note_id stringlengths 13 15 | hadm_id int64 20M 30M | discharge_instructions stringlengths 42 33.4k | brief_hospital_course stringlengths 45 22.6k | discharge_instructions_word_count int64 10 4.86k | brief_hospital_course_word_count int64 10 3.44k |
|---|---|---|---|---|---|
15373895-DS-19 | 28,448,473 | Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital
after undergoing repair of your ventral hernia. You have
recovered from surgery and are now ready to be discharged to
home with services. Please follow the recommendations below to
ensure a speedy and uneventful ... | Mr. ___ was admitted from the emergency department on
___. He was initially seen at his PCP's office where a
KUB was done showing distended loops of bowel concerning for
small bowel obstruction. On evaluation in the ED, CT scan of the
abdomen showed a complex network of ventral hernias with
multiple loops of bowel... | 760 | 398 |
19045496-DS-24 | 22,343,752 | You were admitted to the hospital after walking into a door and
hitting your face. You sustained a left eyelid injury. You
were seen by the paramedics and declined admission to the
emergency room. Shortly afterward, you felt short of breath and
felt like your "airway was closing" prompting arrival to
emergency ... | ___ year old female with past medical history notable for afib on
warfarin and recurrent falls. Per report of primary team, she
suffered a fall earlier and struck her head on a doorknob. She
initially was able to get up and refused transfer to the
hospital, but later (<1 hour after), she noticed swelling in her
ne... | 302 | 515 |
15071083-DS-16 | 24,572,540 | you were hospitalized for gi bleeding that was from ischemic
colitis. you underwent biopsy of your pancreas that did not
show cancer. you received transfusion of blood. blood thinner
was resumed. you were treated for bacterial infection and are
undergoing treatment for C. diff infection.
You will need a repeat ... | ___ gentleman DM2, CAD s/p CABG, ischemic cardiomyopathy with
LVEF 20%, atrial fibrillation on Coumadin, and a recent history
of pancreatitis, cholecystitis, and c. diff colitis presents
with BRBPR and UTI and admitted initially to the MICU due to
transient hypotension while in the ED.
# BRBPR/GI bleeding - Pt. pr... | 73 | 579 |
11669075-DS-16 | 25,889,399 | Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL:
-You were having burning and palpitations in your chest
-You had an abnormal, fast rhythm of the heart. This is called
supraventricular tachycardia (SVT)
WHAT WAS DONE FOR YOU WHILE IN THE HOSPITAL:
-You were given medications to slow your heart rate down
-You wer... | Mr. ___ is a pleasant ___ y/o gentleman with a PMH of
hypertrophic cardiomyopathy s/p ETOH septal ablation, ulcerative
colitis s/p total protocolectomy, and hypertension, who
presented with several weeks of palpitations, found to be in
supraventricular tachyarrhythmia most likely c/w AVNRT. | 113 | 42 |
17164417-DS-7 | 24,903,173 | Take your pain medicine as prescribed.
¨ Exercise should be limited to walking; no lifting,
straining, or excessive bending.
¨ Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Cola... | Mr. ___ was admitted from the emergency department to the
surgical intensive care unit on ___ after being adminstered
Kcentra and vitamen K. His aspirin and coumadin were held. A
trauma evaluation was started which included a dedicated CT
SINUS/MANDIBLE/MAXIL to evaluate for facial fractures. Plastic
surgery was... | 226 | 167 |
15213209-DS-22 | 25,710,540 | It was a pleasure taking care of you at ___
___.
During your hospitalization, you had surgery to remove unhealthy
tissue on your lower extremity. You tolerated the procedure
well and are now ready to be discharged from the hospital.
Please follow the recommendations below to ensure a speedy and
uneventful r... | Patient underwent LLE angiogram with popliteal artery and
anterior tibialis artery stent on ___. It was decided to
pursue a LLE transmetatarsal amputation and was added on for
___. The patient was NPO prior to ___ procedure, but the
case had to bumped to ___ due to limited OR availability.
Surgery was rescheduled ... | 548 | 213 |
18067322-DS-15 | 22,235,504 | Dear Ms. ___,
It was a pleasure participating in your care at ___.
You were admitted with severe abdominal pain that was most
likely due to a small kidney stone, though it was not visualized
on CAT scan and UA was negative.
Your pain has improved, and as we discussed, you will be
discharged with a short course ... | 1. Abdominal Pain due to Hemmorhagic Ovarian Cyst, nausea with
vomitting: Pain was out of proportion to exam, requiring
dilaudid PCA for HD 2, however patient eventually felt it may be
more anxiety related, was switched to oral oxycodone tylenol
motrin. Renal stone is most likely given clinical picture of
writhing... | 96 | 100 |
13013759-DS-22 | 26,057,151 | Discharge Instructions
Activity
· You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
· Heavy lifting, running, climbing, or other strenuous
exercise should be avoided for ten (10) days. This is to prevent
bleeding... | Ms ___ is a ___ yo female who presented with a headache.
Initial CT at OSH showed a SAH with IVH and she was transferred
to ___ for further evaluation.
#SAH/IVH from pseudoaneurysm
CTA showed stable IVH/SAH with mild hydrocephalus and 2mm L ICA
pseudoaneurysm. She was admitted to the Neuro ICU for close
neuro mon... | 410 | 344 |
16311983-DS-13 | 28,630,099 | Dear Mr. ___,
You were admitted to ___ for worsening leg and abdominal
swelling, worsening shortness of breath, and low blood counts.
We gave you medications to help you urinate out extra fluid. We
were able to get fluid out of your lungs and you no longer
requried oxygen to breathe. The fluid in your legs improve... | ___ male with history of CHF, hypertension, and
macrocytic anemia of unknoen etiology, admitted with volume
overload and dyspnea, concerning for acute diastolic CHF
exacerbation, exacerbated by worsening chronic macrocytic
anemia. Symptoms improved with diuresis and two blood
transfusions. Electrolytes repleted du... | 79 | 723 |
12106911-DS-11 | 27,943,344 | Ms ___ it was a pleasure caring for you during your stay at
___. You were admitted with headache and difficulty with
balance. You were found to have multiple brain tumors as well
as swelling in the brain. You were started on radiation
treatment which you have been tolerating well. We did not find
any other areas... | ___ y/o female with history of T4N0M0 Stage IIIA poorly
differentiated adenosquamouscarcinoma of the lung s/p right
pneumonectomy ___, adjuvant cisplatin/gemcitabine ___ now
on active surveillance, on enoxaparin since
___ for PE, now presents with headache and gait imbalance
found to have multiple brain mets.
# Met... | 120 | 292 |
11427507-DS-23 | 27,594,123 | Dear Ms. ___,
You were admitted to the ___ Cardiology Team ___ after you
had worsening chest pain.
What was done?
===============
-You had a cardiac catheterization which showed some narrowing
and blockages, but none were suitable to have new stent
placement.
-We increased your lisinopril dose from 5 mg to 10 mg ... | ___ year-old woman with diabetes mellitus and known CAD S/P CABG
in ___ (LIMALAD, SVG-PDA, SVG-OM/LPL) and post-CABG PCI of
SVG-OM who presented with 1.5 weeks of chest squeezing radiation
at rest and with exertion to both arms similar to her prior
acute coronary syndrome symptoms.
