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15373895-DS-19 | 28,448,473 | Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital
after undergoing repair of your ventral hernia. You have
recovered from surgery and are now ready to be discharged to
home with services. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
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 10 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
- You may start some light exercise when you feel comfortable.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during surgery.
- You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
- You could have a poor appetite for a while. Food may seem
unappealing.
- All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
- Your incision may be slightly red around the edges. This is
normal.
- If you have steri strips, do not remove them for 2 weeks.
(These are the thin paper strips that are on your incision.) But
if they fall off before that that's okay).
- You may gently wash away dried material around your incision.
- It is normal to feel a firm ridge along the incision. This
will go away.
- Avoid direct sun exposure to the incision area.
- Do not use any ointments on the incision unless you were told
otherwise.
- You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
- You may shower, but do not bathe you are seen in clinic for
follow-up.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluitds and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
-You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied.
- Do not take it more frequently than prescribed. Do not take
more medicine at one time than prescribed.
- Your pain medicine will work better if you take it before your
pain gets too severe.
- Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
- If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
- Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
- Take all the medicines you were on before the operation just
as you did before, unless you have been told differently.
- If you have any questions about what medicine to take or not
to take, please call your surgeon. | Mr. ___ was admitted from the emergency department on
___. He was initially seen at his PCP's office where a
KUB was done showing distended loops of bowel concerning for
small bowel obstruction. On evaluation in the ED, CT scan of the
abdomen showed a complex network of ventral hernias with
multiple loops of bowel incarcerated within the hernia. He was
admitted to the Acute Care Surgery team for management and
operative discussion/planning.
Mr. ___ was taken to the OR on ___ and underwent an
exploratory laparotomy with bilateral rectus abdominis component
separation repair of abdominal wall defect with polypropylene
mesh and small bowel resection with primary anastomosis,
performed by Dr. ___. He tolerated the procedure well without
any complications and was taken to the post-anesthesia care unit
in stable condition. At the end of the procedure, Mr. ___ had 2
JP drains in the space overlaying the mesh and an NG tube for
decompression of the stomach.
In the immediate post-operative period, Mr. ___ at an epidural
for pain control and foley catheter while he had an epidural.
The NG tube was removed a few days after the operation and he
was started on sips of clears, awaiting return of bowel
function. However, after a few days, Mr. ___ became
increasingly distended and had an episode of emesis. He was
again kept NPO, started on IV fluids, and given a PCA for pain
control temporarily. An NGT had to be placed to decompress the
stomach after a second episode of bilious vomiting. Once he
began passing flatus, he was started on a clear diet and diet
was advanced as tolerated while he continued to pass flatus.
During the recovery period, he was also started antibiotics for
some mild non-demarcatable erythema noted over the incision,
especially given the risk of mesh infection. The JP drains
remained serosanguinous in output.
On discharge, Mr. ___ continued to pass flatus, although he had
not had a bowel movement. He was tolerating a regular diet
without any nausea and vomiting and continued on a bowel
regimen. He was eager to be discharged and acknowledge that
should he not have a bowel movement in 48 hours, he should call
the clinic or return to the ED. He was given instructions for
medications and scheduled to follow-up early next week for
staple removal and JP drain removal and then another 2 weeks
after for follow-up. | 760 | 398 |
19045496-DS-24 | 22,343,752 | You were admitted to the hospital after walking into a door and
hitting your face. You sustained a left eyelid injury. You
were seen by the paramedics and declined admission to the
emergency room. Shortly afterward, you felt short of breath and
felt like your "airway was closing" prompting arrival to
emergency room. You had an airway placed for airway protection.
You had an elevated INR of 1.8 and was given medication to
lower the level. You underwent imaging and you were reported to
have a retro-pharyngeal hematoma and an isolated fracture to
your neck. You were evaluated by Neurosurgery and no surgery
was indicated. Your vital signs have been stable and you are
preparing for discharge to a rehabilitation center to further
regain your strength and mobility. You are being discharged
with the following instructions:
return to the Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please return to the emergency room if you have a recurrence of
neck pain, headache, and throat pain. If you begin to have
difficulty swallowing it is important to return here.
You will see Dr. ___ prior to resuming your coumadin | ___ year old female with past medical history notable for afib on
warfarin and recurrent falls. Per report of primary team, she
suffered a fall earlier and struck her head on a doorknob. She
initially was able to get up and refused transfer to the
hospital, but later (<1 hour after), she noticed swelling in her
neck and difficulty breathing.
She was brought to the emergency room where a CT scan of the
neck was done, which showed a large prevertebral retropharyngeal
hematoma with active extravasation of contrast. She was
intubated in the emergency room. The patient was admitted to
the MICU for monitoring and pulmonary toilet.
On arrival to the MICU, the neurosurgical, ENT, and spine teams
were consulted, who did not initially plan for surgical
intervention. The ACS team was consulted given multiple other
areas with evidence of trauma, and recommended transfer to the
TSICU. Imaging of the neck showed active extravasation, venous
vs arterial but the source was unclear. Per Neurosurgery/ENT,
there was no clear surgical intervention to be performed. An MRI
of the neck was done which demonstrated an acute fracture
involving the anterior C4 vertebral body. The patient was
placed in a soft collar for comfort but later discontinue
because the spine was stable and there was only 1 column injury.
An oral-gastric tube was placed for the initiation of tube
feedings. Prior to extubation, the patient underwent a bronch
which demonstrated tracheomalacia. She had pneumonia from group
B strep and was started a 7 day course of antibiotics:
ceftriaxone and azithromycin, which was changed to ancef when
culture date was obtained.
The patient was successfully weaned and extubated on ___. To
provide nutrition after removal of the oral gastric tube, the
patient was evaluated by Speech and Swallow and underwent a
Video swallow. She was transitioned to a soft diet. Because of
the patient's underlying cardiac history, she underwent an
echocardiogram which showed an EF 50-55%, and 2+ MR.
___ patient was transferred to the surgical floor on ___. Her
hematocrit remained stable. On ___, she reported increased neck
and posterior head pain. The Neurosurgery service was
re-consulted and recommended a non-contrast head cat scan which
showed severe chronic small vessel ischemic changes with no
acute process. The patient was given pain medication and warm
compresses and her neck pain decreased in intensity. In
preparation for discharge, she was evaluated by physical therapy
and recommendations made for discharge to a rehabilitation
facility.
The patient was discharged on HD # 11. Her vital signs were
stable and she was afebrile. She was voiding without difficulty
and had return of bowel function. Her appetite continued to be
decreased and she was provided with nutritional supplements.
She had no difficulty with swallowing. Her hematocrit and white
blood cell count stabilized. Appointments for ___ were
made in the acute care clinic. Discharge instructions were
reviewed and questions answered.
Her anticoagulation was held during this admission, and should
not be continued until discussion with her PCP at ___. | 302 | 515 |
15071083-DS-16 | 24,572,540 | you were hospitalized for gi bleeding that was from ischemic
colitis. you underwent biopsy of your pancreas that did not
show cancer. you received transfusion of blood. blood thinner
was resumed. you were treated for bacterial infection and are
undergoing treatment for C. diff infection.
You will need a repeat ERCP in 6 weeks and repeat CT scan of
your pancreas in 4 weeks to follow up findings in your pancreas. | ___ gentleman DM2, CAD s/p CABG, ischemic cardiomyopathy with
LVEF 20%, atrial fibrillation on Coumadin, and a recent history
of pancreatitis, cholecystitis, and c. diff colitis presents
with BRBPR and UTI and admitted initially to the MICU due to
transient hypotension while in the ED.
# BRBPR/GI bleeding - Pt. presented with 2 day history of large
bloody bowel movements. Rectal exam revealed maroon stools.
Despite bloody bowel movements, H/H relatively stable on
admission at 9.6/29.8 from 10.6/32.1 one month prior. Pt.
responded appropriately to 1U PRBC in the ED. Pt. had one
episode of hypotension that resolved with transfusion and IVF.
No evidence of source on CT ab/pelvis, though limited by lack of
PO contrast. EGD without clear source of bleed in ___.
Colonoscopy ___ did show hemorrhoids as well as sigmoid
diverticuli. Pt's INR was reversed in the ED with vitamin K and
FFP. Pt. was seen by GI who felt that bleed most likely
diverticular vs ischemic colitis. Pt. remained hemodynamically
stable without further drop in H/H and so was transferred to the
floor on hospital day 2 He got one additional unit of RBC and
hemoglobin prior to discharge was 9.6.
#Pancreas lesion: not consistent with solid mass on endoscopic
ultrasound. Underwent pancreas biopsy that did not show
malignancy. He will have f/u with Dr. ___ adv endoscopy
team for biliary stent removal and can discuss future imaging of
abd at that time. CA ___ tumor marker normal level.
- ERCP in 6 weeks
- CT pancreas protocol in 4 weeks, follow up with Dr. ___
___
# Hypotension: Pt. transiently hypotensive to 86/40 while
undergoing CT scan in the emergency department. Hypotension
resolved with administration of IVF and blood transfusion. He
never required pressors. Given blood loss and bacteremia,
hypotension was likely related to combination of hypovolemia and
possibly sepsis. Pt. had no further episodes of hypotension.
# E. coli bacteremia and UTI - Per nursing home report, culture
from the day prior to admission was growing E. coli, though pt.
had not yet been initiated on antibiotics. UA grossly positive
on arrival to ___. Pt. initiated on ceftriaxone. Blood and
urine cultures, however, grew E. coli resistant to ceftriaxone
and so pt. transitioned to meropenem. He received 9 day of
antibiotics from first day of negative blood culture on ___ to
end on ___. PICC line placed in mid line position to be removed
prior to discharge.
# C. difficile colitis: Per reports, pt. has history of
recurrent C. diff. Pt. admitted on PO vancomycin (DAY ___
END ___. However, consider extending course given recent
treatment with Meropenem for UTI
# Hyponatremia: Pt. hyponatremic on admission with Na 126.
After IVF and blood transfusion, sodium improved to 130.
# DM2: At home, pt. is not on insulin, though he is covered by
low dose sliding scale at rehab. Pt. was continued on insulin
sliding scale during this admission.
# Cardiac disease: Pt. with atrial fibrillation (CHADS2 of 4; on
Coumadin), CAD, and CHF (EF 20%). Pt's INR was reversed on
admission due to active GI bleed with 10 IV vitamin K and FFP.
His home torsemide was held in setting of hypotension and then
resumed at lower dose. Coumadin resumed prior to discharge. He
was continued on home aspirin, digoxin, metoprolol, and
pravastatin.
- Torsemide may require uptitration
# Gout: Continued home prednisone and allopurinol.
# BPH: Continued home finasteride.
# Transitional issues:
- Contact: ___ (wife) ___
- Code: Full | 73 | 579 |
11669075-DS-16 | 25,889,399 | Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL:
-You were having burning and palpitations in your chest
-You had an abnormal, fast rhythm of the heart. This is called
supraventricular tachycardia (SVT)
WHAT WAS DONE FOR YOU WHILE IN THE HOSPITAL:
-You were given medications to slow your heart rate down
-You were monitored closely on a heart rhythm monitor
-You were seen by the electrophysiologists (electrical doctors
of the ___
-Your medications were adjusted to help prevent further episodes
of SVT
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL:
-Please continue taking your medications as prescribed
-Please follow-up with your outpatient doctors as ___
Thank you for allowing us to participate your care. We wish you
the best of luck!
Your ___ Team | Mr. ___ is a pleasant ___ y/o gentleman with a PMH of
hypertrophic cardiomyopathy s/p ETOH septal ablation, ulcerative
colitis s/p total protocolectomy, and hypertension, who
presented with several weeks of palpitations, found to be in
supraventricular tachyarrhythmia most likely c/w AVNRT. | 113 | 42 |
17164417-DS-7 | 24,903,173 | Take your pain medicine as prescribed.
¨ Exercise should be limited to walking; no lifting,
straining, or excessive bending.
¨ Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
¨ Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
¨ If you were on a medication such as Coumadin (Warfarin),
or Plavix (clopidogrel), or Aspirin prior to your injury, you
may not resume taking this until you have been seen in follow up
by Dr. ___.
¨ You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
¨ New onset of tremors or seizures.
¨ Any confusion, lethargy or change in mental status.
¨ Any numbness, tingling, weakness in your extremities.
¨ Pain or headache that is continually increasing, or not
relieved by pain medication.
¨ New onset of the loss of function, or decrease of function
on one whole side of your body. | Mr. ___ was admitted from the emergency department to the
surgical intensive care unit on ___ after being adminstered
Kcentra and vitamen K. His aspirin and coumadin were held. A
trauma evaluation was started which included a dedicated CT
SINUS/MANDIBLE/MAXIL to evaluate for facial fractures. Plastic
surgery was asked to consult regarding.
___, the patient's exam remained stable. Plastic surgery
reviewed the CT of the sinus which showed segmental fracture of
the left zygomatic arch and possible nondisplaced fracture of
the lateral wall of left orbit. Plastics recommended that the
patient follow up with them in clinic following discharge from
the hospital. He had a repeat NCHCT which showed a stable bleed
interval.
On ___, patient was stable and transferred to the floor.
On ___, the patient remained neurologically stable and was
pending a bed to rehab.
On ___, patient was stable on examination. Repeat head CT was
performed and showed stable ventricular size and improved IVH.
He was accepted at rehab and was discharged in stable condition. | 226 | 167 |
15213209-DS-22 | 25,710,540 | It was a pleasure taking care of you at ___
___.
During your hospitalization, you had surgery to remove unhealthy
tissue on your lower extremity. You tolerated the procedure
well and are now ready to be discharged from the hospital.
Please follow the recommendations below to ensure a speedy and
uneventful recovery.
LOWER TRANSMETATARSAL AMPUTATION DISCHARGE INSTRUCTIONS
ACTIVITY
You should keep your amputation site elevated and straight
whenever possible. This will prevent swelling of the stump and
maintain flexibility in your joint.
It is very important that you put no weight or pressure on
your stump with activity or at rest to allow the wound to heal
properly.
You may use the opposite foot for transfers and pivots, if
applicable. It will take time to learn to use a walker and
learn to transfer into and out of a wheelchair.
MEDICATION
Before you leave the hospital, you will be given a list of all
the medicine you should take at home. If a medication that you
normally take is not on the list or a medication that you do not
take is on the list please discuss it with the team!
You will likely be prescribed narcotic pain medication on
discharge which can be very constipating. If you take
narcotics, please also take a stool softener such as Colace.
If constipation becomes a problem, your pharmacist can suggest
an additional over the counter laxative.
You should take Tylenol ___ every 6 hours, as needed for
pain. If this is not enough, take your prescription narcotic
pain medication. You should require less pain medication each
day. Do not take more than a daily total of 3000mg of Tylenol.
Tylenol is used as an ingredient in some other over-the-counter
and prescription medications. Be aware of how much Tylenol you
are taking in a day.
BATHING/SHOWERING:
You may shower when you feel strong enough but no tub baths or
pools until you have permission from your surgeon and the
incision is fully healed.
After your shower, gently dry the incision well. Do not rub
the area.
WOUND CARE:
Please keep the wound clean and dry. It is very important that
there is no pressure on the stump. If there is no drainage,
you may leave the incision open to air.
Your staples/sutures will remain in for at least 4 weeks. At
your followup appointment, we will see if the incision has
healed enough to remove the staples.
Before you can be fitted for prosthesis (a man-made limb to
replace the limb that was removed) your incision needs to be
fully healed.
CALL THE OFFICE FOR: ___
Opening, bleeding or drainage or odor from your stump incision
Redness, swelling or warmth in your stump.
Fever greater than 101 degrees, chills, or worsening
incisional/stump pain
NO OTHER PROVIDER, EXCEPT YOUR VASCULAR SURGEON, SHOULD
DETERMINE IF YOUR STAPLES ARE READY TO BE REMOVED FROM YOUR
SURGICAL SITE.
IF THERE ARE ANY QUESTIONS, THE PROVIDER SHOULD CALL THE
VASCULAR SURGERY OFFICE AT ___ TO DISCUSS. THE
STAPLES/SUTURES WILL BE REMOVED IN THE OFFICE AT YOUR FOLLOWUP
APPOINTMENT WHEN IT IS DETERMINED BY THE VASCULAR SURGEON THAT
THE WOUND HAS SUFFICIENTLY HEALED. | Patient underwent LLE angiogram with popliteal artery and
anterior tibialis artery stent on ___. It was decided to
pursue a LLE transmetatarsal amputation and was added on for
___. The patient was NPO prior to ___ procedure, but the
case had to bumped to ___ due to limited OR availability.
Surgery was rescheduled for ___. Patient received dialysis
on the morning of his procedure, which he has getting every 3
days. After induction of general anesthesia for LLE
transmetatarsal amputation, anesthesia noticed low blood
pressure and ST depressions. At this time, it was decided to
hold off on the procedure and consult cardiology. Cardiology
stated that the event was most likely secondary to demand
ischemia due to no EKG changes post operatively. However, they
wanted to assess patients cardiac status through cardiac
catheterization. He was added on for ___. Patient was unable
to undergo cardiac catheterization and was reschedule for
___. It was on ___ that patient decided he wanted to
leave the hospital and come back at another time for the cardiac
procedure. This was against medical advice and patient
understood. He was advised to continue aspirin and plavix. He
was written a script for Augmentin PO for 2 weeks. Patient was
contacted by vascular and cardiac surgery for follow up
appointments. | 548 | 213 |
18067322-DS-15 | 22,235,504 | Dear Ms. ___,
It was a pleasure participating in your care at ___.
You were admitted with severe abdominal pain that was most
likely due to a small kidney stone, though it was not visualized
on CAT scan and UA was negative.
Your pain has improved, and as we discussed, you will be
discharged with a short course of oxycodone, tylenol and
ibuprofen, as well as Reglan and Zofran. Finally, you are given
a prescription for a medicine to help the stone pass if it has
not already.
Please sip fluids to stay hydrated as you recover. | 1. Abdominal Pain due to Hemmorhagic Ovarian Cyst, nausea with
vomitting: Pain was out of proportion to exam, requiring
dilaudid PCA for HD 2, however patient eventually felt it may be
more anxiety related, was switched to oral oxycodone tylenol
motrin. Renal stone is most likely given clinical picture of
writhing ___ pain, though exams reviewed with radiology and no
evident stone, good ureteral perfusion jets to bladder
indicating no osbstruction, no other intraab pathology.
