concentration tasks, per
family approaching her baseline. Will need to continue
environmental measures to reduce delirium, especially while at
___, and continue vitamin B12 supplementation.
# Candidal intertrigo: Rash noted in right groin area during
admission. It was not itchy, painful or otherwise bothersome to
patient. She was started on nystatin cream with some improvement
prior to discharge. She should continue a 2 week course. To
prevent infection from recurring, make sure to pat area dry
after showers.
# Bowel/bladder incontinence: Resolved. Reported by pt over
several days prior to admission to ___. Initial
evaluation in ED revealed normal rectal tone. MRI was negative
for acute cord compression as above. Pt voided urine
spontaneously and had normal bowel movements during admission
without incontinence.
# Hypercalcemia: Noted to have elevated Ca to 10.6 on ___ that
quickly returned to normal. Albumin and PTH were normal.
Encouraged PO intake, likely dry.
# HTN: Remained well-controlled. Home lisinopril was continued.
# CKD: Cr stable at 1.0-1.1. CKD stage III per records, likely
due to chronic HTN. Medications were renally dosed.
# Glaucoma: Continued home eyedrops.
# Primary prevention CAD: Continue home ASA 81mg. | 155 | 563 |
16842320-DS-15 | 22,622,513 | You were admitted to the hospital for pain in your body, mostly
in your ribs. We tried to treat your pain with pills and a pain
patch but you did not wish to take any pain medications. Our
physical therapists worked with you and felt you would benefit
from rehab. We also had our psychiatrists see you to discuss
your mood but you declined further treatment.
Please follow-up with your PCP after you leave rehab. We made
an appointment for you to see ENT to discuss your ear pain as
below. | Ms. ___ is a ___ year old woman with hx of Rheumatoid
Arthritis and HTN who presented with abdominal and bilateral
flank pain of 8 days duration, with no other GI symptoms apart
from her progressively worsening pain. In summary, she had a
negative CT on ___ and workup was otherwise negative. She
continues to have a chronic left otitis, for which ENT follow up
is recommended.
# Flank/Back Pain/Abdominal Pain: Pt had normal lipase, LFTs,
clean UA, negative urine cultures and legionella antigen,
negative blood cultures, no leukocytosis; as such, UTI/pyelo or
other infection as well pancreatitis both seemed unlikely. Her
CT showed no evidence of compression fracture. Her pain was
unchanged throughout her admission; she took acetaminophen and
reported some small pain relief, but refused any narcotic pain
medication.
.
# Wheezing: Pt had some wheezing on admission, with no SOB or
respiratory distress, adequate O2 sat, and normal resp rate. She
received an albuterol nebulizer treatment on ___, and had
resolution of her wheezing. Her lungs were clear at the time of
discharge on ___.
.
# L ear discharge: The presentation of the ear is concerning for
otitis media or externa; unable to adequately visualize TM due
to purulent discharge. As such, perforated TM could not be ruled
out, which led team to hold off on antibiotic drops. This otitis
is likely chronic and was seen by her PCP, who obtained a cx
sample on ___ (grew S aureus). It is unclear where exactly this
sample was obtained from. Pt was discussed with ENT, who felt
that pt should be seen for outpatient f/u for repeat culture
from within ear canal and appropriate therapy.
.
# Social: Patient was seen by SW to follow up on issues that
came up, including that her husband is her sole caretaker but
also works; therefore, the patient spends the majority of her
time alone. She pays for some private home help. Patient also
reports verbal abuse, but denies phsyical abuse from husband. ___
provided support and also contacted Ethos Elder Services on her
behalf given her isolation, to discuss further resource
availability.
.
# Psych: Psychiatry was consulted given the patient's numerous
psychosocial stressors and question of difficulty coping and
safety going home, as well as some mention in previous PCP notes
about pt seeing demons. Psychiatry corraborated some possible
delusional aspect to her thinking as well as prominent mood
symptoms (though the patient firmly opposed the label of
depression), but psychiatry felt that her primary treatment
concerned her underlying delusional disorder with psychotic
symptoms. They recommended some additional laboratory workup
that is detailed elsewhere for possible organic causes of her
symptoms(negative RPR); brain MRI was not obtained. Pt declined
any treatment for mood symptoms.
.
# Hyponatremia: Pt's Na was 125 on presentation, but resolved
overnight with NS and remained normal throughout her admission.
Previous treatment with bactrim may have contributed to her
hyponatremia, though this is unclear.
.
# HTN - Patient was continued on her home amlodipine 5 mg with
good effect.
.
# Rheumatoid Arthritis: Patient is not currently on and has
never taken DMARDS, and does not like to take muliple
medications at home. She refused pain medication stronger than
acetaminophen, which she reported provided only a small amount
of pain relief.
.
.
.
1. Left-sided otitis: for ENT follow up.
2. Patient will go to rehab following discharge to receive
physical therapy. | 94 | 552 |
13960396-DS-9 | 25,389,707 | Instructions After Orthopedic 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.
Medicines
- Resume taking your home medications unless specifically
instructed to stop by your surgeon. Please talk to your primary
care doctor within the next ___ weeks regarding this
hospitalization and any changes to your home medications that
may be necessary.
- Do not drink alcohol, drive, or operate machinery while you
are taking narcotic pain relievers (oxycodone/dilaudid).
- As your pain lessens, decrease the amount of narcotic pain
relievers you are taking. Instead, take acetaminophen (also
called tylenol). Follow all instructions on the medication
bottle and never take more than 4,000mg of tylenol in a single
day.
- If you need medication refills, call your surgeon's office
3-to-4 days before you need the refill. Your prescriptions will
be mailed to your home.
- Please take lovenox for two weeks to help prevent the
formation of blood clots.
Constipation
- Both surgery and narcotic pain relievers can cause
constipation. Please follow the advice below to help prevent
constipation.
- Drink 8 glasses of water and/or other fluids like juice, tea,
and broth to stay well hydrated.
- Eat foods that are high in fiber like fruits and vegetables.
- Please take a stool softener like docusate (also called
colace) to help prevent constipation while you are taking
narcotic pain relievers.
- You may also take a laxative such as senna (also called
Senokot) to help promote regular bowel movements.
- You can buy senna or colace over the counter. Stop taking them
if your bowel movements become loose. If your bowel movements
continue to stay loose after stopping these medications, please
call your doctor.
Incision
- Please return to the emergency department or notify your
surgeon if you experience severe pain, increased swelling,
decreased sensation, difficulty with movement, redness or
drainage at the incision site.
- You can get the wound wet/take a shower starting 3 days after
surgery. Let water run over the incision and do not vigorously
scrub the surgical site. Pat the area dry after showering.
- No baths or swimming for at least 4 weeks after surgery.
- Your staples/sutures will be taken out at your 2-week follow
up appointment. No dressing is needed if your wound is
non-draining.
- You may put an ice pack on your surgical site, but do not put
the ice pack directly on your skin (place a towel between your
skin and the ice pack), and do not leave it in place for more
than 20 minutes at a time.
Activity
- Your weight-bearing restrictions are: touch down weight
bearing in the right lower extremity
Physical Therapy:
TDWB LLE
ROMAT
Walker when upright
Treatments Frequency:
Daily dressing changes until wound without drainage.
Then, leave open to air.
Stitches/staples to be removed at scheduled follow up in 2 weeks | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left hip periprosthetic hip fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of the left hip periprosthetic
hip fracture which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. On POD3, patient had a
bloody bowel movement, with another one the folowing day. His
lovenox dvt prophylaxis was held for two days. He received
1uPRBC for a hct of 23, which bumped up appropriately to 27 and
remained stable prior to discharge. Gastroenterology was
consulted who recommended a colonoscopy, which he underwent on
___ which revealed diverticulosis without any other
concerning masses. They cleared him for discharge on ___.
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
TDWB in the LLE, and will be discharged on lovenox x 2 weeks for
DVT prophylaxis. The patient will follow up in two weeks with
Dr. ___ team in 2 weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 498 | 340 |
17450913-DS-7 | 25,363,175 | Dear Mr. ___,
You were admitted for symptoms of headache and double vision.
Your imaging results (CT of the head, and MRI of the brain) did
not show any acute pathology to explain your headache. Your
neurological exam is relatively benign, but we recommend close
follow up with our neuro-ophthamologists (Dr. ___ and
neurology clinics (Drs. ___.
Please call either office (phone numbers below) if you have any
change or worsening of your symptoms.
Please continue to take your anti-hypertensive medication
(Chlorthalidone) and warfarin as directed. You have scheduled
follow up in the ___ clinic on ___.
It was a pleasure caring for you during this hospitalization. | ___ M w diplopia and headaches. Headaches described as
"fullness". Fundoscopic exam w/o e/o papilledema. Diplopia on
far lateral gaze bilaterally - appear to be consistent w mild
bilateral ___ nerve palsies. CT head benign. MRI+/MRV benign.
Will follow closely in neurology and neuro-ophtho clinics.
Will follow in ___ clinic on ___. | 104 | 51 |
12058581-DS-20 | 23,154,791 | It was a pleasure taking care of you at ___
___.
You were admitted to the hospital for shortness of breath and
cough. A chest CT was obtained which suggested a worsening
pneumonia. You were treated with IV antibiotics and nebulizers.
Your oxygen saturations were monitored. The pulmonology team was
consulted and recommended that you be discharged on IV
antibiotics, and that you start taking the medication
fluticasone. Your serum creatinine (a measure of kidney
function) also rose during this admission. This was monitored
and remained stable at the time of discharge.
You were also started on Flomax (also known as Tamsulosin) for
your prostate. Please arrange for follow-up appointment with
Urology as you had previously planned. Let your primary care
physician know if you start to experience dizziness or
lightheadedness while on this medication.
Please attend all of your follow-up appointments. Given your
infection, you will go home on IV antibiotics. You should also
start taking fluticasone with a spacer. Please continue all of
your other medications. Please follow up with your primary care
doctor regarding your kidney function. | ___ with history of severe COPD who was treated for bacterial
pneumonia one month ago with levofloxacin and PO steroids, sent
to the ED from pulmonary clinic with worsening cough, dyspnea,
and exertional hypoxia over the past month.
HOSPITAL COURSE BY PROBLEM
#. Dyspnea, cough, and hypoxia.
Given his risk factors of older age, severe obstructive disease,
and failure of recent antimicrobial therapy, the patient was
started on vancomycin and cefepime for pneumonia. PE was felt to
be less likely given that the patient had no other signs or
symptoms suggesting this (no chest pain, not tachycardia, no
history of immobilization, Wells score of zero). A chest CT was
obtained which showed increasing consolidation in the lingula
and left upper lobe compared to prior CT, concerning for a
worsening infection. The patient was continued on his home
impratroprium and albuterol nebulizers. A cardiac etiology of
his dyspnea was thought to be less likely given that he had no
cardiac history, did not appear volume overloaded on exam, and
recent normal LV and RV function on TTE from ___. His EKG on
arrival was negative for acute ischemic changes, though troponin
in ED slightly elevated to 0.02. His subsequent cardiac markers
were negative and an AM EKG showed no acute changes. A urine
legionella antigen was obtained and found to be negative.
Beta-glucan and galactomannan were also checked and were found
to be negative. Alpha-1 antitrypsin levels were also checked and
were also pending at the time of discharge. The inpatient
pulmonology team was consulted and recommended that he be
discharged on IV vancomycin and cefepime and that he begin
taking fluticasone with a spacer. The patient was discharged on
IV vancomycin and cefepime; follow-up with his outpatient
pulmonologist was being arranged by Dr. ___.
#. Elevated troponin.
The patient's troponin was elevated in the ED to 0.02, which was
attributed to a hemolyzed specimen. His EKG showed no acute
ischemic changes, and his cardiac markers were cycled and found
to be negative x2. He was placed on telemetry overnight, which
was discontinued the morning after a morning EKG showed no acute
ischemic changes. The patient denied any chest pain throughout
his admission.
#Creatinine bump.
On day four of his admission, the patient's serum creatinine
bumped from 1.1 to 1.4. Urine electrolytes were consistent with
an intrinsic renal process, likely contrast-induced (as he
received a chest CT with contrast) vs. antibiotic-induced. The
patient's AM and ___ doses of vancomycin were held for one day.
His serum creatinine was monitored and remained stably elevated
on the day of discharge. Upon discharge, the patient will have a
serum creatinine check along with Vancomcyin trough checked upon
discharge by ___ services; patient was provided with presciption
for outpatient lab check.
#. Hyperkalemia.
On admission the patient was found to be hyperkalemic, withou
acute EKG changes. An AM K was checked and found to be within
normal limits.
#. Hyponatremia
Mild, asymptomatic. Thought to be secondary to poor PO intake
versus SIADH in light of the patient's history of lung disease.
Urine electrolytes were checked and found to be consistent with
SIADH. The patient was initially fluid restricted; however this
was discontinued per the patient's request. His sodium was
trended and his hyponatremia resolved.
#. Urinary symptoms: Patient with PSA of 9 as an outpatient; he
is awaiting Urology follow-up at ___. Tamsulosin was started.
Patient tolerated this well, denying symptoms of orthostatics.
The patient was provided with prescription for this medication
and encouraged to follow-up with Urology as an outpatient as per
plan prior to admission.
Transition of care issues:
- follow-up alpha 1 antitripsin level (pending at time of
discharge)
- continuation of IV antiboitics through ___ line
- outpatient pulmonology follow-up | 179 | 611 |
10671331-DS-8 | 27,683,623 | you have facial skin infection
you are leaving against medical advice after the risks were
explained to you. you can lose your vision and cause severe
problems
please seek medical attention if you develop worsened symptoms
of redness, pain, headache, neck stiffness, visual changes | presented with left eye pain and swelling after she manually
lanced it and the pain/swelling has been getting and she came to
the ED where ophthalmo Fellow saw her and he stated that it is
not orbital cellulitis but it is pre-septal cellulitis. Patient
was hard to establish IV access and picc line was placed for
her. Patient is very eager to leave although her cellulitis was
not completely resolved. I discussed with her the risk of
leaving AMA including worsening of her infection to extend to
her neurological system or the risk of losing her eye but she
insisted on leaving and she does not want to stay in the
hospital. I informed her that her abscess around her eye need to
be drained and she refused any further treatment and she does
not want to stay, a prescription of Bactrim has been given and
she was informed that it is not full treatment for her eye
infection and she is aware and understands the risks | 43 | 168 |
13886615-DS-9 | 20,228,294 | Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___!
Why did you come to the hospital?
- Because you were having abdominal pain
What happened while you were in the hospital?
- You were found to have acute pancreatitis, for which you
received iv fluids and pain medication
- You were found to be in alcohol withdrawal and required
several doses of phenobarbital before you improved
- You were also found to have alcoholic hepatitis which
improved.
- Your diabetes was also noted to be poorly controlled and your
insulin regimen was titrated in the hospital. Please follow up
with your doctor for any changes.
- You were seen by our social worker who tried to offered
resources to help you maintain sobriety.
What should you do after you leave the hospital?
-REGARDING YOUR PAIN MEDICATION:
Please take dilaudid 4 mg every 4 hours for the rest of today.
Then tomorrow, take 2 mg every 4 hours.
Then on ___, take 2 mg every 6 hours.
Then on ___, take 2 mg every 8 hours.
Then on ___, take 2 mg every 12 hours and go for your
suboxone appointment.
- Please continue to work on staying sober! You know how
important it is, and we believe that you can be successful this
time.
- Follow up with your primary care doctor about your pain,
suboxone management and your diabetes
- Please schedule an appointment with our Liver clinic to follow
up on your alcoholic hepatitis and Hepatitis C
We wish you the best!
Sincerely,
Your ___ Care Team | Ms. ___ is a ___ female with h/o alcohol use
disorder, previous admissions for alcohol withdrawal requiring
IV phenobarbital as well as previous admissions for necrotizing
pancreatitis presents with alcohol withdrawal,
alcoholic hepatitis, and acute pancreatitis. | 249 | 36 |
13895514-DS-6 | 23,846,493 | Dear Mr. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
======================================
- You were having abdominal pain and had a CT scan that showed a
bad infection.
WHAT HAPPENED IN THE HOSPITAL?
===================================
- You were started on antibiotics.
- You were seen by the gastroenterologists who recommended that
you continue antibiotics and follow up with them as an
outpatient.
WHAT SHOULD I DO WHEN I GO HOME?
=================================
- You should continue your antibiotics.
- You should be receiving a call early this week to schedule a
colonoscopy.
- Please call your PCP, ___, to schedule follow up in ___
weeks.
Take care,
Your ___ Care Team | SUMMARY
===============
___ male with a history of GERD, peptic ulcer s/p vagotomy, and
sigmoid lipoma s/p partial sigmoid colectomy (___) who
presented with fevers and abdominal pain with features of
enterocolitis noted on imaging. He was started on ciprofloxacin
and flagyl with improvement in his symptoms. He was seen by
gastroenterology, who recommended outpatient colonoscopy for
further follow up.
TRANSITIONAL ISSUES
=====================
[] At time of discharge, patient did not have an outpatient
colonoscopy scheduled but had been ordered. Please confirm with
patient that this has been scheduled for the next few weeks
after he completes course of antibiotics.
[] Patient with " Marked wall thickening of the terminal ileum
in very distal ileum and wall thickening to a lesser extent
involving the cecum and proximal ascending
colon. 5 x 4.0 cm region of likely phlegmon superior to the
thickened terminal ileum." found on CT A/P. Recommend that
patient has a follow up CT or colonoscopy once the acute process
resides to ensure resolution and exclude underlying mass.
[] Patient discharged on ciprofloxacin and flagyl for a 10 day
course scheduled to end ___.
[] Patient found to be CMV IGM and IGG positive. Per GI, there
was no indication for antiviral treatment or colonoscopy at this
time because patient is immunocompetant. GI will follow with
outpatient colonoscopy.
[] Recommend outpatient vaccination for hepatitis.
ACUTE ISSUES
=================
# Terminal ileitis
He presented with 2 weeks of abdominal pain and intermittent
fevers and was found on imaging to have findings consistent with
terminal ileitis. This is typically associated with Crohn's
disease although there are other associated conditions such as
ulcerative colitis, infection or less likely NSAID ileitis. CRP
at admission was elevated to 179. He was started on cipro and
flagyl with improvement in his abdominal pain. GI was consulted
and recommended sending off serologies. At the time of
discharge, patient was noted to be CMV IgM positive, IgG
positive, EBV IgG positive. Per GI, since patient was
immunocompetant, they believed this was likely infectious and
recommended continuing antibiotics and setting up an outpatient
colonoscopy once the infection resolved.