# Unstable Angina
# Coronary Ar... | 130 | 208 |
12600024-DS-22 | 25,221,898 | Dear Ms. ___,
It was a pleasure taking care of you
Why you were here:
-You were in the hospital because you were complaining of jaw
pain and swelling from an infection around you tooth
-You were not urinating well
What we did for you:
-You were given antibiotics for the treatment of your infection
-The oral surgeon... | ___ yo F with PMH diabetes and schizophrenia admitted for acute
jaw pain/swelling, found to have a periapical abscess in the
mandibular anterior vestibule. CT scan revealed no drainable
fluid collection in the neck. Patient was started on IV unasyn
for oral infection. ___ was consulted who observed a fluctuant
les... | 160 | 467 |
13944352-DS-27 | 28,779,503 | Dear ___,
You were admitted to the neurology service because of you
worsening gait. We restarted your home medications and this
improved greatly. You were evaluated by ___ and will be going
to acute rehab to work on your gait. | This is an ___ yo woman with PMH significant for multifactorial
gait disorder (frontal + parkinsonian features, on
Levodopa/Carbidopa for Parkinsonism), AFib, CAD, spinal stenosis
s/p lumbar surgery who presents with 3 days of worsened gait
freezing, difficulty moving/getting out of bed and slowing of
her speech. ... | 39 | 247 |
14242530-DS-13 | 23,814,694 | Mr ___
It was a pleasure taking care of you. As you know you were
admitted due to difficulty swallowing which we found was due to
irritated tissue. You were given a short course of steroids and
medications to control the symptoms. Since you are now eating
normally you don't need steroids but can continue the other... | ___ ___ with high grade neuroendocrine mediastinal
carcinoma (on paclitaxel and RT to lung/esophagus), c/b
malignant hemoptysis and compression s/p tracheal stent ___
(now s/p removal ___, DVT (on Xarelto), who presented with
worsening
odynophagia and dysphagia x 8 days ___ mild mucositis, improved
with supportive... | 75 | 420 |
17229222-DS-17 | 28,260,204 | Mr. ___,
You were admitted to the hospital with bleeding and confusion.
Your confusion cleared quickly with lactulose. You underwent
endoscopy that showed non-bleeding esophageal varices, and areas
of bleeding in your stomach related to your cirrhosis. You
underwent a procedure called APC during your endoscopy... | ___ w/NASH vs. cryptogenic cirrhosis c/b esophageal variceal
bleed (___), recurrent
encephalopathy s/p TIPS (___), GAVE s/p APC treatments, and
anemia who presents to ___ as a transfer from ___
with AMS and GI bleed (Hct 18), found to have hepatic
encephalopathy and oozing GAVE.
#) Oozing GAVE - Pt has a history... | 154 | 652 |
19787509-DS-6 | 27,421,515 | ACDF:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without ... | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperati... | 700 | 139 |
15152579-DS-12 | 25,326,352 | Dear Mr. ___,
It was a pleasure taking care of you while you were admitted to
___. You were admitted because of pain at your elbow and
redness/bruising on your right arm. We checked your bloodwork
and found you to have an elevated INR (Coumadin level) which has
lead to ecchymosis or bleeding within the superfic... | ___ year-old male with a PMH of atrial fibrillation on coumadin
who presents with right elbow pain and bruising/redness in the
setting of supratherapeutic INR, most consistent with extensive
ecchymosis.
# Ecchymosis/Right arm pain: He presented with large area of
ecchymosis covering approximately 40% of right upp... | 175 | 347 |
17220099-DS-21 | 20,230,245 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I admitted to the hospital?
- You were dizzy and had difficulty speaking
What was done while I was in the hospital?
- You had an MRI that showed your cancer was stable
- You had a swallow study that showed you are at risk for
aspirating
What s... | ___ w/ thalamic glioblastoma c/b hydrocephalus s/p VP shunt, s/p
IMRT/TMZ ___, TMZ and Bevacizumab, c/b disease recurrence s/p
SRS ___, now on TMZ/Beva q3 mo, started on dex for recent dx
of disease progression on ___, who p/w persistent dizziness
and now intermittent dysarthria.
ACUTE ISSUES
# GBM with progressive ... | 125 | 479 |
10398029-DS-21 | 20,306,012 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for app... | This is a ___ male who had previously underwent an
ascending aortic hemiarch replacement back in ___ for an
aneurysm. He also had a saphenous vein graft to
the posterior descending artery. He presented with shortness of
breath and a CT scan was performed and this demonstrated
possible aortic intramural thrombus o... | 122 | 308 |
18979146-DS-23 | 27,087,881 | Thank you for choosing ___ for your care. You
were seen in the emergency room by the Acute Care/Trauma Surgery
team for a fall that happened a few days before you came in. You
were admitted for pain control and was monitored for alcohol
withdrawal since you had an elevated blood alcohol level. After
evaluation fro... | Mr. ___ presented to ___ emergency room on ___ after a fall that occurred four days prior to admission. He
was evaluated by trauma surgery and admitted for pain control
and further evaluation. His hospital course was complicated by
agitation secondary to likely alcohol withdrawal. Once evaluated
in the ED, he was t... | 318 | 354 |
14014890-DS-10 | 20,149,060 | You were admitted to the hospital with abdominal pain. A CT
abdomen at an outside hospital raised the possibility of a
partial small bowel obstruction and you were transferred here
for further workup. We repeated the CT abdomen, this time with
oral contrast which can provide more information, and there was
no ev... | Ms. ___ was admitted to the bariatric service with
abdominal pain after being transferred from an OSH with a CT
read of possible small bowel obstruction. Due to her ___ en y
gastric bypass, there was concern of an internal hernia and need
for operative intervention. On arrival, she had a nutritional
IV fluids gi... | 187 | 304 |
10717448-DS-14 | 25,638,862 | You were admitted to the hospital after a fall and presumed loss
of consciousness. We evaluated you for causes of your frequent
falls, including arrhythmias, heart attacks, deconditioning, and
low blood pressure. Ultimately we were not able to find a
single unifying reason for your falls, however a condition
cal... | #Found down: Patient with history of falls and dizziness and has
been evaluated by Gerontology at ___ for this. Concern was for
POTS disease because her HR increased >30 with standing. Has not
been worked up for arrhythmia. She is on many medications that
can cause hypotension, will however she was hypertensive on ... | 65 | 205 |
17869062-DS-2 | 24,891,017 | You were admitted to the surgery service at ___ for surgical
evaluation of your biliary obstruction. You have done well in
the
post operative period and are now safe to return home to
complete your recovery with the following instructions:
Please resume all regular home medications, unless specifically
advised not t... | At the time of her admission on ___ the patient was
hypotensive and had an elevated WBC to 16 with a left shift.
She was therefore transferred to the ICU for further management.
She was started on zosyn and given Vitamin K and FFP to reverse
her coagulopathy. Due to her hypotension, CT scan was initially
post-po... | 346 | 875 |
11423061-DS-24 | 24,658,859 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted after you had a fall, and were
vomiting blood. While you were hospitalized, you underwent two
head CT scans, both of which did not demonstrate evidence of
acute bleed after your falls. Given your history of vomiting
blood, you were ... | ___ y.o male with significant Pmhx of bipolar diorder,
depression, osteoarthritis, and DVT/PE s/p IVC filter, on
coumadin, who presents from his nursing home s/p mechanical fall
on his right side of his head and hemetemesis.
