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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M s/p exploratory laparotomy, small bowel decompression,
rectosigmoid colectomy, appendectomy, colorectal anastomosis for
obstructing colon adenocarcinoma (pT3N2b, stage IIIc) in ___
who presents to the ED with symptoms of bloating, abdominal pain
and distention x6 days. He was seen by his PCP today who ordered
a KUB demonstrating dilated loops of bowel and presented to the
ED at his PCP's request for a CT scan given concern for a small
bowel obstruction. He reports ___ pain currently which has been
up to a ___, continued bloating and gas pains. No nausea, no
emesis. He is tolerating PO, although his appetite is decreased
and he is passing flatus and having bowel movements. Last BM
this AM. Radiology showed 1. Complete obstruction with transition in the left lower quadrant. Given the
adjacent narrowing and angulation without obstruction on the nearby the
jejunum, this is felt to be secondary to an adhesion. No bowel wall edema or
intra-abdominal free air.
2. Bilateral subcutaneous drains are well positioned.
NOTIFICATION: The findings were discussed by Dr. ___ with ___
via telephone on ___ at 2:04 ___, 15 minutes after discovery of the
findings. The patient was diagnosed with INTESTINAL OBSTRUCT NOS, HX OF COLONIC MALIGNANCY. The patient was treated with ___ PROCEDURES:
1. Exploratory laparotomy.
2. Bilateral rectus abdominis component-separation repair
of abdominal wall defect.
3. Small-bowel resection with primary anastomosis x1.
4. A 10 x 14 inch polypropylene mesh onlay performed in the
manner of STOPPA.. At the time of discharge, the patient had Large ventral hernias. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted from the emergency department on
___. He was initially seen at his PCP's office where a
KUB was done showing distended loops of bowel concerning for
small bowel obstruction. On evaluation in the ED, CT scan of the
abdomen showed a complex network of ventral hernias with
multiple loops of bowel incarcerated within the hernia. He was
admitted to the Acute Care Surgery team for management and
operative discussion/planning.
Mr. ___ was taken to the OR on ___ and underwent an
exploratory laparotomy with bilateral rectus abdominis component
separation repair of abdominal wall defect with polypropylene
mesh and small bowel resection with primary anastomosis,
performed by Dr. ___. He tolerated the procedure well without
any complications and was taken to the post-anesthesia care unit
in stable condition. At the end of the procedure, Mr. ___ had 2
JP drains in the space overlaying the mesh and an NG tube for
decompression of the stomach.
In the immediate post-operative period, Mr. ___ at an epidural
for pain control and foley catheter while he had an epidural.
The NG tube was removed a few days after the operation and he
was started on sips of clears, awaiting return of bowel
function. However, after a few days, Mr. ___ became
increasingly distended and had an episode of emesis. He was
again kept NPO, started on IV fluids, and given a PCA for pain
control temporarily. An NGT had to be placed to decompress the
stomach after a second episode of bilious vomiting. Once he
began passing flatus, he was started on a clear diet and diet
was advanced as tolerated while he continued to pass flatus.
During the recovery period, he was also started antibiotics for
some mild non-demarcatable erythema noted over the incision,
especially given the risk of mesh infection. The JP drains
remained serosanguinous in output.
On discharge, Mr. ___ continued to pass flatus, although he had
not had a bowel movement. He was tolerating a regular diet
without any nausea and vomiting and continued on a bowel
regimen. He was eager to be discharged and acknowledge that
should he not have a bowel movement in 48 hours, he should call
the clinic or return to the ED. He was given instructions for
medications and scheduled to follow-up early next week for
staple removal and JP drain removal and then another 2 weeks
after for follow-up.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with history of AFib (on warfarin), cognitive
impairment with h/o recurrentfalls, CAD s/p remote CABG ___
ago), CKD (baseline Cr 1.5),
diffuse esophageal spasm, HTN, and ?COPD here after slamming
into
door with active extravastation... retropharyngeal hematoma
requiring intubation.
Patient was walking in the dark and slammed into a door at
home,
hitting her face. She had a L eyelid laceration, paramedics came
to see her, and she ultimately declined ED admission. 45min
afterwards, she felt short of breath and felt like her "airway
was closing" prompting arrival to ED. The patient then underwent
emergent intubation for airway protection. Her INR was 1.8 and
was given K centra and 10 IV vitamin K. CHEST (PORTABLE AP) showed As above. CT HEAD W/O CONTRAST showed 1. No acute hemorrhage or fracture.
2. Chronic small vessel disease.
3. Small left ___ hematoma. CT NECK W/O CONTRAST showed Massive prevertebral hematoma with associated hyper extension teardrop
fracture at C4 without alignment abnormality or distraction. Recommend urgent
CTA to assess active bleeding.
RECOMMENDATION(S):
-Intubation for airway protection.
-C-spine collar placement given acute fracture at C4. CTA NECK WANDW/OC AND RECONS Q25 CT NECK showed 1. Extensive retropharyngeal hematoma spanning from C2 through T1, measuring
4.6 x 2.6 cm axially with active extravasation. Unclear whether this
represents active extravasation from prevertebral artery versus
retropharyngeal branch artery, although the associated vessel does appear to
be likely prevertebral (series 2, image 144). Consultation with neurosurgery
is recommended.
2. An additional linear focus of hyperdensity along the lateral aspect of the
hematoma inferiorly (series 2, image 103) cannot be connected to a larger
vessel. This could represent venous hemorrhage. Close attention on followup
is recommended.
3. Additional findings described above.
NOTIFICATION: The findings were discussed with ___ resident by ___,
M.D. on the telephone on ___ at 10:03 am, 5 minutes after discovery of
the findings.
The findings were discussed with ___, M.D. by ___, M.D. on the
telephone on ___ at 10:30 am, 30 minutes after discovery of the findings. CHEST (PORTABLE AP) showed Interval intubation with appropriately positioned ET tube. OG tube positioned
appropriately. Expanding mediastinal hematoma. CT NECK W/O CONTRAST (EG: PAROTIDS) Q21 CT NECK showed 1. Redemonstration of retropharyngeal hematoma extending from C2 through the
right aspect of the posterior mediastinum, slightly decreased in size from the
prior study with nonvisualized hematocrit levels previously seen, likely
secondary to mass effect from endotracheal tubes and intubation.
2. The hematoma extends to the posterior mediastinum. The component in the
mediastinum appears more prominent when compared to prior examination. This
could represent redistribution, however the findings could represent continued
active extravasation and close interval followup is recommended to document
stability/growth. Chest CT showed 1. A large retropharyngeal hematoma extends into the superior mediastinum, not
appreciably changed compared to the earlier same day neck CTA. There is mild
mass effect on the posterior wall of the trachea, but no significant luminal
narrowing.
2. Somewhat nodular opacification focally within the anterior right lower lobe
probably reflects atelectasis. However, recommend three-month follow-up chest
CT to assess stability.
RECOMMENDATION(S): Somewhat nodular opacification focally within the anterior
right lower lobe probably reflects atelectasis. However, recommend three-month
follow-up chest CT to assess stability. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___, most recently ___.
Lungs clear. Moderate cardiomegaly is chronic. No pulmonary edema or pleural
effusion.
ET tube in standard placement. Nasogastric drainage tube ends in the upper
stomach. MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE showed 1. Acute fracture involving the anterior C4 vertebral body with prevertebral
soft tissue edema and probable injury to the anterior longitudinal ligament as
well the as the interspinous ligament.
2. Edema within the C6-C7 intervertebral disc space with probable osseous
edema of the superior C7 vertebral body.
3. Redemonstration of retropharyngeal hematoma.
4. Retrolisthesis of C4 on C5 and anterolisthesis of C2 on C3.
5. Multilevel degenerative changes as detailed above, with moderate spinal
canal stenosis at C4-C5 through C6-C7 levels with spinal cord remodeling,
without definite cord edema. CHEST (PORTABLE AP) showed In comparison with the study ___, the monitoring support devices are
essentially unchanged. Cardiac silhouette remains mildly enlarged without
evidence of vascular congestion, pleural effusion, or acute focal pneumonia. CHEST PORT. LINE PLACEMENT showed Compared to chest radiographs since ___, most recently ___
through ___ at 05:33.
Combination of small to moderate pleural effusions and moderate bibasilar
atelectasis has increased since earlier in the day. Moderate cardiomegaly is
chronic. There is also very mild perihilar edema.
Indwelling cardiopulmonary support devices in standard placements. CHEST (PORTABLE AP) showed Lines and tubes are in standard position. Bibasilar opacities have markedly
improved. Bilateral effusions have improved. Cardiomegaly, tortuous aorta
and prominent hila bilaterally are stable. There is no evident pneumothorax.
