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19300381-DS-7

Dear Ms. ___, It was a pleasure taking care of you during your hospitalization at ___. You were admitted for altered mental status and confusion which was due to an increased lithium level. You likely became dehydrated, your kidneys got injured and you developed a high level of the drug in your blood which caused adverse effects. You were given fluids and your level decreased. Your kidneys improved.

___ with BPAD on lithium, h/o cocaine abuse, HTN, HLD and DM sent in from ___ on ___ for increased confusion and altered mental status, worse this AM. She was found to have a lithium level of 2.4 on ___. EKG showed sinus bradycardia with a rate of 60, LAD w/ ?LBBB, LVH and T wave inversions # Lithium toxicity: Likely increased level in setting of ___, particularly in a patient on lisinopril with questionable PO intake. She was aggressively hydrated with normal saline and her lithium level trended down, as did her creatinine. ___ was 1.3 on discharge. She was monitored on telemetry and with q4 neuro checks. # Non anion-gap metabolic acidosis: Likely due to increased NS. Stable at discharge, fluids were changed to LR. # Hyponatremia: Na 132 initially, increased to 136. Patient looks euvolemic to hypovolemic on exam. Improvement with fluids suggests hypovolemic hyponatremia as in ___ the sodium would decrease with IVF. Sodium was 137 on discharge. # Hypertension: Amlodipine was held in the setting of hypotension. Blood pressures remained stable and her amlodipine was continued on discharge. It is important that the patient remain well hydrated at all times with antihypertensives and lithium on board. # Diabetes: Hold glucophage in setting of renal dysfunction. She was maintained on insulin sliding scale while in the hospital. # COPD: continued triotropium, advair, albuterol

17814932-DS-3

Dear Ms. ___, It was a privilege caring for you at ___. Please see below for more information on your hospitalization. WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had chest pain. You were found to have had a heart attack. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? - Your heart arteries were examined (cardiac catheterization) which showed a blockage of one of the arteries. This was opened by placing a tube called a stent in the artery. You were given medications to prevent future blockages. - We started you on medications to help your heart - You had a low blood count (anemia) and we did imaging and the GI team looked at your esophagus, stomach and first part of your intestines with EGD. They saw some ulcers and changes in your esophagus but no obvious signs of bleeding. - We gave you blood to maintain your blood counts - You blood counts remained stable and you were ready to go home. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - It is very important to take your aspirin and clopidogrel (also known as Plavix every day. - These two medications keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. - If you stop these medications or miss ___ dose, you risk causing a blood clot forming in your heart stents and having another heart attack - Please do not stop taking either medication without taking to your heart doctor. - You are also on other new medications for your atrial fibrillation including Metoprolol and Digoxin to help control your heart rate. You were also started on Rivaroxaban to help prevent stroke. - Weigh yourself every morning, seek medical attention if your weight goes up more than 3 lbs from your discharge weight of 163.8 lbs. - Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs, chest pain, abdominal distention, or shortness of breath at night. - Follow up with your doctors as listed below It was a pleasure taking part in your care here at ___! We wish you all the best! - Your ___ Care Team

Ms. ___ is a ___ y/o female who presented with chest pain and presyncope and was found to have STEMI. Course complicated by anemia and GI bleed with ulcerations in the esophagus, now stabilized. Patient also developed Afib/Atrial flutter now rate controlled with Digoxin and Metoprolol. # CORONARIES: DES x2 to RCA, 30% ___ LAD # PUMP: EF 47% # RHYTHM: Afib/Aflutter

14572113-DS-22

====================== DISCHARGE INSTRUCTIONS ====================== Dear Ms. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital because you were found to have a low blood pressure by your outpatient providers. WHAT HAPPENED TO ME IN THE HOSPITAL? - Your blood pressure improved after providing you with fluid. This was likely caused by your low food intake from not being able to eat properly. - We placed a tube to provide you extra nutrition with the hopes we may be able to improve your ability to swallow. You were very nausea and uncomfortable with the tube in your nose so you had a tube in your belly placed. - You received teaching on how to use the tube feeds. - Please follow up with your primary care doctor, ___ ___ neurologist, Dr. ___ to determine need for long term need for supplemental feeding. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Make sure you continue to have bowel movements. Can take senna or miralax if you do not have a bowel movement in 2 days. - Continue to take all your medicines and keep your appointments. We wish you the best! Sincerely, Your ___ Team

BRIEF HOSPITAL COURSE ===================== ___ with h/o thoracic outlet syndrome s/p rib resections in ___, subsequent chronic regional pain syndrome, HTN, GERD, IBS, asthma, PE with acute cor pulmonale on 4 L at home with chronic pain requiring a brain stimulator with recent bulbar symptoms leading to oral pharyngeal and esophageal dysphasia. The patient was noted to be hypotensive by ___ likely in the setting of poor p.o. intake over the last several weeks and was admitted to ___ for further workup. The patient could not tolerate a dobhoff so PEG was placed for supplemental enteral feeding. ============== Active Issues ============== #Decreased PO Intake #Oropharyngeal and esophageal dysphagia #Stuttering #Hypotension Patient had a recent admission to ___ for oropharyngeal and esophageal dysphasia and worsening shortness of breath in the setting of possible diaphragmatic weakness. Her symptoms were developing over the last several months and had been evaluated by her outpatient neurologist and workup has so far included normal CK, TSK, myositis panel, alpha glucosidase activity. During the admission to ___, her workup included an EMG which showed decreased recruitment in genioglossus and VSS study showing oropharyngeal and esophageal dysmotility with silent aspiration. Etiology of these symptoms was not determined, there was a concern for functional component. She was discharged with follow-up with the neuromuscular specialist. Her motor cortex stimulator was turned off in the last 3 weeks, but this does not appear to significantly improve her symptoms. Over the last few weeks her dysphasia continued to worsen and she was unable to tolerate p.o. intake. She has close follow-up with ___ and speech therapy as an outpatient and was noticed to be hypotensive which resulted in her admission to ___ ___. ___ was fluid resuscitated which improved her ___ and hypotension. Her hypotension was likely caused by poor p.o. intake given no signs for infection, cardiogenic or obstructive cause. Her antihypertensives were held: Lisinopril 40mg daily, Metoprolol Succ 100mg Daily, Lasix 20mg daily, Amlodipine 7.5mg daily. Neurology was consulted and felt that her CRPS may be contributing to her dysphagia. Dobbhoff was placed and tube feeds were started to supplement nutrition, but the patient could not tolerate the tube d/t gagging sensation particularly with medications. A PEG was placed on ___ and we were working on scheduling with outpatient follow up with neurology with continued outpatient ___ and Speech therapy. #Hypoxia #Restrictive lung disease likely ___ diaphragmatic paralysis #History of unprovoked pulmonary embolism Patient w/ known PE and bronchiectasis and concern for diaphragmatic paralysis. Currently uses ___ O2 at home but was discharged on 1L NC from ___ 1 month ago. Currently feels her breathing is at her baseline. She was on Xarelto at home for anticoagulation. She was started on heparin drip while inpatient given lack of enteral access and after Dobbhoff was placed was started on apixaban twice daily given possibility of Dobbhoff migrating into the jejunum which would limit absorption of rivaroxaban. A PEG was ultimately placed and she continued on apixaban 5mg BID. She was continued on Advair daily. #Anemia Hgb 10.7 in ED with recent baseline around ___ per ___ records. No active signs of bleeding. Her hemoglobin was stable during admission. #UTI UA in ED concerning for infection w/ large leuk esterase, 49 WBCs, few bacteria. Urine culture grew pansensitive E. coli. She was started on ceftriaxone in the ED and was narrowed to nitrofurantoin with sensitivities. She completed a 5-day course of antibiotics. ___ Presented with Cr of 1.3 from last known 0.7 in ___. Received 4L IVF and improved to 0.6. Likely in the setting of dehydration and poor p.o. intake. ============== Chronic Issues ============== #Hypertension -Her home antihypertensives were held initially lisinopril 40mg daily, Metoprolol Succ 100mg Daily, Lasix 20mg daily, Amlodipine 7.5mg daily. She remained normotensive during admission and was restarted on metoprolol succ 25mg XL at discharge. #Reflex Sympathetic Dystrophy #Chronic Pain Patient w/ significant chronic pain. Follows with Dr. ___ in Pain ___ here. He was initially started on IV Dilaudid given lack of enteral access and was transitioned to her home regimen of Dilaudid p.o. ___ mg 4 times daily as needed. -Continue Lyrica 300mg BID -Holding ketamine lozenges while inpatient

13950795-DS-13

You came in with high blood sugars as you felt your diabetes was not well managed at the facility you were at. We increased your long-acting insulin and your blood sugars improved. We are sending you to a different facility for you to continue getting rehab and the nursing care you need It was a pleasure taking care of you at ___ ___.

Ms. ___ is a ___ female with poorly controlled DM2, HTN, pyoderma of R hip, recurrent necrotizing fasciitis of abdomen/groins/p multiple debridement presenting from rehab with hyperglycemia and awaiting insurance auth to be transferred to a different facility. # Hyperglycemia, uncontrolled DM - baseline HgB 11% and has been affected by her recent infections and hospitalizations. She was restarted on glargine and regular insulin 7U (at 1200, 1800, and 0000) with TF's and ISS with regular insulin. FSBG's were in the high 100's to 200's. # Gastroparesis with TF dependence: pt continued on Glucerna

13508515-DS-8

Dear Mr. ___, You were admitted after you were found to have worsening heart failure. We were nervous that you might have been developing a condition called "cardiogenic shock," where your body has difficulty delivering enough oxygen to the organs in your body. You were therefore briefly on a medication that helps strengthen your heart's pumping abilities. We also started you on a lot of the Lasix via a drip, and you had excellent urine output in response, and your heart failure improved. Please weigh yourself every morning, and call your PCP or cardiologist if your weight goes up more than 3 lbs. Your dry weight is 125.5kg.

Mr. ___ is a ___ man with complicated medical comorbidities including CAD status post three-vessel CABG, along with systolic CHF with EF around 30%, with recent finding of kidney mass suspicious of RCC presenting for sudden onset dyspnea.

17353256-DS-12

Dear Ms. ___, You were admitted to the Acute Care Trauma service on ___ after a fall. You were found to have a small subarachnoid hemorrhage, bilateral pulmonary emobli and a left femoral leg blood clot. You underwent IVC placement and were anticoagulated. You were additionally found to be in atrial fibrillation and you were treated with multiple agents- you will be discharged home on metoprolol and amiodarone.

___- A Fib with RVR (asymptomatic), given dilt 10mg x1. CT head - stable SAH. CT abd/pelvis - thrombus extends to just ___ to confluence of iliac veins. Went to OR and had IVC filter placed. Occasionally goes back into a-fib with RVR. Started on dilt gtt. BP remains stable despite RVR. Mentates well. ___- PO dilt started 45 Q6, dilt gtt weaned, then recurrent a fib RVR, back on dilt gtt, increased PO 45->60 Q6; carotid US done; EKG shows persistent prolonged QTc (489); SQH BID started per NSGY ___- added metoprolol 12.5mg po BID to wean dilt gtt. Plan for anticoagulation tomorrow agreed upon by ACS and NSGY: baseline CT head in AM -> heparin gtt (target PTT 60-80) -> repeat CT head when therapeutic; start Coumadin. ___- Started on heparin. Pre and post heparin CT head stable. Heparin at goal PTT. ___- Transfer to SICU for sustained afib w RVR. On arrival, tried metop 5 IV x2 with spontaneous break into sinus, nonsustained. Dilt 15 mg IV x1 given with rate control. Continue PO regimen, converted to metop TID, continued dilt PO 60 q6h, ___ consult for IPMN, 2 brief runs of afib w rvr to 140s spontaneously resolved ___- intermittent a fib RVR, self-limited, BP always stable; in AM, PO dilt increased to 90 QID. Cardiology consulted. Recommended amiodarone load (200 TID x 2 weeks) and diltiazem decreased to 60 QID. Metoprolol left at 25 TID. ___: O/n, HR variability worse since decreasing PO dilt and stopping IV dilt. Amio increased to 400 BID, dilt ___ q6h per cards, recs (should get dilt x2 doses ___ then d/c in ___. Home HCTZ held for low BPs in the setting of other anti-HTN meds. Given warfarin 2.5mg. Diltiazem 30 held once in ___ for hypotension. ___: 5mg warfarin FLOOR COURSE: The patient was transferred to the floor and did well. She was bridged from a heparin drip to warfarin, and her heparin drip was discontinued on ___ once her INR became therapeutic>2. She was also continued on metoprolol and amiodarone for her atrial fibrillation and remained rate controlled throughout the remainder of her stay. Of note, the pancreas surgery service was consulted for an incidentally found cystic lesion of her pancreas, likely an IPMN. She will follow up with Dr. ___ in pancreatic surgery clinic in the next few weeks.

12974577-DS-15

Mr. ___, It was a pleasure participating in your care while you were admitted to ___. As you know you were admitted because you were having abdominal pain. You had a MRI which showed a collection of pus called an abscess. A drain was placed to remove the infected fluid. You were started on antibiotics which you will need to continue for at least 14 more days. You will follow-up with Dr. ___ if you need to continue antibiotics for a longer period of time You were given a medication that reverses the effects of your warfarin so that the drain could be placed. You were started on lovenox in place of the warfarin. You will continue on this medication in the place of the warfarin. You should discuss this further with Dr. ___ at your next appointment. You also had small amount of blood in your urine. You will need to follow up with your PCP about this ___ made the following changes to your medications. 1. START ciprofloxacin 500 mg twice a day 2. START flagyl 500 mg every 8 hours 3. START lovenox 80 mg twice a day 4. STOP Warfarin 5. START oxycodone as needed for pain You should continue to take all other medications as instructed. Please call with any questions or concerns.

PRIMARY REASON FOR ADMISSION Mr. ___ is a ___ gentleman with Crohn's disease (complicated by fistulas & abscess in the past) s/p colectomy, as well as 2 month h/o DVT (currently supratherapeutic on Warfarin) who presents with abdominal pain, fevers, and elevated inflammatory markers in the setting of intra-abdominal abscess. . #. Abdominal pain, R side: The patient was noted to have an abscess in the RLQ extending to the abdominal wall. There was no evidence of fistula or active crohn's disease on MRE. The patient was started on broad spectrum antibiotics with zosyn. A drain was placed by ___ and drained serosanguinous fluid. Culture of the fluid grew 2 species of pan sensitive E. Coli. The patients antibiotics were narrowed to oral cipro/flagyl. The patient was also continued on his home ___. Pain improved and the patient was slowly advanced to a low residue diet. At the time of discharge the patient had been afebrile x 48 hrs and WBC had normalized. Repeat CT demonstrated the abscess had greatly reduced in size and had decompressed. Drain output decreased to the point that GI and ___ were comfortable removing the drain, and the drain was removed. The patient was discharged home. He will follow-up with Dr. ___ at which time his antibiotic course will be determined. He will eventually need a repeat CT Scan to document resolution of the abscess. . #. LLE DVT: The patient was diagnosed with a DVT 2 months prior to admission. He has been anti-coagulated with warfarin. INR on admission was supratherapeutic at 4.0. He was given 10 mg of IV vitamin K prior to placement of drain. Following the procedure he was started on a heparin gtt and transitioned to lovenox. In discussion with his PCP the decision was made not to restart his warfarin, but continue on Lovenox alone. The patient will follow-up with his PCP regarding his ___. . # CKD: Cr at baseline throughout admission. He was pre-hydrated prior to CT. . TRANSITIONAL ISSUES - full code - final fluid cultures and blood cultures were pending at the time of discharge - Patient will follow-up with his gastroenterologist Dr ___ in addition to his PCP.

19438954-DS-7

Dear Mr. ___, It was a pleasure to care for you at the ___ ___. Why did you come to the hospital? -You were having black sticky stools which was concerning for bleeding from your intestines. What did you receive in the hospital? -You underwent a colonoscopy which showed that you had blood clot over the site where they removed a polyp a few weeks ago during a prior colonoscopy. This suggests that you had a recent bleed from this area, though there were no signs of active bleeding seen. You had clips placed over this area to prevent any further bleeding. You were also seen to have an ulcer at another site where you had a polyp remove which is a normal process of healing after a polyp removal; this did not show any signs of bleeding and a clip was placed at that site to prevent any possible future bleeding. -You were monitored for any more signs of bleeding afterwards and we held your blood thinner Eliquis (apixaban) for 48 hours to decrease your risk of rebleeding. -Your blood counts were stable while you were here which was reassuring that you had no more bleeding. -You did not have any bowel movements while here to show that there was no more bleeding but we were reassured by your blood counts. -We felt you were stable after 2 nights of monitoring and discharged you home. What should you do once you leave the hospital? -Please resume your Eliquis on the morning of ___. -Please make sure to get a CT scan of your lungs to work up the lung nodule that we found. -Please monitor your bowel movements at home. It may be normal for you to have a small streaks of black in your first bowel movement from blood that remained in your intestines after the colonoscopy. If you continue to have large black sticky bowel movements or large amounts of blood in your bowel movements - please call your doctor. If you are having any lightheadedness, dizziness, chest pain, trouble breathing or any other symptoms that concern you please go to the nearest emergency room. -Please follow up with your primary care office as scheduled below We wish you the best! Your ___ Care Team

SUMMARY STATEMENT: ================== ___ history of atrial fibrillation on Eliquis and hypertension s/p recent polypectomy on ___ who presents as transfer from ___ with melena, now s/p colonoscopy on ___ with 3 clips to cecal EMR site and ascending colon polypectomy site.

14019165-DS-11

You were admitted to ___ after a bike accident. Your injuries include a right olecranon fracture, a right acetabular fracture, and a small bleed in your head. You were seen by Neurosurgery who reviewed your imaging. Your repeat head cat scan did not show any progression of the bleeding and your neuro exam has been stable. You do not need to follow-up with Neurosurgery. Orthopedics was consulted and you were taken to the operating room for repair of the olecranon fracture. INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Touch down weight bearing right lower extremity - non-weight bearing right upper extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take as prescribed. - You are being discharged home with Lovenox. You should give yourself one injection per day until follow up with the orthopedic surgery department outpatient. 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 can be worn for comfort as needed. - Do NOT get splint wet DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns

Ms. ___ is a ___ yo F who was admitted to the Acute Care Trauma Surgery service on ___ after a fall from her bike. Her CT images showed a small SAH, a right acetabular fracture, and right elbow/olecranon fracture with overlying open wound. Neurosurgery was consulted for the SAH and recommended a repeat head CT and Keppra for seizure prophylaxis. The repeat head CT was stable, the patient was alert and oriented and neurologically intact with no evidence of seizure activity. Orthopedic surgery was consulted for the acetabular fracture and right elbow/olecranon fractures and recommended surgical repair. Given concern for the SAH the patient was admitted to the Trauma Surgical ICU for close neurological monitoring. The patient was hemodynamically stable. She was kept NPO with maintenance IV fluids. On HD2 informed consent was obtained and the patient was taken to the operating room with orthopedic surgery for an open reduction, internal fixation of the right olecranon and an irrigation and debridement of the right elbow. She tolerated the procedure well. Please see operative report for details. She was advanced on a regular diet. She remained hemodynamically stable and neurologically intact and was transferred to the floor for further management. She was kept NPO at midnight with maintenance IV fluid. On HD3 informed consent was obtained and she was taken to the operating room with orthopedic surgery for an open reduction, internal fixation of the right anterior column acetabular fracture. She tolerated the procedure well. Please see operative report for details. Given her negative C-spine and physical exam, her cervical collar removed. Her pain was initially controlled with IV morphine and then transitioned to PO oxycodone and IV dilaudid for breakthrough once tolerating a regular diet. On HD4 she was tolerating a regular diet and fioricet was started for headache with good pain control. Her foley catheter was removed and she voided without difficulty. She was evaluated by physical therapy for mobility assessment and teaching and occupational therapy for a right arm splint. On HD5 lovenox SQ daily was started per orthopedic surgery for DVT prophylaxis. She remained hemodynamically stable and continued to work with physical therapy and occupational therapy, who recommended discharge to home with services at a wheelchair level given her weight bearing status. During this hospitalization, the patient was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient initially received subcutaneous heparin and then started on lovenox subcutaneously on HD 5 after her orthopedic surgeries. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, independently mobilizing, voiding without assistance, and pain was well controlled. The patient was discharged home with ___ and ___ services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Follow up appointments were scheduled with orthopedic surgery. She was advised to follow up with cognitive therapy as needed.

11123456-DS-9

___ were admitted to ___ with fatigues, myalgias and cough and were found to have pneumonia and likely meningitis with bacteria in your blood. ___ improved with antibitoics. ___ were also found to have a low platelet count, which improved with steroids. ___ will be sent home with IV antibioitcs and will need to complete a 2 week course of IV antibiotics. ___ should follow closely with your outpatient team of doctors. ___ will need an outpt colonoscopy. . ___ underwent a transesophageal echocardiogram, which did not show evidence of infection in your heart valves. . Medications changes-see next page. please take as prescribed / listed. . Please f/u with your doctors as listed below. .

. The patient is a ___ year old female with h/o HTN, osteoporosis, COPD who presents with headache, fevers and back pain s/p trigger finger injections and a reclast injection also found to have PTL = 6K on presentation with a CXR also demonstrates PNA. . # Community acquired PNA/ Mennigits: The patient is asplenic and this likely contributing to the patient having Strep Bovis infection, although the original source is unclear. Due to her delayed presentation, the patient likely became bacteremic and developed meningitis from this. Upon her presentation from ___ clinic, the patient was empirically started on vanco/CTX and dexamethasone. LP was deferred in the ED due to low platelets. The patient was followed by ID in-house, and no CSF sample was acquired as it was unclear how it would changed management. She had a PICC line placed and she will be sent home on 14 days of CTX at 2grams IV twice daily, end date is ___. Rheumatologic causes of her symptoms where also considered and the rheumatology team was consulted. They thought that her meningeal signs were less likely due to systemic lupus and more likely due to acute infectious issues. She did have some leukocytosis on discharge with a WBC# of 16K, but was afebrile and without any new or concerning localizing symptoms. . # Strep Bovis bacteremia The patient had blood cultures positive for Strep Bovis on presentation. TTE was checked which was negative for vegatations, as was a TEE. Subsequent blood cultures cleared. The patient had a picc line placed and sensitivities returned with pan-sensitive Strep Bovis, so the patients coverage was narrow down to CTX 2gm IV BID for a 2 week course ___ - ___. She will be followed in ___ at ___ and will also need to have an outpt colonoscopy to further evaluate her Strep Bovis bacteremia and r/o underlying occult malignancy in her lower GI tract. . # Thrombocytopenia This was likely due to her acute infection, but ITP was also considered in the diagnosis. Hematology was following the patient and she was placed on dexamethasone for 3 days. The patient smear showed megakaryocytes and did not show signs of MAHA. With this treatment and treatment of her infectious issues, her platelets count improved. She showed no signs of active bleeding (other then microscopic hematuria) and her Hgb was stable. The patient should have a repeat CBC 1 week after d/c and should follow with ___ Hematology Dr. ___. By day of discharge (___), her plt count had returned to normal levels, with a count of 250K, with a nadir of 6K on day of presentation to ED (___). . # Hyponatremia: This was likely due to dehydration from acute illness. The patient was also found to be taking in fairly large amounts of free water in house. As a result, the patient was free water restricted and and her HCTZ was also held. With these interventions her sodium improved and was stable at 134 on day of discharge. #Hypocalcemia: The etiology of this was unclear but vitamin d deficiency, autoimmune hypoparathyroidism and rheumatologic phenomenon where considered (see below). The patient was repleted in house mostly because she was experiencing facial twitching which was thought to be due to low calcium. The patients PTH was found to be within the normal range. Her vitamin d level was also checked and it was low at 20. She should f/u with her outpt Endocrinologist for further management. . # Sjogrens syndrome The Rheumatology team accessed the patient in house and though that systemic lupus was unlikely but that the patient should start treatment with artifical tears and artificial salvia for sjogrens syndrome. Furthermore, they also recommended treatment for oral ___, the patient was started on nystatin. The patient should follow with Rheumatology as an outpatient. . # microscopic hematuria Pt was noted to have microscopic hematuria x 2 on UA. She had no urinary symptoms, and it is possible that she had some bleeding in the setting of low plt count. However, once her plt count responds, she will need a repeat UA in the outpt setting to assess for resolution of her hematuria. If it persists, she will need further w/u for hematuria. . #Transitional Issues [] repeat CBC in 1 week and fax to PCP/Hematology, will need to assess her plt # and her WBC #, given thrombocytopenia during the hospitalization and also leukocytosis of unknown etiology on discharge. [] follow up with Hematology, Rheumatology, ID clinic and PCP [] follow up any pending blood cultures (surveillance blood cx's from ___, no growth to date) [] complete course of antibiotics with IV Ceftriaxone 2gm IV BID x 2 weeks, f/u with ID [] outpt colonoscopy to further w/u her Strep Bovis bacteremia [] electrolyte check as an outpt to check her sodium levels for stability [] repeat UA as outpt to assess for microscopic hematuria . .

16994397-DS-8

Please call Dr. ___ ___ if you have any of the following: temperature of 101 or greater, chills, nausea, vomiting, abdominal pain, jaundice or diarrhea. -you need to take antibiotics for 5 days (ciprofloxacin and flagyl) -continue a low fat diet -resume Coumadin -resume your outpatient hemodialysis schedule

___ year old female with history of IDDM, HTN, ESRD on HD, protein C deficiency complicated by DVT s/p IVC filter presented with nausea, vomiting, and abdominal pain with labs and imaging suggestive of choledocholithiasis/cholangitis without evidence of pancreatic involvement. IV Ciprofloxacin and Flagyl were started. She met severe sepsis criteria based on source of infection and leukocytosis, hypotension, and elevated lactate. She was kept NPO and an ERCP was performed demonstrating a moderate diffuse dilation at the main duct with the CBD measuring 14 mm. A large filling defect was suggestive of stone in the lower third of the common bile duct. Sphincterotomy was performed. Pus was seen flowing through the ampulla after the sphincterotomy. Multiple dark stones matted together, large amount of sludge and pus were extracted successfully using a 12 mm balloon. Cipro and Flagyl were continued. Blood cultures from ___ were negative. Blood cultuers from ___ and ___ were unfinalized. She remained afebrile. LFTs remained elevated with bilirubin in mid 7 range. MRCP was done noting the following per MRCP report: low and medial insertion of the cystic duct (anatomic variant), incompletely characterized focal lesion in segment ___ of the liver, slightly hyperintense on T2-weighted images, and not well evaluated without contrast was noted. Dedicated hepatic imaging or comparison with prior studies was suggested for further characterization. Multiple cystic lesions in the pancreas, the largest of which measures about 11 mm in size in the pancreatic neck. She was tentatively scheduled for cholecystectomy pending the MRCP and repeat LFTs. LFTs remained elevated. OR was cancelled and a repeat ERCP was done on ___ noting 1 cm narrowing in the distal common bile duct. This was likely due to post-sphincterotomy edema vs neoplasia. Brushings were performed from the narrowing and sent for cytology. Balloon sweep retrieved some sludge. A 5cm by ___ double pig tail biliary stent was placed successfully. Post procedure, she was stable. T.bili decreased slightly. Amylase and lipase were 58 and 156 respectively. Clear diet was advanced the next day without nausea, vomiting or abdominal pain. Blood sugars were managed with sliding scale insulin. Lantus was added once regular diet was taken on ___. Hemodialysis was performed on ___ without incident. Home meds ___, CCB and statin) were resumed on ___. She felt well enough to go home on ___ and was discharged to home. Of note, given MRCP finding of segment ___ lesion, tumor markers were sent (CA ___, CEA and AFP). Results were pending at time of discharge. IV cipro and flagyl were switched to po form. She was instructed to continue these antibiotics for 5 more days upon discharge from hospital. Coumadin had been on hold given procedures and possible OR. Coumadin was resumed on ___ using home dose of 3mg per day. Coumadin management was to be done by her outpatient nephrologist at ___ in ___. She was discharged to home in stable condition with f/u appointment with Dr. ___ on ___.

17021161-DS-18

Dear Mr. ___, It was a pleasure taking care of you. Why you were here? -You were in the hospital because of chest pain. We ruled out any dangerous conditions including heart attack, a clot in your lung, and infection. We suspect your chest pain is related to muscle strain What did we do? -We gave you Tylenol and your chest pain improved -You got a lung scan, chest xray, ultrasound, and EKG which were all normal What you should do when you go home? -Continue taking Tylenol to relieve your chest pain. -Take your medications and follow up with your primary care doctor ___ wish you the best, Your ___ team

___ yo F w/ ___ CAD w/ previous MI, HTN, ESRD on peritoneal dialysis presents with sharp right sided chest pain. EKG revealing normal sinus rhythm, V/Q scan low probability, CXR clear, trops negative x2, and therefore unlikely to be ACS, PE, pneumothorax, or pneumonia. Pain was reproducible on palpation on exam and therefore suspect patient has a musculoskeletal chest pain such as costochondritis. Patient received peritoneal dialysis overnight while hospitalized and her electrolytes were wnl on discharge. #Musculoskeletal Chest Pain Pain was reproducible on palpation on exam and therefore suspect patient has a musculoskeletal chest pain such as costochondritis. EKG revealing normal sinus rhythm, V/Q scan low probability, CXR clear, trops negative x2, and therefore unlikely to be ACS, PE, pneumothorax, or pneumonia. Patient's pain was improved with tylenol and she was stable for discharge #End stage renal disease Patient with hyperkalemia in the setting of ESRD. No EKG changes. Patient received peritoneal dialysis while hospitalized. Patient was continued on nephrocaps #Hypertension Patient's BP goal <170 per renal team, which was at goal during hospitalization. Patient was continued on home lisinopril, isosorbide mononitrate #CAD Stable. Patient was continued on home atorvastatin, metoprolol, lisinopril, and aspirin #Diabetes Mellitus Stable. Patient continued on home glargine and insulin sliding scale #GERD. Patient was continued on home PPI #Hypothyroidism/Neuropathy/Gout Stable. Continued home amitriptyline, levothyroxine, and allopurinol

14970229-DS-15

Dear. Ms. ___, It was a pleasure taking care of ___ during your stay at ___. WHY WAS I HERE? - ___ were having diarrhea and belly pain WHAT WAS DONE WHILE I WAS IN THE HOSPITAL? - ___ were given IV fluids WHAT SHOULD I DO WHEN I GO HOME? - ___ should drink plenty of fluids - ___ can take the medication ondansetron if ___ feel nauseous. - ___ should eat a bland (BRAT) diet for the next day or two - ___ should go to see your PCP - ___ should get your INR checked early next week and fax it over to your doctor! Be well! -Your ___ team

___ with PMH of afib on Coumadin who presented with 24 hours of diarrhea likely ___ viral gastroenteritis who improved after receiving 2L of NS in the ED and was able to tolerate po well without significant diarrhea.

10781985-DS-22

Dear Mr. ___, It was ___ caring for you here at ___. You came in because of fevers. We repeated tests to check for infection and you did not have a new infection. Your fevers are resolved and you are ready to go home.