Discharged hospital day three with tamsulosin. Tolerating PO.
2. Chronic Stable Asthma
- Albuterol
3. ADHD
- Currently off all amphetamines (stopped 4 months prior to
admit)
Full Code
Ambulation | 96 | 100 |
13013759-DS-22 | 26,057,151 | Discharge Instructions
Activity
· You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
· Heavy lifting, running, climbing, or other strenuous
exercise should be avoided for ten (10) days. This is to prevent
bleeding from your groin.
· You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
· Do not go swimming or submerge yourself in water for five
(5) days after your procedure.
· You make take a shower.
Medications
· Resume your normal medications and begin new medications
as directed.
· It is very important to take the medication your doctor
___ prescribe for you to keep your blood thin and slippery.
This will prevent clots from developing and sticking to the
stent.
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
· If you take Metformin (Glucophage) you may start it again
three (3) days after your procedure.
Care of the Puncture Site
· The small bandage over the site was removed.
· Keep the site clean with soap and water and dry it carefully.
· You may use a band-aid if you wish.
What You ___ Experience:
· Mild tenderness and bruising at the puncture site (groin).
· Soreness in your arms from the intravenous lines.
· The medication may make you bleed or bruise easily.
· Fatigue is very normal.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the
puncture site.
· Fever greater than 101.5 degrees Fahrenheit
· Constipation
· Blood in your stool or urine
· Nausea and/or vomiting
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 | Ms ___ is a ___ yo female who presented with a headache.
Initial CT at OSH showed a SAH with IVH and she was transferred
to ___ for further evaluation.
#SAH/IVH from pseudoaneurysm
CTA showed stable IVH/SAH with mild hydrocephalus and 2mm L ICA
pseudoaneurysm. She was admitted to the Neuro ICU for close
neuro monitoring and strict blood pressure control <140. She was
taken to angio suite on ___ and underwent pipeline
embolization of R ICA pseudoaneurysm. Please see operative
report for full details. R groin was angiosealed and she was
transported to ICU intubated. She was started on Keppra 1 g Q12H
BID for 7 days for seizure ppx and nimodipine 60 mg q4h for 21
days for vasospasm ppx. She was successfully extubated. She was
continued on ASA/Brilinta. She remained in ICU for close BP
monitoring and vasospasm watch. Head CT ___ showed slight
worsening of hydrocephalus but she remained neurologically
stable. She had continued nausea and was started on decadron
with improvement. She was transferred to the step down unit on
___. She was evaluated by physical therapy ___, who
recommended rehab at discharge. On ___, she became very
agitated and complained of a headache and had new right ptosis.
She underwent STAT CTA brain, which was negative for acute
findings. She underwent cerebral angiogram which showed complete
resolution of the aneurysm. Physical therapy and occupational
therapy were consulted for disposition planning and recommended
discharge to rehab. On day of discharge, her pain was well
controlled with oral medications. She was tolerating a diet and
getting out of bed with assistance. Her vital signs were stable
and she was afebrile. She was discharged to rehab in a stable
condition.
#Hypertension
She was started on PO labetalol for blood pressure control,
which was titrated and eventually discontinued.
#Leukocytosis
WBC uptrended and she was afebrile. UA was negative. CXR showed
minimal atelectasis and incentive spirometry was encouraged.
LENIs were negative for DVT. WBC downtrended to normal.
#Diarrhea
She had multiple episodes of loose stool. She was negative for
C. difficile. Bowel regimen was liberalized to PRN. | 410 | 344 |
16311983-DS-13 | 28,630,099 | Dear Mr. ___,
You were admitted to ___ for worsening leg and abdominal
swelling, worsening shortness of breath, and low blood counts.
We gave you medications to help you urinate out extra fluid. We
were able to get fluid out of your lungs and you no longer
requried oxygen to breathe. The fluid in your legs improved. You
received blood to elevated your blood count to help your
breathing and fatigue. Your blood counts remained stable.
Please weigh yourself daily. | ___ male with history of CHF, hypertension, and
macrocytic anemia of unknoen etiology, admitted with volume
overload and dyspnea, concerning for acute diastolic CHF
exacerbation, exacerbated by worsening chronic macrocytic
anemia. Symptoms improved with diuresis and two blood
transfusions. Electrolytes repleted during diuresis, likely
worsened in setting of some chronic malnutrition. Discharged to
short term rehab with improved edema and on room air.
ACTIVE ISSUES
# Diastolic heart failure exacerbation
CXR, BNP, history and exam suggestive of volume overload
secondary to diastolic CHF exacerbation; patient with primarily
right-sided heart failure; echo in ___ with LVEF 55%,
moderate MR. ___ with IV lasix. Fluid restricted to
2000cc/day. There was a concern for cirrhosis contributing to
edema with his low albumin and elevated INR in setting of
chronic hepatitis B and EtOH abuse, but RUQ US did not indicate
evidence of a cirrhotic liver. Dyspnea is also worsened by
concomittant anemia and his severe pulmonary hypertension.
Fatigue and shortness of breath improved with RBC transfusions,
as below. On ___ he was transitioned from IV furosemide to PO
torsemide and was able to maintain diuresis. On ___ his foley
catheter was removed and he was able to urinate. He already has
outpatient follow-up scheduled in cardiology clinic.
# Hyponatremia:
Sodium was 119 on admission. Pt has h/o hyponatremia during past
hospitalizations, thought to have beer potomania at that time.
His current hyponatremia was secondary to hypervolemia in
setting of dCHF exacerbation. There could also be a component of
chronic, mild hyponatremia in the setting of citalopram use. His
Na+ slowly trended up with diuresis. Na+ at discharge was 129.
# Macrocytic Anemia:
This is a chronic issue for him. Workup to date revealed normal
B12, folate, iron studies, ___ only with a few colonic
adenomatous polyps in ___, and BM Bx without hypocellularity
and no evidence MDS. ___ without signs of active bleeding,
stool guiac negative. Likely secondary to chronic EtOH abuse.
Received two transfusions of 1U PRBC each for HCT < 21 with
improvement in fatigue. HCT stabilized for several days prior to
discharge. H/H at discharge was 8.2/24.3
# Alcohol Abuse:
Pt has h/o alcohol abuse with prior episode of DT's requiring
intubation for airways protection. H/O fatty liver per medical
record. Unclear how much he drinks, states that he doesn't drink
every day, cannot quantify how much beer, but states that he
drinks to take the edge off of his back pain. He received IV
thiamine and folate x 5 days, continued on home B12 and MVI.
CIWA protocol used, but patient did not score nor receive any
benzodiazepines.
# Tobacco Abuse
He was started on a nicotine patch while hospitalized.
# Severe pulmonary hypertension
Noted on echo in ___, unclear etiology, may be secondary to
chronic hypoxemia from smoking, left-sided valvular disease
(MR), or pulmonary arterial hypertension. Would recommend
oupatient PFTs and perhaps RHC as outpatient when seeing
cardiology.
# Diarrhea: Nonbloody, no recent abx use. No recent travel or
sick contacts. ___ be malabsorptive or in setting of poor
nutrition. C. diff was ordered to be collected but patient did
not have diarrhea once admitted.
CHRONIC ISSUES
# Spinal Stenosis: pt has severe spinal stenosis s/p several
surgeries and now physically disabled. He takes oxycontin for
his pain and seen at ___ steroid injections,
and has h/o opioid abuse in past but not currently abusing it.
Continued on home oxycodone.
# Proteinuria: documented in past PCP ___. Unclear etiology.
Pr/Cr 1.8. Should have outpatient follow-up.
# Depression/Anxiety:
Continued on citalopram and clonazepam.
# Gastritis, GERD:
Continued on omeprazole.
# Hypertension:
Continued on metoprolol and lisinopril
TRANSITIONAL ISSUES
- Alcohol abuse history - unclear exactly how much he is
currently drinking, was on CIWA scale here and highest score was
3 and did not required benzodiazepines; should be followed over
the next several days for any signs of withdrawal
- Required daily IV magensium during aggressive IV furosemide
diuresis, please check Chem-10 within the 48 hours after arrival
to rehab (on ___ and replete electrolytes as necessary. He may
need daily oral magnesium.
-Foley catheter was removed on ___, able to urinate, watch over
next day for any signs of urinary retention
- Being discharged on 60mg PO torsemide - titrate his diuretic
dosing as an outpatient as needed
- Recommend outpatient PFTs given severe pulmonary HTN on
echocardiogram
- Started on 81mg ASA daily given PVD
- Full code | 79 | 723 |
12106911-DS-11 | 27,943,344 | Ms ___ it was a pleasure caring for you during your stay at
___. You were admitted with headache and difficulty with
balance. You were found to have multiple brain tumors as well
as swelling in the brain. You were started on radiation
treatment which you have been tolerating well. We did not find
any other areas where the cancer spread. Your steroid dose will
be determined by the radiation oncologists. You also have a
repeat brain MRI scheduled about one month after you complete
radiation. You are discharged to ___ in ___ to
continue rehabilitation.
You will return to complete radiation this week. ___ at
10:30am. No treatment is scheduled on ___ | ___ y/o female with history of T4N0M0 Stage IIIA poorly
differentiated adenosquamouscarcinoma of the lung s/p right
pneumonectomy ___, adjuvant cisplatin/gemcitabine ___ now
on active surveillance, on enoxaparin since
___ for PE, now presents with headache and gait imbalance
found to have multiple brain mets.
# Metastatic NSCLC with new CNS mets- MRI shows new enhancing
masses within the right frontal, left temporal, and right
cerebellar cortices with adjacent vasogenic edema and mass
effect, consistent with metastatic disease. Exam with multiple
neurologic deficits includiong R facial droop and dysarthria.
CT shows significant edema. Pt also w/ ongoing short term
memory/cognitive difficulty
-Neuro-oncology and radiation oncology consulted. Patient
started whole brain radiation ___, plan for total of 10
fractions (currently ___ completed, will complete on ___.
- dexamethasone for edema now reduced to 4mg BID, further taper
per rad onc. On PPI while on steroids
- MRI spine to evalaute for mets in the spine or leptomeningeal
disease - none seen.
- CT torso to evaluate systemic disease was negative.
- she will have follow up brain MRI in ___
Patient did have improvement in coordination and headaches w/
initiation of steroids and WBRT. She was evaluated by physical
therapy and is able to ambulate independently however continues
to struggle with short term memory, completing tasks/directions.
Due to this patient requires ___ supervision for safety. She
will be discharged to ___ in ___ for further
rehabilitation and possibly long-term care.
#Leukocytosis - likely ___ dex, persistently elevated w/o signs
systemic infxn. surveillance urine/blood cx NGTD on repeat
exams. CXR ___ shows only stable pneumonectomy, clear on L. did
improve w/ reduced dex dose.
# h/o PE - no evidence of bleeding on head CT or MRI. Able to
anticoagulate per neuro-onc
-continue home lovenox.
# Hypothyroidism - on Levothyroxine | 120 | 292 |
11427507-DS-23 | 27,594,123 | Dear Ms. ___,
You were admitted to the ___ Cardiology Team ___ after you
had worsening chest pain.
What was done?
===============
-You had a cardiac catheterization which showed some narrowing
and blockages, but none were suitable to have new stent
placement.
-We increased your lisinopril dose from 5 mg to 10 mg which may
help with your pain.
What to do next?
==================
-Please follow up with your primary care ___ at 12P) and
cardiologist ___ at 2P) for further medication titration as
needed. These appointments have been scheduled for you.
-We recommend no strict exercise limitations, walking is helpful
for your heart, but avoid excessive stress.
-Avoid fast food and fried foods as well as red meat. Eat food
high in fiber such as fruits and vegetables.
We wish you the best!
- Your ___ cardiology team | ___ year-old woman with diabetes mellitus and known CAD S/P CABG
in ___ (LIMALAD, SVG-PDA, SVG-OM/LPL) and post-CABG PCI of
SVG-OM who presented with 1.5 weeks of chest squeezing radiation
at rest and with exertion to both arms similar to her prior
acute coronary syndrome symptoms.
# Unstable Angina
# Coronary Artery Disease s/p CABG
Patient presents with chest pain at rest. She had no biomarker
evidence of myocardial infarction. She exercised to ___ METs on
a non-imaging stress test without symptoms and initially
nondiagnostic 0.5-___epressions which became
horizontal during recovery. She was thus referred for coronary
and bypass graft angiography which showed native three vessel
coronary artery disease with chronic total occlusion of the CX
and RCA, unrevascularized native OM1 disease and LPL disease
downstream of the SVG (both of these in vessels <2 mm in
diameter and thus too small for PCI). No lesions suitable for
PCI as native OM1 and grafted LPL <2 mm in diameter.
Interventional cardiology recommend ___ medical
therapy and reinforcement of secondary preventative measures
against CAD and hypertension. Patient was continued on home
cardiac medications (ASA, Plavix, metoprolol, atorvastatin and
isosorbide mononitrate). Ultimately, lisinopril was increased
from 5 mg to 10 mg daily. Metoprolol was not uptitrated due to
patients HR (50-60s). | 130 | 208 |
12600024-DS-22 | 25,221,898 | Dear Ms. ___,
It was a pleasure taking care of you
Why you were here:
-You were in the hospital because you were complaining of jaw
pain and swelling from an infection around you tooth
-You were not urinating well
What we did for you:
-You were given antibiotics for the treatment of your infection
-The oral surgeons drained a pocket of infection around your
tooth
-A foley catheter was placed to drain the urine in the bladder
What you should do after leaving the hospital:
-Call the oral surgery clinic (___ Building at ___ -
___ at EXACTLY 7:00am any day ___ through ___ so
you can have a same day clinic appointment to get your teeth
removed.
-Please continue taking your antibiotic (augmentin) twice a day
to be completed for a 7 day course (last dose on ___
-please use the chlorhexadine to rinse your mouth twice a day
-Please continue taking all your medicine and follow up with
your primary care doctor and dentist
We wish you the best,
Your ___ team | ___ yo F with PMH diabetes and schizophrenia admitted for acute
jaw pain/swelling, found to have a periapical abscess in the
mandibular anterior vestibule. CT scan revealed no drainable
fluid collection in the neck. Patient was started on IV unasyn
for oral infection. ___ was consulted who observed a fluctuant
lesion at the apex of ___ and performed a beside incision and
drainage. Patient received panoramic radiograph of her teeth.
The dentistry team recommended that she gets full teeth
extraction to be done at outpatient ___ clinic. Patient was
transitioned to PO augmentin (last dose on ___. Patient
also found to be retaining urine with bladder scan>1000cc of
urine. Patient was straight cathed was monitored by bladder
scan, found to have increasing PVR and so a foley was placed.
Patient to follow up with urologist for urodynamic study.
# Dental Infection:
Jaw swelling/pain suspicious for periodontal infection. Patient
started on IV unasyn. ___ was consulted who observed a
fluctuant lesion at the apex of ___ and performed a beside
incision and drainage. Patient received panoramic radiograph of
her teeth. The dentistry team recommended that she gets full
teeth extraction to be done at outpatient ___ clinic. Patient
was transitioned to PO augmentin (last dose on ___.
Patient's jaw swelling/pain improved and she was able to
tolerate soft PO food.
#Urinary retention
Patient found to have poor urine output while hospitalized.
Patient was straight cathed for 1100cc. Patient's urine output
was monitored and patient had increasing PVR >500cc, so a foley
was placed. Unclear etiology for her urinary retention. Patient
on olanzapine, which has anticholinergic effects. UA negative.
No evidence of cord compression or peripheral neuropathy.
Patient discharged on foley with outpatient urology appointment.
# Hypertension:
Patient's blood pressure was in the low 100's-110's. Held home
chlorthalidone and decreased lisinopril to 20mg. Patient's BP
continued to be in relatively low, so she was discharged on 10mg
lisinopril to have outpatient followup for blood pressure
# OSA: Stable. Patient on CPAP at night
# Schizophrenia: Stable. Continued home olanzapine, wellbutrin,
sertraline, cogentin, gabapentin
# Diabetes: Held metformin. Patient was on insulin sliding
scale, but did not require any insulin.
# GERD: Continued home omeprazole 20mg BID
# COPD: stable. Continued Fluticasone Propionate 110mcg 2 PUFF
IH BID, albuterol neb PRN q6h
TRANSITIONAL ISSUES
=======================
[]ensure patient has appointment with ___ (___) to get
full teeth extraction (___). Patient needs to call
EXACTLY AT 7AM to get appointment same day (___)
[]f/u jaw pain/swelling
[]f/u with dentist
[]held chlorthalidone and decreased lisinopril to 10mg given
BP's in the low 100's. f/u blood pressure and titrate meds as
needed
[]foley to remain in place until follow up with urology for
urodynamic study for urinary retention.
[]thyroid gland enlarged on CT scan. Consider thyroid ultrasound
Note: Patient at rehab for convalescent stay <30 days. Do not do
trial of void for patient. Patient has urology appointment
scheduled.
#Code Status: full, confirmed
#Contact: ___ | 160 | 467 |
13944352-DS-27 | 28,779,503 | Dear ___,
You were admitted to the neurology service because of you
worsening gait. We restarted your home medications and this
improved greatly. You were evaluated by ___ and will be going
to acute rehab to work on your gait. | This is an ___ yo woman with PMH significant for multifactorial
gait disorder (frontal + parkinsonian features, on
Levodopa/Carbidopa for Parkinsonism), AFib, CAD, spinal stenosis
s/p lumbar surgery who presents with 3 days of worsened gait
freezing, difficulty moving/getting out of bed and slowing of
her speech. According to the patient's HCP and friend she had
stopped taking her medications at home in a passive suicidal
gesture. She has been very clear with her HCP and family that
her primary aim is staying in her appartment at home. She does
not wish to undergo any life extending treatments. She is
amenable to a short stay at acute rehab to maximize her mobility
followed by discharge with the plan to remain at home with the
aid of palliative services.