# GI Bleed: He reported multiple episodes of non-bloody emesis
prior to emesis with frank ... | 249 | 375 |
18780736-DS-17 | 23,904,202 | Dear Mr. ___,
It was a pleasure taking care of ___ during your recent
admission to ___ came to use because your
creatinine was increased. We gave ___ fluids and your creatinine
improved. We also adjusted your diuretic regimen. Weigh yourself
every morning, call MD if weight goes up more than 3 lbs. We
wish ___ a ... | Mr. ___ is a ___ man with history of CLL,
thrombocytopenia, pure red cell aplasia, chronic kidney disease,
and diastolic congestive heart failure who was admitted for
acute on chronic kidney injury secondary to overdiuresis.
================ | 60 | 36 |
10817631-DS-10 | 25,587,982 | Mr. ___,
You were admitted to ___ with an infection. We treated you for
a respiratory infection, and your symptoms improved. We would
like you to complete a 14-day course of antibiotics to help
clear this up. Your oncologist would like to see you in clinic
on ___. | Mr. ___ is a ___ man with history of CAD s/p CABG,
HTN, HLD, DMII, multiple myeloma s/p auto SCT currently on
pomalidomide/daratumumab presenting with weakness and fever.
#Fever
#Sinusitis
Patient recently was admitted to BID-M for neutropenic fever
with extensive evaluation without source identification. Patient
... | 47 | 407 |
12658758-DS-28 | 27,446,862 | Dear Ms. ___,
You were admitted to ___ because you had pneumonia. During
your hospitalization you were transferred to the ICU because you
were not breathing well, but this improved with positive airway
pressure. You were also treated with antibiotics and responded
well. You will be going to a rehab facility after ... | Ms. ___ is a ___ woman with history notable for
HTN and endometrial cancer with oligometastasis to the left lung
status post TAH-BSO in ___ and radiation in ___,
presenting with fever to Tmax 100.8 (at home) and dyspnea, sent
in by PCP, found to have RML and RLL pneumonia. She was
initially treated on the general ... | 123 | 392 |
17574719-DS-19 | 26,063,950 | Mr. ___,
It was a pleasure to take care of you at ___.
WHY WAS I HERE?
- You were admitted to the hospital because you were found to be
lethargic.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- You were found to have a urinary tract infection and were
treated with antibiotics.
- You were found to have low blood... | ASSESSMENT AND PLAN:
___ yo M with history of HTN, HLD, DM, dementia, BPH s/p
indwelling foley with recent UTI on cipro presenting with
lethargy found to have urosepsis and likely demand ischemia. | 108 | 33 |
13751863-DS-24 | 23,659,790 | Dear Mr. ___,
You were admitted to the hospital after you suffered a fall. You
were found to have a patellar fracture of the left knee.
Incidentally, you were also found to have progression of your
lymphoma. During your hospital stay you underwent radiation and
chemotherapy to alleviate the symptoms you were exper... | Mr. ___ is a ___ year old man with recurrent DLBCL, DM1 and
cirrhosis who presents after a mechanical fall and is found to
have a patellar fracture of the left knee. He incidentally was
found to have a 1.6 cm mass in the right temporal area, highly
suspicious for malignancy now with evidence of extensive
lymphoma... | 111 | 1,199 |
17147211-DS-17 | 21,015,442 | Dear ___,
You were hospitalized due to symptoms of altered mental status
resulting from an INTRAPARENCHYMAL HEMORRHAGE, a condition where
there is bleeding found in the brain tissue. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain can result in ... | Ms. ___ is a ___ year old woman past medical history
of alcoholic cirrhosis c/b portal vein HTN, encephalopathy
esophageal varices, s/p TIPS ___, T2DM, cervical stenosis with
a right frontal intraparenchymal hemorrhage.
#Right frontal IPH
Mic___ initially presented to ___ ___ after being
found on the ground by he... | 233 | 431 |
13485675-DS-2 | 20,482,895 | Mr. ___,
During this admission you were determined to have a transient
ischemic attack and because you are at a high risk of stroke we
have started you on aspirin 81 mg daily and atorvastatin 80 mg
daily. We are uncertain exactly why you had this event, but to
complete our workup we will discharge you with a moni... | ___ without significant past medical history admitted with
transient right-sided facial droop, speech difficulty, upper
extremity weakness, and sensory disturbance, found on CTA at
___ to have left M2 occlusion prior to transfer to
___. Symptoms resolved on arrival to ___, although
examination notable for subtle r... | 91 | 407 |
10961804-DS-10 | 24,010,761 | Dear Ms ___,
You were admitted to the ___ after you had
worsening shortness of breath. We had to give you IV diuretic
medications to help remove the extra fluid from your body and
lungs. We found that you were still in an irregular heart
rhythm, "atrial fibrillation," and after talking with your
Cardiologist Dr _... | Ms ___ is an ___ with HFpEF, AF, HTN, p/w with progressive
SOB, ___ edema found to have CHF exacerbation, s/p IV Lasix
diuresis w/improvement in Sx, s/p ___ (___) of AF to sinus
rhythm
# Acute on chronic HFpEF
Pt had gradual progression of Sx over weeks-months, had declined
CDAC admission earlier for IV diuresis, ... | 238 | 605 |
10312052-DS-19 | 21,567,940 | * You were admitted to the hospital for evaluation of your right
pneumothorax and failure to wean from the respirator following
your surgery.
* You have done well in weaning from the ventilator and
breathing on your own and are now ready to return to rehab for
more therapy.
* You will continue to require tube fee... | Mr. ___ was evaluated by the Thoracic Surgery service in
the Emergency Room and a right pleural pigtail catheter was
placed to evacuate his right pneumothorax. He was then admitted
to the ___ for vent management as well as management of his
pigtail catheter. Most recently at rehab he had been able to
tolerate a t... | 124 | 450 |
13777886-DS-12 | 23,626,152 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cau... | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, which t... | 193 | 239 |
11514055-DS-9 | 27,231,506 | Mr. ___,
You were transferred to ___ because of dyspnea. You had an
ECHO of your heart that showed decreased function. A second ECHO
was done to better evaluate your valve and there was no evidence
of infection or clot. A cardiac cath was done and one of your
stents was opened up.
Medication changes:
START lisi... | ___ year-old-male with a history of CAD s/p CABG in ___, PCI in
___ and ___, AS s/p AVR in ___, atrial fibrillation on
coumadin, permanent pacemaker, chronic angina, hypertension, and
hyperlipidemia presenting with dyspnea found to have new
systolic CHF (EF ___ and aortic valve lesion and new
hyponatremia, now s/p... | 99 | 324 |
19495630-DS-10 | 28,990,611 | You were admitted to the hospital with difficulty breathing and
were diagnosed with pneumonia and a COPD exacerbation. You were
treated with antibiotics, steroids, and nebulizers with
improvement in your breathing. You are being sent home with
continuous oxygen, which you should use at all times.
MEDICATION CHANGE... | ___ with hx of COPD, tobacco use (ongoing), atrial fibrillation
on coumadin, hypercholesterolemia, stage IV CKD presenting with
worsening shortness of breath, productive cough of white/yellow
phlegm found to have multifocal infiltrates consistent with PNA
and COPD exacerbation.
.
## Community-acquired pneumonia: Ad... | 81 | 251 |
12567683-DS-15 | 27,525,077 | Dear Mr. ___,
You were admitted to ___ for shortness of breath and new blood
clots in your lungs. You were also found to have a pneumonia
(lung infection) and a pleural effusion (fluid accumulation in
your chest). We treated you with blood thinners to prevent
further clots. We also treated you with antibiotics and... | ___ y/o M with recent diagnosis of lung adenocarcinoma who
presented as a transfer from ___ with SOB,
found to have bilateral PE's, recurrent malignant right sided
pleural effusion, and post-obstructive pneumonia.
