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name unit no admission date discharge date date of birth sex f service medicine allergies omeprazole attending chief complaint dysphagia major surgical or invasive procedure upper endoscopy history of present illness w anxiety and several years of dysphagia who p w worsened foreign body sensation she describes feeling as though food gets stuck in her neck when she eats she put herself on a pureed diet to address this over the last days when she has food stuck in the throat she almost feels as though she cannot breath but she denies trouble breathing at any other time she does not have any history of food allergies or skin rashes in the ed initial vitals ra imaging showed cxr showed a prominent esophagus consults gi was consulted pt underwent egd which showed a normal appearing esophagus biopsies were taken currently she endorses anxiety about eating she would like to try eating here prior to leaving the hospital past medical history gerd hypercholesterolemia kidney stones mitral valve prolapse uterine fibroids osteoporosis migraine headaches social history family history htn father dementia father physical exam admission discharge exam vs po ra gen thin anxious woman lying in bed no acute distress heent moist mm anicteric sclerae ncat perrl eomi neck supple without lad no jvd pulm ctabl no w c r cor rrr s1 s2 no m r g abd soft non tender non distended bs no hsm extrem warm well perfused no edema neuro cn ii xii grossly intact motor function grossly normal sensation grossly intact pertinent results admission labs 27am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 27am blood ptt 27am blood glucose urean creat na k cl hco3 angap 27am blood alt ast ld ldh alkphos totbili 27am blood albumin imaging cxr impression prominent esophagus on lateral view without air fluid level given the patient s history and radiographic appearance barium swallow is indicated either now or electively neck x ray impression within the limitation of plain radiography no evidence of prevertebral soft tissue swelling or soft tissue mass in the neck egd impression hiatal hernia angioectasia in the stomach angioectasia in the duodenum biopsy biopsy otherwise normal egd to third part of the duodenum recommendations no obvious anatomic cause for the patient s symptoms follow up biopsy results to rule out eosinophilic esophagitis follow up with dr if biopsies show eosinophilic esophagitis brief hospital course ms is a with history of gerd who presents with subacute worsening of dysphagia and foreign body sensation this had worsened to the point where she placed herself on a pureed diet for the last days she underwent cxr which showed a prominent esophagus but was otherwise normal she was evaluated by gastroenterology and underwent an upper endoscopy on this showed a normal appearing esophagus biopsies were taken transitional issues f u biopsies from egd if results show eosinophilic esophagitis follow up with dr for management pt should undergo barium swallow as an outpatient for further workup of her dysphagia f u with ent as planned code full presumed medications on admission the preadmission medication list is accurate and complete omeprazole mg po bid discharge medications omeprazole mg po bid discharge disposition home discharge diagnosis primary diagnosis dysphagia and foreign body sensation secondary diagnosis gerd discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were hospitalized at you came in due to difficulty swallowing you had an endoscopy to look for any abnormalities in the esophagus thankfully this was normal they took biopsies and you will be called with the results you should have a test called a barium swallow as an outpatient we wish you all the best your team followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies omeprazole iodine and iodide containing products hallucinogens attending chief complaint left hip pain major surgical or invasive procedure status post left crpp history of present illness reason for consult femur fracture hpi female presents with the above fracture s p mechanical fall this morning pt was walking when dog pulled on leash pt fell on l hip immediate pain with movement denies head strike loc or blood thinners denies numbness or weakness in the extremities past medical history gerd hypercholesterolemia kidney stones mitral valve prolapse uterine fibroids osteoporosis migraine headaches social history family history htn father dementia father physical exam general well appearing female in no acute distress left lower extremity skin intact no deformity edema ecchymosis erythema induration soft non tender thigh and leg full painless rom knee and ankle fires silt s s sp dp t distributions pulses wwp brief hospital course the patient presented to the emergency department and was evaluated by the orthopedic surgery team the patient was found to have a left valgus impacted femoral neck fracture and was admitted to the orthopedic surgery service the patient was taken to the operating room on for left closed reduction and percutaneous pinning of hip 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 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 home with services 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 in the left lower extremity and will be discharged on lovenox for dvt prophylaxis the patient will follow up with dr routine a thorough discussion was had with the patient regarding the diagnosis and expected post discharge course including reasons to call the office or return to the hospital and all questions were answered the patient was also given written instructions concerning precautionary instructions and the appropriate follow up care the patient expressed readiness for discharge medications on admission the preadmission medication list is accurate and complete lactaid lactase unit oral daily prn calcium citrate d calcium citrate vitamin d3 mg unit oral daily discharge medications acetaminophen mg po q6h prn pain mild fever bisacodyl mg po pr daily prn constipation docusate sodium mg po bid enoxaparin sodium mg sc qhs rx enoxaparin mg ml mg subcutaneously nightly disp syringe refills oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg tablet s by mouth q4 prn disp tablet refills senna mg po bid calcium citrate d calcium citrate vitamin d3 mg unit oral daily lactaid lactase unit oral daily prn multivitamins tab po daily vitamin d unit po daily discharge disposition home with service facility discharge diagnosis left valgus impacted femoral neck fracture discharge condition avss nad a ox3 lle incision well approximated dressing clean and dry fires fhl ta gcs silt n distributions dp pulse wwp distally 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 take tylenol every hours around the clock this is an over the counter medication add oxycodone as needed for increased pain aim to wean off this medication in week or sooner this is an example on how to wean down take tablet every hours as needed x day then tablet every hours as needed x day then tablet every hours as needed x day then tablet every hours as needed x days then tablet every hours as needed x day then tablet every before bedtime as needed x day then continue with tylenol for pain do not stop the tylenol until you are off of the narcotic medication 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 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 do not drink alcohol drive a motor vehicle or operate machinery while taking narcotic pain relievers please take all medications as prescribed by your physicians at discharge continue all home medications unless specifically instructed to stop by your surgeon anticoagulation please take lovenox daily for weeks followup instructions

name unit no admission date discharge date date of birth sex f service urology allergies no known allergies adverse drug reactions attending chief complaint bladder cancer major surgical or invasive procedure robotic anterior exenteration and open ileal conduit history of present illness with invasive bladder cancer pelvic mri concerning for invasion into anterior vaginal wall now s p robotic anterior exent dr and open ileal conduit dr past medical history hypertension laparoscopic cholecystectomy six months ago left knee replacement six to years ago laminectomy of l5 s1 at age two vaginal deliveries social history family history negative for bladder ca physical exam a ox3 breathing comfortably on ra wwp abd s nd appropriate postsurgical tenderness to palpation urostomy pink viable pertinent results 50am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 50am blood plt 45am blood glucose urean creat na k cl hco3 angap 45am blood calcium phos mg brief hospital course ms was admitted to the urology service after undergoing robotic anterior exenteration with ileal conduit no concerning intrao perative events occurred please see dictated operative note for details patient received intravenous antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin the post operative course was notable for several episodes of emesis prompting ngt placement on pt self removed the ngt on but nausea emesis resolved thereafter and pt was gradually advanced to a regular diet with passage of flatus without issue with advacement of diet patient was transitioned from iv pain medication to oral pain medications the ostomy nurse saw the patient for ostomy teaching at the time of discharge the wound was healing well with no evidence of erythema swelling or purulent drainage her drain was removed the ostomy was perfused and patent and one ureteral stent had fallen out spontaneously was consulted and recommended disposition to rehab post operative follow up appointments were arranged discussed and the patient was discharged to rehab for further recovery medications on admission the preadmission medication list is accurate and complete heparin unit sc once start in o r holding area losartan potassium mg po daily atorvastatin mg po qpm levothyroxine sodium mcg po daily discharge medications acetaminophen mg po q6h docusate sodium mg po bid take while taking narcotic pain meds rx docusate sodium colace mg capsule s by mouth twice a day disp capsule refills enoxaparin sodium mg sc daily start first dose next routine administration time rx enoxaparin mg ml mg sc daily disp syringe refills nitrofurantoin monohyd macrobid mg po daily take while ureteral stents are in place rx nitrofurantoin monohyd m cryst macrobid mg capsule s by mouth daily disp capsule refills oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg tablet s by mouth q4h prn disp tablet refills atorvastatin mg po qpm levothyroxine sodium mcg po daily losartan potassium mg po daily discharge disposition extended care facility discharge diagnosis bladder cancer discharge condition wdwn nad avss abdomen soft appropriately tender along incision incision is c d i steris stoma is well perfused urine color is yellow ureteral stent noted via stoma jp drain has been removed bilateral lower extremities are warm dry well perfused there is no reported calf pain to deep palpation no edema or pitting discharge instructions please also refer to the handout of instructions provided to you by your urologist please also refer to the instructions provided to you by the ostomy nurse specialist that details the required care and management of your urostomy you will be sent home with visiting nurse services to facilitate your transition to home care of your urostomy resume your pre admission home medications except as noted always call to inform review and discuss any medication changes and your post operative course with your primary care doctor you have been prescribed ibuprofen please note that you may take this in addition to the prescribed narcotic pain medications and or tylenol first alternate tylenol acetaminophen and ibuprofen for pain control replace the tylenol with the prescribed narcotic if the narcotic is combined with tylenol examples include brand names tylenol w codeine and their generic equivalents always discuss your medications especially when using narcotics or new medications use with the pharmacist when you first retrieve your prescription if you have any questions use the narcotic pain medication for break through pain that is on the pain scale the maximum dose of tylenol acetaminophen is grams from all sources per day and remember that the prescribed narcotic pain medication may also contain tylenol acetaminophen so this needs to be considered when monitoring your daily dose and maximum if you are taking ibuprofen brand names include this should always be taken with food if you develop stomach pain or note black stool stop the ibuprofen please do not drive operate dangerous machinery or consume alcohol while taking narcotic pain medications do not drive and until you are cleared to resume such activities by your pcp or urologist you may be a passenger colace may have been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication discontinue if loose stool or diarrhea develops colace is a stool softener not a laxative you may shower days after surgery but do not tub bathe swim soak or scrub incision for weeks if you had a drain or skin clips staples removed from your abdomen bandage strips called steristrips have been applied to close the wound or the site was covered with a gauze dressing allow any steristrips bandage strips to fall off on their own days please remove any gauze dressings within two days of discharge steristrips may get wet no heavy lifting for weeks no more than pounds do not be sedentary walk frequently light household chores cooking folding laundry washing dishes are generally ok but again avoid straining pulling twisting do not vacuum followup instructions

name unit no admission date discharge date date of birth sex f service urology allergies no known allergies adverse drug reactions attending chief complaint abdominal pain distention nausea major surgical or invasive procedure interventional radiology placement of abdominal abscess drain history of present illness f with h o muscle invasive bladder cancer returning to the ed pod with abdominal pain nausea and distension she has been obstipated for nearly three days kub and ct scan notable for dilated loops air fluids and tapering small bowel without an obvious transition point labwork notable for and leukocytosis concerned for small bowel obstruction or an ileus in presence and leukocytosis she was re admitted for ivf bowel rest ngt decompression past medical history hypertension laparoscopic cholecystectomy left knee replacement six to years ago laminectomy of l5 s1 at age two vaginal deliveries s p robot assisted laparoscopic bilateral pelvic lymph node dissection robot assisted hysterectomy and bilateral oophorectomy for large uterus greater than grams with large fibroid laparoscopic radical cystectomy and anterior vaginectomy with vaginal reconstruction social history family history negative for bladder ca physical exam wdwn nad avss abdomen soft appropriately tender along incision incision is c d i stoma is well perfused urine color is yellow bilateral lower extremities are warm dry well perfused there is no reported calf pain to deep palpation bilateral lower extremities have pitting edema but no erythema callor pain pigtail drain has been removed dressing c d i pertinent results 58am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 45am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 13am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 06pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 06pm blood neuts bands lymphs monos eos baso metas myelos hyperse absneut abslymp absmono abseos absbaso 04pm blood ptt 58am blood glucose urean creat na k cl hco3 angap 45am blood glucose urean creat na k cl hco3 angap 00am blood glucose urean creat na k cl hco3 angap 06pm blood glucose urean creat na k cl hco3 angap 30am blood alt ast alkphos 58am blood calcium phos mg 45am blood calcium phos mg 30am blood albumin calcium phos mg iron 06pm blood calcium phos mg 30am blood caltibc ferritn trf 09am blood triglyc 30am blood triglyc 06pm blood lactate 00pm ascites creat amylase triglyc lipase 00pm other body fluid creat pm blood culture final report blood culture routine final citrobacter koseri final sensitivities sensitivities mic expressed in mcg ml citrobacter koseri cefepime s ceftazidime s ceftriaxone s ciprofloxacin s gentamicin s meropenem s piperacillin tazo s tobramycin s trimethoprim sulfa s aerobic bottle gram stain final gram negative rod s reported to and read back by on pm abscess pelvic aspiration final report gram stain final per 1000x field polymorphonuclear leukocytes per 1000x field gram negative rod s wound culture final no growth anaerobic culture final bacteroides fragilis group sparse growth beta lactamase positive am stool consistency not applicable source stool final report c difficile dna amplification assay final negative for toxigenic c difficile by the illumigene dna amplification assay reference range negative brief hospital course ms was admitted to dr service for management of ileus upon admission a nasogastric tube was placed for decompression on picc was placed and tpn started blood cultures grew gram negative rods and ceftriaxone was started on pt started to pass small amount of flatus ct scan demonstrated improving ileus but concern for possible urine leak and increased free fluid on a llq drain was placed by interventional radiology on pt passed clamp trial and ngt was removed pt continued to pass flatus and also started to have bowel movements on pt was advanced to a clear liquid diet repeat blood cultures were negative and positive blood culture from admission grew citrobacter diet was gradually advanced and ensure added iv medications were gradually converted to po and she was re evaluated by physical therapy for rehabilitative services she was ambulating with walker assistance and prepared for discharge to her facility tpn was continued up until day before discharge at time of discharge she was tolerating regular diet passing flatus regularly and having bowel movements medications on admission the preadmission medication list is accurate and complete atorvastatin mg po qpm levothyroxine sodium mcg po daily losartan potassium mg po daily acetaminophen mg po q6h docusate sodium mg po bid enoxaparin sodium mg sc daily nitrofurantoin monohyd macrobid mg po daily oxycodone immediate release mg po q4h prn pain moderate discharge medications ciprofloxacin hcl mg po q12h duration days last dose metronidazole mg po q6h duration days last dose senna mg po bid acetaminophen mg po q6h atorvastatin mg po qpm docusate sodium mg po bid enoxaparin sodium mg sc daily start first dose next routine administration time levothyroxine sodium mcg po daily lorazepam mg po bid prn anxiety losartan potassium mg po daily nitrofurantoin monohyd macrobid mg po daily oxycodone immediate release mg po q4h prn pain moderate discharge disposition extended care facility discharge diagnosis bladder cancer post operative ileus bacteremia citrobacter koseri and abdominal pelvic abscess bacteroides fragilis group requiring drainage discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions please also refer to the instructions provided to you by the ostomy nurse specialist that details the required care and management of your urostomy resume your pre admission home medications except as noted always call to inform review and discuss any medication changes and your post operative course with your primary care doctor acetaminophen and ibuprofen for pain control ciprofloxacin and metronidazole are new antibiotic medications to treat your infection continue for days through the maximum dose of tylenol acetaminophen is grams from all sources per day if you are taking ibuprofen brand names include this should always be taken with food if you develop stomach pain or note black stool stop the ibuprofen please do not drive operate dangerous machinery or consume alcohol while taking narcotic pain medications do not drive and until you are cleared to resume such activities by your pcp or urologist you may be a passenger colace may have been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication discontinue if loose stool or diarrhea develops colace is a stool softener not a laxative no heavy lifting for weeks no more than pounds do not be sedentary walk frequently light household chores cooking folding laundry washing dishes are generally ok but again avoid straining pulling twisting do not vacuum followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint dyspnea on exertion major surgical or invasive procedure none history of present illness patient is a year old woman s p robotic radical cystectomy with ileal conduit creation with postop course complicated by bacteremia and abscess lle dvt on prophylactic dosing lovenox who presents with dyspnea on exertion for past days briefly patient was initially admitted to the urology service from for robotic anterior exenteration with ileal conduit she was discharged to rehab on prophylactic dosing lovenox for month she was then readmitted from for ileus requiring ngt decompression tpn bcx grew citrobacter for which ctx was started ct showed intra abdominal interloop simple fluid collection and llq drain was placed by patient improved passing bms and tolerating po and was discharged on cipro flagyl she was also discharged on po bactrim for presumed uti though unclear if she actually took this during this admission she was noted to have new bilateral edema lenis at the time showed aute deep vein thrombosis of the duplicated mid and distal left femoral veins she was discharged on enoxaparin sodium mg sc daily she reports that her pcp started po 20mg daily and since then there has been improvement of the swelling per her report a repeat at the rehab facility was negative for dvt patient reports that she recovered well post operatively and was doing well at her assisted living facility up until a week ago when she began experiencing dyspnea on exertion she states that she typically is able to ambulate a block before stopping to catch her breath however in the past week she has been unable to take more than a few steps she states that it has become increasingly more difficult to ambulate from her bedroom to the bathroom when visited by the np her ambulatory saturation was noted to be in the with associated tachycardia to pallor and diaphoresis she endorses associated leg swelling left worse than right and she states that her thighs feel heavy she denies any associated chest pain fever chills pain with deep inspiration abdominal pain rashes dizziness lightheadedness in the ed initial vs were nasal cannula ed physical exam was recorded as patient resting comfortably with nc pursed lip breathing unable to speak in