On presentation her exam was remarkable for Hypophonia and
hypomimia. Prominent grasp reflexes bilaterally. Decreased
upgaze. Subtle left NLF flattening (baseline). +Generalized
whole body bradykinesia. Marked paratonia and rigidity in the
trunk and extremities. Weakness L>R. She can only ambulate a
couple of steps before retropulsing onto bed, but observed
markedly shortened stride length and slowed speed.
Her clinical picture was thought likely the result of worsening
parkinsonism from medication non-compliance. Her course was
complicated by episodes of severe vertigo which is likely BPPV.
We has hoped to do an MRI to evaluate for the cause of her
vertigo and left sided weakness however the patient any family
refused this. The patient's vertigo was treated with meclazine
with improvement. | 39 | 247 |
14242530-DS-13 | 23,814,694 | Mr ___
It was a pleasure taking care of you. As you know you were
admitted due to difficulty swallowing which we found was due to
irritated tissue. You were given a short course of steroids and
medications to control the symptoms. Since you are now eating
normally you don't need steroids but can continue the other meds
to ensure pain relief. Please be sure to followup with Dr
___ and continue your remaining radiation
treatments. | ___ ___ with high grade neuroendocrine mediastinal
carcinoma (on paclitaxel and RT to lung/esophagus), c/b
malignant hemoptysis and compression s/p tracheal stent ___
(now s/p removal ___, DVT (on Xarelto), who presented with
worsening
odynophagia and dysphagia x 8 days ___ mild mucositis, improved
with supportive care and short dexamethasone course, was
tolerating normal diet by discharge, has close outpatient f/u in
___ clinic
# Dysphagia (solids > liquids)
# Odynophagia
Pt presented with significant odynophagia/dysphagia. Pt received
4 days empiric fluconazole for ___ esophagitis since he
presented w/ neutropenia, though was discontinued given lack of
marked improvement and count recovery. ENT performed evaluation
and identified mild mucositis. Dr ___ that
radiation field did not extend up that high to cause findings.
CT showed left sided adenopathy, suggesting that
odynophagia/dysphagia are at least somewhat caused by tumoral
compression in the neck c/b referred pain from extrinsic
compression of the esophagus in the chest. Speech and Swallow
team followed during stay, rec'd diet modifications. Patient was
given short dexamethasone course which was tapered off by
discharge. By time of discharge he was tolerating full diet
without issue but had lingering ___ pain, managed with
combination of liquid oxycodone and magic mouthwash which he was
prescribed on discharge. Pantoprazole continued during stay and
prescribed on discharge. Patient is to followup with ENT
following completion of his ongoing radiation course.
# Metastatic high-grade neuroendocrine carcinoma of the
mediastinum
# Cancer associated chest pain
Diagnosed ___. Completed 4 cycles
cisplatin/etoposide/atezolizumab (___), followed by
2 cycles of atezolizumab (last ___. Admitted ___ for small
volume hemoptysis w/ rapid progression of disease noted on scan.
Started paclitaxel + RT to mediastinum ___. Dr ___
___ patient during stay, noted that he will receive C2D1
on ___. Pt nearing end of radiation course as discussed above
# ___, neutropenia
# Acute on chronic anemia
Counts improved during stay so was likely ___ temporary BM
suppression from recent chemotherapy. Counts to be trended in
outpatient setting with further chemotherapy.
# Malignant hemoptysis and tracheal compression s/p stenting
___
CT reviewed by IP with possible mild migration. Accordingly,
stent removed by IP ___. After removal, patient had mild cough
at night which resolved during the day, and CXR was without
infiltrate. Pt may have lingering airway irritation from stent
removal so abx held, and will need symptoms closely monitored in
outpatient setting after discharge
# HX of RUE DVT (in s/o PICC), LUE DVT
RUE DVT diagnosed ___. LUE DVT diagnosed ___ in setting
of holding rivaroxaban for 4 days while awaiting port placement.
Patient was continued on rivaroxaban during stay. | 75 | 420 |
17229222-DS-17 | 28,260,204 | Mr. ___,
You were admitted to the hospital with bleeding and confusion.
Your confusion cleared quickly with lactulose. You underwent
endoscopy that showed non-bleeding esophageal varices, and areas
of bleeding in your stomach related to your cirrhosis. You
underwent a procedure called APC during your endoscopy to stop
the bleeding, and your blood counts stabilized.
During your admission, you started the evaluation for liver
transplant with laboratory testing and social work consultation.
You should follow up with the transplant hepatologist on
___, as previously scheduled, for further evaluation.
You also underwent an echocardiogram on admission that showed
your aortic stenosis has worsened. You were evaluated by
cardiology. You should follow up with your outpatient
cardiologist for further management of your aortic stenosis.
You may need a special echo called a "trans-esophageal echo" in
the future, if you are to be further evaluated for liver
transplantion. | ___ w/NASH vs. cryptogenic cirrhosis c/b esophageal variceal
bleed (___), recurrent
encephalopathy s/p TIPS (___), GAVE s/p APC treatments, and
anemia who presents to ___ as a transfer from ___
with AMS and GI bleed (Hct 18), found to have hepatic
encephalopathy and oozing GAVE.
#) Oozing GAVE - Pt has a history of recurrent bleeding from
GAVE. An EGD on ___ confirmed the diagnosis, and APC was
repeated. The pt required a total of 4 units of pRBCs at ___
this admission, one each on ___ and 1 just prior to
d/c on ___. His hct was stable but low at 23.5 on the day of
discharge and post-transfusion hct rose to 26.7. The pt needs
repeat CBC drawn in 1 week. He was discharged with a Rx for CTX
to complete 7 days of SBP prophylaxis given the UGI bleed. If pt
continues to have a decline in hematocrit, we suggests a follow
up EGD in ___ weeks with possible APC or RFA. He should continue
taking PPI 40mg PO daily.
#) Encephalopathy - The pt has a history of recurrent
encephalopathy after undergoing TIPS. This episode of HE likely
was a result of GI bleed. Infectious work-up was negative (CXR
clean at OSH. UA neg for infection. No tappable pocket of
ascites to r/o SBP). His doctors at ___ considered TIPS
reversal given frequent HE admissions, however the hepatology
team at ___ recommend against TIPS reversal due to frequent
GAVE bleeding, which would likely worsen with TIPS reversal. In
addition, RUQ U/S this admission showed increased velocity
through TIPS shunt, so it is naturally becoming more stenosed.
The pt should continue taking lactulose TID for goal of ___ BMs
daily. Ideally he should be on rifaximin as well, but financial
restraints prohibit him from taking it. The pt was provided with
1 month of free prescriptions on discharge from ___, but the
free pharmacy would not provide rifaximin.
#) NASH cirrhosis - c/b esophageal variceal bleed ___,
___, recurrent encephalopathy s/p TIPS
(___), GAVE s/p APC treatments, and anemia. Transplant eval had
been delayed, per pt's hepatologist at ___, given social
stresses with wife currently undergoing w/u for possible breast
cancer as well as frequent hospitalizations lately resulting
difficulty making it to outpatient appointments. The pt's
transplant work-up was initiated during this hospitalization
with routine labs, social work consult, and a TTE (see "severe
AS" below). Further work-up is being delayed due to severe
aortic stenosis. He has follow-up at the transplant ___
clinic at ___. MELD labs were trended and stable this
admission. The pt should continue lasix and spironolactone at
home dose.
#) Severe AS - The pt has a history of aortic valve replacement
(bovine, per pt). A TTE was checked this admission due to
anasarca. It revealed severe aortic stenosis with a peak
gradient of 74 which has rapidly increased since last echo at
___ in the ___. A cardiology consult was obtained
and they stated pt "will likely will need aortic valve issue
resolved prior to liver transplant. Since he is a poor
candidate for redo-AVR, we could consider aortic valvuloplasty
as temporary treatment prior to liver transplant or TAVR in the
future when he is on waiting list for liver transplant or AS
worsens. He is followed by private cardiologist in ___, so he
should be followed by his cardiologist as outpatient." ___ was
recommended to further evaluate aortic valve prior to any valve
intervention. However, since pt had just had APC for GAVE, they
recommended holding off on TEE and following up with cards as
outpatient. Pt was continued on his home dose diuretics. He was
also re-started on nadolol for both cardiac protection and
prevention of variceal bleed. Cards recommended aspirin and
statin in the future, however benefit of these meds should be
weighed against bleeding/hepatic injury risk. | 154 | 652 |
19787509-DS-6 | 27,421,515 | ACDF:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Isometric Extension Exercise in the
collar: 2x/day x ___xercises as
instructed.
Swallowing: Difficulty swallowing is not
uncommon after this type of surgery. This should resolve over
time. Please take small bites and eat slowly. Removing the
collar while eating can be helpful however, please limit your
movement of your neck if you remove your collar while eating.
Cervical Collar / Neck Brace: You have been
given a soft collar for comfort. You may remove the collar to
take a shower or eat. Limit your motion of your neck while the
collar is off. You should wear the collar when walking,
especially in public
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___ 2. We are not allowed to call in narcotic (oxycontin,
oxycodone, percocet) prescriptions to the pharmacy. In
addition, we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline x rays and answer any questions.
___ We will then see you at 6 weeks from the
day of the operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions. | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2. Physical therapy
and Occupational Therapy was consulted for mobilization OOB to
ambulate and functional status. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet. | 700 | 139 |
15152579-DS-12 | 25,326,352 | Dear Mr. ___,
It was a pleasure taking care of you while you were admitted to
___. You were admitted because of pain at your elbow and
redness/bruising on your right arm. We checked your bloodwork
and found you to have an elevated INR (Coumadin level) which has
lead to ecchymosis or bleeding within the superficial skin
layers. We evaluated your arm with ultrasound and the
preliminary read confirmed that there was no hematoma or blood
collection that would require further intervention. Also, we
repeated your INR which was trending down. After serial
examinations of your arm, we feel that the current area of
redness is not expanding further.
When you return home, it is important that you do not take
Coumadin today. Tomorrow, you have an appointment with your
PCP, ___, at 3pm for a check-up of your arm and repeat
INR level. Dr. ___ will instruct you on further Coumadin
dosing. Additionally, please call your cardiologist to arrange
an appointment in the next ___ days. | ___ year-old male with a PMH of atrial fibrillation on coumadin
who presents with right elbow pain and bruising/redness in the
setting of supratherapeutic INR, most consistent with extensive
ecchymosis.
# Ecchymosis/Right arm pain: He presented with large area of
ecchymosis covering approximately 40% of right upper extremity,
most notably at the medial aspect and antecubital fossa. Area
of ecchymosis was relatively stable during course of admission.
No drainage, pus or ulcerations consistent with cellulitis. Pt
remained afebrile without leukocytosis. Blood cultures were
drawn and he did receive Vancomycin IV x1 in the ED. Orthopedic
service felt there may be mild hemarthrosis but did not
recommend arthrocentesis given elevated INR and likelihood of
reaccumulation. Ortho recommended elevation, ice, and full
active ROM of elbow. Right upper extremity ultrasound was
performed and prelim read was without obvious pseudoanyeurysms
or blood collections. US final read pending on discharge. He
used tylenol for pain control.
*******************
PLEASE NOTE: after patient's discharge, Blood culture ___
bottles) resulted in gram positive rods consistent with bacillus
or clostridium species. Thought to be skin or lab contaminant as
patient was clinically afebrile, no leukocytosis, did not meet
sirs criteria, and there were only ___ blood cultures with this
species. Pt's PCP (Dr. ___ alerted by inpatient
attending, Dr. ___. Patient will be followed-up
day-after-discharge in clinic with Dr. ___.
********************
# Supratherapeutic INR: On coumadin for AFib with CHADS2 =2.
His INR was elevated to 5.2 at ___ which decreased to 4.7
in ED and 3.5 morning of discharge with just holding coumadin.
His Coumadin was held ___ and ___. He was given specific
instructions to follow with his PCP ___ ___ for INR check and
further instructions about restarting Coumadin.
# AFIB: CHADS2=2, rate control with digoxin. Anticoagulation
with coumadin, which was held given supratherapeutic INR. Plan
to restart Coumadin on ___ after INR check at outpatient appt.
# HTN: stable, he continued home meds
# Normocytic Anemia: at baseline, no need for transfusion.
# BPH: stable, continued finasteride
# Hypercholesterolemia: continued home atorvastatin | 175 | 347 |
17220099-DS-21 | 20,230,245 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I admitted to the hospital?
- You were dizzy and had difficulty speaking
What was done while I was in the hospital?
- You had an MRI that showed your cancer was stable
- You had a swallow study that showed you are at risk for
aspirating
What should I do when I get home from the hospital?
- Be sure to continue to take your medications as prescribed
- Please go to all of your follow-up appointments, including
with oncology and the speech and swallow team
- If you have headache, nausea, vomiting, new weakness,
numbness, tingling, problems speaking, worsening dizziness, or
generally feel unwell, please call your doctor or go to the
emergency room
Sincerely,
Your ___ Treatment Team | ___ w/ thalamic glioblastoma c/b hydrocephalus s/p VP shunt, s/p
IMRT/TMZ ___, TMZ and Bevacizumab, c/b disease recurrence s/p
SRS ___, now on TMZ/Beva q3 mo, started on dex for recent dx
of disease progression on ___, who p/w persistent dizziness
and now intermittent dysarthria.
ACUTE ISSUES
# GBM with progressive disease
# Dizziness
These symptoms have been attributed to disease progression as
enhancement on MRI c/w leptomeningeal disease previously.
Radiation necrosis
is unlikely as she is on Avastin. Was started on dexamethasone
recently ___ to determine if she may have any benefit and
this helped w/ nausea, but did not help w/ dysarthria nor
dizziness. Dizziness is provoked by any movement, dysarthria and
dysphagia are worsening from prior admission. MRI as an
inpatient showed stable disease. The patient was continued on
her home medications and instructed to follow-up as an
outpatient to start chemotherapy.
# Dysphagia: Symptoms appeared to be worse on this admission.
Speech and swallow were consulted and recommended a video
swallow, which showed a risk for aspiration. Swallow
recommendations are the following:
1. Diet: thin liquids and moist ground solids until chewing
improves
2. Medications: whole one at a time with thin liquids
3. Swallowing strategies:
-Add a sip of liquid to the bite of food in your mouth if having
trouble initiating the swallow
-Cough and reswallow after every couple of sips of liquid to
clear the airway
4. Oral care: brush teeth ___ times per day and use mouthwash
prior to eating/drinking to decrease risk of pneumonia
5. Remain as physically active as possible to decrease risk of
pneumonia
6. Consider nutritional supplements (e.g. Ensure, Boost) if
chewing and swallowing food is too effortful
# HTN:
Patient significantly hypertensive. Was started on nifedipine at
last admission as was bradycardic with metoprolol. Dose was
increased to 20mg q8h with improvement in blood pressures. Goal
BP <140/90.
# Leukocytosis: Noted to be as high as 26.6 at the time of
discharge. The patient was otherwise asymptomatic. Etiology
unclear.
CHRONIC ISSUES
# Headaches: Improved w/ fioricet on last admission.
# Dyspnea on Exertion: CTA ruled out PE on recent admission and
these symptoms have resolved.
TRANSITIONAL ISSUES
[]goal BP <140/90
[]nifedipine increased from 10mg q8 to 20mg q8; converted to
total of 60mg nifedipine ER daily
[]will need continued outpatient speech and swallow evaluation;
patient sent with prescription
[]speech and swallow recommendations: 1. Diet: thin liquids and
moist ground solids until chewing improves
2. Medications: whole one at a time with thin liquids
3. Swallowing strategies:
-Add a sip of liquid to the bite of food in your mouth if having
trouble initiating the swallow
-Cough and reswallow after every couple of sips of liquid to
clear the airway
4. Oral care: brush teeth ___ times per day and use mouthwash
prior to eating/drinking to decrease risk of pneumonia
5. Remain as physically active as possible to decrease risk of
pneumonia
6. Consider nutritional supplements (e.g. Ensure, Boost) if
chewing and swallowing food is too effortful
[]should check CBC at next neuro-oncology visit on ___ to
ensure leukocytosis is improving
#CODE STATUS: Full code, presumed
#HCP: Name of health care proxy: ___
___ number: ___ | 125 | 479 |
10398029-DS-21 | 20,306,012 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | This is a ___ male who had previously underwent an
ascending aortic hemiarch replacement back in ___ for an
aneurysm. He also had a saphenous vein graft to
the posterior descending artery. He presented with shortness of
breath and a CT scan was performed and this demonstrated
possible aortic intramural thrombus of the ascending aorta.
Further workup revealed aortic stenosis. The usual preoperative
work up included Dental clearance, carotid US, and Chest CT.
ON ___ he was taken to the operating room and underwent the
following: 1.Redo sternotomy.2.Coronary artery bypass grafting
x2 with left internal mammary artery to left anterior descending
artery and reverse saphenous vein graft to the posterior
descending artery.3. Aortic valve replacement with a 29 mm
___ Ease
pericardial tissue valve, model ___, TFX, serial number is
___. 4. Reconstruction of pericardium with CorMatrix.
Please see operative report for further surgical details.
He tolerated the procedure well and was transferred to the CVICU
for recovery and invasive monitoring. He required inotropy and
pressor support to augment his hemodynamics postop. FFP, PRBCs
and Protamine were administered for elevated chest tube
drainage. He awoke neurologically intact and weaned to extubate.
He was started on ___, Lasix. He continued to
progress and was transferred to the step down unit for further
recovery. Chest tubes remained in due to elevated drainage.
Pacing wires were discontinued per protocol without incident.
Physical Therapy was consulted for evaluation of strength and
mobility. POD# 4 Chest tubes were discontinued per protocol
without incident. His rhythm went into Atrial fibrillation and
Amiodarone was administered. Anticoagulation was initiated and
will be managed by ___ Medical in ___ as discussed
with ___.
By the time of POD 5 he was ambulating independently, wounds
healing, and pain controlled. He was cleared for discharge to
home with ___ services. All follow up appointments were advised. | 122 | 308 |
18979146-DS-23 | 27,087,881 | Thank you for choosing ___ for your care. You
were seen in the emergency room by the Acute Care/Trauma Surgery
team for a fall that happened a few days before you came in. You
were admitted for pain control and was monitored for alcohol
withdrawal since you had an elevated blood alcohol level. After
evaluation from the Trauma service and Psychiatric service, you
are now able to return home for further recovery.