#Acute pulmonary embolism without cor pulmonale: Patient
presented to ___ on ___ with SOB and chest p... | 214 | 578 |
14861352-DS-10 | 24,509,885 | Dear Mr. ___,
You were hospitalized after your MRI revealed an ACUTE ISCHEMIC
STROKE, a condition in which a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. Damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many diff... | Mr. ___ is a ___ year old man man with a history of cerebral
palsy and recent cognitive decline who was found to have an
incidental acute right occipital stroke on his MRI obtained for
cognitive workup. He has no new deficits and is asymptomatic.
Etiology is unclear.
# Acute Stroke: CTA of the head and neck showe... | 342 | 164 |
17761931-DS-21 | 23,803,016 | Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- Your primary care doctor referred you to the ED for low blood
pressures.
- You told us you had been experiencing occasional dizziness,
weakness in your legs, and leg swelling for quite some time.
WHAT HAPPENED TO ME IN THE HO... | PATIENT SUMMARY:
==================
___ hx DM2 on insulin, CAD, OSA who was referred to the ED by
his primary care physician after outpatient BP readings showed
borderline hypotension to 90 systolic, also reporting
fatigue and lightheadedness for the last 2 weeks. | 336 | 40 |
11293234-DS-23 | 24,089,938 | Dear Mr. ___,
You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your obstruction has subsequently resolved after
conservative management. You have tolerated a regular diet, a... | Mr. ___ presented to the ED of ___ on ___ for
management of small bowel obstruction. He was admitted to the
colorectal surgery unit for further management. | 312 | 29 |
15192547-DS-12 | 27,929,558 | You were admitted to the hospital because you had nausea,
vomiting and abdominal pain. This was thought to be related to a
urinary tract infection. You were started on antibiotics and you
improved and will continue to take antibiotics for another 6
days.
You had imaging of your shoulder snd your torso which was
u... | BRIEF HOSPITAL COURSE:
Tachycardia: Ms ___ presented to the ED with tachycardia.
Serial cardiac enzymes were performed, trending down from 0.03
to 0.02. There
# Tachycardia: Ms ___ presented with palpitations found to be
dehydrated and tachycardic in ED following poor p.o intake with
likely demand ischemia with ... | 69 | 300 |
15545526-DS-12 | 22,358,311 | Mr. ___,
You were admitted due to shortness of breath and cough, you were
found to have pneumonia and will continue treatment with your IV
antibiotic at home. Your symptoms greatly improved with your
antibiotics. You will follow up in clinic as stated below. It
was a pleasure taking care of you. Please call with a... | Mr. ___ is a ___ ___ man with high risk
MDS and chronic diastolic heart failure recently admitted for
several days of hemoptysis and CT showing ? PNA vs. other
process
found to have a positive AFB smear from ___, who presented to
clinic ___ with fever and SOB, s/p ICU transfer for Afib with
RVR improved with Dilt/meto... | 58 | 581 |
14862629-DS-3 | 26,424,728 | Dear Ms ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for abdominal pain and blood in your urine
What was done for me while I was in the hospital?
- You had some imaging done of your abdomen. It looked like one
of the cysts on your ki... | ___ hx of polycystic kidney disease on transplant waiting list
(listed but inactive until GFR < 20, not on dialysis), currently
stage IV ckd- b/l Cr 2.8-2.9, HTN, HLD and hx of diverticulosis
who presents with flank pain/LLQ pain and hematuria. | 127 | 41 |
10569306-DS-50 | 20,719,223 | Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ year old female with PCKD s/p failed transplant on HD MWF,
recurrent fevers due to gram negative bacteremia of unknown
source, who presents from dialysis with rigors and temperature
to 100.0, without localizing infection.
ACTIVE MEDICAL ISSUES:
# Elevated temperature: On admission, pt did not meet SIRS
crit... | 14 | 264 |
17989167-DS-21 | 22,366,186 | Dear Mr ___,
You were admitted to the ___ after feeling weak and falling at
home. You were evaluated by our neurology team, who also did CT
and MRI scans of your head, which did not show a stroke. Because
you were retaining urine, you were discharged with a foley in
place. You have a follow up appointment with Dr.... | ___ h/o cardiomyopathy, A-fib, DM and severe mid LAD stenosis
s/p cath with DES who presents from PCP with weakness found to
have Afib with RVR, AMS during admission.
# AMS: On admission patient was A&Ox3 but later became A&Ox1 and
agitated. Possible triggers for delirium included urinary
retention (patient could ... | 186 | 443 |
16915421-DS-7 | 20,186,089 | Dear Ms. ___,
You were admitted to ___ for
evaluation of abdominal pain and you were found to have an
incarcerated right inguinal hernia. You were therefore evaluated
by the acute care surgery team and offered surgical repair,
however you declined surgery during this hospital admission.
Risks of delaying surgery ... | Patient is a ___ year old female with past medical history
significant for thyroid cancer s/p thyroidectomy, IBS,
diverticulosis, and prior repair of a right inguinal hernia in
___ ___. Patient presented to the emergency
department with complaints of abdominal pain and was found to
have right incarcerated inguinal... | 299 | 267 |
13757970-DS-6 | 22,877,162 | Dear Ms. ___,
It was a pleasure caring for you at ___. You presented with
bloody diarrhea, which has since stopped. We are still unsure
what caused it, but we think it either resulted from an
infection in your colon, low blood flow to the colon while you
exercised, or inflammation in the colon from another cause. ... | This is a ___ female with minimal PMH who presents with one day
of watery diarrhea, BRBPR, and abdominal cramping after running
a 5K race, of unclear etiology.
# Diarrhea / BRBPR: Pt's symptoms decreased significantly at
discharge, with little to no blood in the stool (which remained
watery). Very likely lower... | 157 | 226 |
19023440-DS-20 | 29,815,969 | Dear Ms. ___,
___ were admitted to ___ because ___ had a fall at home
resulting in a hip fracture. ___ had surgery on ___ without
complications. ___ were then transferred to the medicine
service because ___ were confused and drowsy. Your labwork
showed a high sodium, likely due to your lithium therapy. ___
we... | Primary Reason for Hospitalization:
___ yo F with nephrogenic DI, breast CA sp mastectomy in ___,
admitted with hip fracture sp ORIF on ___. Post-op course
complicated with AMS and slurred speech, hypernatremia,
hypecalcemia, and pt was transferred to medicine.
. | 517 | 41 |
18003081-DS-40 | 22,035,704 | Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You had bloody vomit
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You had a procedure performed, called an endoscopy, that tried
to find a source of the blood. It did not find any single area
of concern.
- You were monitored closely and did not re-blee... | BRIEF HOSPITAL COURSE
=====================
___ Hx ___, severe intellectual disability, recurrent
GIBs, unprovoked DVT on rivaroxaban, p/w acute on chronic anemia
I/s/o likely UGIB. Patient underwent unrevealing EGD (___)
with self-resolution of ongoing bleeding, with course
complicated by propofol infiltrate requi... | 134 | 317 |
10981725-DS-28 | 21,250,461 | Dear ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were having fevers at home
What was done while I was in the hospital?