Sternal wires are intact. DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS showed Interval placement of Dobhoff feeding tube which coils at the GE junction and
should be repositioned. No other significant interval change. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Mild cardiomegaly improved, lungs grossly clear, small bilateral pleural
effusions new or newly apparent. No pneumothorax. Right jugular line ends in
the low SVC.. DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS showed On the second radiograph, feeding tube tip is in distal esophagus, should be
advanced. VIDEO OROPHARYNGEAL SWALLOW showed No aspiration. Penetration with thin and nectar consistencies.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Findings most consistent with severe chronic small vessel ischemic changes
in the absence of acute symptoms. No intracranial hemorrhage.
2. Paranasal sinus disease, suggestive of acute sphenoid sinusitis in the
absence of recent intubation. CHEST (PA AND LAT) showed In comparison with the study ___, the right IJ catheter has been
removed. Continued enlargement of the cardiac silhouette in a patient with
previous CABG procedure an intact midline sternal wires. Mild elevation of
pulmonary venous pressure with small bilateral pleural effusions and
compressive atelectasis at the bases.
No definite acute focal pneumonia. The patient was diagnosed with Unsp disp fx of fourth cervical vertebra, init for clos fx, Walked into furniture, initial encounter. At the time of discharge, the patient had retropharyngeal hematoma
C4 vertebral body fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with past medical history notable for afib on
warfarin and recurrent falls. Per report of primary team, she
suffered a fall earlier and struck her head on a doorknob. She
initially was able to get up and refused transfer to the
hospital, but later (<1 hour after), she noticed swelling in her
neck and difficulty breathing.
She was brought to the emergency room where a CT scan of the
neck was done, which showed a large prevertebral retropharyngeal
hematoma with active extravasation of contrast. She was
intubated in the emergency room. The patient was admitted to
the MICU for monitoring and pulmonary toilet.
On arrival to the MICU, the neurosurgical, ENT, and spine teams
were consulted, who did not initially plan for surgical
intervention. The ACS team was consulted given multiple other
areas with evidence of trauma, and recommended transfer to the
TSICU. Imaging of the neck showed active extravasation, venous
vs arterial but the source was unclear. Per Neurosurgery/ENT,
there was no clear surgical intervention to be performed. An MRI
of the neck was done which demonstrated an acute fracture
involving the anterior C4 vertebral body. The patient was
placed in a soft collar for comfort but later discontinue
because the spine was stable and there was only 1 column injury.
An oral-gastric tube was placed for the initiation of tube
feedings. Prior to extubation, the patient underwent a bronch
which demonstrated tracheomalacia. She had pneumonia from group
B strep and was started a 7 day course of antibiotics:
ceftriaxone and azithromycin, which was changed to ancef when
culture date was obtained.
The patient was successfully weaned and extubated on ___. To
provide nutrition after removal of the oral gastric tube, the
patient was evaluated by Speech and Swallow and underwent a
Video swallow. She was transitioned to a soft diet. Because of
the patient's underlying cardiac history, she underwent an
echocardiogram which showed an EF 50-55%, and 2+ MR.
___ patient was transferred to the surgical floor on ___. Her
hematocrit remained stable. On ___, she reported increased neck
and posterior head pain. The Neurosurgery service was
re-consulted and recommended a non-contrast head cat scan which
showed severe chronic small vessel ischemic changes with no
acute process. The patient was given pain medication and warm
compresses and her neck pain decreased in intensity. In
preparation for discharge, she was evaluated by physical therapy
and recommendations made for discharge to a rehabilitation
facility.
The patient was discharged on HD # 11. Her vital signs were
stable and she was afebrile. She was voiding without difficulty
and had return of bowel function. Her appetite continued to be
decreased and she was provided with nutritional supplements.
She had no difficulty with swallowing. Her hematocrit and white
blood cell count stabilized. Appointments for ___ were
made in the acute care clinic. Discharge instructions were
reviewed and questions answered.
Her anticoagulation was held during this admission, and should
not be continued until discussion with her PCP at ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with PMH of DM2, CAD s/p CABG, ischemic cardiomyopathy
with LVEF 20%, atrial fibrillation on Coumadin, and a recent
history of pancreatitis, cholecystitis, and c. diff colities at
___ who presents from rehab with 2 day history of bloody
bowel movements and an E. coli UTI. Radiology showed 1. Limited evaluation due to lack of pre-contrast sequence. Focal areas of
hyperdensity within the descending and sigmoid colon without definite
progression, are felt to be hight density intraluminal contents unlikely to
represent GI bleed; however, this cannot be definitely excluded due to
limitation of the study.
2. Diffuse colonic edema, compatible with patient's known history of
Clostridium difficile infection.
3. Small amount of ascites and anasarca, increased since prior.
4. Biliary drain is in place with expected pneumobilia.
5. A 12 mm arterial enhancing hepatic lesion, likely flash-filling
hemangioma, unchanged since ___ exam.
6. A 17 x 15 mm hypodensity in the uncinate process of the pancreas, more
conspicuous since prior studies, which can be further assessed with MRCP, if
patient's pacemaker is MR compatible. Otherwise, consider EUS.
7. Extensive calcified atherosclerotic disease of the aorta with associated
aneurysmal changes, stable.
8. Small hiatal hernia. The patient was diagnosed with GASTROINTEST HEMORR NOS. The patient was treated with endoscopic ultrasound with biopsy. At the time of discharge, the patient had e. coli septicemia
e coli uti
gi bleeding
ischemic colitis
acute blood loss anemia
chronic systolic chf. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ gentleman DM2, CAD s/p CABG, ischemic cardiomyopathy with
LVEF 20%, atrial fibrillation on Coumadin, and a recent history
of pancreatitis, cholecystitis, and c. diff colitis presents
with BRBPR and UTI and admitted initially to the MICU due to
transient hypotension while in the ED.
# BRBPR/GI bleeding - Pt. presented with 2 day history of large
bloody bowel movements. Rectal exam revealed maroon stools.
Despite bloody bowel movements, H/H relatively stable on
admission at 9.6/29.8 from 10.6/32.1 one month prior. Pt.
responded appropriately to 1U PRBC in the ED. Pt. had one
episode of hypotension that resolved with transfusion and IVF.
No evidence of source on CT ab/pelvis, though limited by lack of
PO contrast. EGD without clear source of bleed in ___.
Colonoscopy ___ did show hemorrhoids as well as sigmoid
diverticuli. Pt's INR was reversed in the ED with vitamin K and
FFP. Pt. was seen by GI who felt that bleed most likely
diverticular vs ischemic colitis. Pt. remained hemodynamically
stable without further drop in H/H and so was transferred to the
floor on hospital day 2 He got one additional unit of RBC and
hemoglobin prior to discharge was 9.6.
#Pancreas lesion: not consistent with solid mass on endoscopic
ultrasound. Underwent pancreas biopsy that did not show
malignancy. He will have f/u with Dr. ___ adv endoscopy
team for biliary stent removal and can discuss future imaging of
abd at that time. CA ___ tumor marker normal level.
- ERCP in 6 weeks
- CT pancreas protocol in 4 weeks, follow up with Dr. ___
___
# Hypotension: Pt. transiently hypotensive to 86/40 while
undergoing CT scan in the emergency department. Hypotension
resolved with administration of IVF and blood transfusion. He
never required pressors. Given blood loss and bacteremia,
hypotension was likely related to combination of hypovolemia and
possibly sepsis. Pt. had no further episodes of hypotension.
# E. coli bacteremia and UTI - Per nursing home report, culture
from the day prior to admission was growing E. coli, though pt.
had not yet been initiated on antibiotics. UA grossly positive
on arrival to ___. Pt. initiated on ceftriaxone. Blood and
urine cultures, however, grew E. coli resistant to ceftriaxone
and so pt. transitioned to meropenem. He received 9 day of
antibiotics from first day of negative blood culture on ___ to
end on ___. PICC line placed in mid line position to be removed
prior to discharge.
# C. difficile colitis: Per reports, pt. has history of
recurrent C. diff. Pt. admitted on PO vancomycin (DAY ___
END ___. However, consider extending course given recent
treatment with Meropenem for UTI
# Hyponatremia: Pt. hyponatremic on admission with Na 126.
After IVF and blood transfusion, sodium improved to 130.
# DM2: At home, pt. is not on insulin, though he is covered by
low dose sliding scale at rehab. Pt. was continued on insulin
sliding scale during this admission.