full sentences before becoming short of breath urostomy pouch in rlq stoma pink edema to bilateral lower extremities l r ed labs were notable for hb hct plt ua large wbc many bact epi trop neg x1 probnp normal cta chest showed extensive pulmonary embolism with thrombus seen extending from the right main pulmonary artery into the segmental and subsegmental right upper middle and lower lobe pulmonary arteries no right heart strain identified additionally there are smaller pulmonary emboli seen in the segmental and subsegmental branches of the left upper and lower lobes several pulmonary nodules are noted as noted previously with the largest appearing spiculated and measuring up to cm in the right middle lobe suspicious for malignancy on the previous pet ct re demonstration of left breast nodules for which correlation with mammography and ultrasound is suggested ekg showed nsr with frequent pac patient was given po ng ciprofloxacin hcl mg iv heparin unit iv heparin transfer vs were nasal cannula when seen on the floor she reports significant dyspnea with minimal exertion denies chest pain palpitations lightheadedness a ten point ros was conducted and was negative except as above in the hpi past medical history hypertension laparoscopic cholecystectomy left knee replacement six to years ago laminectomy of l5 s1 at age two vaginal deliveries s p robot assisted laparoscopic bilateral pelvic lymph node dissection robot assisted hysterectomy and bilateral oophorectomy for large uterus greater than grams with large fibroid laparoscopic radical cystectomy and anterior vaginectomy with vaginal reconstruction social history family history negative for bladder ca physical exam admission exam gen nad speaking in word sentences pursed lip breathing no accessory muscle use lying in bed eyes eomi sclerae anicteric ent mmm op clear cardiovasc rrr no mrg full pulses edema bilaterally with compression stockings in place no jvd resp normal effort no accessory muscle use lungs cta to anterior auscultation gi soft nt nd bs urostomy site does not appear infected msk no significant kyphosis no palpable synovitis skin no visible rash no jaundice neuro aaox3 no facial droop psych full range of affect discharge exam vitals 1l gen lying in bed in no apparent distress heent anicteric mmm cardiovascular rrr normal s1 s2 no right sided heave systolic murmur pulmonary lung fields clear to auscultation throughout no crackles or wheezing gi soft distended nontender bowel sounds present urostomy in place extremities no edema though left leg appears larger than right leg warm well perfused with motor function intact her left lower leg is wrapped pertinent results labs admission labs 40pm glucose urea n creat sodium potassium chloride total co2 anion gap 40pm ctropnt 40pm probnp 40pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 40pm plt count 40pm ptt discharge labs 55am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 55am blood glucose urean creat na k cl hco3 angap 55am blood calcium phos mg 15am blood caltibc ferritn trf 15am blood iron microbiology pm urine final report urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination enterococcus sp cfu ml predominating organism interpret results with caution sensitivities mic expressed in mcg ml enterococcus sp ampicillin s nitrofurantoin s tetracycline s vancomycin s imaging cxr impression hilar congestion without frank edema no convincing signs of pneumonia cta chest showed extensive pulmonary embolism with thrombus seen extending from the right main pulmonary artery into the segmental and subsegmental right upper middle and lower lobe pulmonary arteries no right heart strain identified additionally there are smaller pulmonary emboli seen in the segmental and subsegmental branches of the left upper and lower lobes several pulmonary nodules are noted as noted previously with the largest appearing spiculated and measuring up to cm in the right middle lobe suspicious for malignancy on the previous pet ct re demonstration of left breast nodules for which correlation with mammography and ultrasound is suggested impression interval progression of deep vein thrombosis in the left lower extremity with occlusive thrombus involving the entire femoral vein previously only involving the mid and distal femoral vein there is additional nonocclusive thrombus in the deep femoral vein the left common femoral and popliteal veins are patent the bilateral calf veins were not visualized due to an overlying dressing otherwise no evidence of deep venous thrombosis in the right lower extremity tte conclusions the left atrium is normal in size the estimated right atrial pressure is mmhg left ventricular wall thickness cavity size and global systolic function are normal lvef doppler parameters are most consistent with grade i mild left ventricular diastolic dysfunction right ventricular chamber size and free wall motion are normal the aortic valve leaflets are mildly thickened there is no aortic valve stenosis trivial mitral regurgitation is seen there is mild pulmonary artery systolic hypertension cxr impression compared to chest radiographs through heart size top normal lungs grossly clear no pleural abnormality or evidence of central lymph node enlargement brief hospital course ms is a woman s p robotic radical cystectomy omplicated by bacteremia and abscess lle dvt currently on daily lovenox who presents with dyspnea on exertion and dyspnea on exertion and found to have large pe and progression of dvt pe dvt likely due to undertreatment of known lle dvt with prophylactic dosing of lovenox given underdosing of lovenox this was not thought to be treatment failure and ivc filter was deferred she had no signs of right heart strain on imaging ekg exam tte showed no evidence of right heart strain she was treated with a heparin gtt then transitioned to treatment dose lovenox given malignancy associated thrombosis as noted in clot trial she is quite symptomatic and requires oxygen supplementation though improved during hospitalization please wean oxygen as tolerated pulmonary nodules known spiculated masses that were noted on ct in concerning for primary lung malignancy vs mets current ct showed stable nodules still concerning for malignancy she was evaluated by the thoracic team who recommended ct biopsy vs surveillance given her current pe dvt the family and the patient decided for surveillance at this time they will follow up with her primary care provider enterococcal uti she was noted to have rising wbc in the setting of ucx from urostomy growing enterococcus given her rising leukocytosis we proceeded with treatment she was started on iv ampicillin and transitioned to macrobid based on sensitivies leukocytosis improved on antibiotics she should complete a day course day day normocytic anemia no signs of bleeding or hemolysis hb dropped to nadir of stable at discharge at iron studies consistent with likely combination iron deficiency anemia and anemia of chronic disease with low iron but elevated ferritin and low tibc would recommend checking again as outpatient and work up as needed swelling likley multifactorial including venous insufficiency as well as known lle dvt she responded quite well with compression stockings hx of bladder cancer s p turbt high grade tcc t1 no muscle identified then in pelvic mri showed bladder mass invasion perivesical soft tissue anterior vaginal wall on right c w t4 lesion in underwent robotic tah bso lap radical cystectomy and anterior vaginectomy with pathology showing pt2b node and margins negative no plan for any further therapy at this time per dr the patient is safe to discharge today and 30min were spent on discharge day management services transitional issues she will need follow up chest ct for pulmonary nodules in months to complete day course for uti with macrobid day continue oxygen therapy and wean as tolerated to maintain o2 sat please check cbc on to ensure stability of h h and demonstrate resolution of leukocytosis hcp son dr medications on admission the preadmission medication list may be inaccurate and requires futher investigation acetaminophen mg po q6h docusate sodium mg po bid enoxaparin sodium mg sc daily start first dose next routine administration time levothyroxine sodium mcg po daily atorvastatin mg po qpm losartan potassium mg po daily oxycodone immediate release mg po q4h prn pain moderate lorazepam mg po bid prn anxiety senna mg po bid discharge medications nitrofurantoin monohyd macrobid mg po q12h last day enoxaparin sodium mg sc q12h start today first dose next routine administration time lorazepam mg po qhs prn insomnia rx lorazepam mg one half tab by mouth qhs prn disp tablet refills acetaminophen mg po q6h atorvastatin mg po qpm docusate sodium mg po bid levothyroxine sodium mcg po daily oxycodone immediate release mg po q4h prn pain moderate rx oxycodone mg tablet s by mouth q8h prn disp tablet refills senna mg po bid discharge disposition extended care facility discharge diagnosis pe discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions ms it was a pleasure taking care you during your admission to you were admitted for a clot in your lungs and leg you were treated with a blood thinner you will need to continue the blood thinner you were also treated for a urinary tract infection for your pulmonary nodules you should follow up with your primary care doctor followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint subjective fevers lethargy and bloody drain output major surgical or invasive procedure for the large pelvic fluid collections ct guided repositioning of existing drain and placement of an additional drain removal of more recently placed drain history of present illness ms is an with pmh of hypertension and bladder cancer high grade invasive urothelial carcinoma pt2b s p tah bso radical cystectomy w ileal conduit c b intra abdominal infection and pelvic fluid collection s p guided drain placement who presents with days of generalized malaise and day of fevers patient underwent guided jp drain placement for intra abdominal fluid collection and infection thought to be complicated of recent tah bso radical cystectomy and pelvic lymph node biopsy this procedure was done on over the past days she had noticed generalized malaise and day of fever w rigors to tmax at home she notes that the drainage from her intra abdominal drain is darker but her urostomy output has been unchanged she notes some associated mild llq pain she denies diarrhea brbpr rash cough headache neck stiffness she presented initially to osh where she was evaluated with bcx and drain culture and was started on zosyn and vancomycin and given 650mg acetaminophen she was transferred to for further management past medical history hypertension s p lap chole s p left knee replacement s p laminectomy of l5 s1 at age bladder cancer high grade tcc t1 diagnosed in then pelvic mri w invasion into bladder wall perivesical soft tissue and anterior vaginal wall c w t4 staging s p hysterectomy and bilateral oophorectomy for large uterus w fibroid s p laparascopic b l pelvic lymph node resection s p radical cystectomy and anterior vaginectomy with vaginal reconstruction with ileal conduit creation course complicated by bacteremia and development of intra abdominal fluid collection no s p drain placement by h o lle dvt and pe on lovenox social history family history negative for bladder ca physical exam admission exam vital signs po l lying ra general alert oriented no acute distress heent sclerae anicteric mmm oropharynx clear cv rrr normal s1 s2 systolic murmur rubs no rubs gallops lungs clear to auscultation bilaterally no wheezes rales rhonchi abdomen soft non tender non distended bowel sounds present ileal conduit drain in rlq with pigtail drain in llq draining dark sang fluid gu no foley ext warm well perfused nonpitting edema lle neuro cn2 grossly intact moving all extremities spontaneously discharge exam vital signs ra general axo x3 heent sclera anicteric neck supple lungs clear to auscultation bilaterally no wheezes rales rhonchi on anterior auscultation cv regular rate and rhythm normal s1 s2 iii vi sem abdomen bs ileal conduit draining clear yellow urine has one llq drain in place draining serosanguinous fluid ext warm well perfused pulses no clubbing cyanosis or edema pertinent results admission labs 10pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10pm blood neuts lymphs monos eos baso im absneut abslymp absmono abseos absbaso 10pm blood ptt 10pm blood ret aut abs ret 10pm blood glucose urean creat na k cl hco3 angap 10pm blood alt ast alkphos totbili 10pm blood lipase 10pm blood albumin iron 10pm blood caltibc hapto ferritn trf 13pm blood lactate discharge labs 00am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00am blood ptt 00am blood plt 00am blood glucose urean creat na k cl hco3 angap 00am blood calcium phos mg microbiology blood cultures x3 pending pm pelvic aspiration gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen fluid culture final no growth anaerobic culture preliminary no growth pertinent imaging ct abd pel w contrast interval decrease in size of the right hemipelvis fluid collection x x cm previously x x cm with the anterior approach pigtail catheter unchanged in position the pigtail is again located partly within the collection and partly outside its wall interval increase in size of the left pelvic fluid collection now measuring x x cm previously x x cm increased peripheral enhancement may suggest superimposed infection no new fluid collection identified cta abd pelvis decrease in size of right lower quadrant fluid collection that has percutaneous drain within it with areas of high attenuation on noncontrast exam consistent with blood products and associated hyperemia which is likely inflammatory but without evidence of contrast extravasation there is large stable fluid collection in the low left abdomen pelvis with mild linear peripheral enhancement infection cannot be excluded there is severe left and moderate to severe right hydroureteronephrosis with delayed left nephrogram stable from today mass effect about anastomosis between distal ureters and neobladder has resolved all since and while hydronephrosis may be from residual edema if this does not resolve alternative etiologies including stenosis tumor infiltration should be excluded tiny hepatic lesion segment attention to this area on subsequent followups recommended ct interventional procedure complete collapse the patient has recently drained left lower quadrant collection the catheter from this collection was removed near complete collapse of the patient is originally drained collection in the mid pelvis with pigtail catheter in place left lower quadrant and deep pelvic collections as above these findings were discussed with the team given the patient s improving clinical status the decision was made to pursue no further collection drainage at this time severe bilateral hydronephrosis as on prior examinations recommendation given persistence of severe hydronephrosis percutaneous nephrostomy tubes should be considered brief hospital course brief summary year old women with a history of bladder cancer s p cystectomy hysterectomy and bso now with ileal conduit whose post operative course has been complicated by dvt pe ileus and pelvic fluid collections w one llq drain presented with subjective fevers lethargy and bloody drain output she was found to have worsening anemia and was given units of prbc with appropriate increase in hemoglobin noted she was also found on ct imaging to have an interval increase in size of a left abdominal fluid collection decision was made to place a drain per id fluid was sent and revealed negative cultures negative malignant cells no evidence of lymphatic or urinary fluid this new drain was subsequently removed per as fluid collection was completely drained the prior drain was still draining serosanguinous fluid and was kept in but repositioned id was consulted for the fevers leukocytosis and fluid collections and was deemed to need antibiotics and tranisitioned from broad spectrum to iv ertapenem at discharge will require multiple follow ups and imaging as specified in the transitional issues acute issues pelvic fluid collections patient arrived with one anterior drain putting out serosanguinous fluid ct abdomen pelvis revealed enlarging left fluid collection and decision was made to place a drain per the fluid was negative for malignant cells the fluid had cr and triglycerides suggesting that fluid collection is neither urine nor lymphatic fluid fluid culture was negative for bacteria on interval imaging the new enlarging fluid collection had completely collapsed and the drain was removed as for the other fluid collection that already had a drain putting out serosanguinous fluid it continued to drain serosanguinous fluid but at a lower rate than prior to admission the drain was left in place as the fluid collection on imaging had not completely collapsed bid n cultures for the aforementioned fluid collection came back positive for mssa but per id does not reflect rue intra abdominal infection given that patient had a fever at osh and a leukocytosis she was placed on broad spectrum antibiotics with vanc ceftaz and flagyl this was tapered per id team to iv zosyn on discharge id recommended ertapenem for approximately weeks with final length of treatment to be determined by fluid collection changes on repeat imaging on outpatient basis mrs remained afebrile and leukocytosis resolved pulmonary embolism likely developed in the setting of being diagnosed with a post op dvt she was placed on lovenox she was transitioned to heparin ggt as she needed procedures and was transitioned back to lovenox but at a lower dose per weight dosing to 70mg q12h upon discharge acute renal injury scr has been steadily rising from a baseline of around in to likely obstructed uropathy large pelbic fluid collections resolved over the course of her hospital stay with final cr hydronephrosis bilateral and worsening on interval imaging from prior studies given patient s age adequate urinary output adequate creatinine clearance and no significant electrolyte abnormalities patient likely would not significantly benefit from intervention at this time per urology consult deemed stable for discharge and recommended outpatient urology followup anemia likely a combination of anemia of chronic inflammation and acute blood loss to anterior abdominal drain showing serosanguinous fluid labs not consistent with hemolysis received units of prbc with appropriate response patient was discharged with hgb of per hem onc recommendation for threshold hgb as patient feels and functionally performs better with higher blood counts hypokalemia was hypokalemic and was repleted with oral kcl prn chronic issues invasive high grade urothelial carcinoma involving the deep muscularis propria s p cystectomy hysterectomy and bso now with ileal conduit whose post operative course has been complicated by dvt pe ileus and pelvic fluid collections patient stating that there is no plan for chemo and radiation her pet scan does show concerning foci of metastatic disease in the lung and peritoneum per patient s son mrs has seen a doctor to work up the lung mass will need ongoing discussion with outpatient hem onc regarding how to best manage concerning lesions breast mass mammogram showing bi rads solid mass in the o clock left breast with features of a highly suspicious for malignancy per patient s son she has seen a doctor for evaluating the new breast mass would recommend ongoing discussion with aforementioned doctor and outpatient hem onc about plan to manage hld continued atorvastatin without changes consider evaluation regarding stopping atorvastatin on outpatient basis hypothyroidism continued levothyroxine without changes hcp dr son physician code status full code confirmed with patient on transitional issues will need infectious disease follow up if id has not contacted mrs by she should call to set up an appointment the id appointment needs to be after her ct abdomen pelvis has already been done assure that mrs has her ct abdomen pelvis with contrast in the week of she should get weekly lab draws of the following cbc with differential bun cr ast alt tb alk phos all lab requests should be annotated with attn clinic fax if possible please give ertapenem at night time so it does not interfere with her daily activities tentatively she will be receiving ertapenem for weeks but with final treatment length determined by the infectious disease team will need ongoing discussion with outpatient pcp and hem onc regarding how to manage new breast lesion and lung peritoneum lesions reevaluate need for atorvastatin will need outpatient follow up with urology dr his team regarding worsening hydronephrosis medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q6h atorvastatin mg po qpm enoxaparin sodium mg sc q12h start first dose next routine administration time levothyroxine sodium mcg po daily lorazepam mg po daily prn anxiety discharge medications ertapenem sodium g iv 1x duration dose please give ertapenem daily preferably at nighttime to not interfere with her daily activities milk of magnesia ml po q6h prn constipation enoxaparin sodium mg sc q12h start today first dose next routine administration time acetaminophen mg po q6h atorvastatin mg po qpm levothyroxine sodium mcg po daily lorazepam mg po daily prn anxiety discharge disposition extended care facility discharge diagnosis primary diagnosis pelvic fluid collection infection acute blood loss anemia secondary diagnosis acute renal failure acute on chronic anemia recent pulmonary embolism invasive high grade urothelial carcinoma left breast mass birads hypothyroidism discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear did you come to the hospital you were feeling tired and your drain output was bloody what happened at the hospital a ct scan showed very large fluid collections in your pelvis the radiologists placed another drain and removed it once it appeared that the large fluid collection was gone you were given a blood transfusion we placed a picc a long iv so that you can receive antibiotics after you get discharged from the hospital what needs to happen when you leave the hospital please continue seeing the doctors that are your lung and breast lesions and follow their recommendations continue taking lovenox every day to treat the blood clot in your lung if the infectious disease doctor has not contacted you by please call the following number to set up an appointment please make sure you have a repeat ct scan done before your appointment with the infectious disease doctor you will be getting iv antibiotics for several weeks the infectious disease doctor determine how long you will need to be on it it was a pleasure taking care of you