- We found that one of your drains was not draining properly
- We had the interventional doctors ___ the ___
- You were put back on antibiotics that helpe... | Ms. ___ is a ___ year-old woman with history of CAD,
hypertension, diabetes mellitus, NASH cirrhosis with DDLT
(___) (on cyclosporine and mycophenolate) with aortic conduit
complicated by biliary strictures s/p stenting and multiple
percutaneous transhepatic biliary drain exchanges with recurrent
cholangitis, pseu... | 138 | 368 |
16759761-DS-26 | 22,748,003 | Dear Mr. ___,
It has been a pleasure caring for you at ___. You presented to
___ on ___ with 4 days of cough with blood, abdominal
pain, nausea, and fever. Your symptoms were likely due to a
viral illness, and this resolved without antibiotics. However,
the levels of tacrolimus in your blood were undetectable and ... | Mr. ___ is a ___ with a history of cirrhosis (HCV and
EtOH, s/p orthotopic liver transplant ___ with subsequent
recurrence of cirrhosis (s/p treatment with
simeprevir/sofosbuvir ___, who presented to ___ on ___
with ___ days of cough, hemoptysis, abdominal pain, nausea and
fever, found to have subsequent acute liv... | 254 | 458 |
13743156-DS-11 | 29,857,174 | Dear ___,
It was a pleasure participating in your care while you were at
___. You had an episode of unresponsiveness while in your
nephrologist's office, which we think was from a vagal response
in response to nausea as well as reflective of decreased volume
in your vessels. You were monitored on telemetry and we ... | ___ with membranous nephropathy and nephrotic syndrome with
progressive proteinuria who presents after syncopal episode with
concern for pulselessness.
# Syncope: By symptoms consistent with vasovagal syncope,
borderline orthostatic by vital signs. Received IVF and was
monitored on telemetry. Though unlikely, was ... | 77 | 209 |
13653826-DS-4 | 26,057,824 | Dear Ms ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
-You were admitted to the hospital because you were having
shortness of breath.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were seen by our lung experts who tried to drain the fluid
around your lung. They were unable to drain th... | Transitional Issues
====================
[]titrate morphine to quell patient's air hunger
[]titrate Ativan to quell patient's anxiety
[]titate bowel regimen
Summary Statement
==================
This is an ___ with h/o Stage IV NSCLC (recently diagnosed),
COPD and hyponatremia, admitted for recurrent complex pleural
... | 190 | 421 |
17778496-DS-4 | 27,597,329 | You came to the hospital because you felt fatigued. While you
were here you were diagnosed with AML and we started on
treatment with ATRA and arsenic. You tolerated the chemotherapy
well and your blood cells went up at first and then went down.
Also while here you were seen by the colorectal surgeons for a
periana... | ___ otherwise healthy admitted to the MICU for pancytopenia of
unclear etiology and neutropenic fever, found on bone marrow
biopsy to have new diagnosis of acute promyelocytic leukemia.
# Acute Promyelocytic Leukemia: She presented with pancytopenia
and bone marrow biopsy showed hypercellular marrow with 55%
neop... | 106 | 364 |
19758810-DS-11 | 23,710,321 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were having chest pain
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given medications to treat a heart problem however
the origin of the chest pain seemed less likely to be caused by
the heart so those were stopped... | TRANSITIONAL ISSUES
===================
[ ] A1C 7.0. Patient on Invokana only. Patient would benefit
from additional oral hypoglycemic to lower A1C further as an
outpatient.
[ ] Patient started on atorvastatin 40mg daily for ASCVD score
>10% (12%). Please monitor for tolerance.
[ ] Patient with close cardiology foll... | 133 | 148 |
13992480-DS-24 | 29,272,222 | Dear ___ were hospitalized due to symptoms of difficulty talking and
right sided weakness resulting from an ACUTE ISCHEMIC STROKE, a
condition in which a blood vessel providing oxygen and nutrients
to the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of... | Transitional Issues:
[ ] Pt needs to have a repeat CT chest in 10 weeks to follow up
her prior CT findings
[ ] Pt is on day 2 of a 7 day course of IV ceftriaxone (started
___
[ ] Pt should continue to undergo speech and swallow evaulation
with the hopes of advancing her diet further.
[ ] Please monitor the patient... | 312 | 482 |
11527882-DS-21 | 23,048,471 | Dear Ms. ___,
You were admitted to the Acute Care Surgery Service with
abdominal pain and found to have inflammation in your appendix.
You were counseled on different treatment options and elected
for antibiotics. Your pain improved with antibiotics and you are
now ready to be discharged home to complete a course ... | Ms. ___ is a ___ yo F who presents to the Emergency
Department with epigastric abdominal pain and underwent
outpatient CT scan which was concerning for acute appendicitis.
The patient was hemodynamically stable, afebrile, and white
blood cell count was 5.1. Discussed options of possible
operative intervention vers... | 259 | 150 |
19631414-DS-4 | 20,088,323 | Dear ___ you for coming to the ___.
You were in the hospital because of your pain and skin lesions
that were concerning for cancer. We performed a biopsy which
showed that you have metastatic lung cancer. You started
radiation therapy to help with your pain. You will need to
follow up with a lung cancer specialist... | ___ with history of anxiety and hypertension admitted with
worsening back pain in setting of concerning lesions on MRI/CT
for metastases. Hospital course was notable for diagnosis of
metastatic nonsmall cell carcinoma of the lung and radiation
therapy to metastatic bone lesions.
.
#Metastasic nonsmall cell lung ... | 300 | 468 |
11031369-DS-13 | 24,937,357 | 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... | Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right acetabular fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction a... | 295 | 293 |
15961067-DS-7 | 27,262,602 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approx... | He was admitted on ___ and underwent routine preoperative
testing and evaluation. He remained stable and was taken to the
operating room on ___. He underwent aortic valve
replacement and coronary artery bypass grafting x 3. Please see
operative note for full details. He tolerated the procedure well
and was transfe... | 104 | 235 |
10147499-DS-9 | 27,547,361 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were brought in for increasing confusion and
weakness. We believe this was due to a urinary tract infection
in addition to the pain medications you were taking. You were
started on antibiotics which you will continue to take at hpme.
Your pain med... | ___ yo F with a history of HTN, hyperlipidemia and recent C2
decompression with C1-C3 laminectomy/fusion on ___ who was sent
in from rehab facility due to altered mental status and was
found to have urinary tract infection.
# Altered mental status: Patient presented with AMS which
resolved by the time of admission... | 84 | 342 |
13304354-DS-16 | 29,854,899 | Do not smoke.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
___ must wear your brace when out of bed or when sitting.
___ may shower briefly without the collar or back brace;
unless ___ have been instructed otherwise.