Rib Fractures:
* Your injury caused 9 - 10th rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus). | Mr. ___ presented to ___ emergency room on ___ after a fall that occurred four days prior to admission. He
was evaluated by trauma surgery and admitted for pain control
and further evaluation. His hospital course was complicated by
agitation secondary to likely alcohol withdrawal. Once evaluated
in the ED, he was transferred to the TSICU for observation.
Neuro: On admission, he received a rescue dose of phenobarb
2.5mg/kg for acute alcohol withdrawal. His CIWA scales was rated
from ___. After 24 hours, he was transferred to the floor for
further recovery. On ___ a coded purple was called, and patient
required IV Haldol and transfer to the TSICU for management.
Psychiatry was consulted and determined that he was acutely
delirious. After re evaluation, psychiatry noted much
improvement in patient's delirium and noted that patient can be
discharged if no further medical needs. Pain was initially
managed with a narcotic, but primarily Tylenol.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO, then diet was
sequentially advanced as tolerated
MSK: Per imaging, he had a chest wall hematoma adjacent to a
nondisplaced left ___, and 10th rib fractures. Pain was
managed expectantly. A tertiary exam revealed no new injuries.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up is currently as needed, and should follow up with PCP.
Instructions with understanding verbalized and agreement with
the discharge plan. | 318 | 354 |
14014890-DS-10 | 20,149,060 | You were admitted to the hospital with abdominal pain. A CT
abdomen at an outside hospital raised the possibility of a
partial small bowel obstruction and you were transferred here
for further workup. We repeated the CT abdomen, this time with
oral contrast which can provide more information, and there was
no evidence of a small bowel obstruction. There was no evidence
of an acute abdominal process to explain your abdominal pain.
You have been tolerating a stage III bariatric diet and you are
safe to be discharged. Please return to the ___ if you have any
recurrent abdominal pain or have any difficulty taking food
down.
Please also stop taking any NSAIDs, including aleve aspirin or
advil. We also drew nutrition las, and you are iron deficient.
Please be sure to have close follow up with nutrition labs
either by your PCP or ___ nutritionist. We called your PCP to
ensure they also know this information.
Please also continue to take any medications you were on prior
to your arrival EXCEPT for any NSAIDs including aleve or advil;
these should be stopped. | Ms. ___ was admitted to the bariatric service with
abdominal pain after being transferred from an OSH with a CT
read of possible small bowel obstruction. Due to her ___ en y
gastric bypass, there was concern of an internal hernia and need
for operative intervention. On arrival, she had a nutritional
IV fluids given ("banana bag") which consisted of thiamine and
Vitamin B12. Stat CBC/chem10 and lactate revealed no etiology
of her abdominal pain. She had normal LFTs, lipase, lactate,
and white count. She was started on an IV BID PPI and IVF and
made NPO. She had a repeat CT abdomen with PO contrast to
better evaluate for a small bowel obstruction. There were no
abnormal findings on the CT scan. Her diet was advanced to
stage III which she tolerated well. Nutrition labs were drawn
which revealed iron deficiency. On questioning, she reported
not following up with a nutritionist and not being aware of
having her vitamin levels drawn by her PCP since her ___ en Y
gastric bypass. The importance of having close nutritional
follow up due to her altered anatomy was emphasized, including
following closely Vitamin B1, B12, iron, vitamin D, and folate.
Her primary care physician ___ was also telephoned and
a message was with left with his office to communicate these
recommendations. She had also been taking NSAIDs in the past
and was unaware of their danger with after a gastric bypass, and
the need to avoid NSAIDs was also reinforced.
On the day of discharge, she was tolerating a stage III
bariatric diet. Her pain was well controlled. She was voiding
freely. She was ambulating independently without assistance.
She will follow up with her PCP in one to two weeks. | 187 | 304 |
10717448-DS-14 | 25,638,862 | You were admitted to the hospital after a fall and presumed loss
of consciousness. We evaluated you for causes of your frequent
falls, including arrhythmias, heart attacks, deconditioning, and
low blood pressure. Ultimately we were not able to find a
single unifying reason for your falls, however a condition
called orthostatic hypotension may be contributing, as well as
being on multiple sedating medications. | #Found down: Patient with history of falls and dizziness and has
been evaluated by Gerontology at ___ for this. Concern was for
POTS disease because her HR increased >30 with standing. Has not
been worked up for arrhythmia. She is on many medications that
can cause hypotension, will however she was hypertensive on
admission. She also has a murmur on exam that is known but has
not had a recent echo, so one was ordered. It was notable for
mild-mod aortic stenosis. EKG was nonischemic and telemetry not
notable for any arrhythmias. Orthostatics were normal throughout
the admission but the patient felt dizzy with sitting up.
Physical and occupational therapy were consulted and recommended
rehab. On discharge, carvedilol and aldactone were stopped and
her amlodipine and lisinopril were uptitrated, with good control
of BPs.
#Mild Rhabdomyolysis: No evidence of ___, levels elevated to ~5K
on admission.
IVF were continued until CK downtrended to normal.
#Leukocytosis: likely due to stress reaction. No evidence of
infection. Downtrended on recheck.
#Chest pain: Had chest pain episode in ED. On arrival to the
floor she complained of heart burn. Trop neg x 1. ___ trop 0.02
but could be elevated due to rhabdo. No evidence of ischemia on
EKG. Was given Tums and protonix for heartburn. | 65 | 205 |
17869062-DS-2 | 24,891,017 | You were admitted to the surgery service at ___ for surgical
evaluation of your biliary obstruction. You have done well in
the
post operative period and are now safe to return home to
complete your recovery with the following instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you. | At the time of her admission on ___ the patient was
hypotensive and had an elevated WBC to 16 with a left shift.
She was therefore transferred to the ICU for further management.
She was started on zosyn and given Vitamin K and FFP to reverse
her coagulopathy. Due to her hypotension, CT scan was initially
post-poned. Upon stabilization of the patient's blood pressure,
it was decided to proceed with ERCP on ___. ERCP was
unsuccessful due to an obstructing duodenal mass. An NG tube
was placed, and three liters of gastric contents were removed
from her stomach.
At this time, the Hepatobiliary Surgical team was consulted for
evaluation. Upon review of CT Abdomen/Pelvis, it was determined
that the patient had a potentially operable lesion. The patient
was scheduled for an upcoming surgical procedure on ___. For
immediate biliary decompression and relief of the associated
symptoms and abnormal laboratory values, on ___, the patient
underwent percutaneous transhepatic cholangiography with
decompression and drain placement. In the days thereafter, the
patient was noted to have significant improvement in her TBili
laboratory values, and some improvement her jaundiced
appearance. Additionally, on ___, the patient had a PICC line
placed, and TPN was started. The patient was repleted with
intravenous fluids to replace the losses from both her abdominal
drain as well as her NG tube. The patient had notable
improvement in laboratory values and clinical appearance in this
manner, over the following days, leading up to her scheduled
operation on ___.
On ___, the patient underwent an exploratory laparotomy with
biopsy of periduodenal nodule, cholecystectomy, Roux-en-Y,
choledochojejunostomy and gastrojejunostomy, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO with an NG tube, on IV fluids,
on a single-day-course of IV zosyn, with a foley catheter, and
her PTBD in place, and an epidural for pain control. The
patient was hemodynamically stable.
On POD#1 (___), she continued to have the epidural for pain
control. She therefore continued to have a foley catheter. She
required aggressive IV fluid hydration post-operatively, which
she responded well to, as gauged by her urine output and vitals,
which remained hemodynamically stable and normal throughout. Her
TPN was held on this day, and she remained NPO with her NGT n
place.
On POD#2 (___), her pain remained well-controlled with the
epidural. Due to a hematocrit of 23, she was transfused 2 units
of Packed Red Blood Cells on this day. Through follow-up of
post-transfusion hematocrit, it was determined that she had
responded well to this step. She worked on ambulating with
Physical Therapy on this day. Her NG tube and foley catheter
were maintained, and she remained NPO. TPN was restarted on this
day.
On POD#3 (___), she continued to have good pain control with the
epidural. Her foley catheter was therefore also maintained. Her
NGT was clamped on this day, and residuals were checked every
four hours. She consequently also remained NPO. She ambulated
twice with Physical Therapy.
On POD#4 (___), she continued to have good pain control with the
epidural. Her foley catheter was also maintained. Her NGT was
removed, and she was permitted to have sips of liquids, which
she tolerated well. She ambulated with Physical Therapy.
On POD#5 (___), the patient's epidural was removed, and she was
transitioned to oral pain medications, which she tolerated well.
Diet was advanced to clears, in addition to having TPN, which
she also tolerated well. She continued to ambulate multiple
times per day. The foley catheter was removed, and she voided
successfully.
On POD#6 (___), the patient's PTBD drain was removed. She was
advanced to full liquids, which she tolerated well. She was
continued on TPN. She continued to ambulate multiple times
daily, with physical therapy.
On POD#7 (___), the patient was continued on TPN, and Enlive
supplementation was added to her full liquid diet. Her pain was
well controlled with oral medications. She continued to ambulate
frequently and regularly.
On POD#8 (___), per recommendations by Hematology/Oncology, a
CT Chest was obtained for staging purposes. She was continued on
TPN, but the volume was decreased to half. She continued to have
good pain control, tolerating full liquids, and ambulating
regularly.
On POD#9 (___), she was advanced to a regular diet with Enlive
supplementation, and continued on half-volume TPN. She continued
to ambulate regularly, and have good pain control.
On POD#10 (___), she was maintained on half-volume TPN, regular
diet with Enlive supplementation, ambulating regularly, working
with ___.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated.
At the time of discharge, 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. *********Staples were removed, and steri-strips
placed.***** The patient was discharged home without/with
services.***** The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 346 | 875 |
11423061-DS-24 | 24,658,859 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted after you had a fall, and were
vomiting blood. While you were hospitalized, you underwent two
head CT scans, both of which did not demonstrate evidence of
acute bleed after your falls. Given your history of vomiting
blood, you were initially admitted to the ICU. Here you were
started on a new medication, called pantoprazole, to treat your
GI bleed. You were monitored for evidence of bleeding, which you
did not have. You improved, and you were transferred to the
normal medicine floor. You undewent an EGD, where the GI doctors
used ___ to look into your esophagus, stomach, and first
part of your small intestine. During this procedure, it was
discoverd that you have erosive gastritis, which is likley the
cause of the blood in your vomit. Additionally, you were found
to have a large amount of food in your stomach. The GI doctors
who did this procedure recommend that you have a repeat EGD in 8
weeks to evaluate for healing, as well as an outpatient gastric
emptyng study to evaluate the cause of the food retention in
your stomach.
Please note that the following changes were made to your
medications:
1. Please start taking pantoprazole 40 mg by mouth twice a day
Please discuss your medications with your PCP and psychiatrist.
It is possible your medications are contributing to your
unsteadiness, and you may benefit from having your medications
adjusted. | ___ y.o male with significant Pmhx of bipolar diorder,
depression, osteoarthritis, and DVT/PE s/p IVC filter, on
coumadin, who presents from his nursing home s/p mechanical fall
on his right side of his head and hemetemesis.
# GI Bleed: He reported multiple episodes of non-bloody emesis
prior to emesis with frank blood, and the coffee-ground emesis.
Additionally, he was found to be guaiac positive on admission.
He was admitted to the MICU for close monitoring and
observation. There, he was initially started on a PPI drip, and
he was evaluated by GI, who recommended inpatient EGD. He was HD
stable, his crit was stable, and did not have any additional
episodes of vomiting. He was transitioned to IV PPI BID, which
he tolerated well. He underwent EGD which showed erosive
gastritis and duodenitis, as well as a large amount of food in
the stomach. GI recommended repeat EGD in 8 weeks, double dose
PPI PO, and an outpatient gastric emptying study.
#Reported Dyspnea- He reported dyspnea prior to admission,
although this was not an active issue during this
hospitalization. He appeared euvolemic on admission with no
evidence of wheezing or acute heart failure on exam. No
infiltrate on CXR or fevers/chills to suggest pneumonia. Mild
pulm edema on CXR better than ___, and stable on room air. He
was diuresed with lasix, and restarted on his home regimen. He
maintained excellent oxygen saturations throughout this
hospitalization.
# Lightheadedness: Complained of lightheadedness/dizziness on
muptiple days prior to admission. Exact etiology was unclear,
but most likely secondary to medication side-effects. There were
no focal signs to suggest TIA or CVA, and head CT was normal. He
was not orthostatic while on the medicine floor.
#Bipolar disease- Stable on this admission. He was maintained on
his home regmine of divalproex, doxepin, clonazepam, wellbutrin,
paxil and quetiapine.
#Hx PE/DVT- In the setting of GI bleed, his home coumadin was
held, and he was given 10 mg FFP for reversal, prior to EGD. His
INR on discharge was 1.8.
#GERD- Well controlled on omeprazole. He denied any abdominal
pain or reflux symptoms. In the setting of GIB (see above) he
was on PPI drip, and transitioned to IV PPI BID. He was
discharged on PO PPI BID, with close GI follow-up. | 249 | 375 |
18780736-DS-17 | 23,904,202 | Dear Mr. ___,
It was a pleasure taking care of ___ during your recent
admission to ___ came to use because your
creatinine was increased. We gave ___ fluids and your creatinine
improved. We also adjusted your diuretic regimen. Weigh yourself
every morning, call MD if weight goes up more than 3 lbs. We
wish ___ a fast recovery.
Sincerely,
Your ___ Team | Mr. ___ is a ___ man with history of CLL,
thrombocytopenia, pure red cell aplasia, chronic kidney disease,
and diastolic congestive heart failure who was admitted for
acute on chronic kidney injury secondary to overdiuresis.
================ | 60 | 36 |
10817631-DS-10 | 25,587,982 | Mr. ___,
You were admitted to ___ with an infection. We treated you for
a respiratory infection, and your symptoms improved. We would
like you to complete a 14-day course of antibiotics to help
clear this up. Your oncologist would like to see you in clinic
on ___. | Mr. ___ is a ___ man with history of CAD s/p CABG,
HTN, HLD, DMII, multiple myeloma s/p auto SCT currently on
pomalidomide/daratumumab presenting with weakness and fever.
#Fever
#Sinusitis
Patient recently was admitted to BID-M for neutropenic fever
with extensive evaluation without source identification. Patient
was treated with 10 day course of empiric vancomycin/cefepime.
He re-presented with recurrent fever. No clear localizing signs
or symptoms of infection other than cough and possible
conjunctivitis. CXR was without focal infiltrate. CT chest
showed no pneumonia. CT sinus showed possible sinusitis. Patient
did have loose stools prior to admission, but they were
self-limiting. Infectious disease and oncology were consulted to
help advise investigation and management. Patient was treated
with empiric broad spectrum antibiotics with IV vancomycin, IV
cefepime, and IV metronidazole, then transitioned to PO
levofloxacin and flagyl on ___ once it was determined that he
likely had viral URI +/- superimposed bacterial
conjunctivitis/sinusitis. He remained stable on this regimen and
was discharged on levofloxacin and metronidazole to complete a
14-day total course on ___.
# Acute metabolic encephalopathy
Delirium, febrile effects related to immunotherapy versus
infection. Infectious workup and management as above. His
encephalopathy resolved with the aforementioned treatment.
# Multiple myeloma
# Anemia/thrombocytopenia: Currently receiving treatment with
daratumumab/pomalidomide. Intention had been to hold
pomalidomide, but patient took 2 doses since recent discharge.
Held daratumumab/pomalidomide but per Atrius onc. He will see
his oncologist Dr. ___ on ___ to discuss resuming therapy.
He received 1 U pRBC for symptomatic anemia and Hgb <7.
# CAD s/p CABG
# Demand ischemia: Patient with mild troponin elevation on
admission, likely represents mild demand in setting of acute
illness. Patient is asymptomatic and EKG was without acute
ischemic changes. His home cardiac medications were resumed.
# DMII: Labile blood sugars in setting of recent dexamethasone
use. His home medications were resumed
# Weakness
# Fall
Patient with global weakness in setting of febrile illness,
labile blood sugars, and multiple myeloma on new immunotherapy
regimen. ___ worked with the patient, and his mobility progressed
to where they felt he would be safe to return home with home ___.
# Conjunctivitis (viral versus bacterial): Patient had scant
purulent discharge in left eye in ED and started on
erythromycin. He completed 7 days of erythromycin ointment.
# Gout: No evidence of acute flare.
Mr. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes. | 47 | 407 |
12658758-DS-28 | 27,446,862 | Dear Ms. ___,
You were admitted to ___ because you had pneumonia. During
your hospitalization you were transferred to the ICU because you
were not breathing well, but this improved with positive airway
pressure. You were also treated with antibiotics and responded
well. You will be going to a rehab facility after discharge to
continue your recovery.
In the ICU you were also found to have a new diagnosis of atrial
fibrillation, an irregular hearbeat. We started you on 2
medications to prevent clots and stroke. You will also get a
call from the cardiology office to schedule an appointment for
further management. Please also schedule an appointment with
your PCP after you leave rehab.
It was a pleasure taking care of you,
Your ___ Care Team | Ms. ___ is a ___ woman with history notable for
HTN and endometrial cancer with oligometastasis to the left lung
status post TAH-BSO in ___ and radiation in ___,
presenting with fever to Tmax 100.8 (at home) and dyspnea, sent
in by PCP, found to have RML and RLL pneumonia. She was
initially treated on the general medicine floor, subsequently
transferred to the ICU for hypercarbic respiratory failure. She
was never intubated and monitored closely with improvement in
respriatory status with continued treatment of pna. She was
transferred back to the general medicine floor, where she
remained well, breathing comfortably.