# Cardiac disease: Pt. with atrial fibrillation (CHADS2 of 4; on
Coumadin), CAD, and CHF (EF 20%). Pt's INR was reversed on
admission due to active GI bleed with 10 IV vitamin K and FFP.
His home torsemide was held in setting of hypotension and then
resumed at lower dose. Coumadin resumed prior to discharge. He
was continued on home aspirin, digoxin, metoprolol, and
pravastatin.
- Torsemide may require uptitration
# Gout: Continued home prednisone and allopurinol.
# BPH: Continued home finasteride.
# Transitional issues:
- Contact: ___ (wife) ___
- Code: Full </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ man, past medical history of hypertrophic
cardiomyopathy status post alcohol septal ablation, presents
with
epigastric gas-like pain. He states he usually goes away with
antacids. States that it "feels like gas-like pain" but when
further asked, agreed that it felt like palpitations. No
lightheadedness or dizziness. Some mild increased fatigue
recently. No chest pain, chest pressure, SOB, DOE, ___ edema,
orthopnea, dizziness, lightheadedness, syncope, or falls. Had an
episode two months prior where he woke up trying to catch his
breath. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality. The patient was diagnosed with Unspecified atrial flutter. The patient was treated with Supraventricular tachycardia ablation (___). At the time of discharge, the patient had PRIMARY DIAGNOSIS/ES:
====================
-Supraventricular tachycardia due to atrioventricular node
re-entrant tachycardia (AVNRT)
SECONDARY DIAGNOSIS/ES:
========================
-Troponin elevation (demand myocardial infarction)
-Hypertrophic cardiomyopathy
-Hypertension
-Ulcerative colitis
-Depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>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.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male on Coumadin who lives in assisted living who
suffered
a witnessed fall today. He was being transferred from his
wheelchair to bed when he fell onto his left side and struck his
head this morning at 8:45am. It is unclear whether the patient
had loss of consciousness at the time of the fall. A cranial CT
was done at 1pm that revealed a hemorrhage into an old stroke
bed. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST showed Segmental fracture of the left zygomatic arch and possible nondisplaced
fracture of the lateral wall of left orbit. Radiology showed Large parenchymal hemorrhage in the right MCA territory at the site of prior
infarction with overall minimal change from prior exam. Intraventricular
hemorrhage again noted without evidence of obstructive hydrocephalus or
herniation. Left zygomatic arch fracture. CT HEAD W/O CONTRAST showed Unchanged intraparenchymal hemorrhage and left zygomatic fractures from
previous examination. No new areas of hemorrhage or infarction. The patient was diagnosed with BRAIN HEM NEC W/O COMA, FX MALAR/MAXILLARY-CLOSE, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT, HYPERTENSION NOS, LONG TERM USE ANTIGOAGULANT. At the time of discharge, the patient had intraparenchymal hemorrhage
IVH. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted from the emergency department to the
surgical intensive care unit on ___ after being adminstered
Kcentra and vitamen K. His aspirin and coumadin were held. A
trauma evaluation was started which included a dedicated CT
SINUS/MANDIBLE/MAXIL to evaluate for facial fractures. Plastic
surgery was asked to consult regarding.
___, the patient's exam remained stable. Plastic surgery
reviewed the CT of the sinus which showed segmental fracture of
the left zygomatic arch and possible nondisplaced fracture of
the lateral wall of left orbit. Plastics recommended that the
patient follow up with them in clinic following discharge from
the hospital. He had a repeat NCHCT which showed a stable bleed
interval.
On ___, patient was stable and transferred to the floor.
On ___, the patient remained neurologically stable and was
pending a bed to rehab.
On ___, patient was stable on examination. Repeat head CT was
performed and showed stable ventricular size and improved IVH.
He was accepted at rehab and was discharged in stable condition.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ gentleman with a complex vascular
history who has undergone multiple bilateral lower extremity
procedures. He has a history of end-stage renal disease and is
currently being dialyzed through a right groin tunneled
catheter. He presents with dry gangrene of his remaining three
toes on his left foot. We have planned for left lower extremity
angiogram via the right groin with further intervention to be
dictated by our findings. Radiology showed No acute cardiopulmonary process. FOOT AP,LAT AND OBL LEFT showed Status post resection of the first digit with expected postsurgical changes.
Apparent linear lucency extending from the osteotomy toward the base of the
remaining proximal phalanx could be artifactual due to overlying skin defect,
although fracture or osteomyelitis would be difficult to exclude. CHEST (PORTABLE AP) showed Comparison to ___. Stable postoperative right apical changes.
Stable sternotomy wires and inferior vena cava device. Borderline size of the
cardiac silhouette. Stable subtle ___ bronchial opacities, new as compared
to the previous examination, and potentially reflecting mild interstitial
edema. The patient was diagnosed with Local infection of the skin and subcutaneous tissue, unsp. The patient was treated with ___ LLE angiogram
___ LLE TMA. At the time of discharge, the patient had PERIPHERAL VASCULAR DISEASE
CHRONIC RENAL FAILURE
GANGRENE, dry. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient underwent LLE angiogram with popliteal artery and
anterior tibialis artery stent on ___. It was decided to
pursue a LLE transmetatarsal amputation and was added on for
___. The patient was NPO prior to ___ procedure, but the
case had to bumped to ___ due to limited OR availability.
Surgery was rescheduled for ___. Patient received dialysis
on the morning of his procedure, which he has getting every 3
days. After induction of general anesthesia for LLE
transmetatarsal amputation, anesthesia noticed low blood
pressure and ST depressions. At this time, it was decided to
hold off on the procedure and consult cardiology. Cardiology
stated that the event was most likely secondary to demand
ischemia due to no EKG changes post operatively. However, they
wanted to assess patients cardiac status through cardiac
catheterization. He was added on for ___. Patient was unable
to undergo cardiac catheterization and was reschedule for
___. It was on ___ that patient decided he wanted to
leave the hospital and come back at another time for the cardiac
procedure. This was against medical advice and patient
understood. He was advised to continue aspirin and plavix. He
was written a script for Augmentin PO for 2 weeks. Patient was
contacted by vascular and cardiac surgery for follow up
appointments.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old Female who presents with a known hemorrhagic ovarian
cyst with severe left lower quadrant pain which radiates to the
back which began while in exercise class today while performing
a pushup. She apparently felt a popping sensation in the LLQ and
the severe pain shot to her left inguinal crease to her left
labia. She felt the sensation of liquid there, but was dry.
Since then she has had intermittant nausea and severe sharp
shooting pain. PELVIS U.S., TRANSVAGINAL showed 1. 12 mm left ovarian dermoid.
2. Otherwise normal ovaries without evidence of torsion.
3. Millimetric anterior wall fibroid. CT abdomen and pelvis with contrast showed 1. No acute CT findings of the abdomen and pelvis.
2. 9 mm left ovarian dermoid as seen on same-day ultrasound. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. At the time of discharge, the patient had Renal colic. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>1. Abdominal Pain due to Hemmorhagic Ovarian Cyst, nausea with
vomitting: Pain was out of proportion to exam, requiring
dilaudid PCA for HD 2, however patient eventually felt it may be
more anxiety related, was switched to oral oxycodone tylenol
motrin. Renal stone is most likely given clinical picture of
writhing ___ pain, though exams reviewed with radiology and no
evident stone, good ureteral perfusion jets to bladder
indicating no osbstruction, no other intraab pathology.
Discharged hospital day three with tamsulosin. Tolerating PO.
2. Chronic Stable Asthma
- Albuterol
3. ADHD
- Currently off all amphetamines (stopped 4 months prior to
admit)
Full Code
Ambulation</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old female with PMH of PCOMM
aneurysm s/p clipping on ___ with Dr. ___ unsecured
left para-opthalmic artery aneurysm. She had been having
headaches for one week prior to presentation that significantly
worsened on day of presentation with associated nausea and
vomiting. NCHCT at OSH showed acute SAH with IVH. She was
transferred to ___ for further evaluation and treatment. CTA HEAD AND CTA NECK Q16 CT NECK showed -Intraventricular and subarachnoid hemorrhage are stable compared to the
earlier same-day noncontrast head CT.
-Mild hydrocephalus, stable compared to the earlier same-day CT, but new
compared to ___.
-Revaluation of the previously treated right supraclinoid ICA aneurysm is
limited by streak artifact from surgical clips and endovascular coils. Please
refer to the subsequent cerebral angiography results for further detail.
-Stable 2 mm left ICA clinoid segment aneurysm.
NOTIFICATION: According to notes on OMR dated ___ at 17:22 the
neurosurgery team was aware of the subarachnoid and intraventricular
hemorrhage. Right common carotid artery angiogram.