your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint hematuria weakness major surgical or invasive procedure none history of present illness y o female with h o pe on lovenox bladder cancer s p robotic tah bso lap radical cystectomy with ileal loop diversion and anterior vaginectomy in c b abdominal fluid requiring placement of drainage catheters recent abdominal imaging noted worsening of her bilateral severe hydronephrosis and her cr was noted to have risen from to outside lab value patient recently underwent bilateral nephrostomy tube placement by on she first started feeling weak during yesterday doing the exercises had palpitations with ambulation has tightness in chest with ambulating since yesterday felt light headed with ambulation snf noticed increased hematuria with r bag darker than l bag since yesterday her urostomy placed in also positive for hematuria she was transferred to ed for further management in the ed initial vitals were temp hr bp rr ra labs notable for wbc hg platelets na k cl biacrb bun cr ua from bilateral nephrostomy tubes with wbc moderate leukocytes and large blood imaging was notable for ct abd pelvis w o contrast interval placement of bilateral percutaneous nephroureterostomy tubes with resolved hydroureteronephrosis no rp hematoma patient was given lr upon arrival to the floor patient reports that she noticed shortness of breath today with walking in conjunction with bloody output from her ostomy tubes she notes that the output from her nephrostomy tubes was pink tinged when she left the hospital days ago she also endorses associated chest tightness but no pain or pressure she denies cough fever chills abdominal pain or diarrhea she notes that she has an ostomy and nephroureterostomy without sensation of dysuria patient notes feeling dizzy and lightheaded previously though is currently asymptomatic past medical history hypertension s p lap chole s p left knee replacement s p laminectomy of l5 s1 at age bladder cancer high grade tcc t1 diagnosed in then pelvic mri w invasion into bladder wall perivesical soft tissue and anterior vaginal wall c w t4 staging s p hysterectomy and bilateral oophorectomy for large uterus w fibroid s p laparascopic b l pelvic lymph node resection s p radical cystectomy and anterior vaginectomy with vaginal reconstruction with ileal conduit creation course complicated by bacteremia and development of intra abdominal fluid collection no s p drain placement by h o lle dvt and pe on lovenox social history family history negative for bladder ca physical exam admission physical exam vital signs temp po bp hr rr spo2 ra general well appearing elderly woman in no acute distress cardiac rrr no murmurs lungs clear to auscultation bilaterally abdomen soft non tender to palpation normal bowel sounds ostomy draining brown stool nephroureterostomy draining dark red bloody urine bilateral nephrostomy tubes draining blood urine extremities no edema warm and well perfused discharge physical exam vs po ra general well appearing elderly woman in no acute distress cardiac rrr no murmurs lungs clear to auscultation bilaterally abdomen soft non tender to palpation normal bowel sounds nephroureterostomy draining dark red bloody urine bilateral nephrostomy tubes capped extremities no edema warm and well perfused pertinent results admission labs 20pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 48am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 20pm blood glucose urean creat na k cl hco3 angap imaging studies ct abd pel w o contrast impression interval placement of bilateral percutaneous nephroureterostomy tubes with resolved hydroureteronephrosis no rp hematoma partially imaged nodular opacity in the right middle lobe which can be further assessed on a nonemergent dedicated ct chest cxr ap portable upright view of the chest right upper extremity access picc line is seen with its tip in the upper svc overlying ekg leads are present lungs are clear cardiomediastinal silhouette is stable bony structures are intact microbiology pm urine left nephrostomy tube final report urine culture final no growth discharge labs 08am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 08am blood glucose urean creat na k cl hco3 angap 08am blood calcium phos mg brief hospital course ms is an year old woman with history of provoked dvt pe on lovenox bladder cancer s p robotic tah bso lap radical cystectomy with ileal loop diversion and anterior vaginectomy in c b abdominal fluid requiring placement of drainage catheters and recent hydronephrosis requiring placement of bilateral pcn tubes on presenting from rehab with hematuria and weakness on arrival pt had evidence of frank hematuria in her urostomy bag and pcn tubes her hemoglobin was initially which subsequently dropped to her lovenox was held and she was transfused with u prbc with an appropriate hemoglobin bump to hematuria was likely caused by recent instrumentation in the setting of anticoagulation her hematuria improved as did her dizziness weakness was consulted and recommending capping her pcn tubes after discussion with the patient s hematologist it was decided to stop her lovenox treatment given that her dvt pe were provoked in the setting of her recovery from surgery and that she had received almost months of treatment secondary issues asymptomatic bacteruria patient with asymptomatic bacteruria in setting of recent procedural manipulation she was afebrile and without leukocytosis so treatment with antibiotics was deferred hyperlipidemia continued atorvastatin mg daily hypothyroidism continue levothyroxine mcg daily transitional issues medication changes lovenox stopped ct abdomen pelvis showed partially imaged nodular opacity in the right middle lobe which can be further assessed on a nonemergent dedicated ct chest pt s pcn tubes were capped per recommendation during her hospitalization she was discharged with scheduled followup to decide on long term management if pt develops hematuria and or lightheadedness or other symptoms of anemia a cbc should be rechecked to assess for bleeding hemoglobin hematocrit on discharge code presumed full contact md cell home medications on admission the preadmission medication list is accurate and complete atorvastatin mg po qpm enoxaparin sodium mg sc q12h start first dose next routine administration time levothyroxine sodium mcg po daily multivitamins tab po daily probiotic digestive enzymes l acidophilus dig mg oral daily discharge medications atorvastatin mg po qpm levothyroxine sodium mcg po daily multivitamins tab po daily probiotic digestive enzymes l acidophilus dig mg oral daily discharge disposition extended care facility discharge diagnosis primary diagnoses hematuria anemia secondary diagnoses bladder cancer hydronephrosis hypothyroidism dvt pe discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms it was a pleasure taking care of you at why did you come to the hospital you noticed blood in your urine and you were feeling weak lightheaded what happened while you were here we did not give you your blood thinner medication lovenox and we gave you a unit of blood the blood in your urine cleared up what should you do when you leave the hospital along with your oncologist dr have decided that you no longer need to take any lovenox you should continue to follow up with your doctors and take all of your medications as prescribed your followup appointments are listed below again it was a pleasure taking care of you sincerely your team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies no known allergies adverse drug reactions attending chief complaint fevers and chills major surgical or invasive procedure stent exchange history of present illness ms is a female with the past medical history notable for history of bladder cancer status post robotic tah bso lap radical cystectomy with ileal loop diversion and anterior vaginectomy in complicated by abdominal fluid requiring placement of drainage catheters further complicated by a severe bilateral hydronephrosis requiring bilateral urostomy tube placement and then ultimately ureteral stent placements with improvement who presented to the hospital for routine stent exchange and cystoscopy the patient underwent an uncomplicated procedure but then postoperatively in the pacu she developed a fever to and was tachycardic and as such was felt to need admission for treatment of sepsis at that time she was given ampicillin and gentamicin given her history of drug resistant organisms she reported at that time she was feeling feverish and chills with nausea and vomiting x1 she received iv fluids and her iv antibiotics and her symptoms improved she was admitted to the medical service for further evaluation and management on the floor the patient reports that she continues to have persistent chills she feels slightly nauseous she denies any abdominal pain she otherwise reports that she is feeling better than she did immediately postprocedural but is still significantly off of her baseline she reports that she has a history of urinary tract infections and was most recently on ciprofloxacin and she reports that she was on this medication for day course no acute complaints past medical history hypertension s p lap chole s p left knee replacement s p laminectomy of l5 s1 at age bladder cancer high grade tcc t1 diagnosed in then pelvic mri w invasion into bladder wall perivesical soft tissue and anterior vaginal wall c w t4 staging s p hysterectomy and bilateral oophorectomy for large uterus w fibroid s p laparascopic b l pelvic lymph node resection s p radical cystectomy and anterior vaginectomy with vaginal reconstruction with ileal conduit creation course complicated by bacteremia and development of intra abdominal fluid collection no s p drain placement by h o lle dvt and pe no longer on anticoagulation social history family history negative for bladder ca physical exam admission exam vitals temp po bp hr rr o2 sat o2 delivery ra dyspnea rass pain score general alert and in no apparent distress facial twitches eyes anicteric pupils equally round ent ears and nose without visible erythema masses or trauma oropharynx without visible lesion erythema or exudate cv heart regular no murmur no s3 no s4 no jvd resp lungs clear to auscultation with good air movement bilaterally breathing is non labored gi abdomen soft non distended non tender to palpation bowel sounds present no hsm gu no suprapubic fullness or tenderness to palpation foley catheter in place msk neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs skin no rashes or ulcerations noted neuro alert oriented face symmetric gaze conjugate with eomi speech fluent moves all limbs sensation to light touch grossly intact throughout psych pleasant appropriate affect discharge exam avss ambulating comfortably at baseline urostomy bag in place with no surround erythema or pain pertinent results laboratory results 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 09am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood glucose urean creat na k cl hco3 angap 10am blood glucose urean creat na k cl hco3 angap 30am blood calcium phos mg microbiology pm urine site cystoscopy right kidney wash final report urine culture final enterococcus faecium cfu ml requests susceptibility testing staphylococcus coagulase negative cfu ml corynebacterium species diphtheroids cfu ml sensitivities mic expressed in mcg ml enterococcus faecium ampicillin s nitrofurantoin s tetracycline r vancomycin s blood cultures ngtd brief hospital course ms was admitted with sepsis from a urinary tract infection after her stent exchange she was placed empirically on vancomycin and cefepime narrowed to vanc ceftriaxone on hd because of her history of resistant organisms she rapidly improved her urine grew e faecium sensitive to ampicillin therefore a picc line was placed and she will complete two weeks total of ampicillin for a complicated urinary tract infection additional day days she will follow up with dr as an outpatient she will stop her prophylactic tmp while on ampicillin but then resume after finishing her course ampicillin mg tid x additional days restart tmp mg daily for ppx after antibiotic course follow up with dr problems addressed this hospitalization ms initially had an likely prerenal from her sepsis she received iv fluids and antibiotics as above and her creatinine down trended losartan was initially held but restarted on discharge hyperlipidemia continued atorvastatin mg daily hypothyroidism continue levothyroxine mcg daily minutes spent on discharge activities medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q6h prn pain mild fever atorvastatin mg po qpm cyanocobalamin mcg po daily docusate sodium mg po bid levothyroxine sodium mcg po daily lorazepam mg po q12h prn anxiety losartan potassium mg po bid multivitamins tab po daily polyethylene glycol g po daily prn constipation first line trimethoprim mg po q24h discharge medications ampicillin mg iv q8h rx ampicillin sodium mg mg iv every eight hours disp vial refills rx ampicillin sodium mg mg iv every eight hours disp vial refills acetaminophen mg po q6h prn pain mild fever atorvastatin mg po qpm cyanocobalamin mcg po daily docusate sodium mg po bid levothyroxine sodium mcg po daily lorazepam mg po q12h prn anxiety losartan potassium mg po bid multivitamins tab po daily polyethylene glycol g po daily prn constipation first line held trimethoprim mg po q24h this medication was held do not restart trimethoprim until after you finish your ampicillin discharge disposition extended care facility discharge diagnosis complicated e faecium uti discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions you were admitted to the hospital after you developed fevers and chills after you developed fevers and chills from your stent exchange your urine grew the enterococcus species the source of your infection because it was enterococcus a picc line was placed and you will finish a total day course of iv ampicillin you also had kidney injury likely from infection that resolved with antibiotics and fluids it was a pleasure taking care of you followup instructions

name unit no admission date discharge date date of birth sex m service surgery allergies no known allergies adverse drug reactions attending chief complaint locally advanced gastric carcinoma major surgical or invasive procedure cystoscopy for foley catheter placement laparoscopy with biopsy gastroscopy history of present illness mr is a year old male with locally advanced gastric cancer stage ii t3n2 who arrives to for curative intent surgical resection after completion of induction chemotherapy he was started on neoadjuvant chemotherapy with flot4 on overall he tolerated the chemotherapy well without any significant side effects however last month he developed right upper extremity edema and was noted to have a thrombosis in the r svc he was started on lovenox mg kg bid which he is compliant with denies any fever nausea emesis chills weight loss melena hematochezia or hematuria he comes after recent repeat staging with torso ct scan demonstrating no evidence of disease he is now now taken to the operating room for minimally invasive and possibly open radical distal gastrectomy with lymphadenectomy the risks and benefits of surgery have been described with the patient in detail and are documented by dr in a separate note past medical history past medical history prostate cancer thyroid nodule hypothyroid gerd mild diverticulosis on colonoscopy anemia iron def anemia which resolved and no workup past surgical history prostate cancer external beam achilles tendon repair shattered right tibia and fibula tonsillectomy age social history family history father died at from lymphoma mother died at with type ii dm dementia physical exam vs hr data last updated temp tm bp hr rr o2 sat o2 delivery ra gen a ox3 nad resting comfortably heent ncat eomi sclera anicteric cv rrr pulm no respiratory distress abd soft nt nd no rebound or guarding ext warm well perfused no edema psych normal insight memory and mood wound s incision c d i brief hospital course mr is a year old male who presented on for a planned minimally invasive and possibly open radical distal gastrectomy with lymphadenectomy for locally advanced gastric carcinoma after chemotherapy after placement of the right upper quadrant port insufflation revealed the right upper quadrant port to be penetrating the omentum it appeared to miss the transverse mesocolon as well as the colon itself during the surgery there were visually obvious peritoneal deposits on all peritoneal surfaces in all four quadrants which demonstrated undetected carcinomatosis poorly differentiated adenocarcinoma involving the peritoneum for this reason the procedure was then aborted post operatively the patient was taken to the pacu until stable and then transferred to the wards until stable to go home neuro the patient was alert and oriented throughout hospitalization pain was initially managed with dilaudid pca which he was not using and then transitioned to tramadol which he got only one dose pain was very well controlled cv the patient remained stable from a cardiovascular standpoint vital signs were routinely monitored pulmonary the patient remained stable from a pulmonary standpoint vital signs were routinely monitored good pulmonary toilet early ambulation and incentive spirometry were encouraged throughout hospitalization gi gu fen before the procedure started or nurse was unable to pass foley after attempt with standard and coude type pa with usual sterile technique re attempted foley placement after 10cc urojet application with and coude type catheters but was also unable to get passed the prostate urology was consulted and they performed a flexible cystoscope demonstrating a normal urethra using a flexible guidewire cystoscope was advanced into the bladder the scope was withdrawn and a council was advanced over the wire passed the prostate and into the bladder the patient was discharged with the foley in place with instructions to follow up with urology as outpatient in to days for a voiding trial no antibiotics were administered the patient was tolerating a regular diet prior to discharge id the patient s fever curves were closely watched for signs of infection of which there were none heme patient received bid sqh for dvt prophylaxis in addition to encouraging early ambulation and venodyne compression devices on pod1 the patient was restarted on his home enoxaparin before discharge transitional issues at the time of discharge the patient was doing well afebrile with stable vital signs the patient was tolerating diet as above per oral ambulating and pain was well controlled the patient was discharged home with the foley catheter with appropriate teaching for care the patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan medications on admission medications prescription bio throid bio throid mg once a day prescribed by other provider enoxaparin enoxaparin mg ml subcutaneous syringe mg sc daily omeprazole omeprazole mg capsule delayed release capsule s by mouth twice daily ubiquinol ubiquinol mg tabs mouth twice a day prescribed by other provider medications otc ferrous sulfate ferrous sulfate mg mg iron tablet tablet s by mouth twice a day prescribed by other provider lactobacillus combination no probiotic dosage uncertain prescribed by other provider daily discharge medications acetaminophen mg po tid docusate sodium mg po bid senna mg po bid prn constipation first line tramadol mg po q6h prn pain moderate this medication is a low dose narcotic and may cause constipation rx tramadol mg one tablet s by mouth every six hours disp tablet refills enoxaparin sodium mg sc daily discharge disposition home discharge diagnosis metastatic gastric cancer stage iv t3n2m1 urethral stricture discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr it was a pleasure taking care of you here at you were admitted to our hospital for gastric cancer you had an attempted robot assisted laparoscopic partial gastrectomy and gastroscopy on without complications you tolerated the procedure well and are ambulating stooling tolerating a regular diet and your pain is controlled by pain medications by mouth you are now ready to be discharged to home please follow the recommendations below to ensure a speedy and uneventful recovery activity do not drive until you have stopped taking pain medicine and feel you could respond in an emergency you may climb stairs you should continue to walk several times a day you may go outside but avoid traveling long distances until you see your surgeon at your next visit you may start some light exercise when you feel comfortable slowly increase your activity back to your baseline as tolerated heavy exercise may be started after weeks but use common sense and go slowly at first no heavy lifting pounds or more until cleared by your surgeon usually about weeks you may resume sexual activity unless your doctor has told you otherwise how you may feel you may feel weak or washed out for 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 the surgery your bowels constipation is a common side effect of narcotic pain medicine such as oxycodone if needed you may take a stool softener such as colace one capsule or gentle laxative such as milk of magnesia tbs twice a day you can get both of these medicines without a prescription if you go hours without a bowel movement or have pain moving the bowels call your surgeon after some operations diarrhea can occur if you get diarrhea don t take anti diarrhea medicines drink plenty of fluids and see if it goes away if it does not go away or is severe and you feel ill please call your surgeon pain management you are being discharged with a prescription for oxycodone for pain control you may take tylenol as directed not to exceed 3500mg in hours take regularly for a few days after surgery but you may skip a dose or increase time between doses if you are not having pain until you no longer need it you may take the oxycodone for moderate and severe pain not controlled by the tylenol you may take a stool softener while on narcotics to help prevent the constipation that they may cause slowly wean off these medications as tolerated your pain should get better day by day if you find the pain is getting worse instead of better please contact your surgeon if you experience any of the following please contact your surgeon sharp pain or any severe pain that lasts several hours chest pain pressure squeezing or tightness cough shortness of breath wheezing pain that is getting worse over time or pain with fever shaking chills fever of more than a drastic change in nature or quality of your pain nausea and vomiting inability to tolerate fluids food or your medications if you are getting dehydrated dry mouth rapid heart beat feeling