# Pneumonia: Presented with SOB, hypoxia, and tachypnea. CTA
with concern for lower and middle lobe pneumonia superimposed on
atelectasis. She was initially treated broadly for HCAP, then
transitioned to ceftriaxone and azithromycin for treatment of
CAP. On ___, patient was noted to have worsening delirium
and increased somnolence, in the setting of sustained tachypnea
and hypercarbia. She was transferred to the ICU and started on
BiPAP. Hypercarbia resolved and she was considered well enough
to transfer to medicine. On the floor she remained afebrile
without leukocytosis. She was transitioned to RA and breathing
comfortably, sats in the early ___. She completed 8 days of abx
(initally vanc/cefepime, narrowed to CTX/azithro) for CAP.
Of note, vancomycin was re-started on the afternoon of ___
given blood culture showing GPCs but DC'd later as this was
ultimately felt to be a contaminant.
# Atrial fibrillation with RVR: Afib with RVR to the 130s was
noted incidentally on telemetry in the ED on ___. In the
MICU afib with RVR was observed again, and she was started on po
diltiazem. Asymptomatic during episodes. She has a CHADS2-vasc
of 4 and intermittent afib. She was started on warfarin with
lovenox bridge.
#Volume overload: Concern for mild diastolic heart dysfunction.
CT and CXR with evidence of mild pulmonary edema. Underwent IV
and PO diuresis. On discharge, on 1L supplemental O2. O2
requirement most likely thought to be from underlying lung
disease from metastatic cancer to lung and subsequent radiation,
as well as resolving pneumonia.
# Hypertension
Continued home nifedipine with holding parameters for SBP<100 or
DBP<40.
# Hyperlipidemia
Continued home lipitor.
# Chronic back pain ___ spinal stenosis
Continued home gabapentin, but held Tylenol out of concern that
tylenol would mask her fevers. Tylenol was restarted upon
discharge.
# Risk of CAD
Aspirin continued this admission. | 123 | 392 |
17574719-DS-19 | 26,063,950 | Mr. ___,
It was a pleasure to take care of you at ___.
WHY WAS I HERE?
- You were admitted to the hospital because you were found to be
lethargic.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- You were found to have a urinary tract infection and were
treated with antibiotics.
- You were found to have low blood pressure which improved after
receiving fluids through your IV.
- Your mental status improved after starting antibiotics and
giving fluids.
- Your blood
WHAT SHOULD I DO WHEN I GET HOME?
- Follow up with your primary care physician
- ___ taking antibiotics until ___
We wish you the best!
Your ___ Care Team | ASSESSMENT AND PLAN:
___ yo M with history of HTN, HLD, DM, dementia, BPH s/p
indwelling foley with recent UTI on cipro presenting with
lethargy found to have urosepsis and likely demand ischemia. | 108 | 33 |
13751863-DS-24 | 23,659,790 | Dear Mr. ___,
You were admitted to the hospital after you suffered a fall. You
were found to have a patellar fracture of the left knee.
Incidentally, you were also found to have progression of your
lymphoma. During your hospital stay you underwent radiation and
chemotherapy to alleviate the symptoms you were experiencing
from the lymphoma. We treated you for a pneumonia seen on your
chest X-ray with antibiotics, which you will continue through
___. We monitored your blood sugars closely and you
will be discharged with insulin.
You may bear weight as tolerated on your injured leg while
wearing the brace provided.
Please follow up with the appointments listed below. | Mr. ___ is a ___ year old man with recurrent DLBCL, DM1 and
cirrhosis who presents after a mechanical fall and is found to
have a patellar fracture of the left knee. He incidentally was
found to have a 1.6 cm mass in the right temporal area, highly
suspicious for malignancy now with evidence of extensive
lymphoma progression.
ACTIVE ISSUES
=============
# HCAP Pneumonia
CXR on ___ was suggestive of a RUL pneumonia and given that
he had been hospitalized since ___, he was treated for an
HCAP with Cefepime and Vancomycin with plan for a 14 day course
to end through ___. He did not have fevers and was
not symptomatic. His Vancomycin levels were difficult to
control, with Vanc trough of 42 on the day prior to discharge
(at which point Vancomycin was discontinued) and 25.8 on the day
of discharge with evidence ___ (resolved s/p discontinuation
of Vanc). Given that he was clinically asympomtatic from a
pulmonary status and elevated Vancomycin levels his Vancomycin
was discontinued. He will continue to take Cefipime through
___, to complete a 2 week course.
# RLE ulcer
Patient was admitted with a known RLE ulcer which was evaluated
and treated per wound care. However, on ___, given his
neutropenia, there was concern for cellulitis and he began
treatment with Vancomycin (day ___ with plan for a 14
day course through ___. His Vancomycin levels were
difficult to control. His trough was 1.7 on Vancomycin 750 BID
and subsequently 42.3 on Vancomycin 1g BID. Given elevated
trough, as well as evidence of ___, his Vancomycin was
discontinued. His RLE wound was much improved on day of
discharge without evidence of infection and his Vancomycin was
discontinued as noted without plans to restart.
# DLBCL
MRI abdomen as well as PET CT showing evidence of progression of
disease. He is now s/p palliative chemo with cytoxan/etoposide
on ___ and palliative radiation therapy on ___. S/p
rituxan on ___. Methadone was converted to TID dosing for
pain control (methadone 30mg PO TID) and dilaudid was used for
breakthrough pain. He initially required IV dilaudid for pain
control and as his pain decreased after chemo/radiation, he was
transitioned to PO dilaudid. However, he subsequently endorsed
poorly controlled pain with dilaudid ___ PO Q4H PRN and
required 0.25 mg IV for breakthrough. He was started on Ativan
0.5 mg PRN pain/agitation which proved to be effective for
symptom control. Home dose acyclovir was continued as ppx.
# Type I DM
Patient has a known history of type I diabetes. He was followed
by ___ throughout his hospitalization. He had several issues
with both hypoglycemia and hyperglycemia. Ultimately he is
discharged on the following regimen:
- Lantus 11 units QAM
- Humalog sliding scale for goal glucose <300
Breakfast Lunch Dinner Bedtime
71-150 0 0 0 0
151-200 3 3 3 0
___ 5 5 5 1
301-350 6 6 6 2
351-400 7 7 7 2
- He does have a tendency to fall asleep during his meals and it
is thus advised to give him his Humalog after he finishes his
meal to prevent hypoglycemia
# Hyperbilirubinemia: Initially presented with
hyperbilirubinemia, likely related to pRBC transfusion and
resolved.
# Hyponatremia
Patient had hyponatremia to 132 in the setting of hyperglycemia.
Most likely a pseudohyponatremia. Resolved with better control
of his blood glucose levels.
# Thrombocytopenia
Patient has baseline thrombocytopenia-acute drop likely due to
cirrhosis versus lymphoma versus chemo. There was initial
concern for HIT and heparin products were discontinued, however,
platelets dropped after stopping heparin products, making HIT
less likely. Most likely due to chemo and demonstrated slow
improvement throughout his hospitalization.
# Anemia
Patient anemic at baseline (likely multifactorial) now with
acute decrease in Hct, likely due to chemo. Patient was
transfused for Hct<21. His blood counts remained stable
throughout his hospital stay.
# Abdominal pain
Likely due to lymphoma, treated with pain regimen as noted
above.
# Brain mass
Incidentally found on Head CT after fall. Better seen with brain
MRI. Per radiology, the mass did not appear to look like
lymphoma- however it is possible given his extensive disease
progression. Unlikely to be meningioma given that it was not
seen in ___. He received cyber knife treatment once on
___.
# HBV/HCV Cirrhosis
Patient has a known history of hepatitis B and hepatitis C.
Hepatitis B viral load was negative on this admission. His home
dose lamivudine and nadolol were continued during this
admission. The patient intermittantly took lactulose but was
difficult to maintain complete compliance.
# Scrotal swelling
Ascities and scrotal swelling malignant versus due to cirrhosis.
He was treated with lasix 40mg PO daily; however, swelling with
minimal improvement during hospital stay. Will continue on
Lasix. On the day prior to discharge he had low urine output,
and was bladder scanned for >500 cc (likely largely ___ to
narcotic use). He was straight catheterized. He may require
intermittent straight catheterization during his rehabilitation
stay.
# Prolonged QTc
QTc 502 on EKG on ___. From reviewing past EKGs, looks as
though this has been ongoing. Most likely due to his methadone.
QTc was monitored weekly throughout his admission. Qtc 473 on
___.
# ___
Was likely in the setting of hyperuricemia. He was started on
Allopurinol and his renal function resolved back to baseline. He
had another episode ___ in the setting of Vanc trough of
42.3. He was given IVF, Vancomycin discontinued, and his ___
resolved.
# Hyperuricemia
After receiving chemotherapy, patient noted to have
hyperuricemia. Uric acid found to be around 11 and he received
rasburicase on ___. He was also maintained on allopurinol
___ PO daily.
# L knee patellar fracture s/p Mechanical Fall
Patient was evaluated by orthopedic surgery who recommended
conservative treatment with immobilization and pain control.
Patient worked with physical therapy while hospitalized. He will
be discharged with a knee immobilizer.
# Hx of substance abuse
Patient was admitted on maintenance methadone 90mg PO daily.
However, this home dose methadone was transitioned to 30mg PO
TID to be used as pain control instead of as maintenance
methadone.
TRANSITIONAL ISSUES
===================
- Patient to follow up with Dr. ___ on ___
- Please continue patient on Lantus and ISS as noted above
- Please change wound dressing daily
- Patient OK to weight bear as tolerated on left knee with left
knee immobilizer
- Patient to continue on Cefipime Q12 hours through ___ to complete a 2 week course | 111 | 1,199 |
17147211-DS-17 | 21,015,442 | Dear ___,
You were hospitalized due to symptoms of altered mental status
resulting from an INTRAPARENCHYMAL HEMORRHAGE, a condition where
there is bleeding found in the brain tissue. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain can result in a variety of
symptoms.
Brain bleed can have many different causes, including stroke,
trauma, medical conditions. We assessed you for medical
conditions that might raise your risk of bleeding and stroke. In
order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1) Alcoholic cirrhosis (liver disease from alcoholism) with
portal hypertension (elevated blood pressure)
2) Diabetes
3) smoking
We are NOT changing your medications.
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 past medical history
of alcoholic cirrhosis c/b portal vein HTN, encephalopathy
esophageal varices, s/p TIPS ___, T2DM, cervical stenosis with
a right frontal intraparenchymal hemorrhage.
#Right frontal IPH
Mic___ initially presented to ___ ___ after being
found on the ground by her daughter confused and less responsive
and left sided weakness. She was found to have a right frontal
IPH on CTH and was subsequently transferred to ___ for further
evaluation. All antiplatelets and anticoagulants were held. In
the ___, she transiently required a nicardipine gtt to maintain
SBP <150 but this was quickly titrated off. She was given 1 ___ in the ___, and on repeat CBC platelets decreased to
35; another unit of platelets were given for goal platelet count
>50. Patient was clinically improving, and admitted to the ___
for Q2H neuro checks for close monitoring given
thrombocytopenia. Her platelets were trended Q6H for 24 hours,
and she required no further platelet transfusions. CTA H&N
negative for stenosis, occlusion, dissection. CTH was repeated
___ and was stable. MRI stable with 2.8 cm hematoma in R
frontal lobe, and otherwise negative.
Etiology of stroke thought to be secondary to coagulopathy,
could also consider hypertensive etiology. We will plan to
follow up in stroke neurology clinic for repeat MRI to evaluate
for resolution of hemorrhage.
#Thrombocytopenia
Thought to be secondary to coagulopathy. She received a total of
2U of platelets and required no further transfusions. Discussed
case with hematology, who recommended no further workup or
intervention. Also discussed with hepatology, who recommended
continuing to hold SSRI as these medications can worsen a
coagulopathy.
#Hypertension
She was on a tight BP control, with goal SBP <140. We continued
home spironolactone 25 qDaily, and captopril increased from 6.25
TID to 12.5 TID. This medication can be switched to long acting
once per day prior to discharge.
#Trop 0.03 on admisison
Trended down, thought to be secondary to demand. No complaints
of chest pain. EKG with no acute findings.
#DM
A1c 7.9. Patient was put on sliding scale insulin for tight
blood sugar control, and this should be continued at rehab. Her
home lantus dose was cut by 50%, and this should be increased as
needed.
#Pulmonary nodules
Incidental finding of pulmonary nodules on CTA H&N. "Multiple
pulmonary nodules measuring up to 4 mm in the right apex.For
incidentally detected multiple solid pulmonary nodules smaller
than 6mm, no CT follow-up is recommended in a low-risk patient,
and an optional CT follow-up in 12 months is recommended in a
high-risk patient. See the ___ ___ Guidelines
for the Management of Pulmonary | 233 | 431 |
13485675-DS-2 | 20,482,895 | Mr. ___,
During this admission you were determined to have a transient
ischemic attack and because you are at a high risk of stroke we
have started you on aspirin 81 mg daily and atorvastatin 80 mg
daily. We are uncertain exactly why you had this event, but to
complete our workup we will discharge you with a monitor to look
for abnormal rhythms. We will have you follow up in stroke
follow up clinic with Dr. ___.
Thank you for allowing us to care for you
___ Neurology | ___ without significant past medical history admitted with
transient right-sided facial droop, speech difficulty, upper
extremity weakness, and sensory disturbance, found on CTA at
___ to have left M2 occlusion prior to transfer to
___. Symptoms resolved on arrival to ___, although
examination notable for subtle right-sided weakness in the
distal upper > proximal lower extremities. MRI brain revealed
small left parietal infarcts suggestive of a cardioembolic
origin, although no paroxysmal atrial fibrillation noted on
telemetry during the admission. Due to intracranial artery
stenosis noted on vascular imaging, patient was started on
aspirin 81 mg daily and atorvastatin 80 mg daily. TTE revealed a
PFO, but there were no DVTs on MRA pelvis ___ US. Patient was
discharged with ___ and ___ follow up with Dr. ___.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = 123) - () No
5. Intensive statin therapy administered? () Yes - () No [if
LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? () Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A | 91 | 407 |
10961804-DS-10 | 24,010,761 | Dear Ms ___,
You were admitted to the ___ after you had
worsening shortness of breath. We had to give you IV diuretic
medications to help remove the extra fluid from your body and
lungs. We found that you were still in an irregular heart
rhythm, "atrial fibrillation," and after talking with your
Cardiologist Dr ___ decided to perform an electrical
cardioversion, which flipped your heart back into a normal sinus
rhythm.
- Your dry weight is 62.7 kg.
- Our hope is that your heart stays in a normal heart rhythm. If
you start to feel palpitations you may have atrial fibrillation
again, so notify your MD.
- You have urine retention. We discussed this with a urologist
while you were here, and this is typically followed as an
outpatient. You should have follow up with a urologist to figure
out why this is happening. It is probably a chronic problem, and
there is nothing urgent to do about it.
- Please take your medications as below.
- Weigh yourself every day, and if you gain or lose more than 3
lbs please notify your doctor.
- If you aren't feeling well and have a little bit of fluid
buildup again, it is important to call Dr ___ potentially
have yourself scheduled for an appointment to be seen.
It was a pleasure taking care of you!
Zei Gezunt, Refuah Shlaimah, ve'hatzlachah rabah ad me'ah
ve'esrim!!
Your ___ Cardiology Team | Ms ___ is an ___ with HFpEF, AF, HTN, p/w with progressive
SOB, ___ edema found to have CHF exacerbation, s/p IV Lasix
diuresis w/improvement in Sx, s/p ___ (___) of AF to sinus
rhythm
# Acute on chronic HFpEF
Pt had gradual progression of Sx over weeks-months, had declined
CDAC admission earlier for IV diuresis, found to have volume
overload, s/p IV Lasix diuresis. Repeat TTE similar to prior
(symmetric LVH, mild AS, mild pulm HTN, EF >65%). After
discussion with outpt Cardiologist Dr ___ for ___ of
AF to assist with CHF management, increased home Amio to BID but
discharging on once a day due to bradycardia in sinus rhythm.
Admission weight (69.1 kg 152.34 . D/c weight 62.69 kg (138.2
lbs). Restarted home Losartan as tolerated. DC'd on atorvastatin
10 mg daily, losartan 100mg daily , propranolol 10 mg (also has
tremors) BID, Bumetanide 3 mg daily
# Paroxysmal AFib vs Flutter
Pt has been in persistent AFib vs flutter since at least ___,
was initially c/w home Amiodarone + Propranolol. Previous ___
in ___. After discussion w/ outpatient Cardiologist Dr
___ (___) was performed but reverted to Aflutter on ___
and then s/p ___ (___) and returned to sinus rhythm before
discharge. Increased home Amiodarone from 200mg qd to 200mg BID
during most of her stay but now being discharged on amiodarone
200 mg daily, home rivaroxaban 15 mg daily, propranolol 10 mg
BID
# Urinary Retention
Had multiple PVRs >500cc but continued to urinate 100-200ccs
every ___ hours. UA wnl. CTs in two occasions in ___ and ___
showing distended bladder (763 ccs, 528.3 cc) and occupying the
space and creating a 4.5 cm hypodense structure posterior to the
bladder. A pelvic ultrasound had been recommended at that time,
which the patient declined. At this point she should have
outpatient urology follow up for consideration of any further
workup. A foley catheter was not placed at discharge as she was
asymptomatic without UTI ___ at time of discharge.
-F/u outpatient if patient wishes to work up
# Dysuria and pyuria
# Vaginal itching (resolved)
Patient completed a 7d course Augmentin for chalazion on day of
admission, s/p CTX & fluconazole in ED with c/f UTI vs
vaginitis. Started Nystatin w/improvement in Sx. UA w/pyuria,
though UCx was neg, no further Abx given
#Chest rash: related to pads from ___, improving.
CHRONIC ISSUES
==============
# Mild Cognitive Impairment: Alert and oriented but with poor
short-term memory and attention
# Tremor: Pt with baseline tremor, c/w home Propranolol
# ?Viral conjunctivitis: per pt, eye drops stopped per outpt
Optho, started frequent warm compresses w/improvement in Sx.
Gave artificial tears.
# HTN: slowly increased Losartan back to home dose, held home
amlodipine
# CONTACT: HCP: Proxy name: ___ (daughter) Phone:
___
TRANSITIONAL ISSUES
===================
[ ] Re-check EKG to determine if she is still in sinus in
cardiology f/u in 1w
[ ] Patient discharged with ___ of Hearts monitor, please
consider adjusting amiodarone dose based on her afib burden.