Take your pain medication as instructed; ___ may find it best
if t... | Patient was admitted to the neurosurgery. Further review of the
MRI showed no abscess and Neurosurgery was not concerned for
epidural hematoma. A subacute L4 compression fracture was noted
and a Aspen quick draw brace was ordered. Patient complained of
pain and required IV Dilaudid Q2hrs. Neurology continued to
fo... | 226 | 150 |
18853762-DS-43 | 27,217,540 | You were admitted with delirium. You were found to have a
urinary tract infection. You were started on linezolid. Given
the interaction between linezolid and celexa, your celexa was
held. Given your delirium zolpidem was also held. Given your
delirum plans were made for you to go to a geriatric psychiatric
unit. | A/P: ___ yo W with MMP but no psychiatric hx, sent from ___ at
___ for a change in mental status and
resistance to care. This is most like secondary to a UTI. | 52 | 34 |
13196462-DS-3 | 28,562,130 | You were admitted to the hospital because of nausea, vomiting,
and poor appetite, which were most likely due to your
chemotherapy. While in the hospital, you also had low blood
counts due to your chemotherapy. Because you developed a fever
and had evidence of a skin infection around your left eye, we
needed to kee... | ___ is a ___ year old woman with HTN, non-ischemic
CMY (LVEF 45-50% TTE ___, LBBB, and recently diagnosed NSCLC
(___) w/ brain mets s/p CK, on ___, prior
course c/b afib w/ RVR requiring ICU, subsegmental PE now on
enoxaparin, who p/w persistent N/V after her C8 on ___, found
to have likely L preseptal cellulitis,... | 186 | 518 |
16032226-DS-25 | 29,410,714 | Mr. ___, you presented to us with worsening rash on your
legs and worsening mental status due to your kidneys' inability
to clear toxins from your blood. We treated these problems by
initially giving you a temporary hemodialysis line and
performing hemodialysis to clear some toxins. We also had
dermatology evaluat... | Mr. ___ is a ___ gentleman with recent admission
___ for post-procedure MSSA bacteremia that was
complicated by presumed Nafcillin-induced AIN requiring
temporary HD, who re-presented on ___ with renal failure
requiring HD, confusion that continued despite HD, and worsened
petechial leg rash. During his stay, he ... | 151 | 613 |
11533384-DS-5 | 25,717,550 | Mr. ___,
It was a pleasure taking care of you at ___. You were
admitted for a pacemaker for atrial fibrillation with
tachycardia and bradycardia. Your procedure went smoothly.
We started you on a low dose of calcium channel blocker. Please
take as directed. Diltiazem 180mg daily. Please also decrease
simvastati... | Mr. ___ is a ___ man with permanent atrial
fibrillation with recent syncopal episode and holter showing
evidence of tachy-___ syndrome.
# Tachy- ___ syndrome: Patient with permanent afib and recent
syncopal episode during exertion. Holter monitor showing afib
with rates ranging from ___. Admitted to the hospital... | 59 | 156 |
17361720-DS-28 | 29,292,904 | Dear Ms. ___,
It was a pleasure treating you at ___!
Why was I admitted to the hospital?
-You were admitted because you had had diarrhea, and because you
were feeling dizzy.
-When you were admitted, we also saw that your blood levels were
low
What was done while I was admitted?
-We gave you some fluids to make sur... | ___ yo female with h/o afib s/p cardioversion in ___, CHF with
preserved EF, CKD, spinal stenosis presenting with diarrhea of 1
day's duration and lightheadedness, weakness. Afebrile and with
stable vital signs, initial evaluation significant for anemia at
Hgb 7.6 (baseline ___, mild Cr elevation at 1.9 (baseline
... | 146 | 221 |
19723067-DS-19 | 28,283,671 | 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 stri... | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left tibia and fibula fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left tibial IM nail, which the
patient tolerate... | 445 | 264 |
19217375-DS-12 | 20,805,131 | -You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/o... | Mr. ___ is a ___ male with a long
history of uric acid and calcium oxalate nephrolithiasis. He
sought a second opinion from me on ___. I noted that he
had approximately 1.5 to 2 cm of left ureteropelvic junction
stone and was in acute on chronic renal failure with a
creatinine of 3.1 with his last baseline creatinine... | 246 | 275 |
15667769-DS-16 | 21,900,695 | Dear ___,
___ were hospitalized on ___ at ___ for
your chest pain. During your hospitalization, we did not see
any signs of heart attack by your blood work and EKG. While ___
were here, we were concerned about possible slurred speech so
___ got scans of your head and neck to look for a possible
stroke. Neurolo... | ___ with h/o CAD, ischemic cardiomyopathy presents with chest
pain.
.
>> Acute Issues:
# Chest pain: This patient has a history of CAD s/p MI in
___. During her hospitalization, she had two sets of
negative cardiac enzymes and EKG showed non specific ST changes,
unchanged from last EKGs. Due to her negative cardia... | 113 | 527 |
16788215-DS-8 | 25,220,000 | ___ was admitted to the hospital because she had two
seizures. She underwent EEG in the hospital which did not show
any ongoing seizures. She had no further clinical seizures and
her mental status returned to baseline. We did not find any
trigger for her breakthrough seizures - there was no sign of
infection or el... | ___ was admitted to the Neurology floor in stable
condition. A workup for infectious etiologies was negative. A
zonisamide level was sent and is pending. She underwent extended
routine EEG monitoring with no evidene of seizure activity. Her
mental status returned to baseline. After consultation with Dr.
___ AED re... | 101 | 76 |
11855455-DS-23 | 21,762,700 | Dear Mr. ___,
Thank you for allowing us to take part in your care!
WHY WERE YOU ADMITTED:
- You were having chest pain and we wanted to figure out why.
WHAT HAPPENED IN THE HOSPITAL:
- We did bloodwork and a CAT scan, and everything was normal.
- We think your chest pain was related to cocaine use.
WHAT SHOULD YOU ... | ___ with h/o IVDU and recurrent endocarditis involving
bioprosthetic mitral valve, presenting with intermittent central
chest pain, fatigue, and malaise after recent heavy cocaine use.
Currently pain free and hemodynamically stable. | 114 | 32 |
13870141-DS-20 | 21,099,410 | Dear Mr. ___,
It was a privilege caring for you at ___. You were admitted
because you were found on the ground in your apartment. You
underwent imaging of your neck and head which did not reveal any
fractures. You sustained an injury to your neck "whiplash" which
caused swelling at the back of your throat, which m... | ___ PMHx hypothyroidism, ___ disorder (Dx ___, and
recent falls who presented after been having been found down in
his apartment for up to 36 hours. Noted to have mild
rhabodomyolysis and C1-C4 prevertebral edema due to cervical
trauma without evidence of fracture or ligamenetal injury. | 192 | 46 |
15083239-DS-8 | 24,386,191 | You were admitted to the hospital with pelvic pain and kidney
failure. Your pain was better controlled by adjusting your pain
medications and by addressing constipation. You were also found
to have kidney failure which was due to obstruction from
prostate cancer; this was managed with tubes placed in the back
to... | # Renal failure- due to post-renal obstruction ___ tumor
invasion of bladder wall. Discussed with patient and wife prior
to obtaining ultrasound. IVF overnight did not improve
creatinine. ___ consulted for bilateral nephrostomy tube
placement to relieve obstruction as a palliative procedure to
extend his qualit... | 101 | 458 |
18259787-DS-22 | 25,591,637 | Mr. ___,
You were admitted to ___ due to headache, vomiting. On brain
imaging, we found that the bleed in your known stroke from
previous admission was stable, but the swelling around this
brain bleed was increased. This swelling can increase up to 3
weeks after initial brain bleed, therefore we felt your symptoms... | HOSPITAL COURSE:
___ man with past medical history of HTN, HLD, poorly
controlled DM, CAD, and recent admission for right ICA and MCA
occlusion s/p TPA, ICA stent placement, and thrombectomy with
TICI3 reperfusion with ___ hemorrhagic transformation who
presented as a transfer from ___ for severe headache, nausea ... | 151 | 463 |
15793371-DS-13 | 22,384,894 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You came to ___ with concern that
you had Tuberculosis. After we took 3 sputum samples, it was
determined that you do NOT have Tuberculosis in your lungs. You
will continue to need anti-biotics for your spine infection.
You will be treated with or... | ___ pmHx HIV, HCV, IVDA who recently was discharged with
epidural abscess who p/w concern for Tb and with ___ rash ?drug
related
# AFB+ Abscess Cx: Patient with growth of AFB on abscess that
previously was known positive for MRSA. Patient was admitted
from rehab for r/o Tb.