___ year old male with PMH of laryngeal cancer s/p tracheostomy, DM II, minimal change disease on chronic prednisone and discharge from ___ ___ for coag-negative staph UTI and bacteremia presenting from home with fevers up to 102 and diffuse weakness. #ID: Coag-negative staph UTI and bacteremia with presumed endocarditis on 6 week course of vancomycin via ___ line. Febrile to 102 but without focal symptoms. Had some loose stools but not diarrhea. No cough or other URI symproms with an unremarkable chest xray. No voiding symptoms. Urine No signs of pneumonia or other localizing signs of infection. Urine Cx negative and Blood cx with no growth by discharge. His vanc trough was 10.1 prior to discharge and so appropraite dose increases were made. He was afebrile throughout his hospital stay with no new symptoms. His Vancomycin trough was 14.1 prior to discharge and vancomycin increased to 1500mg q12 hours. Next trough to be checked by ___ and faxed to Dr. ___. He will complete a ___s previously planned, with ID follow up. #GU: Hx of BPH. Negative urine culture Continued flomax and finasteride #Renal: Minimal change disease on chronic prednisone, creatinine at baseline. Continued prednisone 10 mg daily #CV: HTN, HL: continued amlodipine, lisinopril and aspirin #DM II: Continued lantus and lispro sliding scale

16508638-DS-20

Dear Mr. ___, WHY YOU WERE ADMITTED ======================= - You had altered mental status and were not behaving like yourself - You had a small brain bleed likely from falling WHAT WE DID FOR YOU IN THE HOSPITAL ==================================== - We made sure you were not having an infection, which you did not - We checked all your electrolytes, vitamin levels, and thyroid levels which were all normal - We made sure your head bleed remained stable with CT scans - We made sure your VP shunt for your normal pressure hydrocephalus was working properly - We changed your medications to make sure they were not affecting your mental status - You had an EEG study done that showed your mental status was most likely affected by something temporary, most likely the mediations you were taking WHAT YOU SHOULD DO WHEN YOU LEAVE ================================= - You should continue to take your medications as prescribed - You should use a cane/walker to get around to make sure you do not fall It was a pleasure taking care of you! Sincerely, Your ___ Care Team

SUMMARY: Mr. ___ is a ___ with past medical history of severe depression (receiving ECT), normal pressure hydrocephalus s/p shunt placement in ___, myasthenia ___, hypothyroidism, and hypertension who presents to the emergency department with suicidal ideation and altered mental status. ====================== ACUTE MEDICAL PROBLEMS ====================== # Toxic Metabolic Encephalopathy Patient presented with agitation and confusion. Was recently hospitalized elsewhere and had negative workup done, although MS improved temporarily after shunt adjustment. Workup for reversible causes ruled out infections, worsening of subdural hematoma, untreated hypothyroidism, neurosyphilis, B12 deficiency, and seizures as cause. Neurosurgery consulted and felt no issues with shunt or change in ventriculomegaly. Likely medication-induced in setting of possible underlying cognitive decline or dementia. Initially required antipsychotics for agitation, but improved with frequent re-orientation and downtitration of psychitatric medications with guidance of Psychiatry. [] Continue clonazepam 0.125 mg qAM with plan to stop on ___ [] Started clonidine 0.1mg qhs to help with restlessness [] Started Ramelteon 8 mg qhs to help maintain sleep-wake cycle [] Continue home thiamine 100 mg PO daily [] If patient becomes altered, get repeat head imaging to evaluate for worsening subdural hematoma or normal pressure hydrocephalus [] Refer back to Geriatrics at ___ for further workup of possible cognitive decline [] Continue ___ #Depression with suicidal ideation Evaluated by psychiatry in ED who issued ___ to ongoing safety assessment for suicidal ideation. Per family members, this change in his mental status was not consistent with his typical depression episodes. Psychiatry was consulted who recommended medication changes as below. Decision was made to hold off on ECT due to ongoing delirum. Patient had intermittent SI during hospitalization but without plan or intent. [] Continued mirtazipine 45 mg PO qhs [] Continued lamotrigine 50 mg PO BID [] Decreased duloxetine to 40 mg PO daily [] Stopped methylphenidate [] Stopped trazadone [] If mental status improves, consider restarting ECT [] Ensure psychiatry ___ [] Ensure patient does not have access to items available to harm himself #Goals of Care Long discussion with case management and Niece who is HCP. Plan is still DNR/DNI and plan to still readmit to hospital if rehab cannot handle symptomatic management of any acute conditions. A decision on weather to escalate care or transition to comfort measures will be made with each hospitalization. ==================== CHRONIC/STABLE ISSUES ==================== #Normal pressure hydrocephalus s/p VP shunt placement Adjusted at recent hospitalization with some improved mental status (reprogrammed from 15 to 13). This admission, shunt series performed with no concern for kink or obstruction (ventricles stable size). Neurosurgery held off on adjustment. [] If urinary retention worsens or mental status worsens, would re-image shunt #Myasthenia ___ Patient with diagnosed severe ___ after recurrent pneumonias in ___. Has been on pyridostigmine, azathioprine, and a prednisone taper. Initial concern for prednisone contributing to AMS however given severe MG, neurology believed the prednisone taper should be continued to avoid precipitating MG crisis. Paraneoplastic workup negative at ___. [] Continued Azathioprine 150 mg PO daily, prednisone 30 mg PO daily, and pyridostigmine 60 mg PO q8h [] Continue Bactrim DS tab ___ and calcium/vitamin D while on steroids # Subdural hematoma: Likely ___ to recent multiple falls. Non-contrast head CT shows left sided SDH with no mass effect. Evaluated by neurosurgery who believed SDH is likely not the cause of altered mental status. However, can definitely be contributing to the patient's overall decompensation. Completed Keppra 1000mg BID x 7 days as per neurosurgery for ppx. [] Consider head imaging if mental status worsens # Left clavicular fracture Exam notable for bulging clavicle. Per HCP, was chronic. Shoulder xray with likely chronic fracture. [] Per Orthopedics, nonsurgical management with sling [] Tylenol prn #Acute kidney injury Patient with Cr 1.4 with reported baseline around 1.1.-1.2. Likely prerenal in setting of poor PO intake. Resolved with IV fluids. #Hypernatremia Patient with mild hypernatremia in setting of poor PO intake which resolved on its own. # Hypothyroidism TSH slightly elevated at 5.1 [] Increased levothyroxine to 125 mcg PO daily [] Continue liothyronine 5 mg PO daily [] Repeat TSH as outpatient # Hypertension SBPs were controlled without medications [] Goal SBP <160 for subdural hematoma. # Benign prostatic hypertrophy Had some urinary incontinence. No urinary tract infection present. #?GERD Continued home omeprazole 20 mg PO daily. [] Discuss need for PPI #Poor PO intake Per family, had poor PO intake at home. Albumin 3.5 [] Diet: ground solid and thin liquid diet, with aspiration precautions [] MVI with nutrients TRANSITIONAL ISSUES =================== Follow up ---------- [] Refer back to Geriatrics at ___ [] PCP ___ for medication changes. Discuss need for PPI [] Outpatient psychiatry ___ --> consider ECT if mental status improving [] Follow up with Orthopedics with x-rays within 2 weeks of discharge [] Follow up neurosurgery for VP shunt monitoring and subdural hematoma [] ___ with Neurology for myasthenia ___ [] Repeat ___ Management ----------- [] Ensure SBP <160 due to subdural hematoma [] If patient with any neurologic deficits, repeat head CT immediately and called Neurosurgery [] Diet: GROUND SOLIDS and THIN LIQUIDS [] Medications: WHOLE WITH WATER [] Aspiration Precautions -1:1 supervision for meals -alert and attentive for meals -encourage PO intake -Frequent oral care (TID) [] Continue to work with ___ and OT [] Continue Bactrim DS 3x/week, calcium, and vitamin D while on steroids for ___ [] Sling for management of clavicular fracture [] Ensure patient does not have access to items available to harm himself [] Stop clonazepam on ___ ADVANCED CARE PLANNING ======================= #CODE: DNR/DNI, MOLST form filled out #CONTACT: ___ (niece), phone: ___- HCP

12392927-DS-11

Dear Ms. ___, It was a pleasure taking care of you. You were admitted to the ___ because your left leg was swollen, red, and painful despite recently being started on treatment for a clot in that same leg. What did we do for you while you were in the hospital? - We were initially concerned for a complication of a leg clot that causes interruption of the blood flow to the leg. We initially started you on a blood thinner called heparin because we were concerned the Xarelto was not working well for you. You were evaluated by vascular surgery who did not think that this complication was present and who recommended that we continue your Xarelto and make sure that we keep the leg compressed and elevated whenever possible. What should you do after you leave the hospital? You should continue to take your Xarelto twice daily with large meals. You should try to elevate your legs as much as possible and wear your compression stockings. This is the primary treatment for your blood clot. You should follow-up with your primary care physician and vascular surgery within ___ weeks of discharge. We recommend at least ___ year of Xarelto, perhaps even life long therapy. This should be discussed with both your PCP and ___ ___ Expert. Wishing you a speedy recovery, Your ___ Care Team

Ms. ___ is a ___ woman with past history of hypertension, dyslipidemia, bipolar disorder, and a recent diagnosis of unprovoked left lower extremity DVT started on xarelto on ___, who presented for two days of worsening left lower extremity soreness, swelling, and purpulish discoloration with initial concern for phlegmasia. # Left Lower Extremity DVT: Initially seen at ___ but was transferred to ___ for concern for phlegmasia cerulea dolens for a vascular surgery evaluation. PAtient had worsening leg erythema, swelling, and pain despite anticoagulation. After arrival to ___, the patient was seen and evaluated by the vascular surgery to given the concern for worsening thrombosis. They deferred any additional intervention as the patient did not have evidence of total vascular flow compromise. Patient was initially switched to a heparin drip, but was subsequently restarted on Xarelto 1 day prior to discharge. Her pain and swelling improved with compression and elevation. Plan is for continued compression (thigh high stockings) and elevation ___ at home with follow-up with vascular surgery. We strongly urged the patient to continue the rivaroxaban for at least ___ year and perhaps lifelong given the extent of thrombus. We also recommended that she follow up with an outpatient hematologist/oncologist and an apt was made for ___ 10:00a with Dr. ___. The vascular surgery team plans to contact her for follow up as well. # Psychiatric history - Severe Depression and Bipolar prior history of ECT therapy. - Continued home Lexapro 20 mg po qd - Continued home Xanax 0.5 mg po qhs - Continued home clozapine 37.5 mg po qd - Continued home Latuda 80mg qd - Continued home Lithium ER 450 QHS # HTN - Continued HCTZ # HLD: - Continued simvastatin # GERD: - Continued PPI # Vitamin deficiency/macrocytosis: - Held home Cerefolin & B12 as non-formulary. - Continued Calcium, vitamin D.

18783830-DS-10

Dear Mr. ___, You were admitted to the hospital with nausea and vomiting. Your blood sugars were high since you had not been able to take your insulin. You were treated with intravenous fluids for dehydration. Your blood sugars returned to normal levels once your insulin was restarted. Please take your medications as prescribed and make sure that you are having regular bowel movements. Please follow up with the ___ doctors and your primary care doctors in the next ___ weeks. Take care, ___ medicine team

___ with a recent dx of insulin dependent DM and severe esophagitis, who presents from his ___ clinic for vomiting and blood sugar control. # Abdominal/Substernal pain: ___ have been a viral gastritis or an exacerbation of diabetic gastroparesis. No obstruction on KUB. Patient was unable to take his home gastritis/esophagitis meds given pain with swallowing and N/V. Nausea improved with IVF and IV ondansetron. Tolerated po intake without emesis prior to discharge. Continued symptomatic management with omeprazole, ranitidine, metoclopramide, sucralfate. # Diabetes/hyperglycemia: His glucose returned to normal with 3L NS. He had no anion gap, but his UA did show trace ketones. Pt reports having stopped his insulin given vomiting/abd pain. glucose now well controlled, back on home regimen. A1c 7.2. # Hyponatremia: Resolved. A component of pseudohyponatremia given hyperglycemia, however dehydration was likely playing a role in hypovolemic hyponatremia. Also BUN/Cr ratio >20 supporting this diagnosis. # Hypertension: His antihypertensive regimen was changed from chlorthalidone to lisinopril, given his history of diabetes and hypokalemia. He will be discharged on lisinopril 5mg daily, which should be uptitrated as outpatient. # Chronic pain: continued lyrica and amytriptiline # Constipation: started docusate and senna.

16797434-DS-5

Dear Mr. ___, You were admitted to ___ after experiencing diarrhea with resultant chest pain and shortness of breath. You were found to have low red blood cell count, known as anemia. This was likely due to destruction of your red blood cells known as hemolysis. You were transfused red blood cells to increase your blood counts. You also received steroids to help stop the destruction of the red blood cells. You also received a medication called rituximab to help control your low blood cells. These helped stabilize your red blood cell counts. By the time of discharge you did not require a transfusion in 6 days. You were discharged on a medication called prednisone. Please take 80 milligrams of prednisone DAILY. You were also started on a medication called acyclovir and a medication called trimethoprim-sulfamethoxazole to help prevent infections. Your lisinopril and hydrochlorothiazide were STOPPED as your blood pressure was well controlled on your other blood pressure medications. Please discuss this medication change with your oncologist. We would like you to follow up in clinic on ___ at 2PM to get a blood check to see what your blood levels are. Also on imaging of your chest, two nodules were noted in your lung. PLEASE FOLLOW-UP WITH A REPEAT CT SCAN OF YOUR CHEST IN 3 MONTHS. If you have any worsening symptoms including shortness of breath, chest pain, lightheadedness, nausea, vomiting, or diarrhea please seek medical assistance at your nearest Emergency Department. It was a pleasure taking care of you during hospitalization! We wish you all the best! Sincerely, Your ___ Care Team

Mr. ___ is a ___ year old gentleman with CLL and autoimmune hemolytic anemia who presents with fever, hypotension, anemia, and chest pain. # AUTOIMMUNE HEMOLYTIC ANEMIA: Patient has known direct Coombs positive warm antibody autoimmune, often triggered by acute illness. This presentation was likely in the setting of an acute diarrheal illness. On admission, his Hct was 15 and labs were consistent with hemolytic anemia. Patient was started on high dose steroids and high dose folic acid. He was transfused a total of 9 units pRBC in the ICU over the course of four days. Hct improved to 20 on transfer to the floor. On the floor he was continued on 40 mg IV methylprednisolone. He required an additional four units of packed red blood cells on the ___ service. While remaining on the 40 milligrams IV methylprednisolone Q12H, he did undergo rituximab infusion on ___ and ___. At the time of discharge his H/H was 7.3/23.1. He did not require any blood transfusions in the six days prior to discharge. He was transitioned to prednisone 80 milligrams PO daily and was discharged on this medication regimen. He was continued on folic acid 5 mg PO daily. He was also discharged on acyclovir and bactrim given the chronic steroid use. Of note: PND labs were negative. G6PD was 25.8. # LEUKOCYTOSIS/FEVER: WBC on admission was 32 with a neutrophil predominance, though it uptrended to 104.5. Although patient has known CLL, neutrophil predominance suggested a possible infectious process vs. steroid-induced leukocytosis. Patient was started on vancomycin, cefepime, and azithromycin initially given CLL/functional neutropenia. Infectious work-up, including C diff and stool studies, respiratory panel, and urine culture was negative. CXR was notable for atelectasis without evidence of pneumonia. Blood cultures remained negative. Antibiotics were discontinued and his WBC continued to trend down. At the time of discharge his WBC count was 10.8. # CHRONIC LYMPHOCYTIC LEUKEMIA: Confirmed by flow cytometry and FISH ___, no bothersome LAD or B symptoms so currently no plan for treatment in the near future. CT of Chest ___: showed severe adenopathy in the axillae, milder in the mediastinum. CT of Abdomen and Pelvis: Mild splenomegaly of 15.7 x 9.2 cm; moderate retroperitoneal lymphadenopathy. Patient underwent rituximab infusion as noted above. # TACHYCARDIA: Patient became persistently tachycardic with HRs to 140s on hospital day 2. Telemetry and EKG were notable for sinus tachycardia, most likely secondary to anemia given acute hematocrit coinciding with the tachycardia. CTA on admission was negative for pulmonary embolism. When arriving on the floor his tachycardia did improve. Heart rate remained around 100 bpm. Patient remained asymptomatic with this tachycardia and was hemodynamically stable while on the bone marrow transplant floor. # HYPOTENSION: Patient was hypotensive on admission and briefly required pressors. Initial concern was for septic shock given ___ SIRS criteria, though no infectious source could be identified. Blood pressure improved after blood transfusions, suggesting hypovolemic shock. After transfer to the ___ floor, his blood pressures were stable. His lisinopril and hydrochlorothiazide were stopped as his blood pressure was well controlled without these medications. # DIARRHEA: Stool culture from the outside hospital grew pseudomonas, though GI did not believe that this was the cause of his diarrhea. Repeat stool studies here, including C diff, were negative. CMV negative. Given decreased oxygen-carrying capacity in the setting of hemolytic anemia, ischemic colitis is possible, though additional work-up was deferred. Patient remained on antibiotics as noted above-vancomycin, cefepime, azithromycin. Diarrhea decreased throughout hospitalization and resolved at the time of discharge. # CHEST PAIN: Patient had chest pain on admission that responded to morphine and did not recur. EKG was unchanged and cardiac enzymes were negative. CTA was negative for pulmonary embolism. Chest pain was likely in the setting of anemia. TRANSITIONAL ISSUES =================== #PULMONARY NODULES: A CTA of the chest revealed "two right upper lobe nodules the largest measuring 4mm x 7mm." Recommendation is for follow-up CT of the chest in 3 months. #FOLLOW-UP H/H: Patient has a follow-up H/H scheduled for ___. #RITUXIMAB THERAPY: Patient underwent rituximab therapy on ___ and ___. Based on this schedule he is set to undergo his third infusion of rituximab on ___. #PREDNISONE TAPER: Discharged on prednisone 80 milligrams PO daily. He was given a prescription for 7 days. Please address tapering of prednisone as an outpatient. #CONTACT: ___ ___ #CODE STATUS: FULL CODE.

12484308-DS-28

You came in with abdominal pain. We think that this pain is either from irritation of your stomach or a very mild pancreatitis. We treated you with pain medications which you did not think helped very much and bowel rest for a day. We also did a CT scan of your abdomen which did not show anything concerning. We also treated you for alcohol withdrawal while you were here and continued you on your methadone. We also treated you for an asthma exacerbation and your breathing was much improved by the time you left.

ASSESSMENT/PLAN: ___ male with PMHx alcoholic cirrhosis, alcohol abuse complicated by withdrawal seizures, asthma with multiple intubations in the past, and chronic pain on methadone presenting with abdominal pain and SOB. # Abdominal pain-- Pt reports mid-epigastric pain on presentation radiating to back and flanks. CT a/p performed in ED negative for any acute processes or signs of acute pancreatitis. Very mild elevation in lipase. This was felt to be more likely alcoholic gastritis rather than acute on chronic pancreatitis. It was managed conservatively with bowel rest and initially IV dilaudid which was transitioned to PO after pt tolerating diet. PO dilaudid was also subsequently tapered and pt was discharged with a 2 day supply for any ongoing breakthrough pain. # EtOH w/d-- ___ was monitored on CIWA and initially required several doses of 4mg PO ativan which was tapered to 2 mg, 1 mg and subsequently off as pt was no longer showing signs of withdrawal. # SOB/Asthma exacerbation-- Pt presents with SOB and is very wheezy on exam with poor air movement. Unclear trigger for asthma exacerbation but suspect possible ?aspiration event in s/o recent ETOH intake. ___ reports medication compliance but this may have also been a precipitating factor. He was started on a prednisone burst, azithromycin, and given duonebs with improvement. # Opiate dependence-- Per reports, pt with long history of hydromorphone use/abuse with issues in the past with getting discharged from methadone clinics. Currently, he is at Habit OPCO and was continued on 80mg methadone. Pt expressed significant discontent with his pain medication regimen while inpatient. However, it was felt to be unsafe to escalate regimen more than 0.5mg IV dilaudid q4H initially as he was also getting his outpatient methadone in addition to Ativan. Staff also found him to be frequently somnolent despite reports that his pain was poorly controlled. # Elevated Transaminases-- Mildly elevated AST, Alk phos in 900's. Alk phos has been significantly elevated in 800's in the past. MRCP was done last admission in ___ and this did not show an intra- or exta-hepatic biliary duct dilatation or masses. Alk phos remained elevated throughout his stay but his AST/ALT downtrended. # Cirrhosis-- home lasix and spironolactone were held initially as pt had poor PO intake. He remained euvolemic despite holding these medications and they will be resumed upon discharge.

10714315-DS-18

Dear Mr. ___, It was a pleasure caring for you at ___ ___. As you recall, you were admitted for throat pain. Imaging did not show progression of your previous known dissection. Imaging of your neck did not show anything that may cause throat pain. Please see below for follow up appointments.

___ with history of emergency repair acute Type A dissection ___ at ___ (30mm Gelveave graft from STJ - innominate artery) who presents with throat pain. # Throat pain: Due to the patient's history of type A dissection, there was concern for aortic dissection. CTA from the outside hospital showed evidence of dissection, but this was thought to represent a chronic flap from his previous dissection. Cardiac surgery was consulted, who recommended repeat CTA in 48 hours to evaluate for progression. Repeat CTA on ___ showed extravasation of contrast into a contained rupture/pseudoaneurysm. Radiology recommended repeat multiphase CTA to assess for active extravasation. Repeat CTA on ___ was negative for acute/active extravasation, however the patient likely had a leak in the past, given the presence of granulation tissue. Radiology recommended repeat CTA in 3 months to evaluate for progression. We were unable to obtain films from ___, where the patient was diagnosed with his dissection. However a post-operative CTA report did not note any leak. The patient remained hemodynamically stable. Blood pressure and pulses were equal in both arms. His losartan dose was increased to 50mg. The patient's throat pain resolved during hospitalization, and the etiology was thought to be due to a viral infection. # COPD: The patient denied any shortness of breath. CT chest with extensive centrilobular and paraseptal emphysema. He was also found to be slightly hypoxic (SpO2 89-91% with ambulation). The patient was continued on spiriva. Smoking cessation was encouraged. # HTN: Currently normotensive. His dose of losartan was increased to 50mg daily as losartan as it has been shown to be beneficial in patients with cystic medial necrosis. # Leukocytosis: Noted on admission labs. Differential was within normal limits. Baseline unknown. The patient was afebrile and without infectious symptoms besides throat pain. WBC trended down during hospitalization. # HLD: Continued atorvastatin.

10291088-DS-28

You were admitted because of chest pain and a slow heart rate. We made sure you did not have a heart attack. Your slow heart rate was likely due to being started on Propranolol. We observed you off the medication and your heart rate resolved. We have listed "beta blockers" as an allergy. Please discuss possible alternative treatments for your tremor with your Primary care doctor. We made the following changes to your home medication list: -STOP Propranolol -START Omeprazole

___ year old lady with history of IDDM, hypertension, CAD s/p MI in ___, seizures, SLE, CKD, and syncope who presented with substernal chest pain, dyspnea on exertion and subjective feeling of her heart slowing, found to have non-sinus bradycardia and shortness of breath. Her bradycardia was felt secondary to recently starting propanolol. She was monitored in the hospital for propanolol washout, and her bradycardia resolved (as such, she did not require a pacemaker). She should avoid beta blockers in the future (now listed as an allergy). >> Active Issues: # Bradycardia: Following initiation of a nodal blocking agent, Ms. ___ presented with a symptomatic ectopic atrial bradycardic rhythm. Her propanolol was stopped, and her bradycardia resolved. She also had first-degree AV block. Hypothyroidism was less likely as a cause (TSH was wnl). Acute MI was also unlikely as she had negative troponins and no obvious ischemic ECG changes from baseline. Her chest discomfort was likely due to new bradyarrhythmia. - She was discharged in sinus rhythm and heart rate consistently between 60-70. - She should avoid all nodal blocking agents in the future. # Shortness of breath: On admission, she was mildly volume overloaded with JVD, rales, mild room air hypoxia, likely an exacerbation of her chronic diastolic CHF. She responded well to gentle diuresis with furosemide 20 mg IV. # Acute Kidney Injury: Cr of 1.7 on admission, improved to 1.2 on discharge. FENa was less than 1%, so more likely pre-renal. She endorsed poor PO intake prior to admission. ___ could also be secondary to poor renal perfusion due to decreased cardiac output when bradycardic, as well as diastolic heart failure. # Hypertension: She was hypertensive on admission, which may have caused exacerbation of diastolic heart failure. She was started on doxazosin every evening to maintain control of BP throughout the day. She was continued on her amlodipine and ACE-I. # CAD: Stable on this admission. Her chest pain today was in the setting of bradycardia, and dyspnea suggestive of exacerbation of diastolic CHF. Her more chronic symptom of morning sub-sternal pain which is relieved with food and worsened by lying down seems more related to dyspepsia or GERD than ischemic in origin. She had no evidence of MI with serial normal troponins, and was continued on her aspirin dihydropyridine calcium channel blocker, and statin. # Epigastric pain: Given the association with lying down and eating, likely dyspepsia or GERD. She was started on omeprazole for this. >> Chronic issues # History of seizures: Continued levetiracetam. # SLE: Continued prednisone, hydroxychloroquine. # DM, type 2: In house, she was managed with Humalog ISS and NPH ___. >> TRANSITIONAL ISSUES - CODE: Full. - Contact: daughter is also HCP, ___ ___ - The patient reports that she actually takes hydroxychloroquine twice daily, as opposed to alternating with lower dose. - She should avoid nodal blocking agents in the future.

15838579-DS-4

Dear Mr. ___, You were hospitalized due to symptoms of dizziness and vomiting resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. We are changing your medications as follows: Start taking warfarin (blood thinner) Start taking atorvastatin (for cholesterol) 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

SUMMARY: ======== Mr. ___ is a ___ year old man with no significant past medical history who presented with a left vertebral dissection and basilar artery thrombus. #LEFT VERTEBRAL ARTERY DISSECTION #BASILAR ARTERY THROMBUS #CEREBELLAR INFARCTS He initially presented with acute onset nausea and dizziness, found to have a left vertebral artery dissection and basilar artery thrombus. He was started on a heparin gtt. He was admitted to the neuro ICU for frequent neurochecks, but remained neurologically intact. An MRI was performed that showed bilateral scattered infarcts in the cerebellum. He was transitioned to lovenox from heparin and was started on warfarin on ___. He was then transferred to the ___. In the NIMU, he was monitored closely (remaining normotensive during his NIMU course). He had only one episode on ___ when he had symptoms including nausea, dizziness, vertigo, tinnitus after exertion that were referable to the brainstem, possibly related to overexertion and inadequate hydration. He was encouraged to increase PO fluid intake and did not require additional fluids or PRN antihypertensives. He was started on atorvastatin 80mg daily and continued on warfarin except for 2 days (___) when his warfarin doses had to be held for a supratherapeutic INR of 4.2. He was given education on restrictions related to his dissection prior to discharge.

11199428-DS-5

Dear ___, You were recently admitted to ___ ___ pain control and evaluation of your post-operative open cholecyctectomy recovery. We have reviewed your imaging with our surgeons and radiologists several times and believe the fluid collection seen on your outside hospital CT scan is a small fluid collection consistent with normal post-operative changes. At this time, you are ready for discharge and can continue to recover at home. Please follow the instructions below: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry.

___ was admitted to ___ on ___ for pain control and evaluation of imaging studies obtained at an OSH concerning for biloma in the setting of her recent open cholecyctectomy. On review of the imaging studies with several surgeons and radiologists, it was determined that the fluid collection on the outside hospital CT scan was a small fluid collection consistent with normal post-operative changes. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.

14522445-DS-16

Mr. ___, you were admitted from the ER for workup of your chronic cough. On arrival you had fluid in your lungs called edema. The fluid in your lungs may cause cough. It seems that you usually have too much fluid in your body, which happens when people require dialysis. Please try sticking to a low salt diet (meaning no fast food, chips, crackers, ___ fries). Feeling better in terms of cough after dialysis may mean that your cough is partially caused by fluid in the lungs. We did not think that you had a bacterial pneumonia requiring antibiotics. The most common causes of cough that does not go away after ___ weeks are not infection. They are usually things like asthma, acid reflux, and allergic post-nasal drip. You were already treated with a stomach acid blocker for reflux in the past few weeks without much help. However, you have not had significant treatment for asthma, so we added an inhaled steroid called fluticasone that you should use daily to prevent any asthma symptoms. If this does not work, you should talk to your primary care doctor (___) about stopping it. Additionally, abdominal fullness and poor appetite you described may be due to diabetes. People with poorly controlled diabetes can develop nerve problems like tingling or numbness in the feet. Occasionally, the nerve problems may affect the stomach and intestines. This can cause food not to move through normally and can make you feel sick or full.

___ yo homeless M with LTBI on INH, ESRD on HD TTS, HTN c/b LVH, poorly controlled DM2, and childhood asthma presenting with subacute on chronic cough x ~10 months, early satiety with N+V x ~9 months, and loose stools ~7 months. #Subacute on Chronic Cough: Patient was initially admitted for a question of a health care associated pneumonia, and was started on clindamycin and ceftriaxone initially. This decision was based on a CXR that demonstrated pulmonary edema, with a pectus deformity causing appearance of RLL consolidation. However, given absent hypoxemia, fever, leukocytosis it is unlikely that he has a bacterial pneumonia (HCAP) and as such the antibiotics were discontinued on hospital day 1. We think the subacute component of his cough could represent worsening of a chronic problem such as hypervolemia with pulmonary edema, chronic asthma, GERD, or possibly subacute infection with atypical organism. That said, his estimated dry weight per HD is <300 lbs, though he has consistently been above 305 lbs at all outpatient visits since late ___, which may suggest that he never fully gets his lungs dry. Of note, he frequently asks to stop HD sessions ___ minutes early, so he never reaches his goal ultrafiltration or estimated dry weight of ~297 lbs. Given that he had childhood asthma that required overnight hospitalizations, with his last asthma attack in his late adolescence, it is possible that this is secondary asthma. Given that albuterol provided temporary abatement of symptoms, we started asthma treatment with fluticasone in addition to albuterol. PFTs may be considered in the outpatient setting. A multimodal approach aimed at allergic post-nasal drip, GERD, and asthma seemed reasonable. As such, he was given: albuterol ___ puffs q6h standing, fluticasone 110 mcg 2 puffs daily, loratadine 10MG every other day (HD dosing). If he does not show symptomatic improvement, then further workup is warranted, but the new medications such as PPI, fluticasone, and loratidine should be discontinued. #Early satiety w/dyspepsia/nausea/emesis: Notably he does not describe dysphagia or odynophagia to liquids or solids. GERD symptoms are not prominent, though occasionally he has epigastric discomfort. Gastroparesis is certainly possible given poorly controlled diabetes. Consider possible gastric emptying study vs possible EGD as an outpatient to further evaluate. #Possible GERD: continue home omeprazole dose. #Loose stools: Per patient, ___ bowel movements per day x 10 months. Painless, without nocturnal symptoms. His weight has been relatively stable x9 months despite reported weight loss. Patient later endorsed soft stool (not loose/watery). He did not show evidence of diarrhea during his admission. #Latent TB: Continued daily isoniazid treatment with pyridoxine inpatient. Of note, patient endorses forgetting about half of his isoniazid pills. LFTs normal. Recommend avoidance of quinolones/macrolides therapy in treating future infections in order to avoid possibility of resistant tuberculosis. Arranged follow-up Dr. ___ in one month for his LTBI therapy, appointment pending at discharge. #Hypertensive Urgency: BPs 170s-200s in clinic, maintained 170's-200's/90's-100's inpatient despite hemodialysis and home medications given. His BPs were somewhat improved after giving his home medications. #Diabetes ___, type II: Hb A1c 10.6 in ___. On Lantus and humalog insulin at home, though patient endorses not having regular access to a refrigerator for his insulin. Inpatient was on Glargine at 20 U qAM (25U qAM at home) with Humalog meal time. A HgA1C was obtained and was 9.7% at the time of discharge. #ESRD on HD: ___ via LUE AVF. Last HD ___, then ___. Patient endorses missing ~1 HD session per month, and also has not been receiving full HD sessions secondary to headache towards end. Had pulmonary edema on admission CXR. Dry wt estimated to be ~295 (135 kg). Patient was counseled to try and get the full HD sessions. Continued nephrocaps, sevelamer, cholecalciferol, and renal diet while inpatient. Will continue regular dialysis schedule outpatient. #Anemia of CKD: Hgb ~10, at baseline. Provided EPO 6000 Units qHD and Venofer 100 mg qHD

16127556-DS-16

Discharge Instructions Dr. ___ of DBS battery and debridement Activity •You may gradually return to your normal activities, but we recommend you take it easy for the next ___ hours. •Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. •You may take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much too soon. •Do not go swimming or submerge yourself in water for fourteen (14) days after your procedure. •You may use a damp washcloth to remove any dried blood or iodine from your skin but do not get your head wet in the shower until your staples or sutures are removed. •The incision on your chest has absorbable sutures and skin sealant. You may take a shower and get your chest wet after 5 days. Medications •Take any new medications (i.e. pain medications) as directed. •If you were on a medication such as Coumadin (Warfarin), or Plavix (Clopidogrel), or Aspirin, do not take this until cleared by your Neurosurgeon. •Do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. until follow up. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: •Mild tenderness along the incisions. •Soreness in your arms from the intravenous lines. •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •Severe Constipation •Blood in your stool or urine •Nausea and/or vomiting •Extreme sleepiness •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg Follow-up Instructions •You will need to follow-up with Dr. ___ in ___ days from your surgery for a wound check and staple/suture removal. Please call ___ to make this appointment.

Ms. ___ is a ___ year old female with a history of medically refractory torsion dystonia s/p DBS placement in ___ most recently s/p battery change ___ ___ presented to the ED with complaints of increased pain and fever. She was febrile to 101 two nights prior to admission. A collection was tapped in the ED which was concerning for purulent drainage from the L IPG site. She was taken to the OR for a wound washout and removal of her stimulator and extension leads to the level of occiput. She was then transferred to the floor for further management. #Infected hardware s/p IPG removal Ms. ___ underwent neuro checks every 4 hours on the floor after returning from the operating room. Skull X-ray demonstrated a small retained fragment, while neck CT demonstrated no retained fragments and a small chest wall abscess. ___ was consulted for drainage of this abscess, but stated that the abscess was too small to drain and it would be better for her to follow up with additional imaging as an outpatient to assess for resolution. Infectious disease was consulted and Ms. ___ was started on Vancomycin and Ceftriaxone. Ceftriaxone was discontinued on POD2, and Vancomycin was discontinued and replaced with Bactrim on POD3. She will complete a four week course of Bactrim as an outpatient and will follow up with ID ___ weeks after discharge for an ultrasound of the chest wall and to assess antibiotic plans. Wound cultures grew out coagulase positive staphylococcus, while blood cultures did not grow out organisms. #DYT1 Dystonia Neurology was consulted for management of dystonia. They discussed the possibility of outpatient botox injections with the patient, to which she was amenable. Should this not alleviate her symptoms, she was given a prescription for Baclofen to be taken at night PRN. Notably, she will have to stop breastfeeding if she takes the Baclofen, and this was communicated to her. Neurology will be calling her to coordinate outpatient follow up. At the time of discharge, Ms. ___ was ambulating independently and was afebrile. She was instructed to follow-up for any symptoms concerning for returning infection.

10285055-DS-14

-You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter. This is normal from the stent irritation. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. -___ ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -You may be given “prescriptions” for a stool softener and/or a gentle laxative. These are over-the-counter medications that may be “health care spending account reimbursable.” -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks

Mr. ___ was admitted Dr. ___ service for nephrolithiasis management with known bilateral ureteral stone and taken urgently to the operative theatre where he underwent cystoscopy, left ureteroscopy, laser lithotripsy, and bilateral ureteral stent placement. He tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. See the dictated operative note for full details. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. Intravenous fluids and Flomax were given to help facilitate passage of stones. At discharge on POD1, patient’s pain was controlled with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. His labs were checked and he was advised to follow up as directed. He was was explicitly advised to follow up as directed as the indwelling ureteral stent must be removed on the left and he will still need definitive stone management on the right.

17646939-DS-18

Dear Dr. ___, ___ were admitted for a change in your behavior following the recent death of your grandmother and other stressors in your life. ___ were also managed for an increase in your heart rate following administration of medication. Your heart rate normalized during the admission and was not affected by the haldoperidol that ___ were started on during this admission. ___ were also seen by Psychiatry for evaluation of your behaviour change who recommended that ___ start haloperidol 2.5mg twice daily. Collectively, it was felt that ___ are safe to go home with your mother and with close psychiatric follow-up which as been arranged for ___ by Psychiatry. ___ have an appointment at ___ Partial ___ Program- ___., ___ on ___ at 9am. ___. Take all medications as instructed. Please note the following medication changes: 1. *ADDED* haloperidol 2.5mg twice daily. ___ and your mother agree to return to the emergency deparment or call ___ should your symptoms worsen again or should ___ experience any suicidal or homicidal ideation. Your mother is to remain with ___ after discharge from ___ ___ to monitor your symptoms and assist with getting ___ to your appointments. In addition to your psychiatric follow-up, ___ will need to make a follow-up with Neurology to follow-up MRI findings that the Neurologists did not feel needed to be worked-up acutely during your admission. Call the following number to schedule an appointment for within 2 weeks of discharge date with the first available appointment: ___. ___ also have a follow-up appointment with your primary care physician on ___ at 9AM.