dizzy or faint especially while standing any change in your symptoms or any symptoms that concern you additional pain that is getting worse over time or going to your chest or back urinary burning or blood in your urine or the inability to urinate medications take all the medicines you were on before the operation just as you did before unless you have been told differently if you have any questions about what medicine to take or not to take please call your surgeon wound care dressing removal you may remove your dressings tomorrow and shower that same day with any bandage strips that may be covering your wound do not scrub and do not soak or swim and pat the incision dry if you have steri strips they will fall off by themselves in weeks if any are still on in two weeks and the edges are curling up you may carefully peel them off do not take baths soak or swim for weeks after surgery unless told otherwise by your surgical team notify your surgeon is you notice abnormal foul smelling bloody pus etc or increased drainage from your incision site opening of your incision or increased pain or bruising watch for signs of infection such as redness streaking of your skin swelling increased pain or increased drainage please call with any questions or concerns thank you for allowing us to participate in your care we hope you have a quick return to your usual life and activities home with you had a foley catheter in your bladder placed by urology on the day of your surgery after difficulty trying to place it you will keep the catheter until your appointment with urology in days please call the number below to schedule your appointment who will decide if you need it longer or attempt to remove it and see if you are able to void empty the bag as needed and as shown to you by nursing staff you will be given a leg bag before your discharge that you may use for short trips this is a smaller bag that straps to your leg to take home and wear if you are traveling outside your home this holds a smaller amount than the bag you have now so it needs to be emptied more often some people find it easier to use the larger bad when they are at home or carry it with them your care team followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies codeine augmentin topamax attending complaint left breast swelling and pain major surgical or invasive procedure evacuation of hematoma history of present illness woman on anticoagulation with l breast idc grade now s p l breast lumpectomy and slnb with left breast swelling and pain concerning for a hematoma past medical history dyslipidemia varicose veins r l s p ligation copd osa cpap recent uri received course of zithromax bilateral pes antiphospholipid antibody syndrome on lifelong anticoagulation t2dm last a1c on cerebral aneurysm followed by dr unchanged gerd diverticulosis h o colon polyps depression s p right cmc joint arthroplasty b l rotator cuff repair excision right digit mass ccy w stone pancreatic duct exploration hysterectomy tonsillectomy social history family history no family hx of dvt or pe two sisters have atrial fibrillation physical exam physical exam vs temp po bp hr rr o2 sat o2 delivery ra gen nad pleasant conversant heent ncat eomi sclera anicteric cv rrr pulm no increased work of breathing comfortable on ra breast l breast with dependent ecchymosis mildly ttp inferior breast incision c d i jp drain with serosanguineous output abd soft non tender non distended no masses or hernia ext warm well perfused no edema no tenderness neuro a ox3 no focal neurologic deficits psych normal judgment insight normal memory normal mood affect pertinent results 33am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 33am blood ptt 33am blood glucose urean creat na k cl hco3 angap 33am blood calcium phos mg examination cta chest with contrast comparison chest ct dated findings heart and vasculature there is no central pulmonary embolism the thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma the heart pericardium and great vessels are within normal limits no pericardial effusion is seen axilla hila and mediastinum there is a x x cm collection in the left breast with density measuring hounsfield units consistent with hematoma there are few foci of air within the collection likely from prior aspiration as well as few punctate hyperdensities at the periphery no axillary mediastinal or hilar lymphadenopathy is present the right axilla is not included on the study no mediastinal mass pleural spaces no pleural effusion or pneumothorax lungs airways partially visualized lungs are clear without masses or areas of parenchymal opacification the airways are patent to the level of the segmental bronchi bilaterally base of neck visualized portions of the base of the neck show no abnormality bones no suspicious osseous abnormality is seen there is no acute fracture impression x x cm left breast hematoma with no evidence of active bleed please note timing was suboptimal as the patient needed to be re scanned due to incomplete field of view on initial images however the density of the collection was unchanged on all series brief hospital course ms is a woman who was admitted to the breast service following a left breast lumpectomy for invasive carcinoma performed on she presented with a recurrent left breast hematoma after it was evacuated by needle aspiration in clinic on she was admitted for observation and surgical evacuation of her hematoma on she was brought to the operating room for evacuation of the left hematoma and placement of a surgical drain hospital course as detailed below neuro pain was controlled with oral pain medication including acetaminophen and tramadol vital signs were monitored per protocol she was continued on her home medications resp she was continued on her home albuterol medications fen gi she was continued on a regular diet throughout her admission she was briefly made npo for the operating room and hydrated with iv fluids in the perioperative period gu she voided without issue throughout her hospital course heme h h was closely monitored with daily labs and found to be stable her home anticoagulation was held during her hospital course she was resumed on her home dose of warfarin on discharge without a lovenox bridge she remained on compression boots during her hospital course to prevent dvts id she was given ancef 2gm iv q8hrs for prophylaxis she remained afebrile and did not develop a leukocytosis during her hospital course endo due to a history of metabolic syndrome and pre diabetes she was kept on a constant carbohydrate diet on the day of discharge she was tolerating a regular diet w o nausea or emesis she was ambulating independently her pain was controlled with oral pain medications she was afebrile and did not have a leukocytosis all antibiotics were discontinued she was discharged home with for drain management and close follow up with dr in clinic for drain removal she will also follow up with dr in clinic in early for routine follow up medications on admission active medication list as of medications prescription albuterol sulfate albuterol sulfate mg ml solution for nebulization ml inhalation four times a day as needed for cough wheeze albuterol sulfate proair hfa proair hfa mcg actuation aerosol inhaler puffs inhalation q4 hours as needed for cough wheeze atorvastatin atorvastatin mg tablet one tablet s by mouth at bedtime prescribed by other provider dose adjustment no new rx enoxaparin enoxaparin mg ml subcutaneous syringe mg sc twice daily approximately hours apart will start last dose am prescribed by other provider dose adjustment no new rx erythromycin erythromycin mg gram eye ointment apply inch affected eye four times a day furosemide furosemide mg tablet tablet s by mouth once a day as needed for leg swelling hydromorphone hydromorphone mg tablet tablet s by mouth every four hours as needed for severe pain do not drink alcohol or drive while taking this medication nebulizer and compressor portable nebulizer system portable nebulizer system use with albuterol nebulizer soln four times a day as needed for cough wheeze omeprazole omeprazole mg capsule delayed release take capsule twice daily for gastroesophageal refluxdisease sertraline sertraline mg tablet tablet s by mouth once a day tramadol tramadol mg tablet one tablet s by mouth three times a day trazodone trazodone mg tablet tablet s by mouth at bedtime as needed for insomia warfarin warfarin mg tablet one tablet s by mouth times a tabs po times a week last dose per clinic prescribed by other provider dose adjustment no new rx medications otc acetaminophen acetaminophen mg tablet tablet s by mouth times daily as needed for pain dc med rec cholecalciferol vitamin d3 cholecalciferol vitamin d3 unit tablet tablet s by mouth once a day otc polyethylene glycol miralax miralax gram dose oral powder powder s by mouth once a day as needed for constipation prescribed by other provider dose adjustment no new rx sennosides senna senna mg tablet tablet s by mouth once a day as needed for constipation otc discharge medications tramadol mg po q4h prn pain moderate reason for prn duplicate override alternating agents for similar severity rx tramadol mg tablet s by mouth q4hr prn disp tablet refills atorvastatin mg po qpm docusate sodium mg po bid omeprazole mg po bid senna mg po hs sertraline mg po daily trazodone mg po qhs prn sleep discharge disposition home with service facility discharge diagnosis breast hematoma discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions personal care you may keep your incisions open to air or covered with a clean sterile gauze that you change daily clean around the drain site s where the tubing exits the skin with soap and water strip drain tubing empty bulb s and record output s times per day a written record of the daily output from each drain should be brought to every follow up appointment your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount you may wear a surgical bra or soft loose camisole for comfort do not shower while your drain is in place the dermabond skin glue will begin to flake off in about days activity you may resume your regular diet walk several times a day do not lift anything heavier than pounds or engage in strenuous activity for weeks following surgery medications resume your regular medications unless instructed otherwise and take any new meds as ordered you may take your prescribed pain medication for moderate to severe pain you may switch to tylenol or extra strength tylenol for mild pain as directed on the packaging please note that percocet and vicodin have tylenol as an active ingredient so do not take these meds with additional tylenol take prescription pain medications for pain not relieved by tylenol take colace mg by mouth times per day while taking the prescription pain medication you may use a different over the counter stool softener if you wish do not drive or operate heavy machinery while taking any narcotic pain medication you may have constipation when taking narcotic pain medications oxycodone percocet vicodin hydrocodone dilaudid etc you should continue drinking fluids you may take stool softeners and should eat foods that are high in fiber call the office immediately if you have any of the following signs of infection fever with chills increased redness swelling warmth or tenderness at the surgical site or unusual drainage from the incision s a large amount of bleeding from the incision s or drain s fever greater than of severe pain not relieved by your medication return to the er if if you are vomiting and cannot keep in fluids or your medications if you have shaking chills fever greater than f degrees or c degrees increased redness swelling or discharge from incision chest pain shortness of breath or anything else that is troubling you any serious change in your symptoms or any new symptoms that concern you anticoagulation you should begin taking your home warfarin dose this evening and resume taking warfarin at your regular scheduled doses you will not need a bridge therapy to begin warfarin drain discharge instructions you are being discharged with drains in place drain care is a clean procedure wash your hands thoroughly with soap and warm water before performing drain care perform drainage care twice a day try to empty the drain at the same time each day pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup record the amount of drainage fluid on the record sheet reestablish drain suction please assist patient with drain care a daily log of individual drain outputs should be maintained and brought with patient to follow up appointment with your surgeon followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies codeine augmentin topamax attending chief complaint rle pain and swelling major surgical or invasive procedure ultrasound guided steroid injection of the right trochanteric bursa right hip history of present illness this is a woman with a history of breast cancer with brca1 gene mutation copd cerebral aneurysm sleep apnea depression hyperlipidemia antiphospholipid syndrome with hx dvt pe ago on warfarin who presents for evaluation of severe right lower extremity pain she was just admitted to the hospital for lumpectomy infiltrating ductal carcinoma of left breast and sentinel lymph node biopsy on complicated by hematoma status post evacuation on prior to these procedures she had severe right lower extremity pain similar to today and underwent a dvt ultrasound on which was negative her anticoagulation was held in the hospital due to the hematoma and she had dvt prophylaxis with pneumoboots during her postoperative hematoma her anticoagulation was held she did not have extremity pain during her time in the hospital however upon returning home she developed severe pain which she describes as cramps in her mid calf on the right she also has pain that intermittently occurs in the right thigh which she describes as spasms she has not had numbness tingling or weakness on that side she was seen in breast clinic today where she complained of this pain and was referred to the ed for further evaluation she initially triggered as a pulseless extremity because of nonpalpable pulses in the right foot she has been taking tylenol as well as tramadol with minimal pain relief of note she resumed her warfarin without any enoxaparin bridge this past she has been wearing compression stockings and elevating her leg in an attempt to relieve the pain in the ed initial vitals t hr bp rr o2 sat ra exam notable for right lower extremity with dopplerable pulses palpable pulses in the left lower extremity the right lower extremity is warm there is tenderness to palpation of the right calf tenderness to palpation of the right thigh labs notable for chem panel unremarkable with cr ck cbc wbc hgb with mcv plt coags ptt inr lactate ua mod leuk few bacteria imaging notable for rle ultrasound right calf veins not visualized otherwise no evidence of deep venous thrombosis in the right lower extremity veins ct lower extremity right unremarkable contrast enhanced ct of the right calf with a two vessel runoff to the foot the veins of the lower extremity are not opacified therefore cannot be assessed for patency consider repeat ultrasound to more fully evaluate no focal collection or obvious muscular abnormality identified by ct pt given iv morphine 4mg iv apap 1g iv ns iv dilaudid mg total 1mg x warfarin 5mg atorvastatin 40mg omeprazole 20mg surgery was consulted recommend vascular surgery consult for possible dvt with history of multiple vein stripping procedures and dvts also recommend admission to medicine for pain control vascular surgery was consulted there is no clear vascular etiology for her pain vitals prior to transfer t hr bp rr o2 sat ra upon arrival to the floor the patient reports the pain is she reports again that this pain is similar to the pain she had on but even then an ultrasound showed no dvt she is able to move her toes but has pain with lifting her leg she has never had this kind of pain before even with the vein stripping that she had in the past age she has no chest pain or shortness of breath she has had no recent travel or trauma to her leg past medical history dyslipidemia varicose veins r l s p ligation copd osa cpap recent uri received course of zithromax bilateral pes antiphospholipid antibody syndrome on lifelong anticoagulation t2dm last a1c on cerebral aneurysm followed by dr unchanged gerd diverticulosis h o colon polyps depression s p right cmc joint arthroplasty b l rotator cuff repair excision right digit mass ccy w stone pancreatic duct exploration hysterectomy tonsillectomy social history family history mother ovarian cancer dx age father brain cancer pgm ovarian cancer aunt ovarian cancer paternal aunt in mgm endometrial cancer mgf prostate cancer brother kidney cancer renal failure congestive heart failure diabetes mellitus tobacco abuse alcohol abuse sister ovarian cancer dx age brother throat cancer dx age died in sister brca1 mutation breast cancer daughter living abnormal pap smear substance abuse son died substance abuse heroin overdose on physical exam admission exam vitals t bp hr rr o2 sat ra general alert oriented no acute distress heent mmm oropharynx clear eomi perrl neck supple jvp not elevated chest l breast incisions well healed s p l axilla surgical drain removal cv regular rate and rhythm normal s1 s2 no murmurs lungs clear to auscultation bilaterally no wheezes or crackles abdomen soft non tender non distended bowel sounds present ext warm well perfused right lower extremity is tender to palpation and movement limited by pain swelling of rle lle palpable pulses bilaterally skin warm dry varicose veins noted in lower extremities neuro cnii xii intact grossly normal strength and sensation and symmetric bilaterally discharge exam vitals temp tm bp hr rr o2 sat o2 delivery ra general alert oriented no acute distress heent mmm oropharynx clear eomi perrl neck supple jvp not elevated chest l breast incisions well healed s p l axilla surgical drain removal cv rrr no murmurs lungs clear abdomen soft non tender non distended bowel sounds present ext warm well perfused no asymmetric swelling minimally tender to palpation along the right trochanteric bursa and minimally tender to palpation along the right tibia normal rom though pain elicited with knee flexion improves with leg raise and extension palpable pulses bilaterally skin varicose veins noted in lower extremities neuro lower extremity sensation is equal on both sides to light touch normal bilateral lower extremity strength negative babinsky ambulating in hallway independently though it precipitates right tibial pain pertinent results admission labs 00pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 00pm blood neuts monos eos baso im absneut abslymp absmono abseos absbaso 00pm blood ptt 00pm blood glucose urean creat na k cl hco3 angap 40am blood calcium phos mg iron 40am blood caltibc vitb12 ferritn trf 15am blood 25vitd 25pm blood lactate discharge labs 41am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 41am blood 41am blood glucose urean creat na k cl hco3 angap 41am blood calcium phos mg imaging unilat lower extremity vein r right calf veins not visualized otherwise no evidence of deep venous thrombosis in the right lower extremity veins ct rle unremarkable contrast enhanced ct of the right calf with a two vessel runoff to the foot the veins of the lower extremity are not opacified therefore cannot be assessed for patency consider repeat ultrasound to more fully evaluate no focal collection or obvious muscular abnormality identified by ct uneventful ultrasound guided injection of long acting anesthetic and steroid into theright greater trochanteric bursa prior injection small amount of fluid in the right greater trochanteric bursa and dystrophic calcification within the bursal space findings raise suspicion for chronic trochanteric bursitis brief hospital course summary ms is a with a pmh significant for antiphospholipid syndrome with dvts and pes on coumadin recent l sided breast cancer s p lumpectomy who presented to the ed with acute on chronic right lower extremity and right hip pain making it difficult to ambulate right lower extremity u s and ct did not reveal a dvt though calf veins were not well visualized active issues right trochanteric bursitis right anterior lower leg pain right sided varicose veins pt endorsed 4mths of pain in rle that became acutely worse over the last few wks her initial exam was most consistent with severe trochanteric bursitis on the right she also has some focal pain along the right tibia which she felt was most consistent with pain from her varicose veins the xrs of her tibia fibula and right hip were without obvious pathology there are no concerning neurologic symptoms to suggest a radiculopathy no weakness or numbness though she may have some degree of chronic sciatica mildly decreased patellar reflex on the right as compared to left may have been in the setting of pain and guarding strength was normal bilaterally as was her sensation she underwent u s guided steroid injection of her trochanteric bursa w significant improvement in symptoms stated that there was some fluid near the bursa suggestive of acute on chronic trochanteric bursitis her anterior shin pain improved with initiation of gabapentin and lidocaine patch in addition to her home tylenol and an increase in the frequency of her home tramadol q8h prn to q4h prn pt was not given her home hydromorphone prn though she did require one dose of mg iv hydromorphone following her injection in the setting of an acute pain episode she was discharged with tramadol 50mg x15 tablets given increased requirement by discharge she was able ambulate and was felt safe for discharge home with a cane per evaluation pt was eager to leave and will reach out to her vascular surgeon for an appointment early in the new year for treatment of her painful varicose veins iron deficiency anemia anemia is new since normocytic downtrended overnight to from no concern for active bleeding per iron studies she is iron deficient with a ferritin of she endorses fatigue and restless leg syndrome etiology is unclear though it may be related to the recent left breast hematoma of her breast unlikely though the timing fits prior egd with gastritis for which she is on a bid ppi prior colonoscopy with findings that may be suggestive of celiac disease though ttg at that time was normal with a normal iga she also had two polyps biopsied and were normal on this admission a vitamin d level was obtained to assess for evidence of malabsorption iso daily supplementation level was she was given ferric gluconate iv x1 on ttg was repeated and pending at discharge chronic issues history of dvt pe on warfarin antiphospholipid antibody syndrome subtherapeutic inr lupus