# Mild normocytic anemia
Suspect reactive from illness however pt has prior hx of BRBPR
iso lipoma. Low iron. Hemolysis labs negative. No evidence of
active bleeding.
# Mild transaminitis
Initially presented with transaminitis that improved by
discharge. RUQUS negative for biliary process. Likely secondary
to infection as above. Hepatitis panels negative. | 100 | 396 |
13457677-DS-8 | 24,433,813 | You were seen following a fall after a bicycle ride. You
sustained multiple facial fractures for which you were taken to
the operating room with the Oral Maxillo-Facial Surgery service.
You tolerated your procedure and post-operative course well,
your packing was removed prior to discharge, and you are now
both voiding reliably and taking in enough liquids for
discharge.
You can have a full liquid diet as you had in the hospital.
Make sure you are taking in plenty of calories and protein; we
recommend taking nutritional supplements like "Ensure" three
times daily with meals to help make sure you are taking in
enough nutrition.
You may resume your regular level of activities but you must not
drive nor operate any other form of machinery while under the
influence of narcotic pain medicine like oxycodone. Do not take
more pain medicine than needed.
Take Keflex (cephalexin), an antibiotic, four times daily for 1
week as prescribed. Please resume all other prescribed
medicines you were taking at home before your accident. Take
pain medicine as needed but do not take more than you need and
NEVER operate a vehicle or other machinery while using narcotic
pain medicine. Use your prescription mouth rinse twice daily.
Use nasal spray as needed.
Please follow up in clinic with OMFS and also with occuloplastic
surgery as described below. You do not need to follow up with
the ___ clinic. | Mr. ___ was admitted to the ACS service with HPI as
stated above. He underwent imaging which revealed bilateral
___ I fractures, right LeFort II fracture, and left LeFort
III fracture. OMFS and ophthalmology were consulted. OMFS
determined that operative repair would require a substantial
block of OR time and so scheduled the case for ___.
Ophthalmology evaluated the patient and determined that no acute
ophthalmologic operative intervention was indicated but that the
patient should follow up with the Mass Eye and Ear Institute
department of occuloplastics. He was given a full liquid diet
as he was not expected to go to the OR immediately.
On ___, the patient was noted to have substantial facial
swelling secondary to his injuries and so he was placed on
continuous O2 saturation monitoring and transferred to the SICU;
his condition did not worsen and he required no additional
interventions. A tertiary survey on that day did not reveal any
new injuries. He returned to the floor on ___ and was kept on
full liquids.
On ___, a syncope workup was initiated. EKG and CXR on
___ were not acutely concerning for evidence of a cause for his
syncopal episode. A carotid ultrasound was similarly
non-concerning. Ancef was initiated on that day per ___
recommendations. A TTE on ___ did not reveal any clear cause
of his syncope but was reassuring for his appropriateness as an
operative candidate.
Mr. ___ went to the OR on ___ and underwent ORIF of
facial fractures of his facial fractures and he tolerated the
procedure well; for full details please see the operative
report. He remained intubated for airway protection in the
context of edema and went to the ICU post-op; he was extubated
on POD#1, went to the floor in good condition, and was resumed
on a full liquid diet.
He initially was unable to tolerate the liquid diet due to
difficulty swallowing as a consequence of the packing in his
nose. He remained on IV fluids for hydration. ___ was
involved in discussion of disposition and it was decided to keep
Mr. ___ in the hospital for the time being. Ultimately,
packing was discontinued by ___ on ___ in the early afternoon
and the patient tolerated a full liquid diet very well after
this action.
On the day of his discharge, foley was removed and the patient
voided multiple times successfully. It was noted that his right
antecubital fossa was inflamed and indurated at his former IV
site and so an ultrasound was ordered which revealed superficial
clot but no DVT; he was advised to apply moderate comfortable
heat to the area.
Discharge meds were prescribed and follow-up with ___ and
ophthalmology services in accordance with the recommendations of
these services. He will remain on chlorhexadine mouth rinse and
PO Keflex for 1 week.
Mr. ___ was discharged to home on ___ with
appropriate information, warnings, prescriptions, and follow-up. | 247 | 508 |
17561636-DS-16 | 20,968,296 | Dear Mr. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted on ___ due to abdominal pain. You underwent
an extensive work-up which found that you had a blockage in your
bile ducts (tubes that carry bile away from the liver) and this
led to an infection. You were given antibiotics and also
underwent a procedure to remove the blockage. You did very well
with this treatment and are now improved enough to return home.
Please be sure to follow-up at the appointments below. If you
develop any fevers, chills, abdominal pain, or other concerning
symptoms, please call your doctor right away. | Brief Narrative (more details below):
___ with history of presumed ETOH cirrhosis, GERD, BPH,
biliary colic s/p ERCP in ___ with sphincterotomy admitted
___ for recurrent right upper quadrant abdominal pain with
initial concern for cholecystitis. Given his Child ___ Class C,
he was deemed a high-risk surgical candidate and was therefore
managed medically with IV antibiotics. His pain persisted and he
began to develop low-grade fevers with rising T bili, so he went
for ERCP which revealed 2 stones in the Common Bile Duct which
were successfully removed with good drainage. Given these
findings and his clinical presentation, he was diagnosed with
cholangitis. He improved significantly after ERCP and with IV
unasyn and was subsequently narrowed to po ciprofloxacin. He
should continue on this ciprofloxacin through ___.
His blood pressure while inpatient was in the 90-100 systolic
range after resolution of his infection - likely due to poor
nutritional intake while hospitalized and amidst his acute
illness. For this reason, though, his home lasix/spironolactone
regimen and his new nadolol were NOT CONTINUED on discharge -
these should be re-addressed and possibly restarted at his
upcoming appointment on ___ ___.
Of note, he also underwent routine screening EGD for varices
while inpatient which discovered Grade I-II varices, no
intervention needed, with recommendation for nadolol
prophylaxis. He also underwent routine MRI screening which was
negative for HCC.
** TRANSITIONAL ISSUES **:
- continue ciprofloxacin 500mg po q12h through end of ___.
- check full labs (CBC, basic chemistries, LFTs) on ___ ___ - ensure stable liver function and also renal
function.
- on ___ ___ blood pressure should be
assessed to determine whether he is safe to restart his normal
lasix 40mg daily and spironolactone 25mg daily, as these are
HELD on discharge. Nadolol prophylaxis can also be re-addressed
since this was NOT STARTED on discharge due to his BP
- his home potassium supplements were HELD since his lasix is
being held as above. re-evaluate with his labs and if restarting
lasix as above as outpatient
- initiated HBV vaccine series on ___ - should complete routine
initial vaccination series with 2 more administrations
- iron/TIBC ratio noted to be elevated (116/174) - hereditary
hemochromatosis panel was ordered and should be followed-up
================================================================
___ with history of presumed ETOH cirrhosis, GERD, BPH,
biliary colic s/p ERCP in ___ who presents with right upper
quadrant pain found to have radiographic evidence equivocal for
acute cholecystitis, initially admitted to surgery service but
subsequently transferred to the liver service given high
surgical risk with subsequent development of cholangitis. | 105 | 413 |
16341066-DS-6 | 27,198,347 | 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 as listed below.
We also generally recommend that patients follow up with their
primary care provider after having surgery.
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. | Ms. ___ was admitted to ___ for abdominal pain. At CT
scan showed Appendix is fluid-filled and dilated to 1 cm
demonstrating wall thickening and adjacent fat stranding
consistent with acute appendicitis. She was taken to the
operating room that night for a laparoscopic appendectomy. She
improved through out the night. By morning she was able to
tolerate a regular diet. Her pain was well controlled. Upon
discussion with the pt concerning discharge it was noted the her
left pupil was dilated compared to the right. She had no visual
complaints at the time. A cranial nerve exam showed that both
pupils were reactive to light, with the left less so than the
right. Neurology was notified, and she was scheduled to visit
the neurology clinic as an outpatient. At the time of discharge
she was doing well. | 701 | 139 |
10795434-DS-31 | 27,393,389 | Ms. ___,
You were admitted to ___ for
care of advancing dementia. You will need further outpatient
management to help better care for you at home. It is very
important that you follow up with Dr. ___ ___ at 10am (see contact information below). | ___ with dementia here with FTT and hypokalemia. | 46 | 10 |
17257394-DS-17 | 25,013,348 | Mrs. ___ you were admitted to ___ for
evaluation of reported left sided sensory changes. You had a
full neurological workup which was negative for stroke and TIA.
We encourage you to continue to take your home medications, no
changes were made to your home medications. | Mrs. ___ is a ___ woman with a past medical
history and recent admission for dyspnea and chest pain, who
presents with a generalized feeling of being unwell, some
dyspnea on exertion, and acute onset of left V2 to V3 facial and
hemibody paresthesias that progressed into 50% decrease in
sensation. NIHSS was 1 for her sensory changes, otherwise
patient demonstrated good strength, no language deficits, no
dysarthria, and no cortical signs such as extinction or neglect.
Patient also has full visual fields and no asymmetry in her
smile.
Given the acute onset of paresthesias and numbness in the
hemibody distribution, she was worked up for TIA versus stroke
which was negative. No concern for metastasis to the brain.
There was no other evidence to suggest that the patient was
experiencing a seizure as there was no alteration in
consciousness nor any abnormal movements. The patient denied
paresthesias at the time of discharge.
Patient's left iliopsoas was slightly weak with signs of left
lumbar radiculopathy. There was numbness of the left lateral
thigh concerning for left lateral cutaneous neuropathy of the
thigh (otherwise known as meralgia paresthetica).
Hospital course by system | 46 | 194 |
11728692-DS-8 | 22,553,685 | You were admitted to the hospital with abdominal pain. You
underwent a cat scan which showed appendicitis. You were taken
to the operating room to have your appendix removed. You are
recovering from your surgery. You are preparing for discharge
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 hospital with abdominal pain.
Upon admission, the patient was made NPO, given intravenous
fluids, and underwent imaging. A cat scan of the abdomen was
done which showed a 7 mm appendix with slight wall thickening
and mild surrounding stranding. These findings were suggestive
of acute appendicitis. The patient was taken to the operating
room where she underwent an appendectomy. The operative course
was stable with minimal blood loss. The patient was extubated
after the procedure and monitored in the recovery room
The post-operative course was stable. The patient was started
on clear liquids and advanced to a regular diet. Her vital
signs remained stable and she was afebrile. She was
transitioned to oral analgesia for management of her incisional
pain. The patient was discharged home on POD # 1 in stable
condition. Follow-up appointments were made with the acute care
service. | 825 | 158 |
17982968-DS-33 | 27,641,485 | Dear Mr. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were having abdominal pain.
A CT scan of your abdomen showed some mild inflammation but
otherwise no evidence of a serious acute process. Your blood
tests were all reassuring. It is possible that you have a viral
infection or a small ulcer. You were treated with intravenous
fluids and some medications to settle your stomach.
.
In the emergency department you were also found to have a small
abscess on your abdomen that was drained. You were started on an
antibiotic called clindamycin for this. Please take the entire
course of the medication, even if you start to feel better. If
you experience increasing redness or pain at the site of your
abscess, please call your primary care physician or visit the
Emergency Department.
.
The following changes have been made to your medication regimen
Please START taking
- clindamycin (continue until ___
- omeprazole (to reduce stomach acid)
- maalox (to relief stomach pain and irritation)
.
Please take your medications as prescribed and follow up with
your doctors as ___. | ___ yo M with hx of HTN, IDDM, and R. BKA who presents with
abdominal pain x ___bdomen only showing mild
mesenteric stranding.
.
# Abdominal pain: Patient presented with abodminal pain x 1 week
with no associated n/v/d. In the emergency department, he
underwent CT abdomen which showed mild mesenteric stranding and
was given a dose of intravenous cipro and flagyl. Patient
remained afebrile without leukocytosis. Other labs including
lipase and liver function tests were within normal limits. Upon
arrival to the flood antibiotics were discontinued. Abdominal
pain thought to be due to viral etiology given known sick
contacts with GI symptoms. Also given the location and nature of
the pain, PUD vs gastritis was considered. He was treated with
IVF on the floor and his lactate improved. He was given a GI
cocktail and percocet for pain. H. pylori antibody was sent. At
time of discharge pain improved and he was able to tolerate
diet. He was discharged with maalox and omeprazole with plans to
follow up with his primary care physician.
.
# Cellulitis - Patient found to have small abscess on his RLQ
that was drained in ED, however cultures were not sent. The
surrounding skin was erythematous and warm. Given that patient
is a diabetic and that there was purulent drainage, clindamycin
was started for MRSA coverage. He was discharged with plans to
complete a ___nd follow up with his PCP.
.
# back pain - Patient with known chronic back pain. There were
no concerning symptoms for acute process on presentation. He was
continued on his home percocet.
.
# Hypertension - Patient remained normotensive during admission.
He was continued on his home lisinopril and amlodipine.
.
# IDDM - Blood sugars were controlled with sliding scale during
admission.
.
Transitional Issues
- H. pylori and blood cultures pending at time of discharge
- patient was full code on this admission
- contact: ___ (brother, HCP) ___ | 188 | 319 |
13874942-DS-21 | 21,441,406 | Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were initially
admitted to the hospital for concerns about your transplanted
kidney. During your hospital stay, you were given several rounds
of treatment to help prevent rejection of your transplanted
kidney. Unfortunately, with treatment your kidney function began
to worsen and we had to start dialysis. Before leaving the
hospital, we have changed your immunosuppression, and set you up
with dialysis as an outpatient.
You have surgery scheduled for fistula placement on ___,
___. Please arrive at the Main Entrance of the ___
___ at 8:15am. Please do not eat or drink anything past
midnight the night before the procedure.
Many changes were made to your home medication regimen, please
continue to take medications as prescribed. Please follow up
with your primary care physician and your transplant
nephrologist upon leaving from the hospital. We have also set up
appointments for you to meet with the transplant surgery team to
develop long-term solution for your dialysis.
Take Care,
Your ___ Team. | ___ year old male, with a history of ESRD ___ Alport Syndrome,
s/p LURT in ___ (from his wife), presenting with ___. Hospital
course complicated by BK viremia, and biopsy proven acute
humoral rejection.
.
>> ACTIVE ISSUES:
# Acute Humoral Rejection: Patient initially presented with an
increased creatinine, and there was question of rejection given
outpatient testing which was significant for low titer of donor
specific antibodies. Patient underwent a renal biopsy, and
repeat donor specific antibody testing, which revealed a > test
MFI. Further, BK testing done at that time also showed an
increasing BK viremia in both the serum and urine. Biopsy
results included a multitude of findings, including an acute on
chronic humoral rejection, with multiple crescenteric glomeruli.
Further, in the background of his acute rejection was BK
positivity on biopsy (SV40) as well. After much discussion
regarding treatment options, it was thought that patient should
be placed on high dose immunosuppression with both tacrolimus
and MMF. With increasing immunosuppression, patient started to
have increased hemolysis as well and thought to be ___ to
tacrolimus microangiopathy. Peripheral smears did show ___
schistocytes/HPF. Per acute rejection guidelines, patient was
initially started on plasmapheresis to remove donor specific
antibodies, and was replaced full FFP instead of half albumin
because of risks of bleeding with renal biopsy. Patient also was
started on high dose steroids at that time, and during
plasmapheresis sessions patient started to develop a cough
(reported below). Given concerns for aspergillus, and the risk
for invasive disease with higher immunosuppression, patient
underwent plasmapheresis and was transitioned to an IVIG load of
2 grams, with lower immunosuppression. Tacrolimus was also
discontinued in the setting of increased TMA with severely
elevated levels ___ to initiation of voriconazole. Patient
started to undergo dialysis sessions ___ to increased volume,
although urine output consistently stayed between 500-1L per
day. Patient eventually was transitioned to permanent dialysis,
with loss of his graft function, and was transitioned to a
regimen including low dose prednisone and MM sodium.
.
#ESRD s/p LURT : As described above, patient was transitioned to
dialysis during hospital stay after acute humoral rejection.
Patient underwent transplant evaluation for AVF, with vein
mapping bilaterally, and scheduled to undergo AVF after hospital
discharge. Plans for patient include home hemodialysis set up as
well in the future. Patient was discharged with negative
Hepatitis Serologies, and pending quantiferon gold for dialysis
placement.
.
# Pneumonia: As indicated above, patient started to develop a
cough during his plasmapheresis sessions, and initial imaging
showed a possible cavitary lesion. Patient was started on broad
spectrum antibiotics, however given concerns for invasive
aspergillus in the setting of higher dosed immunosuppression for
acute rejection, confirmatory testing with bronchoscopy was
performed. Patient's BAL did not show any evidence, and no
serologic evidence of fungi either. Patient was originally
started on amphotericin given interactions of voriconazole with
immunosuppression, however this was discontinued as suspicion
was low after testing. Patient was continued on Zosyn for 7 day
course, with resolution of cough and CT imaging showed
resolution of cavitary lesion.
.
# Hypertension: Patient was up-titrated to labetolol 200 mg TID
for better control as started to have both elevated diastolic
and systolic pressures. Patient tolerated dose adjustment well.
.
# Chest Pain: Patient was found to have acute chest pain, with
respiratory difficulty after bronchoscopy. He described this
pain as chest pressure, and since no DVT prophylaxis as risk of
bleeding with renal biopsy, initial concerns for PE. ABGs at
that time were significant for a resppiratory alkalosis (pH 7.8,
CO2 15). Patient underwent V/Q scan which showed low likelihood,
and LENIs which were negative for DVT. Patient also started to
have resolution with anxyiolitic, thought to be more panic
attack with pain ___ bronchoscopy.
.
# Gout: Patient was continued on allopurinol renal dose without
flare.
.
# History of C. diff: Patient would be classified as severe C.
diff in the past, and was finishing a course of PO vancomycin to
prevent recurrence. His course was extended given antibiotics
while inpatient and higher dose immunosuppression, and was
continued until ___ per ID recommendations. Patient did not
have diarrhea while inpatient and reported resolution of
symptoms.
.