# Psychosis: Patient with no psychiatric history presented with what seemed to be first psychotic break in setting of increasing psychosocial stressors. Serum and urine toxin screen was negative, arguing against substance-related mania. The patient was admitted to medicine to rule out organic causes of psychosis. Work-up included Head CT, head MRI, TSH, HIV serology, serum coritisol, infectious work-up, and liver function tests. The patient was also empirically started on IV acyclovir out of concern that she may have an underlying HSV encephalitis. Neurology was consulted for the concern of an encephalitis that was the cause of her symptoms. Neurology was thought that the patient's symptoms were more consistent with a psyhciatric diagnosis and recommended getting a brain MRI as well as serum ___ and ___ and ___ were pending on day of discharge. All other work-up proved to be negative. The patient was followed by psychiatry throughout the admission. She was started on 2.5mg haldol twice daily. On day of discharge, psychiatry deemed that there were no psychiatric contraindication to discharge home with her mother. The patient was scheduled for an appointment at ___ Partial Hospitalization Program- ___., ___. ___ at 9am. The patient was discharged on haldol 2.5 mg PO BID. The patient and the patient's mother agreed to return to the ED or call ___ should symptoms worsen again or she experiences any SI/HI. Mother is to remain with patient after discharge to monitor symptoms and assist with getting her to treatment. OUTPATIENT ISSUES: Continuation of haldol 2.5mg twice daily. Follow-up at ___ Partial Hospitalization Program- ___., ___. ___ at 9am. . # Abnormal Head MRI: Several small scattered FLAIR hyperintense foci in the cerebral white matter in the frontal and the parietal lobes predominantly, without associated enhancement were noted on head MRI. Per radiology, these are nonspecific in appearance and can be seen with small vessel ischemic changes, post-inflammatory sequela, post-infectious sequela,vasculitis type of disorders or less likely demyelinating disease given the appearance and distribution. Neurology recommended that this by followed-up by neurology on an outpatient basis. Given the holiday weekend, a follow-up appointment could not be arranged. However, the patient was given the telephone number to contact the neurology office for an appointment for within two weeks from discharge date. OUTPATIENT ISSUES: Follow-up on an outpatient basis with neurology regarding hyperintensities noted on Head MRI. Follow-up of pending ___ and ___ that was obtained as part of neurology work-up. ___ was positive at 1:160, cerruloplasm normal range at 26 . # Hematuria: Patient was noted to have hematuria on a urine analysis on admission. Urine culture was drawn that showed mixed bacterial flora consistent with contamination. A repeat urine analysis did not show blood. . # Tachycardia: Patient with episodes of tachycardia, heart rate ranging 110s to 160s in the emergency department. EKGs showing sinus tachycardia. Heart rate increased with agitation/activity and was in the low 100s while sleeping on morning of admission. Given onset of tachycardia following ativan/haldol administration, toxicology consult obtained who suggested tachycardia could be secondary to anticholinergic effect of haldol or paradoxical reaction to ativan. The patient's heart rate trended down through the admission. The patient was challenged with oral haldol and had no other rebound tachycardia.

18367270-DS-6

Discharge Instructions Brain Hemorrhage without Surgery Activity • We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. • You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. • No driving while taking any narcotic or sedating medication. • If you experienced a seizure while admitted, you are NOT allowed to drive by law. • No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications • Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. • You have been prescribed a steroid (dexamethasone) taper. Please take this medication as follows: • 4mg every six (6) hours for two days (8 doses) • 3mg every six (6) hours for two days (8 doses) • 2mg every six (6) hours for one day (4 doses) • 2mg every eight (8) hours for one day (3 doses) • 1mg every eight (8) hours for one day (3 doses) • Then stop. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: • You may have difficulty paying attention, concentrating, and remembering new information. • Emotional and/or behavioral difficulties are common. • Feeling more tired, restlessness, irritability, and mood swings are also common. • Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: • Headache is one of the most common symptom after a brain bleed. • Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. • Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. • There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: • Severe pain, swelling, redness or drainage from the incision site. • Fever greater than 101.5 degrees Fahrenheit • Nausea and/or vomiting • Extreme sleepiness and not being able to stay awake • Severe headaches not relieved by pain relievers • Seizures • Any new problems with your vision or ability to speak • Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: • Sudden numbness or weakness in the face, arm, or leg • Sudden confusion or trouble speaking or understanding • Sudden trouble walking, dizziness, or loss of balance or coordination • Sudden severe headaches with no known reason

Ms ___ was admitted to the ___ for monitoring and observation out of concern for possible rehemorrhage of her known brain stem cavernous malformation. MRI was performed which showed no significant hemorrhage, but increased local edema and evolution of blood products. She was given a 10mg dose of IV dexamethasone, and started on a one week dexamethasone taper. #Disposition ___ evaluated her and determined she was at her baseline, had an adequate support system, and had strategies in place to make a home discharge safe. She was discharged home with plans for the clinic to contact her for close outpatient follow-up.

14149233-DS-17

You were admitted to the hospital after you were assaulted in the face. You were taken to the operating room where underwent repair of your jaw. Your vital signs have been stable and you are preparing for discharge with the following instructions: Wound care: Do not disturb or probe the surgical area with any objects. The sutures placed in your mouth are usually the type that self dissolve. If you have any sutures on the skin of your face or neck, your surgeon will remove them on the day of your first follow up appointment. SMOKING is detrimental to healing and will cause complications. Bleeding: Intermittent bleeding or oozing overnight is normal. Placing fresh gauze over the area and biting on the gauze for ___ minutes at a time may control the bleeding. If you had nasal surgery, you may have occasional slow oozing from your nostril for the first ___ days. Bleeding should never be severe. If bleeding persists or is severe or uncontrollable, please call our office immediately. If it is after normal business hours, please come to the emergency room and request that the oral surgery resident on call be paged. ___: Normal healing after oral surgery should be as follows: the first ___ days after surgery, are generally the most uncomfortable and there is usually significant swelling. After the first week, you should be more comfortable. The remainder of your postoperative course should be gradual, steady improvement. If you do not see continued improvement, please call our office. Physical activity: It is recommended that you not perform any strenuous physical activity for a few weeks after surgery. Do not lift any heavy loads and avoid physical sports unless you obtain permission from your surgeon. Swelling & Ice applications: Swelling is often associated with surgery. Swelling can be minimized by using a cold pack, ice bag or a bag of frozen peas wrapped in a towel, with firm application to face and neck areas. This should be applied 20 minutes on and 20 minutes off during the first ___ days after surgery. If you have been given medicine to control the swelling, be sure to take it as directed. Hot applications: Starting on the ___ or ___ day after surgery, you may apply warm compresses to the skin over the areas of swelling (hot water bottle wrapped in a towel, etc), for 20 minutes on and 20 min off to help soothe tender areas and help to decrease swelling and stiffness. Please use caution when applying ice or heat to your face as certain areas may feel numb after surgery and extremes of temperature may cause serious damage. Tooth brushing: Begin your normal oral hygiene the day after surgery. Soreness and swelling may nor permit vigorous brushing, but please make every effort to clean your teeth with the bounds of comfort. Any toothpaste is acceptable. Please remember that your gums may be numb after surgery. To avoid injury to the gums during brushing, use a child size toothbrush and brush in front of a mirror staying only on teeth. Mouth rinses: Keeping your mouth clean after surgery is essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass of warm water and gently rinse with portions of the solution, taking 5 min to use the entire glassful. Repeat as often as you like, but you should do this at least 4 times each day. If your surgeon has prescribed a specific rinse, use as directed. Showering: You may shower ___ days after surgery, but please ask your surgeon about this. If you have any incisions on the skin of your face or body, you should cover them with a water resistant dressing while showering. DO NOT SOAK SURGICAL SITES. This will avoid getting the area excessively wet. As you may physically feel weak after surgery, initially avoid extreme hot or cold showers, as these may cause some patients to pass out. Also it is a good idea to make sure someone is available to assist you in case if you may need help. If you develop the following, please return to the emergency room: *fever *chills *nausea/vomitting *abdominal pain *bleeding from mouth *difficulty breathing

___: The patient was involved in an altercation and and incurred bilateral mandible fractures and nasal fractures. He was intubated at an OSH for bleeding, and was transferred to ___ and admitted to ___. Plan per OMFS was for repair on ___. He did spike a fever to 101.6, and was given tylenol, and blood/urine cx were sent. Due to his history of ETOH, he was given Ativan at that time, and was started on ___ ___: Vent was weaned to CPAP, and he was off all sedation. RISBI was 22, so he was extubated. He was switched to a Phenobarb protocol from CIWA scale (Ativan). His C-collar was cleared at that time, SQH was started and he was made NPO at midnight in preparation for OR with OMFS on ___. ___: Pt nasotracheally intubated. He underwent fixation of right subcondylar mandible fractures, extraction of teeth # 24,25,26,27, closed reduction of mandibular alveolar fracture, repair of chin laceration. ___: He underwent a seizure post OR that was managed with just Phenobarb taper. His HCT dropped from 27 to 19.5, and he was transfused 1 unit of blood. He was febrile to 100.5, he had blood clots suctioned from the oral cavity. JP R neck had 145 CC serosanguinous output, and JP L had 25 CC serosanguinous output. ___: He was extubated. The patient pulled his NGT and foley was d/c'd. He was again febrile to 100.1. JP R had 20 CC serosanguinous output, JP L had 10 CC serosanguinous output. No other events. He continued on his Phenobarb taper. He was voiding without difficulty. ___: He continued on his Phenobarb taper. No acute events overnight. Pt was transferred to the floor. ___: JP drains were removed. Rehabiliation process started. The patient continued on Phenobarbital taper, no further evidence of sz. activity. The patient was tolerating a full liquid diet, he was ambulatory. ___: The patient was discharged to the ___ ___ in stable condition. Phenobarb d/c., prescription for pain meds was given. A follow-up appointment was made with the ___ service. Social worker met with patient and addressed out-reach programs.

13447385-DS-8

Mr. ___, You were admitted to the ___ Surgery service at ___ after sustaining multiple stab wounds - to the right flank, anterior neck and posterior neck. We obtained several imaging scans including CT of your head and neck, as well as CT with contrast to evaluate the vessels in your head and neck. This scan showed a small dissection in your L internal carotid artery. You were also seen by our colleagues in Vascular Surgery who advised a carotid doppler imaging study to further evaluate the dissection. This study was reassuring; however, you should follow-up with Vascular Surgery in ONE (1) month for a repeat study and clinic visit. Please keep in mind the following instructions: 1) Activity: You may resume all previous activities. You should limit your alcohol intake as this appears to be causing damage to your liver, a condition called alcoholic cirrhosis, which is irreversible and can lead to very serious medical problems including esophageal varices, bleeding and infection. 2) Medications: you may continue all previous medications. However, you should check with your doctor before starting any new medications that may interfere with, or worsen your liver function. 3) Pain: we are providing you with oxycodone, an opiate pain medication. Please wait at least four hours between doses, and do not drive while taking this medication. You should avoid overusing Tylenol (>3 grams/day) since this can affect your liver as well. 4) Food: You may resume your previous diet.

Pt was admitted to trauma surgery service on ___. Vascular surgery consulted for evaulation of stab wounds with possible involvment of carotid artery. He was monitored closely. Received appropriate pain control. Social work consulted for substance use and safety of home environment. On repeat duplex ultrasound ___, there were no defects to the carotid. He was discharged home on ___ with aspirin. No focal neuro deficits on exam.

13310560-DS-26

Dear Mr. ___, You came to the hospital because you were more confused and having trouble walking. You were also nauseated. You were found to be constipated which was likely causing your confusion and your nausea. You felt better after having a bowel movement. You were also found to have impaired kidney function. Dehydration likely caused your constipation and the problem with your kidneys. Your kidneys got better with fluids. You worked with ___ for your walking and they recommended that you go to rehab to get stronger. It was a pleasure participating in your care. We wish you all the best in the future. Sincerely, Your ___ team

This is a ___ year old male with past medical history of dementia, systolic CHF, bioprothestic MVR, atrial fibrillation on xarelto, history of VT/VF, atrial fibrillation, peripheral vascular disease, admitted with metabolic encephalopathy, dehydration and constipation, now renal function and mental status back to baseline, able to be discharged to rehab # Nausea/vomiting # Contipation: Patient's son described decreased PO intake within the 2 days prior to presentation as well as a few episodes of non-bloody, non-bilious emesis. A CT A/P was done in the ED which showed a large stool ball and no other acute findings. He was treated with an aggressive bowel regimen and had bowel movements with improvement in his nausea. He had no episodes of emesis and was able to tolerate a diet and maintain his nutritional and hydration status. Started and continued miralax at discharge. # Acute kidney injury: Baseline Cr around 1 but was 1.8 on admission. Likely prerenal in the setting of poor PO intake secondary to nausea and constipation. Resolved to baseline with IV fluids. . # Acute metabolic Encephalopathy # Dementia with behavioral disturbance Patient with baseline severe dementia admitted with lethargy in the setting of dehydration and ___ as above. After IV fluids and moving bowels his mental status improved to his baseline per his son. At baseline, he was non-lethargic, alert and oriented to self only but calm and answered questions appropriately. An infectious work up for other causes of encephalopathy was done and was unremarkable. TSH and B12 were unremarkable. # Gait instability: # Fall: Patient's son described more instability with walking and falls. A trauma work up including CT head was negative. ___ assessed the patient and recommended discharge to rehab. B12, TSH, and SPEP were sent and were normal. # Dysphagia Evaluated by speech and swallow with recommendation for pureed solids and thin liquids. # Chronic Systolic CHF Initially dehydrated as above. Continued Labetalol. Of note, has not been maintained on metoprolol or lisinopril for unclear reasons. If consistent with goals of care, would consider starting. Per report from his facility, he is no longer on a diuretic. Once taking PO, he remained euvolemic without the need for diuresis this admission. # Afib # History of VT/VF Patient continued on rivaroxaban # Dementia Discontinued Seroquel given initial encephalopathy. Course notable for absence of agitated, behavioral disturbance or other indication for this medication.

18943220-DS-12

1. Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions 2). Please NO lotions, cream, powder, or ointments to incisions 3). Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4). No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive 5). No lifting more than 10 pounds for 10 weeks Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**

Mrs. ___ was transferred from outside hospital with a myocardial infarction and cardiac cath that revealed severe three vessel coronary artery disease. Upon admission she was medically managed and underwent appropriate work-up prior to surgery. On ___ she was brought to the operating room where she underwent 1. Urgent coronary artery bypass graft x3; left internal mammary artery to left anterior descending artery, and saphenous vein graft to ramus and posterior descending arteries. Mitral valve replacement with a 27 mm ___ mechanical valve. The cardiopulmonary bypass time was 168 minutes with a cross clamp of 141 minutes. She tolerated the operation well and following surgery he was transferred to the CVICU for invasive monitoring in stable condition. She remained hemodynamically stable, sedation was weaned, awoke neurologically intact and was extubated. All other tubes, lines and drains were removed per cardiac surgery protocol without complication. She was started on Beta-blockers, diuretics and these were titrated as needed. On POD1 she was transferred from the ICU to the stepdown floor for continued recovery. Chest tubes and pacing wires were discontinued without complication. Heparin bridge was started with coumadin on POD2 for her mechanical valve, INR goal 2.5-3.5. She received a course of Keflex for erythema at ___ site. She was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 12 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with ___ in good condition with appropriate follow up instructions.

14262740-DS-13

Activity: -Continue to be non weight bearing on your right leg. -Elevate right leg to reduce swelling and pain. -Do not remove splint. Keep splint dry. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the aspirin 325 every day to prevent blood clots. -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. - 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 you have questions, concerns or experience any of the below danger signs then please call your doctor at ___ or go to your local emergency room.

Mr. ___ was admitted to the Orthopedic service on ___ for a right ankle fracture. On ___ he underwent closed reduction and cast application under anesthesia without complication. His pain was controlled with PO oxycodone, tylenol and IV morphine. On HD3 he cleared physical therapy and was medically stable for discharge. He will follow up in 2 weeks to assess swelling of ankle and possible surgical intervention at this time.

14589477-DS-13

Dear Miss ___, You were admitted due to weakness and leg pains. From your laboratory results, we concluded you had rhabdomyolysis. This also led to a rise in liver enzymes which is usually expected. You were given fluids to help this resolve. We are unclear what led to this happening; we suspect sitting in one place for days could have caused that or the use of atorvastatin. We reviewed the rest of your medications to ensure you're not on any new other medications which could have caused this. We also treated you for a urinary tract infection which was initially treated with ciprofloxacin but your cultures showed an organism called Enterococcus which was resistant to it, so we switched you to Doxycyline 100mg daily for a 7 day course, last dose on ___. Note that we STOPPED your atorvastatin. Please do not take it until you see your doctor. Please ensure close follow up with your doctors after ___. It was a pleasure being part of your care. Sincerely, Your ___ Liver Team

Ms. ___ is a ___ y/o woman with a PMH notable for NASH cirrhosis c/b recurrent HE, GAVE s/p APC, PG, and brittle T2DM, presenting with acute onset b/l ___ weakness and pain (in proximal distribution) in setting of chronic weakness and labs notable for transaminitis and CK >7000 and UTI now with CK and LFT downtrending after fluid resuscitation. It is likely she developed rhabdomyelisis in the setting of acute confusion caused by the UTI. With volume resuscitation and treatment of the UTI, her symptoms improved. #Rhabdomyolysis, weakness: The patient's elevated CK >7000 on admission. AST and ALT elevation are likely in [large] part due to rhabdo as well. Likely etiology of immobility at home in setting of acute confusion due to UTI. Drug-mediated causes also possible including atorvastatin as potential trigger and statin was held. No crush injuries or compartment syndrome suspected based on history or exam. Inflammatory etiology investigated but inflammatory makers low-normal at CRP 10.5, ESR 31 not suggestive of PMR. She was given 500cc NS, 50g 25% albumin, and total 50g 5% albumin during her hospital course in increments of 12.5g. CK trended down with level at discharge 124. Physical therapy evaluated the patient and recommended rehab. #UTI: Patient has positive blood and WBCs on U/A. History of UTI and three days of confusion coming in may be reflection of infection. She received 1 dose of Ceftriaxone in ED empirically. Urine culture grew mixed bacterial flora. History of Klebsiella oxytoca infection in ___ sensitive only to cipro, ___, zosyn. E. coli resistant to cipro noted in ___. She was started on ciprofloxacin 500mg Q12H on ___ with planned 7 day course; however urine cultures came back as Enterococcus with multiple resistances (Including cipro) and sensitive to doxycycline. We therefore started doxycycline 100mg daily for 7 days (end date ___ #Transaminitis: Attributed to rhabdo with normal bilirubin with labs remaining at baseline synthetic hepatic function would suggest non-liver etiology. #Metabolic and hepatic encephalopathy: Likely secondary to UTI and reduced bowel movements prior to admission. Improved with fluid resuscitation, continuing lactulose and rifaximin, and treatment of UTI. She was at baseline on HD #2. #NASH cirrhosis: History of NASH cirrhosis c/b HE and GE varices and GAVE s/p APC in ___. Appears compensated at this time. She was continue on home PPI, nadolol, nutritional supplements. #HFpEF: Currently euvolemic appearing. ___ edema is likely due to local inflammation and slight hypoalbuminemia. -holding diuretic as above, I/s/o potential rhabdo. Furosemide and spironolactone held with plan to restart at discharge. #Celiac disease: gluten-free diet #Hypertension: Held diuretics and continued home nadolol. #T2 Diabetes mellitus complicated by neuropathy: She was continued on home lantus, ISS, gabapentin. #HLP: holding home statin in the setting of transaminitis and elevated CK #Pyoderma gangrenosum/Venous stasis uclers: Per recent outpatient notes, patient is not on any oral therapy and is recently s/p 10 day course of PO Keflex for ___ cellulitis. She was given local wound care without signs of worsening or cellulitis. #Iron deficiency anemia: per patient she has anemia at baseline, treated with PO iron. #Depression: continued home sertraline TRANSITIONAL ISSUES ============== #NEW MEDICATIONS - Doxycycline #CHANGED MEDICATIONS - None #HELD MEDICATIONS - Atorvastatin was STOPPED [] Restart diuretics on discharge (held for elevated CK and elevated LFT during admission) [] Reassess if a lower dose of a statin or different lipid lowering regimen as CK and LFT improve [] Dermatology follow up for lower extremity ulcers is scheduled for ___ [] Urogynecology follow up is scheduled for ___ #CODE: Full (confirmed with patient and husband) #CONTACT: Husband - ___ ___ #DISCHARGE WEIGHT - 121 Pounds

11285534-DS-11

You were admitted for vaginal bleeding and weakness. You had an ultrasound of the uterus which showed thickened endometrium which is abnormal. You should contact gynecology clinic to schedule a biopsy of the endometrium. On admission you felt well and did not have further episodes of heavy bleeding or clots, and your blood counts were stable. You felt at you baseline but were found to have low magnesium and low bicarbonate which were repleted. You should continue the bicarbonate supplement at home and have your labs rechecked on ___.

___ woman with history of HTN, DM2, CKD V (baseline Cr ___, gout presenting with acute episode of vaginal bleeding as well as several weeks of malaise and decreased appetite # Post Menopausal Bleeding: Concerning for malignancy given history of weight loss with associated bleeding, pelvic ultrasound with heterogeneous endometrium. Alternatively consider atrophic bleeding, especially given that decreased appetite may be secondary to renal disease. She will follow-up with outpatient GYN for endometrial biopsy. # Anemia: Patient with baseline normocytic anemia secondary to chronic disease and CKD, on procrit q5 weeks as outpatient. Baseline Hgb ___ down to 8.5 on admission. Most likely secondary to acute episode of vaginal bleeding, possible malignancy with post menopausal vaginal bleeding. # Weakness: No neurologic deficits on exam. Most likely secondary to CKD, although malignancy is also on the ddx. No signs/symptoms of depression. TSH normal. Patient has upcoming renal appointment with Dr. ___ to discuss initiation of RRT; no indication for inpatient renal consult at this time. # asymptomatic pyuria: WBCs in urine from ED without symptoms (other than very longstanding generalized weakness, which is more likely related to her renal disease), started on CTX unfortunately without urine culture. Given low level bacteria and asymptomatic nature, this was deemed unlikely to be a UTI her antbiotics were discontinued. Blood cultures remain no growth to date, but recommend a repeat urinalysis and culture with further w/u as necessary. (Discussed this by phone with Dr. ___ team at ___ on ___, and gave my phone number for any further follow up, since patient did not answer my call.) CHRONIC MEDICAL ISSUES: #CKDV: Creatinine at baseline ___. Patient met with nephrology nurse ___ discussing renal replacement therapy options, has not made decision per Atrius records. She was continued on calcitriol 0.25mcg three times/week, and Vit D3 ___ IU daily and started on sodium bicarbonate 650 mg BID for low bicarb and given lab slip to have electrolytes rechecked ___. # HTN: Normotensive in ED and on admission. Continue home metoprolol XL 25mg PO daily, amlodipine 5mg PO daily, and torsemide 10mg PO daily. # DM2: Continued home regimen lantus of 19 U QHS, ISS. Discharged home on home regimen with lantus, novolog scale and glipizide. # Glaucoma: Continued on home latanoprost 0.005% qhs and timolol 0.5% gel forming solution 1 gtt both eyes qAM # HLD: Continued on home atorvastatin 40 mg PO qhs # Gout: continued on home allopurinol ___ PO daily (stable dose with current renal function) # GERD: continued on home omeprazole 20 mg daily # Chronic pain: continued on home acetaminophen 325mg PO q4-6h prn pain TRANSITIONAL ISSUES: ================ -Patient to call and schedule appointment with gynecology on ___ for endometrial biopsy. -Started on sodium bicarbonate for low bicarb during admission. -Labs to be checked and sent to PCP ___ ___

16550015-DS-16

Ms. ___, It was a pleasure meeting and caring for you during your most recent hospitalization at ___. You were admitted with an episode of unresponsiveness witnessed by your daughter. Once you were admitted, we found that you have a slow heart rate which you told us has been known about for a long time. We asked the cardiologists and the neurologists to evaluate you. The cardiologists did not believe that your slow heart rate was related to your symptoms. Following an extensive evaluation, we felt that your symptoms were probably the result of ongoing confusion known as delirium (a common condition we see in elderly patient's) or possibly due to a condition called ___ Body Dementia. Please continue to follow-up with your outpatient doctors. We wish you a speedy recovery. All the best, Your ___ Care Team

BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ with PMH of afib on coumadin, diastolic heart failure, and known bradycardia (previously considered for pacemaker) who presents from home with AMS and ongoing bradycardia. Pt. was witnessed to have several episodes of AMS that were not related to bradycardia. She had no events of hypoglycemia. Her TSH returned normal. Pt. noted to have ulceration of lip and oropharynx. Dermatology consulted thought may be ___ thrush +- HSV stomatitis. For thrush and evidence of vulvovaginitis, pt. given 2 doses of fluconazole with resolution of symptoms. She was without any other clear source of infection in addition to pan-negative culture data. Neurology evaluated the pt. and believed that her ___ Disease was likely not contributing to her AMS. Autonomic Neurology evaluated and thought her clinical situation may be consistent with ___ body dementia given her recent hallucinations, but it may also have been due to delirium. Overall pt's presentation was attributed to worsening dementia with likely ongoing hypoactive delirium ___ recent hospitalization, pain from oropharyngeal ulceration, and ongoing vulvovaginitis. Her mental status improved slightly with improved pain control and treatment of her vulvovaginitis. ACTIVE ISSUES ============== # Altered Mental Status: Pt. with waxing and waning mental status consistent with hypoactive delirium. Thought to be multifactorial with contributing factors including admission where new onset delirium was noted, significant constipation, vulvovaginits/thrush (in the setting of recent course of prednisone/azithro), and pain from healing oral mucosal ulcerations. Pt. initially presented with bradycardia which was not thought to be contributing factor as pt's mental status acutely worsened on different occasions during the hospitalization without evidence of bradycardia at that time. For concern of hypoperfusion, pt's blood pressure regimen was discontinued. Infectious work-up was sent including blood cultures, urine cultures, and CXR all which returned negative. Thyroid function was checked and TSH returned normal. Pt. was without evidence of hypoglycemia. For concern of worsening of her underlying dementia and ___ Disease, neurology and autonomics was consulted. An MRI Brain/Neck was done which revealed no acute intracranial process. Autonomics thought that her overall presentation may be consistent with ___ Body Dementia vs. Hypoactive Delirum. She remained somewhat somnolent with evidence of ongoing delirium and dementia at time of discharge. # Atrial Fibrillation with Slow Ventricular Rate: Pt. with evidence of atrial fibrilation with slow ventricular rate on admission. Per family, this has been well documented and investigated in the past. Per daughter, pacemaker had been considered prior. She also had evidence on admission of afib with RVR. This clinical picture suggests possible sick sinus syndrome. Pt. was thought to be asymptomatic from her bradycardia as she has had multiple episodes of AMS without bradycardia. Outpatient cards follow-up was arranged. # Vasovagal Presyncope: In AM ___, pt. had brief episode of hypotension and diaphoresis following straining episode and massive bowel movement. This was thought to be ___ vasovagal presyncope. Pt. was started on a bowel regimen without repeat episode. # Lip and Soft Palate Oral Mucosal Ulceration: Pt. presented recently with lip swelling/lip ulceration/ and palate ulceration which previously was thought to be a possible allergic reaction. Dermatology was consulted for evaluation and felt that pt's condition was most consistent with HSV stomatitis. Pt. was out of the treatment window for anti-virals. Various mouth care and lip care was enacted with viscous lidocaine, mupirocin, orabase, and nystatin swish and spit for possible thrush component. Pt's symptoms improved during hospitalization. # Blurry Vision: Pt. complained of worsening blurry vision. This was difficult to assess given pt's mental status. This was thought to be related to recent anticholinergic/cholinergic medications pt. had received recently. Case was discussed with ophthalmology who thought that given lack of conjunctival injection or drainage, unlikely infectious or other concerning etiology at this time. Pt was given saline eye drops and outpatient ophthalmology follow-up was recommended. # Vulvovaginitis: Pt. with evidence of white exudative vaginal discharge. Given recent course of prednisone and clinical presentation, her symptoms were thought ___ candidal vulvovaginitis. She was given 2 doses of fluconazole 150mg with resolution of symptoms. CHRONIC ISSUES ================== # ___ disease: Continued home Carbidopa-levodopa. # HTN: Continued on valsartan when SBP>110. Amlodipine was discontinued at discharge. # HFpEF: Continued lasix daily. # Atrial fibrillation: Stable. No rate control needed. Continued on warfarin. # GERD: Continued home PPI. TRANSITIONAL ISSUES ===================== # Goals of Care: Palliative Care saw pt. during hospitalization. Hospice was described. Pt. and family seem interested. Would continue to discuss code status, goals of care, and possible hospice transition as outpatient. # Blurry Vision: Pt. c/o blurry vision worsening recently. Discussed case with ___ on admission. No evidence of conjunctival injection or acute process requiring inpatient evaluation. They recommended outpatient follow-up. # Thrush: Pt. should continue on nystatin swish and spit until resolution of symptoms, no longer than 2 week duration. If symptoms persist, pt. should be evaluated. # Vulvovaginitis: Pt. given 2 doses of fluconazole with resolution of symptoms. If whitish vaginal discharge remains, pt. should be evaluated for further treatment. # Bradycardia: Likely sick sinus syndrome. Stable for several years per family. Would consider d/c'ing timolol as patients can have bradycardic effect on medication. # Autonomic Neurology Eval: Pt. seen by autonomics. Recommended to have SPEP/UPEP for further evaluation. ___ pending at discharge. # Hypertension: continued on valsartan, but amlodipine was discontinued given her BPs were low in 100-110s range on admission. Goal BP for her is between 130-160 systolic. # COPD: has used home O2, but here in the hospital was satting well on room air. Can continue to monitor saturations at home and use O2 as needed # CHF: will continue lasix 20mg daily and recommend following daily weights and sypmtoms (leg edema, shortness of breath) for further titration as an outpatient. # Macrocytic Anemia: B12 and folate return normal. Further work-up is recommended. # CODE: Full, confirmed but family will continue discussing this in the setting of her goals of care # CONTACT: ___ (daughter, HCP, ___

14120635-DS-39

Dear Mr. ___, It was a pleasure taking care of you during your hospitalization at the ___. You were admitted to ___ because you were more confused than usual. This is likely because you had a urinary tract infection. We gave you antibiotics to treat the infection and your mental status improve back to your regular baseline. You also received dialysis for your kidney disease while you were hospitalized. We had a family meeting with your wife and your son, ___, to discuss the next best step with you. The neurology (brain) doctor, explained that your mental status may not get much better than it is now. We recommend that you follow up with a urologist (urinary tract doctor) to evaluate the cause of your frequent urinary tract infections. We also recommend that you talk to your primary care doctor and liver doctor about whether or not you need a feeding tube for nutrition. If you have fevers, chills, worsening confusion, or any symptoms that concern you, please seek medical attention. We wish you the best of luck in your health. Sincerely, Your ___ care team

Mr. ___ is a ___ year old ___ speaking man with ESRD (on HD ___, HBV cirrhosis s/p liver transplant ___ on cyclosporine c/b large varices and recent upper GIB (___), Afib (on ASA), T1DM, CAD and previous subdural hematoma with persistent neurologic deficits (___), recent admission ___ for MRSA bacteremia thought to be seeding from HD graft, who presented with acute encephalopathy and fever, found to have a UTI. #Goals of care: Patient often refuses medications and will try to pull out lines at dialysis. Today he very clearly said no to the transport team when he was going to be brought to dialysis. There was a family meeting (___) and the patient's wife and son expressed that they had considered hospice for him if his mental status is not going to improve beyond his new baseline since the stroke/hemorrhage. The wife and son expressed the afternoon to think about the next best step for the patient. They will not pursue hospice at this time. # Toxic Metabolic Encephalopathy: Patient presented more lethargic and less responsive than his baseline, likely in the setting of UTI. Patient has history of encephalopathy with infections previously. CT head limited given pt agitation but no gross intracranial hemorrhage seen. His mental status improved with treatment of UTI as below. Neurology was consulted to discuss his long term prognosis. Infectious encephalopathy, which appears to be resolving. On head CT there is no evidence of repeat infarct or new hemorrhage, however he does have significant frontal lobe atrophy. As such, Mr. ___ is expected to return to his cognitive baseline, with the understanding that this baseline will likely involve persistent deficits in executive functioning and that he will likely not improve beyond where he has been in the past 12 months. This assessment was provided to Mr. ___ and his son as part of a family meeting held ___. #Sepsis ___ urinary source: UA suggestive of UTI, with cultures growing E coli. Patient intermittently tachycardic to 110s. As above, patient appears to have had similar encephalopathy in the past in the setting of infections, and he has also increased his rate before with infections. Blood pressures remained stable. He was initially treated with IV cefepime (___), then zosyn (___), then transitioned to Bactrim (___-). He was given IV albumin for volume repletion, which improved his tachycardia. He was continued on Bactrim SS BID with a plan for a total 2 week course to end ___. # HBV cirrhosis s/p liver transplant ___: c/b large varices w/ UGI bleed ___. Continued home cyclosporine 75 mg po q12h, home entecavir 0.5 mg PO 3X/WEEK (___), home Pantoprazole 40 mg PO Q24H. #Pancytopenia: Likely secondary to longstanding immunosuppression with cyclosporine and possibly lamictal effect; likely worsened in the setting of acute infection. His CBC was trended. #ESRD: Continued HD ___. Continued Calcium Acetate 667 mg PO TID W/MEALS; sevelamer CARBONATE 800 mg PO TID W/MEALS #T1DM: On home glargine 10U qHS, 3U qAC, and ISS #HLD: Continued atorvastatin #CAD: Patient has a history of CAD with cardiac cath in ___ w/ 40% mid LAD and 40% diagonal stenoses. Circumflex with 40-50% mid stenosis; RCA with mild diffuse disease; 50% PDA stenosis. Continued isosorbide dinitrate, metoprolol, atorvastatin, and aspirin #Papillary thyroid cancer s/p thyroidectomy: Continued levothyroxine 100 mcg daily. #HTN: Continued home amlodipine, isosorbide. Held lisinopril and clonidine. #Afib: CHADS-VASC 5 but not on anticoagulation given a history of subdural hematoma and GI bleed. Continued metoprolol tartrate 50 mg Q6H. #h/o seizure disorder: continued home LevETIRAcetam 250 mg PO BID #h/o depression: continued home Sertraline 25 mg PO DAILY #Vitamin D deficiency: continued home Vitamin D 1200 UNIT PO DAILY #Glaucoma: continued home Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS Transitional issues =================== - New medications: Bactrim (___) - Recommend urology follow up for recurrent UTIs - Follow up glucose control and adjust insulin as needed - Lisinopril discontinued as blood pressures well controlled without it (and sometimes on lower end in systolics 100s) - Recommend nutrition follow up for discussion of feeding tube if patient continues to refuse medications and food, while family choosing to continue to pursue aggressive care - Cyclosporine level goal 50-100 - Draw next cyclosporine on ___ and fax results to ___: ___ - Continue goals of care discussion with family - HCP ___ (son) ___ - Code status: DNR/DNI

15792067-DS-2

Dear Ms. ___, You were admitted because you had more oral mucous than you normally do and you were having difficulty with these secretions. Your symptoms may have been due to difficulty swallowing or a pneumonia. We will be sending you home with antibiotics to treat a pneumonia. A scan of your chest revealed that you do have mucous build-up in your lungs. We have arranged for you to receive suctioning at home, which will help with these symptoms. We performed some tests to determine if your symptoms are due to the flu. This test has not yet returned. We will discharge you home with a mask until the tests return. Please wear the mask whenever you are in public until we call you with the results. We were also concerned about your fast heart rate. This may have been, in part, the result of dehydration. However, even though you received a lot of fluids, your heart rate was still quite fast. Sometimes this is due to a clot on your lungs. We performed a scan of your chest which did not reveal a clot, but did reveal a build up of mucous in your lungs. The fast heart rate may be your body's response to this mucous build up. We will manage this with suctioning at home. Please continue to take your antibiotics through ___. Please follow up with the appointments listed below. It was a pleasure to be a part of your care! Happy birthday from your ___ treatment team.