[ ] Stopped home amlodipine during admission due to soft BPs.
[ ] Discharge diuretic dose is 3mg Bumex daily
[ ] Monitor weights and titrate bumex (dry weight 62.69 kg
(138.2 lbs))
[ ] Patient had urine retention, which is likely chronic. She
should be seen by urology as an outpatient for further
evaluation. Please arrange this. She had a pelvic finding on
prior abdominal CT imaging where a mass could not be excluded
posterior to the bladder, but refused further follow up. This
could be addressed with pelvic ultrasound.
[ ] repeat chem 10 panel in ___ days to ensure stable. Cr at
discharge 1.2
Discharge weight: 62.69 kg (138.2 lbs)
>30 minutes spent on discharge planning/coordination of care | 238 | 605 |
10312052-DS-19 | 21,567,940 | * You were admitted to the hospital for evaluation of your right
pneumothorax and failure to wean from the respirator following
your surgery.
* You have done well in weaning from the ventilator and
breathing on your own and are now ready to return to rehab for
more therapy.
* You will continue to require tube feedings via your PEG tube
and the Speech and Swallow therapist will evaluate you when you
are ready to safely swallow food.
* Continue to work hard with Physical Therapy to get strong and
improve your endurance.
* You will need to follow up with Dr. ___ in ___ weeks
and the rehab will arrange transportation for you to return to
the Thoracic Clinic.
* Call ___ with any questions about this
hospitalization. | Mr. ___ was evaluated by the Thoracic Surgery service in
the Emergency Room and a right pleural pigtail catheter was
placed to evacuate his right pneumothorax. He was then admitted
to the ___ for vent management as well as management of his
pigtail catheter. Most recently at rehab he had been able to
tolerate a trach collar during the day and PSV overnight. He
felt that his dyspnea improved following placement of the
pigtail catheter but on xray, the pneumothorax was the same.
There was no air leak from his pigtail catheter.
The Pulmonary service was consulted to comment on his fibrotic
lung disease which was confirmed on pathology (UIP). After the
patient's initial roughly
1-month Prednisone taper, he was not on prolonged steroids. They
felt that he didn't have clinical evidence of an ILD flare, and
CT imaging did not demonstrate progressive fibrosis or ground
glass in a pattern consistent with flaring. However, he did have
significant LLL consolidation and mucus plugging; pulmonary
hygiene and mucus clearance is key to help with vent weaning.
They also felt that his remaining R lung has less parenchymal
abnormality than his L lung and his oxygenation would
significantly be affected by any pleural process that impairs R
lung ventilation. They recommended starting albuterol nebs q6hr
with dedicated coughing and airway
clearance after, starting start Mucinex ___ mg BID. They will
also arrange outpatient pulmonary follow-up for consideration of
pirfenidone.
Mr. ___ was able to be weaned off the ventilator and has
been on a 60% trach collar for the last 72 hours. His pigtail
catheter was removed on ___ and he denies any change on his
baseline dyspnea. He was evaluated by the Speech and Swallow
therapist and cleared for use of a passey muir valve for ___
minute spurts with supervision.
His tube feedings were changed to Osmolite 1.5 from Jevity 1.2
due to loose bowel movements. All stool studies have been
negative including C diff, banana flakes have been added and the
beneprotein has been stopped.
Cardiology was also consulted to comment on his PAF with RVR and
they recommended titrating up his Metoprolol to 37.5 q 6 hrs,
continuing his diltiazem at 60 mg q 6 hrs and if needed for rate
control, possibly adding digoxin. Currently with his Metoprolol
at 37.5 mg q 6 hrs his rate is better controlled.
Anticoagulation was also discussed and deferred given his ___
sore is 1 and prior chest wall hematoma.
Mr. ___ is gradually getting stronger and now off the
ventilator but still needs more physical therapy as well as SLP
before returning home. He was discharged back to rehab on
___ and will follow up with Dr. ___ in 4 weeks. | 124 | 450 |
13777886-DS-12 | 23,626,152 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- Nonweightbearing in the right leg
- Range of motion at the right knee as tolerated, in an unlocked
___ brace
Physical Therapy:
NWB RLE
ROMAT in unlocked ___
Treatments Frequency:
Dressings may be changed as needed for drainage. No dressings
needed if wound is clean and dry.
Staples will be removed in ___ weeks at follow up appointment in
Ortho trauma clinic. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is nonweightbearing in the right
lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 193 | 239 |
11514055-DS-9 | 27,231,506 | Mr. ___,
You were transferred to ___ because of dyspnea. You had an
ECHO of your heart that showed decreased function. A second ECHO
was done to better evaluate your valve and there was no evidence
of infection or clot. A cardiac cath was done and one of your
stents was opened up.
Medication changes:
START lisinopril 10 mg by mouth daily for your heart and blood
pressure
START metoprolol XL 25 mg by mouth daily for your heart and
blood pressure
STOP hydrochlorothiazide as you will be on metoprolol XL and
lisinopril for your blood pressure
Please have INR drawn on ___. | ___ year-old-male with a history of CAD s/p CABG in ___, PCI in
___ and ___, AS s/p AVR in ___, atrial fibrillation on
coumadin, permanent pacemaker, chronic angina, hypertension, and
hyperlipidemia presenting with dyspnea found to have new
systolic CHF (EF ___ and aortic valve lesion and new
hyponatremia, now s/p POBA to ___.
# New-Onset Systolic CHF EF ___: Patient presented with
symptoms of new onset heart failure. TTE showed severe regional
LV systolic dysfunction (EF ___ with akinesis of the
inferior wall, hypokinesis of the lateral and anterior walls
with preservation of the septum which appeared to be new.
Cardiac cath performed on ___ with successful angioplasty of
subtotal occulusion of the left circumflex at the site of the
bare metal stent. Otherwise the LIMA to LAD was patient, mid
RCA occluded with collateral flow. Patient was diuresed with
lasix, discharge weight 76.6kg. He was also started on
lisinopril and metoprolol.
# Aortic Valve s/p AVR: ___ at OSH showing possibly thrombus or
endocarditis of mechanical prosthetic aortic valve. TEE
performed on ___ showed no evidence of vegetation or thombus.
Further no evidence of endocarditis on exam and blood cultures
negative. Patient initially received Vitamin K. He was started
on a heparin drip that was continued until INR was therapeutic
(>2.5).
# Coronary artery disease: Patient has known CAD s/p CABG in
___ ___ to LAD, SVG to RCA (known to be occluded) and SVG to
OM (known to be occluded), also BMS to Left circumflex/OM.
Patient presented with new wall motion abnormalities on ECHO as
described above, EKG without evidence of ischemia, Troponins
elevated with flat CK-MB. Cardiac cath performed ___ as above
with successful angioplasty of LCx stent. Patient continued on
aspirin, ranexa and statin.
# Hyponatremia: Patient presented with hypervolemic
hyponatremia, sodium of 119 and was asymptomatic. Sodium
improved with diuresis to 132.
# HLD: Patient continued on simvastatin. Consider rechecking as
outpatient. | 99 | 324 |
19495630-DS-10 | 28,990,611 | You were admitted to the hospital with difficulty breathing and
were diagnosed with pneumonia and a COPD exacerbation. You were
treated with antibiotics, steroids, and nebulizers with
improvement in your breathing. You are being sent home with
continuous oxygen, which you should use at all times.
MEDICATION CHANGES:
- you were started on Albuterol nebulizers and given a
prescription for a nebulizer machine
- you were started on home oxygen
- you should use the Nicotine patch daily
- do NOT smoke cigarettes while using oxygen | ___ with hx of COPD, tobacco use (ongoing), atrial fibrillation
on coumadin, hypercholesterolemia, stage IV CKD presenting with
worsening shortness of breath, productive cough of white/yellow
phlegm found to have multifocal infiltrates consistent with PNA
and COPD exacerbation.
.
## Community-acquired pneumonia: Admission CXR showed multifocal
infiltrates supportive of pneumonia. He completed 7 days of
Levofloxacin symptomatic improvement. Repeat CXR prior to
discharge showed significant regression of the infiltrates noted
on initial CXR.
.
## COPD exacerbation: Symptoms improved with antibiotics as
above as well as 5-day course of Prednisone 40mg daily and
nebulizers. He was discharged home with rx for a nebulizer
machine and Albuterol nebs. He still had mild wheezing on
discharge but overall improved.
.
## Hypoxemia: Patient is not usually on home oxygen and his
normal oxygen saturation is around 93-95% on room air with one
recent finding as low as 88% at his cardiologist's office. Here,
he initially required 3L NC to maintain sats in the low ___.
Despite multiple attempts, he could not be weaned off oxygen
completely. He had consistent desaturation to 85-88% on room air
with ambulation. Therefore, he was discharged on continuous ___
O2 and set up with ___. Repeat CXR prior to discharge showed
improvement of pneumonia and also was not remarkable for volume
overload to account for the persistent hypoxemia.
.
## Tobacco dependence: He was maintained on a Nicotine patch
with good effect. He was told that he cannot smoke now that he
is on supplemental oxygen.
.
The remainder of his medical issues were stable during this
admission.
. | 81 | 251 |
12567683-DS-15 | 27,525,077 | Dear Mr. ___,
You were admitted to ___ for shortness of breath and new blood
clots in your lungs. You were also found to have a pneumonia
(lung infection) and a pleural effusion (fluid accumulation in
your chest). We treated you with blood thinners to prevent
further clots. We also treated you with antibiotics and a
procedure, called a thoracentesis, to drain the extra fluid. You
were seen by our oncologists, who recommended that you ___
soon for further imaging and staging of your cancer. We are very
sorry about this diagnosis.
Please do the following once you leave the hospital:
- Continue taking the prescribed antibiotics: Augmentin 875 mg
every 12 hours, ending on ___, which will treat
your pneumonia
- Start taking oxycodone 5 mg every 3 hours as you need it for
pain control. We have given you enough pills to last one week,
before which you will see your primary care physician for
___
- Please also start taking the following medications: 1)
Albuterol inhaler with spacer, and guaifenesin as needed for
cough, 2) Colace and Senna as needed for constipation
- Please continue doing the Lovenox injections (90 mg every 12
hours) to help prevent further blood clots
It was a pleasure to participate in your care. We wish you all
the best.
Sincerely,
Your ___ team | ___ y/o M with recent diagnosis of lung adenocarcinoma who
presented as a transfer from ___ with SOB,
found to have bilateral PE's, recurrent malignant right sided
pleural effusion, and post-obstructive pneumonia.
#Acute pulmonary embolism without cor pulmonale: Patient
presented to ___ on ___ with SOB and chest pressure and found
to have bilateral subsegmental PE's on imaging. Hypercoaguable
state secondary to malignancy. Was transferred to ___ for
management and further work-up. On admission to ___, he denied
chest pain or dyspnea and his vitals were stable. His cardiac
workup was negative with unremarkable EKG and negative
troponins. He received heparin on admission and was transitioned
to lovenox. Discharged on lovenox 90mg SC q12h to continue
indefinitely.
#Malignant pleural effusion: On presentation to ___, patient was
found to have a right-sided pleural effusion on imaging. Prior
to this, he had recently undergone a US-guided thoracentesis on
___ at ___ with 60cc fluid drained. Pleural fluid cytology
results were positive for malignant cells. Based on history, was
likely a re-accumulated malignant effusion but there was also
concern for a parapneumonic effusion given the patient's recent
h/o of pneumonia. IP performed a thoracentesis on ___ and 2L
were drained from right pleural effusion. Cultures negative at
both outside hospital and during this hospitalization. Fluid
results were consistent with exudative effusion, cytology
confirmed the presence of malignant cells. Patient was weaned
from 2L oxygen to RA without issues. A repeat CXR on ___ showed
mild right sided pleural effusion, but much improved from
admission. Patient was discharged on oxycodone 5mg and an
outpatient ___ with IP scheduled for ___. He was
counseled on the warning signs which should prompt emergent
re-evaluation such as dyspnea, fever, worsening chest pain,
hemoptysis.
#HCAP: Prior to admission on ___, patient had been treated for
CAP at ___ and completed a ___ day course of Augmentin and
Azithromycin on ___. He represented to ___ on ___ with
productive cough, SOB and fevers/chills. Had CXR and CT torso.
CXR showed evidence of postobstructive pneumonitis in the right
upper lobe with partial
collapse of the right upper lobe. Upon admission to ___, he
was started on vancomycin/cefepime given concern for HCAP(start
date ___. MRSA, legionella, sputum and blood cultures sent.
Sputum culture was not valid and remaining cultures were
negative. Legionella was negative. Patient was switched to
Augmentin PO on ___ to complete a 2 week course to end ___.
He received ipatroprium and albuterol nebs PRN, guaifenesin
600mg BID for management of respiratory sxs, and given a flutter
valve.
#Pain control: Had significant pain secondary to cancer, pleural
effusion, recent procedure. While inpatient his pain management
was oxycodone 5 mg mild pain, oxycodone 10 mg moderate pain,
dilaudid 0.5 mg IV severe pain. He was discharged on
oxycodone 5 mg q3h pain x1 week and bowel regimen with ___
with PCP.
#Stage IV lung adenocarcinoma: Recently diagnosed with
adenocarcinoma with positive lymph node, invasion of mediastinum
and malignant pleural effusion. Cytology was positive for
malignancy at ___ and again on this hospitalization. A recent CT
chest with contrast demonstrated invasion into mediastinum,
vasculature and bronchial tree. CT also showed evidence of
adrenal mass with concern for a possible met. Given malignant
effusion, patient has stage 4. A bone scan on ___ was negative
for bone metastases. The patient has decided to establish care
at ___ and has scheduled an outpatient appt on ___. Summary of
hospital course will be faxed to ___. Imaging results given to
patient in a CD | 214 | 578 |
14861352-DS-10 | 24,509,885 | Dear Mr. ___,
You were hospitalized after your MRI revealed an ACUTE ISCHEMIC
STROKE, a condition in which a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. Damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- high cholesterol
- high blood pressure
We are changing your medications as follows:
- starting plavix
- stopping aspirin
- increasing your atorvastatin dose
Because we did not find the cause of your stroke, you will have
a cardiac monitor outpatient (called ___ of Hearts). Please
call ___ to set this up.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization. | Mr. ___ is a ___ year old man man with a history of cerebral
palsy and recent cognitive decline who was found to have an
incidental acute right occipital stroke on his MRI obtained for
cognitive workup. He has no new deficits and is asymptomatic.
Etiology is unclear.
# Acute Stroke: CTA of the head and neck showed patent vessels
and small outpouching of basilar which is likely incidental. He
was switched from Plavix 75mg daily from aspirin for secondary
prevention. He was monitored on tele for afib. His atorvastatin
dose increased from 40mg to 80mg daily. Echo did not reveal
cardiac source. A1c was 5.6% and LDL was 107. No etiology of his
stroke was found and he was discharged with plan for ___
___ to monitor for afib.
# Hypertension: Lisinopril and chlorthalidone were held to allow
for permissive hypertension but were restarted prior to
discharge.
# Cognitive Decline: continued his B-12 for replacement. He will
follow up in neurology clinic for further management. | 342 | 164 |
17761931-DS-21 | 23,803,016 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- Your primary care doctor referred you to the ED for low blood
pressures.
- You told us you had been experiencing occasional dizziness,
weakness in your legs, and leg swelling for quite some time.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had lab work that showed your red blood cells and
platelets were lower than normal levels.
- You had an ultrasound of your heart (echocardiogram) that
showed no change in heart function from prior studies, but did
show pulmonary hypertension (increased pressures in your lungs).
- You had CT-imaging done of your chest to help determine why
you have pulmonary hypertension.
- You had CT-imaging of your stomach and pelvis to help figure
out why your legs have been swelling over the past year or so.
This showed lymph nodes deep in your abdomen that are larger
than normal, and will need to be biopsied to get a clear answer
as to why.
- We monitored your blood pressures, and they were never low.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
-You will need an Interventional Radiologist (___) guided biopsy
of a lymph node. We have asked your PCP to help you arrange this
biopsy.
-You will need to see a pulmonologist for your new diagnosis of
pulmonary hypertension. See below for your appointment
scheduling instructions with a pulmonary hypertension
specialist.
- We held your ___, as well as metoprolol since it may be
contributing to your low blood pressures and light-headedness.
Speak with your Primary physician about restarting ___ if
you are still having difficulty with urinary symptoms. Speak
with your cardiologist before restarting metoprolol.
- Your cardiology office should call you with a follow-up
appointment. Please contact them if you don't hear in the next
few days.
We wish you the best!
Sincerely,
Your ___ Team | PATIENT SUMMARY:
==================
___ hx DM2 on insulin, CAD, OSA who was referred to the ED by
his primary care physician after outpatient BP readings showed
borderline hypotension to 90 systolic, also reporting
fatigue and lightheadedness for the last 2 weeks. | 336 | 40 |
11293234-DS-23 | 24,089,938 | Dear Mr. ___,
You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your obstruction has subsequently resolved after
conservative management. You have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery. You had some
evidence of inflammation of the bowel on your cat scan and your
symptoms improved with antibiotics. You will continue to take
flagyl for 3 weeks.
If you have any of the following symptoms please call the office
for advice or go to the emergency room if severe: increasing
abdominal distension, increasing abdominal pain, nausea,
vomiting, inability to tolerate food or liquids, prolonged loose
stool, or extended constipation.
You have a midline incision from your prior surgery. We opened a
portion of this wound and it will need to be packed with gauze.
The rest of the incision is closed with steristrips. Please
monitor for worsening signs of infection: increasing redness of
the incision lines, white/green/yellow/malodorous drainage,
increased pain at the incision, increased warmth of the skin at
the incision, or swelling of the area.
You may shower; pat the incisions dry with a towel, do not rub.
The small incisions may be left open to the air. If closed with
steri-strips (little white adhesive strips), these will fall off
over time, please do not remove them. Please no baths or
swimming until cleared by the surgical team.