# Anemia: Patient was found to be anemic several times during
hospital stay, requiring multiple transfusions. Anemia was
thought to be ___ to TMA evidenced by hemolysis and peripheral
smear findings. Further, patient's renal biopsy also
demonstrated thrombi as well. Patient also encountered a
dialyzer reaction, and therefore had an acute blood loss as
well. Patient's renal biopsy site was ultrasounded given
increased pain, but not significant for bleeding as well.
Patient remained hemodynamically stable, and will require checks
as an outpatient.
.
>> TRANSITIONAL ISSUES:# Dialysis: Set up ___. Plan for
transition to home HD
# TMA?: Concerns while inpatient for hemolysis, stable H/H.
Continue to trend as outpatient.
# C. diff: Patient completed course with PO Vanc, CTM for
diarrhea.
# CT Chest Imaging: Several bronchiolar nodules, f/u in 3 months
for resultion and tracking to compare (___)
# AVF: Patient to have AVF on ___ for planned hemo-dialysis.
# HTN: Up-titrated Labetolol 200 TID.
# Dialysis Placement: Quantiferon Gold pending upon discharge.
# ? Dialysis Rxn: Possible Dialysis Rxn to optiflux 180, but not
definitive. Please monitor. | 174 | 866 |
15444445-DS-4 | 20,274,957 | You were admitted to the hospital after being struck by a car.
You were thrown 20 - 30 feet and lost consciousness. Your
injuries include a left fibula fracture (smaller of the two long
bones connecting your knee to ankle) and a left flank (side)
hematoma. You were admitted to the intensive care unit after
the accident. You were transferred to the floor after you were
assessed to be stable enough for transfer. You are slowly
recovering and will need continuing rehab after your inpatient
stay.
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. | He was monitored closely in the TSICU. He was alert and
responsive. He had a L flank hematoma and his hct was monitored
closely, it was stable. His diet was advanced but he had a
possible aspiration event. His o2 sats remained stable, however,
in the low ___. He was placed on metoprolol for his tachycardia.
He was restarted on his home anti-seizure medications. He had a
speech and swallow consult.
Patient was transferred to the floor once stable. He remained on
the floor and was doing well until the evening of ___ when he
began to become agitated, stating "I've had enough," and warning
that he would leave that night despite knowing that his primary
team did not think it was wise. Pt was also aware that he was
likely to be discharged to rehab the following day. The intern
on call had multiple conversations with him totaling about 30
minutes explaining the risks of leaving against the team's
advice in his condition (requiring 4L of oxygen d/t severe COPD
and incomplete transition to rehab). As patient was ambulatory
at this time, he proceeded to walk out of floor despite advice,
after all lines were d/c'd. He was directed towards the lobby at
this time and left hospital. | 129 | 210 |
16540367-DS-21 | 23,646,284 | Dear Ms. ___,
You were hospitalized due to symptoms of confusion resulting
from a hemorrhagic STROKE, a condition where there is a bleed in
the brain resulting in parts of the brain not getting enough
oxygen. 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. You then proceeded to have a seizure.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Diabetes
- High blood pressure
We are changing your medications as follows:
- We are stopping your aspirin
- We are holding your atorvastatin
- We added Keppra 750mg BID for seizure prevention
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 | Ms. ___ is a ___ year-old woman with diabetes, HTN, and HLD
who presented from ___ after she was found down with
left sided weakness, aphasia, and forced left gaze followed by
convulsions consistent with GTC.
#Neuro: Subarrachnoid hemorrhage with GTC:
At OSH stroke code called followed by telestroke. While on
telestroke, observed to have GTC. She was given Ativan with
resolution, loaded with fosphenytoin, and given IV labetalol for
SBP >220. She was intubated and transferred to BI. Initial CT
head showed no hemorrhage. Repeat head CT in ICU showed she had
a right frontal subarachnoid hemorrhage in the right sylvian
fissure. CTA negative for any large vessel occlusion.
Conventional angio done with no vascular malformation found. MRI
done with no evidence of metastatic disease given history of
breast cancer. She was hooked up to EEG with no further
epileptiform discharged. She was started on keppra 750mg BID for
further seizure prevention. Etiology likely underlying CAA
causing SAH which then led to seizure. She was transferred out
of the ICU to the floor. Initially issues passing swallow study
therefore requiring NG feeds for a few days. Video swallow was
passed and diet was advanced. She continued to improve with ___
and OT on the floor and was deemed ready for DC to ___
rehab.
#Uncontrolled Diabetes:
While in the ICU she was put on an insulin drip given
uncontrolled blood glucose. She was transitioned to standing
glargine dose with Joseline Diabetes team following closely.
Glargine dose with increased periodically given persistently
elevated blood glucose.
#HTN:
Elevated BPs above 200 and nicardapine drip in ICU. BPs
regulated and home losartan restarted at 50 then increased to
100. Coreg added for additional BP control.
# UTI:
found to have leukocytosis while in ICU. Started on CTX
empirically. Found to have an E. coli UTI. Switched to
nitrofurantoin and completed a 7 day course.
# vaginal discharge:
found to have significant vaginal discharge while in ICU.
Started on 7 day course of
miconazole nitrate vaginal cream. | 296 | 332 |
10253919-DS-11 | 20,517,461 | You were admitted to the hospital with severe infection of your
leg and urine. You were treated in the intensive care unit
followed by treatmet for cellulitis (infection of the leg).
With antibiotics your symptoms improved although significant
amount of swelling and redness in your leg persisted.
You were given water pills to help get rid of some of the water
in your legs. In addition, you required wrapping of your legs
with ACE bandages to help get rid of the fluid.
The following changes were made to your medications.
STARTED:
- Furosemide 20mg daily for one week
- Keflex ___ three times daily
- Potassium 20 meq daily for one week
STOPPED:
- Hydrochlorothiazide
- Lisinopril (until you complete your furosemide)
Please ensure that you elevate your legs daily and wrap them
with ACE bandage.
Should you develop any symptoms concerning to you, please call
Dr. ___, ___ or go to the emergency room.
You have an appointment with Dr. ___ at the end of
___, but his office will contact you to set up a follow up
within the next week. If you don't hear from him by middle of
next week, please call his office.
Please also obtain labs to check your coumadin level next week. | Assessment and Plan: Mr. ___ is a ___ with afib/flutter,
and ?previous DVTs who presents with RLL pain/erythema and who
was found to be profoundly hypotensive with bandemia and ___.
# SEPTIC SHOCK: Felt to be due to cellulitis and possible UTI.
Received ~ 8 liters NS for fluid resuscitation and was on
norepinephrine briefly. Started on vanc/cefepime for cellulitis
and presumed UTI. Urine culture was negative, but tx for seved
days with Ciprofloxacin as culture was obtained after antibiotic
administration. He remained in intensive care unit overnight
only.
# Cellulitis. Initially well responded to vancomycin, however
given negatie nasal swab and no evicence of abcess, was changed
to ___ was negative.
Slow but steady improvement in erytheme and induration was made
and he was transition to PO Keflext on ___. He was diuresed
with lasix for lower extremity edema and was discharged on a
week's course of lasix. ACE bandages are to be applied on daily
basis at time of discharge.
# ACUTE KIDNEY INJURY: due to hypoperfusion. Improved to 1.2
(baseline 1.1 with IVF). Lisinopril was held at discharge until
patient completes course of lasix at which point it can be
reinstituted. HCTZ was likewise held at discharge.
# ATRIAL ARRHYTHMIA: has both atrial flutter and fibrillation
patterns in previous EKGs/telemetry. According to cards notes,
spends about 35% time in atrial arrhythmia. During his ICU
stay, he remained often in atrial fibrillation although
occasionally was atrial paced or venticular paced. As patient
was diuresed his rate normalized and he remained in SR vast
majority of the time. | 206 | 271 |
14386417-DS-22 | 23,391,764 | It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had recent
episode of diarrhea, had fatigue, and were generally feeling
unwell.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You were found to be in hear failure, which led to markedly
reduced the blood perfusion to the vital organs of the body.
-You were given medications to treat heart failure, and to
improve heart function.
-You underwent kidney replacement therapy while in the CCU to
remove excessive fluid
-For atrial fibrillation, you underwent a procedure to change
the rhythm back to normal, but this did not work. Then you had a
procedure to change the electrical conduction in your heart,
which fixed the irregular fast rhythm.
-You were evaluated by physical therapy, who felt that you
should be discharged to a rehab facility for continued therapy.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor if your weight
goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 139.55 lb. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team | Ms. ___ is an ___ year old female with atrial fibrillation
on apixaban s/p multiple DCCVs and recent PPM placement, CML in
remission, DMII, CVA with left hemianopia, HTN, PVD s/p
bilateral lower extremity interventions, and history of C diff
who presents with diarrhea, generalized malaise, weakness, and
poor PO intake and was found to have heart failure exacerbation
and uncontrolled afib. She was treated in CCU for cardiogenic
shock and renal failure with improvement in cardiac function and
hemodynamics. She will be discharged to rehab for treatment of
deconditioning. | 238 | 91 |
15175429-DS-18 | 22,096,802 | Dear Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because of
chest pain and found to have a small blood clot in your right
lung. You were treated with blood thinners. You were continued
on your antibiotics for your blood and spine infection. You had
an ultrasound of your PICC line to make sure that this was not
the source of the clot in the lung. You also had a
transesophageal echocardiogram which did not show any evidence
of active infection in the heart at this time.
Your antibiotics should continue through ___. | ___ w/ Hx of IVDU who presented in ___ w/ serratia bacteremia
and aortic valve vegetations causing severe AR, s/p Aortic Valve
replacement (___) and discitis/osteomyelitis on MRI (___),
on 8wk course of Meropenem/Gent (through ___, who
re-presented on ___ w/ L pleuritic chest pain, found to have
small right subsegmental PE. | 104 | 52 |
12504826-DS-22 | 24,603,912 | You were admitted to ___ on ___ for gallstone
pancreatitis. You received an ERCP with sphincterotomy and
stone removal. You have recovered well and are ready to return
home to continue your recovery there.
MEDICATIONS: Continue all medications you take at home.
ACTIVITY: Continue to follow activity restrictions as
recommended by Dr. ___. Otherwise, you have no restrictions
on your activity. | Patient was admitted to the hospital for ERCP after having acute
pancreatitis episode related to choledocholithiasis. He
underwent ERCP and had stone and sludge extracted from the CBD.
After ERCP his labs trended down appropriately and his pain was
much improved. He was started on a diet the day after the ERCP
and was discharged after tolerating this. At time of discharge
he was voiding, had no abdominal pain, and was voiding. | 62 | 72 |
14360319-DS-12 | 28,673,850 | You were admitted to ___ after sustaining a fall. Your
injuries were addressed, and you are now ready for discharge.
Activity:
You may perform all your regular activity as tolerated. Please
remember to take pain medicine to make moving easier.
Please call the Orhtopaeidic Spine clinic at ___ if you
develop any numbness, tingling, weakness, pain not relieved by
pain medication, or any other symptoms that concern you. | Briefly, Mr. ___ was admitted to ___ after falling from the
___ step of a ladder. He was found to have L3 and L5 vertebral
compression fractures on imaging, was evaluated by the
orthopaedic spine team, and had serial lumbar spine films which
showed stable fractures on imaging. He was initially placed on
bedrest, his activity was advanced after his spinal injuries
were cleared by the spine team. He was tolerating a regular
diet, and he had a stable pain control regimen on oral
medication. He was discharged in good condition after being
cleared by both ___ and OT with follow-up scheduled in the
outpatient spine clinic. | 67 | 107 |
16545345-DS-20 | 28,783,774 | Dear Ms. ___,
You were admitted to ___ because you were having shortness of
breath. You were seen in the emergency room and found to have
the flu along with blood clots in your lungs.
We treated you for a COPD exacerbation exacerbation with
prednisone and azithromycin. We also treated you for the flu
with Tamiflu. You will take each of these medication for a 5 day
course to end on ___.
We started you on a blood thinner medication to treat the blood
clots in your lungs called apixiban. You should take 10mg twice
a day for the next 5 days followed by 5mg twice a day after
that.
You were also found to have high blood pressure in the hospital.
We started you on a medication called lisinopril. You should
continue to take this medication daily until you meet with your
primary care physician.
Please return to the hospital if you have worsening shortness of
breath, fevers, chest pain, or leg swelling.
It was a privilege taking care of you and we wish you the best.
Sincerely,
Your ___ Team | Ms. ___ is a ___ with MGUS and Stage 1a uterine cancer s/p
hysterectomy who presented to the ED with dypnsea and tachypnea.
She was found to have influenza A and multiple
segmental/subsegmental pulmonary emboli. She was treated for an
asthma/COPD exacerbation with prednisone and azithromycin. She
was treated for influenza A with apixaban 10mg BID. She will be
transitioned to abixipan 5mg BID after the 1 week loading dose.
Given concern for malignancy causing pulmonary embolus with
patient's prior history of malignancy she underwent CT torso
without evidence of malignancy. Also had repeat FLC that showed
slightly increased levels compared with ___ with increased
Fr-K/L ratio. She will have follow up with oncology as an
outpatient, but no active signs of malignancy.
# Asthma exacerbation ___ Influenza A:
Patient with influenza A which has likely triggered asthma
exacerbation with diffuse wheezing. Also found to have pulmonary
embolism on CTA. She was treated with oseltamivir, azithromycin
and prednisone, each for a 5 day course. She was also treated
with duonebs and albuterol. She should continue nebulizer
treatments as an outpatient.
- oseltamivir for 5 days [___]
- azithromycin for 5 days [___]
- prednisone 40mg daily [___]
- duonebs PRN
- albuterol PRN
# Pulmonary emboli:
Noted on CTA to have multiple segmental and subsegmental emboli.
History of MGUS and uterine cancer, but denies prior thrombosis,
family history of blood clots, personal history of spontaneous
abortions, or recent travel. Admits to sedentary lifestyle. CT
torso without evidence of active malignancy. SPEP with elevated
serum FLC compared to prior with elevated Fr K/L ratio. Appears
trending towards smouldering myeloma. A skeletal survey was
deferred given absence of bone pain. She will be continued on
apixaban 10mg BID for 7 day loading dose to end on ___, followed
by apixaban 5mg daily.
# MGUS: Patient with M-spike on SPEP from ___ with free kappa
37.6 and free lambda 29.7, increased from ___. Concern for
progression given bilateral segmental/subsegmental pulmonary
embolism. Will have follow up with oncology as an outpatient.
FreeKap ___ FreeLam ___
Fr-K/L: 1.69
IgG 1059
IgA 429
IgM 33
# Multi-nodular thyroid:
CTA showed enlarged heterogeneous thyroid gland containing
calcification and extending to the upper mediastinum. Had prior
u/s in ___ that was unchanged along with iodine uptake scan in
___ that was not concerning for cancer. Thyroid ultrasound
during this admission without suspicious imaging with
recommendation for f/u in ___ year.
# GERD
Continued on omeprazole
# PVD
Continued on aspirin
Transitional Issues
====================
[] Started on apixiban for treatment of pulmonary embolism. Will
continue on 10mg BID for 7 day load to end on ___ followed by
5mg BID. She should be treated indefinitely given unprovoked PE.
[] C/w azithromycin, prednisone, oseltamivir for 5 day course to
end on ___
[] Patient will follow with her oncologist regarding progression
of MGUS with increasingly elevated Fr-K/L ratio.
[] Repeat thyroid ultrasound in ___ year to assess for stability
[] Follow-up CT chest in 3 months is recommended to establish
stability given less than 3 mm multiple pulmonary nodules in the
setting of known malignancy.
[] Patient had significant hypertension in house and was
discharged on lisinopril 10mg daily
Greater than 30 minutes were spent on this patient's discharge
day management. | 182 | 531 |
11080338-DS-14 | 29,840,787 | It was a pleasure taking care of you while you were here at
___. You were admitted after being transferred from an
outside hospital where you were taken after having an episode of
unresponsiveness. You were also having severe back pain. An
MRI of the back was performed which found no acute new lesions
of the spine that would cause the back pain, but did find
infiltration of the bone by myeloma. You had a CT scan of your
head which was normal. You were seen by the oncology team who
indicated that there was no indication to start systemic
treatment. You had a chest CT scan which showed pneumonia and
you were started on antibiotics with a planned course of 8 days,
starting ___. A PICC line was placed so that you could be
discharged with IV antibiotics. | ___ w/PMHx multiple myeloma, arthritis, and spinal stenosis
presenting with complaints of poorly controlled back pain, acute
changes in mental status and failure to thrive, now with chest
CT showing consolidation vs. atelectasis on left, with possible
evolving right infectious process on right.
ACTIVE ISSUES
1 Goals of care: After extensive discussion with the patient's
son ___ and daughter (and HCP) ___, the decision was made
to transition to comfort measures only. Antibiotics were
discontinued and medication list was reviewed with unnecessary
medications removed (Simvastatin, vitamin D). The patient was
discharged to skilled nursing with inpatient hospice care. Goals
of care are comfort measures only, DNR/DNI, do not hospitalize
unless symptoms are not controlled with hospice care.
2. Healthcare Associated Pneumonia: Left pleural effusion
discovered on chest x-ray early in admission. After review of
patient's outside CT scans, no effusion was present in CT of ___, only an area of rounded atelectasis on the right. With
these findings, chest CT was performed and possible infectious
process was found on the right, with large areas of
consolidation vs. atelectasis on the left. It was thought that
these areas could likely represent pneumonia in the setting of
this patient who had been persistently delirious and has a
history of stay in a ___ care facility for the last
several months, who is likely to have aspirated, and likely does
not mount a large immune response. He was started on treatment
for presumed HCAP with vancomycin, cefepime, and metronidazole
to be continued for an 8 day course starting ___. After
goals of care discussion, antibiotics were discontinued ___.
PICC line was removed prior to discharge.
3. Altered mental status: Per the patient's family, he had
experienced a decline in mental status after his kyphoplasty
several months ago with a possible history of stroke, however,
his mental status had become acutely worse over the week prior
to admission. CT of the head revealed no acute process, but did
show evidence of chronic ischemic changes. Narcotics were
minimized with the thought that these were contributing to his
delirium. The patient was found to be hypercalcemic to 10.7 and
this was thought to be a possible cause of AMS. Oncology was
consulted and noted that this level of hypercalcemia was not
dramatic enough to cause AMS of the degree seen in this patient.