Ms. ___ is a ___ year old young woman with a past medical history of cerebral palsy who presents with increased mucous production x2 weeks, found to be tachycardic in the ___ with elevated lactate and admitted to medicine for further management. # Increased mucous production/increased oral secretions: Ms. ___ presented with increased oral secretions appearing uncomfortable and moaning on initial exam, with fever to 100.2. Given her symptoms and low grade fever, she was treated empirically for community acquired pneumonia with Ceftriaxone and Azithromycin. The other etiology of presentation included the possibility that she had a sore throat and was reluctant to swallow her secretions, which eventually built up and caused her distress. She underwent CTA to further evaluate her tachycardia as below, with the incidental findings of endobronchial plugging of the right lower lobe. She underwent suctioning overnight and was back to her baseline on hospital day #2, according to her father who is her primary caregiver. She is discharged home to complete a course of antibiotics for CAP and with ___ services for deep suctioning three times weekly. Respiratory viral culture is pending on discharge and the patient was instructed to wear a mask until contacted with the final results. # Tachycardia: Ms. ___ presented with tachycardia to the 130s, confirmed on EKG to be sinus tachycardia, as well as elevated lactate to 3.9. She received a total of 5L IVF with improvement of heart rate to the low 100s. Initial EKG was concerning for S1, Q3, T3 pattern. Given that her tachycardia did not completely resolve even after 5L IVF, she was evaluated for PE. LENIs were negative for DVT and CTA scan was negative for PE (though notable for incidental findings as described above). The etiology of her tachycardia was thought in part secondary to hypovolemia as well as physiologic response to endobronchial plugging. Prior to discharge she demonstrated the ability to tolerate PO intake and she was discharged with ___ services for deep suctioning as above. # Cerebral Palsy: Patient undergoing ___ as outpatient. Disposable liners provided in house for incontinence. # Constipation: Continued on home Miralax # Secondary amenorrhea: Patient on medroxyprogesterone as needed for no menstruation every ___ months. She is currently not taking this medication.

16483496-DS-19

Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Weightbearing as tolerated left lower extremity MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down: then 1 tablet every 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - Splint must be left on until follow up appointment unless otherwise instructed. - Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever ___ 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. You will have follow up with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for any new medications/refills. THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB Physical Therapy: Weightbearing as tolerated left lower extremity No other activity or range of motion restrictions Treatments Frequency: Skin staples or sutures to be removed at 2-week follow-up

The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left intertrochanteric femur fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left TFN, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weightbearing as tolerated left lower extremity , and will be discharged on Lovenox for DVT prophylaxis and will also continue her dual antiplatelet therapy. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.

16779560-DS-12

Dear Ms. ___, You were hospitalized due to symptoms of left facial droop and slurred speech resulting from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. 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: -Hypertension -Hyperlipidemia -Atrial fibrillation -Congestive heart failure -Type 2 Diabetes We are changing your medications as follows: -Apixaban 2.5mg twice daily Please take your other medications as prescribed. Please followup with Neurology and your primary care physician. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team

Ms. ___ is an ___ year old woman with a PMHx of L frontal lobe infarct (___), L temporal-parietal grade 2 meningioma s/p resection ___, CAD s/p MI, HFpEF, stage III CKD, HTN, T2DM on insulin, and atrial fibrillation not on AC (unclear reason) who is admitted to the Neurology stroke service with L facial weakness and dysarthria secondary to an acute ischemic/hemorrhagic stroke in the R MCA. Exam notable for dysarthria, left NLFF but good activation and left pronator drift with subtle left proximal weakness that has improved. MRI with acute infarction within the right temporoparietal lobe and a small infarction in the left precentral gyrus, as well as chronic infarction within the right cerebellar hemisphere and diffuse parenchymal volume loss with nonspecific white matter signal abnormality, likely a sequela of chronic small vessel ischemic disease. Her stroke was most likely secondary to a cardioembolic event, given her history of atrial fibrillation not on AC and pattern of acute MRI changes. Her calculated CHADS-VASc Score is 9, indicating a ___ risk of stroke per year. The benefits of anticoagulation for prevention of further strokes is greater than the risk of bleeding in this situation. Therefore, we have added Apixaban 2.5mg BID to her current medication regimen. She technically qualifies for 5mg BID dosing, given that her Cr at discharge was below 1.5 and her body weight is greater than 60 kg. However, because she is ___ and her Cr was 1.9 on admission, coupled with her history of neurosurgery (meningioma s/p resection), we will start her on 2.5mg BID for ___ weeks, with a plan to increase her dose to 5mg BID at her stroke followup appointment, if tolerated. Her deficits improved greatly prior to discharge and the only notbale weakness was in the L IO muscles with subtle L pronator drift, as well as mild dysarthria. She also has chronic visual deficits. She will continue rehab at home with home ___, with speech/swallow follow up.

16473254-DS-5

Dear ___, ___ was a pleasure to take care of you at ___ ___. You were admitted on ___ with a transient episode of right hand numbness that progressed to problems with your speech. The whole event lasted approximately 1 hour. When you arrived, a Code Stroke was called an you were taken urgently for CT which showed ___ new stroke or problems with your blood vessels to account for your symptoms. We also did an MRI which showed ___ stroke or obvious vascular cause of your symptoms. We checked additional laboratory tests to evaluate for increased lipids or diabetes. You do not have diabetes, but you did have elevated cholesterol. We would like to start you on: fish oil and feel strongly that you should start Pradaxa, which you refused at this time but stated you will discuss with your primary care doctor. An ultrasound of your heart was also done which showed normal function. At this time we think your symptoms of a transient ischemic attack or TIA. This is a brief stroke-like event that resolves and causes ___ permanent deficit. You may be at increased risk for future TIAs or stroke and it is important that you come back to the ED if you have new or persistent symptoms. Please remain on the medications listed below and follow up as we have scheduled. Thank you for allowing us to participate in your care.

___ woman w AFib on amio and ASA, history of left subclavian steal syndrome, HTN/HLD who developed acute onset of right hand numbness followed by diminished speech output and dysarthria initially concerning for TIA/stroke. On admission, her symptoms had largely resolved and neurological exam was significant only for mildly slurred speech. Code Stroke was called with ___ for dysarthria. CT/CTA and MRI have showed ___ acute lesion or gross vascular compromise, although severe stenosis of the left vertebral artery due to atherosclerosis was seen. Labs do not identify gross metabolic disturbances. TIA with possible thromboembolic etiology from transient Afib vs small vessel disease. ___ evidence to support vertebrobasilar ischemia despite her history of subclavian steal. During this admission she had a brief run of transient questionable Afib with HR 130s that resolved in less than 30 seconds. We had lengthly discussions about her stroke risk due to paroxysmal Afib going forward, but she continues to defer anticoagulation due to concerns about bleeding. She would like to discuss possibly starting Pradaxa after discussion with her PCP.

14828875-DS-20

Dear Ms. ___, It was a pleasure participating in your care at ___. You were admitted to the hospital with abdominal pain due to severe constipation. You had a CT scan of your abdomen that showed significant stool, but no other concerning process. You were treated with laxatives and your symptoms improved. You should continue to take laxatives at home as needed and make sure to drink plenty of fluid and include fiber in your diet to prevent this constipation from happening again in the future. You spoke with the nutrition team to help with your diet. Please discuss setting up a nutrition follow up appointment with your doctor. You appear to have a lot of stress in your life which may be contributing to your abdominal pain and constipation. You felt much better after talking to a social worker, so we recommend that you see a social worker or other therapist after returning home. Please follow up as scheduled with your new primary care provider and note the changes to your medications on the next page.

___ with h/o well controlled asthma who presented with 4 day h/o abdominal pain in the setting of constipation. # Constipation: Presented with ___ days of constipation, no prior h/o severe constipation. Reported that she eats plenty of fruits and vegetables, drinks ___ glasses of water daily and had had occasional constipation relieved with OTC laxatives, no chronic laxative use. No recent changes in medications or diet, no narcotic pain meds at home, although received several doses of morphine and hydromorphone in ED. Based on imaging and ACS consult, no concern for active SBP, although inflammation on CT abd/pelvis may represent resolving obstruction. Was started on bowel regimen which was gradually intensified. Pt was able to have several bowel movements on day of discharge. Discharged patient home with bowel regimen and plan to follow up with nutrition for outpatient nutrition education to prevent recurrent constipation. . # Abdominal Pain: Gradual onset in the setting of severe constipation. Initial KUB suggestive of constipation, CT abd pelvis with nonspecific inflammation of proximal jejunem. Abd exam remained benign, pain improved after patient was able to move bowels, repeat KUB showed decreased fecal load. Repeat lipase, LFTs normal. . # Anxiety/Depressed mood: Likely contributor to abdominal pain/constipation. Patient was noted to have significant anxiety/depressed mood related to stress from difficult family dynamic. Reported tension between herself and her husband related to fertility issues. Has very strained relationship with her mother, who she reports forced her to undergo a medical procedure in the ___ as a teenager which she now believes was a tubal ligation. Her mother reportedly is very intrusive in her family life and she and her husband decided during the admission to move to another ___ to mitigate the situation. She was initially very tearful, but affect greatly improved after discussion with SW. Medical team recommended continued outpatient SW follow up and consideration of initiating SSRI if symptoms persist. Discharged home with short course of low dose lorazepam. . # Asthma: Well controlled on rescue inhaler only. Never hospitalized or intubated for asthma. Continued prn albuterol MDI.

11535733-DS-13

MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment or by your rehab facility. - No dressing is needed if wound continues to be non-draining. ACTIVITY AND WEIGHT BEARING: - Out of bed w/ assist - Right lower extremity: Full weight bearing - Left lower extremity: Full weight bearing - Encourage turning, deep breathing and coughing Qhour when awake Physical Therapy: - Activity: Out of bed w/ assist - Right lower extremity: Full weight bearing - Left lower extremity: Full weight bearing - No ROM restrictions - Encourage turning, deep breathing and coughing Qhour when awake. Treatments Frequency: Site: Incision Type: Surgical Dressing: Gauze - dry - Change daily or as needed to keep dry; OK to leave open to air once non-draining.

The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left hip hemiarthroplasty, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to her baseline diet and oral medications by POD#2. The patient was given perioperative antibiotics and anticoagulation per routine. She did require blood transfusion for postop Hct of 22.5. Her Hct stabalized at 33.3 2 days post-transfusion. The patient was also found to have UTI with pan-resistant E. coli and was started on IV meropenem per medicine recommendations, which she will continue upon discharge. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the left lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient's family regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge.

16804204-DS-28

Ms. ___, You were admitted due to fever when your blood counts were low. You were placed on IV antibiotics for your fever spikes. No source of infection was found. Your counts recovered and you are feeling better and are ready to be discharged home today. You will follow up in the clinic as stated below. It was a pleasure taking care of you.

ASSESSMENT AND PLAN: Ms. ___ is a ___ y/o female with a hx of high-grade DLBCL (CD5+, BCL6 gene arrangement) s/p cycle 6 da-EPOCH-R (c6d1 ___ who presented with febrile neutropenia. Overall, she is doing well clinically and HD stable. #Febrile neutropenia: Presented with ___ SIRS (fever/HR) and elevated lactate concerning for severe sepsis. Additionally, ANC was 90 on admission. Initially, she was started on vancomycin, cefepime, and oseltamivir. However, no infectious source was found; therefore, we de-escalated antibiotics. -Cefepime ___ Vancomcyin [___] -Discontinued Tamiflu with viral swab negative -BCx/urine culture--NTD #Diffuse large B-cell lymphoma: Diagnosed with high grade DLBCL in ___. Cytogenetics notable for CD5+ and BCL6 rearrangement. Initial involvement of C3 paraspinal mass, spleen, putamen, and diffuse lymph nodes (axillary, retroperitoneal, pelvic, mesenteric). S/p 6 cycles of da-EPOCH-R with prophylactic intrathecal MTX. Plan to re-image after cycle 6. Currently, she is day 18 of cycle 6 of EPOCH. Her counts have recovered. -VZV PPx: Continue acyclovir 400 mg q8h -PCP ___: Discontinued atovaquone at discharge per Dr. ___ -___ up scheduled for ___ with Dr. ___ scheduled for ___ #Pancytopenia: Resolved. Likely due to most recent cycle of EPOCH-R. Filgrastim discontinued ___ with counts recovery. She needed PRBCs transfusion on ___ but no other transfusions needed during her hospital course. -Transfuse for Hgb <7 or plt <10 #Chronic HBV Infection: Receiving monthly viral load monitoring. Last level on ___ was detected but less than 1.3. Continue home regimen of entecavir

12738850-DS-14

Please shower daily -wash incisions gently with mild soap, no baths or swimming, look at your incisions daily Please - NO lotion, cream, powder or ointment to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion, unless otherwise specified **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**

___ MEDICAL COURSE: ___ male with bicuspid aortic valve stenosis and mitral regurgitation post-tandem surgical mechanical AVR/MVR, complete heart block post-CRTP, valvular cardiomyopathy and recent hospitalization for ICD upgrade after sustained monomorphic VT who presented after last discharge with ongoing palpitations, with plan for MV paravalvular leak repair. on ___, he went to the OR for his MV paravalvular leak repair. #Monomorphic VT, sustained, s/p ICD upgrade #Palpitations Mr. ___ presented with continued palpitations after CRTD placement and lead extraction on ___. No events with pacer interrogation. Patient noted to have short runs of non-sustained VTs on telemetry accompanied by palpitations. Concern for pocket hematoma noted on ___ in the setting of heparin infusion. #HFrEF ___ LVEF 37%) #Valvular cardiomyopathy post-tandem mechanical AVR/mitral repair. # Severe MR ___ on ___ showing severe MR with dehiscence of the mitral annular ring. Currently appears euvolemic so he was kept on his home diuretic dosing. #Hemolytic anemia iso mechanical valve Stable. #Hepatitis B Patient with positive HepB core Ab. HBV viral load was nondetectable during last admission. RUQUS with normal hepatic parenchyma. #Pulmonary Nodules Incidentally found on ___nd 3 month follow up scan recommended by radiology. #Small Left hematoma s/p ICD upgrade

15679298-DS-28

Dear Ms. ___, You were admitted to ___ because of acute kidney dysfunction and anemia (low blood count). You were transfused both at ___, and at ___. Your low blood count was thought to be due to your long term kidney dysfunction. You were started on a new medication to improve your blood counts. We also treated you with IV medication in order to help you lose some of the excess water in your body. You were also seen by a diabetes specialist to help you regulate your blood sugar. It is IMPERATIVE that you quit tobacco. While you were here, some changes were made to your medications, please see the sheet below. Please follow up below.

BRIEF HOSPITAL COURSE =============== ___ year old female with history of CAD s/p CABG, Type I Diabetes with ESRD s/p renal transplant in ___ on chronic immunosuppressive agents who was transferred to ___ with elevated Cr, evidence of pulmonary vascular congestion, and anemia (she received 4 units of pRBCs). Her creatinine was actually at her baseline. She was diuresed and underwent work-up which revealed new worsened biventricular systolic dysfunction. She was also found to have community acquired pneumonia, and underwent a 7 day course of levofloxacin. Her course was complicated by labile blood sugars. She was started on EPO for anemia related to kidney disease, and was discharged with follow-up with a new nephrologist, as well as ___ transplant nephrology. ACTIVE ISSUES ========= # CHF exacerbation with volume overload: She was noted to have pulmonary vascular congestion on admission. She is s/p kidney transplant in ___ with new worsened systolic function and tricuspid regurgitation. Volume overload was in the context of recent down-titration of diuretic medications in the past month. Creatinine normalized to her baseline (mid 2.0's) during admission. She was treated with intravenous diuresis and restarted on her home regimen of metolazone and torsemide at discharge. - She may need pulmonary investigation in the future due to new biventricular systolic dysfunction AND new pulmonary artery hypertension (esp given that LV dysfunction seems more mild than RV dysfunction). # Pneumonia: She was noted to have radiographic findings of pneumonia and was started on levofloxacin for treatment of community acquired pneumonia. This regimen was not ideal given her prolonged QTc, but she has a penicillin allergy. She underwent an 8 day course (levofloxacin frequency was decreased in the context of chronic kidney disease). # Anemia: She was transferred from an OSH with significant anemia, s/p 2 units of pRBCs at OSH and 2 units at ___. She underwent work-up which was more consistent with anemia of chronic [kidney] disease. She was guaiac negative in the ED and had no evidence of hemolysis (of note, haptoglobin was normal prior to transfusion at ___ - see scanned records for further details). She was started on EPO during her admission; this will be continued by her new nephrologist. She was hemodynamically stable during admission. # Acute on chronic kidney disease s/p renal transplant: She underwent kidney transplant in ___. She was continued on her immunosuppressives and tacrolimus level was sent daily. She should follow up with Dr. ___ at ___, and will follow with a new nephrologist closer to her home. #) Diabetes (type 1): This appears to be brittle diabetes; she had episodes of early morning hypoglycemia. ___ was consulted and her insulin sliding scale and once daily lantus were adjusted accordingly. This could also have been exacerbated by changing renal dysfunction. By discharge, hypoglycemia resolved and blood sugars were better controlled. # Prolonged QTc: She had elevated QTc, possibly due to taking standing prochlorperazine TID at home in conjunction with other QTc prolonging medications, such as tacrolimus. Her magnesium was consistently repleted. She was started on levofloxacin during admission for pneumonia (due to allergies) and QTc was carefully monitored. It was 485 on the day of discharge with fully repleted magnesium. CHRONIC ISSUES ========== #) CAD/PVD: She was continued on aspirin, atorvastatin, and clopidogrel. # Tobacco cessation: She declined nicotine patches saying she lacked cravings. She was counselled on the importance of quitting tobacco, especially due to her chronic medical problems. She is not yet ready to quit but will consider. #) Depression: Continued cymbalta. TRANSITIONAL ISSUES ============== - Code status: DNR/DNI, confirmed with patient on admission. - Emergency contact: husband, ___, ___, ___. - Studies pending at discharge: All micro that was pending is now finalized and added to discharge summary. - She may need pulmonary investigation in the future due to new biventricular systolic dysfunction and new pulmonary artery hypertension, especially given that LV dysfunction seems more mild than RV dysfunction. - Use care with QTc prolonging medications (she and her husband were counselled on only taking compazine as a PRN). - Needs EPO prescription and monitoring of her HCT. - She has follow-up with a hematologist for bone marrow biopsy (this was rescheduled as she missed prior appointment during admission). - A copy of this discharge summary was faxed to Dr. ___ at ___ nephrologist) at ___.

11998285-DS-2

You were admitted because of low blood pressure secondary to dehydration, low blood counts, low blood sugars, high calcium levels in your blood, and damage to your heart from a mild heart attack. During your admission, a large mass in the upper aspect of your right lung was found. Initially, this mass thought to be an infection and you were treated with antibiotics; however, these antibiotics were discontinued after further studies suggested it was not an infection. The mass was biopsied, and the results of the biopsy are pending. To correct your low blood counts, you received a blood transfusion. To correct your low blood pressure, dehydration, and high calcium, you received intravenous fluids. To evaluate your heart, you received a heart ultrasound, which suggests that you may have mild heart failure and that one of your heart valves is permitting backflow. To correct your low blood sugar, you received sugar intravenously. During your hospitalization, urinary retention and difficulty urinating was noted. You received a catheter in your bladder to facilitate urine excretion, and were discharged with this catheter.

RUL lung mass: Initial finding of space occupying process on CXR prompted CT evaluation, which revealed a substantial RUL mass from hilum to chest wall, destroying the second and third ribs. This large mass was biopsied through US guidance, and the results were still pending at the time of discharge. The medical team discussed with the patient that malignancy was high on the list of differential diagnosis. Urinary retention: At ___, 1L urine output was obtained after foley was inserted. At home, patient notes that he will urinate frequently and excrete very small volumes. At ___, Abd CT revealed symmetric bladder wall thickening and enlarged prostate, suggestive of outflow tract obstruction. He received a foley for two days, and then failed two trials to void with 700 mL and 800 mL of residual in the bladder. The patient reported he did not feel the urge to urinate with these volumes. He was started on tamulosin 0.4 mg QHS for presumptive BPH. Hypercalcemia: At ___, patient's corrected calcium was 12.7. At ___, PTH of 6 which is markedly low. Likely hypercalcemia of malignancy given imaging findings. Ordered PTHrP to confirm diagnosis, which was still pending at discharge. Received aggressive IV hydration for a total of about ___ liters since admission, and his calcium trended dowards to correct calcium of 11.5. He also received 1 dose of pamidronate and 1 dose of lasix to further diminish his hypercalcemia. We discontinued his Vitamin D therapy given his hypercalcemia. Consideration should be given to starting a bisphosphonate routinely if confirmed hypercalcemia of malignacy. On discharge, his calcium was WNL at 10.2. Phosphorus was low at 2.4 on day of discharge and he required several packets of neutraphos for repletion. His electrolytes should be checked on a daily basis and repleted as needed while at rehab. Hypoglycemia/DM2: Pt reports low blood sugars at home and had sugars in ___ at ___. Hypoglycemia likely from poor po intake in setting of continued oral hypoglycemics (glimeprimide, metformin). During hospitalization, held hypoglycemic agents and monitor QID fingersticks. FSBG came up nicely to 120s-150s after IVF. Given his lack of appetite, we discontinued his oral anti-hyperglycemics in order to prevent further hypoglycemic episodes. Anemia, inflammation: Pt with Hct of 21 at ___ and received 1 unit PRBC prior to transfer from ___. Etiology of anemia initially unclear butt likely anemia of chronic disease given RUL lung mass. Guaiac negative with good rectal tone. Additionally had colonoscopy in ___ which showed 1 rectal polyp but was otherwise unremarkable. He received 1U PRBC in the MICU prior to transfer to the floor. Hct was 29 on the floor and stable throughout the remainder of the hospitalization. Iron studies showed high ferritin and low TIBC, suggesting anemia of chronic disease as the primary etiology. chronic systolic CHF: TTE showed significant inferior wall motion abnormalities with diminished EF (35-40%). His enalapril was held throughout his hospitalization secondary to hypotension in the setting of hypovolemia; similarly, initiation of diuretic therapy was held. Leukocytosis: On admission, his WBC was elevated to ___. Pt does not have localizing symptoms to suggest infection, urine culture and blood cultures with no growth, Chest CT with complete oblieration of RUL suggesting no physical space for infection. No fevers documented at ___ or here and continued to be afebrile in the throughout the hospitalization. Possibly stress response vs consequence of malignancy. Hypotension (resolved): Pt with reported low blood pressures in systolic ___ at PCP's office. At our ED and in the MICU, BPs were 100s-110s. After IVF on the floor, BPs remained in 110s and he was not orthostatic. Hypotension was likely secondary to volume depletion (diarrhea, frequent urination secondary to hypercalcemia, poor po intake). Infectious cause was considered possible given elevated WBC of ___, however patient was afebrile and reported no localizing symptoms. He received 750mg IV levofloxacin for right upper lobe opacity concerning for PNA, but this was discontinued as malignancy appeared more likely than pneumonia. Additionally also had TTE to look for pericardial effusion which was negative. NSTEMI (resolved)/CAD: Had elevated trop I at ___ and in house with elevated trop T of 0.85. EKG showed LBBB with nonspecific ischemic changes (STE in V1-3, STD V5-6). There were no prior EKGs for comparison, but did not meet Sgarbossa criteria for diagnosing an acute MI in the setting of a LBBB. Cardiology saw the pt and felt he likely has stable CAD and diastolic dysfunction and presented with demand-related ischemia in setting of anemia and hypovolemia. Bedside TTE suggested inferoseptal and inferior wall hypokinesis, with normal RV, EF 50%, moderate pericardial effusion without tamponade. His troponins peaked at 0.87 and trended downwards thereafter. A formal TTE revealed diminished EF (35-40%), inferior wall motion abnormalities, and mitral regurgitation. Once his hypotension resolved, he was started on a low dose beta blocker. Diarrhea (resolved): Pt reported history of IBS and frequent diarrhea at home. Initially he had diarrhea, and in the context of marked leukocytosis, C. diff toxin assay was sent and he was empirically started on antibiotics. C. diff assay was negative and the diarrhea resolved spontaneously.

16968989-DS-21

Dear Mr. ___, It was a pleasure participating in your care at ___ ___. You were admitted with abdominal pain and you had a fever. As you know, given your status, we are concerned that you may have a CMV infection. You received a dose of antiviral medication and then were transferred to the ___ for continued care. You received a study to determine if gastroparesis was contributing to your abdominal pain, and the results are not available. We will send you a letter with the results.

___ yo M with history of T2DM, ESRD s/p cadaveric kidney txp in ___ c/b acute cellular rejection ___, HTN, hypothyroidism p/w fever, abdominal pain, elevated lipase and transaminitis. # Fever/Lipase/Transaminitis: Most concerning for CMV given recipient CMV negative and donor positive, received Valcyte until ___ but records indicate inconsistently filled. In addition, the patient had lipase 500 with some concern for pancreatitis. Triglyercides 232, Ca normal, no history of active EtOH and remote EtOH without reported history of pancreatitis. He was given cipro/flagyl when he spiked in the morning, made NPO and given 1LNS with second liter hanging at time of discharge. Initial RUQ ultrasound is reassuring with normal pancreas head and no evidence of stone or ductal dilation, however LFT's are uptrending. CMV viral load and hepatitis serologies pending at time of discharge, the patient was given a dose of gancyclovir prior to transfer. Plan at the time was CT abd/pelvis with oral contrast only but the study was not completed. Blood and urine cultures pending at time of discharge. # DM: Sugars poorly controlled on arrival, ___ in 300's with some ketones in urine (likely starvation), no AG but bicarb 21, given 8units humalog and 30 units glargine (home dose is 40 at night) in the context of NPO, will need tight glucose attention on arrival. # Abd Pain: See above, could also be coexistant gastroparesis, got gastric emptying study read pending at time fo DC, started protonix IV. #Hyponatremia: Likely combination of hypovolemia in the setting of poor PO intake and pseudohyponatremia from hyperglycemia. Sodium corrects to 131 accounting for plasma glucose. IVF as above. #Hyperkalemia- chronic issue per records, has been on Florinef in past. Now likely ___ mild acidosis and possibly hypovolemia in the setting of pancreatitis. Improved in ED. #Hypomagnesemia: Repleted 4g IV Mg sulfate #Thrombocytopenia: Unclear etiology. ___ be ___ acute inflammation. Sequestration unlikely without evidence of portal congestion or enlarged spleen. No evidence of destruction or bleeding (consumption). Would evaluate for HIT if continues to drop though less likely. Hapto/fibrinogen normal. #ESRD s/p DDRT: DDRT ___, s/p ACR ___ which was treated with IV methylprednisone with peak creatinine 2.4. Presents with Cr 1.3 which is now baseline, tacro trough 5.0, no adjustments made to immunosuppressants. #HTN- Mildly elevated in ED and uptrending, had not received home medications all day. Cont'd Amlodipine and Aspirin 81.

11474065-DS-20

Dear ___ was a pleasure caring for you. You were hospitalized with leg pain after your fall. There is thankfully no fracture and your pain is slowly improving. ___ addition, you were found to have low sodium due to a condition called "SIADH" or syndrome of inappropriate antidiuretic hormone. SIADH is likely caused by your pain and maybe your lung issues. This improved with fluid restriction, and we recommend you continue to limit yourself to 1.5L of free water daily. This will hopefully be temporary, but your doctors ___ when you can stop restricting. We also found that you had lesions ___ your lungs ("cavitary lesions"), the cause of which is not completely clear but which may be from infection of mycobacteria. Tests are pending and you will follow up with the lung doctors here to decide what if any management will be necessary. We also found you had a clot ___ your heart with an aneurysm ___ the heart. For this we started you on a blood thinner. You are currently taking 2 blood thinners (Lovenox injections and warfarin) until the warfarin kicks ___, after which you will stop taking the Lovenox and just take the warfarin. You will be on the warfarin for at least 3 months and will have follow up with your cardiologist to consider what if any further diagnosis/management will be necessary. We found that you had slight widening of some of the biliary tubes around your liver. This is likely not a problem, but at some point ___ the near future you will need to have a test called an "MRCP". We have informed your doctors about this. We have increased some of your pain and anxiety medications, but as we discussed, these increase your risk of fall and other adverse outcomes, so we recommend you work with your doctors to reduce these sedating medications as soon as able.

___ w chronic pain, TBM, sarcoid, aspiration, chronic pancreatitis, with prior compression fractures, here with left leg pain after mechanical fall. While here was found to have SIADH, cavitary lung lesions, LV aneurysm with LV thrombus. # mechanical fall # L hip pain No evidence of syncope or even of sedation by history (though at risk for sedation as below). CT imaging at OSH and on re-read here did not demonstrate any fracture. Her pain was managed with uptitration of her hydromorphone (from 4mg to 6mg) and standing acetaminophen, physical therapy. Her pain improved with this management and has been improving almost daily. # cavitary lesions: OSH CT abd/pelvis showed concern for pulmonary nodules, for which she underwent a CT chest. Surprisingly, was found to have cavitary lesions. Pulmonary was consulted who felt that this was the result of structural lung disease history (sarcoid, prior RUL calcified nodule and bronchiectasis ___ the lower lobes upon which recurrent aspiration is resulting recurrent injury, neumonitis/pneumonia, and structural lung disease) which has resulted ___ the development of two cavitary lesions. See below regarding aspiration. It's also possible this reflects chronic infection with NTM, most worrisome would be M.abscessus and M.___, which is progressing, especially given some ___ seen ___ the anterior RML; alternatively these could reflect Actinomyces, Nocardial, or Aspergillus infections, but all thought less likely given non-toxic appearance. Finally, she has a history of sarcoidosis, and it is possible this is a cavitary sarcoid process which is slowly progressing. Underwent 3 induced sputa ___ returned with negative AFB, but as above no concern for pulmonary TB, these were sent for non-tuberculous mycobacteria), one of which showed commensal flora and staph aureus but per pulmonary this is likely just oral flora rather than staph cavitary pneumonia given how well she has been throughout pulmonary wise. Pulmonary plans for repeat interval CT/PFTs/evaluation as outpatient. They report that a positive mycobacterial culture might not even need to be treated if it occurred, but they will follow up with her as outpatient. They also recommended aggressive treatment of aspiration as below. # LV aneurysm and LV thrombus: this was found incidentally also on the CT chest. Underwent TTE which showed 1cm clot ___ LV. Cardiology was consulted and felt the aneurysm was consistent with the prior distribution of her LAD infarction, although it could be related to a stress-induced cardiomyopathy. Review of her echo, showed that she has wall motion abnormalities present after placement of the stent ___ ___. They felt sarcoidosis was not consistent as etiology. Given the apical aneurysm with associated clot, she was anticoagulated, initially w heparin gtt-->LMWH as bridge to warfarin (d1 ___, d1 ___. They recommend at least 3 months of anticoagulation (___) with repeat TTE ___ 3 months to assess for resolution of clot and presence of aneurysm. They would not recommend ischemia evaluation at this time but can consider a pMIBI as an outpatient. They advised against DOAC given not approved for this indication. # hyponatremia: appears euvolemic, worsened with IVF. Labs consistent with SIADH. Likely Likely SIADH is caused by pain, lung process. Home HCTZ was held throughout admission, pain was treated, and she had 1.5L free water restriction. With the restriction she had general improvement of her sodium, but at times she may have been drinking more than this and this led to very slight worsening of Na during last 2 days (see above for trend), though anticipate this will improve again. Suggest continued monitoring of Na, continued holding of HCTZ for now, continued free water restriction. Consider salt tabs if necessary. When SIADH resolves, can start to undo these treatments. As a result of SIADH, we did not start SSRI as below. # Hypomagnesemia: required repletion ___ house, discharged on 3 dose regimen which will end on ___ but suggest monitoring. # T2 DM: hgba1c 8.9%. Goal would not be very low given age and multiple sedating meds, but would want lower than that. Continued home Lantus 20U qd, but started aspart 3U QAC with good effect. Note that patient is not on ACE. # Hypertension: as above, held HCTZ. BP ___ normal range ___ house. Consider ACE as below. # Chronic pancreatitis: continued home creon, reglan and ppi # Chronic anxiety: was worsened ___ house, and had to increase Lorazepam to TID prn from BID prn. Would ideally want to start SSRI but given the sodium questions as above, this was deferred for now. # biliary ductal dilatation: noted incidentally on CT imaging. # dysphagia: # aspiration: Aspiration likely multifactorial and related to vocal cord dysfunction, known oropharyngeal dysphagia, multiple prior thoracic surgeries/interventions which contribute to esophageal dysfunction. Was followed by speech/swallow ___ house and underwent video swallow. This showed mild-moderate oropharyngeal dysphagia. Her swallow is most remarkable for delayed swallow response time, reduced laryngeal vestibular closure, and reduced distention and duration of the upper esophageal sphincter, with early closure and trace backflow into the pyriform sinuses. These deficits resulted ___ intermittent penetration with nectar-thick liquids and thin liquids, and frank aspiration with sequential sips of thin liquids via straw. The patient's swallow safety and efficiency were maximized using the below compensatory swallow strategies. Of note, the dilated cervical esophagus and reduced UES/PES opening was seen during previous studies. The backflow into the pyriform sinuses did not appear to impact this patient's swallow safety this date. However, further work-up with gastroenterology may be beneficial. This can be completed on an outpatient basis. On follow up, she consistently remembered to swallow 2x per bite/sip and only take single sips, but required cuing to sit upright. By the end of the meal, she recalled independently that during meals she should sit upright and demonstrated this via repositioning herself when she slouched to the L side. # tracheobronchomalacia # sarcoid No steroids indicated. We continued home Advair (unclear if actually has obstruction). Started on Acapella BID per pulm. # chronic urinary incontinence: at baseline, recommend o/p urodynamics # HLD: continued home statin. # recurrent UTI, recent yeast infection: received her last dose of fluconazole (which she had been on as outpatient) on hospital day 1. (Had already completed abx as o/p.) >30 minutes spent on patient care and coordination on day of discharge. ============= TRANSITIONAL ISSUES # Contacts/HCP/Surrogate and Communication: Name of health care ___ Phone ___ Cell ___ Date on ___ Proxy form ___ chart: No Filed on ___ Comments:Alternate: ___ (son) ___ - please wean hydromorphone back to home dose (4mg) from current 6mg as pain control improves - please wean off standing APAP as able - please continue physical therapy - sputum cx, AFB (not for TB), fungal x3 (can be followed up as o/p per pulm) - o/p ENT for dysphagia as this may be contributing per pulm - o/p GI with consideration of repeat emptying study per pulm - please have patient follow up with her cardiologist (Dr. ___ at ___ ___ ___ for repeat TTE, anticoagulation duration decision, consideration of pMIBI - please complete enoxaparin bridge to warfarin, and after therapeutic INR for 1d, can stop LMWH - after discharge from rehab, will need to be set up with an anticoagulation management clinic - monitor sodium, initially qd to qod, continue free water restriction (and reinforce), continue to hold HCTZ; consider salt tabs; stop these treatments when SIADH resolves - monitor Mg - monitor FSG and adjust DM regimen as appropriate - discuss with PCP why patient not on ACE with HTN/DM - wean Lorazepam as able (particularly at least to BID prn which is what she came ___ on) but ideally further reductions - consider starting SSRI for anxiety when comfortable from a sodium perspective - consider psychiatry, geriatric psychiatry or geriatrics to discuss pain/psych/deprescribing given fall risk - recommend o/p MRCP given asymptomatic biliary ductal dilatation - swallowing recommendations: 1. Diet: Regular solids with thin liquids 2. Pills: whole or crushed ___ puree 3. Oral care: TID 4. Aspiration precautions: - Fully upright for all PO intake - Small, single sips of liquids at a time; no chugging - Swallow x2 per bite/sip - Alternate bites and sips - recommend outpatient GI consultation to consider repeat gastric emptying and consideration of esophageal motility studies given her swallowing issues - recommend outpatient ENT consultation to consider any ENT interventions that may be helpful for her swallowing - recommend continued speech/swallow evaluations as outpatient - Acapella valve BID to help with pulmonary toilet please - please schedule patient with outpatient INTERVENTIONAL pulmonary visit with Dr. ___ at ___ (pt missed this routine follow up while admitted) - recommend outpatient gyn/urodynamics given chronic urinary incontinence - other than ___ pulmonary and ___ interventional pulmonary, patient would otherwise prefer to follow up with specialists closer to home for all issues

13987970-DS-17

Ms. ___, It was a pleasure taking care of you at the ___ ___. You were transferred to our hospital from ___ because you had a fall while on the blood thinner coumadin. ___ did a CT scan of your head and did not see any evidence of bleeding. They transferred you to ___ for a second opinion and any further management that you would require. You had a carotid ultrasound which showed no significant disease. You were seen by the physical therapists in the hospital who determined that you are safe for discharge home with physical therapy. Please take all your medications as prescribed. We changed or stopped the following medications: Metoprolol: Please stop the metorpolol. Amiodarone: Please continue your amiodarone at 100 mg by mouth daily. Coumadin: Your coumadin was decreased to 1 mg by mouth daily. Lisinopril: Please start 1 tablet by mouth daily for blood pressure control. You will need to make a follow up appointment with your primary care physician ___ 7 days after discharge. You have an appointment with your cardiologist as listed below. It is important that you make/keep these appointments as they might want to make medication changes. You will need to have an INR and renal function checked on ___ and have the results sent to Dr. ___ ___. Thank you for allowing us to participate in your care.