anticoagulant positive in she has been taking her home dose of warfarin mg and mg other days her warfarin was held last iso hematoma and she was not bridged with lovenox upon reinitiation inr on this admission was subtherapeutic at bridged during this hospitalization with lovenox for goal inr she was given an increased dose of warfarin mg daily while in house inr at discharge was with plan to continue home warfarin regimen patient will get repeat inr on vitamin d deficiency pt takes u vitamin d daily repeat level is which suggests against malabsorption to account for her iron deficiency transitional issues code status full presumed hcp granddaughter right trochanteric bursitis consider repeat injection consider physical therapy right anterior leg pain discharged on gabapentin mg three times daily discharged with tramadol 50mg home regimen is q8hrs and required q4hrs during hospitalization will give two day supply of increased dose plan to see pcp next week consider outpatient mri of the lumbar spine for chronic pain consider emg vascular surgery follow up as outpt for treatment of painful veins iron deficiency anemia consider repeat iv iron infusion f u pending ttg consider further work up though may be related to left breast hematoma history of dvt pe antiphospholipid antibody syndrome subtherapeutic inr f u clinic on patient can continue home warfarin regimen medications on admission the preadmission medication list is accurate and complete atorvastatin mg po qpm docusate sodium mg po bid omeprazole mg po bid senna mg po hs sertraline mg po daily trazodone mg po qhs prn sleep tramadol mg po q8h prn pain moderate reason for prn duplicate override alternating agents for similar severity polyethylene glycol g po daily prn constipation first line proair hfa albuterol sulfate mcg actuation inhalation q4h prn acetaminophen mg po q8h prn pain mild fever albuterol neb soln neb ih q6h prn cough wheeze vitamin d unit po daily erythromycin ophth oint in both eyes qid furosemide mg po daily prn leg swelling hydromorphone dilaudid mg po q4h prn pain severe warfarin mg po 2x week warfarin mg po 5x week discharge medications gabapentin mg po tid rx gabapentin mg tablet s by mouth three times daily disp tablet refills lidocaine patch ptch td qam right hip rx lidocaine apply patches daily disp patch refills tramadol mg po q6h prn pain moderate rx tramadol mg tablet s by mouth every six hours as needed disp tablet refills acetaminophen mg po q8h prn pain mild fever albuterol neb soln neb ih q6h prn cough wheeze atorvastatin mg po qpm docusate sodium mg po bid erythromycin ophth oint in both eyes qid furosemide mg po daily prn leg swelling omeprazole mg po bid polyethylene glycol g po daily prn constipation first line proair hfa albuterol sulfate mcg actuation inhalation q4h prn senna mg po hs sertraline mg po daily trazodone mg po qhs prn sleep vitamin d unit po daily warfarin mg po 2x week warfarin mg po 5x week discharge disposition home with service facility discharge diagnosis primary right trochanteric bursitis right anterior leg pain right sided varicose veins secondary iron deficiency anemia history of dvt pe on warfarin antiphospholipid antibody syndrome subtherapeutic inr vitamin d deficiency discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions dear you were admitted because you were having a lot of leg pain making it difficult to walk in the hospital we gave you a steroid injection near your right thigh for a condition called trochanteric bursitis we also gave you a medication called gabapentin to help with your leg pain lower down we also started you on a medication called lovenox in order to bridge you back to your warfarin currently your warfarin dose is mg daily and your inr was at discharge goal finally you received dose of intravenous iron because you are iron deficient which may be why you are more fatigued than usual when you go home please take your medications as prescribed and make an appointment with your primary care doctor we do not know what exactly is causing the lower leg pain so you may want to talk to your doctor about having an mri of your spine you can also ask your doctor about prescribing a medication called diclofenac gel also called voltaren this is essentially motrin or advil in a topical form and may help your pain additionally please talk to your doctor about why you may be iron deficient it was a pleasure taking part in your care we wish you all the best with your health sincerely the team at followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies codeine augmentin topamax attending chief complaint low back pain with radiation down the right leg major surgical or invasive procedure decompression l2 s1 fusion l4 l5 duraplasty on history of present illness ms is a female with a past medical history significant for cerebral aneurysm abdominal aortic aneurysm antiphospholipid syndrome w multiple dvts and one event of bilateral large pes on warfarin brca1 mutation w l sided breast cancer s p lumpectomy who presents with over one month of right lower back pain with radicular pain down the right leg pain she had recent admission for acute worsening of rle pain and swelling in background of about months right leg pain rle us did not show evidence of dvt exam was most consistent with right trochanteric bursitis and pt received a steroid injection her right tibia pain was felt to be to her varicose veins on this admission imaging notable for normal ct a p with no e o nephrolithiasis mr spine with disc bulge at l2 l3 and l3 cause severe narrowing of the spinal canal with crowding of the traversing cauda equina past medical history dyslipidemia varicose veins r l s p ligation copd osa cpap recent uri received course of zithromax bilateral pes antiphospholipid antibody syndrome on lifelong anticoagulation t2dm last a1c on cerebral aneurysm followed by dr unchanged gerd diverticulosis h o colon polyps depression s p right cmc joint arthroplasty b l rotator cuff repair excision right digit mass ccy w stone pancreatic duct exploration hysterectomy tonsillectomy social history family history mother ovarian cancer dx age father brain cancer pgm ovarian cancer aunt ovarian cancer paternal aunt in mgm endometrial cancer mgf prostate cancer brother kidney cancer renal failure congestive heart failure diabetes mellitus tobacco abuse alcohol abuse sister ovarian cancer dx age brother throat cancer dx age died in sister brca1 mutation breast cancer daughter living abnormal pap smear substance abuse son died substance abuse heroin overdose on physical exam physical exam on admission vitals temp po bp r lying hr rr o2 sat o2 delivery ra general tearful expressing right back and leg pain with spasms chest l breast incisions well healed s p l axilla surgical drain removal cv regular rate and rhythm normal s1 s2 no murmurs lungs clear to auscultation bilaterally no wheezes or crackles abdomen soft non tender non distended bowel sounds present ext warm well perfused right lower extremity is tender to palpation and movement limited by pain swelling of rle lle palpable pulses bilaterally skin warm dry varicose veins noted in lower extremities neuro grossly oriented msk exam right si joint tenderness radicular pain worsened with back flexion and relieved with extension strength bilaterally w hip flexion and extension knee flexion and extension foot plantar and dorsiflexion sensation in tact bilaterally ortho spine exam pe vs temp po bp r lying hr rr o2 sat o2 delivery ra temp po bp r lying hr rr o2 sat o2 delivery ra nad a ox4 nl resp effort rrr sensory ue c5 c6 c7 c8 t1 lat arm thumb mid fing sm finger med arm r silt silt silt silt silt l silt silt silt silt silt t2 l1 trunk silt l2 l3 l4 l5 s1 s2 groin knee med calf grt toe sm toe post thigh r silt silt silt silt silt silt l silt silt silt silt silt silt motor ue dlt c5 bic c6 we c6 tri c7 wf c7 ff c8 finabd t1 r l flex l1 add l2 quad l3 ta l4 r l reflexes bic c4 br c5 tri c6 pat l3 ach l5 s1 r l negative babinski downgoing clonus no beats pertinent results imaging mr thoracic spine w o contrast mr spine w o contrast impression severe central canal narrowing at l4 level from degenerative changes large right paramedian superior disc extrusion l4 level extends into right l4 lateral recess mass effect on exiting right l4 traversing l5 nerves severe right l4 foraminal narrowing advanced degenerative changes lumbar spine moderate central canal narrowing l2 l3 moderate to severe at l3 l4 levels multilevel significant foraminal narrowing lumbar spine as above degenerative changes thoracic spine mild to moderate central canal narrowing foraminal narrowing ct abd pelvis with contrast impression no acute ct findings in the abdomen or pelvis to correlate with patient s reported symptoms specifically no evidence of obstructive renal stone or pyelonephritis sigmoid diverticulosis without evidence of acute diverticulitis admission labs 49pm blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 49pm blood ptt 49pm blood glucose urean creat na k cl hco3 angap 06am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 53am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 06am blood plt 30am blood glucose urean creat na k cl hco3 angap 30am blood glucose urean creat na k cl hco3 angap 49am blood glucose urean creat na k cl hco3 angap 30am blood calcium phos mg 49am blood calcium phos mg 30am blood calcium phos mg brief hospital course initial admission active issues r low back pain and leg pain radiculopathy patient presents with severe right lower back pain with prominent lancinating component ct a p with no evidence of visceral pathology or nephrolithiasis mri l spine with significant disc bulge at l2 l3 and l3 cause severe narrowing of the spinal canal and extrusion at l4 with significant l4 nerve root compression likely the cause of patient s pain she was recently admitted with right leg pain with exam notable for trochanteric bursitis now s p injection of corticosteroid currently neruovascularly intact with no evidence of cord compression by history or on exam per ortho spine would benefit from decompression she had a decompression l2 s1 fusion l4 l5 duraplasty on w ortho spine once her inr was she was started on a heparin bridge on when her inr dropped below and transitioned to lovenox bridge to coumadin on dysuria resolved uti states she has been having burning pain with urination recently she also feels that she needs to push on her abdomen to urinate most concerning for uti ua demonstrating large leukocytes and wbc however urine culture showing mixed bacterial flora consistent with contamination will treat given symptoms abdominal pain could also be from constipation in the setting of opioid use reports resolution of symptoms on was treated with bactrim ds bid for days starting and ending chronic issues history of dvt pe antiphospholipid antibody syndrome lupus anticoagulant positive in had bilateral pe in she has been taking her home dose of warfarin mg and mg other days warfarin held on admission for procedure with heparin drip until procedure aaa has a reported history of aaa in chart but does not follow up with anyone for surveillance and ct abd pelvis did not show an abdominal aortic aneurysm vitamin d deficiency continued vitamin d daily osa remained on cpap other home meds continued omeprazole 20mg bid for gerd continued sertraline 150mg po daily for depression continued albuterol neb soln neb ih q6h prn cough wheeze held proair held trazadone while getting opioids held furosemide 20mg po daily prn takes rarely d c gabapentin not helping and not taking d c erythromycin no longer taking admission to ortho spine ms is a female with a past medical history significant for osa cerebral aneurysm abdominal aortic aneurysm antiphospholipid syndrome w multiple dvts and one event of bilateral large pes on warfarin brca1 mutation w l sided breast cancer s p lumpectomy who presents with over one month of right lower back pain with radicular pain down the right leg pain found to have significant disc herniations at l2 l5 she is now s p l2 lami l4 discectomy and non instrumented fusion c b durotomy s p post op course patient was admitted to the spine surgery service and taken to the operating room for the above procedure refer to the dictated operative note for further details the surgery was without complication and the patient was transferred to the pacu in a stable condition postoperative dvt drip post op with trasition back to lovenox bridge to coumadin on activity remained flat bedrest for dural tear precautions for hours activity was advanced after hours intravenous antibiotics were continued for 24hrs postop per standard protocol initial postop pain was controlled with oral and iv pain medication diet was advanced as tolerated foley was removed on pod physical therapy and occupational therapy were consulted for mobilization oob to ambulate and adl s post op course was notable for acute blood loss anemia constipation pain and hypokalemia acute blood loss anemia is stable and did not require intervention she was treated with immediate release morphine valium and tylenol for pain control oral potassium was given for hypokalemia of on vitals and labs are otherwise stable hospital course was otherwise unremarkable on the day of discharge the patient was afebrile with stable vital signs comfortable on oral pain control and tolerating a regular diet medications on admission the preadmission medication list is accurate and complete acetaminophen mg po q8h prn pain mild fever albuterol neb soln neb ih q6h prn cough wheeze atorvastatin mg po qpm docusate sodium mg po bid omeprazole mg po bid polyethylene glycol g po daily prn constipation first line senna mg po hs sertraline mg po daily trazodone mg po qhs prn sleep vitamin d unit po daily warfarin mg po 2x week lidocaine patch ptch td qam right hip furosemide mg po daily prn leg swelling proair hfa albuterol sulfate mcg actuation inhalation q4h prn warfarin mg po 5x week gabapentin mg po tid tramadol mg po q6h prn pain moderate discharge medications diazepam mg po q8h prn pain spasm may cause drowsiness rx diazepam mg tablet by mouth every eight hours disp tablet refills enoxaparin sodium mg sc q12h antiphospholipid syndrome treatment bridge dosing morphine sulfate mg po q6h prn pain severe please do not operate heavy machinery drink alcohol or drive rx morphine mg tablet s by mouth every six hours disp tablet refills furosemide mg po daily prn leg swelling acetaminophen mg po q8h prn pain mild fever albuterol neb soln neb ih q6h prn cough wheeze atorvastatin mg po qpm docusate sodium mg po bid lidocaine patch ptch td qam right hip omeprazole mg po bid polyethylene glycol g po daily prn constipation first line proair hfa albuterol sulfate mcg actuation inhalation q4h prn senna mg po hs sertraline mg po daily trazodone mg po qhs prn sleep vitamin d unit po daily warfarin mg po 5x week warfarin mg po 2x week discharge disposition extended care facility discharge diagnosis lumbar spinal stenosis spondylolisthesis l4 l5 uti constipation secondary diagnoses history of dvt pe antiphospholipid antibody syndrome aaa osa on cpap discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions it was a pleasure to care for you at the why did you come to the hospital you came to the hospital because you were having worsening back pain with pain radiating down your right leg this pain started about a month ago and progressively got worse making it difficult to walk you also had burning pain with urination what did you receive in the hospital you had an mri that showed significant disc herniation in your lower back which was the cause of your pain the spine surgeons felt that you would benefit from surgery given that your pain was constant and worsening over the past month we gave you pain medications and stopped your warfarin until it was safe for you to have surgery you had a spinal decompression on we also gave you antibiotics for your burning pain with urination which we believe was caused by a urinary tract infection what should you do once you leave the hospital lumbar decompression with fusion you have undergone the following operation lumbar decompression with fusion immediately after the operation activity you should not lift anything greater than lbs for weeks you will be more comfortable if you do not sit or stand more than minutes without getting up and walking around rehabilitation physical times a day you should go for a walk for minutes as part of your recovery you can walk as much as you can tolerate limit any kind of lifting diet eat a normal healthy diet you may have some constipation after surgery you have been given medication to help with this issue brace you may have been given a brace if you have been given a brace this brace is to be worn when you are walking you may take it off when sitting in a chair or while lying in bed wound care please keep the incision covered with a dry dressing on until your follow up appointment do not soak the incision in a bath or pool if the incision starts draining at anytime after surgery do not get the incision wet call the office at that time you should resume taking your normal home medications you have also been given additional medications to control your pain please allow hours for refill of narcotic prescriptions so please plan ahead you can either have them mailed to your home or pick them up at the clinic located on we are not allowed to call in or fax narcotic prescriptions oxycontin oxycodone percocet to your pharmacy in addition we are only allowed to write for pain medications for days from the date of surgery follow up please call the office and make an appointment for weeks after the day of your operation if this has not been done already at the week visit we will check your incision take baseline x rays and answer any questions we may at that time start physical therapy we will then see you at weeks from the day of the operation and at that time release you to full activity please call the office if you have a fever degrees fahrenheit and or drainage from your wound physical therapy weight bearing as tolerated gait balance training no lifting lbs no significant bending twisting treatments frequency please keep the incision covered with a dry dressing on until your follow up appointment do not soak the incision in a bath or pool if the incision starts draining at anytime after surgery do not get the incision wet call the office at that time followup instructions

name unit no admission date discharge date date of birth sex f service orthopaedics allergies codeine augmentin topamax attending chief complaint left knee osteoarthritis pain major surgical or invasive procedure left total knee arthroplasty history of present illness year old female w left knee osteoarthritis pain who failed conservative measures now admitted for left total knee arthroplasty past medical history dyslipidemia varicose veins r l s p ligation copd osa cpap recent uri received course of zithromax bilateral pes antiphospholipid antibody syndrome on lifelong anticoagulation t2dm last a1c on cerebral aneurysm followed by dr unchanged gerd diverticulosis h o colon polyps depression s p right cmc joint arthroplasty b l rotator cuff repair excision right digit mass ccy w stone pancreatic duct exploration hysterectomy tonsillectomy social history family history no family hx of dvt or pe two sisters have atrial fibrillation physical exam well appearing in no acute distress afebrile with stable vital signs pain well controlled respiratory ctab cardiovascular rrr gastrointestinal nt nd genitourinary voiding independently neurologic intact with no focal deficits psychiatric pleasant a o x3 musculoskeletal lower extremity aquacel dressing with scant serosanguinous drainage thigh full but soft no calf tenderness strength silt nvi distally toes warm pertinent results 30am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 10am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 22am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30am blood plt 30am blood 10am blood plt 10am blood 22am blood plt 22am blood 55am blood 22am blood glucose urean creat na k cl hco3 angap 22am blood calcium phos mg brief hospital course the patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure please see separately dictated operative report for details the surgery was uncomplicated and the patient tolerated the procedure well patient received perioperative iv antibiotics postoperative course was remarkable for the following pod patient was administered 500ml bolus of iv fluids for hypotension which she responded to appropriately she reported nausea on oxycodone and was switched to dilaudid with no reported adverse effects pod patient had inr of and lovenox was discontinued patient will continue coumadin 5mg daily next inr check day after discharge please direct results and all questions to pcp for inr monitoring coumadin dosing pod inr and patient will be due for 5mg coumadin upon arrival to rehab facility otherwise pain was controlled with a combination of iv and oral pain medications the patient received coumadin starting on pod with a lovenox bridge starting on pod lovenox to be continued until inr and discontinued on pod with inr coumadin was dosed daily based on her inr levels the surgical dressing will remain on until pod after surgery the patient was seen daily by physical therapy labs were checked throughout the hospital course and repleted accordingly at the time of discharge the patient was tolerating a regular diet and feeling well the patient was afebrile with stable vital signs the patient s hematocrit was acceptable and pain was adequately controlled on an oral regimen the operative extremity was neurovascularly intact and the dressing was intact the patient s weight bearing status is weight bearing as tolerated on the operative extremity please use walker or crutches wean as able ms is discharged to rehab in stable condition patient will be in rehab facility for less than days medications on admission albuterol neb soln neb ih q4h prn wheezing cough atorvastatin mg po qpm econazole topical bid enoxaparin sodium mg sc q12h start today first dose next routine administration time furosemide mg po daily prn leg swelling metformin glucophage mg po qpm omeprazole mg po bid sertraline mg po daily trazodone mg po qhs prn insomnia triamcinolone acetonide ointment appl tp bid prn rash itching warfarin mg po daily16 aspirin mg po daily vitamin d unit po daily discharge medications docusate sodium mg po bid gabapentin mg po tid hydromorphone dilaudid mg po q4h prn pain moderate do not drink alcohol or drive while taking med senna mg po bid acetaminophen mg po q8h warfarin mg po to be dosed daily per pcp dosed daily per pcp goal inr albuterol inhaler puff ih q6h prn shortness of breath aspirin mg po daily atorvastatin mg po qpm econazole topical bid furosemide mg po daily prn leg swelling metformin xr glucophage xr mg po daily omeprazole mg po bid sertraline mg po daily trazodone mg po qhs prn insomnia triamcinolone acetonide ointment appl tp bid prn rash itching vitamin d unit po daily discharge disposition extended care facility discharge diagnosis left knee osteoarthritis pain discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions please return to the emergency department or notify your physician if you experience any of the following severe pain not relieved by medication increased swelling decreased sensation difficulty with movement fevers greater than shaking chills increasing redness or drainage from the incision site chest pain shortness of breath or any other concerns please follow up with your primary physician regarding this admission and any new medications and refills resume your home medications unless otherwise instructed you have been given medications for pain control please do not drive operate heavy machinery or drink alcohol while taking these medications as your pain decreases take fewer tablets and increase the time between doses this medication can cause constipation so you should drink plenty of water daily and take a stool softener such as colace as needed to prevent this side effect call your surgeons office days before you are out of medication so that it can be refilled these medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house please allow an extra days if you would like your medication mailed to your home you may not drive a car until cleared to do so by your surgeon please call your surgeon s office to schedule or confirm your follow up appointment swelling ice the operative joint minutes at a time especially after activity or physical therapy do not place ice directly on the skin you may wrap the knee with an ace bandage for added compression please do not take any non steroidal anti inflammatory medications nsaids such as celebrex ibuprofen advil aleve motrin naproxen etc until cleared by your physician anticoagulation lovenox discontinued on due to inr inr goal is please continue coumadin 5mg daily inr to be checked day after discharge please direct all inr results to patient s pcp you may continue your dose of aspirin 81mg daily wound care please remove aquacel dressing on pod after surgery it is okay to shower after surgery after days but no tub baths swimming or submerging your incision until after your four week checkup please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage otherwise leave it open to air check wound regularly for signs of infection such as redness or thick yellow drainage once at home home dressing changes as instructed and wound checks activity weight bearing as tolerated on the operative extremity two crutches or walker wean assistive device as able mobilize rom as tolerated no strenuous exercise or heavy lifting until follow up appointment physical therapy wbat lle no range of motion restrictions wean assistive devices as able mobilize frequently treatments frequency remove aquacel pod after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed followup instructions