Left common carotid artery angiogram.
Left vertebral artery angiogram.
Right common femoral artery angiogram. showed Right ICA communicating segment pseudoaneurysm was identified, measuring
around 4 mm in maximum diameter. Post pipeline embolization, successful
deployment of the stent across the neck of the aneurysm with no InStent
narrowing or stenosis. Significantly improved distal M1 vasospasm likely
secondary to manipulation.
RECOMMENDATION(S):
1. Continue on dual antiplatelet.
2. Follow-up angiogram within 4 weeks.
3. Tight blood pressure control for the next few days.
4. Subarachnoid hemorrhage management as per usual protocol. Radiology showed The tip of the endotracheal tube projects 2.2 cm from the carina and the tip
of the feeding tube projects over the stomach. There are low bilateral lung
volumes. New streaky opacities in the left lower lung may reflect atelectasis
or aspiration. The right lung is grossly clear. No pleural effusion or
pneumothorax. The size of the cardiac silhouette is within normal limits. Radiology showed The tip of the nasogastric tube projects over the distal stomach. The tip of
the endotracheal tube projects 2 cm from the carina. CT HEAD W/O CONTRAST showed 1. Interval new intraventricular hemorrhage and slight worsening of
hydrocephalus.
2. No midline shift or evidence of infarct.
3. Redemonstrated embolization coils and surgical clips limiting assessment of
surrounding structures.
NOTIFICATION: The findings were discussed with ___, N.P. by ___
___, M.D. on the telephone on ___ at 4:02 pm, 2 minutes after
discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Surgical hardware streak artifact limits examination.
2. Within limits of study, no evidence of new or enlarging hemorrhage and no
definite evidence of territorial infarct. Please note MRI of the brain is
more sensitive for the detection of acute infarct.
3. Interval resolution of layering intraventricular hemorrhage.
4. Grossly stable ventriculomegaly with near complete effacement of the sulci.
5. Grossly stable intraventricular septum 1.4 cm probable blood products
compared to ___ prior exam, new compared to ___
prior. CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD showed 1. No significant change in size of the interventricular hemorrhage.
2. Unchanged moderate hydrocephalus, suggestion of periventricular edema.
3. Intracranial arterial vasospasm, similar to ___ exam..
Suggestion of areas of parenchyma edema, without definite ischemia. Diagnostic cerebral angiogram for evaluation of previously
ruptured right posterior communicating artery aneurysm in the setting of new
right eye ptosis.
During the procedure the following vessels were selectively catheterized
angiograms performed:
Right internal carotid artery
Three-dimensional rotational angiography of the right internal carotid artery
circulation requiring post processing on an independent workstation and
concurrent attending physician interpretation and review
Left common femoral artery
Ultrasound-guided access to the left common femoral artery showed ___ 1, no residual filling of previously ruptured, coiled, clipped,
and pipelined right posterior communicating artery aneurysm.
RECOMMENDATION(S):
1. Continue aspirin and relate to. Plans for remote treatment of
contralateral ICA aneurysm on the left. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___ most recently ___.
Heart size top-normal. Lungs clear. No pleural abnormality. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. The patient was diagnosed with Headache. The patient was treated with ___ - Pipeline embolization for R ICA pseudoaneurysm. At the time of discharge, the patient had Subarachnoid hemorrhage
Right ICA pseudoaneursym
Hypertension
Headache. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms ___ is a ___ yo female who presented with a headache.
Initial CT at OSH showed a SAH with IVH and she was transferred
to ___ for further evaluation.
#SAH/IVH from pseudoaneurysm
CTA showed stable IVH/SAH with mild hydrocephalus and 2mm L ICA
pseudoaneurysm. She was admitted to the Neuro ICU for close
neuro monitoring and strict blood pressure control <140. She was
taken to angio suite on ___ and underwent pipeline
embolization of R ICA pseudoaneurysm. Please see operative
report for full details. R groin was angiosealed and she was
transported to ICU intubated. She was started on Keppra 1 g Q12H
BID for 7 days for seizure ppx and nimodipine 60 mg q4h for 21
days for vasospasm ppx. She was successfully extubated. She was
continued on ASA/Brilinta. She remained in ICU for close BP
monitoring and vasospasm watch. Head CT ___ showed slight
worsening of hydrocephalus but she remained neurologically
stable. She had continued nausea and was started on decadron
with improvement. She was transferred to the step down unit on
___. She was evaluated by physical therapy ___, who
recommended rehab at discharge. On ___, she became very
agitated and complained of a headache and had new right ptosis.
She underwent STAT CTA brain, which was negative for acute
findings. She underwent cerebral angiogram which showed complete
resolution of the aneurysm. Physical therapy and occupational
therapy were consulted for disposition planning and recommended
discharge to rehab. On day of discharge, her pain was well
controlled with oral medications. She was tolerating a diet and
getting out of bed with assistance. Her vital signs were stable
and she was afebrile. She was discharged to rehab in a stable
condition.
#Hypertension
She was started on PO labetalol for blood pressure control,
which was titrated and eventually discontinued.
#Leukocytosis
WBC uptrended and she was afebrile. UA was negative. CXR showed
minimal atelectasis and incentive spirometry was encouraged.
LENIs were negative for DVT. WBC downtrended to normal.
#Diarrhea
She had multiple episodes of loose stool. She was negative for
C. difficile. Bowel regimen was liberalized to PRN. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with PMHx new diagnosis CHF (EF 55%),
hypertension, spinal stenosis, anxiety, depression, alcohol
abuse, and chronic macrocytic anemia presenting with 1 week of
worsening dyspena on exertion. He was seen in his PCP's office
on ___, was started on furosemide and told to go to the ED
for worsening anemia. He was not able to make it to the ED as
recommended, and has had worsening DOE, leg, scrotal, and
abomdinal edema despite diuretics. In the ED, he was afebrile,
hypertensive to 142/68, and SaO2 96% on RA. Labs remarkable for
Na+119, proBNP 9033, HCT 23 (MCV 99), INR 1.2, trop <0.01.
Received 40mg IV furosemide, albuterol and ipratropium, nebs. Radiology showed Mild pulmonary vascular congestion/interstitial edema and small
bilateral pleural effusions. Radiology showed 1. No focal liver masses.
2. Patent hepatic vasculature with hepatopetal flow. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPOSMOLALITY/HYPONATREMIA, HYPERTENSION NOS. At the time of discharge, the patient had Primary: diastolic CHF exacerbation
Secondary: peripheral edema, macrocytic anemia, alcohol abuse. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ male with history of CHF, hypertension, and
macrocytic anemia of unknoen etiology, admitted with volume
overload and dyspnea, concerning for acute diastolic CHF
exacerbation, exacerbated by worsening chronic macrocytic
anemia. Symptoms improved with diuresis and two blood
transfusions. Electrolytes repleted during diuresis, likely
worsened in setting of some chronic malnutrition. Discharged to
short term rehab with improved edema and on room air.
ACTIVE ISSUES
# Diastolic heart failure exacerbation
CXR, BNP, history and exam suggestive of volume overload
secondary to diastolic CHF exacerbation; patient with primarily
right-sided heart failure; echo in ___ with LVEF 55%,
moderate MR. ___ with IV lasix. Fluid restricted to
2000cc/day. There was a concern for cirrhosis contributing to
edema with his low albumin and elevated INR in setting of
chronic hepatitis B and EtOH abuse, but RUQ US did not indicate
evidence of a cirrhotic liver. Dyspnea is also worsened by
concomittant anemia and his severe pulmonary hypertension.
Fatigue and shortness of breath improved with RBC transfusions,
as below. On ___ he was transitioned from IV furosemide to PO
torsemide and was able to maintain diuresis. On ___ his foley
catheter was removed and he was able to urinate. He already has
outpatient follow-up scheduled in cardiology clinic.
# Hyponatremia:
Sodium was 119 on admission. Pt has h/o hyponatremia during past
hospitalizations, thought to have beer potomania at that time.
His current hyponatremia was secondary to hypervolemia in
setting of dCHF exacerbation. There could also be a component of
chronic, mild hyponatremia in the setting of citalopram use. His
Na+ slowly trended up with diuresis. Na+ at discharge was 129.
# Macrocytic Anemia:
This is a chronic issue for him. Workup to date revealed normal
B12, folate, iron studies, ___ only with a few colonic
adenomatous polyps in ___, and BM Bx without hypocellularity
and no evidence MDS. ___ without signs of active bleeding,
stool guiac negative. Likely secondary to chronic EtOH abuse.