___ F with PMH significant for Afib, HTN, recent small strokes with no residual defects now on warfarin and s/p fall at home presenting from ___ for further evaluation with concern for intracranial bleed.

16893401-DS-16

You suffered a small brain bleed after a fall. This did not require surgery, but you will need follow-up as an outpatient with repeat imaging. Activity - We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. - You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. - No driving while taking any narcotic or sedating medication. - If you experienced a seizure while admitted, you are NOT allowed to drive by law. - No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. - Continue to use your Incentive Spirometer 10x every hour to encourage deep breathing. Medications - You may take your Aspirin 81mg as previously prescribed. Please do NOT take any additional blood thinning medication (Ibuprofen, Plavix, Coumadin) until cleared by your Neurosurgeon. - You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. - You may use Oxycodone for more severe pain as needed. This medication may make you drowsy. Do not drive or drink alcohol while taking this medication. What You ___ Experience: - You may have difficulty paying attention, concentrating, and remembering new information. - Emotional and/or behavioral difficulties are common. - Feeling more tired, restlessness, irritability, and mood swings are also common. - Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: - Headache is one of the most common symptom after a brain bleed. - Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. - Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. - There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: - Fever greater than 101.5 degrees Fahrenheit - Nausea and/or vomiting - Extreme sleepiness and not being able to stay awake - Severe headaches not relieved by pain relievers - Seizures - Any new problems with your vision or ability to speak - Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: - Sudden numbness or weakness in the face, arm, or leg - Sudden confusion or trouble speaking or understanding - Sudden trouble walking, dizziness, or loss of balance or coordination - Sudden severe headaches with no known reason

Mr. ___ is a ___ year-old male with HLD, gout, mild dementia admitted to Neurosurgery at ___ for close neurological monitoring on ___ after a fall with loss of consciousness. He is amnestic to the event. He was found to have a chronic left-sided subdural collection and small, scattered foci of left frontal traumatic SAH. Repeat CT head revealed interval enlargement in chronic subdural collection. The patient remained Neurologically intact with only mild intermittent confusion during hospitalization, which is baseline per family report. The patient complained of anterior chest wall pain. ACS was consulted for finding of rib fractures. FAST ultrasound was performed and was negative for intra-abdominal free fluid. Pain control was recommended without further workup or investigation. Medicine was also consulted given history concerning for syncopal event, as patient does not recall the events surrounding his injury. EKG was without evidence of arrhythmia. TTE was without structural abnormalities. Orthostatics were also negative when evaluated by Physical Therapy. No further inpatient workup was deemed necessary, and the patient was instructed to follow-up with his PCP. The patient was evaluated by ___ who recommended discharge to a rehabilitation facility. The patient was discharged to rehab on ___ in stable condition.

19381010-DS-9

Dear Ms. ___, You were admitted to the hospital with difficulty breathing due to fluid in your lungs and excess fluid in your legs. We gave you medication to remove this extra fluid. Your breathing and swelling improved as the fluid was removed and you were able to walk comfortably and no longer needing oxygen. Please remember to continue to limit salt and total fluid intake and to measure your weight every day. It was a pleasure taking care of you. Sincerely, Your ___ Cardiology Team

Ms. ___ is a ___ with a PMH of CHF (EF 50-55%), severe TR, CHB s/p dual chamber PPM (___), pAfib s/p failed ___ (___), and aortic regurgitation s/p bioprosthetic AVR (___) now s/p TAVR (___) who is presenting with worsening shortness of breath and lower extremity swelling with a ___ exacerbation. # Sub-acute on chronic ___ exacerbation - likely has been worsening over course of month post-procedure as patient has had difficulty breathing throughout this time period. Appeared volume overloaded on admission exam (though cannot use JVP in setting of TR), elevated BNP, R-sided disease with worsening TR and likely exacerbated by L-sided disease due to HTN and AS. SOB less likely due to pulmonary cause as no wheezes on exam and no history of URI sx or previous pulmonary disease (remote history of smoking). Recently started on lasix as an outpatient and per husband has had multiple admissions for diuresis, with intermittent improvement and then readmission. BP normal throughout admission. Given recent hospitalizations with TAVR and LV tear, also concern for arrythmias but no events on telemetry during this admission. Diuresed to dry weight with IV lasix transitioning to PO lasix, discharging on 80 mg PO lasix daily. Continued metoprolol, ASA, statin. Discharge BNP 3209. #AR s/p TAVR w/ LV tear requiring thoracotomy for repair: Continued dressing changes for left thoracotomy wound healing. Patient had two episodes of non-exertional left-sided chest/flank pain during admission without EKG changes, improved by Tylenol, attributed to wound. #Pleural effusion: Patient noted to have small left-sided pleural effusion with atelectasis on CXR, unchanged from prior CXR in ___ s/p TAVR. CT chest confirmed nonhemorrhagic left-sided pleural effusion with subsequent left lower lobe atelectasis. Interventional radiology consulted and felt it was too small to tap. As she was asymptomatic after diuresis, further intervention was not performed.

11979534-DS-26

Weigh yourself every morning, call MD if weight goes up more than 3 lbs. You were admitted to the hospital for a partial small bowel obstruction vs gastroenteritis. You were given bowel rest and intravenous fluids. Your symptoms have subsequently resolved after conservative management. You have tolerated a regular diet, are passing gas and your pain is controlled with pain medications by mouth. Furthermore you have not had any diarrhea, bloody bowel movements, and your hematocrit (blood count levels) have been stable. You may return home to finish your recovery. Please monitor your bowel function closely. If you notice that you are passing bright red blood with bowel movements or having loose stool without improvement please call the office or go to the emergency room if the symptoms are severe. 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. 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. Good luck!

The patient presented to the emergency department and was Acute Care Surgery Team. The patient was found to have a possible small bowel obstruction vs gastroenteritis and was admitted for observation. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by HD2. The patient received anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The ___ hospital course was otherwise unremarkable. At the time of discharge, the patient was tolerating a regular diet, passing flatus, and voiding/moving bowels spontaneously. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.

19230956-DS-21

Dear Ms. ___, Taking care of you at ___ was our pleasure. You came in because you were having chest pain and had findings on your stress test suggesting that your heart was possibly not getting enough blood flow. Because of your ongoing pain, which worsened over the last two days, decision was made to admit you for a cardiac catheterization. The procedure showed normal coronary arteries and no evidence of blockages. Your chest pain is not related to heart disease. Please follow up with your primary care doctor and continue all medications as before. We wish you all the ___. Sincerely, The ___ medical team

# Unstable angina: Patient presented with anginal chest discomfort and recent positive stress test. No EKG changes at rest and cardiac enzymes negative x3. Story very atypical for cardiac chest pain given not substernal, not associated with exertion or relieved by rest. However, given positive stress test gave full dose aspirin and plavix. Given mild nature of pain at presentation, as well as ongoing nature for several days, did not give heparin. The day after admission continued aspirin at 81mg dose and added lopressor 6.25mg BID. Additionally, performed LHC afternoon of ___, which showed normal coronaries. Therefore, she was discharged late in the day. # Anxiety: Her home alprazolam 0.25mg qHS prn for insomnia was continued # OSA: Home CPAP was continued at night.

14010784-DS-16

Dear Mr ___, Thank you for allowing us to participate in your care. You were admitted on ___ with symptoms of low back pain and fevers. Our tests showed bacteria in your blood and we started you on intravenous antibiotics for it. We continued your home medications, and gave you medications for your back pain as well. You responded well to therapy, and we placed a tube in your arm veins through which you will continue to receive antibiotics for 9 more days for a total of 14 days since you started the antibiotics. Our neurosurgery, and infectious disease teams who also saw and evaluated you while you were admitted recommend that you follow up with them after you're discharged at the appointments scheduled below. Discharge instructions - Continue receiving antibiotics through your PICC line till ___ for a total 2 week course till you see the infectious disease team as scheduled below - Please continue your coumadin on discharge and follow up with your regular ___ clinic - Please care for your PICC line as instructed to minimize infections - Your rehab can help remove the staples in your back on ___, ___ - Please remember to wear the TLSO brace whenever you are out of bed till you see the neurosurgery team as scheduled below - You were started on a small dose of metoprolol and statin to help protect your heart. Please follow up with PCP to further discuss these medication changes - Weigh yourself every morning, call MD if weight goes up more than 3 lbs - Please follow up with our infectious disease and neurosurgery teams as scheduled below

___ y/o man w/ h/o DM2, CAD s/p CABG ___, redo in ___, multiple stents, AS s/p core valve ___, and severe lumbar stenosis s/p L3-L5 laminectomies in ___ who represented to ___ on ___ for revision of laminectomies and re-exploration in the setting of progressive neurogenic claudication, s/p L3-L5 fusion c/b dural tear intraoperatively on ___, recently discharged, returning with back pain and fever of unknown origin, found to have MSSA bacteremia. # MSSA acute blood stream infection with sepsis: On presentation, patient met ___ SIRS criteria for fever, respiratory rate and leukocytosis with neutrophil predominance. Given a complaint of diarrhea, C diff was sent, but came back negative. Blood cultures on ___ grew methicillin-sensitive staph aureus so patient was narrowed to Nafcillin 2g IV Q4H, ___ dose ___. WBC trended down to 6.7 by discharge. Given patient's pacemaker was incompatible with MRI, we proceeded to do a CT scan with contrast, premedicating him with benadryl, prednisone, and IVF per protocol (over 13 hours) given his documented anaphylactic allergy to contrast agents. He tolerated the dye without incident. CT of his L spine with contrast on ___ showed subcutaneous fluid collection and pockets of air, likely postoperative changes though cannot exclude underlying infection given limitations of image modality. An aspiration of the fluid pocket was negative for growth on culture. Urine and sputum cultures, as well as multiple daily surveillance blood cultures following treatment, were negative. Patient remained afebrile throughout the rest of his hospital course, with no focal neurological symptoms, though with notable weakness in R lower extremity, which per him, predated his surgery. TEE on ___ showed 1+ mitral regurgitation, with no vegetations noted on aortic ___. Our neurosurgery and infectious disease teams saw and evaluated the patient throughout his hospitalization, with recommendations to continue his Nafcillin via a PICC line placed on ___ for a minimum of 2 week course. He will follow-up with Infectious Disease on ___, who will consider need for repeat imaging to assess the fluid collection. Of note, if he is imaged w/ contrast dye, he will need to be premedicated again. # Spinal Stenosis s/p L3-L4 fusion: Patient underwent revision laminectomies by neurosurgery on ___ with intraoperative complication of dural tear which was repaired. His back pain was maintained on PRN Oxycodone ___ Q4H with good effect. Our physical therapy team also saw and evaluated him while inhouse. Per neurosurgery, staples will come out on ___, and have instructed he wear his TLSO brace when out of bed. # ___: Patient initially presented with BUN of 49, creatinine of 2.1 on admission ___ Cr is 1.2). He had a foley placed on admission given h/o urinary retention and was given gentle fluid rescuscitation given his history of CHF. We also held his lisinopril, renally dosed his meds, and trended his kidney function and urine output. His kidneys responded well, with a BUN to 20, and Cr to 0.9 at discharge. On discontinuing his foley, he failed a void trial so foley was replaced which will be managed at his rehab. # Urinary retention: urinary retention prior to admission, w/ foley placement. Has h/o BPH. We did a due to void trial on ___, which he failed, and foley was replaced. Should have ongoing trial of foley removal at rehab, with follow-up with a Urologist as needed if unable. We continued avodart, tamsulosin. # COPD/OSA: This was stable, without significant wheezing during this hospitalization. He required no O2 during this hospitalization. We also had PRN dual nebs, continued his home theophylline, had him on continuous O2 monitoring, and placed him on CPAP at night (though he declined use on several occasions), and he remained stable throughout his hospital course. # chronic diastolic CHF: Last ECHO in ___ showed EF 35%. Repeat ECHO on ___ showed EF stable at 35%, with no vegetations on his valve. We held her metolazone, torsemide and lisinopril in the setting of ___. Per patient, his metoprolol was discontinued in the past because of severe hypoglycemia and hypotension but we restarted a small dose of metoprolol succinate (12.5mg) given his extensive cardiac history. We also sent a lipid panel, and started simvastatin 10mg daily. We strictly monitored his fluid input and output, monitored him on telemetry and repleted his lytes as needed. #) Volume status: he has previously been on torsemide 40mg QOD, 60mg QOD, and metolazone 2.5mg daily. Given ___, these diuretics were stopped. He continues to have poor PO intake and is euvolemic on exam, so we are sending him to rehab off of diuretics, to be restarted as needed in the outpatient setting. # s/p PPM for AV Block: Patient had a ___ model ___ dual-chamber pacemaker which was non compatible with MRI. The implant date of this pacemaker was ___. We monitored his cardiac function on telemetry throughout his hospital course. # History of lupus anticoagulant on Coumadin: Coumadin was held at prior discharge and per neurosurgery, could be restarted 10 days post op (___). However, this was held during this admission given his INR was elevated, likely secondary to poor nutrition and ongoing bloodstream infection with antibiotics. His INR eventually stablized to 2.0 on discharge and we restarted his regular coumadin dose with plans to continue his routine INR checks at his outpatient ___ clinic. Next check ___, dose adjustment per rehab doctors. # DM2, controlled without complications: blood sugars ran low in 60-70's AM, so we decreased NPH dose from 25 units BID to 22 units BID. Diabetic diet. # Hypothyroidism: This was also stable, and we continued Levothyroxine at her regular home dose # Code status: Full code # Emergency Contact: ___ (Wife/HCP) ___ home Wife cell # ___ TRANSITIONAL ISSUES # Continue receiving antibiotics through your ___ line till ___ for a total 2 week course till you see the infectious disease team as scheduled. ID may continue the total course of antibiotics when they see you on ___. Consider re-imaging of pocket. # If he gets ___ need iodine contrast allergy prevention, per ___ PPGD guideline # INR and chem 7 to be checked on ___. Coumadin to be managed by rehab physicians. # Please have the staples in your back removed on ___, ___, by rehab # TLSO brace at all times when out of bed, until follow-up with Neurosurgery # Restart diuretics as needed in the outpatient setting

16595729-DS-13

Dear Mr. ___, It was a pleasure caring for you during your stay at ___. You were admitted to the hospital with low blood counts. You were found to have evidence of bleeding from your GI tract which is caused by your cirrhosis. You were treated with a procedure called a TIPS which can help lower the pressure in your liver to help prevent further bleeds. Dilated blood vessels in your GI tracts were also fixed by the interventional radiologists. You were restarted on diuretics (water pills) while you were here in the hospital. You should weigh yourself every morning and call your doctor if your weight goes up by more than 3 lbs. It is very important that you follow up with our primary care doctor, the interventional radiologists, liver doctors and ___ ___ after you leave the hospital. You will need to have labs drawn on ___ and every ___ after. Your updated medication list and appointments are listed below. We wish you the best! - Your ___ Care Team

___ year old male with history of Hep C cirrhosis c/b varices s/p Harvoni, diastolic heart failure with recent admission at OSH requiring intubation, presenting with symptomatic anemia ___ variceal bleeding now s/p TIPS, course complicated by demand NSTEMI, bradycardia, and ___. #HCV cirrhosis s/p sustained virologic response complicated by variceal bleeding: Pt had a prior known history of esophageal varices s/p banding. He presented with dyspnea and chest discomfort and was found to have Hgb of 5 at ___ on ___. He was transferred to ___ for further evaluation, and EGD revealed extensive gastric varices with signs of recent bleeding. He received a total of 4 units pRBCs. He was unable to tolerate beta blocker for bleeding prophylaxis (see below). The patient was treated with PPI BID, and received IV Ceftriaxone for SBP prophylaxis. Diagnostic paracentesis fluid cultures grew coagulase negative staph in only 1 bottle, and this was thought to be a contaminant and treatment was discontinued. The patient underwent TIPS via R IJ approach on ___ with improvement with improvement in portosystemic gradient from 14 to 6 mmHg. Additionally during the procedure the patient had sclerosis/embolization of varices. His Hgb remained stable for the duration of his remaining hospitalization. The patient developed some abdominal pain post TIPS, and serial RUQ US revealed findings concerning for possible TIPS stenosis, however imaging of TIPS limited in the immediate post procedural follow up. The interventional radiology team who performed the TIPS procedure evaluated the images, and recommended repeat venogram in 1 month for follow up, and that there were not concerning findings requiring immediate intervention. An HCV VL was sent during the admission which was negative. #Symptomatic bradycardia: Pt received a dose of 20mg nadolol and developed sinus bradycardia with rate of 30. He was also relatively hypotensive to SBPs ___ and felt nauseated. He required dopamine support to maintain HR and BP for nearly 48hrs after nadolol was discontinued. Pt reported having similar symptoms with propranolol in the past. EP was consulted for consideration of PPM, and they felt this would be a possibility if there was a strong indication for beta-blockers for his varices. Hepatology did not recommend beta blockers for this current hospitalization. Beta-blockers were added to his allergy list. Ocreotide was also held due to concern for bradycardia as a potential side effect. Off beta blockers, the patient had no further episodes of bradycardia on the Liver floor. #NSTEMI: Likely type 2 due to demand ischemia and severe anemia. Troponin peaked at 0.35 and downtrended after transfusions. He was started on high dose atorvastatin but aspirin was held due to bleeding risk and beta blocker held as above. Low dose lisinopril was started prior to discharge. Outpatient cardiology follow up was set up prior to discharge, and the patient will need CAD evaluation. #Low grade fever: While on the Liver floor the patient developed a low grade fever 10 100.1. CXR unremarkable, recent ___ US negative for DVT. UA with pyuria though initial culture negative. There was not evidence of leukocytosis or hemodynamic instability, and the patient remained afebrile for the remainder of the hospitalization. The patient was asymptomatic. A repeat urine culture was sent one day subsequent to the prior negative culture and returned positive for ___ stenotrophomonas maltophila after the patient had been discharged from the hospital. #Acute on chronic diastolic CHF: Volume overloaded on exam at admission. He was diuresed with furosemide IV boluses and metolazone. The patient had not been on any diuretics prior to admission, but was transitioned to PO torsemide prior to discharge. He was continued on hydralazine for afterload reduction, and low dose lisinopril was started with improvement in ___. Home imdur was held, and the patient was not discharged on a beta blocker due to above symptomatic bradycardia. ___: Cr increased from 0.9 to 1.7. Improved with blood transfusion and urine studies were consistent with pre-renal azotemia. Thought most likely in setting of hyperperfusion given low BP and venous/portal hypertension in volume overloaded state. Improved with diuresis in the MICU. The patient had a slight bump in creatinine with re initiation of diuresis on the Liver floor that resolved. # LLE swelling and pain: Patient reported left lower extremity swelling and pain over patella and to palpation of shin. ___ negative for DVT. No clinical evidence of infection. Pain resolved, and asymmetric edema appears chronic secondary to prior CVA. ======================= CHRONIC ISSUES ======================= #Hyperaldosteronism: Home epleronone restarted s/p EGD with improvement in ___, electrolytes. #History of CVA c/b seizures: The patient was continued on home lamotrigine. #Psych: The patient was continued on home escitalopram. #Vitamin D deficiency: Patient continued on home vitamin D. #Prolonged QTc: QTc trended and improved prior to discharge. ======================= TRANSITIONAL ISSUES ======================= # Weight on discharge: 77.3 [ ] Will need TIPS venogram in 1 month to assess for pressures studies and evaluation of varices [ ] Please obtain electrolytes on ___ and ___ - Na, K, HCO3, Cl, BUN, Cr, Ca, Mg, Phosphate - ensure results faxed to PCP ___ at ___ at ___ [ ] Consider titration of diuresis pending electrolytes and weights [ ] Consider starting Aspirin at cardiology follow up [ ] Consider uptitration of lisinopril at PCP/cardiology follow up pending electrolytes [ ] Consider restarting Imdur at next PCP/Cardiology visit pending blood pressures [ ] No beta blockers or ocretotide given bradycardia [ ] Care with QTc prolonging medications, would obtain EKG for QTc monitoring prior to starting any new QTc prolonging medications [ ] Outpatient workup for CAD [ ] Ensure follow-up with PCP, ___, ___, and cardiology [ ] A repeat urine culture was sent one day subsequent to the prior negative culture and returned positive for ___ stenotrophomonas maltophila after the patient had been discharged from the hospital. If symptomatic, please treat appropriately. CODE STATUS: FULL CODE

16992453-DS-13

Ms. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to ___ because you were feeling fatigued and short of breath when you laid flat on your back. WHAT WAS DONE FOR YOU IN THE HOSPITAL? - You were treated with a medicine called Lasix, which was given to you through your vein to help remove the extra fluid in your body that was making it hard for you to breath. You were then switched to an oral version of Lasix that you should take every day to prevent more fluid from building up. - You were started on a new medicine called spironolactone that will protect your heart. You will take a 12.5mg tablet of this medicine once a day. Your home lisinopril 5mg daily was increased to 10mg daily. - You were having some abdominal pain, so you had an ultrasound of your stomach that showed you had gallstones. There is nothing to do for this right now. WHAT SHOULD YOU DO WHEN YOU GO HOME? - You should continue taking all your medicines, as prescribed. As we discussed, you should consider taking your Lasix pill in the morning so you won't have to get up several times in the middle of the night to urinate. - You should follow up with your primary care doctor and cardiologist. - You should weigh yourself every morning using the same scale and call your cardiologist if your weight increases by more than 3 lbs. in one day or 5lbs. in two days. Your discharge weight is: 199.96 lb. - You should drink less than 2 liters of fluid per day and avoid eating salty foods, such as deli meats and canned soups. You should consume less than 2 grams of salt per day. - You should stop smoking. This is one of the most important things you can do to protect your heart from further damage. It was a pleasure taking care of you, and we wish you all the best! Sincerely, Your ___ Team

Ms. ___ is a ___ y/o woman with a PMH of CAD (s/p silent MI, c/b LV thrombus on warfarin), splenic infarction, HFrEF (LVEF=35%), COPD, recently discharged from ___ on ___, who re-presents with persistent SOB. #CORONARIES: multivessel disease, no stenting or PCI #PUMP: LVEF=35% #RHYTHM: Normal sinus rhythm

18674922-DS-8

Dear Mr. ___, It was a pleasure taking care of you at ___. You came in with 7 days of constipation, loss of appetite, generalized weakness, cough, and sudden onset of chest pain. While ___ were here, we ran some tests including EKG, Troponins, and chest X-ray in order to investigate cardiac causes of your pain. These tests were all negative. You were found to have some upper right quadrant abdominal pain on exam and some of your liver enzymes associated with gallbladder injury were elevated. We did several studies to investigate this further including an ultrasound and a HIDA scan. The ultrasound showed that the gallbladder was distended, there were gallstones and some biliary sludge present, as well as gallbladder wall thickening. The HIDA scan showed normal empting of the gallbladder. We had the surgical team examine you to determine if emergent surgery was necessary. Because you continued to have an elevated white blood cell count and pain, you were taken to the operating room where you had your gallbladder removed. You are slowly recovering from your surgery and you are preparing for discharge home with the following instructions: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your surgeon at your next visit. Don't lift more than ___ lbs for 6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap.) You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. 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 aroudn the stitches or staples. This is normal. You may gently wash away dried material around your incision. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). 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 r clothes. If the staining is severe, please call your surgeon. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. Ove the next ___ months, your incision will fade and become less prominent. YOUR BOWELS: Constipation is a common side effect of medicine such as Percocet or 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. In some cases you will have a prescription for antibiotics or other medication. If you have any questions about what medicine to take or not to take, please call your surgeon. DANGER SIGNS: Please call your surgeon if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound

___ with history of afibrillation presented with sudden-onset chest pain, increasing right upper quadrant tenderness, and generalized weakness for the last 8 days. Clinical picture concerning for acute cholecystitis. Since there was concern for acute coronary syndrome, troponins were cycled x 3 which were normal. The patient underwent a ultrasound which showed gallstones and slugde which could be consistent with acute cholecystitis. On blood work, he was noted to have an elevated alkaline phosphatase. He underwent serial abdominal examinations which remained stable. He then underwent a HIDA scan which was normal and showed no cholecystitis. However, his white blood cell count continued to rise with reported increased in right upper quadrant pain. He was started on intravenous ciprofloxacin and flagyl. Because of these findings, he was evaluated by the acute care service. On HD # 4, he was taken to the operating room where he underwent a cholecystectomy. He was reported to have acute gangrenous cholecystitis with a pericholecystic abscess.At the close of the procedure, he had ___ drain placed into the galbladder fossa. His operative course was stable with minimal blood loss. He was extubated after the procedure and monitored in the recovery room. His post-operative course has been stable. THe swab from the gallbladder grew E.coli. The patient remainded afebrile and his white blood cell count normalized. After bowel function returned, he was started on clears and advanced to a diabetic diet. His incisional pain was controlled with intravenous analgesia with a conversion to oral agents. He was voiding without difficulty. He was evaulated by physical therapy and they determined that no acute needs were evident and that when medically stable, the patient could be discharged home. The ___ drain was removed on ___ and the patient was discharged home in stable condition. Follow-up appointments were made with the acute care service and with the primary care provider.

18830959-DS-12

Dear ___, ___ was a pleasure taking care of you at ___ ___. You were transferred from ___ due to concern for a seizure. While there, bloodwork showed extremely abnormal electrolytes. While at ___, your electrolytes were normal. An MRI of your brain was normal. The EEG of your brain appeared normal and is in final review at the time of discharge. Nevertheless, please follow-up with your PCP to have repeat bloodwork done to ensure your electrolytes remain normal. Also, please make sure to follow-up with a neurologist as outlined below. Because of the concern for seizure, **you cannot drive for six months.** When yawning or opening your mouth wide, you should brace jaw with hands to avoid another jaw dislocation. You should apply an ice pack to your face as needed to decrease swelling. Regards, Your ___ Team

___ F with history of hyperparathyroidism (s/p parathyroidectomy), obesity s/p bariactric surgery who presents after being found down with bystander report of convulsions concerning for first seizurea. #) SYNCOPE: Sudden syncopal event without prodrome and subsequent confusion is suggestive of seizure activity with post-ictal period; this was considered a provoked seizure in the setting of hypophosphatemia. However, it appears ___ record of low phosphate was likely inaccurate (see below) and thus if this truly was a seizure it was not a "provoked" seizure. Further, second/third-hand report of convulsions by non-medical observers may be unreliable. No evidence of cardiac cause of syncope (EKG/tele normal), or dysautonomia (orthostatics negative.) MRI head negative for pathology ___ (although not "seizure protocol" so should have this repeated as an outpatient.) EEG without epileptiform activity. Neurology was consulted and did not recommend anti-epileptics. A follow-up appointment was arranged with Neurologists of ___ to consider further work-up. She was advised that she cannot drive for 6 months. #) HYPOPHOSPHATEMIA: Documented value at ___ was 0.8 and she received IV repletion there. Did not recur at BI in absence of repletion, bringing into question accuracy of this lab value at ___. Further, there were no other stigmata of hypophosphatemia (ex. elevated CK from rhabdo which you would expect at a level that low.) Upon arrival, urine phosphate was high (FEPhos 27% on ___. Serial measurements of phosphate and magnesium where normal at ___ without any supplementation whatsoever. Repeat urinary phosphate on ___ was normal (FEPhos 5%) A normal FEPhos is ___. Thus her initial phos-wasting urine studies may have been physiologic if she received an inappropriate load of IV phosphate at ___ when she was believed to be truly hypophosphatemic. Her PTH was normal at 45 and calcium was normal. Vitamin D was low but in isolation this does not explain a reported phosphate of 0.8. Repeat electrolytes should be checked as an outpatient. #) HYPOMAGNESEMIA: Reported mag at ___ was 1.1. Similar story as with phosphate as above; No evidence of hypmagnesemia at ___ on serial measurements. EKG with normal QTc. Likely a lab error at ___. Should be re-checked as an outpatient. #) MANDIBULAR DISLOCATION: Reduced in ED with MAC (ketamine) #) FACIAL FRACTURES: Nondisplaced fractures of the right orbital floor. Right maxillary wall fractures and hematoma within the right maxillary sinus. OMFS was consulted in the ED, who recommended non-surgical management with pain control and ice packs. She had anesthesia in the right infra-orbital nerve distribution likely representing nerve damage from the above injuries. She was given the outpatient follow-up information. #) DEPRESSION: Continued home venlafaxine and escitalopram. #) LOW BACK PAIN: Continued home oxycodone and fentanyl patch. Held celecoxib since non-formulary #) INSOMNIA: Continued home zolpidem, lorazepam. # CODE STATUS: Full (confirmed) # CONTACT: ___ (husband) ___, ___ (sister/HCP) ___ TRANSITIONAL ISSUES =================== [] F/U with outpatient neurology and consideration of MRI with seizure protocol [] Repeat electrolytes including Ca, Mg, Phos as outpatient - No driving x 6 months

17204052-DS-13

Dear Mr. ___, It was a pleasure caring for you at ___ ___. You were admitted for chest pain, and you appeared to have had a small heart attack. An echocardiogram revealed that the muscle function of your heart seems to be stable to prior. We recommend medical management for your heart disease, including a baby aspirin, controlling your blood pressure, and other medication changes as noted below. Please be sure to follow up with a cardiologist, as below. Your CT-scan showed relatively stable tumor, and you should discuss the imaging with your oncologists. Weigh yourself every morning, call MD if weight goes up more than 3 lbs.

Mr. ___ is a ___ year old gentleman with advanced NSCLC and cardiomyopathy of unclear etiology with EF 40%, who presents with chest pain and dyspnea, found to have an NSTEMI. ACUTE ISSUES # NSTEMI: The patient received medical management of his NSTEMI given his life-limiting illness and poor prognosis with advanced malignancy. He was started on a heparin drip and received Enoxaparin to complete 48 hours of anti-coagulation. He was also started on metoprolol for a heart rate goal <70, and SL nitro PRN chest pain. His home statin was switched to Atorvastatin 80mg. He was also further evaluated with a cardiac echo which revealed an improved left ventricular function from prior and a stable pericardial effusion. By morning of admission, the patient was chest pain free and denied chest pain throughout his hospital stay. # Pericardial effusion: The patient was noted to have a small pericardial effusion on CT imaging. A cardiac echo revealed a small to moderate sized pericardial effusion without echocardiographic signs of collapse. # Cardiomyopathy The patient has a known cardiomyopathy with an EF of 40% on echo from ___. He was euvolemic on exam despite an elevated BNP. His chest CT did not show evidence of pulmonary edema, and a repeat cardiac echo showed an improved EF of 50-55%. He was maintained on his home Lisinopril 2.5mg daily, and his home furosemide was initially held and then restarted on discharge. # R pleural effusion: The patient was noted to have a right pleural effusion, increased in size from prior imaging. His dyspnea improved with resolution of his chest pain, and he was satting well on RA. Thus further work up of his right pleural effusion was deferred. CHRONIC ISSUES # NSCLC: The patient's CTA demonstrated stable appearing paratracheal and paramediastinal masses. He was continued on his home inhalers and should follow up with his out-patient oncologists.

10774120-DS-12

Dear Ms. ___, It was a pleasure taking care of you at ___ ___. You presented to us with shortness of breath and worsening of your asthma. We placed you on antibiotics, scheduled nebulizer treatments, and IV steroid. You are being discharged on prednisone, a new medication called azathioprine as recommended by your pulmonologist, and bactrim. We consulted pulmonology who agreed with our plan and made recommendations. Please follow up with your pulmonology, Dr. ___, as scheduled. We also consulted rheumatology to assess for Churg ___ and they believed that your current presentation is unlikely to be due to this illness since you lack many symptoms suggestive of this disease. Please take your medications as instructed. Please attend all your follow up appointments.