name unit no admission date discharge date date of birth sex f service neurosurgery allergies no known allergies adverse drug reactions attending chief complaint headaches major surgical or invasive procedure suboccipital craniotomy for resection of cerebellar lesion history of present illness is a female with hx cerebral aneurysm clipping in who presents from osh with left cerebellar hypodensity concerning for underlying lesion patient reports that three weeks ago she started having headaches which is abnormal for her she describes the headaches to be global and resolve with tylenol but at the worst was an she also reports having difficulty walking which also started about three weeks ago she describes her walking as staggering side to side she denies any vision changes nausea vomiting confusion or word finding difficulty she saw her eye doctor this morning for routine visit who referred her to the ed for evaluation of these symptoms osh ct showed an area of hypodensity in the left cerebellum concerning for underlying lesion she was subsequently transferred to of note patient reports her aneurysm clip is not mri compatible past medical history hypertension s p aneurysm clipping at by dr social history family history no known history of stroke cancer aneurysm physical exam on admission o t bp hr r o2sats ra gen wd wn comfortable nad heent pupils l r eoms full neck supple extrem warm and well perfused neuro mental status awake and alert cooperative with exam normal affect orientation oriented to person place and date language speech fluent with good comprehension and repetition naming intact no dysarthria or paraphasic errors cranial nerves i not tested ii left pupil 4mm right 3mm both equally reactive to light iii iv vi extraocular movements intact bilaterally without nystagmus v vii facial strength and sensation intact and symmetric xi sternocleidomastoid and trapezius normal bilaterally xii tongue midline without fasciculations motor normal bulk and tone bilaterally no abnormal movements tremors strength full power throughout slight left upward drift sensation intact to light touch coordination normal on finger nose finger and heel to shin on discharge exam opens eyes x spontaneous to voice to noxious orientation x person x place x time follows commands simple x complex none pupils right 3mm left 4mm chronic eom full x restricted chronic most prominent left lateral face symmetric x yes notongue midline x yes no pronator drift yes x no speech fluent x yes no comprehension intact x yes no motor trapdeltoid biceptricepgrip right left ipquadhamatehlgast right5 left5 x sensation intact to light touch pertinent results please see omr for pertinent lab and imaging results brief hospital course brain lesion patient was found to have cerebellar hypodensity on nchct from osh ct w wo contrast was obtained while in the ed at which was concerning for underlying mass lesion and hydrocephalus of note she was unable to get mri due to reportedly having a non compatible aneurysm clip that was placed in at patient was admitted to the for close monitoring and surgical planning she was started on dexamethasone 4mg q6hr for mass effect ct torso was obtained which showed two lung nodules see below for more information neuro and radiation oncology were consulted plan was made for surgical resection of the lesion on it was determined that her aneurysm clip was mri compatible and she was able to have a mri brain for surgical planning she went to the or the evening of for a suboccipital craniotomy for resection of her cerebellar lesion postoperatively she was monitored in neuro icu where she remained neurologically and hemodynamically stable she was transferred to the on pod and made floor status her dexamethasone was ordered to taper down to a maintenance dose of 2mg bid over the course of one week her pathology finalized as small cell lung carcinoma lung lesions ct torso was obtained which showed two lung nodules one in the left paramedian abutting the aortic arch and the other in the right upper lobe pulmonary was consulted and stated that no further intervention was indicated until final pathology was back heme onc was also consulted and made recommendations that no further lung imaging or separate lung biopsy was needed both pulmonary and heme onc stated that staging and treatment could be determined based on the tissue pathology from resection of the brain lesion her final pathology came back as small cell lung carcinoma she will follow up with the thoracic oncologist on steroid induced hyperglycemia throughout her admission the patient intermittently required sliding scale insulin for elevated blood sugars while on dexamethasone she was evaluated by the inpatient team on who decided that she did not need to go home on insulin they recommended discharging her with a glucometer so that she could check her blood sugars daily with a goal blood sugar less than she was advised to record her readings and follow up with her pcp and bradycardia she was due to transfer out to the on pod1 however was kept in the icu for asymptomatic bradycardia to the she remained asymptomatic and her heartrate improved with fluids and administration of her levothyroxine she intermittently dipped to the however remained asymptomatic bell s palsy the patient was resumed on her home valacyclovir and prenisolone gtts urinary urgency on pod the patient complained of urinary urgency and increased frequency u a was negative and culture was negative her symptoms had resolved at the time of discharge dispo the patient was evaluated by and ot who cleared her for home with services she was discharged on in stable condition she will follow up in on medications on admission asa 81mg alendronate 70mg weekly vitamin d3 units daily levothyroxine 88mcg daily lisinopril 20mg daily discharge medications acetaminophen mg po q6h prn pain mild fever bisacodyl mg po pr daily dexamethasone mg po q8h duration doses start 3tabsq8hrs x2 2tabsq8hrs x6 2tabsq12hrs maintenance dose this is dose of tapered doses rx dexamethasone mg tablet s by mouth every eight hours disp tablet refills docusate sodium mg po bid famotidine mg po q24h rx famotidine mg tablet s by mouth twice a day disp tablet refills polyethylene glycol g po daily prn constipation first line senna mg po hs levothyroxine sodium mcg po daily lisinopril mg po daily prednisolone acetate ophth susp drop left eye qid valacyclovir mg po q8h vitamin d unit po daily held alendronate sodium mg po 1x week this medication was held do not restart alendronate sodium until pod held aspirin mg po daily this medication was held do not restart aspirin until pod glucometer freestyle glucometer check blood sugars hours after a starchy meal record numbers and show to your oncologist test strips check blood sugars qd refills lancets check blood sugars qd refills discharge disposition home with service facility discharge diagnosis brain tumor discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory requires assistance or aid discharge instructions surgery you underwent surgery to remove a brain lesion from your brain a sample of tissue from the lesion in your brain was sent to pathology for testing please keep your incision dry until your sutures are removed you may shower at this time but keep your incision dry it is best to keep your incision open to air but it is ok to cover it when outside call your surgeon if there are any signs of infection like redness fever or drainage activity we recommend that you avoid heavy lifting running climbing or other strenuous exercise until your 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 months medications please do not take any blood thinning medication aspirin ibuprofen plavix coumadin until cleared by the neurosurgeon we held your aspirin 81mg daily you are cleared to resume this medication on pod we held your home alendronate during this admission you are cleared to resume this medication on pod you may use acetaminophen tylenol for minor discomfort if you are not otherwise restricted from taking this medication you were started on dexamethasone a steroid that treats intracranial swelling this dexamethasone is being tapered down to a maintenance dose of 2mg bid please take this medication as prescribed while admitted you had elevated blood glucose levels that needed to be treated by insulin you should continue to check your blood sugars daily at home with the prescribed glucometer you visiting nurse should teach you how to use this device at home please record your blood sugars and follow up with your pcp and regarding the results your goal blood sugar is less than what you experience you may experience headaches and incisional pain you may also experience some post operative swelling around your face and eyes this is normal after surgery and most noticeable on the second and third day of surgery you apply ice or a cool or warm washcloth to your eyes to help with the swelling the swelling will be its worse in the morning after laying flat from sleeping but decrease when up you may experience soreness with chewing this is normal from the surgery and will improve with time softer foods may be easier during this time feeling more tired or restlessness is also common constipation is common be sure to drink plenty of fluids and eat a high fiber diet if you are taking narcotics prescription pain medications try an over the counter stool softener when to call your doctor at for severe pain swelling redness or drainage from the incision site fever greater than 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 followup instructions

name no admission date discharge date date of birth sex f service medicine allergies meropenem penicillins attending chief complaint brbpr major surgical or invasive procedure aborted flexible sigmoidoscopy attempt due to stool in vault flexible sigmoidoscopy history of present illness this is an year old female with past medical history of sjogrens hypothyroidism recent diagnosis of l1 compression fracture prior cdiff infection presenting with bright red blood per rectum patient reports that on morning of presentation she awoke in her normal state of health her home health aid helped her to the commode and she suddenly had a large volume over blood per rectum over the next minutes she then had subsequent episodes home health aid consulted with family and then called in the ed vs were ra labs were notable for wbc hgb plt k cr lactate ua neg leuk nitr exam reported as tachycardia grossly blood rectum without large hemorrhoids peg lavage reported as negative for blood gi note on the ed dashboard stated with c diff on flagyl presenting with maroon colored gib hds hct with normal coag please continue with supportive care with fluids and transfusion as needed if on going bleeding or hemodynamic changes please get cta if concern of upper gi bleeding can lavage via peg please give ppi if positive patient was given 1l normal saline and was admitted to medicine on arrival to the floor patient reported above reported recent diagnosis of l1 compression fracture and intermittent difficulty with flushing her peg tube at home full point review of systems positive where noted otherwise negative past medical history sjogrens hypothyroidism h o severe cdiff protein calorie malnutrition s p peg osteoporosis s p l1 compression fracture depression hemorrhoids normocytic anemia bronchiectasis h o shingles dementia mitral regurgitation social history family history has children father had hemorrhoids no history of cancer gi bleeding physical exam admission vs on recheck ra gen supine in bed comfortable pale eyes eomi ent op clear mmm heart regularly tachycardic ii vi systolic murmur loudest at axilla lungs cta bilaterally abd soft nontender normoactive bowel sounds peg in place rectum dark maroon blood in vault no large hemorrhoids palpated ext trace edema to mid shin skin pale no rashes vasc dp radial pulses neuro aox2 full name moving all extremities psych appropriate discharge vs ra gen supine in bed comfortable appearing eyes eomi ent op clear mmm heart rrr ii vi systolic murmur loudest at axilla lungs cta bilaterally unchanged from day prior abd soft nontender normoactive bowel sounds peg in place unchanged from yesterday ext no edema skin no rashes vasc dp radial pulses neuro aox3 full name moving all extremities psych appropriate pertinent results admission 37am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 37am blood glucose urean creat na k cl hco3 angap 00am blood alt ast alkphos totbili discharge 20am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 20am blood glucose urean creat na k cl hco3 angap flexible sigmoidoscopy mucosa normal mucosa was noted in the rectum and sigmoid colon other no bleeding sources or blood identified though extent of sigmoid colon evaluated was limited by poor prep impression normal mucosa in the rectum and sigmoid colon no bleeding sources or blood identified though extent of sigmoid colon evaluated was limited by poor prep otherwise normal sigmoidoscopy to sigmoid colon at cm recommendations if bleeding recurs would recommend full colonoscopy with prep brief hospital course this is an year old female with past medical history of sjogrens hemorrhoids prior cdiff infection admitted with bright red blood per rectum thought to be acute lower gi bleed subsequently stabilizing without intervention status post flexible sigmoidoscopy without identifiable source remaining stable x greater than days able to be discharged to rehab facility acute gi bleed nos patient presented with acute episode of brbpr concerning for lower gi source patient subsequently monitored without new or worsening anemia after discussion with family and patient regarding whether or not to further workup they opted for flexible sigmoidoscopy felt colonoscopy might be too invasive patient underwent aborted flexible sigmoidoscopy on due to pressence of copious stool in rectal vault and then underwent successful flexible sigmoidoscopy on without identifiable source for her bleeding from admission hgb discharge hemoglobin was per gi could consider outpatient colonoscopy if consistent with patient s wishes osteoporosis chronic l1 compression fracture deconditioning patient with recent l1 compression fracture as outpatient prior to admission patient noted to be significantly deconditioned this admission requiring assistance with adls patient seen by and recommended for rehab continued home calcium vitamin d calcitonin placed on tylenol and tramadol for pain control with good effect chronic severe protein calorie malnutrition per discussion with family and review of chart patient has lost weight despite peg placement and bolus tube feeds has had difficulty maintaining po intake due to her sjogrens at home patient has not be using full recommended cans of nutren cal 250ml bid here patient seen by nutrition continued on above cans and was given oral supplementation with her po meals as well depression continued home bupropion and mirtazapine hypothryoidism continued levothyroxine transitional issues code status dnr dni discharged to rehab no source for bleeding identified this admission can consider future colonoscopy to look for source of bleeding but would first discuss if consistent with patient s goals of care would consider encouragement of po intake and peg tube supplementation given her malnutrition medications on admission the preadmission medication list is accurate and complete bupropion xl once daily mg po daily calcium d calcium carbonate vitamin d3 mg 250mg unit oral daily levothyroxine sodium mcg po daily mirtazapine mg po qhs tramadol mg po bid prn back pain acetaminophen mg po q6h prn back pain alendronate sodium mg po qsun calcitonin salmon unit nas daily multivitamins tab po daily tramadol mg po qhs prn back pain artificial tears drop both eyes qid discharge medications acetaminophen mg po q8h prn pain bupropion xl once daily mg po daily calcitonin salmon unit nas daily levothyroxine sodium mcg po daily mirtazapine mg po qhs multivitamins tab po daily tramadol mg po bid prn back pain alendronate sodium mg po qsun calcium d calcium carbonate vitamin d3 mg 250mg unit oral daily tramadol mg po qhs prn back pain artificial tears drop both eyes qid discharge disposition extended care facility discharge diagnosis acute gi bleed nos depression osteoporosis chronic l1 compression fracture hypothryoidism chronic severe protein calorie malnutrition dementia discharge condition mental status confused sometimes level of consciousness alert and interactive activity status ambulatory requires assistance or aid walker or cane discharge instructions ms it was a pleasure caring for you at you were admitted with gastrointestinal bleeding you were seen by gi specialists and underwent a flexible sigmoidiscopy without signs of a source of your bleeding you were monitored and your blood levels were stable you are now ready for discharge home in the future you may wish to consider a colonoscopy to look for the source of your bleeding especially if it occurs again you should discuss with your family and primary care doctor regarding if this is within your goals of care followup instructions