Received two transfusions of 1U PRBC each for HCT < 21 with
improvement in fatigue. HCT stabilized for several days prior to
discharge. H/H at discharge was 8.2/24.3
# Alcohol Abuse:
Pt has h/o alcohol abuse with prior episode of DT's requiring
intubation for airways protection. H/O fatty liver per medical
record. Unclear how much he drinks, states that he doesn't drink
every day, cannot quantify how much beer, but states that he
drinks to take the edge off of his back pain. He received IV
thiamine and folate x 5 days, continued on home B12 and MVI.
CIWA protocol used, but patient did not score nor receive any
benzodiazepines.
# Tobacco Abuse
He was started on a nicotine patch while hospitalized.
# Severe pulmonary hypertension
Noted on echo in ___, unclear etiology, may be secondary to
chronic hypoxemia from smoking, left-sided valvular disease
(MR), or pulmonary arterial hypertension. Would recommend
oupatient PFTs and perhaps RHC as outpatient when seeing
cardiology.
# Diarrhea: Nonbloody, no recent abx use. No recent travel or
sick contacts. ___ be malabsorptive or in setting of poor
nutrition. C. diff was ordered to be collected but patient did
not have diarrhea once admitted.
CHRONIC ISSUES
# Spinal Stenosis: pt has severe spinal stenosis s/p several
surgeries and now physically disabled. He takes oxycontin for
his pain and seen at ___ steroid injections,
and has h/o opioid abuse in past but not currently abusing it.
Continued on home oxycodone.
# Proteinuria: documented in past PCP ___. Unclear etiology.
Pr/Cr 1.8. Should have outpatient follow-up.
# Depression/Anxiety:
Continued on citalopram and clonazepam.
# Gastritis, GERD:
Continued on omeprazole.
# Hypertension:
Continued on metoprolol and lisinopril
TRANSITIONAL ISSUES
- Alcohol abuse history - unclear exactly how much he is
currently drinking, was on CIWA scale here and highest score was
3 and did not required benzodiazepines; should be followed over
the next several days for any signs of withdrawal
- Required daily IV magensium during aggressive IV furosemide
diuresis, please check Chem-10 within the 48 hours after arrival
to rehab (on ___ and replete electrolytes as necessary. He may
need daily oral magnesium.
-Foley catheter was removed on ___, able to urinate, watch over
next day for any signs of urinary retention
- Being discharged on 60mg PO torsemide - titrate his diuretic
dosing as an outpatient as needed
- Recommend outpatient PFTs given severe pulmonary HTN on
echocardiogram
- Started on 81mg ASA daily given PVD
- Full code </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o female with a past medical history of T4N0M0 Stage IIIA
poorly differentiated adenosquamouscarcinoma of the lung s/p
right pneumonectomy ___, adjuvant cisplatin/gemcitabine
___ now on active surveillance, recent admission for CAP
(D/C
___ on cefpodox/azithro through ___, on enoxaparin since
___ for PE, now presents with headache and gait imbalance. Radiology showed No pneumonia. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Interval development of multiple intracranial mass lesions with associated
vasogenic edema, new from ___. Recommend further evaluation with
contrast enhanced MRI of the head.
2. Vasogenic edema from the left temporal parietal lobe mass results in
effacement of the temporal horn of the left lateral ventricle.
RECOMMENDATION(S):
1. Interval development of multiple intracranial mass lesions with associated
vasogenic edema, new from ___. Recommend further evaluation with
contrast enhanced MRI of the head.
NOTIFICATION: Wet read was discussed with Dr. ___ by Dr. ___ telephone
at 3:32 am on ___, approximately 10 min after discovery. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed Enhancing masses within the right frontal, left temporal, and right cerebellar
cortices with adjacent vasogenic edema and mass effect, consistent with
metastatic disease. These are new in comparison to ___. MR ___ AND W/O CONTRAST T___ MR SPINE showed 1. No evidence of metastases to the cervical, thoracic or lumbar spine.
2. No abscess, osteomyelitis/discitis or cord signal abnormalities.
3. Mild degenerative changes without significant spinal canal narrowing.
Mild right neural foraminal narrowing at C5-C6 and C6-C7 as described above.
4. Benign appearing superior endplate compression deformities at T12 and L1. Radiology showed 1. Interval decrease in the size of the right adrenal nodule.
2. Colonic diverticulosis without diverticulitis. CT CHEST W/CONTRAST showed 1. Marked improvement of previous ground-glass opacities, consistent with
resolving infectious/inflammatory etiology. There is no evidence for
intrathoracic malignancy.
2. Please see abdomen/ pelvic CT for additional findings. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. The patient was diagnosed with BRAIN CONDITION NOS. At the time of discharge, the patient had Brain metastases
Cerebral edema
History of lung cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o female with history of T4N0M0 Stage IIIA poorly
differentiated adenosquamouscarcinoma of the lung s/p right
pneumonectomy ___, adjuvant cisplatin/gemcitabine ___ now
on active surveillance, on enoxaparin since
___ for PE, now presents with headache and gait imbalance
found to have multiple brain mets.
# Metastatic NSCLC with new CNS mets- MRI shows new enhancing
masses within the right frontal, left temporal, and right
cerebellar cortices with adjacent vasogenic edema and mass
effect, consistent with metastatic disease. Exam with multiple
neurologic deficits includiong R facial droop and dysarthria.
CT shows significant edema. Pt also w/ ongoing short term
memory/cognitive difficulty
-Neuro-oncology and radiation oncology consulted. Patient
started whole brain radiation ___, plan for total of 10
fractions (currently ___ completed, will complete on ___.
- dexamethasone for edema now reduced to 4mg BID, further taper
per rad onc. On PPI while on steroids
- MRI spine to evalaute for mets in the spine or leptomeningeal
disease - none seen.
- CT torso to evaluate systemic disease was negative.
- she will have follow up brain MRI in ___
Patient did have improvement in coordination and headaches w/
initiation of steroids and WBRT. She was evaluated by physical
therapy and is able to ambulate independently however continues
to struggle with short term memory, completing tasks/directions.
Due to this patient requires ___ supervision for safety. She
will be discharged to ___ in ___ for further
rehabilitation and possibly long-term care.
#Leukocytosis - likely ___ dex, persistently elevated w/o signs
systemic infxn. surveillance urine/blood cx NGTD on repeat
exams. CXR ___ shows only stable pneumonectomy, clear on L. did
improve w/ reduced dex dose.
# h/o PE - no evidence of bleeding on head CT or MRI. Able to
anticoagulate per neuro-onc
-continue home lovenox.
# Hypothyroidism - on Levothyroxine </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH HLD, HTN, DM, CAD s/p IMI and CABG in ___ followed by
PCI of SVG-OM that same year, p/w atypical chest pain for 1.5
weeks. Patient reports one and a half weeks of crescendo chest
pain that comes and goes. Prain pressure-like, in L isde of
chest, occurring ___ times a day and lasting ___, no clear
inciting or relieving factors. With associated flushing and mild
headache, radiation to back and arm, facial numbness. Not
exertional or pleuritic. Pain worse on ___ so took nitro
with no/little relief. Different from reflux pain, but similar
to the pain she felt prior to needing a stent in ___. No
association with eating or BMs. She denies fevers, chills,
shortness of breath, diaphoresis, abdominal pain, nausea,
vomiting. Significantly, patient reports this chest pain pattern
is very similar to that which she had prior to her last
cath/stent in ___ Chest: Frontal and lateral views showed No acute cardiopulmonary process. The patient was diagnosed with Other chest pain. The patient was treated with ___ Cardiac Catheterization with no PCI. At the time of discharge, the patient had PRIMARY:
-Unstable Angina, s/p catheterization
-Coronary Artery Disease s/p CABG. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year-old woman with diabetes mellitus and known CAD S/P CABG
in ___ (LIMALAD, SVG-PDA, SVG-OM/LPL) and post-CABG PCI of
SVG-OM who presented with 1.5 weeks of chest squeezing radiation
at rest and with exertion to both arms similar to her prior
acute coronary syndrome symptoms.
# Unstable Angina
# Coronary Artery Disease s/p CABG
Patient presents with chest pain at rest. She had no biomarker
evidence of myocardial infarction. She exercised to ___ METs on
a non-imaging stress test without symptoms and initially
nondiagnostic 0.5-___epressions which became
horizontal during recovery. She was thus referred for coronary
and bypass graft angiography which showed native three vessel
coronary artery disease with chronic total occlusion of the CX
and RCA, unrevascularized native OM1 disease and LPL disease
downstream of the SVG (both of these in vessels <2 mm in
diameter and thus too small for PCI). No lesions suitable for
PCI as native OM1 and grafted LPL <2 mm in diameter.