___ yo F with poorly controlled asthma, bronchiectasis, history of positive PPD and tobacco use presents with shortness of breath. # Asthma exacerbation - Most likely due to discontinuing home prednisone and non-compliance with medications. We initially placed pt on solumedrol 125mg Q6hr x2 days and further transitioned her to prednisone 40mg. However, patient's symptoms and lung exam worsened upon transitioning to prednisone and thus, taper may have been too quick for her. We resumed solumedrol 125mg Q6hr x2 days, then tapered to 80mg Q8 x1 day and then to prednisone 60mg daily with the following taper: 60mg x5 days, 50mg x3 days, 40mg x3 day, 30mg x3 days, 20mg x3 days, 10mg until f/u with Dr. ___. We also treated her with levofloxacin for total of 7 days, last dose on ___. Per pulmonogy recommendation, we initiated azathioprine 50mg daily upon discharge upon normal LFT's, negative hepatitis serology, and negative serum HCG. Given concern for EGPA on behalf of primary pulmonologist, we consulted rheumatology who believed that current presentation is unlikely to be due to EGPA given lack of symptoms suggestive of vasculitis and other systemic involvement. We also initiated bactrim for PCP ___. There was evidence of thrush due to chronic steroid use and patient was started on nystatin mouth wash. The following were found on outside hospital records: IgE 181 and ESR 34. # hand and leg pain/numbness - Peripheral neuropathy is a common presentation in EGPA but usually presents as mononeuritis multiplex, or as peripheral neuropathy in "stocking and glove" distribution. Her presentation is more c/w radicular vs. vasculitic. - outpatient f/u w/ neurology as previous work-up suggestive of cervical stenosis, had recommended MRI. - Rheum consult as above # pulmonary nodules - unclear significance - radiology recommends f/u study with CT in ___ year. TRANSITIONAL ISSUES: [] neuropathy of ___ - has appointment scheduled with neurology as there is concern for radicular neuropathy [] hypertension: pt hypertensive to 150's/100's throughout hospital course. Currently, on no antihypertensives. Renal function normal. [] attention to follow-up regarding LLL pulmonary nodule noted on chest CT dated ___ [] please schedule close follow-up (within ___ weeks) with Dr. ___ pulmonary) and with PCP [] drug monitoring as above [] follow-up pending studies as above [] follow-up blood glucose level as outpatient while on steroid therapy [] Has received pneumonia vaccine in ___ at ___ and flu vaccine on ___. Will need prevnar at clinic follow-up when on lower dose of steroids

17864490-DS-12

Mr ___ it was a pleasure caring for you during your stay at ___. You were admitted again with fever. Given your history of multiple pseudomonas infections in the recent past and recent removal of the gallbladder tube you were restarted on IV antibioitcs. However you did not have any fevers here in the hospital and there were no signs of infection on blood cultures, liver ultrasound or liver MRI.

___ hx HIV recently started on HAART, recently dx metastatic panc CA c/b biliary obstruction s/p CBD stent and recently removed perc chole tube, who presents from ED w/ recurrent fever. # Fever with SIRS: Remained HD stable since IVF bolus in ED. Given pt hx concerning for recurrent cholangitis/cholecystitis or liver abscess although no WBC elevation, GB not thickened on U/S and no RUQ pain. Also possible recurrent pseudomonas bacteremia but no signs of sepsis since admission. - given vanco/tobra in ED but did not cont as tobra led to renal insufficiency in recent past and no hx MRSA or other indication for vanco at this time - pt was resumed on ceftolazone/tazobactam to cover prior MDR pseudomonas (had been stopped on ___ however cx neg for 48 hrs, stopped am ___ - no further fevers off antibiotics. Liver U/S and MRI without signs of cholecystitis/cholangitis. - discussed w/ ___, no plans for replacement of drain given stable imaging During his admission was noted to have nightly temp elevation ___, reports some night sweats at home. suspect fevers prior to admission may have been related to underlying malignancy #Anemia - symptomatic w/ fatigue. possible chronic blood loss w/ iron def as there was some invasion of duodenum by panc mass on last ERCP in ___ but no ulceration or bleeding at that time. iron studies this admission more c/w ACD, is able to mount some reticulocytosis. - hapto/LD normal - mod low iron, elevated ferritin, low TIBC more c/w ACD than true iron def - hgb declined to 6.7 after IVF on admission, pt received total 2U PRBCs ___ and ___ - guiac stools x 3 negative #Renal insufficiency - timing c/w prior tobra nephrotoxicity, has been slowly improving, Cr 1.2 on discharge (prev up to 1.9) # Right PICC-assocd DVT: RUE U/S positive for DVT on ___. PICC removed, swelling has resolved. Cont on daily lovenox. # Pancreatic adenocarcinoma: Followed by Dr ___ w/ ___. Chemotherapy has been delayed due to mult prior infectious complications. per Dr ___ like him to be off antibiotics for 2 weeks prior to starting therapy. Other than 48 hrs antibiotics this admission, last antibiotic course ended ___. He will f/u w/ Dr ___ week # HIV: recently initiated HAART w/ triumeq. Per ID notes is long term nonprogressor. Last known CD4 313 & viral load 20K on ___, recently started receiving HIV care by Dr ___ at ___. triumeq continued while inpt PAIN: cont home oxycodone BOWEL REGIMEN: cont home regimen senna/docusate increase miralax to daily (was prn)

11968239-DS-3

Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted with bleeding from your sarcoma. The bleeding stopped and we started you on your radiation treatment, which you tolerated well. We also started you on new pain medications. You also had a port placed to prepare you to start the chemotherapy, along with radiation, to start next ___. Be sure to return to 11 Reismann to be re-admitted early ___ morning before your radiation session. Sincerely, Your ___ Care team

PRINCIPLE REASON FOR ADMISSION: =============================== ___ is a ___ year old man with recently diagnosed high-grade soft tissue sarcoma of the right upper arm who was transferred to ___ with bleeding from his tumor and plan to urgently initiate radiation treatment. # High grade sarcoma: His external bleeding has stopped, and he initiated his first session of radiation on ___, which he continued daily through ___. We prepared to start concurrent doxorubicin next week with TTE and obtained POC access. Ultimate plan for 4 additional weeks of neoadjuvant chemoradiation prior to surgical evaluation. He will return to 11R on ___ morning to resume concurrent chemoradiation. # Hemorrhage: # Anemia # B12 deficiency: Superficial hemorrhage of fungating tumor resolved. He also has areas of internal hemorrhage in the tumor. CTA showed no active extravasation, and HCT stayed generally stable. Also found to be B12 deficient, likely nutritional. We started 1000mcg B12 daily with MVI and folate. MMA is pending on discharge. # Cancer associated pain: Due to severe cancer associated pain, with high oxycodone requirement, he was started on Oxycontin. We titrated the dose to 30mg q12 hours along with 10mg po oxyocodone q4 hours as needed. ___ benefit from palliative care consult in future admissions. # Edema: Doppler US negative for clots. Improved after restarting home HCTZ. # HTN: Restarted home HCTZ and home lisinopril 20mg bid # Coronary artery disesea: No known clinical CAD, but CT on ___ noted proximal LAD atherosclerotic calcification. TTE was normal. Consider outpatient stress testing. # Billing> >30 minute spent coordinating and executing this discharge plan

14695516-DS-14

Dear Mr. ___, It was a pleasure to care for you here at ___. As you know, you were hospitilized for severe abdominal pain. We are unsure of the cause of your abdominal pain. Obstruction of your gallbladder can sometimes cause the type of pain your were having. However, all of your labs were normal and a HIDA scan, which is an imaging test used to look to see if your gallbladder is obstructed, showed no gallbladder obstruction. We also performed an ultrasound of your gallbladder which was equivocal, but HIDA scan is a much better test to look for obstruction of your gallbladder. It is possible that your abdominal pain is being caused by gastritis (inflammation of the stomach) or peptic ulcer disease. We ordered an H. pylori test, which is currently pending, so you will need to contact the hospital in 48 hours for these results. We started you on famotidine, which is a medication that will block acid secretion in your stomach and may help with your symptoms. You are being discharged because you are clinically stable, but you should follow up with your primary care doctor. You should also follow up in the ___ clinic. The information needed in order to make an appointment is included in this document. Please return to the hospital if you are experiencing any symptoms that are concerning, including worsening or persistent abdominal pain, blood in stool or black stool, fevers, chills, nausea/vomiting, or any other symptoms that concern you.

Mr. ___ is a ___ yo M with HIV presenting with acute onset severe RUQ abdominal pain radiating to the epigastric region initially concerning for cholecystitis but more likely gastritis, after having normal labs and negative HIDA scan.

14063651-DS-22

It was a pleasure to participate in your care at ___. You came to the hospital for dark stools and dizziness. We found that your blood counts were low. You were seen by the Gastroenterology Team who elected to do a camera study called an EGD (upper endoscopy). Your study showed old blood in your small bowel but no active bleeding. A repeat EGD should similar results. Your blood counts were monitored after the procedure and remained stable. You developed shoulder pain while in the hospital. We treated your pain with tylenol. Please do NOT take medications like ibuprofen, motrin, or naproxen for your pain, as these medications (NSAIDs) can cause bleeding in your gastrointestinal tract. Please take all medications as prescribed. Please follow up with your primary care physician for further care. You will need to have your blood counts checked soon to make sure that there is no further bleeding. If you get dizzy or lightheaded please call your PCP or go the ED to have your labs rechecked.

___ year old gentleman with h/o CAD and diverticulosis who presented with dark stools and drop in hematocrit concering for a upper GI bleed. # Upper GI bleed: At admission the patient reported dark stools, associated with dizzyness. He Hct in the ED was 32 from a baseline of Hct ~40. His stools in the ED were noted to be melanotic and guaiac positive. He was seen by GI who were concerned about a possible upper GI bleed. He was started on a PPI gtt and home beta blocker and diltiazem were held. On the floor his hematocrit was trending down 32 -> 29 -> 27 so the patient was transfused 1 unit overnight on ___ . His hematocrit increased to 29 after the transfusion. GI performed an EGD on ___ which was notable for erythema and petechiae in the antrum compatible with gastritis, granularity and erythema in the duodenal bulb compatible with duodenitis, and blood was seen in the duodenum -- however there did not appear to be any sites of active bleeding. He was transitioned to PO BID high dose PPI. He was dizzy with ambulation and noted to have a hematocrit of 26 on ___ so he was transfused 2 units. Post transfusion hematocrit was 31. GI repeated EGD on ___, which again did not identify a source of active bleeding. Serial hematocrits were checked and were noted to be stable (___) in the day prior to discharge and on the day of discharge. The patient will f/u with PCP to have another CBC checked in the coming days. Patient will be seen by ___. # Right shoulder pain, likely muscle sprain: The patient developed new right shoulder pain overnight on ___. His exam was not concerning for a septic joint or acute monoarticular process. He denied any trauma. His shoulder pain did not radiate or appear to be neuropathic. Shoulder x-ray was negative for acute process. Pain improved with tylenol. The patient also reported some mild lower extremity pain on the day of discharge. He was able to ambulate and was not significantly limited by the pain. ___ was negative for DVT. # CAD s/p CABG ___: Continued home dose of statin. Full dose aspirin was changed to 81mg aspirin given risk for bleeding. Initially held beta blocker and diltiazem in setting of acute bleed -- these medications were restarted prior to discharge. # Hypercholesterolemia: Continued home dose of statin.

17951605-DS-19

-You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent (if there is one). -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume all of your pre-admission medications and review your post-operative course with your PCP. -As advised, review your post operative course and medications with your pediatrician and your OB-GYN. Medications that you have been given may be excreted in your breat milk and this can effect your child. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and while nephrostomy is in place. No sports, water-immersion (pool/tub). NEPHROSTOMY TUBE INSTRUCTIONS FOR CARE---FOR ___ & FAMILY: Please leave RIGHT PCN tube capped. If there is increased RIGHT FLANK/BACK pain, the PCN may be uncapped and put to to external gravity drainage. Please monitor and record urine output from the PCN tube. Catheter flushing for troubleshooting only: If there are excessive blood clots or debris or thick urine within the connecting tubing, this can also be flushed as needed to clear from the stopcock into the drainage bag. Change dressing daily. Gently cleanse around the skin entry site of the catheter with povidone iodine or dilute hydrogen peroxide. Dry and apply sterile gauze dressing. Dressing should be changed daily for the first three days and then Q3days and prn saturation. Catheter security: a) Every shift, check to be sure the catheter, the connecting tubing and the drainage bag are securely attached to the patient and are not kinked. b) If the catheter appears to be pulling, please notify Interventional Radiology. c) If the catheter pulls out, please notify Interventional Radiology with in 8 hours. SAVE THE CATHETER for us to inspect. Do not throw it away. Call Angio for ANY catheter related questions or problems. ___ or Fellow/Resident (pager# ___ IF Catheter is attached to drainage bag for external drainage; please measure and record the net output every shift (or more often if the urine output is high).

Hospital course prior to transfer to urology service: ___ w/ h/o obstructive nephrolithiasis presents with right flank pain and fevers, found to have severe hydronephrosis ___ large ureteral stone, now s/p percutaneous nephrostomy. # Pyelonephritis / Obstructive nephrolithiasis: Patient's presentation with right flank pain, fevers, and pyuria is consistent with pyelonephritis. Evidence of severe obstructive nephrolithiasis qualifies this as complicated pyelonephritis. She received right percutaneous nephrostomy, spiked fever to 105.5 shortly after her procedure, likely representing an episode of transient bacteremia. Treated complicated pyelonephritis with IV ampicillin/sulbactam. She was admitted to the MICU for monitoring given her fever and tachycardia. Remained hemodynamically stable although with mild orthostasis by heart rate. Overnight febrile to 101. Pain at nephrostomy site treated with oxycodone. She was sent to the floors where she remained febrile and was started on ceftriaxone. # ___: Patient presents with an elevated creatinine of 1.4 (bl of 1.0). This may be related to her obstructive nephrolithiasis, though this is unlikely because the obstruction is unilateral. A more likely explanation is pre-renal azotemia in combination with recent NSAID use. She received 4L NS in the ED, a further 1L NS in the MICU given asymptomatic orthostasis. Her creatinine returned to normal. # Postpartum: The patient was one week post-partum, recovering well with scant vaginal bleeding. She was pumping breast milk, advised to discard after antibiotic administration. # Glucose management: check daily FSGs # FEN: regular diet, IVF as above, replete electrolytes # Prophylaxis: - DVT: heparin SC - GI: none required # Access: 2 PIVs # Restraints: not needed # Communication: Patient # Code: Full # Disposition: ICU pending clinical improvement Ms. ___ was transferred to the general urology service on ___ morning, ___, where she remained until discharge. She was prepped for operative intervention and taken to the OR on ___ where she underwent right ureteroscopy with laser lithotripsy, and placement of double-J stent, and basket extraction of stone. She tolerated the procedure well; see dictated note for full details. The right percutaneous nephrostomy was open to gravity drainage until she arrived back on the general surgical floor when it was capped. On POD1 she was takne to the ___ suite where they attempted PCN removal but because of a stone/blockage, this was terminated and she was sent back to the general surgical floor. She was voiding independently and pain was well controlled. She was therefore set up with visiting nurse services to facilitate care of the PCN and her transition home. She will follow up with Dr. ___ definitive management in the next ___ days. She was given a course of Keflex and additional pain medications with instructions to check in with her pediatrician and OBGYN clinicians.

19225984-DS-6

Dear Ms. ___, It was a pleasure taking care of you during your hospitalization at ___! Why did you come to the hospital? - Because you were having bloody stools What happened while you were in the hospital? - You were diagnosed with colitis of the left side of your colon. You were treated with antibiotics and improved. - You were tested for common bacteria that cause bloody diarrhea, but tests came back negative. What should you do after you leave the hospital? - Please complete a total of 7d of antibiotic therapy (last day ___ - Follow up with Dr. ___ Dr. ___ as scheduled - Please stick to a bland diet until your diarrhea improves. - If you notice any recurrent bleeding, worsening abdominal pain, intolerance of oral intake, please come back to the ED right away. We wish you the best! Sincerely, Your ___ Care Team

Ms ___ is a ___ with PMH of multiple sclerosis who presented to the ED with BRBPR and was found to have colitis, thought to be most likely infectious in etiology. Patient presented initially with 1 day of BRBPR. She reportedly passed a normal stool which was then followed by a large amount of red blood and clots and subsequent frequent bleeding. In the ED she was found to be hemodynamically stable, with stable Hgb, and CT consistent with colitis of the entire descending colon from the splenic flexure to the junction of the sigmoid colon. She had mild leukocytosis, normal lactate and CRP 42. Cdiff, Ecoli O157, Shigella, Campylobacter all negative. She improved with ceftriaxone and flagyl, had no further bleeding, and was switched to ciprofloxacin (trialed off flagyl and monitored overnight as she reported intolerance of the medication with severe nausea) with plan for a 7d course. She was afebrile during her hospitalization. Patient reported a history of a very similar episode in the past during a trip to ___, the etiology of which was never discovered which reportedly also involved the left colon. In discussion with GI, she was set up with close outpatient GI follow-up with Dr. ___ at ___ for re-evaluation and consideration of outpatient colonoscopy. With regards to her MS, her copaxone was held initially in the setting of her infection, but was restarted after patient improved clinically. Patient's Neurologist Dr. ___ was notified of admission per patient's request and agreed current symptoms are unrelated to her MS. ___, spironolactone was held in house but restarted on discharge due to improved po intake.

13085510-DS-7

Dear ___ ___ were admitted for abdominal pain and elevated liver enzymes. ___ underwent ERCP with sphincterotomy. No stones were found but sludge was removed. Your liver enzymes improved after the procedure. Your abdominal pain improved and ___ tolerated food. ___ will need to follow up with your PCP next week to check labs again. Thank ___ for allowing us to participate in your care Your ___ team

Ms. ___ is a ___ female with the past medical of cholelithiasis s/p CCY who presents with abdominal pain. #Abdominal pain #elevated LFTs #dilated CBD concerning for choledocolithiasis #s/p ERCP - initially there was concern for choledocolithiasis given constellation of findings included elevated LFTs and dilated CBD however patient underwent ERCP with no stones visualized, sludge removed. Patient was placed on ciprofloxacin after the procedure per ERCP recs. Patient will be on cipro for 5 days total. She was maintained on IVF overnight. Patient denied further abdominal pain the following day and tolerated a regular diet. LFTs improved. She was discharged home in stable condition. Transitional issues -LFTs down-trending on day of discharge although not full normalized, will need repeat labs with PCP ___ than 30 minutes were spent coordinating and providing care for this patient on day of discharge.

14829914-DS-12

Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted due to shortness of breath. Lab test revealed that you have iron deficiency anemia. The most common cause of which is blood loss. This is most likely due to chronic urinary blood loss however gastrointestinal blood loss is possible as well. You were transfused red blood cells and your numbers were stable after this. Your primary care doctor may want to do a colonoscopy or a bladder test after discharge. You were also evaluated by physical therapy who recommended rehab, which you did not want to do. You will go home with physical therapy instead. You also had some R jaw pain with chewing, most likely from irritation. There were no signs of infection. You were discharged with some pain medications as needed. Please follow up with your PCP and dentist if the pain persists. Thank you, Your ___ Team

Admitted with iron deficiency anemia. No evidence of GI losses so this may be due to chronic urinary blood loss. He was transfused one unit and improved symptomatically with this, but will need further urological work up and potentially colonoscopy as oupatient. Physical therapy evaluated patient and recommended ___ rehabilitation, however, patient was not agreeable and wished to go home with rehabilitative services. He was discharged in stable condition to outpatient follow-up with his outpatient providers. Discharged on percocet for 7 days(Q8H) for jaw pain, likely TMJ. #. Dyspnea on exertion: Pt. c/o dyspnea on exertion. CXR with no acute cardiopulmonary process to suggest pneumonia. Also no pulmonary edema on CXR, BNP elevated similar to prior value. PE unlikely in setting of normal oxygen saturation and another explanation. Etiology most likely anemia due to urinary blood loss. Repeat H+H stable and symptoms resolved post-transfusion. Pt worked with patient and recommended rehabiliation but patient deferred in preference of home with services. He will follow-up continued resolution of symptoms with his PCP as outpatient. #. Anemia: Normochromic normocytic anemia. Differential includes anemia of chronic disease or multifactorial anemia (mixed microcytic and macrocytic) given that patient has been macrocytic in the past. Guaic negative in the ED and on repeat on floor. Given normocytic anemia with low ___ represent mixed dx given history of macrocytosis. Maintained active type and screen. Monitored for s/s bleeding. Held on CBI given continud voiding. Urologicy plan per below. #. Hematuria: Intermittent for many years. Outpatient urologist called how did not recommend CBI unless stops urinating and inpatient urology consult. Hematuria had grossly resolved on hospital day #2. After discussion with outpatient urologist, Dr. ___, decided to defer further evaluation to outpatient setting given stability of symptoms. Will likely undergo cystoscopy with Dr. ___. # UTI UA floridly positive but difficult to interpret given hematuria. No leukocytosis, fever, dysuria. UCx grew yeast. # Jaw discomfort New onset, mild, day of admission. No sign of local infection (no erythema, LAD, leukocytosis). Has not tried pain reliever. Trop negative x1. Sx improved with acetaminophen. Improved hospital day #2. Patient prescribed percocet and will follow-up with his PCP as outpatient for further work-up.

16913649-DS-14

Dear Mr. ___, Why was I admitted? You were admitted because your blood pressure was low and you were found to have an infection in your lung called pneumonia. We were was also concerned that you had bleeding in your belly. What was done while I was here? You were treated with antibiotics for your pneumonia. We watched your bleeding from your belly very closely and looked down your throat with a camera. You have no active bleeding but are prone to bleeding from your underlying liver disease. Your liver disease is thought to be due to alcohol. You were monitored closely for withdrawal from alcohol and given medication to prevent this. In addition, we discovered that Your oxygen becomes low at night and you are diagnosed with sleep apnea. Therefore, we tried to have you sleep with a CPAP machine. Your oxygen also becomes low when you walk; this is probably due to your resolving pneumonia and your liver disease. What should I do now? You should take your medications as instructed. It is very important that you never drink alcohol again to avoid worsening your liver disease. If you continue to drink alcohol, you will be at very high risk of dying from liver disease or problems caused by liver disease. Make sure you seek support in maintaining sobriety through help from you social workers and doctors. You can try a group like AA if you think it would help you stop drinking. You will be discharged with home oxygen. You can use this when you are walking and your oxygen level becomes low. A nurse ___ come to your home and help to measure your oxygen levels to see how much you need. Because you have sleep apnea, you will need to wear oxygen at night at 4L per minute. You will need to see the sleep medicine doctors after leaving the hospital to get a formal sleep study so that you can obtain a CPAP machine. Once you get a CPAP machine, you must use it every night. You should attend your doctor appointments as below. We wish you the best! -Your ___ Care Team

Mr. ___ is a ___ year old male with alcohol abuse who presented with upper GI bleed and concern for septic shock. # Septic shock secondary to pneumonia: Patient presented with cough, leukocytosis, and CXR with consolidation concerning for pneumonia. No ascites for spontaneous bacterial peritonitis and hemoglobin relatively stable so unlikely blood loss. There was some initial concern for blood loss contributing to his shock, but his hemoglobin remained stable. He briefly required pressor support and was given volume resusictation for hypotension. He was treated with ceftriaxone and azithromycin for a total of 5 days. # Upper GI bleed: Patient had episodes of coffee ground emesis before presentation. His stool was noted to be brown on exam. Upper endoscopy performed on ___ showed evidence of portal hypertensive gastropathy but no varices. He was briefly treated with IV PPI and octreotide drip and later transitioned to PO PPI. # EtOH use disorder: Patient with significant drinking history at home, drinking up to 1 bottle of vodka per day. He was given a phenobarbital load and taper. He was also started on high-dose thiamine, folate, and multivitamin. Social work was consulted. # Nighttime desaturations: # OSA: Patient with nighttime desaturationa. Given body habitus and nighttime occurrences, most likely sleep apnea, but it has never been diagnosed formally. Sleep medicine consulted and recommended empiric CPAP while inpatient. Given persistent hypoxia (especially with ambulation), patient underwent ECHO with bubble study that showed moderately increased PASP with no evidence of right to left shunt. Given persistent hypoxia, patient discharged on home oxygen with plan for outpatient sleep study. Until he has CPAP at home, he should wear 4 LPM of O2 at night. He can also use supplemental oxygen if desaturating with ambulation activity; this can be titrated and weaned by a visiting nurse. # Alcohol hepatitis: Patient presented with elevated t.bili and coagulopathy with ___ Discriminant Function of 34 on admission, concerning for alcoholic hepatitis. He was not given steroids in the setting of active infection. Total bilirubin downtrended throughout admission. # Coagulopathy: INR elevation likely due to cirrhosis and poor nutrition. His labs were monitored daily without need for vitamin K. # Cirrhosis: No formal diagnosis but evidence of cirrhosis on RUQUS with splenomegaly, mild jaundice, and consistent history of alcoholic cirrhosis. MELD-Na 20. AST>ALT 2:1 so likely alcoholic. Workup for other causes of cirrhosis including elevated IgG, IgA as well as normal IgM. ___, AMSA, AMA, tTGA anti-tissue transglutaminase pending at time of discharge. Right upper quadrant ultrasound showed evidence of portal hypertension including hepatofugal portal venous flow and splenomegaly. Upper endoscopy on admission without varices but with portal hypertensive gastropathy. He will need outpatient Hepatology follow up with ___ screening and varices screening. # Thrombocytopenia: Most likely due to underlying liver disease. Blood smear without shistocytes and hemodynamically stable so DIC/TTP unlikely. Low fibrinogen likely in the setting of liver disease. Subcutaneous heparin was held given his low platelets but restarted once platelets were over 50. # anisocoria: Patient with dilated left pupil>right but no diplopia, eye pain, or other neuro symptoms. Left pupil sluggish to react. Rest of neurologic exam unremarkable so less concern for aneurysm/intracranial process. Patient was on ipatroprium which can cause anisocoria so it was discontinued with resolution of anisocoria. =====================

13681398-DS-15

Dear Mr. ___, It was a pleasure to care for you at the ___ ___. Why did you come to the hospital? - You were brought in to the hospital due to concerns for an abdominal infection. What did you receive in the hospital? - Because of how sick you were and your low blood pressure, we had to admit you to the intensive care unit. There you were found to have cholecystitis, or inflammation of your bladder. On ___, our interventional radiologist placed a tube to help drain your gallbladder. - You then had your gallbladder removed by our surgery team. - In addition, we found an infection in your blood related to your gallbladder, and treated it with antibiotics. - After starting antibiotics, you developed a small herpes outbreak around your lips. We treated this with a anti-viral medication. What should you do once you leave the hospital? - Please continue to take your medications as prescribed. - Please keep all your follow-up appointments We wish you the best! Your ___ Care Team

Mr. ___ is a ___ history of chronic pneumobilia thought to be secondary to sphincter of Oddi incompetence, seizure disorder, GERD, gout, who initially presented with worsening abdominal pain to ___, found to have pneumobilia transferred here for consideration of ERCP. Underwent HIDA found to have acute cholecystitis with E. Coli bacteremia. Underwent percutaneous cholecystostomy and narrowed to ciprofloxacin and flagyl. Then underwent laparoscopic cholecystectomy. ACUTE ISSUES ==================== #E. Coli bacteremia #Cholecystitis s/p percutaneous cholecystostomy s/p laparoscopic cholecystectomy #Septic Shock Patient initially presented with acute on subacute worsening abdominal pain, fevers, chills to ___. There with normal LFTs, however on CT A/P WO contrast found to have pneumobilia, cholelithiaisis, with RUQ U/S equivocal for cholecystitis. Given pneumobilia was transferred to ___ for consideration of ERCP. Found to have septic shock with E. coli bacteremia requiring pressors. Ultimately underwent HIDA confirming acute cholecystitis. In consultation with both ACS and ___, underwent percutaneous cholecystostomy. Was initially started on vancomycin for enterococcus coverage, cefepime, flagyl however narrowed to IV cipro based on sensitivities. Was weaned off of vasoactive support prior to transfer to floor. Transitioned to oral cipro, but given continued abd pain and borderline fevers, flagyl was added back on ___. Patient underwent uncomplicated laparoscopic cholecystectomy on ___. Patient had significant pain secondary to the drain and the procedure, and was controlled with oxycodone and lidocaine patch. #Pneumobilia With chronic pneumobilia for which patient underwent ERCP in ___ for work-up of pneumobilia. Showed duodenal ulceration however without evidence of enteric-biliary fistula. Also found to have duodenal stenosis on ERCP in ___ for which was unable to pass duodenoscope past stricture. Given known stricture, per ERCP during this admission deferred ERCP given would be unlikely to pass scope past the stricture. Underwent CT A/P WC which ruled out duodenal diverticulum perforation as cause of his pnuemobilia. Found to have contrast reflux into CBD suggestive of sphincter of oddi dysfunction/incompetence which is likely the cause of patient's known chronic pneumobilia. #Herpes re-activation Post percutaneous cholecystostomy, had oral HSV re-activation. Was treated with five day course of Valtrex. CHRONIC ISSUES ==================== #Gout Continued home allopurinol ___ PO QD #GERD Continued home omeprazole 20mg PO QD #Seizure disorder Continued home phenobarbital 64.8mg PO BID TRANSITIONAL ISSUES =================== [ ] Patient evaluated by occupational therapy as inpatient, complete MOCA evaluation with score of ___ suggestive of cognitive impairment. Arranged for neurocognitive follow up as outpatient This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated.

17549518-DS-17

* You were admitted to the hospital for replacement of your J tube and also for a cellulitis around the tube. You were placed on antibiotics which initially seem to be working. The j tube is not sutured in place but it's taped down securely so that the skin around the tube can heal and you can have it resutured in a day or 2. * You should resume your tube feedings but be very careful not to dislodge the tube. No showers until the tube is sutured in place. For now a sponge bath. * Keep a dry gauze over the insertion site. Dr. ___ see you in clinic tomorrow to look at the site and possibly suture. * Continue the Bactrim for a 10 day course. * If you have any fevers > 101, abd pain, chills or any other symptoms that concern you call Dr. ___ at ___

Mrs. ___ was evaluated by the Thoracic surgery service in the Emergency Room and admitted to the hospital for obcervation of her abdominal cellulitis. She remained afebrile and had a normal WBC. An attempt was made to drain an area adjacent to the J tube but the entire area was hard and erythematous. There was no fluctuant area. The J tube was replaced with an ___ Fr tube and placement was confirmed by xray. The tube was taped securely to an area that had no skin breakdown. Bactrim was started and the plan is for her to continue a 10 day course of oral Bacrtim. She will be seen tomorrow by Dr. ___ to assess the area and potentially suture the tube in place tomorrow in the Thoracic Clinic. She was discharged on ___ prior to her radiation appointment.

19995595-DS-14

Mr. ___- It was a pleasure taking care of you at ___ ___. You were admitted to the hospital after transfer from an outside institution for ruptured abdominal aortic aneurysm. You underwent emergent repair which required placement of a graft in you aorta. You also required an incision made into your abdomen to release the blood that collected after the rupture. Please follow the recommendations below to ensure a speedy and uneventful recovery. Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm Repair Discharge Instructions PLEASE NOTE: After endovascular aortic repair (EVAR), it is very important to have regular appointments (every ___ months) for the rest of your life. These appointments will include a CT (“CAT”) scan and/or ultrasound of your graft. If you miss an appointment, please call to reschedule. WHAT TO EXPECT: •Bruising, tenderness, and a sensation of fullness at the groin puncture sites (or incisions) is normal and will go away in one-two weeks CARE OF THE GROIN PUNCTURE SITES: •It is normal to have mild swelling, a small bruise, or small amounts of drainage at the groin puncture sites. In two weeks, you may feel a small, painless, pea sized knot at the puncture sites. This too is normal. Male patients may notice some swelling in the scrotum. The swelling will get better over one-two weeks. •Look at the area daily to see if there are any changes. Be sure to report signs of infection. These include: increasing redness; worsening pain; new or increasing drainage, or drainage that is white, yellow, or green; or fever of 101.5 or more. (If you have taken aspirin, Tylenol, or other fever reducing medicine, wait at least ___ hours after taking it before you check your temperature in order to get an accurate reading.) FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) •If you have sudden, severe bleeding or swelling at either of the groin puncture sites: -Lie down, keep leg straight and apply (or have someone apply) firm pressure to area for ___ minutes with a gauze pad or clean cloth. -Once bleeding has stopped, call your surgeon to report what happened. -If bleeding does not stop, call ___ for transfer to closest Emergency Room. •You may shower 48 hours after surgery. Let the soapy water run over the puncture sites, then rinse and pat dry. Do not rub these sites and do not apply cream, lotion, ointment or powder. •Wear loose-fitting pants and clothing as this will be less irritating to the groin puncture sites. MEDICATIONS •Take aspirin daily. Aspirin helps prevent blood clots that could form in your repaired artery. •It is very important that you never stop taking aspirin or other blood thinning medicines-even for a short while- unless the surgeon who repaired your aneurysm tells you it is okay to stop. Do not stop taking them, even if another doctor or nurse tells you to, without getting an okay from the surgeon who first prescribed them. •You will be given prescriptions for any new medication started during your hospital stay. •Before you go home, your nurse ___ give you information about new medication and will review all the medications you should take at home. Be sure to ask any questions you may have. If something you normally take or may take is not on the list you receive from the nurse, please ask if it is okay to take it. PAIN MANAGEMENT •Most patients do not have much pain following placement of the stent alone. You had an abdominal incision in addition to this, so recovery may take longer. Your puncture sites may be a little sore. This will improve daily. If it is getting worse, please let us know. •You will be given instructions about taking pain medicine if you need it. ACTIVITY •You must limit activity to protect the puncture sites in your groin. For ONE WEEK: -Do not drive -Do not swim, take a tub bath or go in a Jacuzzi or hot tub -Do not lift, push, pull or carry anything heavier than five pounds -Do not do any exercise or activity that causes you to hold your breath or bear down with your abdominal muscles. -Do not resume sexual activity •Discuss with your surgeon when you may return to other regular activities, including work. If needed, we will give you a letter for your workplace. •It is normal to feel weak and tired. This can last six-eight weeks, but should get better day by day. You may want to have help around the house during this time. ___ push yourself too hard during your recovery. Rest when you feel tired. Gradually return to normal activities over the next month. •We encourage you to walk regularly. Walking, especially outdoors in good weather is the best exercise for circulation. Walk short distances at first, even in the house, then do a little more each day. •It is okay to climb stairs. You may need to climb them slowly and pause after every few steps. BOWEL AND BLADDER FUNCTION •You should be able to pass urine without difficulty. Call you doctor if you have any problems urinating, such as burning, pain, bleeding, going too often, or having trouble urinating or starting the flow of urine. Call if you have a decrease in the amount of urine. •You may experience some constipation after surgery because of pain medicine and changes in activity. Increasing fluids and fiber in your diet and staying active can help. To relief constipation, you may talk a mild laxative. Please take to your pharmacist for advice about what to take. SMOKING •If you smoke, it is very important that you STOP. Research shows smoking makes vascular disease worse. This could increase the chance of a blockage in your new graft. Talk to your primary care physician about ways to quit smoking.