Other oncologic causes, including hyperviscosity and uremia
were also ruled out. Per oncology, there was no clear
indication that myeloma could be causing this AMS. Medication
effect from over sedation with oxycodone was thought to be a
large part of the etiology for delirium and the patient was
treated conservatively for pain, limiting narcotics.
3. Mutiple myeloma: The patient and family history on this topic
were vague; the outside oncologist Dr. ___ was called to
clarify. Per Dr. ___ patient was discovered to have
an isolated plasmacytoma at L3 in ___, which he was
treating with palliative radiation, with the possibility of
definitive treatment as this was thought to be his only lesion,
and he was thought to be free of systemic disease based on an
unremarkable skeletal survey. The patient had never received
chemotherapy for myeloma, nor had he had bone marrow biopsy.
IgG on ___ was 2500 with elevated kappa spike 27.2. However,
on lumbar MRI performed to evaluate back pain on this admission,
systemic disease was suggested by infiltration of the spine
consistent with extensive myeloma. Oncology was consulted who
noted that there was no urgent indication to treat the patient
for myeloma at this time and that myeloma was not likely to be a
contributing factor to his AMS. Repeat IgG was 2665 and Beta 2
microglobulin was elevated at 3.4. Skeletal survey showed no
definite lytic lesions. At the time of discharge, UPEP, serum
viscosity, and Free kappa and lambda light chains were still
pending and should be followed by the outpatient oncologist
depending on goals of care.
4.Back pain: The patient has a longstanding history of back pain
as well as surgery on the spine with most recently being
kyphoplasty in ___. However, this pain seemed worse.
Lumbar MRI was performed which did not reveal any obvious cause
for his pain but did show an ill-defined region of abnormal
density in the pre-coccygeal/pre-sacral area. The spine service
was consulted who reviewed the MRI with the neuroradiologist and
found no involvement of the spine by the presacral tissue
abnormality. The chronic pain service was also consulted. For
pain, the patient received: tylenol ___ tid, gabapentin 300mg
TID, oxycodone 5mg q6hours PRn, as well as morphine ___ IV prn
q8hrs for breakthrough pain. Narcotics were minimized due to
contribution to delirium. His neuropathic pain with
sciatica-like features improved. However, the patient had
difficulty communicating his overall pain effectively due to
delirium and consistently rated his pain low on a severity
scale.
5. Aspiration: Nursing raised concern for aspiration. Speech and
swallow study was performed with recommendations for
nectar-thick liquids and ground solids.
CHRONIC ISSUES
1. Glaucoma-stable on brimonidine and dorzolamide.
2. ___ esophagus-stable on omeprazole.
TRANSITIONAL ISSUES
UPEP, serum viscosity, and free kappa/lambda light chains are
still pending at discharge and should be followed up by the
outpatient PCP and oncologist
CODE STATUS DNR/DNI, Comfort measures only. Do not hospitalize. | 145 | 886 |
10919141-DS-34 | 20,194,235 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were having fevers.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were diagnosed with acute influenza (the flu).
- You were given medication to help reduce the severity/duration
of your infection.
- You had a CT scan of your brain, which was normal.
- You were given intravenous fluids.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below, please
call your primary care doctor or go to the emergency department
immediately.
We wish you the best!
Sincerely,
Your ___ Team | Patient is a ___ with history of atrial fibrillation on
apixaban, type 2 diabetes c/b neuropathy with diabetic foot
ulcers, chronic diastolic CHF, and CKD Stage III who presented
with fever and hypoxia, found to have acute influenza A
infection, course complicated by altered mental status (most
likely toxic metabolic encephalopathy), hypernatremia, and
recurrent fevers/persistent hypoxia with supplemental oxygen
requirement. Now completed Tamiflu and on room air. | 135 | 68 |
15820378-DS-4 | 22,550,318 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted for treatment and evaluation
of nausea, vomiting and fever shortly after discharge from a
prolonged hospitalization for esophagitis due to treatment of
your cancer. You were restarted on medications to treat your
pain and nausea. You were evaluated by the Palliative Care team
who helped to treat your pain.
Please follow-up with your outpatient providers as instructed
below. You have a follow up in 1 week with oncology. Please try
to cut back on your opiates over the course of the upcoming week
as discussed with the palliative care team. Try not to take more
than 5 doses per day.
Thank you for allowing us to participate in your care. All best
wishes for your health.
Sincerely,
Your ___ medical team | ___ yo man with esophageal cancer on chemo and s/p XRT with plans
for esophagectomy at some point who was just discharged from my
service yesterday ___ after a 5 week hospitalization where he
was managed for radiation esophagitis, s/p J-Tube
placement, HA-PNA s/p completed course of ABx and intractable
nausea and vomiting with intolerance to tube feeds who was
readmitted from nursing facility <12 hours from discharge with
recurrent symptoms and isolated fever.
# Fever
# Abdominal pain
One isolated fever to 101 without new or focal symptoms. Seems
that the fever was an adrenergic response to severe abdominal
pain and nausea while at ___. During his course he had no focal
findings on exam and no localizing symptoms other than chronic
issues and with stable labs without leukocytosis. CT A/P, CXR,
UA, Flu swab and Cdiff PCR all negative. BCx and stool Cx NGTD.
He remained hemodynamically stable without signs of sepsis
throughout his course without need for antibiotics.
# Radiation Esophagitis
# Stage III-IV esophageal cancer on chemo s/p XRT
# Moderate Malnutrition: No PO intake, albumin 3.0 during prior
admission, peripheral muscle wasting on exam.
# Nausea with vomiting
Overall he appeared stable, pain and nausea controlled and at
baseline from prior to last discharge. As per prior work up and
documentation from last admission, radiation esophagitis was
confirmed on biopsy EGD ___. His last admission pain was very
difficult to control following J tube placement and he required
high dose IV Morphine which was changed to PO solution AND SC
morphine. Prior to discharge he was only requiring oral morphine
solution. Recurrent severe pain at ___ was likely related to
missing several doses of morphine and being underdosed from what
he was receiving at ___. Furthermore, nausea and vomiting were
best controlled at ___ when zofran and compazine were
staggered Q4 Hr. While at ___ seems he did not receive any
antiemetics, this likely accounted for worsening symptoms rather
than new acute pathology. During his admission he had no
evidence of worsening diarrhea, fevers, chills or leukocytosis
to support infectious etiology. No abdominal tenderness on exam
and normoactive bowel sounds, CT A/P negative and passing
flatus, SBO highly unlikely. Cdiff and stool cultures all
negative. Continued continuous tube feeds at 70ml/hr as per
prior hospitalization, restarted Ondansetron Q8H and Compazine
Q8H standing and stagger within 4 hours of each other. EKG
monitored and QT remained around 425. Continued Fentanyl 25
mcg/patch for basal pain control, Omeprazole, liquid
acetaminophen, sucralfate slurry, lidocaine patch as during
prior admission. Continued also
Maalox/diphenhydramine/lidocaine/levsin. Continued 10 mg oral
morphine solution q2hrs initially as recommended by palliative
care which was tapered to Q3HRS:PRN in conjunction with
palliative care recs. On discharge the plan was to continue
weaning to Q4HRs:PRN, this was communicated to outpatient
providers by palliative care.
# Hyponatremia
Mild and consistent with prior values during last admit. Likely
hypovolemic from vomiting, resolved with IVFs.
# Anemia:
# Leukpenia
Stable on admission from prior to discharge, downtrended in
setting of IVFs but remained stable therafter. Likely related to
chemotherapy, radiation and chronic disease, not neutropenic and
without signs of blood loss.
# Opiate use disorder:
History of and no longer active. For now priority is achieving
pain control for his severe esophagitis as before then discuss
weaning opiates in conjunction with palliative care. Morphine
tapering should continue as discussed in notes and in discussion
with palliative care, high risk for addiction. | 147 | 600 |
19819468-DS-21 | 24,055,855 | Dear Mr. ___,
It was a pleasure caring for you at ___.
You were admitted for management of infected fluid in your lung.
You received an imaging study (CT Scan) that showed new pockets
of infected fluid in your lung. A medication was placed in your
chest tube to help release this fluid. You will continue your
home antibiotics until your follow-up appointment with the
Infectious Disease clinic. Please also follow-up with your lung
doctors (___) on ___.
Best wishes,
Your ___ Team | Mr. ___ is a ___ year old male h/o SCLC s/p XRT ___ years ago,
HTN, afib on apixiban, gout recently admitted with complicated
R-sided empyema and presented from ___ clinic for management of
worsening hydropneumothorax and new loculations of this known
empyema. He was recently treated with 6 week course of
ceftriaxone and placement of a chest tube for drainage of the
empyema. Previous pleural fluid culture grew S. pneumo. CT scan
obtained in ___ clinic on the day of admission showed loculations
of the empyema, and he was sent to ___ ED. ___ was held
and TPA placed in the chest tube X 3 with good effect. He was
restarted on a 6 week course of CTX. He was mildly tachycardic
on admission but this resolved with home metoprolol. Plan for
patient to follow-up in clinic regarding continued care of this
complex loculated hydropneumothorax.
Active Medical Issues
======================
#Empyema: Patient presented from ___ clinic for management of
worsening hydropneumothorax and new loculations of this known
empyema. He was recently treated with 6 week course of
ceftriaxone and placement of a chest tube for drainage of the
empyema. Previous pleural fluid culture grew S. pneumo. CT scan
obtained in ___ clinic on the day of admission showed loculations
of the empyema, and he was sent to ___ ED. The patient was
evaluated by Infectious disease who recommended repeat 6 week
course of CTX (anticipated end date ___. Apixiban was held
and TPA placed in the chest tube X 3 with good effect. Of note,
chest CT showed a new mass highly suspicious for recurrence of
small cell lung cancer, which may explain the etiology of the
patient's persistent empyema. Plan for patient to follow-up in
clinic regarding continued care of this complex located empyema
and further workup of lung mass.
#Sinus tachycardia: Patient with history of sinus tachycardia
and Afib. Had afib and pauses on telemetry ___ seconds) on his
last admission at ___. On this admission, found to be in sinus
tach, resolved with resumption of home metoprolol. HD stable.
Home ASA and apixaban were initially held iso tPA infusion,
restarted upon discharge. Home diltiazem was stopped given
patient had intermittent low BPs during hospital course.
#Pericardial effusion: Pt w/ persistent small pericardial
effusion since at least ___, per previous notes.
Patient with tachycardia, however pressures normal and stable w/
negative pulsus paradoxus. TTE on ___ and ___ also
showed very small pericardial effusion, without
echocardiographic signs of tamponade. Patient did show evidence
of new epicardial edema on CT scan ___ concerning for
pericarditis, but patient asymptomatic and EKG w/ no e/o
pericarditis.
Chronic Medical Issues:
=======================
#Gout: Patient notes several acute gout exacerbations per year,
most recently involving L knee. Continued home allopurinol.
#COPD: continued home inhalers, albuterol prn
#HLD: continued home simvastatin, home fenofibrate
#HTN: continued home quinapril, continued home spironolactone. | 79 | 486 |
19774387-DS-33 | 28,115,555 | You were admitted to the hospital after vomiting with aspiration
and were treated with antibiotics with improvement in your
symptoms. You experienced some confusion while in the hospital
which improved. You were discharged to ___ for
rehabilitation. | Mr. ___ is a ___ year old male, with prior history of
aspirations by history, CAD s/p CABG, who presented to ___
acute respiratory distress and hypotension after vomiting.
ACUTE ISSUES
# Sepsis ___ Aspiration Pneumonia: Patient briefly febrile with
leukocytosis on admission. Lactate elevated and there was a new
infiltrate noted in b/l bases concening for aspiration pneumonia
vs pneumonitis. Hypoxic on arrival, briefly requiring NIPPV, but
rapidly down-titrated to NRB and then NC. Initially treated with
vancomycin/zosyn. Zosyn later changed to cefepime/metronidazole
given a penicillin allergy and vancomycin discontinued. After
24 hours, patient no longer had on oxygen requirement, was
afebrile, had appropriate urine output and lactic acidosis had
resolved. Patient's blood pressures remained lower than reported
baseline however improved and home bblocker was restarted. He
was called out of the ICU where he was transitioned to
levo/flagyl with continued improvemnt. ___ompleted while in the hospital.
# Aspirations: Patient with aspiration pneumonia in the setting
of recurrent aspiration and dysphagia. Originally evaluated by
speech and swallow who recommended he remain NPO, but on
re-evaluation he was deemed safe to place on a modified diet.
On further discussion with the patients family, they do not want
to pursue further w/u for this. Per family request, patient was
seen by palliative care in the hospital for discussions about
end of life and DNH, however ultimately pt was discharged to
rehab with ongoing discussions about goals of care.
# Delerium: pt with AMS while in the hospital, likely due to
infection. Pt was aaox 3 throughout and was improved at the
time of discharge although is intermittently somnolent.
# Heart Failure with preserved EF: Patient appeared euvolemic on
examination. BNP 465 on admission, not concerning for
exacerbation of diastolic CHF.
# ___ on CKD: Patient with baseline creatinine of 1.3, presented
with 1.8. Improved with IVF hydration to 1.4.
# Paroxysmal Atrial fibrillation: Occured in the setting of
infection, no recurrent tachycardia. | 39 | 321 |
19888315-DS-22 | 28,965,100 | Dear Mr. ___,
You were admitted to the ___ Inpaitient Neurology Service for
an episode of being unable to speak correctly. You had a
similar episode in ___. At that time, the MRI of your
brain was negative for stroke. However, this time, your MRI
showed a stroke in the left side of your brain in a part called
the temporal lobe. We have continued your blood thiner,
Coumadin, to help prevent further strokes. We have also
continued your cholesterol lowering medication, Atorvastatin.
We have also increased your seizure medication because we are
unsure if your previous episode was a seizure and if you had a
seizure preciptated by a stroke this time. Due to the
possibility of seizures, do not drive for the next 6 months.
Please follow up with your primary care doctor and your
neurologist.
Sincerely,
Your ___ Neurology Team | Mr. ___ is an ___ year old left handed man who presented with
isolated global aphasia similar to a prior MRI-negative episode
in ___ thought to be seizure vs stroke.
Initially, given the exam and the identical nature of his
current aphasia to an MRI-negative spell in ___, seizure
was higher consideration than stroke. However, EEG showed no
epileptiform activity. It showed left greater than right
slowing. Previous EEG showed right greater than left slowing.
However, due to the clinical suspicion for seizure, whether of
unknown etiology or secondary to stroke, we have increased his
Keppra 1000mg BID. Although the initial CT was negative, an MRI
showed a small posterior insular cortex. His stroke risk
factors have been assessed. He is currnetly on Atorvastatin
40mg qday. His last LDL was 66. He has afib and is currently
on Coumadin 2mg with theurapeutic INRs. His INR on discharge
was 3.1. His INR will continue to be trended by his primary
care doctor. We were going to obtain an Echo since his last
Echo was ___, however, the result will not change management.
He will follow up with his outpatient Neurologist.
In regards to pulmonary, Mr. ___ had some wheezing on inital
exam that improved throughout the hospital course. He had a CTA
that showed bronchiectasis visualized in the upper lungs with
apparent new bronchial wall thickening compared to ___, which may represent superimposed infectious/inflammatory
process. Mr. ___ did endorse a recent viral illness.
Additionally, Mr. ___ was found to have pancytopenia of unknown
etiology. The pancytopenia improved over the course of the
hospitalization. He will follow up with his outpatient primary
care doctor. | 148 | 291 |
11363157-DS-16 | 20,971,867 | Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
after you injured your arm and it became infected. You were
treated with antibiotics and had surgical removal of the
infected tissue. We also adjusted the medications you are taking
to prevent strokes. We are discharging you to rehab so that you
can regain your strength.
Take care, and we wish you the best.
Sincerely,
Your ___ medicine team | BRIEF SUMMARY
=============
Ms. ___ is a ___ with a PMH of A-fib on warfarin, R MCA
stroke, HTN, and dementia who presented to ___ with falls and
injuries to her left arm. She was found to have evidence of
necrotizing fasciitis of the left arm likely secondary to a
wound sustained after a recent fall. She was admitted to the
plastic surgery service and underwent significant debridement of
the left arm from above the elbow to the dorsum of the hand,
with a washout several days later and skin grafting a few days
later. Her initial operation was complicated by Afib w/ RVR, and
she required an ICU stay for BP support. After achieving stable
vitals, she was transferred to the floor. For the
supratherapeutic INR, she was given FFP and vitamin K. She was
continued on her metoprolol for her Afib, but subsequently
developed bradycardia, which held stable until discharge. She
was started on Apixaban for anticoagulation and was discharged
to rehab after her wound vac was taken down.
ACUTE ISSUES
============
#L elbow necrotizing fasciitis: The patient was recently
hospitalized at ___ for a supratherapeutic INR ___ the setting
of poor PO intake. After discharge, she suffered several falls
resulting ___ a wound on her left elbow, which became
progressively more reddened and swollen. The day prior to
presentation, she noted blisters on her forearm and was taken to
the ED. ___ the ED, she was noted to have e/o necrotizing soft
tissue infection on exam. She was started on vancomycin,
clindamcyin, and meropenem and taken to the OR, where the L arm
was extensively debrided. Her OR course was complicated by A-fib
w/ RVR requiring multiple doses of esmolol. She was briefly
admitted to the TSICU w/ intubation, pressor support, and close
monitoring, then transferred to the plastic surgery service. Her
wound cultures revealed group A strep, and her antibiotics were
switched to clindamycin and ceftriaxone per ID. The patient was
subsequently transferred to the medicine floor, and was taken
back to the OR for a washout, again for a skin graft placement,
and then again for wound vac takedown (done at bedside). Her
clindamycin was discontinued with plans to continue her
Ceftriaxone for 2 weeks post-debridement. She remained afebrile
with negative cultures and was discharged to rehab.