If you have pain you may take Tylenol as needed. Do not drink
alcohol while taking Tylenol. Please do not take more than
3000mg of Tylenol in 24 hours.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. | Mr. ___ presented to the ED of ___ on ___ for
management of small bowel obstruction. He was admitted to the
colorectal surgery unit for further management. | 312 | 29 |
15192547-DS-12 | 27,929,558 | You were admitted to the hospital because you had nausea,
vomiting and abdominal pain. This was thought to be related to a
urinary tract infection. You were started on antibiotics and you
improved and will continue to take antibiotics for another 6
days.
You had imaging of your shoulder snd your torso which was
unremarkable. Weigh yourself every morning, call MD if weight
goes up more than 3 lbs. | BRIEF HOSPITAL COURSE:
Tachycardia: Ms ___ presented to the ED with tachycardia.
Serial cardiac enzymes were performed, trending down from 0.03
to 0.02. There
# Tachycardia: Ms ___ presented with palpitations found to be
dehydrated and tachycardic in ED following poor p.o intake with
likely demand ischemia with associated mild troponin leak that
trended down (0.03 to 0.02) and EKG not suggestive of myocardial
infarction. Much improved after IVF. HR wnl, patient remained
chest pain free. Her PCP should arrange for an outpatient stress
test. She will continue home services, ___ to review that she is
taking adequate p.o intake.
.
Abdominal pain: pt with diffuse abdominal pain initially, with
pain resolved on discharge. She had also endorsed associated n/v
and found to have UTI. Pain did not appear related to recent
surgery and CT abdomen and pelvis did not reveal any acute bowel
pathology. She was started empirically on IV ciprofloxacin,
switched to nitrofurantoin based on sensitivities from prior
urine cultures. A urine culture performed this hospitalization
was contaminated and she was treated empirically for UTI with
nitrofurantoin for planned 7 day total antibiotic course.
.
# CKI: pt with Cr from 2.1 from 1.0 in setting of n/v and poor
p.o intake leading to dehydration, with ___ likely prerenal in
etiology.Cr improved to 1.2 from 2.1 after receiving intravenous
fluids.
.
# s/p L salpingoopherectomy; pathology shows large cyst. Steri
strips remained in place per ob/gyn. She will f/u with her
gynecologist at ___.
.
# Recent shoulder surgery: continue home physical therapy.
.
# Anemia: pt had 8 point HCT drop from 38 to 30.2 in the setting
of receiving intravenous fluids. This HCT was believed to be
dilutional with subsequent HCT trend showing increase in HCT to
31.8 consistent with this. She should have repeat HCT check on
follow up with her PCP. | 69 | 300 |
15545526-DS-12 | 22,358,311 | Mr. ___,
You were admitted due to shortness of breath and cough, you were
found to have pneumonia and will continue treatment with your IV
antibiotic at home. Your symptoms greatly improved with your
antibiotics. You will follow up in clinic as stated below. It
was a pleasure taking care of you. Please call with any
questions or concerns. | Mr. ___ is a ___ ___ man with high risk
MDS and chronic diastolic heart failure recently admitted for
several days of hemoptysis and CT showing ? PNA vs. other
process
found to have a positive AFB smear from ___, who presented to
clinic ___ with fever and SOB, s/p ICU transfer for Afib with
RVR improved with Dilt/metoprolol, now hemodynamically stable in
NSR sputum +klebsiella.
#Afib with RVR: Transferred to ICU on ___ for this, now
converted to sinus and hemodynamically stable since then.
Cardiology following. TTE with no evidence of pericardial
effusion. Resumed home metoprolol with holding parameters.
#Fever/SOB: Recent admission with chest CT ___ showing LL
predominant multifocal consolidations c/f multifocal infection
v.
vasculitis v. COPD v. pulmonary infarcts. He was treated for
HCAP. Sputum sample ___ grew AFB, repeat samples neg now off TB
precautions. Beta glucan level also highly elevated on ___.
However, most recent B-glucan is negative without a clear
therapy. Has had ongoing intermittent productive cough. CT chest
___ shows rapid progression of pulmonary infection. He is
growing klebsiella on his sputum cultures which could certainly
account for his interval change on imaging and it appears to
have
been somewhat high grade as is on three different cultures
despite therapy. Per pulmonary recs, should obtain chest CT 2
weeks after treatment for klebsiella to evaluate for possible
secondary infectious process. If no improvement or significant
residual disease per imaging, bronchoscopy would then be
indicated. Pulmonary also recommended evaluation for aspiration
risk given distribution of disease but this may be difficult to
obtain due to TB precautions.
-crypto antigen in blood and urine histo negative
-ceftazidime (___) then changed to ceftriaxone to
complete 14d course ___, off ___ and vanco since ___
-appreciate ID recs-see note AFB unlikely at this point,
negative
sputums x3
-repeat CT chest 2 weeks after most recent
-weekly fungal markers
-IgG level 796 on ___
#Acute on chronic diastolic heart failure: BNP on admission was
elevated at 4800 and patient was mildly volume overloaded on
exam the afternoon of ___, resumed home lasix. CXR ___
shows
mild pulmonary edema; however, repeat ___ in the setting of
worsening SOB showed progressive pulmonary edema w/ bilateral
effusions. Continues on home regimen of lasix 40mg BID and
baseline crackles at b/l bases.
-Lasix IV x 1 on ___, consider repeat dose if no improvement
-telemetry for continuous 02 monitoring
-monitoring strict I/Os
#Coagulopathy: Likely vit K deficient, received PO vitamin K.
Low suspicion for inhibitor but we checked a mixing study since
if he did have an inhibitor with worsened hemoptysis treatment
would be different.
-vitamin K 5mg x 1 on ___ and ___
-f/u mixing study
-restarted prophylactic heparin daily dosing and when
checking PTT, this should be done peripherally (not from his
port)
#HR MDS: He has been maintained on dacogen for about a year now,
currently on C14 so holding now in the setting of active
infection. Exjade on hold while inpatient.
-transfuse to maintain hgb > 7,
-will need Lasix prn with transfusions
#Acute on chronic kidney disease: CKD stage III attributed to
HTN
and vascular disease. Cr slightly above baseline of 1.4-1.6
though downtrending since admission. Possibly in the setting of
volume overload.
-Lasix as above
-Trend Cr
-Avoid nephrotoxins
-Hold lisinopril
#Hernia: Etiology likely due to previous abdominal surgery in
___ ? incisional-related. No abdominal discomfort or
tenderness.
We will continue to monitor closely
#HTN:
-Continue metoprolol with holding parameters
-Hold lisinopril given acute on chronic renal failure
#CAD: Continue ASA 81
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: SQ heparin daily
# Access: Port
# Communication: ___ (___)
# Code: Full (confirmed)
# Disposition: home, to complete 1wk course of ceftriaxone
outpatient, f/u next week ___ or sooner if issues arise | 58 | 581 |
14862629-DS-3 | 26,424,728 | Dear Ms ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for abdominal pain and blood in your urine
What was done for me while I was in the hospital?
- You had some imaging done of your abdomen. It looked like one
of the cysts on your kidney had ruptured.
- You were given pain medication and closely monitored.
What should I do when I leave the hospital?
- Continue to take all of your medications as prescribed.
- Please obtain bloodwork at ___ prior to your appointment on
___. The order for your labwork has already been placed.
Sincerely,
Your ___ Care Team | ___ hx of polycystic kidney disease on transplant waiting list
(listed but inactive until GFR < 20, not on dialysis), currently
stage IV ckd- b/l Cr 2.8-2.9, HTN, HLD and hx of diverticulosis
who presents with flank pain/LLQ pain and hematuria. | 127 | 41 |
10569306-DS-50 | 20,719,223 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ year old female with PCKD s/p failed transplant on HD MWF,
recurrent fevers due to gram negative bacteremia of unknown
source, who presents from dialysis with rigors and temperature
to 100.0, without localizing infection.
ACTIVE MEDICAL ISSUES:
# Elevated temperature: On admission, pt did not meet SIRS
criteria and was afebrile however she had report temperature to
100.0 ___s rigors at dialysis. In the past, pt has had two
episodes of E. coli bacteremia, and most recently completed a
course on ___ of cefazolin for Klebsiella bacteremia. On
admission, she had few localizing symptoms other than a cough
which is chronic as well as back pain with standing which she
reports is also chronic. She denied abdominal pain, n/v/d. No
headaches or neck pain to suggest CNS infection. CXR did not
show evidence of pneumonia. Blood cultures from ___ at both
dialysis and BI were pending, no growth at discharge. CMV viral
load was also pending. She was empirically treated with
vancomycin (HD protocol) and cefepime. Her antibiotics were
stopped as she had no symptoms, remained afebrile with no
leukocytosis. Her elevated temperature and malaise may represent
viral process rather than overt bacterial infection. Her
antibiotics were stopped on the day prior to discharge, and she
remained stable. She had an appointment to follow up with her
PCP the day after discharge.
# HYPERCALCEMIA: Pt noted to have hypercalcemia due to
hyperparathyroidism in the past. Her calcium on admission was
11.0. An SPEP was checked (given her back pain and malaise)
which is pending at discharge. Her dialysis was also modified as
below. | 14 | 264 |
17989167-DS-21 | 22,366,186 | Dear Mr ___,
You were admitted to the ___ after feeling weak and falling at
home. You were evaluated by our neurology team, who also did CT
and MRI scans of your head, which did not show a stroke. Because
you were retaining urine, you were discharged with a foley in
place. You have a follow up appointment with Dr. ___ on
___.
During hospitalization you had imaging performed which revealed
a 1 cm thyroid nodule. Please discuss with Dr. ___ an
ultrasound of your thyroid to better characterize the nodule.
Please take note of the following:
- Please stop taking your Coumadin for 2 days. Your primary care
physician, ___, has asked that you restart your Coumadin on
___ at 1 tablet of 5mg and check your INR. Contact Dr
___ with your INR results.
- Please follow up with urology to have your foley removed on
___
- Please follow up with your PCP Dr ___ on ___ at 2:30 ___
- Continue all your other home medications as normal
It was a pleasure taking care of you at ___. We wish you all
the best!
- Your ___ care team | ___ h/o cardiomyopathy, A-fib, DM and severe mid LAD stenosis
s/p cath with DES who presents from PCP with weakness found to
have Afib with RVR, AMS during admission.
# AMS: On admission patient was A&Ox3 but later became A&Ox1 and
agitated. Possible triggers for delirium included urinary
retention (patient could not void spontaneously and was
discharged with foley), constipation. Workup for CVA including
MRI and CT was negative. Workup for infection including renal
u/s, cultures, and UA was negative. Renal u/s showed
non-obstructing stones. On discharge patient was A&Ox3 but very
combative. Questionable component of dementia given history from
wife. He may benefit from cognitive testing by Neurology as an
outpatient for evaluation of dementia.
# BPH with active urinary retention: Bladder scanned on ___ ___
and again had 700+cc urine in bladder. Patient was straight
cath'd multiple times for failure to void. A foley was placed
and he was discharged with a foley with plan to follow up with
urology.
# ___: Most likely post-renal in setting of urinary retention,
but may have component of prerenal due to poor po intake at
home. Creatinine decreased to 1.1 after placement of foley.
# Afib on warfarin: Developed rapid rates to 150's in setting of
missing evening dose of Metoprolol tartrate. Improved to
100's-110's after receiving PO dose of Metoprolol tartrate 50
mg. INR supratherapeutic at 5.2 (pt had been taking ___
daily). NO evidence of bleeding. Warfarin held again on ___ for
INR of 3.6. Per his PCP ___ for patient to re-start
warfarin 5 mg daily on ___.
# Leukocytosis: Mild elevation of WBC to 11.5. UA negative,
renal u/s showed non-obstructing stones. Down-trended to normal
without antibiotics.
CHRONIC ISSUES:
# CAD s/p DES in ___: Continued Aspirin and Plavix,
atorvastatin, losartan.
# dCHF: Euvolemic, home torsemide held due to ___ but then
restarted on d/c.
# DM: Metformin held in setting of elevated lactate, restarted
on d/c.
# H/o gout: Continued home colchicine + probenecid.
Transitional Issues
===================
-Patient discharged on foley due to failure to void. Needs to
followup with urology to discontinue foley.
-INR 3.6 on discharge. Warfarin was held on ___ and
___. Patient should restart Warfarin on ___ at 5mg and
check his INR at home per recommendation of Dr. ___.
-Please follow up 9mm thyroid nodule with thyroid ultrasound.
-History obtained from patient's wife and patient's
combativeness in hospital concerning for early dementia. Please
evaluate with cognitive testing as outpatient with possible
referral to cognitive neurology.
-Please consider downtitrating tramadol and lorazepam given
concern for altered mental status.
-Code Status: Full Code (confirmed)
-Contact: Name of health care proxy: ___
Relationship: wife
Cell phone: ___ | 186 | 443 |
16915421-DS-7 | 20,186,089 | Dear Ms. ___,
You were admitted to ___ for
evaluation of abdominal pain and you were found to have an
incarcerated right inguinal hernia. You were therefore evaluated
by the acute care surgery team and offered surgical repair,
however you declined surgery during this hospital admission.
Risks of delaying surgery were discussed at length, however you
have elected to follow up as an outpatient with Dr. ___. You
are therefore now ready for discharge. Please follow the
instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. | Patient is a ___ year old female with past medical history
significant for thyroid cancer s/p thyroidectomy, IBS,
diverticulosis, and prior repair of a right inguinal hernia in
___ ___. Patient presented to the emergency
department with complaints of abdominal pain and was found to
have right incarcerated inguinal hernia on imaging. Therefore
acute care surgery was consulted for evaluation and management.
The hernia was partially manually reduced at the bedside and she
was admitted to the inpatient unit for operative planning.
Surgical repair of her incarcerated inguinal hernia with acute
care surgery was then offered however the patient declined
surgery during current admission. She reported she wishes to
have surgery completed by Dr. ___ as an outpatient. Risks of
delaying surgery were discussed at length. This included risk of
worsening pain and/or bowel incarceration, and need for emergent
operation that could require bowel resection. She reported she
was accepting of these risks. She was then given the contact
information for Dr. ___ clinic to schedule her
follow up care.
During this hospitalization, the patient voided without
difficulty and ambulated early and frequently. The patient was
adherent with respiratory toilet and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay. At the time of
discharge, the patient was doing well. She was afebrile and her
vital signs were stable. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and her pain was
well controlled. The patient was discharged home without
services. Discharge teaching was completed, and follow up was
reviewed with reported understanding and agreement. | 299 | 267 |
13757970-DS-6 | 22,877,162 | Dear Ms. ___,
It was a pleasure caring for you at ___. You presented with
bloody diarrhea, which has since stopped. We are still unsure
what caused it, but we think it either resulted from an
infection in your colon, low blood flow to the colon while you
exercised, or inflammation in the colon from another cause. You
were given IV fluids and monitored closely. Your blood counts
were stable, you are feeling better, are no longer having bloody
diarrhea like you were yesterday, and are eating solid food, so
we feel that you are ready for discharge.
Additionally, the use of ibuprofen can exacerbate (or cause)
gastrointestinal bleeding (typically from the stomach). Please
use this sparingly and alternate with acetaminophen.
Please keep yourself well-hydrated with drinks like gatorade
while you continue to have diarrhea and only eat food that you
can tolerate.
Please review your medications below closely and take them as
prescribed.
Please keep your follow-up appointment below. | This is a ___ female with minimal PMH who presents with one day
of watery diarrhea, BRBPR, and abdominal cramping after running
a 5K race, of unclear etiology.
# Diarrhea / BRBPR: Pt's symptoms decreased significantly at
discharge, with little to no blood in the stool (which remained
watery). Very likely lower GI in origin (vomitus was
non-bloody). She was hemodynamically stable throughout her
admission, and HCT was stable at 37-40. No clear cause at this
point, though given absence of prior GI disease, epidemiology,
CT scan, conincident nausea/vomiting, and elevated white count,
an infectious colitis seems most likely. EHEC and C.Diff neg.
Potential culprits could be shigella, salmonella, or
campylobacter (cultures pending), though she denies any obvious
exposures and absence of fever would be somewhat atypical. Other
less likely possibilities include IBD (though she is appropriate
age range) or ischemic colitis (she is young, no risk factors -
exercise-associated ischemic colitis has been described but is
rare and the inflammation in her colon is not at a watershed
area). She was given IVF while not taking POs, her nausea was
controlled with Zofran, and her diet was advanced to regular.
She was told to avoid ibuprofen for the time being given risk of
re-bleeding.
# Depression / Anxiety: Currently stable. Her home Sertraline
was continued.
# OCPs: Her home OCP was continued. | 157 | 226 |
19023440-DS-20 | 29,815,969 | Dear Ms. ___,
___ were admitted to ___ because ___ had a fall at home
resulting in a hip fracture. ___ had surgery on ___ without
complications. ___ were then transferred to the medicine
service because ___ were confused and drowsy. Your labwork
showed a high sodium, likely due to your lithium therapy. ___
were given IV fluids and your sodium returned to normal. ___
should continue to drink plenty of water at home to prevent your
sodium level from getting too high.
___ also were noted to have high calcium levels, likely due to
the effects of lithium on a gland called the parathyroid gland.
___ should follow up with an endocrinologist and general surgeon
to discuss management of your calcium levels, which may require
surgery.
We made the following changes to your medications:
-START lovenox injections 30 units once daily (continue until
your follow up appointment with orthopedics)
-START tylenol ___ every six hours as needed for pain
-START oxycodone 2.5-5mg every six hours as needed for pain not
relieved by tylenol
-START senna, docusate, and bisacodyl to prevent constipation
while taking oxycodone
We made no other changes to your medications while ___ were in
the hospital. Please continue taking your medications as
prescribed by your outpatient providers.
Please see below for your currently scheduled appointments. If
___ are unable to make an appointment please call and
reschedule.
It has been a pleasure taking care of ___ at ___ and we wish
___ a speedy recovery.
Wound Care:
- Keep Incision clean and dry.
- ___ can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be full weight bearing on your left leg
- ___ should not lift anything greater than 5 pounds.