name unit no admission date discharge date date of birth sex m service medicine allergies no allergies adrs on file attending chief complaint chest pain major surgical or invasive procedure bedside pericardiocentesis at history of present illness history of presenting illness mr is a male with rheumatoid arthritis dmard holiday and recent brief hospitalization for presumptive pericarditis returned to outside hospital with probable cardiac tamponade now post bedside pericardiocentesis with drain placement prior to transfer importantly patient was hospitalized at on with acute pleuritic chest pain of two day duration in the context of constellation of fatigue malaise upper respiratory symptoms and non productive cough while cta exonerated pulmonary embolism thickened pericardium and small effusion were noted suggesting pericarditis ecg revealed subtle diffuse st elevations in keeping with pericarditis echocardiogram confirmed said effusion though no features of tamponade were appreciated he was discharged the same day with ibuprofen mg tid and colchicine mg bid he had persistence of minor residual chest pain which began to worsen two days later but was tolerable until yesterday evening when it evolved to severe unrelenting pain across his precordium likened to wearing shoulder pads bearing down on him he notes a new concurrent substernal chest pain that goes straight to his back he then became dyspneic prompting him to seek care he arrived at hypotensive with sbp in the range he was borderline tachycardic and in mild respiratory distress but oxygenation was acceptable he rapidly received three liters of fluid for presumptive tamponade within the confines of poor windows on bedside echocardiogram pericardiocentesis yielded cc or more of serous fluid and a pericardial drain was placed hemodynamics rapidly improved on arrival to ed patient was indeed hemodynamically stable but was then in moderate respiratory distress requiring non rebreather he was given lasix mg iv bedside echocardiogram was limited but preliminarily suggestive of small residual effusion in the ccu patient notes resurgence of said chest pain his dyspnea is improving an additional cc was drained past medical history past medical history cardiac history pericarditis as above hypertension dyslipidemia other pmh rheumatoid arthritis remote traumatic dvt cholecystectomy appendectomy tonsillectomy left wrist reconstruction right rotator cuff reconstruction social history family history paternal history of ureothelial carcinoma maternal history of diabetes physical exam admission physical examination vs t hr bp o2 6l general obese male in mild to moderate respiratory distress heent anicteric sclerae oropharynx clear neck jvp at mandibular angle cardiac tachycardic regular with rare ectopy s1 s2 within the confines of body habitus subtle pericardial rub pericardial drain with serosanguinous fluid sternal tenderness lungs conversational dyspnea but tachypnea is slowing diffuse wheezing and crackles in bilateral lung fields abdomen obese soft non tender extremities warm well perfused pitting edema to knees skin chronic bilateral venous stasis dermatitis pulses distal pulses palpable and symmetric neuro non focal discharge physical examination general obese male in mild to moderate respiratory distress heent anicteric sclerae oropharynx clear neck jvp not appreciated cardiac normal rate and rhythm s1 s2 within the confines of body habitus no pericardial rub appreciated lungs decreased respiratory effort compared to yesterday expiratory wheezing and bibasilar crackles abdomen obese soft non tender non distended extremities warm well perfused to pitting edema to knees skin chronic venous stasis dermatitis pulses distal pulses palpable and symmetric neuro non focal pertinent results admission labs 57pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 57pm neuts lymphs monos eos basos im absneut abslymp absmono abseos absbaso 57pm ptt 57pm glucose urea n creat sodium potassium chloride total co2 anion gap 57pm calcium phosphate magnesium 57pm ctropnt 03pm lactate 05am pleural fluid studies polys lymphs monos imaging tte the left atrium is normal in size the inferior vena cava is dilated cm there is normal left ventricular wall thickness with a normal cavity size there is suboptimal image quality to assess regional left ventricular function overall left ventricular systolic function is normal quantitative biplane left ventricular ejection fraction is left ventricular cardiac index is normal l min m2 no ventricular septal defect is seen normal right ventricular cavity size with normal free wall motion there is abnormal interventricular septal motion the aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender the aortic arch diameter is normal there is no evidence for an aortic arch coarctation the aortic valve leaflets appear structurally normal there is no aortic valve stenosis there is no aortic regurgitation the mitral valve is not well visualized the tricuspid valve is not well seen the pulmonary artery systolic pressure could not be estimated there is no pericardial effusion micro am fluid other pericardial fluid gram stain final per 1000x field polymorphonuclear leukocytes no microorganisms seen this is a concentrated smear made by cytospin method please refer to hematology for a quantitative white blood cell count fluid culture preliminary reported to and read back by 53pm staphylococcus coagulase negative colony on plate anaerobic culture preliminary no anaerobes isolated fungal culture preliminary acid fast smear final no acid fast bacilli seen on direct smear acid fast culture preliminary discharge labs 01am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 30pm blood glucose urean creat na k cl hco3 angap 01am blood alt ast alkphos totbili 30pm blood calcium phos mg 57pm blood probnp 29am blood tsh 04am blood po2 pco2 ph caltco2 base xs brief hospital course summary male with rheumatoid arthritis dmard holiday and recent brief hospitalization for presumptive pericarditis returned to outside hospital with pericardial effusion with possible tamponade physiology now post bedside pericardiocentesis prior to transfer with persistent pericardial effusion now s p drain placement with course complicated by acute hypercapneic respiratory distress coronaries unknown pump normal biventricular structure and function rhythm nsr paf transitional issues he was discharged on ibuprofen 600mg tid and colchicine 6mg bid for his inflammatory pericarditis he should continue colchicine for months he should have his ibuprofen tapered weekly following resolution of his symptoms over weeks to reduce the risk of recurrence he was discharged on a ppi and should continue this while on ibuprofen strongly recommend that patient receive outpatient pfts given high suspicion for baseline obstructive restrictive pulmonary disease patient developed paroxysmal afib with rvr during this admission which is a new diagnosis chadsvasc for hypertension and diabetes anticoagulation was not started during this admission given that he was felt to have relatively low risk for cva however please make a note of this new diagnosis and reassess need for anticoagulation as medically appropriate he was newly diagnosed with dm hba1c at and will be discharged on metformin bid will require outpatient follow up for this and can consider uptitration in the outpatient setting please reassess need for diuretic in the outpatient setting he had no echocardiographic evidence of heart failure during this admission so was not discharged on diuretics new medications metformin 500mg bid metoprolol xl 50mg qd omeprazole 20mg qd continued medications atorvastatin 10mg qpm colchicine 6mg bid ibuprofen 600mg tid folic acid 1mg po qd sertraline 100mg po qd stopped medications methotrexate 20mg po famotidine 20mg qd acute issues acute pericarditis cardiac tamponade now s p pericardiocentesis and drain placement he presented with inflammatory pericarditis of probable viral nature in the context of viral like prodrome versus rheumatic pericarditis given serologic positive active disease in the absence of dmard pericardial fluid cultures from negative cultures here with colony on plate of coag negative staph felt to be contaminant negative acid fast smear no biochemical evidence of myocardial injury on admission unlikely to have concurrent myocarditis or cardiac event sequelae at was initially noted to have sbps in the and received fluid resuscitation and pericardiocentesis given concern for tamponade physiology hemodynamics subsequently stabilized and remained so throughout the duration of his admission here tte on showed no pericardial effusion pericardial drain was initially left to gravity due to continued output and was removed he was treated with colchicine 6mg bid which he will continue for months after discharge he also received ibuprofen 600mg po tid and will be discharged on a slow taper he received ppi while receiving nsaids acute hypercapnic respiratory failure resolving probable flash pulmonary edema from rapid large volume fluid administration on tamponade as evidenced by radiographic pulmonary edema earlier echocardiogram otherwise not suggestive of ventricular dysfunction and bnp is within normal limits tte on was without evidence of cardiac etiology for his pulmonary edema respiratory failure patient likely has unappreciated restrictive pulmonary physiology additionally no emphysematous changes noted on ct one week ago but background obstructive defect is conceivable given compelling smoking history he had a negative cta one week prior to admission patient had leukocytosis on admission without clear radiographic consolidation suggestive of pneumonia one dose of empiric azithromycin was given overnight and discontinued on he received iv diuresis with significant improvement in his respiratory status o2 weaned morning he was breathing comfortably on ra at the time of discharge with ambulatory saturations paroxysmal afib new diagnosis patient went into afib with rvr on and subsequently received metoprolol he subsequently flipped back into nsr his chadsvasc dm htn anticoagulation was discussed but ultimately deferred at the time of discharge given the patient s lower overall risk for cva and concerns regarding medication adherence cost he was discharged on metoprolol he should have his need for anticoagulation reassessed as an outpatient as medically appropriate type ii diabetes he was newly diagnosed with dm with a a1c of during this admission he was maintained on an insulin sliding scale during this admission and will be discharged on metformin 500mg bid chronic stable issues rheumatoid arthritis rf and anti ccp positive per outpatient rheumatology not currently endorsing sx suggestive of ra flare per discussion with op rheumatologist deferred restarting mtx and or other dmard until outpatient htn his home bp meds were held initially due to soft bps and were stopped at the time of discharge as he remained normotensive core measures code dnr dni contact hcp ex wife medications on admission the preadmission medication list is accurate and complete atorvastatin mg po qpm colchicine mg po bid ibuprofen mg po tid famotidine mg po daily lisinopril hydrochlorothiazide mg oral daily methotrexate mg po 1x week sertraline mg po daily folic acid mg po daily discharge medications albuterol inhaler puff ih q6h prn wheezing shortness of breath rx albuterol sulfate proair hfa mcg puffs ih every hours as needed disp inhaler refills metformin glucophage mg po bid rx metformin mg tablet s by mouth twice a day disp tablet refills metoprolol succinate xl mg po daily rx metoprolol succinate mg tablet s by mouth daily disp tablet refills omeprazole mg po daily rx omeprazole mg capsule s by mouth daily disp capsule refills atorvastatin mg po qpm colchicine mg po bid rx colchicine mg capsule s by mouth twice a day disp capsule refills folic acid mg po daily ibuprofen mg po tid sertraline mg po daily held lisinopril hydrochlorothiazide mg oral daily this medication was held do not restart lisinopril hydrochlorothiazide until instructed by your primary care doctor or cardiologist held methotrexate mg po 1x week this medication was held do not restart methotrexate until a doctor tells you to discharge disposition home discharge diagnosis primary diagnosis inflammatory pericarditis secondary diagnosis rheumatoid arthritis discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear mr why were you admitted to the hospital you were admitted to the hospital with chest pain what was done while you were in the hospital you were found to have inflammation and a build up of fluid in the lining of the heart you had a procedure to remove the fluid from the lining of the heart and a temporary drain placed this was removed before you left the hospital you received medication to help you pee off the excess fluid in your body you developed an abnormal heart rhythm afib while in the hospital you were started on a new medication for this metoprolol you were diagnosed with diabetes during this admission you were started on a new medication for this metformin what do you need to do when you leave the hospital take all of your medications as prescribed listed below follow up with your doctors as listed below weigh yourself every morning seek medical attention if your weight goes up more than lbs seek medical attention if you have new or concerning symptoms or you develop swelling in your legs abdominal distention or shortness of breath at night please see below for more information on your hospitalization it was a pleasure taking part in your care here at we wish you all the best your care team followup instructions

name unit no admission date discharge date date of birth sex f service neurology allergies amoxicillin attending chief complaint weakness and lethargy major surgical or invasive procedure none history of present illness patient is a year old female with history of chronic abdominal pain and anemia w recent fe sucrose infusion complicated by infusion reaction mottling and discoloration of feet s p iv steroids who presents with increasing lethargy and headache history per records and per her aunt as patient cannot provide much history per her aunt has been doing well recently without any illness behavioral change she had a cold she was getting over but otherwise doing well she had an fe transfusion on around 30p at and the aunt accompanied her to the visit towards the end of the infusion developed mottle purple lower extremities and was having nausea heart racing she was sent to where she had sbp up to her exam per records notable for shivering doesn t open her eyes mottled hands and feet there was no concern for respiratory distress she was given mg iv benadryl mg iv hydrocortisone and observed for hours and then discharged at that time was reportedly lethargic meaning sleeping frequently but able to sit up and walk without issue they arrived home and went to bed around am on aunt check on her and she was still sleeping she was reporting a headache which the transfusion place said would happen but did not mention other characteristic aunt gave her acetaminophen and water and went back to sleep over the next few hours she heard awake several times and use the bathroom then as it got later and later into the day and was not up and about yet her aunt became worried she told to call the which she was able to do she reportedly said she continued to have a headache and felt sleepy she was instructed to go to the ed she went to the ed at for evaluation at she had t p rr and sat bp she was reportedly drowsy and arousing to voice alert oriented x3 consistent eye fluttering pupils reactive to light and extraocular eye movements full with reportedly non focal exam lab work notable for wbc hgb na bicarb cr ca normal lfts fe ferritin vbg ph was pco2 was she had a normal and lp with wbc monocytes glucose protein no xanthochromia she ultimately had mra and mrv which showed no thrombus or venoous thrombosis she was transferred to for further management on my interview she cannot provide much history other than to say she is here because i m tired she keeps her eyes closed during questioning she reports headache but cannot describe where it is or features other than photophobia she is unable to participate in other questioning often getting tearful and saying the questions are hard per her father and aunt she has no history of seizures or cns infection she did have a concussion at years old past medical history anemia social history family history mother with a celiac disease and autoimmune hypothyroidism dad is healthy she has a cousin with seizures physical exam admission exam ra general appears to be sleeping occasional eye lid fluttering lip movements occasional slow movements of head from side to side heent no trauma no jaundice no lesions of oropharynx cv rrr wwp pulm breathing comfortably on ra ext clammy warm and no rash neurologic mental status she frequently gets upset during exam and is tearful at times then abulic at other times eyes open only briefly to voice she is oriented to but not full date knows she is in a hospital but not the name she says she is in the hospital because i m tired she is unable to provide history speech is not dysarthric says words when asked questions no spontaneous speech output follows simple commands like open eyes lift legs she is able to name key and feather on stroke card but then stops naming and closes her eyes she reads the first sentence on stroke card but then no more and closes her eyes when asked to describe stroke card picture she says dishes she does not participate in further exam cranial nerves ii iii iv vi pupils mm mm eomi without nystagmus vff to confrontation fundoscopic exam revealed no papilledema exudates or hemorrhages vii no facial droop facial musculature symmetric with grimace viii hearing intact to exam ix x palate elevates symmetrically xii tongue protrudes in midline motor normal bulk tone throughout she says she cannot move her arms when arms placed over her head her arms slowly miss her face and slowly drops to the bed in a controlled fashion she does lift her arms to hold the side rails of the bed spontaneously she lifts her legs antigravity and holds them without drift sensory slightly withdrawals in upper extremities and says ouch briskly withdrawals in lower extremities to noxious stimuli and says ouch dtrs tri pat ach l r plantar response was flexor bilaterally coordination patient could not participate gait could not assess as patient would not get out of bed discharge exam general sitting up in her chair with eyes closed heent no trauma no jaundice no lesions of oropharynx cv sinus bradycardia no m r g pulm breathing comfortably on ra ext warm and well perfused no rash or mottling neurologic mental status answering questions with slow short sentence more humor and complex sentences observed today eyes intermittently close while she is talking speech is not dysarthric no spontaneous speech output follows simple commands cranial nerves ii iii iv vi pupils mm mm eomi without nystagmus v facial sensation intact throughout vii no facial droop facial musculature symmetric with grimace but limited facial movements ix x xii palate elevates symmetrically tongue midline motor normal bulk tone throughout lifting arms and legs against gravity but not against resistance sensory sensation intact to touch and temperature throughout dtrs patellar biceps brachioradialis throughout coordination no dysmetria or tremor gait ambulated well with a pertinent results admission labs 59pm glucose urea n creat sodium potassium chloride total co2 anion gap 59pm alt sgpt ast sgot alk phos tot bili 59pm calcium phosphate magnesium 59pm ttg iga 59pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 59pm plt count 11am urine hours random 11am urine ucg negative 11am urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg oxycodn neg mthdone neg 11am urine color straw appear clear sp 11am urine blood lg nitrite neg protein neg glucose neg ketone tr bilirubin neg urobilngn neg ph leuk neg 11am urine rbc wbc bacteria few yeast none epi 11am urine mucous rare 34am ptt 28am wbc rbc hgb hct mcv mch mchc rdw rdwsd 28am neuts monos eos basos im absneut abslymp absmono abseos absbaso 28am plt count 11am po2 pco2 ph total co2 base xs comments green top 10am glucose urea n creat sodium potassium chloride total co2 anion gap 10am estgfr using this 10am alt sgpt ast sgot ck cpk alk phos tot bili 10am ck mb 10am albumin calcium phosphate magnesium 10am vit b12 10am tsh 10am tsh 10am titer crp dsdna negative 10am c3 c4 10am asa neg ethanol neg acetmnphn neg tricyclic neg eeg impression this telemetry captured no pushbutton activations the background showed normal waking and sleep patterns there were no focal abnormalities epileptiform features or electrographic seizures a bradycardia was noted imaging mri brain with without contrast findings a mm flair hypointense and t1 isointense lesion at midline between the anterior and posterior pituitary is noted there is no evidence of hemorrhage edema mass effect midline shift or infarction the ventricles and sulci are normal in caliber and configuration there is no abnormal enhancement after contrast administration impression a mm flair hypointense and t1 isointense lesion at midline between the anterior and posterior pituitary likely represents a rathke s cleft cyst further evaluation is needed dedicated pituitary mr may be obtained brief hospital course see worksheet medications on admission famotidine mg daily birth control per her aunt mcg po daily famotidine mg po daily metoprolol tartrate mg po daily multivitamins w minerals tab po daily nortriptyline mg po qhs item miscellaneous once prognosis good months rx once disp each refills discharge disposition extended care facility discharge diagnosis functional neurological syndrome discharge condition mental status clear and coherent level of consciousness lethargic but arousable activity status ambulatory independent discharge instructions dear ms it was a pleasure taking care of you at you were in the hospital because of headache lethargy and weakness after an iron infusion you had a number of tests performed in the hospital all of which were reassuring an mri of your brain showed no evidence of stroke or inflammation an eeg to monitor your brain waves showed no evidence of seizure your weakness gradually improved over the course of your hospitalization and will continue to improve after you leave the hospital after leaving the hospital you should continue to work on improving your strength it will improve as long as you work hard we wish you the best your care team followup instructions