- 3 induced sputums with AFB sputum was ... | 84 | 260 |
19517966-DS-14 | 26,332,025 | You were admitted to ___ for abdominal pain from ___
___ in ___. You got an endoscopy which showed an
ulcer and a fistula between two parts of your stomach. You were
also found to have a bacteria called h. pylori in your blood.
You will need to be on 4 medications for this for 14 days. Take
your last dose of b... | This is a ___ yo F with a PMHx of gastric by pass, idiopathic
intermittent abdominal pain who initially p/t ___
for a clonidine and alcohol overdose, course c/b self limiting
bradycardia and hypotension, transferred to ___ for
psychiatric treatment now transferred to ___ for further
evaluation of about 5 days of R... | 104 | 749 |
14446098-DS-23 | 24,908,383 | Dear Ms. ___,
You were admitted to the hospital for shortness of breath. You
were found to have the flu that is causing your difficulty
breathing. You also had mild heart failure from the flu.
You should continue to take the oseltamivir (Tamiflu) for flu
treatment until ___.
Please follow-up with your transplant ... | Ms. ___ is a ___ with PMH significant for LRRT ___ and
recent diagnosis of humoral rejection s/p IVIG and rituximab who
presented with dyspnea, cough, wheezing, and hypoxemia. BNP was
elevated to 11,000 and patient had evidence of mild fluid
overload on exam. Additionally, she tested positive for
influenza A. She ... | 101 | 302 |
17425699-DS-17 | 29,775,166 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were having
severe abdominal pain, nausea, and vomiting.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had lab tests and imaging that showed that you had
inflammation of the gallbl... | P - Patient summary statement for admission
===========================================
___ with PMH of HLD, CAD s/p CABG and multiple PCI, GERD, HTN,
DM presenting with RUQ abdominal pain, nausea, and vomiting.
A - Acute medical/surgical issues addressed
===========================================
# Acute cholecysti... | 266 | 663 |
16846688-DS-14 | 23,370,796 | Mr. ___,
You were admitted after sustaining a fall secondary to the
visual deficits from the mass in your brain. You underwent
work-up including a CTA, Audiogram, Speech and Swallow, and
Ophthalmology evaluation. We are transferring you to Dr. ___
at ___ for further care. | Mr. ___ was admitted to neurosurgery service after a fall
with large cystic cerebellopontine angle mass.
#CPA mass
He was started on Decadron for cerebral edema. He underwent CTA
for operative planning. Ophthalmology evaluated patient and
findings were consistent with bilateral ___ nerve compression,
causing his ... | 44 | 99 |
19023118-DS-11 | 25,046,338 | Mrs. ___,
___ were admitted to ___ due to a
recurrent small bowel obstruction. Due to your history of
multiple prior surgeries as well as your other comorbidies, we
initially attempted to treat your small bowel obstruction with
bowel rest and a nasogastric tube. ___ were started on total
parental nutrition to mai... | The patient presented to the ___ ED on ___, two days out
from prior discharge due to intermittent chronic abdominal pain,
cramping and increaing nausea. An NG tube was placed and CT
abdomen/pelvis showed high grade small bowel obstruction. She
was subsequently admitted to the ___ surgery service
and treated intial... | 556 | 255 |
17517983-DS-105 | 23,411,823 | Dear Ms. ___,
It was a pleasure taking care of you during your admission to
___. You were admitted for abdominal pain,
hyperglycemia, and hypertension. You with treated with insulin
drip, labetolol drip, and dialysis. Your sugars improved
although they remained difficult to control. Your abdominal pain
improved a... | Ms. ___ is a ___ woman with a history of poorly controlled
T1DM, ESRD on HD, and gastroparesis who presented with
hemoptemesis, nausea, vomiting, and abdominal pain found to have
elevated blood sugars in and acidosis, most consistent with HHS. | 134 | 41 |
16014771-DS-37 | 23,356,223 | Dear Ms. ___,
It was a pleasure being able to participate in your medical care
during your stay at the ___.
You came to the hospital because of your headache and chest
pain. We performed several tests of your heart and there were no
major signs of a heart attack. We also performed a CT scan of
your head that was ... | Ms. ___ is a ___ year old woman with multiple cardiovascular
risk factors (HLD, pre-DM, Fhx, ongoing cig smoking), CAD s/p
stent with prior MI in ___, CVAs x2 including left occipital
stroke in ___, lung CA s/p chemotherapy and surgery, atypical
chest pain, who presents with headache and chest pain found to
have a... | 179 | 412 |
11050647-DS-14 | 21,265,607 | Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because your liver was
damaged from drinking alcohol again
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were continued on steroids to help you recover.
- You improved and were ready to leave the hospital.
... | Ms. ___ is a ___ y/o female with HCV s/p treatment, EtOH
cirrhosis c/b ascites, varices, and HE, and recent admission for
alcoholic hepatitis who presented as a transfer w/ concern for
PVT but was found not to have PVT by MRI and found to have
worsening alcoholic hepatitis. | 214 | 49 |
15137016-DS-20 | 21,354,934 | Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WERE YOU ADMITTED?
- You had back pain and were found to have abnormal lung
findings on chest CT.
WHAT HAPPENED THIS ADMISSION?
- You were seen by the lung doctors and ___. You
received a procedure called a percutaneous ("through the skin")
lung biops... | Mr. ___ is a ___ with no significant past medical
history who presented to OSH with pleuritic back pain, found to
have abnormalities with lung mass on CTA chest, transferred to
___ for further workup, ultimately underwent lung biopsy for
suspected malignancy vs infection.
#Left lower lobe peripheral lung mass
#Pl... | 87 | 233 |
15636557-DS-14 | 24,563,720 | Dear Ms. ___,
You came to the hospital because you were having symptoms of
vision loss in your right eye with flashing patterns and lights.
We saw that you cannot see well out of the right side of your
vision. On MRI we see that you have an MS flare, which is
affecting the part of your brain that processes vision.... | ___ presented with one week of right-sided visual
artifacts and difficulty seeing on the right. She was found to
have a right homonymous hemianopsia. MRI brain showed multifocal
FLAIR hyperintensities with contrast enhancement, consistent
with an acute MS flare. She was treated with IV
methylprednisolone. She rece... | 226 | 118 |
15798647-DS-3 | 23,119,190 | Dear Mr. ___,
It was a pleasure taking care of you during your
hopsitalization.
You were admitted in order to treat an infection of your blood.
We believe that the infection was caused by a blockage of your
bile system in your liver. We replaced these biliary drains and
gave you antibiotics to treat the bacteria ... | Mr. ___ is a ___ year old gentleman with a history of
adenocarcinoma of unknown primary causing biliary obstruction
now s/p biliary drain placement x2 during his prior admission,
who is admitted to the MICU with septic shock secondary to
cholangitis/infected bilomas.
# Septic shock: Cholangitis vs infected biloma... | 76 | 316 |
17693798-DS-54 | 21,188,787 | Dear Ms. ___,
You were admitted to ___ for abdominal pain and diarrhea.
While you were here your kidney function was found to be
worsened, likely because you were not eating or drinking very
much while also having diarrhea. This improved with IV fluid,
encouraging you to drink more, and medications to improve th... | ___ female with a hx of crohns disease and collagenous colitis
s/p colectomy, ___ syndrome s/p stenting to ___, depression
who presents with acute on chronic abdominal pain, diarrhea, and
swelling of left face with MRV not showing signs of ___
syndrome.