Mr. ___ is a ___ PVD s/p aortobifemoral bypass (___) who presented to the OSH with sudden onset of abdominal pain with CTA confirming p/w ruptured ___ anastomosis. He was transfused 4u rPBC 2uFFP in medflight with worsening hypotension. He was taken immediately to the OR where he underwent infrarenal ___ aortic cuff x4 w open abdomen (see op note for further details). He was transferred to the ICU in critical condition. He was started on fondaparinux prophylaxis due to his history of HIT. His respiratory status was tenuous and he frequently desatted and required increasing FiO2 while he remained intubated. Pulmonology was consulted and he was started on Lasix. During this initial post-op period his antibiotic coverage was adjusted as appropriate and he was started on tube feeds. He had a TTE that showed a PFO, but cardiology did not feel that any intervention was necessary at this time. He returned to the OR on POD4 for an abdominal washout, lysis of adhesions, and abthera placement. Following his second trip to the OR he had continued PRN Lasix requirements in the ICU. Two days following this he became febrile and his R IJ line had evidence of pus when it was removed, so a L IJ was placed. His fevers continued and he was taken back to the OR again for another washout and at this time his abdomen was closed. After this third trip to the OR he was persistently hypertensive and required nicardipine for BP control. In the following days the ICU team attempted to wean him from the vent but it was not well tolerated. He also went into Afib and was started on metoprolol. He continued to be febrile so a CTA of his torso was obtained, but it showed no obvious source of infection that would explain his fevers. On POD12 from his original operation he was extubated, but developed respiratory distress and needed to be reintubated. The following day he continued to be febrile so ID was consulted. The following day he went into Afib with RVR again and was started on a dilt drip. He had an echo for unexplained hypotension which didn't show a cardiac cause, but revealed a thrombus in his IJ. At this time he was also transitioned to bivalirudin for a short period before being restarted on fondaparinux. On POD16 from his original operation he was successfully extubated and his oxygen requirements were subsequently weaned down. His mental status then became one of his chief issues, as he would only occasionally follow commands and would not communicate in any meaningful manner. His fevers subsided and on POD18 he was transferred to the VICU. While on the floor in the VICU his blood pressure and mental status were his main issues. Vascular medicine provided assistance with his anti-hypertensive regimen, which needed to be adjusted multiple times for adequate control. Neurology was consulted for his altered mental status, which they attributed to delirium secondary to an extended ICU stay. Additionally, ACS was consulted for placement of a PEG tube as he would likely need long term feeding access due to his mental status. Ultimately, his family opted not to go through with the PEG so that they could avoid reintubation, so his feedings were continued with the Dobhoff. Neurology attributed his mental status to delirium related to his prolonged ICU stay, so delirium precautions were put in place. His mental status began to improve and he became more conversant and oriented as time progressed. Vascular medicine continued to be involved in his care and he was diuresed as necessary. On hospital day ___ he had a brief run of afib that was seen on telemetry, but had no further issues with afib afterwards. On hospital day ___ he was hemodynamically stable and his mental status continued to improve so he was determined to be fit for discharge. His discharge was ultimately delayed due to difficulties with finding rehab placement, but by hospital day 27 case management had found a rehab facility and he was transferred there with plans to follow up with vascular surgery clinic for re-imaging of his abdomen.

18773704-DS-9

Dear Mr. ___, It was a pleasure to take care of you at ___ ___. You were admitted because you fainted and broke several bones in your spine, which in turn hurt your spinal cord. Orthopedics performed surgery to stop the bones blocking your spinal cord, you were monitored for improvement, and you were discharged to rehab. Best of luck to you in your future health. Please take all medications as prescribed, attend all physician appointments as scheduled, and call a doctor if you have any questions or concerns.

Mr. ___ is a ___ year old man with h/o lung ___, currently on chemo, who is transferred from ___ after a syncopal event and subsequent paresthesias. His MRI revealed narrowing of C3-C5 with cord edema and compression, now s/p decompression surgery by ortho spine for ___. His delirium and post-syncope workup were managed and he was discharged to ___ rehabilitation. # Syncope: Patient had unwitnessed fall immediately prior to going to bathroom. The differential includes vasovagal syncope, carotid artery stenosis, orthostatic hypotension, arrhythmia, and structural heart disease. Echocardiogram and carotid ultraound did not reveal significant disease, orthostasis improved with IV fluids, and the patient had no further presyncopal episodes. Discharged to ___ rehab. # Cervical stenosis and paresthesias: Patient had multiple compression fractures status-post syncope with cervical cord compression. Orthopedic Spine surgery performed an operative decompression, he was maintained on C-spine collar. He had residual arm weakness and moderate to severe hand weakness. Patient was discharged to ___ rehab and outpatient orthopedic followup. # Urinary Retention: No spontaneous void in hospital and initial concern for urinary retention and so a Foley was placed. Patient had difficulty spontaneously voiding post-Foley being pulled. Unclear if purely delirium, spinal cord injury, or medication-related. Patient had intermittent straight catheterization, tamsulosin dosing was altered, and ultimately he was voiding spontaneously on the day of discharge without difficulty. # Lung ___: Was on weekly chemotherapy. He will follow-up with oncologist Dr. ___ ___. ___ ___. # Delirum: AM ___ noted disorientation to time and visual hallucinations. Remainder of neuro exam essentially unchanged, has not had BM in 3 days. Normal LFTs aside from albumin 2.6. Per wife ___, he does not have much to drink, maybe ___ drinks/week or 1 case of beer per month. Had 25 WBC and moderate leukocytes on UA. B12/TSH within normal limits. Ultimately, patient had bowel movements, void spontaneously, was maintained on delirium precautions, and his mental status improved. No antipsychotics were needed for agitation. # COPD: Currently presenting with rhonchi and wheezing on exam, requiring 3L of 02, though is not on 02 at home, though currently having difficulty bringing up sputum while in C-Collar. On spiriva at home and albuterol nebs Q4H PRN here. Denies increased cough or sputum production. Chest X-ray was negative. Patient given incentive spirometry ___/hour, counseled on smoking cessation, given oxygen therapy, and chest physiotherapy was performed to optimize pulmonary status. # Anemia: Labs notable for Hct drop from 34 on admission to 27 today. Hgb 10.8 to 9.2. No evidence of acute bleed in the ICU. ___ be secondary to post-operative losses combined with IVF. He is now s/p 2 units pRBC transfusion in the ICU. By the time of discharge, his H/H was improving, stool guaiac was negative, and pRBCs were never utilized. # Sinus tachycardia: Likely secondary to volume depletion, particularly in the setting of positive orthostatics this morning. Currently denying pain or pleurisy. He has been progressively more net negative in the ICU throughout the day with progressive increase in HR. Thus the most likely etiology is hypovolemia. Less likely secondary to PE, though he does have an 02 requirement now (see above). Patient was repleted with IV NS several liters and his heart rate improved. # Atrial fibrillation: Chronic stable issue in sinus during this hospital stay. Patient received no rhythm control and no rate control (sinus tachycardia felt to be physiologic). Maintained on home aspirin 81mg (held prior to surgery). # HLD: Chronic stable condition continued on home atorvastatin # T2DM: HbA1c 7% , needs repeat draw in 3 months. # Small Bilateral Pleural Effusions: Patient has no known metastatic disease. A CXR may be done to document resolution and should require further diagnostics/interventions if no resolution. # Code Status: Full Code confirmed. Emergency contact is wife ___ ___

16538698-DS-10

Dear Mr. ___, It was a pleasure to look after you. As you know, you were admitted with flank pain and signs of kidney infection on a CT scan. You were initially placed on intravenous antibiotics; both catheters (foley and nephrostomy tube) were exchanged. Urine cultures grew out a resistant pseudomonas, and for that reason, infectious disease team was consulted and made recommendations regarding changes in the antibiotic. You will be on Daptomycin and Zosyn through ___. Please do not take your atorvastatin until you complete the daptomycin to prevent a possible reaction. Given elevated blood pressures in the hospital, your amlodipine dose was increased to 10mg daily. Please take your medications as prescribed and follow up with your outpatient doctors as below. With best wishes, ___ Medicine

___ h/o lumbar spinal injury, marked b/l ___ weakness, multifactorial CKD stage IV (b/l Cr ~2.1-2.3), obstructive uropathy w/ chronic Foley, L ureteral stricture s/p L PCN, recent admission to ___ ___ for UTI (ESBL E.coli and Stenotrophomas, s/p treatment with Ceftaz/Bactrim) presenting with b/l flank tenderness, imaging suggestive of b/l pyelonephritis and cystitis. UCx grew Pseudomonas and Corynebacterium, for which he will complete two week course of Daptomycin/Zosyn. S/p Foley and L PCN exchange. # Bilateral pyelonephritis: # Urinary retention (with chronic Foley): # L ureteral stricture s/p L PCN: Mr. ___ was recently admitted ___ with E.coli/Stenotrophomonas UTI, treated with Bactrim/Ceftaz, with subsequent UCx in ___ again positive for those organisms (for which he was evaluated by ID, with decision not to treat given presumed colonization). He presented this admission with b/l flank tenderness, malaise, WBC 9.4, and a CT scan with fat stranding c/w cystitis and b/l pyelonephritis with no hydronephrosis. He underwent a Foley exchange and a L PCN exchange ___. He was initially restarted on Bactrim/Ceftaz and ID was consulted. When UCx from admission grew MDR Pseudomonas and Corynebacterium (not urealyiticum per micro lab), he was transitioned to Vanc/Cefepime (despite Pseudomonas with only intermediate sensitivity to cefepime). Subsequent sensitivity testing showed sensitivity with Zosyn and Ciprofloxacin; given prolonged QTC, Cefepime was transitioned to Zosyn. A midline was placed on ___ for access. Given inability to administer Vancomycin through a midline, ID recommended transitioning Vancomycin to Daptomycin (rather than replacing midline with PICC). He will continue a 2 week course of Daptomycin 300mg IV q24h and Zosyn 4.5g IV q12h (per ID pharmacy recommendations given urinary source and infeasibility of home q6 or q8h dosing), ___. He was discharged home with home infusion services; daughter ___ (a ___) will administer antibiotics. ID ___ is scheduled for ___. In addition, patient will transfer urology care to ___ for consideration of L ureteral stenting (appointment scheduled for this month). L PCN exchanged scheduled for ___ with ___. Of note, suppressive UTI therapy has been considered by ID and thought suboptimal (oral B-lactams inadequate, fosfomycin resistance on ___ cultures, suspected nitrofurantoin ___, inability to use methenamine given CKD, TMP/SMX wouldn't cover known organisms and would risk nephrotoxicity). # Acute on chronic CKD stage IV: # Non-gap metabolic acidosis: Followed by Dr. ___ for multifactorial CKD stage IV (thought due to AIN, obstructive uropathy, IgA nephropathy). Baseline Cr appears to be 2.1-2.3, 2.6 on admission, likely pre-renal, and improved to 2.3 at discharge. Home prednisone 2.5mg daily was continued. HCO3 19 on discharge; initiation of sodium bicarbonate deferred to outpatient nephrologist, Dr. ___ scheduled for ___. # Afib: # Possible CHB with junctional bradycardia: Patient with hx of afib on Coumadin with EKG suggestive of possible complete heart block with narrow junctional escape in the ___. I spoke with the patient's former cardiologist (Dr. ___ at ___, who last saw patient in ___ while the patient was hospitalized. Dr. ___ that this rhythm dates back to ___. Given stability, Dr. ___ PPM placement. ___ EP was consulted this admission and recommended outpatient ___ given stability. Patient remained asymptomatic and HD stable. Coumadin was held initially for procedures and subsequently resumed. Given CHADs2=1, he was not bridged. He received Coumadin 5mg on ___, 5mg on ___, 5mg on ___, and 3.5mg on ___. He was discharged on Coumadin 5mg daily and will resume Coumadin monitoring through the ___ Anticoagulation Management Clinic (___) after discharge. Next INR should be checked on ___ (1.6 on discharge) by ___. Patient requested that cardiology care be transitioned to ___ he was scheduled for ___ with Dr. ___ on ___. # Normocytic anemia: Hgb 11.9 on admission. Patient has chronic anemia dating back to ___ (b/l appears to be ~8), for which he has intermittently required transfusions and was recently seen by hematology (Dr. ___ on ___. Thought secondary to CKD and low Epo vs MDS. ___ was deferred, and Procrit 40,000u weekly was initiated (held in-house). Hgb stable while hospitalized, 10.2 on discharge. # Hyperkalemia: K peaked at 5.4 on ___, likely in setting of captopril initiation for hypertension (see below). Captopril was discontinued, and K improved to 5.2 on discharge. Would benefit from repeat BMP at PCP ___. # HTN: Intermittently hypertensive this hospitalization to SBPs 180s (without evidence of end organ damage) in absence of clear pain or anxiety. Home HCTZ was continued. Home amlodipine was uptitrated to 10mg daily, continued at discharge. Captopril was briefly trialed with plan to transition to long-acting ACE-I, discontinued for hyperkalemia as above. BPs improved, particularly on manual rechecks, and further titration of anti-hypertensives was deferred to patient's PCP and nephrologist. Of note, B-blockers should be avoided going forward given bradycardia. # Hypothyroidism: Continued home levothyroxine. # HLD: Held home statin on discharge pending completion of daptomycin course. To be resumed by PCP. # Anxiety: Continued home sertraline and lorazepam. # Gout: Continued home allopurinol. # Pain ___ prior crush injury Continued home oxycodone 10mg q6h PRN and oxycontin 10mg BID with hold parameters. # Pancreatic cyst: Incidental 1.5 cm cystic lesion in the uncinate process of the pancreas seen on CT. ___ as outpatient with non-emergent MRCP. ** TRANSITIONAL ** [ ] Daptomycin 300mg IV q24h and Zosyn 4.5g IV q12h, ___. [ ] INR on ___ call results to ___ Clinic ___ [ ] repeat BMP to monitor K at PCP ___ [ ] consider sodium bicarb initiation if metabolic acidosis persists [ ] resume statin after completion of daptomycin course [ ] trend BPs; adjust anti-hypertensives as needed [ ] MRCP for incidentally seen cystic lesion in uncinate process [ ] consideration of PPM

14515291-DS-15

Dear Mr. ___, You were admitted to ___ treatment and work-up of your chest pain. While you were here you were found to have elevated cardiac enzymes and changes in your EKG which were concerning for a type of heart attack called Non-ST segment myocardial infarction (NSTEMI). While you were here you underwent a cardiac cath, which showed that you have a blockage in one of your vessels in your heart. You had a stent placed in this vessel to help open it up. Also, while you were here you had an unwitnessed fall. You had a head CT scan which did not show any acute damage to your head from the fall.

___ with Type 2 diabetes mellitus complicated by neuropathy, multiple prior strokes and HCV who was transferred from ___ ___ with chest pain, EKG changes and biomarker elevations consistent with NSTEMI. # NSTEMI/CAD: Patient presented with chest pain, troponin elevation, and some EKG changes, all consistent with NSTEMI. He was treated with heparin gtt, nitro gtt, morphine, beta-blocker, ACE-I, aspirin, and statin (changed from simvastatin to atorvastatin) and was rendered pain free after arrival to the ___. He underwent echocardiography, which showed mild left ventricular hypertrophy, but no regional wall motion abnormalities. Since the patient occasionally became somewhat agitated and there was concern about his ability to cooperate by lying still during a prolonged procedure, cardiac catheterization was deferred for several days until the procedure could be performed under MAC coverage by anesthesia. Cardiac catheterization on ___ showed LVEDP 18-20 mm Hg, diffuse mild disease (including a 50% stenosis in the mid RCA), with a 90% ostial stenosis of the ___ diagonal branch. A DES was placed in this location, and he was discharged on full-dose aspirin and Plavix. # Fall: He had an unwitnessed fall on the morning of discharge. Head CT performed shortly thereafter was negative for any acute intracranial process. # Laboratory artifact: In retrospect, the initial laboratory values from ___ were likely artifactual, possibly diluted. The patient's Hct recovered too well and too quickly after 1 unit of pRBCs, and his hypokalemia and hypocalcemia also normalized very quickly.

16074558-DS-12

Dear Mr. ___, It was a pleasure taking care of you. You were admitted to ___ ___ for evaluation and treatment of abdominal pain. While you were here, we performed imaging of your abdomen and spine. This showed a lesion in the T9 bone, which is likely the cause of your pain. We treated you with pain medicines that help neurologic pain and also medicines that decrease inflammation in your stomach. You were treated with antibiotics to treat an infection in your stomach. Please continue these medications (Pantoprazole 40mg po 2/day, Clarithromycin 500mg 2/day, Amoxicillin 1 g 2/day) until ___. It is very important that you attend follow-up appointments and that you take your medicines as prescribed. We wish you the best in the future. Sincerely, Your ___ Care Team

SUMMARY ___ M with new MM (diagnosed ___, s/p XRT to T9 on ___, never had chemo) who presented with 2 months of epigastric pain, much worse in the past week. Initially, pain was thought to be ___ gastritis because of location, and EGD at OSH showed mild gastritis. Upon further examination, discovered that pain followed a T9 distribution from his vertebra, along ribs laterally, to his epigastrum. MRI on ___ showed T9 vertebral plana with canal narrowing, so pain is likely neuropathic from cord compression. Pain was controlled with Fentanyl patch, Gabapentin, and prn Dilaudid; patient also took Protonix & Ranitidine for his gastritis. He was found to be positive for H.pylori, and thus was started on triple therapy for 14 days for treatment. ACTIVE ISSUES #ABDOMINAL PAIN: Originally, the patient reported severe epigastric pain, which was thought to be ___ gastritis. EGD at OSH showed mild gastritis, but this did not fit with the severity of the patient's symptoms. Radiation effect was also considered, but the timeline didn't fit, because radiation gastritis/edema typically occurs ___ after XRT, then improves. Patient also received Protonix & Ranitidine for gastritis. He was found oto be H.pylori positive, with triple therarpy started ___ in pm:Pantoprazole 40mg po BID, Clarithromycin 500mg BID, Amoxicillin 1 g BID for ___ (stop date ___. #T9 Compression Fracture: Patient has tenderness along the T9 distribution, where he has known MM involvement. His was tender along his T9 spine, around both ribs, and ending in epigastric pain. MRI on ___ showed vertebral plana of T9 with focal kyphosis, which is the likely cause of patient's symptoms. He was assessed by orthopedics who saw no current indication for spine surgery. Given minimal low back pain and that he was ambulating well, he had no need for TLSO brace with plan to follow up with Dr. ___ in 1 month if pain persists. He was stated on gabapentin, continued this Gabapentin 300mg TID, which helped the patient's pain signifcantly. He was also continued on a Fentanyl patch and Dilaudid PO ___ mg PO/NG Q3H:PRN severe pain. # Multiple Myeloma: Patient was diagnosed in ___, and received XRT to T9 lesions in ___. He has never received chemotherapy. His lab studies shows IgG 1280, IgA 240, IgM 58. He was scheduled for appointments with his oncologists for the day after discharge. #CONSTIPATION: Patient was initially consipated given substantial narcotics needs for pain. He was given Docusate and Senna, with Miralax and Bisacodyl as needed, and resumed having regular BMs. # Hypertension: Given overalln normal blood pressures, home Lisinopril was held while in house.

19369785-DS-4

-You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed AND/or there may fragments/others still in the process of passing. -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. HOLD ASPIRIN and aspirin containing products for one week unless otherwise advised. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -You MAY be discharged home with a medication called PYRIDIUM that will help with the "burning" pain you may experience when voiding. This medication may turn your urine bright orange. -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and while ___ catheter is in place. IF YOU ARE DISCHARGED HOME WITH A FOLEY CATHETER: -Please refer to the provided nursing instructions and handout on Foley catheter care, waste elimination and leg bag usage. -Your Foley should be secured to the catheter secure on your thigh at ALL times until your follow up with the surgeon. -Follow up in 1 week for wound check and Foley removal. DO NOT have anyone else other than your Surgeon remove your Foley for any reason. -Wear Large Foley bag for majority of time, leg bag is only for short-term when leaving house.

Mr. ___ was admitted to urology service for nephrolithiasis management with a known right ureteral stone with obstruction and hydronephrosis causing acute kidney injury with a creatinine to 1.7. He was admitted, given intravenous fluids and expulsive therapy but without nephrotoxic agents like Toradol. He had taken a Pyridium provided by outside provider from prior hospital visit for same complaints. No stone was passed overnight or since admission so he was made NPO and taken to the OR where he underwent right ureteroscopy with laser lithotripsy and placement of a double-J stent. Mr. ___ tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. See the dictated operative note for full details. He remained in observation on the general surgical floor until voiding well and without complaint. He was subsequently discharged home. At discharge, Mr. ___ 's pain was controlled with oral pain medications and he was tolerating a regular diet, ambulating without assistance, and voiding without difficulty. He was given antibiotics and pain medications on discharge with explicit instructions to follow up as directed as the indwelling ureteral stent must be removed and or exchanged.

11184097-DS-20

Dear Mr. ___, You were admitted to the hospital because there was concern about possible bleeding in your brain from a recent stroke. You had an MRI which showed multiple recent strokes in different areas of the brain. There was some bleeding and tissue injury due to the recent strokes. You got an echocardiogram which showed you still have a very large clot in the heart, which could break off and cause more strokes. You were continued on aspirin but Plavix (clopidogrel) was stopped. You were started on Coumadin (or warfarin) as a blood thinner, which requires regular blood tests to make sure the levels are not too high or too low. You will follow up with your primary doctor (___) to measure your INR levels and adjust your Coumadin dose. We discussed your condition with your neurologist (Dr. ___ and your primary doctor (___). Follow up with your neurologist in the next ___ weeks. The neurology clinic will call you to set up an appointment. Follow up with your primary doctor (___) this ___ ___. Take your medications as prescribed. Thank you for allowing us to participate in your care. Sincerely, Your ___ Neurology Team

Mr. ___ is a ___ R handed gentleman with a past medical history significant for hyperlipidemia, htn, CAD, diabetes mellitus type II, and recently diagnosed R temporo-parietal infarct treated at ___. He presents today as a transfer from ___ after he had an "interval follow up ct scan" to evaluate his stroke which revealed concern for possible hemorrhage prompting transfer to ___. CT scan showed an area of hyperdensity in a linear/ribbon-like fashion concerning for possible SAH vs. Cortical laminar necrosis prompting transfer to ___. He was previously found with a large LV thrombus at ___ but he was not discharged on anticoagulation due to concern for hemorrhagic conversion. On this admission, his exam was mostly nonfocal except for anisocoria and mild inattention. MRI found "large subacute infarct involving the right parietal lobe, temporal lobe, and posterior insula, with hemorrhagic transformation, plus/minus pseudolaminar necrosis. Additionally, there was smaller right anterior lobe infarct with hemorrhagic transformation plus/minus pseudolaminar necrosis, also subacute, which appears to be older than 10 days. There was also patchy small subacute infarctions in the right posterior inferior cerebellar hemisphere. Small focus of cortical subacute infarction in the right posterior frontal lobe." TTE showed LVH, severe distal anterolateral hypokinesis, large LV apical thrombus. Plavix was held but ASA continued. Patient was started on Coumadin 5 mg daily. He understands importance of compliance with his meds & the need to monitor warfarin/INR closely. He also stated that his sister "keeps a very close eye on him". Spoke with his outpatient neurologist, Dr. ___ agreed with AC. Transitional Issues: []INR checks by VNS initially and at PCP ___ []PCP ___ on ___ at 12 pm. []Neurology ___ in next ___ weeks. Office will contact patient. 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. If no, reason why: 2. DVT Prophylaxis administered? () Yes - (x) No. Hemorrhagic transformation. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? () Yes - (x) No. If not, why not? Hemorrhagic transformation (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL = 104) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - atorvastatin 40mg () 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 - () No [reason (x) non-smoker - recently quit, on nicotine patch () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) 9. Discharged on statin therapy? (x) 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: () Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - If no, why not (I.e. bleeding risk, etc.) (x) N/A

15128244-DS-18

You were readmitted to the hospital on ___ with nausea and vomitting. You were also reported to have an elevated white blood cell count. You underwent a cat scan of the abdomen and you were found to have a fluid collection in the abdominal wall. You were started on intravenous antibiotics. You had the fluid collection drained and no bacteria was reported. Your white blood cell count has normalized and you are preparing for discharge home with the following instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items ___ pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips ___ days after surgery. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision site

The patient was admitted to the hospital 24 hours after discharge with nausea, vomiting, and abdominal pain. Her white blood cell count was reported at 20. Upon admission, the patient was made NPO, given intravenous fluids, and underwent cat scan imaging of the abdomen which showed an intra-abdominal fluid collection posterior to the surgical mesh measuring 13.0 x 2.4 cm. This was concerning for a developing abscess. The patient was started on intravenous vancomycin and zosyn. The patient then underwent ___ drainage of the fluid collection where 50 cc of sanguineous fluid was removed and sent for culture. The patient's vital signs remained stable and she was afebrile. She was tolerating a regular diet and voiding without difficulty. Her white blood cell count decreased to 10. Because the diarrhea persisted, a stool culture for c.diff was sent which was negative. The patient was discharged home with ___ services on HD #3 in stable condition. The patient was transitioned to oral antibiotics for 1 week. Post-operative instructions were reviewed. A follow-up appointment was made with the acute care clinic.

19813144-DS-22

Dear Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted with abdominal pain. You had a CT scan done, which did not show any abnormalities. There was no evidence of infection. Please make the following changes to your medications: # CONTINUE azithromycin 250 mg daily for 2 more days Continue all other medications as prescribed.

___ man with a history of cirrhosis secondary to hepatitis C and alcohol use who was admitted with fever and abdominal pain. Pt remained afebrile throughout his stay and his abdominal exam and imaging were not concerning for any acute process. .

13723320-DS-28

You were admitted with headache which was likely due to tapering steroids too quickly after whole brain radiation. Your symptoms improved with steroids. You also experienced some nausea and abdominal fullness that was in part due to steroids. You were started on some medications to help with these symptoms. This is the steroid taper recommended by radiation oncology: Decadron 4mg bid until ___. Then, Decadron 4mg daily for 3 days, then Decadron 2mg daily for 3 days, then Decadron 1mg daily for three days, then stop.

___ year old female with metastatic lung cancer with progressive brain metastases s/p metastasis resection and craniotomy ___ for brain met felt to be causing intractable nausea/vomiting who started fraction 1 of 5 of whole brain radiation therapy today ___ now presenting with chief complaint of nausea, vomiting and headache concerning for radiation induced edema (treatment effect). # nausea/vomiting/headache - Suspected sequelae of too rapid a taper of dexamethasone. Headache improved rapidly with steroids. Patient was discharged on an long dexamethasone taper. # Abdominal pain - Improved with a bowel movement. Started on ranitidine and simethicone for "fullness" with improvement in sypmtoms. On discharge she was able to tolerate a regular diet. # Lung cancer - plan had been to try nivolumab/immunotherapy but currently pursuing WBRT as recently found to have progression of intracranial mets; s/p resection of one large met earlier in ___. Received ___ days of whole brain radiation while hospitalized. Final day will be ___. She will follow up with oncology as an outpatient. # H/O DVT: continued on home lovenox.

16088475-DS-11

Dear ___, You were admitted to the hospital from rehab with confusion. This confusion was due to high levels of carbon dioxide in your blood. You were in the ICU and needed oxygen for a while, but improved by the time you left the hospital. The fluid around your pancreas became infected, and you were treated with strong antibiotics for two weeks. You had an additional drain placed, which helped drain the infected fluid. The will keep these drains until you are seen by the surgeons, flushing them with saline several times a day. You developed fluid around your heart and left lung during this admission. The fluid was drained from both places and did not come back. We did not find that exact cause of this, but it may have been related to the infection in your abdomen. Your diabetes was managed with insulin in the hospital. You are being discharged with diabetes supplies. Please inject 20 units of Lantus every night. Check your blood sugar before you eat/drink each morning and once after you eat/drink in ___. Bring these numbers with you to your PCP and they ___ adjust your insulin. You were started on a different blood thinner, Lovenox, this admission for you ___ and pulmonary embolism. You will inject this medicine twice a day. Surgery ___ with Dr. ___ able to be arranged in the hospital. Please call ___ to set up an appointment time in the next ___ weeks. It was a privilege to care for you in the hospital, and we wish you all the best. Sincerely, Your ___ Health Team

HOSPITAL COURSE =============== Mr. ___ is a ___ M with HTN, HLD, OSA, afib, PNET s/p distal pancreatectomy/splenectomy (___) w/ recent hospitalization (___) for pancreatic fistula and a PE, who presented from rehab with hypoxia and AMS, course complicated by pericardial and pleural effusions. ACTIVE ISSUES ============= # Pancreatic fistula # PNET s/p distal pancreatectomy/splenectomy: Patient presented to the hospital with two JP drains in place. He was persistently febrile on Zosyn (___), thus a third abdominal drain was placed by ___ on ___. Afterwards the patient was largely afebrile. ID was consulted and gave abx recs. Continued Zosyn for 2 week total course from drain placement on ___, last day ___. Repeat CT ___ showed persistent LUQ fluid collection. Repositioned LUQ JP drain with ___ on ___. Stable at discharge, still with 3 JP drains, will f/u with surgery in ___ weeks and continue tube feeds and clear liquids until that time. # Left Pleural effusion: During ___ admission patient had bilateral pleural effusions attributed to ___. However, now this admission was unilateral and persistent despite diuresis. S/p thoracentesis by IP on ___ with fluid studies suggestive of an exudative effusion, Gram stain negative for microorganisms. Cytology negative for malignant cells. Rheumatology feels unlikely systemic rheum disorder, more likely related to abdominal infection/inflammation. Negative ___, RF. Will f/u in ___ clinic. # Pericardial effusion: Patient presented with large pericardial effusion seen on admission with tamponade physiology. Underwent pericardiocentesis on ___ with drainage of 470ml sanguineous fluid. Cytology without malignant cells. Total nucleated cells # ___. No recurrence of symptoms. # Prior PE # Atrial fibrillation: Diagnosed with both atrial fibrillation and PE during ___ admission, started on warfarin. During ICU course was on heparin gtt. Heparin gtt transitioned to Lovenox on ___. Will continue Lovenox ___ BID. Received Metoprolol Tartrate 25 mg PO/NG Q6H inpatient, transitioned to Metoprolol Succinate 100 mg PO/NG DAILY on discharge. CHRONIC ISSUES ============== # Chronic pain - Continued Acetaminophen 500 mg PO/NG Q6H:PRN Pain - Continued OxycoDONE Liquid 5 mg PO/NG Q4H:PRN - Continued OxyCODONE SR (OxyconTIN) 20 mg PO Q12H # Diabetes: Patient received Lantus 20U Nightly with Humalog sliding scale, BG still not completely controlled on discharged, BG ___, should be titrated up by PCP. # BPH: Admitted with Foley due to urinary obstruction with failed voiding trial last admission. Foley pulled ___, able to void. Continued tamsulosin 0.4 mg PO QHS. # HLD: Continued Simvastatin 20 mg PO/NG QPM. # GERD: Continued Pantoprazole 40 mg PO Q24H. RESOLVED ======== # Delirium: Multifactorial given medical problems above. # OSA # Hypercarbia: Presented with hypercapneic respiratory failure in the setting of an acute illness, encephalopathy, opioid use, shock, enlarging pericardial effusion, and persistent left pleural effusion. Intubated < 24 hours with intermittent BIPAP. Resolved, patient on room air by discharge. TRANSITIONAL ISSUES =================== [] PCP to follow up patient blood sugar, titrate up Lantus and/or short acting insulin if consistently hyperglycemic [] Patient to continue current tube feed regimen with only clear liquids by mouth [] JP drains #2 and #3 to be flushed 4 times a day with normal saline [] Appointments - PCP - ___ - ___ Pulmonology - Surgery ___ with Dr. ___ arranged. Patient to call ___ to set up an appointment time in the next ___ weeks. [] New medications - Metoprolol Succinate 200 mg PO DAILY - Enoxaparin Sodium 100 mg SC Q12H - Insulin (Glargine) 20 Units at Bedtime [] Stopped medications - Metoprolol Tartrate 50 mg PO Q6H - Creon 12 6 CAP PO Q8H - Diltiazem 30 mg PO Q6H - Warfarin I have seen and examined Mr. ___, reviewed the findings, data, and plan of care documented by Dr. ___, MD dated ___ and agree with the discharge summary and plan. ___, MD, PharmD Section of Hospital Medicine ___ ___ ___

12349077-DS-6

Dear Ms ___, It was a pleasure taking care of you during your hospitalization at ___. You were admitted because of your shortness of breath and recurrent pneumonia, which we treated with the same antibiotics you had been getting at home. While you were here, the bariatric surgery team was involved and removed fluid from your lap band, which improved your symptoms and will help decrease your risk of other pneumonias. You will remain on a bariatric diet for 3 weeks, when you will follow up with the bariatric team as below. While you were here, we were unable to take you off oxygen without your oxygen levels decreasing. Because of this, we did an ECHO (ultrasound) of your heart which revealed high blood pressure in the arteries in your lungs (pulmonary artery hypertension). You will need to follow up with the lung doctors (___) as below. You then had a right heart catheterization which showed that one of your valves is leaky; you will need to follow up with the heart doctors (___) as below. In terms of your medications: You should CONTINUE taking all your other medications as you had been doing prior to being hospitalized. In terms of your home oxygen, please use your pulse oximeter while you are at home. We would like your pulse oxygen to remain above 92%. While you do not feel short of breath when your oxygen saturation is low, please continue taking your albuterol inhaler as needed and keep your oxygen on.