SURGICAL/ICU COURSE: Data upon admission: WBC 23, Cr 2, Na 147,
lactate 5.5, fascial plane air on plain films, and necrotic
bullae formation. INR was 7 and she was given 2 units FFP and
IV vitamin K x 1. She was taken to the OR once INR down to 2.4
a few hours later. Patient was tachycardic and somnolent ___ the
ED, but maintaining her pressure. ___ OR, she developed A-fib w/
RVR requiring multiple bouts of esmolol before starting the
case. She was maintained on neo throughout case. The patient
was taken to the OR and circumferentially debrided soft tissue
of entire left forearm, dorsal and including some digital soft
tissue, down to the elbow proximally. Much of the dorsal
tendons paratenon had to be removed, adaptic placed on this
before the VAC. Circumferential VAC applied on 75 mmHg,
intermittent suction. The patient was transferred to the ICU
post-surgery for blood pressure support with pressor therapy.
Pressor therapy was discontinued on hospital day #2. Patient
given digoxin load for a-fib with RVR. Patient restarted her
amlodipine on hospital day #4 and she was also started on PO
Lopressor with good control. The patient was maintained
intubated and on ventilator until she was able to be weaned from
vent on hospital day #2. Post-operatively, the patient was given
IV fluids. An NG tube was inserted and coffee ground gastric
contents were drained, guaiac positive. Patient was started on
IV pantoprazole and monitored closely. On hospital day#4,
patient pulled out her NG tube. Her diet was advanced when
appropriate, which was tolerated well. She was also started on a
bowel regimen to encourage bowel movement. Wound cultures
revealed beta streptococcus group A and patient's antibiotic
therapy to changed to ceftriaxone and clindamycin per Infectious
Disease.
#A-fib with RVR: At home, the patient is controlled with
metoprolol 25 mg BID and anticoagulated with warfarin 5 mg. The
patient was noted on admission to have a supratherapeutic INR,
requiring vitamin K and FFP. As noted above, the patient
developed A-fib with RVR during her initial OR course, requiring
several doses of esmolol, with subsequent hypotension and
pressor requirement ___ the ICU. On the medicine floor, she was
noted to be ___ A-fib with controlled rate on metoprolol 25 mg
BID, however she subsequently converted to sinus rhythm with
bradycardia. Her metoprolol dose was decreased to 12.5 mg BID
for this. Regarding her anticoagulation, because of her need to
go to the OR several times, the patient was maintained on a
heparin drip. After a discussion with her son (HCP), he felt
that the risks of anticoagulation ___ the setting of her falls
were outweighed by the risks of stroke, so felt that she should
be anticoagulated at discharge. Given her INR lability, she was
started on Apixiban on the day of discharge. She was discharged
on 12.5 bid metoprolol with holding parameters (to be
administered if HR ?60).
#Supratherapeutic INR: The patient was hospitalized ___ ___
for a supratherapeutic INR ___ the setting of poor PO intake, and
was again found to have a supratherapeutic INR during this
admission. See above two problems for further detail.
#Sinus bradycardia: Patient ___ A-fib at admission which
converted to sinus rhythm during her floor course. Bradycardia
likely due to metoprolol effect. She was also noted to have
occasional atrial and ventricular ectopy on telemetry. She
remained asymptomatic during her course. Metoprolol adjusted per
above.
#Anemia: Likely secondary to post-op blood loss combined with
dilutional effect. H/H slowly trended down and required a
transfusion of 1 u pRBCs on the day of discharge.
#Malnutrition: The patient was noted to have poor PO intake with
no dysphagia. Nutrition was consulted, and recommended
supplements and possible feeding tube placement. Given her
functional ability to eat and difficulty with rehab placement ___
the setting of feeding tube placement, we opted to continue her
on a PO diet with supplements and assistance with eating. She
will eat well with one-to-one assistance with feeding and this
should be encouraged.
#new diagnosis of systolic CHF: The patient had a TTE during
this admission showing an EF of ___ with moderate (2+) aortic
regurgitation, mild to moderate (___) mitral regurgitation, and
moderate to severe [3+] tricuspid regurgitation. After talking
with the PCP, this is a new diagnosis, and according to the PCP
the patient has never experienced CHF symptoms. ___ consider
starting ACE/statin ___ the future after further discussion
regarding patient goals.
#Chest pain: The patient reported chest pain on two occasions,
once while working with ___. Pain was described as dull and
intermittent, ___ the ___ her chest. No SOB. EKG showed no
evidence of ischemia.
CHRONIC ISSUES
==============
HTN: Patient is on metoprolol and amlodipine at home, these
medications were continued and her BPs remained stable.
TRANSITIONAL ISSUES
===================
-Ms. ___ need a CBC checked on ___ to ensure that her
Hgb/Hct is stable (she required 1U PRBC's on ___.
-Patient was discharged on ceftriaxone only with her course
ending on ___.
-Patient's metoprolol should be administered only if HR is >60
to avoid bradycardia; it is important to continue this
medication when possible, however, to prevent A-fib with RVR.
-Patient needs assistance with feeding and should be encouraged
to take po's.
-The patient was started on Apixaban due to INR lability on
warfarin. Will need to continue discussions as an outpatient
with the patient's son regarding risks and benefits.
- She was noted to have an EF of ___, however we have no
previous ECHOs on record and her PCP was unaware of any previous
reports.
- ___ consider starting ACE-I given reduced EF
- ___ Consider statin therapy, although risks and benefits will
need to be assessed given patient's goals.
-Patient will f/u with plastic surgery | 70 | 1,327 |
15299762-DS-6 | 21,129,429 | ___ Tumor
Surgery
You underwent surgery to remove a ___ lesion from your
___.
You may shower at this time but keep your incision site as dry
as possible.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your ___ appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some ___ swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a ___ diet. If you are taking narcotics (prescription
pain medications), try an ___ stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | ___ year old woman with PMH significant for HTN, DM, HLD, visual
hallucinations, and blindness who was recently diagnosed with
intracranial mass. Now she presents with acute on chronic
worsening of visual hallucinations. | 479 | 33 |
15409138-DS-13 | 29,239,077 | Ms. ___,
It was a pleasure meeting you during your hospitalization. You
were admitted with forehead pain, blurry vision, and chest pain.
Your symptoms came on very suddenly and seemingly improved with
minimal interventions. Given that your blood pressure was very
high during these symptoms, we believe that you experienced
something called "hypertensive emergency", which means that your
blood pressure was so high that it effected several different
organs in your body. As your blood pressure decreased, your
symptoms of improved. Because you had blurry vision, we
performed a carotid ultrasound which was unremarkable. You had a
stress test which showed that your heart is pumping less
efficiently. You have been scheduled to see a cardiologist on
discharge to discuss how this may be further managed. Your blood
pressure improved without new medications. | BRIEF SUMMARY STATEMENT:
Ms. ___ is a ___ year old female with PMH significant for
DM type II on insulin, hypercholesterolemia, hypertension,
NAFLD, and hx. of pulmonary embolism at ___ y/o on OCPs who
presents with acute onset headache, blurred vision, and chest
pain. The patient's symptoms occured in the setting of elevated
blood pressures likely consistent with an episode of
hypertensive emergency.
# Chest Pain: The pt. has history of similar type of chest
pain, not necessarily related to activity and more related to
anxiety type events. On this admission, her chest pain occurred
in the setting of elevated blood pressures in the 220s/120s.
Her chest pain slowly improved as her blood pressures improved.
She was found to have a mildly elevated troponin at 0.02. Her
troponin peaked at this level and slowly returned to normal. It
was thought that the mechanism of her chest pain is related to
transient ischemic injury from increased cardiac demand in the
setting of high afterload with significantly elevated blood
pressures. This type of mechanism supports an episode of
hypertensive emergency as there is evidence of end organ damage.
The patient's EKG was without significant change (Sinus rhythm
with LBBB) other than a slight change in QRS morphology in the
lateral leads likely attributable to lead placement. Stress
test showed possible anginal type symptoms in the setting of
Persantine infusion, with uninterpretable ST segment changes for
ischemia in the setting of LBBB. Nuclear perfusion test showed
decreased cardiac output of 47%, down from 70% previously. The
patient was asymptomatic during her stay. She will follow up
with cardiology as an outpatient.
# Headache and Blurry Vision: The patient presented with acute
onset left-sided supraorbital sharp pain associated with blurry
vision that lasted approximately 5 minutes. The quick onset and
remission of these symptoms in the setting of significantly
elevated blood pressures is consistent with hypertensive
emergency causing end organ damage manifested in this case by
blurry vision and headache. Other diagnoses we considered were
transient ischemic attach from sometype of embolic event. The
patient was noted to be in sinus rhythm without evidence of
atrial fibrillation. A carotid ultrasound was performed which
showed Less than 40% stenosis on the right and no
atherosclerotic plaque noted on the
lef. This made an embolic event less likely. Her neurologic
exam remained non-focal and she remained hemodynamically stable
throughout admission.
# Hypertension: The patient's blood pressure at home before
admission was in the 220s. However, during admission the
patient's blood pressure was well controlled. The patient was
continued on lisinopril 40mg PO daily and HCTZ 12.5mg PO daily.
CHRONIC ISSUES
# Diabetes Mellitus: Stable. The patient was continued lantus
34 units in the AM and on a humalog insulin sliding scale.
# Constipation with Right upper quadrant pain: The patient
reported a chronic history of stable abdominal pain since
antibiotic treatment several months ago for her pneumonia. She
denied a history of diarrhea, however she does endorse
significant constipation associated with RUQ abdominal pain.
This was managed with constipation regimen.
# Chronic Cough: Likely related to the lisinopril. The
patient was tried on losartan in the past and was not able to
tolerate secondary to GI upset. As such, will continue
lisinopril.
# Hyperlipidemia: Pt. with known history however is no longer
taking statin ___ myalgias. She is also not taking primary
prophylaxis with aspirin ___ gastric intolerance
# GERD: Stable. Continued on omeprazole
TRANSITIONAL ISSUES
#Hypertension Management: We discharged the patient on her home
regimen; however it is unclear why the patient's blood pressure
was in the 220s at home before admission. She may need increased
blood pressure control and should be monitored. | 137 | 637 |
11296936-DS-110 | 29,328,007 | Dear Mr. ___,
It was a pleasure to take care of you at ___. You were
admitted with fevers and cough. You were treated with
antibiotics with improvement in your symptoms. You should
complete a course of antibiotics, which will be given at your
dialysis sessions. | Mr. ___ is a ___ year old gentleman with ESRD on HD, T2DM,
CHF, HTN, HLD, Afib (not anticoagulated ___ history of GI Bleed)
presenting with fever, cough x1 day, and shortness of breath.
# Fever, leukocytosis, cough, hypoxia - Concerning for pneumonia
vs ILI. Given his recent hospitalizations, rehab residence, and
dialysis, patient was started on HCAP coverage with vancomycin
and cefepime. Sputum cultures did not grow a specific pathogen
and viral DFA and culture was negative. Patient's symptoms
improved with empiric HCAP coverage. Vanc/cefepime was changed
to vanc/ceftazadime at discharge for ease of dialysis dosing.
Patient will complete a 7d course of antibiotics, last dose of
vanc and ceftazadime to be given after dialysis session on
___.
# Diastolic CHF: BNP is lower than recent admissions, though pt
does have bilateral lower crackles, concerning for contribution
of mild fluid overload. Echo in ___ with EF 55-60%. Patient was
maintained on a low-sodium diet with a 2L fluid restriction.
Patient was dialyzed as per outpatient schedule, supplemental 02
was weaned and patient remained comfortable on room are for
>___.
CHRONIC ISSUES
# History of GI bleed. Per GI Dr. ___ was
pursued in ___ given hx of GI bleed requiring transfusions,
and the study indicated single non-bleeding pseudopolyp in the
proximal jejunum. Otherwise normal EGD to mid jejunum.
Patient has f/u with GI. Hematocrits were stable throughout his
course without signs of active bleed.
# ESRD on HD: outpatient schedule ___. Nephrology was
consulted, continued sevelamer, nephrocaps. Nephro recommended
holding cinacalcet at discharge as patient's calcium was low.
Recommend following calcium and PTH at outpatient dialysis and
restarted cinacalcet as per outpatient nephrologist.
# T2DM: Last HbA1c 10.7 on ___. Repeat during this
admission was 7.4. Multiple complications including peripheral
neuropathy, retinopathy, nephropathy. He was continued on his
home insulin regimen.
# Atrial fibrillation/AFlutter (s/p ablation ___ s/p ablation
x 2 in ___, EPS for atach in ___ (thought to be trigger vs.
reentrant) not on warfarin due to history of GIBs. Continued
diltiazem.
# Hypertension. Stable. Continued home diltiazem and imdur.
TRANSITIONAL ISSUES
# Code: Full, confirmed
# Emergency Contact: ___ (girlfriend/HCP) ___
Cell ___. Alternate HCP is son ___
___/ home ___.
# cinacelcet held on discharge due to low calcium, recommend
following calcium and PTH at outpatient dialysis and restarting
as per outpatient nephrologist
# needs to complete course of antibiotics for HCAP (vanc and
ceftazadime, last dose after dialysis session ___ | 48 | 420 |
13932038-DS-17 | 25,605,794 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You had blood in your stool and required blood transfusions
for low blood counts
What was done while I was in the hospital?
- You were given blood transfusions for low blood counts
- A camera was used to check your GI tract for bleeding and
you were found to have an ulcer in your colon which was likely
the source of your bleeding. It was not bleeding so no further
procedures needed to be done
What should I do when I go home?
- It is very important that you take your medications as
prescribed
- Please go to your scheduled appointment with your GI doctor
and are seen by the primary doctor at your extended care
facility.
- If you have more blood in your stool and black tarry stool,
please tell your primary doctor or go to the emergency room.
Best wishes,
Your ___ team | =========
Summary
=========
___ year old man with PMH of GERD, CVA, DMII, celiac disease,
pressure ulcer on coccyx, depression and poor hearing who
presented with GI bleeding. Colonoscopy revealed stercoral
ulcer. Hgb stabilized, no further bleeding.
=============================
Acute Medical/Surgical Issues
=============================
# GI Bleed:
# Acute blood loss anemia
Patient presented with hgb drop in the setting of dark stools
without hematemesis with a history of GERD on daily aspirin. No
history of liver disease, malignancy, trauma. Required 3 units
pRBC and 1 unit FFP and H/H stabilized with no further
melena/hematochezia. BPs recovered with blood and fluid. EGD
unrevealing. Colonoscopy on ___ revealed a stercoral ulcer in
the rectum with no signs of bleeding. Biopsies were take which
are pending at discharge. His home aspirin 81 was held but
restarted at discharge.
# Hypotension: initially hypotensive to ___ (baseline is
100s systolic), felt to be related to hypovolemia/blood loss. He
was pancultured without revealing infectious source to
contribute to a sepsis etiology of hypotension. BP improved to
95-105 systolics which appears to be his baseline.
#DMII: Hyperglycemic on admission, unclear etiology but could be
due to stress of infection or bleed. Given that he is NPO, dosed
reduced home insulin regimen of glargine 14U qHS with ISS while
on clear liquid/NPO diet here. Once diet resumed, restarted on
home dose.
CHRONIC
# Coccyx wound: in the setting of bedbound status and potential
malnutrition. Wound does not currently look infected on
admission. CRP low making osteo less likely. Wound care was
consulted and recommended pressure relief per pressure ulcer
guidelines with turn and reposition every ___ hours and prn off
affected area. Nutrition consulted and given celiacs disease,
started on supplementation with vitamin C, zinc sulfate for 14
days, vitamin D, and calcium carbonate.
# Potential HIV
Chart diagnosis without labs or medications by history. Patient
confused and does not know if he has diagnosis. CD4 and HIV
viral load negative making HIV unlikely. Would remove from past
medical history
#CAD primary prevention: continued Atorvastatin 20 mg PO QPM and
restarted ASA at discharge.
#Constipation: Stercoral ulcer likely developed in setting of
chronic constipation. Would put patient on standing bowel
regimen with Senna 8.6mg PO daily and Miralax. Would continue
PRN regimen of Bisacodyl ___AILY:PRN constipation; Milk
of Magnesia 30 mL PO DAILY:PRN constipation; and Fleet Enema
(sodium phosphates) ___ gram/118 mL rectal DAILY:PRN if patient
without stool for 2 days.
#Rhinitis: continued home Fluticasone Propionate 110mcg 1 PUFF
IH BID; GuaiFENesin 10 mL PO Q6H:PRN cough; Albuterol Inhaler 2
PUFF IH Q6H:PRN dyspnea
#Depression/insomnia: continued home Sertraline 12.5 mg PO
DAILY, Mirtazapine 15 mg PO QHS
#Nutrition: continued Multivitamins W/minerals 1 TAB PO DAILY
and started on supplementation with vitamin C, zinc sulfate for
14 days, vitamin D, and calcium carbonate given history of
celiacs disease.
#Dyspepsia: Restarted Sodium Bicarbonate 650 mg PO BID heartburn
at discharge.
==================
Medication Changes
==================
- Started vitamin C 250mg BID
- Zinc sulfate 220mg daily for 14 days (D1: ___
- Vitamin D 800U daily
- Calcium Carbonate 1000mg daily
=====================
Transitional Issues
=====================
[] Constipation: important in preventing further stercoral
ulcers. Place patient on standing bowel regimen with senna 8.6mg
PO daily and miralax daily. Would try PRN medications in this
order if no stool in 2 days: Bisacodyl ___AILY:PRN
constipation; Milk of Magnesia 30 mL PO DAILY:PRN constipation;
and Fleet Enema (sodium phosphates) ___ gram/118 mL rectal
DAILY:PRN
[] Ascending colon polyp: Will schedule follow-up appointment
with GI to consider EMR for ascending polyp at a later date and
follow-up stercoral ulcer pathology
[] History of Celiac's Disease: Please have patient on
gluten-free diet. Nutrition recommendations are supplementation
with vitamin C, zinc sulfate for 14 days, vitamin D, and calcium
carbonate as patient likely malnourished.
[] Coccyx wound: Wound care was consulted and recommended
pressure relief per pressure ulcer guidelines with turn and
reposition every ___ hours and prn off affected area. Please
have on gluten free diet and continue supplementation as above
as malnutrition will impair wound healing.
[] Continue aspirin 81mg here at discharge. Given patient's age
and functional status, would continue to evaluate risk of
bleeding vs cardiovascular benefit and consider stopping if
indicated.