#Diarrhea/abdominal pain: Acute on chronic for last 4 weeks.... | 147 | 433 |
15024110-DS-21 | 26,569,618 | Dear Mr. ___,
You came to the hospital at ___
because you were feeling unwell and had low blood sugar. You
were found to have a mass in the middle of your brain, called a
pituitary macroadenoma. You were seen by neurosurgery, who
recommended an outpatient follow up along with ENT (ear nose and
throat surgeons) f... | BRIEF SUMMARY
=============
Mr. ___ is a ___ with history of atrial fibrillation on
Coumadin (chads2 4), HFpEF (LVEF 63% ___, hypertension, and
T2DM who presented with weakness in setting of hypoglycemia,
subsequently found to have new pituitary mass concerning for a
pituitary macroadenoma.
# Expansile sellar mass... | 245 | 320 |
18531371-DS-11 | 27,014,747 | Dear ___,
___ were hospitalized due to symptoms of left sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so dama... | ___ woman with a history of HTN and DM presented with
acute onset left-sided weakness and slurred speech that lasted
for 2 hours before resolving spontaneously prior to presentation
to the hospital. She was admitted to the stroke service. CT head
showed hypodensity in the right basal ganglia. MRI brain w/o
contras... | 358 | 238 |
16371478-DS-5 | 21,304,150 | You were admitted to the hospital after a Right Sided Colectomy
for surgical management of your Colon Cancer. You have recovered
from this procedure well and you are now ready to return home.
Samples from your colon were taken and this tissue has been sent
to the pathology department for analysis. You will receive ... | Mr. ___ was initially admitted to the ___ medical service
from the emergency department:
___ y/o M with h/o remote duodenal ulcer, presents with abdominal
pain, BRBPR x2 months, CT showing cecal and terminal ileum
inflammation.
# Colon Mass: Presented with RLQ abdominal pain and BRBPR. Per
discussion with outpa... | 611 | 329 |
12964119-DS-29 | 21,442,888 | Ms. ___,
You were admitted to the antepartum service for nausea,
vomiting, and abdominal pain. You were observed in the hospital
for several days. Because you were unable to tolerate sufficient
amount of nutrition, you were started on tube feeds. You
received tube feeding for about a week, and subsequently you
we... | Patient is a ___ year old G6P3 who was admitted to the hospital
on ___ given persistent nausea in early pregnancy. Her
hospital course was notable for several other issues below:
1. Persistent nausea/abdominal pain: On admission patient had
reported a 10 pound weight loss over several weeks, as well as
vomiting at... | 443 | 659 |
12058674-DS-10 | 22,598,778 | Ms ___,
It was a pleasure participating in your care while your were
admitted to ___. You were
admitted because there was a blockage in your intestine that was
causing you to become very ill. In speaking with your power of
attorney it was decided that the focus of your care would be on
making you comfortable. ... | PRIMARY REASON FOR ADMISSION
___ F with severe dementia who presents with emesis with CT
showing SBO, pt is admitted for for medical management of SBO,
acute renal failure, hyperkalemia, leukocytosis. After
discussion with patient's power of attorney, pt was made comfort
measures only.
.
# Small bowel obstruct... | 173 | 542 |
15789056-DS-4 | 21,574,798 | Dear Ms. ___,
You were admitted to ___ for shortness of breath due to extra
fluid in the lungs after your recent Rituximab dose. You
improved with several dose of a diuretic by IV.
While here, you developed new left-sided weakness concerning for
possible stroke. You are being transferred to the Neurologic
servi... | This is a ___ with CLL, secondary ITP on prednisone and recently
started on Rituxan, HTN, HL, carotid artery stenosis, likely CAD
s/p recent demand-type NSTEMI with TTE showing regional WMAs c/w
CAD and increased LVEDP, who presents with dyspnea on exertion
consistent with pulmonary edema. Course complicated by
a... | 83 | 628 |
14835486-DS-31 | 23,895,432 | Dear Ms. ___,
You came to the hospital because you felt unwell and had a
fever. At the hospital, it was determined you had a urinary
tract infection. Our doctors started ___ on IV antibiotics, and
later switched you to oral antibiotics. Please stop your
antibiotics on the evening of ___. during your hospital stay,... | Mrs. ___ is a ___ year old woman with neurogenic bladder
complicated by multiple urinary tract infections presenting with
fever, mental status change, increased urinary urgency with
leukocytes and white blood cells on urinalysis. Given patient's
history of chronic UTIs and the clinical presentation the most
likel... | 68 | 306 |
11233477-DS-8 | 21,789,333 | Discharge Instructions
Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try t... | #IPH with cerebral edema
The patient was admitted from the emergency department to the
neuro intensive care unit where she was started on Mannitol
therapy. A bolus of Decadron was given but then shortly after
discontinued. She was started on Keppra for seizure prophylaxis.
A CTA was performed which demonstrated a ... | 411 | 226 |
11064934-DS-4 | 24,224,193 | Discharge Instructions:
Call your neurosurgeons office and speak to the Nurse
Practitioner if you experience:
- Any neurological issues, such as change in vision, speech
or movement
- Any problems with medications, such as nausea vomiting or
lethargy
- Fever greater than 101.5 degrees Fahrenheit
- ... | Ms. ___ was admitted to the Neurosurgical Service for further
evaluation of left ear fullness, headache, & dizziness on ___
s/p left posterior fossa craniotomy for TGN. The patient's pain
was well controlled with Tylenol and oxycodone. Head CT was
reported to show no acute intracranial findings, but was notable
fo... | 148 | 233 |
18399227-DS-7 | 24,050,352 | Dear Ms. ___,
It was a pleasure to care for you. You were hospitalized due to
your symptoms of nausea, vomiting, and abdominal pain. A CT scan
showed inflammation of your large intestine. Based on the
sigmoidoscopy (looking at your large intestine with a camera),
we believe you have ischemic colitis, which is infla... | ___ with history of HTN and vasovagal syncope as well as prior
constipation and N/V following prior non-abdominal surgeries who
presents with constipation, N/V, and abdominal pain following L
thumb surgery on ___, found to have pancolitis on CT and
findings consistent with ischemic colitis on sigmoidoscopy.
#Isch... | 126 | 269 |
12298542-DS-16 | 25,743,442 | Mr. ___, it was a pleasure taking care of you here at ___.
You were admitted to the hospital because you were having a
heart attack (myocardial infarction). A cardiac catheterization
was performed and a stent was placed to open up the corononary
artery that was blocked. It is VERY important that you take
Aspirin a... | Mr. ___ is a ___ yo M with a history of hyperlipidemia, but no
known history of CAD who presented with ongoing substernal chest
pain found to have elevated cardiac biomarkers and ECG showing
ST depressions in V2-V4 concerning for posterior STEMI (vs.
anterior ischemia), now s/p coronary angiography with bare metal ... | 141 | 231 |
11223240-DS-22 | 27,709,930 | You were admitted to the surgery service at ___ for
observation after you incarcerated incisional hernia was reduced
in ED. You are now safe to return home to complete your recovery
with the following instructions:
Please return in ED if you will have severe abdominal pain,
obstipation, severe nausea with emesis.
... | The patient with history of incisional hernia was admitted to
the General Surgical Service for evaluation of severe abdominal
pain. In ED patient was found to have incarcerated hernia,
which was manually reduced. After patient's hernia was reduced,
patient's diet was advanced to regular and was well tolerated.
On... | 207 | 157 |
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