- Elevate left leg to reduce swelling and pain.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- ___ have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. ___ can either have them mailed
to your home or pick them up at the clinic located on ___.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If ___ have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room. | Primary Reason for Hospitalization:
___ yo F with nephrogenic DI, breast CA sp mastectomy in ___,
admitted with hip fracture sp ORIF on ___. Post-op course
complicated with AMS and slurred speech, hypernatremia,
hypecalcemia, and pt was transferred to medicine.
. | 517 | 41 |
18003081-DS-40 | 22,035,704 | Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You had bloody vomit
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You had a procedure performed, called an endoscopy, that tried
to find a source of the blood. It did not find any single area
of concern.
- You were monitored closely and did not re-bleed.
- You had a seizure in setting of acute illness
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___. We
wish you all the best,
- Your ___ Care Team | BRIEF HOSPITAL COURSE
=====================
___ Hx ___, severe intellectual disability, recurrent
GIBs, unprovoked DVT on rivaroxaban, p/w acute on chronic anemia
I/s/o likely UGIB. Patient underwent unrevealing EGD (___)
with self-resolution of ongoing bleeding, with course
complicated by propofol infiltrate requiring MICU transfer for
observation and generalized seizure in setting of acute illness
and not receiving home medications
TRANSITIONAL ISSUES
===================
[] HEART MURMUR: Holosystolic murmur best heard at apex noted on
exam, please monitor and consider TTE on outpatient basis.
[] ASPIRATION RISK: Patient continues to demonstrate chronic
risk of aspiration. Recommend ongoing precautions as well as
ongoing discussions with guardian regarding the risks of
complications with aspiration
[] PPI: Patient should complete a 12 week twice a day PPI course
for likely UGIB
ACTIVE ISSUES
=============
# UGIB
He presented with coffee-ground emesis with Hgb 5.5 (baseline
___. EGD ___ was unrevealing. Of note, patient has had
extensive GI work up in the past with negative colonoscopy and
capsule studies in past. His bleeding self resolved and he was
started on lansoprazole 30 BID, and he was discharged with GI
follow-up.
# Seizure
# ___ syndrome
Known history ___ Gastaut syndrome. He was continued on
felbamate 1400 big + phenytoin 150 bid + levetiracetam 750 bid
throughout this admission. He had two breakthrough, generalized
seizures during this admission which were treated with IV
lorazepam. Neurology was consulted and this was believed to be
due to difficulty with medication administration in the ED as
well as in the setting of acute illness and no changes were made
to his medication regimen.
#Aspiration Risk: Patient was evaluated by speech and swallow
service and felt to be at baseline swallowing capacity.
# Propofol IV infiltration
# Arm swelling
Midline infiltrated during propofol bolus prior to EGD. He was
transferred in the MICU and toxicology was consulted. There were
no complications.
CHRONIC ISSUES
==============
# Hx unprovoked DVT - his home anticoagulation was resumed by
the time of discharge after short bridge with heparin gtt to
ensure stability after bleed. | 134 | 317 |
10981725-DS-28 | 21,250,461 | Dear ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were having fevers at home
What was done while I was in the hospital?
- We found that one of your drains was not draining properly
- We had the interventional doctors ___ the ___
- You were put back on antibiotics that helped with your fevers
What should I do when I get home from the hospital?
- Be sure to take all of your medications as prescribed,
especially your antibiotics (last day ___ and your
immunosuppression drugs
- Please go to your follow-up appointments with your primary
care doctor, your liver doctor, and the infectious disease
doctor
- If you have fevers, chills, abdominal pain, yellowing of the
skin, or generally feel unwell, please call your doctor or go to
the emergency room
Sincerely,
Your ___ Treatment Team | Ms. ___ is a ___ year-old woman with history of CAD,
hypertension, diabetes mellitus, NASH cirrhosis with DDLT
(___) (on cyclosporine and mycophenolate) with aortic conduit
complicated by biliary strictures s/p stenting and multiple
percutaneous transhepatic biliary drain exchanges with recurrent
cholangitis, pseudomonas bacteremia, on suppressive cipro, VRE
infections, and left hepatic abscess, who presented with fevers,
and elevated ALP concerning for recurrent cholangitis.
ACUTE ISSUES
#Cholangitis: The patient presented with 1 day of fever &
elevated LFTs concerning for recurrent cholangitis. She did not
have abdominal pain, however she denies ever abdominal pain with
her recurrent cholangitis. Fever occurred while on suppressive
cipro. Previous bile cultures grew MDR pseudomonas sensitive
only to cipro & aminoglycosides as well as VRE. RUQ U/S revealed
persistent perihepatic collection, so likely continued source of
infection. The patient's PTBD was uncapped with significant
drainage to bag concerning for PTBD dysfunction. She was started
on high dose ciprofloxacin and linezolid and ultimately
underwent cholangiogram with dilation of biliary stricture and
subsequent improved flow. The patient remained afebrile
throughout her hospitalization. Her PTBD was capped on ___.
Patient did not spike fever overnight, after capping. ID
consulted and recommended to complete a 2 week course of cipro
750mg BID and linezolid ___ BID (last day ___, followed
by return to ___ 500mg daily for suppression.
CHRONIC ISSUES
#Idiopathic cirrhosis s/p DDLT: With aortic conduit (___) and
stenosis of arterial graft of liver. Patient with multiple
complications. Now more stable, though with continued biliary
strictures.
# Anemia: Patient anemic to 6.9 on ___. Given 1U pRBCs. Likely
related to chronic disease/bone marrow suppression given low
retic index. Anemia improved appropriately. Now stable in 8s.
Iron studies consistent with inflammatory picture (high
ferritin, low iron).
TRANSITIONAL ISSUES
[] Labs on ___: CBC, Chemistries, cyclosporine level.
Should be faxed to Dr. ___ ___, Dr. ___
___.
[] discharge antibiotic regimen: ciprofloxacin 750mg q12h,
linezolid ___ q12h (last day ___
[] once initial antibiotic regimen is complete, should stay on
suppressive ciprofloxacin 500mg daily indefinitely
[] follow-up to be scheduled with ___ for PTBD and JP drain
management
[] discharge hemoglobin: 7.7
[] discharge immunosuppression: Mycophenolate Sodium ___ 360 mg
PO BID, CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H
# CODE: FULL CODE (presumed)
# CONTACT: ___ (sister and HCP), ___ | 138 | 368 |
16759761-DS-26 | 22,748,003 | Dear Mr. ___,
It has been a pleasure caring for you at ___. You presented to
___ on ___ with 4 days of cough with blood, abdominal
pain, nausea, and fever. Your symptoms were likely due to a
viral illness, and this resolved without antibiotics. However,
the levels of tacrolimus in your blood were undetectable and
your liver tests continued to increase throughout your
hospitalization, raising concern for transplant rejection.
Therefore, we increased your dose of tacrolimus. We also
performed a biopsy of your liver which showed rejection of your
liver by your immune system. We gave you additional medicines
including steroids to suppress your immune system, however your
liver tests remained elevated. You received a second liver
biopsy which showed ongoing rejection of your liver. We then
added another medicine called ATG (anti-thymocyte globlulin) to
further suppress your immune system. After 7 days of therapy
with ATG, your liver tests improved. You will need to return to
___ next week for another liver biopsy to make sure that your
immune system has stopped rejecting your liver.
You will be following up with pulmonology as you have coughed up
small amounts of blood and were found to have a nodule in the
lung as well as high pressures in the blood vessels of the lung.
You will also need an ultrasound of the heart (echocardiogram)
to further evaluate this.
Your blood sugars have been high so please follow up with your
___ endocrinologist.
It has been a pleasure taking care of you,
Best wishes,
Your ___ Team | Mr. ___ is a ___ with a history of cirrhosis (HCV and
EtOH, s/p orthotopic liver transplant ___ with subsequent
recurrence of cirrhosis (s/p treatment with
simeprevir/sofosbuvir ___, who presented to ___ on ___
with ___ days of cough, hemoptysis, abdominal pain, nausea and
fever, found to have subsequent acute liver rejection.
# Acute liver transplant rejection: Patient was admitted to
___ on ___ with fevers to 103, ___ days of productive
cough, hemoptysis, abdominal pain, nausea, and vomiting of all
POs including his immunosuppressive medications. His LFTs were
elevated on admission and continued to increase during his
hospitalization with peak AST of 144 and peak ALT of 148. His
elevated LFTs were concerning for transplant rejection in the
setting of decreased tacrolimus level. CT abdomen was concerning
for an intraparenchymal process. He then underwent liver biopsy
on ___ with confirmed acute liver rejection. Patient was
started on high dose steroids for 5 days along with tacrolimus
and cellcept, but continued to have elevated LFTs. He underwent
repeat liver biopsy on ___ which showed ongoing rejection. He
then received 7 days of anti-thymocyte globulin (ATG) for
steroid resistant rejection. His LFTs improved with ATG
administration to ALT 82 AST 52, and patient was discharged with
planned repeat liver biopsy and hepatology follow up.
___: Patient had mild ___ during his admission. His creatinine
was elevated to creatinine 1.4 above baseline 1.1-1.2. This
stabilized to 1.3 at discharge after fluid administration. His
___ was thought to be secondary to tacrolimus vs hypovolemia.
# Diabetes: Patient had difficult hospital course with regard to
his glycemic control likely due to steroid administration. He
was at times hypoglycemic and hyperglycemic but was not
symptomatic. He was managed with his home 70/30 and an insulin
sliding scale. His insulin was adjusted per ___ consult
recommendations.
# Viral syndrome: Presented with ___ days of productive cough,
hemoptysis, abdominal pain, nausea, and fever to 103. Likely
viral given improvement off antibiotics. Pt had fever of 103
days prior to seeking care and may benefit from prompt
evaluation next time he is febrile, given his immunosuppression.
Team has counseled patient to seek care immediately with future
fevers. He received guaifenisin/dextromethorphan and benzonatate
for symptomatic relief of cough. He receieved a CT scan for
ongoing mild hemoptysis that showed a small nodule that will
need subsequent follow up with pulmonology.
# Hyponatremia: Patient had Na+ that was initially downtrending,
but resolved with IVF. Patient did not have any associated
symptoms.
# Medications: You have the following new or adjusted
medications:
Tacrolimus 3 mg po twice a day
Mycophenolate Mofetil 1000mg twice a day
Prednisone 20 mg po daily
Valganciclovir 450 mg po daily
Fluconazole 400 mg po daily
Insulin dosing now 24 Units in AM and 26 units in ___ | 254 | 458 |
13743156-DS-11 | 29,857,174 | Dear ___,
It was a pleasure participating in your care while you were at
___. You had an episode of unresponsiveness while in your
nephrologist's office, which we think was from a vagal response
in response to nausea as well as reflective of decreased volume
in your vessels. You were monitored on telemetry and we gave you
IV fluids.
Please schedule ___ in the near future with Dr. ___
your primary care doctor.
We wish you the best!
Your ___ team | ___ with membranous nephropathy and nephrotic syndrome with
progressive proteinuria who presents after syncopal episode with
concern for pulselessness.
# Syncope: By symptoms consistent with vasovagal syncope,
borderline orthostatic by vital signs. Received IVF and was
monitored on telemetry. Though unlikely, was ruled out for ACS.
No tachycardia, pleuritic chest pain, leg swelling or hypoxia to
suggest DVT/PE. Felt better day after. Was persistently
borderline orthostatic per BP and HR but w/o symptoms, likely
due to hypoalbuminemic state resulting in relative intravascular
volume depletion. PO intake encouraged upon discharge
# Chest pain: Noted upon admission, not pleuritic, unchanged.
Acute coronary syndrome ruled out. Resolved by HD 1. Etiology
may be muscle soreness/MSK.
# Hyponatremia: Improved with more IVF to 134.
# Membranous nephropathy/nephrotic syndrome: On prednisone and
cyclosporine, recent 24 hr urine with > 6g protein. No
significant edema on exam, BPs ok and renal function stable.
Continued these medications and associated prophylaxis with
atovaquone.
# T2DM: Recent HbA1c 7.2%. Glipizide held at last admission, and
continued to be held during this admission. Trended FSBG while
inpatient as on prednisone, reasonable control achieved on
sliding scale alone. Will continue to hold glipizide upon
discharge as may potentially be contributing to
SIADH/hyponatremia.
# Anemia: Mild and stable. Trended while inpatient with no other
intervention. | 77 | 209 |
13653826-DS-4 | 26,057,824 | Dear Ms ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
-You were admitted to the hospital because you were having
shortness of breath.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were seen by our lung experts who tried to drain the fluid
around your lung. They were unable to drain the fluid
unfortunately. We discussed possible surgery to treat this. You
decided not to do surgery. We gave you antibiotics to control
your lung infection and morphine to help with your shortness of
breath. We arranged hospice services so help you spend quality
time outside the hospital with family.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Take your medicines as prescribed. Take morphine 30 minutes
before you exert yourself for best effect.
- You have a follow-up appointment with your oncologist to check
on you and make sure your symptoms are under control. If it is
too difficult to make it to the office, your oncologist is happy
to speak by phone instead. See below for details and phone
number.
We wish you the best!
Sincerely,
Your ___ Team | Transitional Issues
====================
[]titrate morphine to quell patient's air hunger
[]titrate Ativan to quell patient's anxiety
[]titate bowel regimen
Summary Statement
==================
This is an ___ with h/o Stage IV NSCLC (recently diagnosed),
COPD and hyponatremia, admitted for recurrent complex pleural
effusion on CT and leukocytosis concerning
for pleural infection. The patient's effusion was too viscous to
be drained by IP. After the unsuccessful drainage, the patient
requested no more interventions or escalations in care. Her
symptoms were treated with morphine and Ativan as well as
amox/clav to prevent worsening of her likely pleural infection.
She was discharged to ___ with hospice and comfort focused care.
Active Issues
==============
#Left loculated pleural effusion
#Leukocytosis
The patient presented with a loculated appearing pleural
effusion on the left side, leukocytosis to 36,000, and mild
hypoxemia requiring 2L O2. She was seen in the emergency
department by Interventional Pulmonology who attempted bedside
thoracentesis but was unable to extract any fluid due to its
viscosity. Given the patient's malignancy as well as
significant leukocytosis and fevers, her effusion is likely
malignant in nature with possible super-infection. Patient was
initially started on empiric vancomycin and cefepime. Treatment
options were discussed with the patient and her family, and she
decided that she did not want surgical drainage or any further
escalations in her care. Palliative Care was consulted.
Outpatient hospice services were arranged, and she was switched
to p.o. amoxicillin-clavulanate, given p.o. morphine and
lorazepam for air hunger and anxiety, and discharged to ___
___ for ongoing hospice care.
#Goals of care
During the ___ hospital stay, we had an extensive
conversation regarding her goals of care. She noted that she
would not want to be intubated or have chest
compressions done. She initially thought she would want to be
transferred to the ICU for BiPAP but reconsidered and decided
that it would not be within her
goals of care. We discussed the potential of a VATS surgery
which the patient noted she would not be interested in. The
patient was seen by the thoracic surgeons and declined any
further interventions including thoracentesis. The patient would
like her infection treated if possible with po antibiotics. She
was treated with po morhine for air hunger and po Ativan for
anxiety.
#Hyponatremia
Patient has a history of chronic hyponatremia with sodium around
130. Serum sodium here on presentation was 130 with serum
positives of 265 consistent with hypotonic hyponatremia. Urine
electrolytes were not consistent with SIADH. Likely some
component of hypovolemia as the patient received IV fluids as
well as p.o. intake and sodium stabilized. | 190 | 421 |
17778496-DS-4 | 27,597,329 | You came to the hospital because you felt fatigued. While you
were here you were diagnosed with AML and we started on
treatment with ATRA and arsenic. You tolerated the chemotherapy
well and your blood cells went up at first and then went down.
Also while here you were seen by the colorectal surgeons for a
perianal phlegmon. They did not want to do any surgery on it and
you were treated with antibiotics. You will continue with
antibiotics till Dr. ___ you and tells you that you
don't need to take them anymore. If you have a temp of 100.4
please come to the hospital | ___ otherwise healthy admitted to the MICU for pancytopenia of
unclear etiology and neutropenic fever, found on bone marrow
biopsy to have new diagnosis of acute promyelocytic leukemia.
# Acute Promyelocytic Leukemia: She presented with pancytopenia
and bone marrow biopsy showed hypercellular marrow with 55%
neoplastic promyelocytes. FISH study confirmed the diagnosis
with the characteristic t(15:17)(q22;q12) translocation. Given
leukopenia on presentation, she is classified as low-risk APML
and treatment consisted of ATRA with arsenic (added on day 10 of
tx). Her WBC went as high as 60 but she never required
dexamethasone (she had no symotoms of differentiation
syndrome)and never required hydrea. Her counts eventually went
down and she became pancytopenic from the chemo. She was
discharged still neutropenic but no signs of active infection no
fevers (Still on cipro and flagyl) and was advised to all if any
fevers
# Neutropenic Fever: Fever on presentation, likely secondary to
tumor fever or perirectal fistula (described below).
Antibiotics initially started were cefepime/Vancomycin. Flagyl
and fluconazole were added on ___ given perirectal fistula and
antibiotic course was eventually switched to cipro and flagyl
while neutropenic.
# Perirectal Enterocutaneous Fistula/Diarrhea: One week of anal
fissure prior to presentation for which she was using
nitroglycerin topical. Onset of diarrhea (cdif negative) as
inpatient resulted in pain and development of perirectal
fisutula. MRI pelvis showed no abscess. Colorectal did not feel
surgery was necessary. Flagyl was added to vanc/cefepime on
___. Her fistula improved with ___ baths and dilaudid for
pain control and antibiotcs were switched to cipro and flagyl.
# Reaction to Transfusion and IV Contrast:
On ___ she developed hypotension and complaints of pain/burning
at the IV site, lightheadedness and chills/rigors, during the
transfusion of the second of two units of PRBCs. This resolved
with steroids, H1/H2 blockers, and fluids. Blood bank did not
believe that this is a typical transfusion reaction,
specifically no evidence of hemolysis. On ___, she developed
respiratory distress and fever to 103 after IV contrast for CT
that resolved with steroids, H1/H2 blockers, and fluids. Future
transfusions and IV gadolinium contrast infusions went smoothly
with premedication (hydrocortisone, tylenol, benadryl). | 106 | 364 |
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