# Communication: HCP: ___, sister - ___
# Code: DNR/DNI, confirmed | 173 | 680 |
11851678-DS-19 | 22,405,052 | You were transferred to ___ for viral gastroenteritis. This
improved, but you were also found to have some mild injury to
your heart, some enlargement of your bile ducts, gallstones and
sludge in your gallbladder, and also a GI bleed. The GI bleed
resolved and you underwent endoscopy which showed diverticulosis
which is the likely cause of bleed.
The other issues can be examined as an outpatient. You will need
some cardiac testing to evalute the health of your heart and an
MRI of your liver to evaluate for the enlargement of your bile
duct in the area of the left portion of your liver. You also
had mildly elevated LFTs on the day prior to and after
discharge. You should have repeat lipase and LFTs at your
follow up appt. | ___ yo woman with a PMH of HTN and treated Hepatitis C w/SVR
(previously followed by Liver clinic at ___ presenting with
2-day history of vomiting and diarrhea, admitted for inability
to tolerate POs, went initially to ___ had CT demonstrating
likely gastroenteritis as well as elevated lipase level without
clinical evidence of pancreatitis and very mild troponin
elevation with non specific ECG changes in setting of ___.
Transferred to ___ and over course of hospitalization
developed maroon stools from likely diverticular bleed.
# Vomiting/diarrhea: Resolved, likely from gastroenteritis
# Elevated lipase: Unclear etiology. Clinically does not have
pancreatitis and never had pain. ___ have had transient
obstruction in panc duct, but presentation is odd. ? related to
gastroenteritis. Will need follow up lipase level
# GI bleed: Maroon stools. No evidence of hemodynamic
instability or HCT drop. Likely from diverticulosis seen on
___. No active bleeding found. EGD also performed with
insignifcant AVM in duodenum. The bleeding only took place over
the course of one morning then resolved.
# Potential demand ischemia: Trop I at OSH 0.07 (nl <0.03).
EKGs with Nonspecific ST-T changes, pt denies CP, SOB, ___ edema,
orthopenia, diaphoresis to suggest active ischemia or failure.
Pt with serial cardiac enzymes here which were negative.
Possible demand in setting of dehydration, illness and ___. Pt
may benefit from ETT as OSH. Discussed with PCP. Pt continued
on beta blockade and started on baby aspirin after resolution of
GI bleed.
# Rising LFTs: Pts LFTs initially normal. Over the last two
days of admission had rise in LFTs to 100 Asymptomatic. Should
f/u as outpt. Potentially from stone although no symptoms, no
pain. ? recurrence of hep C. ? autoimmune hepatitis. ?
associated with viral infection. Pt should have follow up LFTs
at outpt appt next week. If rising or still elevated should have
follow up HCV viral load level and should be referred to liver.
Also needs outpt MRCP
# Mild intrahepatic ductal dilatation within the left hepatic
lobe: Needs MRCP
# Hypertension: Currently well controlled
# Hypothyroidism:
- Continue home levothyroxine - med dosing confirmed with pt's
pharmacy | 134 | 376 |
17145467-DS-3 | 24,267,539 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had fever,
shortness of breath, and cough and were found to have a drug
reaction called Pneumonitis. This was from the Pembrolizumab you
received.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received a breathing tube for several days to help you
breathe.
- You received steroids to decrease the inflammation in your
lungs (pneumonitis) and a medicine called IVIG.
- You were found to have a blood clot (pulmonary embolism) and
you were started on blood thinners (anticoagulation).
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Go to your appointment with your Oncologist.
- Go to your appointment with the pulmonologists.
- Follow-up with Palliative Care - if you are at rehab and are
having difficulty finding a palliative care doctor for support,
please contact Dr. ___ or contact Dr. ___
the number he left you in his card.
We wish you the best!
Sincerely,
Your ___ Team | SUMMARY:
___ female with history of breast cancer, hypertension, HLD,
hypothyroidism, now recently diagnosed with metastatic lung
adenocarcinoma, on palliative chemotherapy, presented with
fevers and acute on chronic dyspnea on exertion. Imaging on
admission notable for extensive consolidation consistent with
multifocal pneumonia superimposed on underlying malignancy. She
was started on broad antibiotics. She was admitted to ICU for
hypoxic respiratory failure and intubated ___. Infectious workup
was unrevealing. CT showed pulmonary embolisms for which she was
started on heparin and ultimately lovenox. Her respiratory
failure was attributed to penbrolizumab induced pneumonitis. She
was treated with high dose steroids and IVIG with improvement,
and was extubated on ___ and weaned to nasal cannula. She had
persistent dyspnea on exertion and desaturations but her
respiratory status was improving by time of discharge. She was
discharged on prednisone 80mg with plan for long steroid taper. | 180 | 142 |
14589995-DS-10 | 21,891,266 | You were admitted to the ACS service for your injuries, which
included bleeding in your head and an elbow fracture. You are
ready to continue your recovery at home. Please resume all home
medications. You may take tylenol or motrin for pain control and
narcotic medication if needed, and only as directed. You can
continue on a regular diet. You may resume all your usual
activities. Keep your R elbow in a splint and keep the R arm as
non-weight-bearing until you follow-up with orthopedic surgery.
You may do passive range of motion exercises with that arm. | Ms. ___ was admitted to the ___ service for her injuries.
Orthopedic surgery was consulted and placed her R elbow in a
splint. She is to follow-up with them in 2 weeks in clinic.
Neurosurgery was consulted for her SDH. Her neurological exam
remained stable and no further imaging was performed. She
remained hemodynamically stable. She was given a regular diet,
which she tolerated. She worked with physical therapy and
occupational therapy. She voided without difficulty. She was
ready for discharge to her assisted living facility with
services on HD3. | 97 | 90 |
10425845-DS-4 | 21,284,404 | Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
If your doctor allows, non steriodal ___ drugs are
very effective in controlling pain (i.e. Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
Please abstain from taking Plavix until you follow up with
Neurosurgery in clinic in 4 weeks.
Please take a full liquid (non-chew) diet for the next two weeks
or until you follow up with a dentist for definitive dental care
regarding your tooth injury. | Mrs. ___ was admitted to our institution after being
transferred from an outside hospital where she was brought in by
ambulance after sustaining mechanical fall face forward while
showering. Reportedly, patient was intubated at OSH for airway
protection after an episode of bloody emesis. Upon arrival she
was sedated and had visible diffuse facial ecchymosis and a lip
laceration. Repeat imaging studies showed interval increase in
prepontine and interpeduncular subarachnoid hemorrhage tracking
inferiorly, and confirmed the presence of a small
intraventricular and a left subdural hemorrhage. Given findings,
the neurosurgery team was consulted and recommended conservative
management and monitoring for further interval changes. Patient
was thus admitted to the ___ for further care.
Regarding her facial injuries, the ___ team was consulted to
assess the lip laceration and dental injuries. Evaluation and
repair was initially difficult given the presence of an
endotracheal tube. A repeat head CT scan showed no interval
changes 24 hours later. Upon stabilization of her respiratory
status, patient was extubated on hospitalization day #1. A
tertiary survey revealed no further injuries. At this point,
___ was able to repair the lip laceration. There was avulsion
of tooth #9, as well as mild mobility in teeth #8 and 10. At
this point, decision was made not to place a dental splint given
time elapsed from injury and questioned benefit from it. She was
advised to stay on a full-liquid diet and follow-up with outside
dentist once medically stable for definitive care.
On hospitalization day #2 patient was started on ciprofloxacin
for a urinary tract infection (confirmed by urinalysis and
cultures positive for Klebsiella). Home medications were
restarted upon diet tolerance, except for Plavix, to be held for
one week post-injuries per neurosurgery recommendations. Given
favorable response, she was transferred to the floor on
hospitalization day #4. Foley catheter was then removed and
patient had several episodes of incontinence. Anticipating
discharge, physical therapy was consulted and determined need
for extensive ___ rehab. Case management was
involved in the rehab selection process.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. She was tolerating a full-liquids diet,
and pain was well controlled. The patient's family members and
aide received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. | 136 | 377 |
15459380-DS-11 | 25,767,123 | You were admitted for symptoms of left hand and leg weakness
which had resolved prior to your arrival. Your head imaging was
negative for stroke, so you likely had a "TIA" which stands for
transient ischemic attack. Please follow up with your Atrius
doctor and have him set you up with an Atrius Neurologist for
follow up. We have not changed any of you medications so you
should continue to take all of your home medications as
instructed by your primary doctor. | 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 = pending at time of discharge)
- () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? x() Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
___ right-handed obese ___ man with past medical history
significant for afib (with subtherapeutic INR this past week
just finished Lovenox bridge,) also HTN, DM, HL, OSA, CKD-III,
who presented with transient left-hand weakness which has since
resolved.
# Neurologic: likely had a TIA
- head CT normal
- MRI/MRA head and neck showed No evidence of infarct. No
vascular occlusion in the head or neck. Mild generalized brain
volume loss. White matter signal changes, which are nonspecific,
but likely reflect the sequela of chronic small vessel disease.
- TTE showed no cardiac source of embolus identified other than
atrial fibrillation. However, views were suboptimal secondary to
obesity.
- telemetry stable throughout admission
- EEG was considered on admission due to intermittent speech
arrest episodes, but by the following day this was no longer
evident and so EEG was not pursued
- BP was 100/Doppler on AM on ___, held valsartan and
amlodipine and BPs normalized shortly thereafter
- AM fasting lipids were drawn and are pending, (as he was
already on Lipitor 80; we would recommend Crestor if LDL is
still high)
- tox screens WNL, TSH pending at time of discharge
- continue carbamazepine (200mg BID) and gabapentin
(300/300/1200mg)
- held baclofen overnight for somnolence, this was improved by
the next day so restarted on ___
- We left a message with his PCP ___: recs for follow up with
___ Neurology
# Pulmonology: severe OSA, obesity hypovent/restrictive etiology
- stable overnight without CPAP but would likely benefit from
this in the future
# Infectious Disease: no active issues (non-toxic, afeb, no
leukocytosis)
- CXR showed no evidence of pneumonia
# Cardiovascular:
- Troponin normal
# Hematology/Oncology: no active issues
- CBC stable on admission
# Endocrine: IDDM
- Gave half dose of insulin glargine (Lantus) first night of
admission to prevent hypoglycemic worsening of TIA, but as his
symptoms did not return he was sent home on full dosing
- DM diet
- HbA1C quite elevated 11
# Nephrology/Urologic:
- Stage 3 CKD, Cr at baseline 2.0 during admission
# GI/Liver: no active issues
- Took in enteric feeds (DM diet), passed dysphagia screen
# Prophylaxis:
- DVT: boots; already A/C (continued warfarin INR goal ___, INR
on d/c was 2.1)
- ___ Eval --> safe for home | 84 | 550 |
17719206-DS-5 | 20,817,624 | Dear Mr. ___,
It was a pleasure to meet you and your family. You were admitted
because you were confused. This was because your prostate was
blocking urine from leaving your bladder and so your
electrolytes and toxins were building up in your body. You had
dialysis to improve your electrolyte balance, and placed a foley
catheter to drain the urine. You were feeling better, and were
able to be discharged.
You will need to follow-up with the urology team to talk about
the next steps so that this does not happen again.
Please see below for more information about any changes made to
your medications.
Again, it was very nice to meet you, and we wish you the best.
Your ___ Care Team | ___ male with PMHx HTN who is presenting with altered
mental status, found to have acute renal injury and was
emergently dialyzed for uremia and hyperkalemia.
# Acute renal injury: Patient presenting with acute kidney
injury (BUN 184, Cr 41). Patient's Cr has been trending up over
the past ___ years (1.1 in ___, 1.5 in ___. In the ED he was
underwent a bedside ultrasound, which showed bilateral
hydronephrosis, an enlarged prostate, with 3+ liters in his
bladder. Given that he had a PSA of 30 in ___, most likely
cause thought to be obstructive uropathy secondary to enlarged
prostate or prostate malignancy. Patient had foley placed by
urology which initially revealed clear urine which quickly
become bloody, consistent with hemorrhagic decompression.
Patient emergently dialyzed overnight for uremia and
hyperkalemia with improvement in electrolyte abnormalities. He
was started on tamsulosin. Following emergent dialysis, renal
function ultimately improved with discharge Cr of 1.2 and normal
electrolytes. Though patient previously declined work up for
prostate cancer, he will follow up with urology as an
outpatient.
# Altered Mental Status: Patient's altered mental status
initially alert and oriented only to person likely secondary to
toxic metabolic encephalopathy in the setting of uremia and
gross electrolyte abnormalities. Following treatment of
obstructive uropathy with dialysis and foley placement, his
mental status significantly improved. Patient was alert and
oriented x3 at time of discharge.
# Hypertensive Urgency: Patient severely hypertensive on
admission, BP 234/101. Patient had not taken meds in a couple of
days prior to admission and it is unknown how long patient has
been hypertensive. Patient was given 10 mg IV Hydralazine
overnight and was started on Amlodipine in the ICU. Patient's
BPs stabilized with amlodipine 5mg daily. His lisinopril was
held in the setting of ___, and his home hydralazine was stopped
with the initiation of tamsulosin.
# Social Issues: At baseline, patient was living at home
independently and taking care of sick wife. During admission,
family raised concerns for safety to care for himself at home
alone. Reportedly, family went to the home and saw blood and
garbage and disarray that was concerning. Social work was
consulted and their team began filing documentation to Elder
Protective Services.
======================
TRANSITIONAL ISSUES
======================
- Patient will have followup with urology for workup of enlarged
prostate and possible cystoscopy.
- Patient's foley should remain in place until urology followup.
- Patient was found to have anemia in the setting of hematuria.
He should have a repeat h/h on ___.
- The patient's electrolytes have largely normalized, but he
continues to have low phosphorus levels. Lytes, including phos,
should be checked on ___ to assess levels.
- Due to concern for inadequate housing situation, Elder
Services was notified, and will follow up on any need for
increased services.
- The patient's lisinopril was held in the setting of ___, and
hydralazine was held after he was started on tamsulosin. He was
started on amlodipine and tamsulosin in the hospital. He may
need additional blood pressure medication titration in the
outpatient setting.
# CONTACT: wife ___ ___
# CODE STATUS: Full (confirmed) | 121 | 508 |
15711512-DS-15 | 26,130,800 | 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** | The patient was admitted to the hospital and brought to the
operating room on ___ where the patient underwent CABGx3.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable requiring Neosynepherine for hypotension, that was weaned
off by POD#1. He developed acute on chronic renal failure, with
significant acidosis/hyperkalemia, required bicarbonate gtt. His
PPM was interrogated in the post-op period and it was determined
that his A wire was not working. His device was changed to VVI.
He has been in SR/SB with occasional pacing and prolonged QTC.
He will need to have his PPM lead revised as determined by
cardiology as an outpatient. He is tolerating Beta blocker. He
was followed by the renal service for his acute on chronic renal
failure and was gently diuresed. His creat peaked at 3.6 and is
currently downtrending. He is being discharged on daily Lasix
and will f/u with Dr. ___ in 2 weeks. The patient was
transferred to the telemetry floor POD#3 for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 6 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to home in good condition with
appropriate follow up instructions | 137 | 269 |
17473098-DS-19 | 25,430,316 | Dear Ms. ___,
It was our pleasure caring for you at ___
___. You were admitted to the hospital with
dehydration and malnutrition. After discussion with your
outpatient oncologist, radiation oncologist and family, the
decision was made to place a device called a "percutaneous
enteral gastrostomy tube," or G-tube, for providing nutrition
until you complete your course of radiation and chemotherapy.
You were started on continuous tube feeds which you tolerated
well, and then you were transitioned to bolus tube feeds. We
also increased your dose of oxycontin to better control your
pain, and we started two new medications for nausea (reglan,
also called metoclopramide, and ativan, also called lorazepam).
When you go home, you are going to administer 1 can of Jevity
1.5 through your G-tube five times per day. You will have a
visiting nurse who will help you to do this at home, and your
family will also assist you.
Thank you for allowing us to participate in your care. | ___ is a ___ female with a history of head and neck cancer,
squamous cell carcinoma of the soft palate, uvula and tonsils
who presents with malnutrition and dehydration.
# Malnutrition, moderate
# Dehydration
# Squamous cell carcinoma of soft palate, uvula, tonsils
At this point in time it appears that she is failing oral
nutrition and hydration and needs enteral feeding via PEG tube.
After multidisciplinary discussion with oncology, radiation
oncology, patient's daughter/healthcare proxy and patient
herself, decision was made to pursue PEG placement. PEG was
placed uneventfully, and she was started on cycled tube feeds
that were gradually transitioned to bolus feeding. The patient
was discharged on self-administered bolus TFs (Jevity 1.5, one
can (240mL), 5 times daily), which she was tolerating well prior
to discharge.
# Pancytopenia:
Chemo related, monitoring CBC/Diff to evaluate for ANC, which
nadired at 1020 during this hospitalization. In discussion with
her outpatient oncologist, decision was made to hold off on her
last scheduled chemotherapy cycle and re-evaluate in the
outpatient setting. | 167 | 166 |
18823151-DS-16 | 22,900,744 | Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with a gallstone blocking your biliary duct, and inflammation in
your pancreas (pancreatitis). You were seen by GI specialists
and underwent a special kind of endoscopy (ERCP) where a stone
was removed from your gallbladder. You will need to take an
antibiotic called cipro for 5 days after your ERCP and to see
the surgery team in clinic to discuss options for gallbladder
removal surgery. | This is a ___ year old male with past medical history of
head/neck squamous cell cancer s/p chemo and XRT, previously
trach dependent, s/p G-tube, admitted ___ with
choledocholithiasis and gallstone pancreatitis, status post ERCP
w sphincterotomy and stone extraction.
# Gallstone pancreatitis / Choledocholithiasis Patient
presented with abdominal pain with lipase of 3k, and abnormal
LFTs. Imaging was concerning for choledocholithiasis. Patient
was made NPO, started on IV fluids, and given concern for
cholangitis on OSH CT scan, started on antibiotics. Patient
underwent ERCP with sphincterotomy and stone extraction without
signs of purulence or cholangitis. He was recommended to take
cipro for 5 days post procedure. Last day ___ AM. He was
evaluated by the surgical team during admission and they did not
recommend any surgery during admission but recommended short
interval outpt f/u (arranged).
# Esophageal Stricture
ERCP incidentally found a "A benign intrinsic 9 mm stricture" at
20cm, which was subsequently dilated. Per advanced endoscopy;
no follow-up is necessary unless patient were to develop
dysphagia in the future--if so, the would recommend repeat
endoscopy.