Interventional cardiology recommend ___ medical
therapy and reinforcement of secondary preventative measures
against CAD and hypertension. Patient was continued on home
cardiac medications (ASA, Plavix, metoprolol, atorvastatin and
isosorbide mononitrate). Ultimately, lisinopril was increased
from 5 mg to 10 mg daily. Metoprolol was not uptitrated due to
patients HR (50-60s).</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old woman with history of diabetes and
schizophrenia who presents with jaw swelling. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed 1. Soft tissue stranding anterior to the mandible without definite abscess.
2. Right mandibular incisor. Apical infection. The patient was diagnosed with Cellulitis of face, Chronic apical periodontitis. The patient was treated with Periapical Incision & Drainage (___)
Foley inserted ___. At the time of discharge, the patient had PRIMARY:
Periapical Abscess
Multiple Dental Carries
Urinary Retention
SECONDARY:
Schizophrenia
Obstructive Sleep Apnea
Hypertension
Diabetes
Gastroesphageal reflux
Chronic Obstructive Pulmonary Disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F with PMH diabetes and schizophrenia admitted for acute
jaw pain/swelling, found to have a periapical abscess in the
mandibular anterior vestibule. CT scan revealed no drainable
fluid collection in the neck. Patient was started on IV unasyn
for oral infection. ___ was consulted who observed a fluctuant
lesion at the apex of ___ and performed a beside incision and
drainage. Patient received panoramic radiograph of her teeth.
The dentistry team recommended that she gets full teeth
extraction to be done at outpatient ___ clinic. Patient was
transitioned to PO augmentin (last dose on ___. Patient
also found to be retaining urine with bladder scan>1000cc of
urine. Patient was straight cathed was monitored by bladder
scan, found to have increasing PVR and so a foley was placed.
Patient to follow up with urologist for urodynamic study.
# Dental Infection:
Jaw swelling/pain suspicious for periodontal infection. Patient
started on IV unasyn. ___ was consulted who observed a
fluctuant lesion at the apex of ___ and performed a beside
incision and drainage. Patient received panoramic radiograph of
her teeth. The dentistry team recommended that she gets full
teeth extraction to be done at outpatient ___ clinic. Patient
was transitioned to PO augmentin (last dose on ___.
Patient's jaw swelling/pain improved and she was able to
tolerate soft PO food.
#Urinary retention
Patient found to have poor urine output while hospitalized.
Patient was straight cathed for 1100cc. Patient's urine output
was monitored and patient had increasing PVR >500cc, so a foley
was placed. Unclear etiology for her urinary retention. Patient
on olanzapine, which has anticholinergic effects. UA negative.
No evidence of cord compression or peripheral neuropathy.
Patient discharged on foley with outpatient urology appointment.
# Hypertension:
Patient's blood pressure was in the low 100's-110's. Held home
chlorthalidone and decreased lisinopril to 20mg. Patient's BP
continued to be in relatively low, so she was discharged on 10mg
lisinopril to have outpatient followup for blood pressure
# OSA: Stable. Patient on CPAP at night
# Schizophrenia: Stable. Continued home olanzapine, wellbutrin,
sertraline, cogentin, gabapentin
# Diabetes: Held metformin. Patient was on insulin sliding
scale, but did not require any insulin.
# GERD: Continued home omeprazole 20mg BID
# COPD: stable. Continued Fluticasone Propionate 110mcg 2 PUFF
IH BID, albuterol neb PRN q6h
TRANSITIONAL ISSUES
=======================
[]ensure patient has appointment with ___ (___) to get
full teeth extraction (___). Patient needs to call
EXACTLY AT 7AM to get appointment same day (___)
[]f/u jaw pain/swelling
[]f/u with dentist
[]held chlorthalidone and decreased lisinopril to 10mg given
BP's in the low 100's. f/u blood pressure and titrate meds as
needed
[]foley to remain in place until follow up with urology for
urodynamic study for urinary retention.
[]thyroid gland enlarged on CT scan. Consider thyroid ultrasound
Note: Patient at rehab for convalescent stay <30 days. Do not do
trial of void for patient. Patient has urology appointment
scheduled.
#Code Status: full, confirmed
#Contact: ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ F with h/o vascular parkinsonism
and multifactorial gait disorder (frontal + parkinsonian
features, on Levodopa/Carbidopa), 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. CHEST (PA AND LAT) showed Cardiomegaly with mild pulmonary venous congestion. Radiology showed Chronic changes as described above. No intracranial hemorrhage. Of note MR is
more sensitive to the detection of acute infarction. The patient was diagnosed with OTHER MALAISE AND FATIGUE, FAILURE TO THRIVE,ADULT. The patient was treated with na. At the time of discharge, the patient had peripheral vertigo
vascular parkinsonism
Gait instability. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is an ___ yo woman with PMH significant for multifactorial
gait disorder (frontal + parkinsonian features, on
Levodopa/Carbidopa for Parkinsonism), AFib, CAD, spinal stenosis
s/p lumbar surgery who presents with 3 days of worsened gait
freezing, difficulty moving/getting out of bed and slowing of
her speech. According to the patient's HCP and friend she had
stopped taking her medications at home in a passive suicidal
gesture. She has been very clear with her HCP and family that
her primary aim is staying in her appartment at home. She does
not wish to undergo any life extending treatments. She is
amenable to a short stay at acute rehab to maximize her mobility
followed by discharge with the plan to remain at home with the
aid of palliative services.
On presentation her exam was remarkable for Hypophonia and
hypomimia. Prominent grasp reflexes bilaterally. Decreased
upgaze. Subtle left NLF flattening (baseline). +Generalized
whole body bradykinesia. Marked paratonia and rigidity in the
trunk and extremities. Weakness L>R. She can only ambulate a
couple of steps before retropulsing onto bed, but observed
markedly shortened stride length and slowed speed.
Her clinical picture was thought likely the result of worsening
parkinsonism from medication non-compliance. Her course was
complicated by episodes of severe vertigo which is likely BPPV.
We has hoped to do an MRI to evaluate for the cause of her
vertigo and left sided weakness however the patient any family
refused this. The patient's vertigo was treated with meclazine
with improvement.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: As per admitting MD
___ is a ___ yo ___ man with high grade
neuroendocrine mediastinal carcinoma on paclitaxel and RT to
mediastinum, c/b malignant hemoptysis s/p tracheal stent ___,
DVT on Xarelto, who presents with 2 days of worsening
odynophagia and dysphagia. CT CHEST WITH CONTRAST showed 1. Redemonstration of a large mediastinal mass/lymph node conglomerate within
the anterior upper mediastinum, overall similar in size and appearance
compared to prior CT chest from ___, with associated mass effect
deviating the trachea and upper esophagus to the right.
2. Tracheal stent is widely patent, with trace dependent secretions, and
slight (approximately 4 mm) inferior migration compared to the prior study.
The inferior portion the stent protrudes into the carina.
3. Redemonstration of numerous solid and cavitating pulmonary lesions
scattered throughout the bilateral lungs, some of which have slightly
decreased in size.
4. Small right pleural effusion with adjacent compressive atelectasis,
unchanged. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT showed 1. Large central thoracic inlet, mediastinal mass, increasing since ___.
2. Tracheal deviation to the right, mild tracheal narrowing, tracheal stent.
Loss of fat planes between tumor and esophagus, trachea, which may be invaded.
3. Left level ___ adenopathy, mildly increased since ___.
4. Lung nodules, right pleural effusion, refer to chest CT from yesterday. CHEST (PA AND LAT) showed Interval resolution of mild pulmonary edema with increased lung volumes.
Minimal interval decrease in upper mediastinal widening with persistent right
tracheal shift. No progression of mild tracheal narrowing following removal
of previous tracheal stent.
Small right pleural effusion persists. No pneumothorax. CHEST (PORTABLE AP) showed In comparison with the study of ___, there are lower lung volumes, which
may account for the increased transverse diameter of the heart. Nevertheless,
there is engorgement of indistinct pulmonary vessels, consistent with
pulmonary vascular congestion. Blunting of the right costophrenic angle is
again seen and the Port-A-Cath extends to the right atrium.
No evidence of acute focal consolidation.
