-History of [HFrEF] w/LVEF [ ] on TTE: [ ].
-Home Regimen: [Current medical therapy].
-Evidence of acute exacerbation with [ ]
-[No obvious inciting incident, mild trop leak with AKI that improved with diuresis suggestive of cardiorenal process].
-No adherence issues suspected, consider gut wall edema with poor absorption to be reason for readmission.
-Admit to medicine service to intermediate care given risk of decompensation in the setting of known heart failure.
-Obtain new TTE to r/o new structural cause.
-[Holding GDMT].
-Lasix 40mg IV qAM, prn qPM depending on UOP. Goal UOP >300cc out @ 2h.
-Monitor I/Os, Obtain daily standing weights.
-Restrict fluid intake to <2L daily.
-Repeat BMP and Mg in the morning.
-CHF powerplan in, will need close f/u with CHF clinic once outpatient.
-[Non-Oliguric] Stage [ ] AKI w/o underlying CKD with baseline creatinine of [ ].
-[Likely 2/2 ATN]
-[Creatinine improved today to]
-[Plan to monitor I/Os. Will repeat labs in the morning for change.]
-Primary Cardiologist: [ ].
-History of CAD as seen on [CT/Cath], [without] previous intervention, currently [asymptomatic.]
-Last imaging/testing: [ ].
-EKG: [No current evidence of ischemia.]
-Currently on: [All should be on statin, RR of death decreased by 24%, stroke by 31%, need for CABG/Angioplasty by 27%; ASA for secondary prevention, increased risk of thromboembolic events if stopped, 70% within 7-10 days]
-Discussed risk factor modification as tolerable (HTN, HLD, Smoking, Diabetes).
Follow-up Appointment in: [3 months for ][]
Interval Items: [Outpatient Ultrasound]
Next visit: [CBC/CMP]
*********** End of Note ***********
-First Last Name, MD/DO, IM PGY - 1/2/3 -
**** Attending addenda to follow ****
-COPD not on home oxygen, follows w/Dr. [ ] outpatient.
-Continues to smoke 15 cigarettes/day.
-On Symbicort, Spiriva.
-LDCT will be ordered for January, previously [normal].
-[No] interest in smoking cessation at this time.
-Continue home inhalers.
-1) You were admitted to the hospital for: Exacerbation of Heart Failure
-2) What was done during your admission:
-3) What you need to do:
-Please follow up with your PCP within 1 week of discharge.
-Please follow-up with specialists as listed above.
-Please take your medications as instructed above.
-Return to the Emergency Room if you experience:
-New or worsening chest pain
-Shortness of breath, increased leg swelling
-Dizziness, seizures, or loss of consciousness
-4) Why it is important:
-[ ]
-5) Additional Instructions
-Low salt, low cholesterol/fat diet, and restrict fluid intake as directed by your doctor.
-Gradually increase your activity, as tolerable; schedule rest breaks as needed.
-Weigh yourself daily on same scale in the morning; bring your weight record to your follow-up appointment.
-If you gain 2 or more pounds in one day or 5 or more pounds in one week, return to the hospital.
-1) You were admitted to the hospital for: Heart Attack/Stent Placement.
-2) What was done during your admission:
-3) What you need to do:
-Please follow up with your PCP within 1 week of discharge.
-Please follow-up with specialists as listed above.
-Take your aspirin and antiplatelet (Plavix, Brilinta, Effient) every day, without missing any doses.
-Return to the Emergency Room if you experience:
-New or worsening chest pain
-Shortness of breath, increased leg swelling
-Dizziness, seizures, or loss of consciousness
-4) Why it is important:
-Taking your Antiplatelet and Aspirin keep your stent open.
-If you have any trouble getting your medicine, please call cardiology office.
-5) Additional Instructions
-No lifting over 10lbs x 10 days. No driving x 3 days.
-No tubs baths, swimming pools, or hot tubs x 7 days. OK to shower.
-If you notice any bleeding from the cath site, hold pressure above the site and call 911.
-Gradually increase your activity, as tolerable; schedule rest breaks as needed.
-Weigh yourself daily on same scale in the morning; bring your weight record to your follow-up appointment.
-If you gain 2 or more pounds in one day or 5 or more pounds in one week, return to the hospital.
-No alarm features present.
-Will evaluate for H Pylori with stool antigen test (must be off PPI prior to testing) given that dyspepsia is predominant symptom.
-Intermittent symptoms: Antacids or H2 blocker
-If persistent symptoms despite lifestyle modifications, will trial PPI.
-Daily symptoms: Omeprazole, Esomeprazole, Pantoprazole 8 week trial, taken 30-60 minutes before meal (dosing: omeprazole 10mg once daily, can increase to 20mg daily in 4-8 weeks; pantoprazole 20mg once daily, can increase to 40mg daily in 4-8 weeks. Advise lowest effective dose)
-Advised lifestyle modifications including avoidance of smoking, drinking, specific triggering foods, weight loss, avoiding NSAIDS, and avoiding lying down for 2-3 hours after eating.
-Patient [has] BP cuff at home, checks BP [daily].
-Compliant with current regimen of: [Amlodipine 10mg daily.]
-Goal BP < [120/80, 130/80, 140/90], currently [uncontrolled/controlled].
-Plan: [ ]
-Pt educated on lowering salt intake, weight loss, and increasing exercise.
-Indication: [Mechanical Aortic Valve].
-Goal INR: [2.5-3.5].
-INR & Source (venipuncture): [ ].
-Daily dose: [4mg and 6mg on alternating days].
-Total weekly dose: [35mg average per week].
-Next INR: [1 week].
-Plan: [Will decrease to MF 6mg, remaining days 4mg for a total of 32mg weekly. Pt provided extensive education on compliance with INRs w/Jodie prior to appointment today].
Constitutional: Alert, no acute distress, appears stated age
Eye: Normal conjunctiva, without scleral icterus
HENT: Atraumatic, hearing grossly intact, without nasal discharge, moist oral mucosa, grossly average neck circumference
Resp: Clear to auscultation bilaterally, non-labored respiration on room air, without rales/rhonchi, without wheezing
CV: Normal rate, regular rhythm, without murmurs on auscultation
GI: Soft, non-tender, non-distended, without obvious masses, w/o rigidity or guarding
MSK: Extremities non-tender to palpation, without LE edema bilaterally
Skin: Skin is warm, dry, and pale
Heme/Lymph/Imm: Without obvious bleeding, without significant bruising
Psychiatric: Cooperative, appropriate mood and affect, normal judgement
Neurologic: Awake and oriented X4
-Body Mass Index Measured: [ ] kg/m2.
-Class [III] Obesity w/BMI of [ ].
-Counseled patient on increasing exercise to at least 150 minutes weekly, improving diet with increased vegetables/fruits, and decreasing total calorie by 500-750 kcal/day.
-Pt not currently interested GLP-1s for weight loss, will re-address next visit.
-Would like to be referred to bariatric center for her weight.
-Previously trialed Ozempic but feels she did not lose any weight, made her feel unwell.
-Referral sent.
-Suspected to be [Orthostatic] syncope due to [Prodrome], [Clean] EKG, [w/] RF present.
-Low suspicion for PE (if able, PERC rule[ ])
-Orthostatic Vital Signs: [ ]
-CTH: [ ]
-Admit to Telemetry to monitor for arrhythmia.
-Continue conservative measures.