# Hyperlipidemia
Held home atorvastatin pending normalization of LFTs. Would
repeat LFTs in outpt setting and resume when able.
# Anxiety
Continued Bupropion, trazodone
# Hypothyroidism
Continued Levothyroxine
# Oropharyngeal squamous cell cancer s/p prior radiation therapy
Continued scopolamine patch for help with secretions. Outpt f/u.
Resumed tube feeds. Would consider need for repeat speech and
swallow study as outpt.
# BPH
Continued tamsulosin | 80 | 244 |
14402678-DS-11 | 25,925,526 | * You were admitted to the hospital for evaluation of your chest
and back pain which ultimately was due to an infected mass ___
your anterior mediastinum. You eventually required surgery and
you've recovered well. You are now ready for discharge but will
need antibiotics at home until ___. The Infectious Disease
service will continue to follow you as an out patient.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol ___ mg every 6 hours ___ between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions.
* Your kidney function was initially abnormal probably due to
the use of Ibuprofen prior to admission and multiple contrast
studies while hospitalized. Your kidney function is improving
daily but you cannot take Ibuprofen and should not have any
studies with contrast until your kidneys have time to heal and
function properly. It is important for your kidneys to stay well
hydrated too.
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you. | Mr. ___ was admitted to the hospital and taken to
Interventional Radiology for CT guided drainage of his anterior
mediastinal abscess. Yellow pus was aspirated and he was placed
on broad spectrum antibiotics. MSSA grew from that sample and he
was scheduled for surgical washout. His WBC was 14K and he
continued Vancomycin and Zosyn therapy. His admission blood and
urine cultures were negative. On ___ he underwent a left
video-assisted thoracoscopic surgery (VATS) and debridement of
mediastinal abscess. He tolerated the procedure well and
returned to the PACU ___ stable condition with 3 chest tubes ___
place for drainage.
Following transfer to the Surgical floor he had adequate pain
relief and his chest tubes remained ___ place. His WBC gradually
trended down but he developed acute renal failure to a maximum
creatinine of 2.7. His urine output was adequate and the renal
service was consulted. They felt it may be due to a combination
of multiple contrast studies as well as the use of high dose
Ibuprofen during his episodes of severe pain. With adequate
hydration his creatinie gradually decreased and he will remain
off of NSAIDS and not receive contrast until his kidney function
is back to normal.
The Infectious Disease service followed him closely during his
admission and ___ addition to pan culturing also recommended a
cardiac echo which showed no vegetations. His antibiotics were
tapered to Cefazolin with plans to change to Nafcillin once his
renal function returned to normal.
His chest tubes were gradually removed and he felt much better.
He was afebrile and his WBC was normal. He had a palm sized area
above his waist along the left posterolateral area which was
minimally erythematous. It was well below the incisions or
chest tube sites but was watched closely and remained stable.
He underwent a chest CT on ___ which showed a decreased
fluid collection. The plan will be to treat him with 6 weeks of
IV antibiotics via a right PICC line which was placed on
___.
His creatinine gradually decreased and on ___ was 1.6. At
that time he was switched to Nafcillin for better coverage. he
will receive this at home at 2 Gm every 4 hours which will
continue through ___. The ___ will draw labs twice a week
including CBC w/diff, chem 7, LFT's, ESR, CRP. If there is any
trouble with his renal function the Infectious Disease service
will adjust the medication. He will have an MRI of the chest on
___ to evaluate the collection and R/O any evidence of
osteomylitis and will then follow up with Infectious Disease and
Thoracic Surgery. After a long hospital course he was
discharged to home on ___ aqnd will have ___ services to
help with home IV antibiotic therapy and wound assessment. | 322 | 479 |
12459180-DS-7 | 29,889,997 | You came to the hospital because of chest pain and abdominal
pain. You had imaging done of your abdomen which showed you are
constipated. It is most likely your abdominal pain is from
constipation and also from drinking alcohol. We recommend you
stop drinking alcohol, follow up with your primary care doctor
___ below for appointment times). You may need a scope (a
camera that goes down your throat to look at your stomach) to
see if you have any inflammation of your stomach from alcohol | ___ y/o M with h/o alcohol abuse p/w positional CP and abdominal
pain that he feels is related to alcohol. Pt was intiially on
the ___ service and they cardiologist felt this was unlikely
cardiac related and more likely abdominal pain related and pt
was transferred to medicine service for further workup.
.
#abdominal pain - Etiology likely from constipation (CT imaging
showing lots of stool in colon) vs alcohol gastritis vs PUD. ACS
was ruled out by serial EKGs while on the cardiology service.
Lipase/LFTs WNL. CT abdomen showing no acute findings except for
stool on colon. On exam he was diffusely tender and abdoinal
exam did not change while here but he was able to tolerate PO.
No fever/leukocytosis to suggest major infectious process. He
was started on ranitidine, was given bowel regimen with miralax,
senna, docusate, bisacodyly. H pylori serologies sent were neg.
He had BM day of d.c and was tolerating PO. He still had
abdominal pain when he was discharged and knows to follow up
with PCP for further workup if this persisits.
.
#. EtOH abuse - No reported h/o withdrawal seizures. Last drink
3 days prior to admission. Has did not score on CIWA. was given
Thiamine, folate, MVI. Social work saw him and pt showed no
interest in stopping alcohol
.
#. HTN
- Continued home medication regimen | 87 | 232 |
15896763-DS-6 | 21,847,118 | Mr. ___,
You were admitted to the neurology service for symptoms of left
arm weakness which was concerning for stroke. Your brain MRI was
normal and did not show any stroke or other abnormalities. On
examination, you did not have physiologic weakness. We
recommended a cervical soft-collar for your neck pain which was
exacerbating your headache. You were seen by physical therapy
who recommended outpatient ___.
Please follow-up with Dr. ___ as already scheduled.
Best,
Your ___ Neurology Team | Mr. ___ is a ___ year-old right-handed man with a history
of myoclonic and abdominal seizures, undifferentiated
mitochondrial disorder, migraines, and radiculoneuropathy,
recent prolonged hospitalization in ___ for perforated
diverticulitis s/p ___ repair and stomal retraction, now
s/p reversal of colostomy who presents for evaluation of an 11
day history of progressively severe headache and left arm
weakness. Given his history and constellation of symptoms, he
was admitted for neuroimaging to evaluate for central process.
MRI was negative for stroke or other CNS lesion. Exam was
notable for give-way weakness on left side with normal
proprioception and sensation. His headache improved moderately
with a migraine cocktail. He endorsed significant
musculoskeletal discomfort and was seen by ___. He will be
discharged home with a cervical soft collar and will follow-up
with Dr. ___ week. | 79 | 134 |
16699110-DS-8 | 28,552,687 | Dear ___,
___ was a pleasure taking care of you here at ___. You were
admitted to the hospital for a clot in a blood vessel in your
liver called the portal vein. You were evaluated by the liver
specialists who do not feel you need blood thinners for this. We
recommend that you followup with the liver tumor clinic to
further discuss treatment of your liver cancer. | ___ with HCV cirrhosis and ___ s/p cyberknife sent in for
evaluation of portal vein thrombosis.
# PORTAL VEIN THROMBUS: Etiology of thrombus is either due to
tumor vs clot. She was initially started on anticoagulation x 1
(Lovenox and warfarin) which was stopped after review of images
revealed this could be tumor clot, which would not need
anticoagulation. Hepatology was consulted. She has also never
had an EGD despite known cirrhosis, and she will require
outpatient EGD to rule out varices prior to discussion of
anticoaguation. She will be discussed at upcoming Liver Tumor
conference.
# HCC: s/p cyberknife. There is concern for possible progression
of her tumor. LFTs were stable in obstructive pattern. She did
not have jaundice or asterixis on exam. She was asymptomatic and
will need outpatient hepatology followup.
# CIRRHOSIS FROM CHRONIC HEP C. No evidence of decompensation.
No ascites or asterixis on exam.
# DM2: Initially hypoglycemic in ___ and complained of
presyncope, which resolved after dextrose administration.
Continue home glargine and ISS.
# HYPERTENSION: Orthostatics negative. Continue home amlodipine
and atenolol.
# CKD: Cr stable in 1.0-1.2 range.
# HYPOTHYROIDISM: Cont home levothyroxine
#CODE: Full
#CONTACT: neighbor ___ (___)
### ___ ISSUES ###
-No medication changes
-Will need outpatient EGD to rule out varices
-Needs hepatology followup | 68 | 203 |
12017902-DS-7 | 24,220,450 | Dear Mr. ___,
You were hospitalized due to worsening unsteadiness and
dizziness. These symptoms represent a worsening of your chronic
vertigo due to your right ear surgery. As you were found to have
decreased vibration and position sense in your legs, we also
checked a cervical spine MRI. This did show some degenerative
changes (arthritis) in your neck and narrowing of the spinal
canal, but there was no compression.
Physical therapy worked with you in the hospital and recommended
discharge home with outpatient ___ rehab and physical
therapy. You have a prescription for this. Please call the
numbers for home care services.
Please follow-up with your primary care doctor within 1 week. | Mr. ___ is a right handed man with past medical history
including chronic labyrinthitis, hyperlipidemia, diabetes
mellitus (type 2), prior right caudate infarct, and coronary
artery disease status post CABG who presented to the ___ ED
___ with acute worsening of his chronic vertigo. NCHCT was
unremarkable. Due to pt's inability to ambulate independently,
he was admitted to the stroke neurology service for further
management.
While on the floor, pt was noted to have loss of vibration and
proprioception in the right > left lower extremity. He denied
any recent urinary incontinence or saddle anesthesia. Due to
these exam findings, pt underwent an MRI of the cervical spine
which showed cervical spondylosis. There was no cord
compression. Physical therapy worked with patient who
recommended home with outpatient physical therapy. TSH, RPR,
B12, and folate were all normal.
During hospital stay, pt's vertiginous symptoms greatly
improved. Pt will undergo ___ rehab as an outpatient to
further treat his chronic labyrinthitis.
Otherwise, pt was continued on home medications for his chronic
medical conditions while in the hospital.
==========================
TRANSITIONS OF CARE
==========================
-MRI cervical spine incidentally showed: "Incompletely
characterized are T2 hyperintense nodules within expected
location of the thyroid gland measuring up to 1.2 cm on the
sagittal images. Correlation with clinical history and prior
imaging if available. Recommend further evaluation with thyroid
ultrasound if clinically indicated."
-Will need ___ rehab and physical therapy as an
outpatient. | 111 | 228 |
17829604-DS-13 | 24,940,067 | Dear ___,
You were admitted to ___ after
imaging done at your local ___ showed that you had suffered
a large stroke. The stroke was in the middle cerebral artery in
your brain on the right side. This is a very serious medical
condition, and your recovery will likely be a long one, but
since you are so young, your prognosis to regain some
functioning is very good.
.
It is very important that you take all of your medications as
prescribed especially the aspirin. Additionally, you MUST stop
smoking. It places you at a very high risk of having another
stroke. People who are trying to quit smoking have the best
success when they surround themselves with supportive people who
also do not smoke. If you need a Nicotine patch, Nicorette gum,
or other nicotine supplements, please ask your doctor at rehab
to help you attain some.
.
When you were medically stable to leave the hospital, you were
discharged to a rehab facility where you can have more intensive
physical, occupational, and speech therapy.
.
It was very nice to meet you and your family. We wish you the
very best in your recovery. | This is the brief hospital course for a ___ year old woman with
ADHD on atomoxetine, on oral contraceptive therapy, and a
history of tobacco use who presented with dysarthria and left
sided weakness with a subsequent finding of a large right MCA
territory. This notably occurred in the setting of synthetic
cannabis abuse (smoking K2). She was found to have a mid-M1
occlusion of unknown etilogy with otherwise normal blood vessels
of the neck and head. She was initially admitted to the SDU but
overnight developed a headache. An NCHCT revealed 4mm of
parafalcine herniation and she was started on hyperosmolar
therapy with mannitol. She was transferred to the ICU for closer
monitoring.
.
Her NCHCTs remained stable for the next few days (except for
small amounts of hemorrhagic transformation), and her exam
continued to improve with more wakefulness, attention, and
improved speech. She remains hemiplegic with no movement on the
LEFT side, including to noxious stimuli.
.
She was found to have a PFO on her TTE, but negative lower
extremity dopplers and an MRI of her pelvic region did not
reveal any venous clots (anticoagulation is not an option for
her at this time). Hypercoagulability labs were sent, and some
remain pending at the time of discharge (see above results
section). These can be followed up at her appointment with Dr.
___ in a few weeks.
.
She conditionally passed her bedside dysphagia screen but
requires 1:1 supervision and soft consistency solids. She was
left-sided plegic when initially starting physical and
occupational therapy, and remained this way throughout her stay
with us.
.
At discharge, she will be continued on ASA 325mg daily, a daily
statin, and prozac. Until she is more mobile, Heparin SC 5000U
TID should be continued.
.
She was discharged to rehab for rigorous physical, speech, and
occupational therapy when medically stable by the neurology
team. She will have follow-up with Dr. ___ on ___. | 190 | 314 |
16119498-DS-12 | 22,640,661 | Dear Mr. ___,
WHY WERE YOU ADMITTED?
- You had chest pain and shortness of breath
WHAT WAS DONE?
- You were observed while exercising to see how well your heart
could handle it
- We found that your valve that was replaced recently has become
narrowed and is the reason for your symptoms
WHAT TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please follow up with your doctor appointments as listed below
- Your outpatient cardiologist (heart doctor) will tell you the
next steps to fixing your valve
- If you have the SAME chest pain (that hurts when you push on
it), you can take Tylenol Extra-Strength 2 tablets (1,000 mg)
every 8 hours as needed.
- If you have any NEW chest pain or chest pressure, shortness of
breath, or sudden weight gain, please call a doctor.
It was a pleasure taking care of you,
Your ___ Team | This is a ___ with a reported h/o CAD (unknown anatomy),
hypertension, hyperlipidemia, "CHF," s/p AVR (severe stenosis of
a bicuspid AV that was repaired at ___ ___ with a 19 mm
___ Pericardial Magna Ease valve) who presented with
chest pain and shortness of breath with concern for worsening
prosthetic aortic stenosis. An echocardiogram revealed LVEF 70%,
AV peak gradient of 45 mm Hg, mean of 25 mm Hg and valve area of
1.2 cm2 consistent with moderate to severe prosthetic aortic
stenosis (vs. ___ ___ 0.8 cm2 with peak gradient
42 and mean gradient 28). Given level of AS so early after SAVR,
there is concern for early valve failure. Plan at discharge was
for the patient to follow up with outpatient cardiologist for
planning of revision/replacement at ___ of his bio-prosthetic
aortic valve.
Troponin-T 0.02 twice followed by 2 normal values with normal
CK-MB consistent with a tiny NSTEMI. Exercise MIBI provoked no
symptoms and showed no perfusion defects, but poor functional
capacity to only ___ METs. Based on patient's course and
exercise stress, patient's chest pain was deemed to be unlikely
a result of his aortic stenosis. Patient was discharged without
coronary angiography as there was no objective evidence of
residual ischemia. Dose of atrovastatin was increased from 40 mg
to 80 mg in light of his history and risk factors for CAD. | 140 | 226 |
15853302-DS-10 | 28,590,390 | You were admitted to the transplant surgery service for
observation in the setting of increased abdominal pain and
diarrhea. Your pain resolved shortly after admission and you are
tolerating your tube feeds without pain or nausea. Your stool
was checked for infection and was negative and your diarrhea has
also resolved. You are safe to return home and continue your
tube feed and dialysis regimen.
If you experience worsening abdominal pain, nausea, vomiting,
fevers, chills, significant diarrhea, or other symptoms that
concern you please call the Transplant Surgery Office at
___. | Mr. ___ is a ___ year old male with prior failed LRRT
subsequently requiring peritoneal dialysis who is well-known to
our service after his recent episode of necrotizing pancreatitis
in ___ complicated by pseudocysts. Now on HD via RIJ
tunneled line and on tube feeds via a post-pyloric dophoff tube.
He is otherwise NPO. Recent imaging in late ___ showed
improvement in the size of his known pseudocyst and fluid
collections. He returned to the ED on ___ with band like
abdominal pain, vague nausea, and a few episodes of diarrhea.
His lipase was 290, minimal LFT elevation, normal WBC, and
normal vitals. He was admitted to the transplant surgery service
for hydration and observation. His pain resolved after one dose
of dilaudid in the ED. His cdiff specimen was negative and his
diarrhea stopped after an episode in the evening of hospital day
1. His vitals remained stable, his lipase came down to 190. His
peritoneal dialysis catheter and his blood were cultured, both
of which are no growth to date at the time of discharge.
On HD2, the patient underwent routine HD via his RIJ tunneled
line. He was run even for 3.5 hours. The session was stopped 30
minutes early because he had some heaviness in his chest that
lasted for about 3 minutes. It self resolved, he had normal
vitals during the episode, and an EKG was performed which was
within normal limits and stable in comparison to the EKG that he
had on ___. He was observed for a few hours and did not have
recurrence of the chest or abdominal pain. The patient notes
that he gets leg and chest symptoms on and off pretty regularly
during his HD sessions. After HD, his tube feeds were restarted
which he tolerated without difficulty and he was discharged home
to follow up with Dr. ___ week in clinic. No new
medications were prescribed during this admission. | 90 | 320 |
18030487-DS-16 | 25,132,336 | Dear Ms. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted on ___ after you were found to be fatigued
and a little confused. You underwent an evaluation including
physical exams, blood tests, and CT scan of the head. Based on
this work-up, there were no worrisome findings. Your symptoms
were most likely due to medications. We have changed around some
of the medicines to try to help prevent this from happening in
the future.
If you begin to experience any worrisome symptoms such as
confusion, dizziness, lightheadedness, falls, or any other
concerning symptoms, please call your doctor right away. | PRINCIPLE REASON FOR ADMISSION:
___ w/ Afib, CAD, dCHF, CVA on aggrenox, HTN, and dementia who
presents with self-limited episode of fatigue and confusion.