Substantial displacement of the upper thoracic trachea to the right is
consistent with thyroid mass. The patient was diagnosed with Dysphagia, unspecified, Chest pain, unspecified. The patient was treated with Rigid bronchoscopy and tracheal stent removal ___. At the time of discharge, the patient had # Dysphagia (solids > liquids) ___ tumoral compression
# Odynophagia ___ mucositis
# Metastatic high-grade neuroendocrine carcinoma of the
mediastinum
# Cancer associated chest pain
# Leukopenia, neutropenia
# Acute on chronic anemia
# Malignant hemoptysis and tracheal compression s/p stenting
___ s/p stent removal. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ ___ with high grade neuroendocrine mediastinal
carcinoma (on paclitaxel and RT to lung/esophagus), c/b
malignant hemoptysis and compression s/p tracheal stent ___
(now s/p removal ___, DVT (on Xarelto), who presented with
worsening
odynophagia and dysphagia x 8 days ___ mild mucositis, improved
with supportive care and short dexamethasone course, was
tolerating normal diet by discharge, has close outpatient f/u in
___ clinic
# Dysphagia (solids > liquids)
# Odynophagia
Pt presented with significant odynophagia/dysphagia. Pt received
4 days empiric fluconazole for ___ esophagitis since he
presented w/ neutropenia, though was discontinued given lack of
marked improvement and count recovery. ENT performed evaluation
and identified mild mucositis. Dr ___ that
radiation field did not extend up that high to cause findings.
CT showed left sided adenopathy, suggesting that
odynophagia/dysphagia are at least somewhat caused by tumoral
compression in the neck c/b referred pain from extrinsic
compression of the esophagus in the chest. Speech and Swallow
team followed during stay, rec'd diet modifications. Patient was
given short dexamethasone course which was tapered off by
discharge. By time of discharge he was tolerating full diet
without issue but had lingering ___ pain, managed with
combination of liquid oxycodone and magic mouthwash which he was
prescribed on discharge. Pantoprazole continued during stay and
prescribed on discharge. Patient is to followup with ENT
following completion of his ongoing radiation course.
# Metastatic high-grade neuroendocrine carcinoma of the
mediastinum
# Cancer associated chest pain
Diagnosed ___. Completed 4 cycles
cisplatin/etoposide/atezolizumab (___), followed by
2 cycles of atezolizumab (last ___. Admitted ___ for small
volume hemoptysis w/ rapid progression of disease noted on scan.
Started paclitaxel + RT to mediastinum ___. Dr ___
___ patient during stay, noted that he will receive C2D1
on ___. Pt nearing end of radiation course as discussed above
# ___, neutropenia
# Acute on chronic anemia
Counts improved during stay so was likely ___ temporary BM
suppression from recent chemotherapy. Counts to be trended in
outpatient setting with further chemotherapy.
# Malignant hemoptysis and tracheal compression s/p stenting
___
CT reviewed by IP with possible mild migration. Accordingly,
stent removed by IP ___. After removal, patient had mild cough
at night which resolved during the day, and CXR was without
infiltrate. Pt may have lingering airway irritation from stent
removal so abx held, and will need symptoms closely monitored in
outpatient setting after discharge
# HX of RUE DVT (in s/o PICC), LUE DVT
RUE DVT diagnosed ___. LUE DVT diagnosed ___ in setting
of holding rivaroxaban for 4 days while awaiting port placement.
Patient was continued on rivaroxaban during stay. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/___ 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). His wife called EMS when she
discovered him urinating in the wrong place and he was found to
have Hct 18 at ___. He was given 1U PRBC's and
transferred to ___, where repeat Hct was 21.8. Other labs
significant for INR 1.5, Tbili 2.5, AP 91, ALT 23, AST 35, Lip
27, and ammonia 120. At transfer, he was hemodynamically stable.
Of note, he is initiating transplant work-up but is not
currently listed. He receives most of his care at ___
___ and has had multiple recent admissions for AMS since
having TIPS in ___, averaging 2 admissions/month. Head CT in
___ was negative. His last EGD was in ___ and showed
grade I nonbleeding esophageal varices, and severe gastric
antral vascular ectasia with active bleeding throughout the
antrum, treated extensively with argon plasma coagulation with
some oozing at the end of the procedure. US in ___ showed
patent TIPS. He is now being transferred to ___ for EGD here
and consideration of TIPS reversal.
Upon arrival in the ED, vitals: 98 91 120/75 17 97%. Patient
was oriented x 1 and stool was guaiac positive. CT head was
negative. In the ED, GI evaluated the patient. RUQ US showed
patent TIPS. She was given ceftriaxone, lactulose, and plan was
initiated for EGD in the AM. There was no pocket for diagnostic
tap. Vitals prior to transfer were 97.5 86 114/59 11 98% RA.
Labs were notable for HCT of 21.8 and INR 1.5 and bili 2.5. He
was given 1U PRBCs in route.
ROS:
Otherwise negative in detail Radiology showed Limited examination due to patient motion and streak artifact.
No definite hemorrhage or acute large territorial infarction. Color Doppler and spectral waveform analysis was
performed. The main portal vein is patent with hepatopetal flow with a
velocity of 36 cm/sec. The TIPS stent is patent with wall-to-wall flow and
velocities of 156, 206, 128 cm/sec in the proximal, mid and distal portions
respectively. Helical flow is again seen within the anterior right portal
vein. Flow towards the TIPS shunt is seen within the left portal vein. The
velocities are slightly increased in the shunt, findings are overall similar
compared to most recent prior examination.
IMPRESSION:
1. Patent TIPS shunt. Slightly elevated velocities as compared to recent
prior.
2. Cirrhotic liver without definite lesion.
3. Trace perihepatic ascites and splenomegaly.
4. Gallbladder sludge. showed 1. Patent TIPS shunt. Slightly elevated velocities as compared to recent
prior.
2. Cirrhotic liver without definite lesion.
3. Trace perihepatic ascites and splenomegaly.
4. Gallbladder sludge. The patient was diagnosed with ALTERED MENTAL STATUS , GASTROINTEST HEMORR NOS. The patient was treated with esophagogastricduodenoscopy with APC. At the time of discharge, the patient had gastric antral vascular ectasias
decompensated cirrhosis
acute toxic/metabolic encephalopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/NASH vs. cryptogenic cirrhosis c/b esophageal variceal
bleed (___), recurrent
encephalopathy s/p TIPS (___), GAVE s/p APC treatments, and
anemia who presents to ___ as a transfer from ___
with AMS and GI bleed (Hct 18), found to have hepatic
encephalopathy and oozing GAVE.
#) Oozing GAVE - Pt has a history of recurrent bleeding from
GAVE. An EGD on ___ confirmed the diagnosis, and APC was
repeated. The pt required a total of 4 units of pRBCs at ___
this admission, one each on ___ and 1 just prior to
d/c on ___. His hct was stable but low at 23.5 on the day of
discharge and post-transfusion hct rose to 26.7. The pt needs
repeat CBC drawn in 1 week. He was discharged with a Rx for CTX
to complete 7 days of SBP prophylaxis given the UGI bleed. If pt
continues to have a decline in hematocrit, we suggests a follow
up EGD in ___ weeks with possible APC or RFA. He should continue
taking PPI 40mg PO daily.
#) Encephalopathy - The pt has a history of recurrent
encephalopathy after undergoing TIPS. This episode of HE likely
was a result of GI bleed. Infectious work-up was negative (CXR
clean at OSH. UA neg for infection. No tappable pocket of
ascites to r/o SBP). His doctors at ___ considered TIPS
reversal given frequent HE admissions, however the hepatology
team at ___ recommend against TIPS reversal due to frequent
GAVE bleeding, which would likely worsen with TIPS reversal. In
addition, RUQ U/S this admission showed increased velocity
through TIPS shunt, so it is naturally becoming more stenosed.
The pt should continue taking lactulose TID for goal of ___ BMs
daily. Ideally he should be on rifaximin as well, but financial
restraints prohibit him from taking it. The pt was provided with
1 month of free prescriptions on discharge from ___, but the
free pharmacy would not provide rifaximin.
#) NASH cirrhosis - c/b esophageal variceal bleed ___,
___, recurrent encephalopathy s/p TIPS
(___), GAVE s/p APC treatments, and anemia. Transplant eval had
been delayed, per pt's hepatologist at ___, given social
stresses with wife currently undergoing w/u for possible breast
cancer as well as frequent hospitalizations lately resulting
difficulty making it to outpatient appointments. The pt's
transplant work-up was initiated during this hospitalization
with routine labs, social work consult, and a TTE (see "severe
AS" below). Further work-up is being delayed due to severe
aortic stenosis. He has follow-up at the transplant ___
clinic at ___. MELD labs were trended and stable this
admission. The pt should continue lasix and spironolactone at
home dose.