name unit no admission date discharge date date of birth sex f service medicine allergies amoxicillin iron attending major surgical or invasive procedure none attach pertinent results admission labs 45pm plt count 45pm neuts monos eos basos im absneut abslymp absmono abseos absbaso 45pm wbc rbc hgb hct mcv mch mchc rdw rdwsd 45pm asa neg ethanol neg acetmnphn neg tricyclic neg 45pm albumin calcium phosphate magnesium 45pm lipase 45pm alt sgpt ast sgot alk phos tot bili 45pm glucose urea n creat sodium potassium chloride total co2 anion gap 17am urine blood neg nitrite neg protein neg glucose neg ketone bilirubin neg urobilngn normal ph leuk neg 17am urine color straw appear clear sp 17am urine bnzodzpn neg barbitrt neg opiates neg cocaine neg amphetmn neg oxycodn neg mthdone neg 17am urine ucg negative 17am urine hours random pertinent labs 45am blood vitb12 45am blood tsh 45am blood free t4 45am blood vitamin b1 whole blood pnd micro am urine final report urine culture final mixed bacterial flora colony types consistent with skin and or genital contamination imaging none discharge labs no labs on day of discharge discharge physical exam vitals temp po bp r lying hr rr o2 sat o2 delivery ra general nad sitting up in chair smiling moving head around eyes sclera anicteric and without injection cardiac rrr audible s1 and s2 no murmurs rubs gallops resp clear to auscultation bilaterally no wheezes rhonchi or rales no increased work of breathing abdomen normal bowels sounds non distended non tender extremities pulses dp radial bilaterally skin warm cap refill 2s no rash neurologic speech slow but markedly improved today and speaks in simple sentences sitting in a chair and able to move all extremities follow commands such as moving fingers toes on command and sticking thumb up psych alert and awake pleasant smiling brief hospital course brief hospital summary female with history of disordered eating ptsd gad with panic disorder depression and functional neurological disorder presenting from a therapy session with weakness abnormal movement and aphasia concerning for an acute functional neurological episode she was evaluated by neurology and psychology who felt this was consistent with functional neurological disorder similar to her prior presentation she began working with and ot and had made great improvement at time of discharge to acute rehab transitional issues for rehab please continue aggressive and ot for further improvement in functional status on discharge please ensure patient has follow up with her pcp and her therapist patient was having some intermittent nausea as appetite improved please continue zofran tid prn qtc was on ekg on if continuing zofran use for week please recheck qtc on and d c medication if prolonged patient has a history of disordered and restrictive eating she does well eating with encouragement and did not show any evidence of eating disorder while inpatient please continue ensure supplements tid with meals for pcp therapist please refer patient to psychiatrist for further titration of psychiatric medications given report of previous sensitivity to medications and concern for possible bipolar disorder diagnosis please follow up pending thiamine level acute issues gad panic disorder depression ptsd functional neurological disorder patient presented from a therapy session where she had acute onset of weakness abnormal movement and aphasia in the setting of potential trigger of seeing shadows outside the door per her therapist over the past several weeks she has been increasingly more hypervigilant and stressed about going home for the holidays to see her mom which is a major trigger for her ptsd her therapist also reports a history of sexual physical verbal abuse but patient is very guarded about it and will not discuss it on presentation to the had significant and acute functional neurological symptoms including weakness abnormal movement and aphasia resulting in impaired functioning there was concern for catatonia and she improved after mg iv ativan in the er she endorsed significant anxiety but denied si and per psychiatry she did not meet criteria she had a similar episode in after iv iron infusion and was admitted to the neurology service where she was diagnosed with functional neurological disorder and she improved with and rehab she was also started on nortriptyline mg qhs at that time per her therapist she is sensitive to medications and when she was on ssris she became manic although she has not formally been diagnosed with bipolar disorder once admitted she was re evaluated by neuro and psychiatry who determined this was not consistent with catatonia and instead was likely functional neurological disorder she was recommended for acute rehab to continue aggressive she was continued on home nortriptyline 10mg qhs disordered eating restrictive eating over exercising she has a history of restrictive eating and over exercising and in the past she has had bradycardia and electrolyte abnormalities per her therapist her disordered eating has become much worse over the past few months in the setting of traveling a lot for work she started an intensive outpatient program at eating on per her therapist she restricts her calories to about or less a day and over exercises and is good at hiding it from people from review of omr her bmi seems to be normal between and she currently does not have any electrolyte abnormalities but she has been intermittently bradycardic with hr in the her appetite improved as her neurological symptoms began resolving per nutrition evaluation no need for eating disorder protocol while inpatient she received ensure supplements heart rates were stable bradycardic in electrolytes were monitored tsh t4 and b12 levels were all normal she received thiamine supplementation she received zofran prn for nausea qtc core measures code full code contact per patient s request do not contact her mother emergency contacts and uncle therapist and coordinates all of her care and available for questions calls at anytime medications on admission the preadmission medication list is accurate and complete nortriptyline mg po qhs discharge medications multivitamins w minerals tab po daily ondansetron odt mg po q8h prn nausea vomiting first line thiamine mg po daily nortriptyline mg po qhs discharge disposition extended care facility discharge diagnosis functional neurological disorder gad depression ptsd h o disordered eating discharge condition mental status clear and coherent level of consciousness alert and interactive activity status out of bed with assistance to chair or wheelchair discharge instructions dear ms it was a privilege taking care of you at why was i admitted to the hospital you came to the hospital because you acutely had trouble moving and speaking what happened while i was in the hospital you were seen by the neurologists who diagnosed you with functional neurological disorder you worked with physical and occupational therapists your symptoms began to improve what should i do after i leave the hospital please continue to take all your medications and follow up with your doctors at your appointments please continue to work with your physical and occupational therapists we wish you all the best sincerely your care team followup instructions

name unit no admission date discharge date date of birth sex f service surgery allergies percocet cucumber attending chief complaint left breast invasive ductal carcinoma major surgical or invasive procedure left breast total mastectomy w sentinel lymph node biopsy history of present illness ms is a year old pregnant female with breast cancer she had a palpable left breast lump underwent ultrasound mri and core biopsy that showed a grade invasive ductal carcinoma er positive pr positive her2 negative she later was found to be pregnant she is currently feeling fine apart from tiredness she reports that her levothyroxine dose was increased earlier this week she also notes some left nipple crusting that there initially after the biopsy was some bloody output that has since declined and become mild and crusty otherwise no changes past medical history past medical history thyroid ca postsurgical hypothyroidism ibs ovarian cysts pid spine arthritis asthma mononucleosisreported history of lyme disease status post weeks of antibiotic therapy hashimotos negative prior to surgery per her report social history family history family history aunt and mother with als mother aunt grandmother father prostate cancer age physical exam vs refer to flowsheet gen wd wn in nad cv rrr pulm no respiratory distress breast l breast no evidence of hematoma seroma small amount of ecchymoses mildly tender to palpation incision healing well abd soft nt nd ext wwp neuro a ox3 brief hospital course the patient was admitted on with left breast invasive ductal carcinoma for left total mastectomy and left axillary sentinel lymph node biopsy with dr please see operative note the patient tolerated the procedure well there were no immediate complications she was awoken from general anesthesia in the operating room and transferred to the recovery room in stable condition on post operative check she reported pain at the site of the incision and nausea and had an episode of emesis the ob gyn team recommended pain control with dilaudid she was placed on subq heparin and compression devices for prophylaxis she tolerated a regular diet on the pain continued to have pain which was discussed with ob gyn and her dosage of dilaudid was increased she was given stool softener given the usage of narcotics she reported some mild pink spotting which was discussed with ob and they performed an ultrasound which showed a strong fetal heart rate of per their report she has been spotting since earlier in the pregnancy as well the dressing on the incision site continued to be clean dry and intact there was no ecchymoses or hematoma on the chest wall drain output was serosanguineous at the time of discharge on vitals were stable pain well controlled and patient felt ready for discharge to home with with follow up appointments in place medications on admission meds allergies reviewed in omr and medications listed here albuterol sulfate proair hfa dosage uncertain prescribed by other provider levothyroxine levothyroxine mcg tablet tablet s by mouth daily in the morning on empty stomach minutes prior to any food or other meds pnv fumarate fa prenatal dosage uncertain prescribed by other provider discharge medications acetaminophen mg po q6h docusate sodium mg po bid hydromorphone dilaudid mg po q3h prn pain severe albuterol inhaler puff ih q6h prn wheezing dyspnea levothyroxine sodium mcg po daily prenatal vitamins tab po daily discharge disposition home with service facility discharge diagnosis left breast invasive ductal carcinoma discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to for left breast total mastectomy w sentinel lymph node biopsy you are now stable for discharge personal care you may keep your incisions open to air or covered with a clean sterile gauze that you change daily clean around the drain site s where the tubing exits the skin with soap and water strip drain tubing empty bulb s and record output s times per day a written record of the daily output from each drain should be brought to every follow up appointment your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount you may wear a surgical bra or soft loose camisole for comfort you may shower daily with assistance as needed be sure to secure your drains so they don t hang down loosely and pull out the dermabond skin glue will begin to flake off in about days activity you may resume your regular diet walk several times a day do not lift anything heavier than pounds or engage in strenuous activity for weeks following surgery medications resume your regular medications unless instructed otherwise and take any new meds as ordered you may take your prescribed pain medication for moderate to severe pain you may switch to tylenol or extra strength tylenol for mild pain as directed on the packaging please note that percocet and vicodin have tylenol as an active ingredient so do not take these meds with additional tylenol take prescription pain medications for pain not relieved by tylenol take colace mg by mouth times per day while taking the prescription pain medication you may use a different over the counter stool softener if you wish do not drive or operate heavy machinery while taking any narcotic pain medication you may have constipation when taking narcotic pain medications oxycodone percocet vicodin hydrocodone dilaudid etc you should continue drinking fluids you may take stool softeners and should eat foods that are high in fiber call the office immediately if you have any of the following signs of infection fever with chills increased redness swelling warmth or tenderness at the surgical site or unusual drainage from the incision s a large amount of bleeding from the incision s or drain s fever greater than of severe pain not relieved by your medication return to the er if if you are vomiting and cannot keep in fluids or your medications if you have shaking chills fever greater than f degrees or c degrees increased redness swelling or discharge from incision chest pain shortness of breath or anything else that is troubling you any serious change in your symptoms or any new symptoms that concern you drain discharge instructions you are being discharged with drains in place drain care is a clean procedure wash your hands thoroughly with soap and warm water before performing drain care perform drainage care twice a day try to empty the drain at the same time each day pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup record the amount of drainage fluid on the record sheet reestablish drain suction please assist patient with drain care a daily log of individual drain outputs should be maintained and brought with patient to follow up appointment with your surgeon followup instructions

name unit no admission date discharge date date of birth sex f service obstetrics gynecology allergies percocet cucumber tegaderm attending chief complaint cracked tooth s p fall major surgical or invasive procedure tooth extraction history of present illness patient is a year old g1p0 at by u s w h o breast ca on ddac chemotherapy in pregnancy and thyroid ca who presents after transfer from ed for tooth pain and for evaluation after a fall two days ago when she tripped on the ice and hit her shoulder she reports progressive dental pain in the right lower molar she has been unable to get dental treatment of her fractured molar in the outpatient setting due to concerns about pregnancy and medical complexity she was therefore referred to the ed omfs was consulted while she was in the ed w plan for removal in the or tomorrow findings included cracked tooth w carriers extending to pulp the patient was sent to ob triage given the mechanical fall the patient denies any abdominal trauma or bruising she has been having very irregular cramping no contractions she also reports intermittent sharp shooting pain from the groin to her belly button not exacerbated by anything pain cannot be reproduced she denies and vb or lof past medical history pnc by us labs rh ab neg rprnr ri hbsag neg hiv neg gbs unknown genetics lr era ffs wnl glt wnl us breech nl fluid anterior placenta issues breast cancer in pregnancy unilateral mastectomy w sentinel ln biopsy s p chemotherapy completed plan for pp tamoxifen mild asthma history of papillary thyroid cancer x on levothyroxine 175mcg daily labs tsh elevated but normal ft4 ros per hpi gynhx h o breast cancer obhx g1 current pmh h o breast cancer mild asthma h o papillary psh s p unilateral mastectomy w sentinel ln biopsy social history family history family history aunt and mother with als mother aunt grandmother father prostate cancer age physical exam on admission 03temp f 03bp gen nad respiratory no increased wob abdomen no bruising non tender gravid sve lcp taus vtx anterior placenta no sonographic evidence of abruption mvp fht moderate accels no decels on discharge vs o2 gen x nad resp x no evidence of respiratory distress abd x soft x non tender ext x no edema x non tender date time fht 120s mod var accels no decels reactive toco occ ctx pertinent results n a brief hospital course patient is a year old g1 with hx of breast ca on ddac chemotherapy in pregnancy and thyroid ca admitted at 34w2d after a fall on admission she had no evidence of abruption or preterm labor she reported mild cramping and her cervix was lcp fetal testing was reassuring she also had a painful cracked tooth and had been evaluated by omfs in the emergency room a plan was made for extraction in the or on hd she underwent an uncomplicated tooth extraction under local anesthesia her pain resolved she continued to have some intermittent cramping and pink discharge however she had no evidence of preterm labor she was discharged to home in stable condition on hd and will have close outpatient follow up medications on admission albuterol levothyroxine discharge medications acetaminophen mg po q6h prn pain mild rx acetaminophen mg tablet s by mouth every hours disp tablet refills levothyroxine sodium mcg po daily discharge disposition home discharge diagnosis cracked tooth discharge condition mental status clear and coherent level of consciousness alert and interactive activity status ambulatory independent discharge instructions dear ms you were admitted to the service for monitoring after a fall and prior to your procedure with the oral surgeons for a tooth extraction you procedure went well and your baby was monitored before and after the procedure you are now stable to be discharged home please see instructions below you should continue biting down on a piece of gauze for minute interval you may stop after gauze changes you should not have any hot solid foods for the time being you may continue drinking cool liquids you may transition to soft foods eggs pasta pancake tonight for pain control you may take tylenol as needed do not take more than 4000mg in hours please call your primary dentist with any questions or concerns please call the office for worsening painful or regular contractions vaginal bleeding leakage of water or concern that your water broke abdominal pain nausea vomiting fever chills decreased fetal movement other concerns followup instructions

name unit no admission date discharge date date of birth sex f service plastic allergies cucumber tegaderm attending chief complaint surgical absence of l breast major surgical or invasive procedure right prophylactic mastectomy bilateral reconstruction take back to or for exploration of left flap vessels history of present illness is a year old female with history of l breast cancer stage i idc and paget s and previous left sided mastectomy slnb she was admitted to the hospital after her prophylactic r mastectomy with reconstruction on she was taken back to the or on for flap exploration due to declining vioptix recordings past medical history pnc by us labs rh ab neg rprnr ri hbsag neg hiv neg gbs unknown genetics lr era ffs wnl glt wnl us breech nl fluid anterior placenta issues breast cancer in pregnancy unilateral mastectomy w sentinel ln biopsy s p chemotherapy completed plan for pp tamoxifen mild asthma history of papillary thyroid cancer x on levothyroxine 175mcg daily labs tsh elevated but normal ft4 ros per hpi gynhx h o breast cancer obhx g1 current pmh h o breast cancer mild asthma h o papillary psh s p unilateral mastectomy w sentinel ln biopsy social history family history family history aunt and mother with als mother aunt grandmother father prostate cancer age physical exam gen well appearing f in no acute distress heent normocephalic sclerae anicteric cv rrr r breathing comfortably on room air no wheezing breasts bilateral reconstructed breasts soft and without palpable fluid collection right mastectomy flap with lateral ecchymosis skin paddles warm bilaterally with good capillary refill jp drains x to bulb suction draining serosanguinous fluid abdomen soft non distended umbilicus viable lower abdominal incision without erythema or drainage jp drains x2 to bulb suction draining serosanguinous fluid ext no cyanosis or edema pertinent results 38am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt 44am blood wbc rbc hgb hct mcv mch mchc rdw rdwsd plt or right prophylactic mastectomy bilateral reconstruction per protocol patient stayed in pacu overnight or patient was recovering well in pacu with morning plan of clear liquid diet out of bed to chair and transfer to floor however vioptix signal of left breast with declining values so patient taken back to or for exploration of l breast flap again stayed in pacu overnight per protocol recovering well febrile overnight to but nurse removed bair hugger and re measured temperature at clear liquid diet out of bed to chair transfer to floor she was admitted to the plastic surgery service where she was began the postoperative pathway she was given asa daily to be continued at discharge ancef transitioned to duricef at discharge and sch during her stay she will discharge home with drains in place to be removed at office visit she will daily bacitracin bid application to right mastectomy flap necrosis site medications on admission the preadmission medication list is accurate and complete levothyroxine sodium mcg po daily bupropion xl once daily mg po daily albuterol sulfate mcg actuation inhalation q6h prn discharge medications resume taking your previous home prescriptions including levothyroxine sodium mcg po daily bupropion xl once daily mg po daily albuterol sulfate mcg actuation inhalation q6h prn lidocaine prilocaine lidocaine prilocaine topical cream apply thick layer to port a cath site at least minutes prior to port access c not taking as prescribed omeprazole omeprazole mg capsule delayed release capsule by mouth daily for heartburn symptoms not taking as prescribed tamoxifen tamoxifen mg tablet tablet s by mouth daily in addition patient discharged with these new medications aspirin mg qd for month duricef 500mg po bid x7 days w refill oxycodone tablets q4 hours discharge disposition home with service facility discharge diagnosis surgical absence of left breast breast cancer discharge condition awake alert oriented stable discharge instructions personal care you may keep your incisions open to air or covered with a clean ile gauze that you change daily if any areas develop blistering you will need to apply bactroban cream twice a day clean around the drain site s where the tubing exits the skin w ith soap and water strip drain tubing empty bulb s and record output s times per day a written record of the daily output from each drain should be broug ht to every follow up appointment your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount do not wear a normal bra for weeks you may wear a soft loose camisole for comfort you may shower daily with assistance as needed be sure to secure your upper drains to a lanyard that hangs down from your neck so they don t hang down and pull out y may secure your lower drains to a fabric belt tied around your waist the dermabond skin glue will begin to flake off in about days no pressure on your chest or abdomen okay to shower but no baths until after directed by your doctor activity you may resume your regular diet keep hips flexed at all times and then gradually stand upright as tolerated do not lift anything heavier than pounds or engage in strenuous activity for weeks following surgery medications resume your regular medications unless instructed otherwise and take any new meds as ordered you may take your prescribed pain medication for moderate to severe n you may switch to tylenol or extra strength tylenol for mild pain as directed on the packaging take prescription pain medications for pain not relieved by tyleno l take colace mg by mouth times per day while taking the prescript ion pain medication you may use a different over the counter stool softener if you wish do not drive or operate heavy machinery while taking any narcotic pain m edication you may have constipation when taking narcotic pain medications oxycodone percocet vicodin hydrocodone dilaudid etc you should continue drinking fluids you may take stool soften ers and should eat foods that are high in fiber call the office immediately if you have any of the following signs of infection fever with chills increased redness sw warmth or tenderness at the surgical site or unusual drainage from the incision s a large amount of bleeding from the incision s or drain s fever greater than of severe pain not relieved by your medication return to the er if if you are vomiting and cannot keep in fluids or your medications if you have shaking chills fever greater than f degrees or c es increased redness swelling or discharge from incision chest pain shortness of breath or anything else that is troubling you any serious change in your symptoms or any new symptoms that concern you drain discharge instructions you are being discharged with drains in place drain care is a c lean procedure wash your hands thoroughly with soap and warm water before performing drain care perfo rm drainage care twice a day try to empty the drain at the same time each day pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup record the amount of d rainage fluid on the record sheet reestablish drain suction followup instructions