___ yo female with hx of lap band ___, partial nephrectomy for ___, and several recent hospitalizations for PNA now presenting with shortness of breath and ___. # Shortness of breath- Patient complained of worsened shortness of breath, though improved since presentation to OSH. CXR demonstrated new opacity, OSH CT revealed multifocal nodular infiltrate in lower left lobe and lingula. She was started on a course of IV Vancomycin and Zosyn while hospitalized at ___ ___, per OSH records to finish on ___. However, vancomycin trough on ___ was 74, so vanco was discontinued. She did recieve Zosyn until ___ given continued inability to wean O2 (described below). She had a speech and swallow evaluation ___, where it was felt that her symptoms of reflux were consistent with post-prandial regurgitation in the setting of lap band, which improved per patient report after lap band fluid removal. 1cc was removed from the band on initial admission (in the ED) by bariatric surgery, and UGI study following this procedure revealed no obstruction. The patient's symptoms resolved to baseline, which she states is chronically mildly short of breath. However, she did continue to have an O2 requirement which proved difficult to wean, with continued desaturations to low ___ while ambulated on RA, so pulmonology was consulted. Initiated hypoxemia workup which included ABG which revealed pO2 57 PCO2 39 pH 7.49. Bglucan neg, antiGBM neg. ECHO was performed, revealing moderate pulmonary artery systolic hypertension; subsequent right heart cath demonstrated elevated right and left sided filling pressures and moderate to severe pulmonary hypertension. Additionally, rheumatologic workup revealed ___ neg, RF neg, ANCA neg, ___, antiCCP neg. Bronchoscopy or further imaging were deferred at this time. The patient was discharged satting >92% on 2L, and has follow up in place with cardiology, pulmonology, and will need follow up imaging in ___. # Hx lap band, anorexia- Pt underwent removal of 1cc from lap band; she tolerated the procedure well. As above, upper GI revealed no e/o leak or slippage on imaging. As above, her symptoms of reflux improved after the procedure, and she was maintained on a stage 3 bariatric diet while in house. # ___: While hospitalized, the patient's Cr was noted to be 2.9 (up from normal baseline 0.8-1.0). Bland urine sediment, UA negative. Elevated Cr was felt to be consistent with vancomycin associated toxicity in the setting of significantly elevated Vancomycin levels (trough 74). Vancomycin levels trended down to 7.9 at time of discharge. Cr initially trended upward to peak at 3.2, but came down to 2.3 at time of discharge. # Asthma- Patient was maintained on her home medications. #?history of IgG deficiency - In speaking with the patient's PCP, and mentioned in OSH records, the patient has a documented question of IgG deficiency. Workup was initiated while hospitalized with IGG 680* IGM 321 IGA 95. Levels of antiTB, antidiptheria, and antipertussis were obtained. # HTN- the patient's home betablocker and ASA were continued while in house. # CAD- per report pt with stent in ___, on ASA/B-blocker. Home simvastatin was discontinued upon admission given acute kidney injury, but was restarted upon discharge. # Code: full

12484308-DS-13

Mr. ___, It was a pleasure taking care of you at ___ ___. You were admitted with alcohol intoxication and pancreatitis. We gave you IV fluids, pain medicines, vitamins and medicines to help you detox safely. We slowly advanced your diet and you did well. It is important that you refrain from drinking alcohol to prevent this from happening again.

___ yo male with PMH notable for EtOH dependence, opiate dependence, EtOH cirrhosis p/w abdominal pain in the setting of recent 2 week EtOH binge, found to have transaminitis and elevated lipase consistent with alcoholic hepatitis and pancreatitis and in need of safe EtOH detox.

19280086-DS-19

INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - touch down weight Bearing in left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns Physical Therapy: TDWB in LLE ROMAT Treatments Frequency: ___ & Rehab

The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have periprosthetic fracture of L distal femur and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for Internal fixation L distal femur , which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to Rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is TWBB in the LLE, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.

17155395-DS-14

Dear Mr. ___, It was a pleasure taking care of you at the ___ ___. You were admitted for your dark stools, fatigue, and anemia due to bleeding in your gastrointestinal tract. We followed your blood counts closely and had the liver doctors ___. As you know, you were at increased risk for bleeding because of the aspirin and Plavix you are taking for your recent stent, which you must continue for the time-being (discuss this with your cardiologist). While here, you had a esophagogastroduodenoscopy (EGD) and colonoscopy to identify sources of bleeding, which did not show any area concerning for acute bleeding though there were large esophageal varices (which is a complication of liver disease). In order to keep your blood counts up, we gave you 6 units of blood. Your blood counts were stable the last 2 days of your hospital stay with non-bloody stools, both of which are reassuring that you are no longer bleeding. Unfortunately you will stay at continued risk of bleeding because of the medications you are taking for your stent, and therefore you must remain cautious for any sources of bleeding. With signs of bleeding or increasing weakness, you should seek medical care.

___ w several prior lower GI bleeds, NAFLD cirrhosis, pancytopenia, CAD s/p CABG & recent stents who p/w fatigue, melena ___ GIB now s/p ___ which did not show an active source.

17367952-DS-9

Dear Mr. ___, It was a pleasure participating in your care here at ___ ___. You were admitted for shortness of breath WHAT HAPPENED WHILE YOU WERE HERE: - Your shortness of breath resolved without intervention. It did not appear that you had residual pneumonia. - You had a run of fast heartbeat on the heart monitor. We did not see any signs of heart attack on your lab test or EKG. - You had episodes of feeling sweaty, so we kept you an additional night to watch you on the heart monitor. - We increased the dose of your metoprolol, to keep the heart rate down. We also decreased your dose of losartan so that your blood pressure doesn't drop when on the higher dose of metoprolol. WHAT YOU SHOULD DO AFTER YOU LEAVE: - Please follow up with your cardiologist, Dr. ___ the next week. - You will need a repeat ultrasound of your heart in about 2 weeks. - You will receive ___ of hearts monitor in the mail to monitor your heart rate. Please follow the instructions that come with the monitor. If you have questions, call Dr. ___ ___ they ___ be able to assist you with questions. We wish you the best. Sincerely, Your ___ Team

Mr. ___ is a ___ yo man with a history of CAD, inferior MI in ___ s/p DES to LCx, HTN, HLD, who was recently discharged on ___ with RUL CAP, on a course of levofloxacin, now returning with worsening shortness of breath for 3 days. # Dyspnea His dyspnea had resolved at the time of transfer to the floor. Possibly was related to recent URI symptoms (rhinorrhea, cough, congestion) a few days prior to dyspnea. Pulmonary edema was unlikely given euvolemic on exam, recent TTE with normal EF, BNP < 450. Pneumonia was also unlikely given no fever, leukocytosis, or sputum production. CXR with streaky opacities on L lung that could represent atelectasis or pneumonia, but this was in the setting of recent pneumonia 3 weeks prior. Antibiotics were held. Angina/ischemia was also unlikely given EKG without ischemic changes, non-exertional nature of dyspnea, and negative troponin. # Rhythm Abnormalities: new atrial bigeminy, SVT with aberrancy The patient has no documented history of arrhythmia. In the ED, the patient had episode of bradycardia, thought to be in the setting of metoprolol administration. EKG revealed new atrial bigeminy. He was asymptomatic. He was kept on telemetry monitoring after transfer to the floor. On the morning after admission, he developed a 23-beat run of SVT with aberrancy in the 150s. He was asymptomatic. EKG was unchanged from admission EKG with atrial bigeminy. Cardiology was consulted and recommended increasing metoprolol to 100 from 50, and decreasing losartan to 25 from 50. # Diaphoresis The morning after admission, the patient had two episodes of diaphoresis. The first was gradual onset and non-exertional. The second was when opening his window. He had no chest pain, palpitations, dyspnea, lightheadedness, or nausea. Troponin was negative and EKG was stable. He was therefore kept an additional night for monitoring on telemetry, as it was felt that this may have been related to SVT discussed above. # New murmur IV/VII holosystolic murmur with obliteration of S2 loudest over base. TTE on last admission without any valvular disease. Plan for outpatient follow up with ___ and repeat TTE with bubble study to assess for VSD as outpatient. # Hypertension - Losartan and metoprolol as above # CAD s/p PCI - Continued home ASA 81, atorvastatin 80, and metoprolol (dosing as above) CAD with IMI ___ with 95% proximal circumflex lesion treated with DES. LAD with ostial ___ eccentric calcified lesion, mid and distal mild diffuse disease. D1 moderate size vessel with moderate diffuse disease. # OSA - Continued CPAP in house # BPH - Continued home tamsulosin and finasteride =================================== TRANSITIONAL ISSUES =================================== [ ] Medication change: metoprolol increased to 100 from 50, losartan decreased to 25 from 50. [ ] Continue to titrate metoprolol and losartan as outpatient. [ ] Repeat TTE with bubble study to assess for VSD as outpatient. [ ] ___ of ___ cardiac monitoring will be followed up Dr. ___ #CODE: Full #HCP: ___ ___

15319609-DS-19

Dear Ms. ___, It was a pleasure to be part of your care. You were admitted to the hospital because you were having headaches, vomiting and erratic blood pressure at home. We were concerned that your recent brain bleeding having worsened. You received repeat head imaging which was evaluated by neurosurgery and they determined that no intervention was necessary. Your blood pressure remained quite variable during this admission. We adjusted your blood pressure medications to try to maintain your systolic blood pressure between 110 and 160. Please check your blood pressure at home and HOLD your labetalol dose if your systolic blood pressure is <120. If your blood pressure is dropping lower than systolic of 100 at home or rising higher than systolic 160 at home then please call your doctor. If you are falling down at home or your systolic blood pressure is greater than 180 please return to the hospital. Additionally, if your headaches worsen or you develop new weakness or changes in sensation, please seek medical attention immediately. Of note, your headaches or feeling of head "pressure" will take over several weeks to resolve. Please take Tylenol for your headache. Occasional doses of ibuprofen (<400mg) are ok, but this should not be taken daily as it has some risk of bleeding. We wish you the best, Your ___ Team

Ms. ___ is a ___ F h/o subdural hemorrhage on ___ (resolving on interval CT) now p/w worsening n/v, weakness, found to be neurologically stable, and now being admitted to medicine for optimization of her BP management.

15249401-DS-14

Dear Ms. ___, It was pleasure caring for you at ___. You were admitted with low sodium in your blood, probably related to your head injury and the hydrochlorothiazide you were taking. Your levels trended back to normal with fluid restriction, salt tabs, lasix, and stopping of the hydrochlorothiazide. Do not restart taking your hydrocholorothiazide unless a physician tells you to. Your subdural hematoma was found to be shrinking on CT of your head. Your scalp stitches were removed.

___ with hx of GERD, HTN with recent parafalcine hematoma in setting of mechanical fall, presenting with hyponatremia likely ___ SIADH. # Hyponatremia - Likely subacute. Not symptomatic. Improved slowly after nadir of 121. Her HA/LH have been present since her fall and are improving at time of discharge, and likely post-concussive. Likely was a mixed SIADH/volume picture on presentation, now only SIADH ___ SDH, CXR neg) after volume repletion. Renal was consulted, who recommended fluid restriction (1000 cc at discharge), salt tabs (stopped at discharge), and furosemide daily. Urine osms trend down. HCTZ was not restarted. She will have close PCP follow up and Na monitoring (___), as well as renal follow up. # Sinus sx: Treated with Flonase and saline spray. # Parafalcine Subdural Hematoma - stable per neurosurgery. Post-concussive symptoms continuously improved. Gait was stable. C-spine imaging was negative for gross injury. Restarted asa 81 per neurosurgery recommendations. Per neurosurgery, no indication for repeat imaging at this time. # Hypothyroidism: Continued levothyroxine. # HTN: Remained stable despite salt tabs. HCTZ was not restarted. Continued home lisinopril, increased dose to 40 mg to compensate for stopped HCTZ and new high salt diet. # GERD: Continued omeprazole. # HLD: Continued simvastatin.

18253112-DS-26

Dear Mr. ___, You came into the hospital because you were having fevers and chills and feeling very tired. We started you on broad spectrum antibiotics. You had multiple tests to look for infection including chest xray, right foot xray, abdominal CT scan, blood and sputum cultures which showed no evidence of infection. We had the podiatry team come evaluate your right lower extremity wound who felt it was not infected and recommended that you follow-up with your podiatrist when you leave the hospital. Your fever was most likely from a viral illness. You improved and your antibiotics were stopped because we couldn't find any source of infection, after which you continued to feel well. You were evaluated by physical therapy who felt you need physical therapy at home to help improve your transfers and safety at home. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. It was a pleasure taking care of you! Your ___ Care Team

___ with ESRD, COPD with 3L O2 requirement at baseline presents with chronic cough and new fevers,rigors and lethargy following dialysis. #Fever: On presentation to the ED, pt was afebrile, hemodynamically stable and sating 93% on 3L NC ___ no acute distress. Labs were notable for leukocytosis of 12.1, CRP 71, ESR 22. CXR showed bibasilar opacities consistent with atelectasis. On the floor, his max temp was 100.5 when he first arrived, but he defervesced without intervention and he remained afebrile throughout the rest of the admission. He was initially started on vanc/cefepime empirically for HCAP/bacteremia given comorbidities and significant health care exposure/HD. Blood cultures and sputum cultures had no growth. Noted to have R calcaneal ulcer that appeared to be at baseline with no purulent discharge or surrounding cellulitis. R foot x-ray showed no signs of osteomyelitis. Podiatry was consulted to evaluate, who had low suspicion for infection and recommended daily dressing changes and podiatry outpatient f/u. Wound culture grew flora and sparse growth of pseudomonas thought to be colonization. CT abd/pelv w/o IV contrast showed no acute abnormality. He was noted to have an intermittent systolic murmur thought to be a flow murmur, and given lack of blood culture growth no TTE was performed. Leukocytosis resolved. Antibiotics were discontinued given lack of culture growth without subsequent fever or symptoms, so fevers were attributed to likely viral illness. He was evaluated by ___ who recommended home ___. # ESRD Continued with hemodialysis on ___, ___ schedule. #DM: Managed on home regimen of glargine 60u BID as well as lispro sliding scale coverage. Noted to have an episode of fasting hypoglycemia with blood sugar ___ the ___ resulting ___ need to hold home glargine dose. Continued on home dose of glargine on discharge to be further modified as outpatient as needed. # CAD: continued ___, ___ (pt continues to take at home despite NSAID listed as allergy, resumed yesterday) metoprolol and atorvastatin . # Restrictive Lung Disease/COPD: Continued home oxygen of 3L and home inhalers. TRANSITIONAL ISSUES: -Noted to have episodes of morning hypoglycemia on current insulin regimen of glargine 60units BID, which per pt he and his wife modify based on his blood sugar levels. Please f/u appropriate insulin dosing as an outpatient. -To continue outpatient hemodialysis with ___ and ___ schedule (last HD on ___. -Discharged with home physical therapy. -Needs f/u ___ ___ clinic ___ days after discharge -Noted to have mild thrombocytopenia to 118 likely ___ setting of viral syndrome, please follow with repeat CBC as outpatient -Code: Full Code -Contact: ___ (Wife, HCP): ___

14834613-DS-18

Activity • We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. • You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. • No driving while taking any narcotic or sedating medication. • If you experienced a seizure while admitted, you are NOT allowed to drive by law. • No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications • Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. • You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: • You may have difficulty paying attention, concentrating, and remembering new information. • Emotional and/or behavioral difficulties are common. • Feeling more tired, restlessness, irritability, and mood swings are also common. • Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: • Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. • Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. • There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: • Severe nausea and/or vomiting • Extreme sleepiness and not being able to stay awake • Severe headaches not relieved by pain relievers • Seizures • Any new problems with your vision or ability to speak • Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: • Sudden numbness or weakness in the face, arm, or leg • Sudden confusion or trouble speaking or understanding • Sudden trouble walking, dizziness, or loss of balance or coordination • Sudden severe headaches with no known reason

Mrs. ___ is a ___ year old female S/P pipeline embolization of left PCA aneurysm with Dr. ___ on ___ who presents with severe headache and nausea and vomiting. A NCHCT was performed and demonstrated a thrombosed aneurysm. An MRI was performed to assess patency of the stent and did not show any occlusion, hemorrhage, or infarct. On HD 1 the patient continued with headache and was started on Dexamethasone for headache control. She continued on Brilinta and Aspirin. The patient remained neurologically and hemodynamically stable. Her nausea and headache improved. She was discharged home in stable condition on HD2.

19007931-DS-7

Dear Mr. ___, It was a pleasure taking care of you during your hospitalization at ___. You came to the hospital after you had fell and hit your arm. We found that your broke your left shoulder. The orthopedic doctors saw ___ and did not think you need surgery. We found that you were dehydrated, and we gave you fluid to replenish you. We did not give you your Flomax on the first day and then restarted it at a once a day dosing to make sure we prevent any further episodes of dizziness. You were evaluated by physical therapy after your fall, and they felt that over the course of your hospital stay you progressed to where you could go home with physical and occupational therapy services. Please follow up with your primary care doctor who can help ___ on the above issues and continue to work on getting stronger. We wish you the best. Sincerely, Your ___ Care Team

for Outpatient Providers: Mr ___ is a ___ male with CLL on ibrutinib, CAD/HLD with NSTEMI in ___, non-ischemic cardiomyopathy, CKD stage III, depression, presenting with presyncope and fall with humeral fracture, with elevated troponin, CK and ___. Patient's humeral fracture was treated non-operatively. He was fluid resuscitated to good effect, with normalization of Cr and CK. His troponin downtrended on repeat; CK-MB was normal, ECG was unremarkable and patient was asymptomatic throughout. Patient was followed by ___ and felt safe to go home with services.

11358644-DS-15

Dear Ms. ___, It was a pleasure caring for you at ___ ___. You came to the hospital with shortness of breath, fatigue, and dizziness. We were concerned for pneumonia and treated you with IV antibiotics. A CT of your chest showed no sign of pneumonia, so antibiotics were stopped. You had a bronchoscopy to better understand what is causing your symptoms. The results of these tests will be available by next week. This is likely progression of your underlying lung cancer. During your stay you had difficulty with anxiety. We recommend that you use your medications to help control this problem, which can make your breathing harder. Please discuss your anxiety with your therapist. While you were in the hospital, we noticed several short periods of irregular heartbeat called atrial fibrillation. You were previously on a medication called atenolol which we switched to a similar medication metoprolol, which will better help to control your heart rate. This irregular heartbeat can put you at risk of forming blood clots, which increases your risk of stroke. You had a blood clot in your heart in ___ for which you were treated with Lovenox. To avoid forming similar clots, you decided to start taking a blood thinning medication called coumadin (warfarin). This medication requires regular monitoring that can be done by the Rehab facility. Dr ___ ___ help manage this medication after you leave the facility. Thank you for allowing us to participate in your care.

___ with a history of b/l breast cancers s/p mastectomies ___, ___, LUL NSCLC (___) s/p lobectomy and RUL NSCLC (___) s/p CK therapy, left atrial clot on ASA, h/o BPPV, p/w worsening sx of profound fatigue, shortness of breath and dizziness, found to have multifocal pneumonia and progression of lung cancer as well as newly diagnosed afib with RVR.

17434499-DS-37

Dear Ms. ___, It was a pleasure taking care of you during your hospital stay at ___. You were admitted to the hospital for abdominal pain after a procedure by our interventional radiologists. While here, you underwent drainage of a peritoneal cyst with some fluid removal and started to have relief of your pain. We continued to monitor you until you were able to eat or drink, and your pain was controlled. In addition, you had urinary retention. You were periodically bladder scanned, and your bladder was drained with a straight catheter. We wrote a prescription catheters for you to be able to self-cath at home. Please return to the hospital if you have worsening abdominal pain, fevers, nausea, vomiting, diarrhea, pain with urination, or blood in your urine. Please continue to follow up with your primary care physician and your your specialists upon discharge from the hospital. Take Care, Your ___ Team.

Ms. ___ is a ___ year old woman, with past history of UC s/p colectomy with ileal pouch anal anastomosis, PSC, SBO, depression, GERD, Bipolar disorder, PTSD, now presenting with RLQ abdominal pain, urinary retention, concerning for symptomatic peritoneal cyst. . >> ACTIVE ISSUES: # Peritoneal Inclusion Cyst: # Abdominal Pain: Patient has had an inclusion peritoneal cyst for the past several months, as documented by MRE during past hospitalization. Patient over the past several months has been having increased waxing / waning abdominal pain, with urinary retention / incontinence. Patient had seen her outpatient providers, underwent transvaginal ultrasound demonstrating 11 cm peritoneal inclusion cyst, and because of persistence of symptoms came to the ED. Patient was evaluated by ___, with laboratory values normal, and underwent ___ guided aspiration and drainage of the cyst (150 cc of straw colored fluid) prior to arrival to medical floor. Upon arrival, patient was maintained on pain regimen of IV ketorolac and acetaminophen, and intermittent oxycodone as needed because of significant pain. Patient continued to have urinary retention, which she has had a history of in the past, and thought to be related to the cyst abutting the bladder. Patient underwent repeat ultrasound to identify if any obstructive from the cyst itself, which continued to show an adnexal cyst with ? septation, however no significant obstruction. Outpatient providers contacted for continuity, and alerted that patient may require MRI for further evaluation if needed. Prior to hospital discharge, patient's pain was controlled, and was given short supply of oxycodone upon discharge. Patient was instructed on use given concomitant benzodiazapenes, and able to teach back understanding of safety and use. Further, case was again discussed with ___ to determine the interval for repeat imaging, and was informed that likely will be based on symptoms on whether to re-image in the future and consider further drainages or more definitive type solutions in outpatient setting. . # Urinary Retention: Thought to be multifactorial. Patient has been evaluated several times in the outpatient setting, and has had to straight catheterize in the past. As above, repeat transvaginal ultrasound without any significant obstruction even post-drainage, and thought to be combination of irritation from the cysts, urinary tract infection likely from self catheterization, as well as medications. Patient was started on oxybutynin as previously been prescribed and well-tolerated, and monitored on technique for self catheterization. Patient did have supplies that last until end of ___, and therefore will be renewed in the outpatient setting by her urogynecologist as needed. Follow up appointment arranged, and patient started to have improvement in symptoms upon discharge. . # Urinary Tract Infection, complicated: Patient was found to have mixed culture upon arrival to the ED, however with straight catheterization started to note worsening dysuria and repeat urine culture with E. coli (despite normal U/A). Patient was started on TMP-SMX for course of 5 days given complicated, and will follow up sensitivities and make changes upon discharge. Patient reported dysuria starting to improve. . # Ulcerative Colitis: Patient now s/p colectomy s/p ileal pouch and anal anastomosis, with mild pouchitis documented previously Patient was continued on hydrocortisone PR, budesonide, hyocyamine, and vedolizumab to be continued in outpatient setting. . # Anxiety / PTSD / Depression: Patient on complex regimen including diazapem, clonazepam, and lorazepam as an outpatient. Patient does also have other sedating and activating medications including hydroxyzine (used for itching given PSC), as well as fiorcet and Adderall. PMP verified during hospital stay, prescribed by outpatient providers. Patient continued on modified regimen, and continued on discharge. Discussed extensively that with additional oxycodone, patient should refrain from driving or other activities given additional sedative effects. Would consider re-evaluating regimen to tailor in outpatient setting. . # History of Right Ankle Sprain: Patient was noted to be using a cane during hospital stay, has had previous workup including Xray and MRI. Patient to have f/u in outpatient setting. . # Primary Sclerosing Cholangitis: Patient was continued on cholesytramine, and ursodiol. . # Vitamin D Deficiency: Patient continued on home vitamin D. . # GERD: Patient continued on home famotidine. . # ADD: Adderall on hold given that patient only utilizes at work. An out of school letter was presented to patient upon discharge. . >> TRANSITIONAL ISSUES: # Peritoneal Cyst: Please continue to follow up with outpatient GYN and urogynecology. Patient may require serial imaging of this in the future to be determined as an outpatient by her outpatient GYN. ___ require MRI imaging based on ultrasound report. # Benzodiazpenes: Patient is on several different medications that are similar class (clonazepam, diazepam, and lorazepam), please continue to address as an outpatient. # Patient with urinary retention while hospitalized, likely secondary to cyst as above vs. pelvic floor dysfunction (previously evaluated with urodynamic studies). Started tamsulosin in house, discharged with instructions to straight cath PRN. Should f/u with urology vs. gyn as outpatient. # UTI: Found to have E. coli in urine s/p catheterization Urine culture sent and started on TMP-SMX (end date ___. Please follow up urine culture for sensitivities. # Ulcerative Colitis: Patient to have f/u with outpatient GI to continue vedolizumab as outpatient. # PMP: PMP was checked prior to discharge to verify prescribers. Discussed with patient to limit use of narcotics especially with use of benzodiazapenes in outpatient setting. # CODE STATUS: Full # CONTACT: ___, ___

10644529-DS-12

-Please also reference the instructions provided by nursing on SUPRAPUBIC TUBE (SPT) catheter care, hygiene and waste elimination. -ALWAYS follow-up with your referring provider ___ your PCP to discuss and review your post-operative course and medications. Any NEW medications should also be reviewed with your pharmacist. -Resume your pre-admission medications except as noted on the medication reconciliation -You may take ibuprofen and the prescribed narcotic together for pain control. FIRST, use Tylenol and Ibuprofen. Add the prescribed narcotic (examples: Oxycodone, Dilaudid, Hydromorphone) for break through pain that is >4 on the pain scale. -The maximum dose of Tylenol (ACETAMINOPHEN) is 3- 4 grams (from ALL sources) PER DAY. -Ibuprofen should always be taken with food. If you develop stomach pain or note black stool, stop the Ibuprofen. Ibuprofen works best when taken “around the clock.” -For your safety and the safety of others; PLEASE DO NOT drive, operate dangerous machinery, or consume alcohol while taking narcotic pain medications. -Do NOT drive while Foley catheter is in place. -AVOID lifting/pushing/pulling items heavier than 10 pounds (or 3 kilos; about a gallon of milk) or participate in high intensity physical activity (which includes intercourse) until you are cleared by your Urologist in follow-up. Generally about FOUR weeks. Light household chores are generally “ok”. Do not vacuum. -No DRIVING until you are cleared by your Urologist -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery -You may be given “prescriptions” for a stool softener ___ a gentle laxative. These are over-the-counter medications that may be “health care spending account reimbursable.” -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -You may shower as usual but do not immerse in bath/pool while foley in place -Your Foley should be secured to the catheter secure on your thigh at ALL times until your follow up with the surgeon. -DO NOT allow anyone that is outside of the urology team remove your Foley for any reason. -Wear Large Foley bag for majority of time; the leg bag is only for short-term when leaving the house, etc. -___ medical attention for fevers (temp>101.5), worsening pain, drainage or excessive bleeding from incision, chest pain or shortness of breath.

___ male hx prostate cancer, DVT (LLE) POD4 from channel TURP, presented to the on ___ with hematuria. Had perforated bladder and developed abdominal compartment syndrome. Opened acutely at bedside after circulatory arrest, then taken to OR for exploration. Subsequently wound vac removed and abdominal wound closed by ACS on ___ and returned to ___. Extubated ___ ready for floor ___. Mr. ___ received ___ intravenous antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin, later converted to lovenox and restarted on Coumadin. With the eventual passage of flatus, diet was gradually advanced and the patient was transitioned from IV pain medication to oral pain medications. At the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. His drain was removed and his SPT care reinforced. Post-operative follow up appointments were arranged/discussed and the patient was discharged home with visiting nurse services to further assist the transition to home with OT, ___, Coumadin titration and waste elimination/care of the SPT.

12032671-DS-22

Dear Mr. ___, It was a pleasure taking care of you during your stay at ___. You were admitted for abdominal pain and diarrhea. You were found to have a fever and elevation in serum inflammatory markers concerning for infection and/or ___ flare. You were started on antibiotics and your symptoms improved. A colonoscopy showed no sign of active ___. By discharge, you were tolerating a regular diet with improved pain and decreased inflammatory markers. You should continue the antibiotics as prescribed and will be contacted by the ___ department for an outpatient follow-up appointment. Wishing you well, Your ___ Medicine Team

___ hx ___ on Remicaide, gastritis, h/o MV endocarditis ___ picc line infection, s/p cholecystectomy, s/p prior pancreatic stent no longer present, s/p appendectomy, presents with acute abdominal pain and diarrhea. Febrile to 102 with elevation in CRP prompting initiation of cipro/flagyl with no further fevers. C. diff negative. Pain managed with morphine. MRE initially concerning for proctocolitis but colonoscopy negative for inflammation or signs of CMV infection. By discharge, tolerating PO with improved pain. Plan for outpatient GI follow-up.

15751809-DS-3

Discharge Instructions Spinal Fusion Surgery •Your dressing may come off on the second day after surgery. •Your incision is closed with staples or sutures. You will need suture/staple removal. •Do not apply any lotions or creams to the site. •Please keep your incision dry until removal of your staples. •Please avoid swimming for two weeks after staple removal. •Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity •You must wear your brace at all times when out of bed. You may apply your brace sitting at the edge of the bed. You do not need to sleep with it on. •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •No contact sports until cleared by your neurosurgeon. •Do NOT smoke. Smoking can affect your healing and fusion. Medications •Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc… until cleared by your neurosurgeon. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. •It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •New weakness or changes in sensation in your arms or legs.

___ year old male with h/o IVDU, recent SBO with ostomy in ___ ___, chronic back pain with multiple disk herniations and recent hx T12 osteomyelitis treated with ___ weeks vancomycin in ___ with evidence of progression of osteomyelitis with associated with paraspinal asbcesses. He was transferred to the ED on the day of admission, ___ ___ for spine surgery evaluation. On ___, the patient underwent a MRI for possible ___ drainage of psoas abscess. On ___, the patient underwent a bilateral psoas muscle abscess drainage. On ___, the patient was transferred from medicine to neurosurgery. On ___, the patient underwent an ECHO which was negative for endocarditis. He underwent a spinal diagnostic angiogram later that day. On ___, the patient remained neurologically stable on examination. His Vanc trough was 22 and his Vancomycin was decreased to 1g every 12 hours. He noted new onset bilateral anterior thigh radiculopathy. He was started on Gabapentin BID dosing. ___: Neuro exam stable. To start Gabapentin TID dosing today. HCT downtrending to 23.7/7.2; Vanco level 18.6 ___: Transfused for H/H 6.___. Sent anemia labs. Re-consulted Medicine. ___ discontinued as medicine thinks there may be an internal bleed. ___: vanco 16.3, added bowel meds ___: 1 units packed cells, consent for surgery, t spine ct no contrast ___: OR, chest tube placed intraop ___: Chest tube to waterseal by Thoracics, CXR at 1000 with small PTX. AM CXR ordered per Thoracic. ___: Micro called- growing rare staph aureus in the vertebral body sent from OR on ___. Dressing removed, drain kept in place. Hct drop 3 pts today. ___: Patient is doing well and continues to work with ___. Pt was evaluated by CPS today who recommended stopping the PCA and starting him on Oxycodone 20mg PO Q 4 PRN pain and continuing his Oxycontin. His Hgb and HCT was 7.1 and 22.4, however he remains asymptomatic and we will continue to trend his levels. His JP put out 40cc overnight and was removed. ___: The patient's hemoglobin was 7.6, though he remained asymptomatic. His pain was well controlled. The vancomycin dosing was increased to 1250 q12 for trough 11.8 ___: His hemoglobin was 7.3, and again was asymptomatic. His back brace was available at bedside. ___: The hemoblgobin was up to 8.1, and hematocrit up to 25.2. An order was placed for a PICC line to be placed for longterm vancomycin treatment. The screening process for rehab was initiated. On ___ PICC line was placed. He was screened for rehab placement. His Hct/Hgb was stable. On ___ Patient remained stable awaiting insurance authorization for discharge to rehab. Home medications adderal, gabapentin and klonopin were restarted. On ___, the patient remained hemodynamically and neurologically stable with no overnight events. The patient was transitioned to PO pain medication. His insurance was accepted for rehab, and he is stable and ready for discharge to rehab for ongoing physical therapy.

19054301-DS-17

Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours**

The patient had a large left effusion on chest xray. His INR on admission was 2.4 and his coumadin was held. He was diuresed but there was no change in the effusion. His INR came down to 1.7 and he had a left thoracentesis and 2 liters of serosanguineous drainage was obtained. His breathing improved greatly. He remained in sinus rhythm throughout this hospitalization and his coumadin was discontinued. His blood sugars had been high and his metformin and glucophage were increased. He was discharged to home in stable condition with follow up appointments.

12188288-DS-25

Care Group ___ for IV Antibiotics . Please call the transplant clinic at ___ for fever of 101 or greater, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, liver drain and biliary drain sites have redness, drainage or bleeding, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, weight gain of 3 pounds in a day or any other concerning symptoms. . Bring list of current medications to every clinic visit. . You will need to have labwork drawn on ___ then twice weekly as arranged by the transplant clinic. Usually ___ and ___ . *** On the days you have your labs drawn, do not take your Tacrolimus until your labs are drawn. Bring your Tacrolimus with you so you may take your medication as soon as your labwork has been drawn. . Follow your medication card, keep it updated with any dosage changes, and always bring your card with you to any clinic or hospital visits. . Patient may shower with assist. Do not allow drain bag to hang freely. Keep biliary drain (PTBD)open. Change gauze dressing daily and as needed. Make sure to pin your drain to prevent accidently pulling out . Flush the PTBD drain with 5cc STERILE saline-FORWARD flush ONLY 3 times a day. DO NOT ASPIRATE/PULL back. . Continue IV antibiotics via the PICC line as ordered. No end date is established for the antibiotics. PICC line care per protocol . No tub baths or swimming . Avoid direct sun exposure. Wear protective clothing and a hat, and always wear sunscreen with SPF 30 or higher when you go outdoors. . Report consistently elevated blood sugars or blood pressure values above 160 or less than 110 systolic to the transplant clinic . Do not increase, decrease, stop or start medications without checking with the transplant coordinator at ___.

___ year old male h/o deceased donor liver transplant ___ for HCV cirrhosis and HCC with prolonged postoperative course complicated by hepatic artery thrombosis with hepatic lobe necrosis, early mild to moderate cellular rejection, infected biloma with recurrent bacteremia, multiple intraabdominal collections, several ___ interventions, and a right iliacus hematoma causing RLE compression paralysis, resolved with ___ drainage and multiple hospitalization. He was most recently admitted ___ for failure to thrive and scute SDH after several falls at home. He was also noted to have increased fluid collections and underwent ___ drainage exchange of existing left hepatic lobe drain with ___ APDL. He was continued on pre-admission Daptomycin and Cefepime. . He presented for CT scan on ___ to evaluate known collections. At the appointment, potassium was elevated to 7.3. He was sent to the ED for hyperkalemia management. In the ED he received calcium gluconate, insulin/dextrose, sodium bicarb, and 20 IV Lasix. Repeat K was 5.3. He reported eating a diet rich in tomatoes/red sauce and potatoes over the last few days. Bactrim was stopped and he was put on a low K diet. He was continually monitored on telemetry and there were no abnormalities. K on repeat checks was 5.3, 5.0 and 5.0. . On ___ he underwent Cholangiogram through existing right percutaneous transhepatic biliary drainage access, Exchange of the existing right percutaneous transhepatic biliary drainage catheter with a new 10 ___ anchor catheter. Sinogram through existing left drain and Exchange of left drain to a 10 ___ APD He remained afebrile after this procedure . On ___ he went back to ___ for Scout radiograph image of the indwelling drains, Antegrade cholangiogram through the indwelling anchor drain, Drain check injection through the existing percutaneous drain in the hepatic collection. Over the wire Pull-back cholangiogram via the right PTBD, Balloon angioplasty of the hepaticojejunostomy using a 6 mm Conquest balloon with Post HJ plasty antegrade cholangiogram and new right 10 ___ biliary internal-external drainage catheter. . The patient was also seen by ___ while inpatient. ___ recommended home for discharge after a right ___ brace was obtained that he was able to apply himself. . DM was also monitored and he was continued on Lantus and standing meal time doses of Humalog with sliding scale. Glucoses averaged 100s to 200. . LFTs were stable. Immunosuppression consisted on Prednisone 5mg daily and Tacrolimus dosed per trough levels. . Immuknow was sent on ___, result pending at time of discharge . Patient became increasingly neutropenic during the admission. He received 2 doses of 300 mcg each of filgrastim with good recovery of white count and the ANC. . Transitional issues: f/u weekly transplant labs f/u with ___ ... ID.... transplant surgery