# Fatigue/Confusion: Patient reported to have acute confusion
night prior to admission, and to be lethargic morning of
presentation. Apparently self-resolved spontaneously, as patient
was at her baseline cognitive status on arrival to the medicine
floor. Delirium in this patient with reported dementia has a
wide differential and most commonly may include medication
effect, infectious etiology, electrolyte abnormality or other
metabolic disturbances, seizures also considered. No new
medications per report, however patient is on clonazepam which
certainly could cause delirium in the elderly as well as
amitriptyline. These medications were held and should be used
cautiously or at decreased doses if indicated. Dig level was
also checked and was normal. She had no symptoms or signs of
infection including clean u/a and negative CXR along with any
clinical symptoms of infection. The rash on her abdomen appears
more consistent with irritation dermatitis or candidal rash
rather than cellulitis. Basic chem panel was all within normal
limits. Patient lacked any reported worrisome symptoms for
seizures such as myoclonus, tongue biting, urine incontinence,
though difficult to know whether post-ictal state was possible.
Given the past concern for seizure activity, could consider EEG
as outpatient to further evaluate.
# Ostomy leak: Patient noted to have some leakage from her
ostomy on arrival. Also with bright red rash around ostomy site
concerning for a irritation dermatitis or perhaps candidal rash.
Would recommend careful ostomy nursing to minimize leakage.
Could consider empiric topical antifungal if rash does not
improve with improved hygeine. | 103 | 270 |
15259244-DS-32 | 21,969,255 | You were admitted to the hospital for fevers and rigors during
dialysis. You were found to have a bacterial infection in your
blood and were started on broad-spectrum antibiotics. You then
became septic, had low blood pressure, and were transferred
briefly to the ICU, where you were given fluids and started on
high-dose steroids. Your dialysis line was also pulled because
it may have been the cause of your infection. Your urine did not
show any sign of infection, nor did your chest X-ray. Your
echocardiogram did not show any signs of endocarditis, but your
prior mitral regurgitation has worsened to severe and your
pulmonary hypertension is also worse. When you first came, you
developed right leg pain of unclear etiology. This may have been
due to low blood pressure from sepsis worsening your baseline
poor leg perfusion from your peripheral vascular disease. You
also developed some shortness of breath, likely because you were
fluid overloaded. Your symptoms resolved after you had a new
dialysis catheter placed and were dialyzed. Your blood cultures
eventually grew E coli. You were initially treated with
meropenem, but this was switched to ceftazidime with
hemodialysis to avoid putting another line and potential source
of infection. Although you had a potential drug reaction to a
cephalosporin causing neutropenia, our infectious disease
experts felt that treatment with ceftazidime was the preferred
option due to your brief treatment course of 2 weeks, no need of
another line, and no renal toxicity (as with gentamicin). Your
blood levels will be closely monitored to ensure that you do not
develop neutropenia. Your stool sample was negative for C diff
infection.
We have made the following changes to your medications:
-START ceftazidime 2g/2g/3g with hemodialysis until ___.
-INCREASE sevelamer to 1600mg three times daily with meals
Please continue to take your other medications as previously
prescribed. | ___ yo F child psychiatrist w/ complicated PMH significant for
type 1 IDDM (s/p revision renal and pancraes transplants, ___
and ___, diastolic CHF (Echo 35-40%, ___, recurrent MDR E
coli UTIs, chronic anemia, currently on dialysis for repeated
hyperkalemia, who developed fevers during dialysis and later
septic shock.
. | 303 | 49 |
19791899-DS-21 | 29,547,197 | You were admitted to ___ because of pain in your abdomen and
nausea and vomiting. You were diagnosed with pyelonephritis
(infection of the kidneys that occurs because the urine is
infected). Please finish a 14 day course of antibiotics for
this. Also, you may take the medication pyridium for up to
three days to help with symptoms of bladder spasm. I have also
given you a prescription for medication for nausea in case you
need something. You may also take tylenol with codeine for your
back pain from your kidney infection. Your antibiotics reduce
the efficacy of your birth control pills in their ability to
prevent pregnancy; if you are sexually active for the rest of
this pack of pills make sure that your partner uses a condom. | ___ F with no prior PMHx presents with 1 day suprapubic
discomfort (likely cystitis), polyuria, abd pain, N/V and CVA
tenderness (with ascending pyeloonephritis) with CT findings
suggestive of bilateral pylenopnephritis.
#Pyelonephritis:
-Treated with ciprofloxacin during her hospitalization, and her
symptoms of flank pain improved, as did her nausea. Although
final culture grew out 3 species of bacteria, ___ d/w ___
medical director continuation of antibiotics for now.
Discharged with oral anti-emetics, tylenol and oxycodone prn for
flank pain. She also had pain in her pelvis - ? from cystitis
or menstruation. Prescribed three days of pyridium
# ___: (Cr = 1.3, likely higher than baseline given weight, age,
build)
Creatinine improved to 1.0 on discharge. | 134 | 119 |
18216796-DS-7 | 24,390,420 | Ms ___,
It was a pleasure treating you during this hospitalization. You
were admitted for pancreatitis. You were seen by the Pancreas
doctors and ___ surgery. With time and conservative
care your pancreatitis resolved and by discharge you were
tolerating a regular diet. | ___ is a ___ woman with a history of recurrent acute
idiopathic pancreatitis with extensive work up without clear
cause, followed by Drs. ___ and ___ who presents
with recurrent symptoms concerning for recurrent acute
pancreatitis.
# Acute pancreatitis, idiopathic
# Chronic pancreatic insufficiency
# Post procedure pancreatitis
History of chronic recurrent acute pancreatitis with extensive
negative work up followed by Drs. ___ and ___.
At one point considered radical pancreatectomy though after
review with multi-disciplinary pancreas board decision not to
pursue that line of treatment given friable pancreas and her
chronic pain syndrome had resolved. On admission, BISAP score
was 1 (for age) portending favorable prognosis and lipase
downtending rapidly. With conservative care including NPO, IVFs,
pain and nausea control her symptoms abated and she was
tolerated a clear liquid diet. CTA showed widened PD that would
allow advanced endoscopic intervention. On ___, she underwent
ERCP and received a PD stent across the minor papilla in an
effort to keep the PD patent. Post-procedure on ___, she
developed abd pain and nausea with lipase elevated to 2400. The
pain has been waxing and waning since then with fluctating
lipase levels of unclear significance.
Continued Pancrelipase (usually on Viokace at home) at an
approximate dose, which she takes for pancreatic insufficiency
# Seizure disorder
s/p temporal lobectomy, without seizures for many years.
Continued Lamotrigine
and Levetiracetam | 43 | 222 |
18041094-DS-6 | 22,435,677 | Dear Ms. ___,
It was a pleasure caring for you during your stay at ___
___. You were admitted with throat pain and
were found to have epiglottis and a blood stream infection
caused by the bacteria, Pasteurella. We believe your dog
transmitted this infection to you. You were initially admitted
to the ICU and required a breathing tube. After treatment with
antibiotics, you improved and transitioned to the general
medicine floor. Our infectious disease colleagues evaluated you
and recommended a 14 day course of ceftriaxone, an IV
medication. You should have home infusions of this medication
daily through ___.
You were also found to have a primary herpes simplex I infection
of your mouth. You were started on acyclovir, which you should
continue to take for a total of 7 days (day 1: ___, day 7:
___.
You should follow-up with the ear, nose, and throat doctor, ___.
___ in ___ weeks. Please call ___ to make an
appointment. You have an appointment with your PCP, ___,
___ for ___ at 9:20am.
Please take care,
Your ___ Team | Ms. ___ is a ___ y/o woman who presented with sore throat and
was found to have pasteurella epiglottitis and bacteremia.
=================== | 177 | 21 |
18203081-DS-9 | 23,964,193 | You were admitted for pain and swelling of your left hand. You
were seen by the hand surgery team. You were put on IV
antibiotics and your symptoms improved. You had a possible
allergic reaction or side effect to Vancomycin which caused
tingling in your throat. Please continue antibiotics and
follow-up in the hand surgery clinic as scheduled. | ___ year old male with PMH of well controlled asthma presenting
with left hand pain and swelling.
#Flexor tenosynovitis of left hand. Hand surgery was consulted
in the ED. No obvious inciting cause of inflammation.
Significant improvement on Vanc/Unasyn and elevation. With
Vancomycin he developed some redness at the injection site and
some tingling in his mouth/throat, Vancomycin was discontinued.
-Transitioned to Bactrim DS for a 14 day course
-Follow with hand surgery in ___ days.
#Asthma: No signs of exacerbation, continue PRN albuterol
#FEN/PPX: regular, ambulatory
Full code | 62 | 89 |
17749813-DS-2 | 24,151,360 | Dear Mr ___,
You were admitted to the hospital because of a fall. You
evaluation showed no heart attack, stroke, bleeding in your
brain, or abnormal heart rhythm as the cause of your fall. Your
fall was likely related to a urinary tract infection, for which
you will need to complete a course of antibiotics. You were
evaluated by ___, who felt that you would benefit from home ___. | Mr ___ is an ___ with history of A. fib on Coumadin,
hypertension, presenting with an unwitnessed fall/syncope.
# Fall
Patient with syncopal episode of unclear etiology. No clear
mechanical cause for fall and no h/o prior falls. Patient denied
any ___ symptoms. No neurologic deficits on exam to
suggest CVA and NC head CT neg for bleed or acute stroke. No h/o
seizures. ___ revealed LBBB on EKG, which was later
confirmed to be present on EKG in ___. Cardiac enzymes were neg
x 3. Monitored on telemetry with no arrhythmias. Echocardiogram
with normal EF, no e/o valvular disease and no wall motion
abnormalities. Syncope likely occurred in setting of UTI for
which patient will complete a ten day course of antibiotics. If
recurrent episode, would consider event monitor. Patient
evaluated by ___ who recommended regular use of a cane and home
___ for balance training.
# UTI
Patient reported h/o BPH and prior UTIs. Denied dysuria or
recent difficulty urinating. Urinalysis for w/u of fall showed
pyuria and bacteriuria. Initially treated with Ceftriaxone IV,
then transitioned to PO Bactrim to complete a ten day course.
Urine culture grew ___ E.coli. (Of note, patient had
foley placed in ED as part of trauma protocol. Removed on
arrival to the floor with few subsequent self limited episodes
of hematuria. Reported clear urine prior to discharge. Has had
h/o intermittent hematuria in past and this is not uncommon for
him).
# PAfib
In SR throughout course. Continued Atenolol. Patient
anticoagulated on warfarin with INR 1.6 on admission. Patient
reported goal ___, confirmed with ___
___ clinic that goal has been ___. Given above
antibiotics, discharged on lower dose of warfarin 2.5mg daily
with INR ___ on ___. INR on day of discharge 1.5.
# Incidental finding:
CT noted ___ left thyroid gland. TSH WNL. Recommend
outpatient ultrasound for further evaluation.
# HTN
BP elevated on arrival to 190/90. Treated acutely with
Labetolol, then resumed home Atenolol.
# CKD III
___ ~ 1.3. GFR 53. Remained at baseline.
# BPH
Continued finasteride. | 68 | 331 |
16880383-DS-19 | 23,698,337 | You were admitted to the hospital with appendicitis requiring an
operation to remove your appendix. You are being discharged to
home with the following instructions: You are being discharged
on medications to treat the pain from your operation. These
medications will make you drowsy and impair your ability to
drive a motor vehicle or operate machinery safely. You MUST
refrain from such activities while taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep 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.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care: You may shower, no tub baths or swimming. If there
is clear drainage from your incisions, cover with clean, dry
gauze. Your steri-strips will fall off on their own. Please
remove any remaining strips ___ days after surgery. Please call
the doctor if you have increased pain, swelling, redness, or
drainage from the incision sites. | The patient was admitted to the Acute Care Surgery team and
underwent CT imaging of her abdomen showing acute appendicitis
with intestinal malrotation. She was consented and taken to the
operating room for laparoscopic appendectomy. There were no
complications. Reader referred to operative note for full
details. Postoperatively she progressed well; her diet was
advanced on the morning following her surgery and her home
medications were restarted. She was able to tolerate her diet
without problems and is ambulating independently with adequate
pain control. She is being discharged to home and will follow up
with her PCP and in ___ Care Surgery clinic in the next few
weeks. | 274 | 108 |
14810438-DS-17 | 22,175,867 | Dear Mr. ___,
You were found down unresponsive on the side walk after drinking
alcohol and taking suboxone. You required support of your
breathing because of this. It is very important that you do not
take this combination of medications again in the future as it
can make you stop breathing and kill you. We are happy that you
improved and are ok. It was a pleasure being involved in your
care.
Your ___ Team | ___ with unknown PMH found unresponsive with serum EtOH level of
131 now intubated and sedated after apneic episode with
respiartory failure likely secondary to toxic metabolic
encephalopathy.
#Hypercarbic Respiratory Failure
Patient with respiratory failure secondary to altered mental
status and inability to protect the airway. Hypercarbia now
improved with intubation with normal pH and pCO2. Patient was
quickly weaned from mechanical ventilation and extubated
successfully and on RA prior to discharge.
#Toxic Metabolic Encephalopathy
Patient found down with bottle of EtOH with pinpoint pupils
unresponsive to narcan. Serum EtOH level of 131 supports EtOH
intoxication. Tox screen otherwise negative with negative CT
head. Upon awakening patient endorsed taking a half tab of
suboxone with alcohol. Infectious etiology also less likely
given absence of leukocytosis, normal UA, and normal CXR. Mental
status improved post-extubation.
#Alcohol intoxication
Patient with elevated serum EtOH level to 131. LFT's and INR all
within normal range. Patient denied history of DT's or
complicated alcohol withdrawel. Social work evaluated patient.
Additionally patient monitored with CIWA scale for withdrawal.
Thiamine, folate, and MVI given. Counseled regarding ETOh abuse
and also seen by SW prior to discharge.
#Pancytopenia
Patient noted to develop pancytopenia on labs while in the ICU
likely secondary to bone marrow suppression from alcohol use and
dilutional effect from IVF since all counts were down.We
requested that patient stay to have repeat CBC to ensure
stability but patient refused to stay for blood draw. Otherwise
was stable without bleeding so recommended he should have this
rechecked upon follow up as outpatient if not willing to stay.
#Hematemesis
Questionable hematemsis vs. trauma from OG tube placement in ED.
Differential included gastritis and ___ tear though
patient was without any evidence of ongoing bleeding in the ICU.
#Lactic Acidosis
Patient with evidence of lactic acidosis initially with lactate
of 3.4 on arrival. Elevated lactate likely secondary to poor PO
intake in addition to EtOH effect favoring preferential
conversion of pyruvate to lactate. Lactate improved with IVF to
1.1 prior to discharge. | 73 | 325 |
11009074-DS-12 | 22,895,157 | Dear Ms. ___,
It was our pleasure participating in your care. You were
admitted on ___ after being found to have blood in your
stool. You were found to have low blood and platelet counts but
fortunately did not need any blood transfusions. On evaluation
of your low counts, you were found to have large abdominal lymph
nodes concerning for lymphoma. You were also found to have an
infection, called anaplasmosis, for which you were started on an
antibiotic. .
You also underwent bone marrow biopsy. The results of this are
currently pending. You will be called when these results are
finalized.
Your platelets have remained low and puts you at risk for
bleeding. Please let your doctor know if you develop any
headaches, bleeding of your gums or nose bleeds or other
episodes of black stool or bleeding. You will need to get your
blood drawn on ___ to check your blood count.
Again, it was our pleasure participating in your care,
Your ___ Team | PRIMARY PRESENTATION:
___ yo woman with hx of GERD who presented with weakness and
fatigue, with melena in setting of likely UGIB with associated
pancytopenia. She has elevated LDH with lymphadenopathy seen on
CT abdomen concerning for lymphoma, along with heme workup
revealing anaplasma. She also likely had gastritis from NSAIDS
use, leading to bleeding in setting of severe thrombocytopenia.
She underwent bone marrow biopsy on ___ that showed anaplamsa
with final stains for lymphoma pending at time of discharge.
ACTIVE ISSUES
#Lymphocytosis and Thrombocytopenia, concerning for CLL vs
Mantle cell: Per ___ report, the lymphocytosis is concerning for
CLL, however may need further investigation. Patient was aware
of working diagnosis, and had follow up with oncology
outpatient. Patient did not have any repeat episodes of melena
after initial admission ___ and on ___, with her Hgb/Hct
remaining stable and thrombocytopenia remained stable with
slight improvement during hospitalization. It was recommended
that she remain hospitalized until final pathology was
determined, in the event that an aggressive lymphoma were
identified and needed to be treated urgently. The patient, her
husband, and in consultation with her PCP preferred discharge
home with follow-up with hematology/oncology once her final
pathology was back. These results were communicated over the
phone by the resident physician and confirmed her follow-up
appointment with heme/onc.
# Anaplasma: Anaplasmosis or other tick borne illness could
explain thrombocytopenia and subsequent bleeding, but prominent
lymphadenopathy was thought to be less likely due to the
infection. Her CBC was closely trended, and she was treated with
Doxycycline 100mg TID, Day 1: ___, with plan for a ___ day
course on discharge.
#Upper GI Bleed from gastritis in setting of severe
thrombocytopenia: Patient's Hgb/Hct remianed stable over
admission. Patient was on Pantoprazole 40 mg IV twice a day
inpatient. An upper endoscopy was not performed given presenting
symptoms and thrombocytopenia. On discharge, she was given
ranitidine 150 mg PO BID and Pantoprazole 40 mg PO twice a day.
H. pylori antibody was negative, checked prior to admission.
CHRONIC ISSUES
#Cough/Asthma: Patient complained of mild cough, and audible
"wheezing", correlated with physical exam. Patient was continued
on home Symbicort, with sympotamtic relief with Guaifenesin. She
remained stable on room air and did not require any supplemental
oxygen therapy.
#Osteoporosis: Patient was continued on home medications of
Calcium Carb-Vit D3 600mg-400mg, with advil held in setting od
inpatient GI bleeding.
#Hyperlipidemia: Patient continued on home Lipitor 10 mg daily
TRANSITIONAL ISSUES
--------------------
- Follow up H. pylori serum antibody: negative
- Follow up bone marrow biopsy: report as of ___ consistent
with Chronic Lymphocytic Leukemia
- Continue doxy for total 14 day course
- Please recheck CBC + diff on ___
- Full code | 162 | 440 |
Subsets and Splits