#) Severe AS - The pt has a history of aortic valve replacement
(bovine, per pt). A TTE was checked this admission due to
anasarca. It revealed severe aortic stenosis with a peak
gradient of 74 which has rapidly increased since last echo at
___ in the ___. A cardiology consult was obtained
and they stated pt "will likely will need aortic valve issue
resolved prior to liver transplant. Since he is a poor
candidate for redo-AVR, we could consider aortic valvuloplasty
as temporary treatment prior to liver transplant or TAVR in the
future when he is on waiting list for liver transplant or AS
worsens. He is followed by private cardiologist in ___, so he
should be followed by his cardiologist as outpatient." ___ was
recommended to further evaluate aortic valve prior to any valve
intervention. However, since pt had just had APC for GAVE, they
recommended holding off on TEE and following up with cards as
outpatient. Pt was continued on his home dose diuretics. He was
also re-started on nadolol for both cardiac protection and
prevention of variceal bleed. Cards recommended aspirin and
statin in the future, however benefit of these meds should be
weighed against bleeding/hepatic injury risk. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ w four days of RUE weakness and neck pain. She
has a 6 month history of intermittent neck pain, but it had
recently become worse and the weakness is a new finding. She is
otherwise well. She has no bowel or bladder sx, she does state
she has had clumsiness in her RUE intermittently. Radiology showed No acute cardiopulmonary abnormality. Radiology showed 1. No cervical spine fracture or malalignment.
2. Multilevel degenerative disease with severe cord compression at C4-5,
better assessed on the preceding MR. Radiology showed Anterior cervical fusion at C4-C5 without definite hardware complication.
Please refer to the intraoperative report for further details. Radiology showed C7/T1 interval not optimally seen, although grossly, anatomic alignment is
likely maintained. If there is high clinical concern at this location,
suggest swimmer's view or CT. Otherwise, mild degenerative changes without
definite acute fracture or dislocation. Radiology showed 1. At C4-5, there is a large central disc herniation, larger on the right
than left, which compresses the spinal cord and severely narrows the spinal
canal. Abnormal cord signal at this level may indicate edema or myelomalacia.
2. At C3-4 and C5-6, there is moderate spinal canal stenosis with deformation
of the spinal cord, but no abnormal cord signal.
Cord compression and cord signal abnormality were documented in the ___
medical record and immediately transmitted to the ED dashboard by Dr. ___
on ___ at 9:11 p.m. At the time of final dictation, the patient
had already been taken to the operating room. The patient was diagnosed with CERVICAL DISC DISPLACMNT. The patient was treated with 1. Anterior cervical diskectomy and arthrodesis C4-5.
2. Application of interbody cage, machined allograft C4-5.
3. Arthrodesis C4-5.
4. Anterior instrumentation C4-5 with a plate.. At the time of discharge, the patient had 1. Cervical disk herniation C4-5.
2. Cervical right upper extremity radicular symptoms with
weakness.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2. Physical therapy
and Occupational Therapy was consulted for mobilization OOB to
ambulate and functional status. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M w/ h/o AF on coumadin p/w right arm redness and swelling
since ___. Per wife, was watching TV, when pt noted
pain with movement of his R arm. Went to ___'s office on ___
where plain films were obtained and sent to Dr. ___
(___), who felt that there may be hemarthrosis given
elevated INR 5. Patient's wife noted redness was more extensive,
arm more warm, tender on ___ so she brought pt to ___
for further evaluation. At ___, labs notable for INR 5.2,
WBC 6.9, hct 34.9 (c/w baseline). He received ancef for possible
cellulitis, was going to be admitted for further abx and
monitoring but patient requested transfer to ___.
In the ED, initial vs were: 98.5 70 149/73 18 94% RA. Labs were
remarkable for INR 4.7, hct 36.1, creatinine 1.2 w/ BUN 27,
lactate 1.0. Patient was given 1g IV vancomycin. Was seen by
ortho who felt exam was not c/w septic arthritis and recommended
admission to medicine for antibiotics and monitoring. Vitals on
Transfer: 98.7 78 144/77 16 98%.
On the floor, vs were: T 97.8 P 93 BP 144/77 R 16 O2 99% on RA.
Patient was comfortable without any complaints except pain in
his R arm with movement. Denied fevers, chills, any recent
trauma or injury, no recent dietary changes or medication
changes/antibiotics. Per patient has not had many difficulties
keeping INR in therapeutic range and has only had one other
episode of bleeding- lower GI bleed in ___.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies myalgias. Ten point review of
systems is otherwise negative. Radiology showed No evidence of pseudoaneurysm or drainable fluid collection.
Small hematoma at the site of patient's echhymosis. The patient was diagnosed with JOINT EFFUSION-UP/ARM, JOINT PAIN-UP/ARM, ABNORMAL COAGULATION PROFILE, ADV EFF ANTICOAGULANTS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had Ecchymosis
Supratherapeutic INR
Mild hemarthrosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year-old male with a PMH of atrial fibrillation on coumadin
who presents with right elbow pain and bruising/redness in the
setting of supratherapeutic INR, most consistent with extensive
ecchymosis.
# Ecchymosis/Right arm pain: He presented with large area of
ecchymosis covering approximately 40% of right upper extremity,
most notably at the medial aspect and antecubital fossa. Area
of ecchymosis was relatively stable during course of admission.
No drainage, pus or ulcerations consistent with cellulitis. Pt
remained afebrile without leukocytosis. Blood cultures were
drawn and he did receive Vancomycin IV x1 in the ED. Orthopedic
service felt there may be mild hemarthrosis but did not
recommend arthrocentesis given elevated INR and likelihood of
reaccumulation. Ortho recommended elevation, ice, and full
active ROM of elbow. Right upper extremity ultrasound was
performed and prelim read was without obvious pseudoanyeurysms
or blood collections. US final read pending on discharge. He
used tylenol for pain control.
*******************
PLEASE NOTE: after patient's discharge, Blood culture ___
bottles) resulted in gram positive rods consistent with bacillus
or clostridium species. Thought to be skin or lab contaminant as
patient was clinically afebrile, no leukocytosis, did not meet
sirs criteria, and there were only ___ blood cultures with this
species. Pt's PCP (Dr. ___ alerted by inpatient
attending, Dr. ___. Patient will be followed-up
day-after-discharge in clinic with Dr. ___.
********************
# Supratherapeutic INR: On coumadin for AFib with CHADS2 =2.
His INR was elevated to 5.2 at ___ which decreased to 4.7
in ED and 3.5 morning of discharge with just holding coumadin.
His Coumadin was held ___ and ___. He was given specific
instructions to follow with his PCP ___ ___ for INR check and
further instructions about restarting Coumadin.
# AFIB: CHADS2=2, rate control with digoxin. Anticoagulation
with coumadin, which was held given supratherapeutic INR. Plan
to restart Coumadin on ___ after INR check at outpatient appt.
# HTN: stable, he continued home meds
# Normocytic Anemia: at baseline, no need for transfusion.
# BPH: stable, continued finasteride
# Hypercholesterolemia: continued home atorvastatin</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a very pleasant ___ 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 w/ recent dx of disease progression who p/w
slurred speech. Chest: Frontal and lateral views showed No acute cardiopulmonary process. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Allowing for differences in modality, ill-defined hypodensity about the
posterior midline pons, middle cerebellar peduncles, and upper cervical spine
appears grossly similar. MRI is more sensitive. Nonspecific periventricular
and subcortical white matter hypodensities appear similar as well. No
evidence of acute large territory infarction or intracranial hemorrhage.
2. Stable appearance of ventricular system. MR HEAD W AND W/O CONTRAST T9112 MR HEAD. showed 1. Slight interval decrease in leptomeningeal enhancement along the
anteroinferior surface of the fourth ventricle. Otherwise, no interval change
compared with the MRI of ___.
2. Specifically, FLAIR hyperintense signal and swelling of the brainstem
primarily involving the pons as well as with extension into the medulla and
cervicomedullary junction is re-demonstrated, with slight effacement of the
inferior fourth ventricle, no associated parenchymal enhancement or restricted
diffusion.
3. Appearance is nonspecific and differential is broad, including disease
progression, atypical/central-variant hypertensive encephalopathy (PRES),
radiation necrosis, as well as demyelinating or other inflammatory conditions,
viral encephalitis. Correlate with CSF analysis, if not recently performed.
Additionally, MR perfusion and spectroscopy could be performed for further
evaluation.
4. Unchanged faint enhancement along the floor of the fourth ventricle.
5. No new abnormal enhancement or new acute intracranial process. No recent
infarction or extra-axial collection.
6. Stable right thalamic post treatment changes.
7. Unchanged right frontal ventriculostomy, tip at the foramina of ___.
Stable shunted ventricular caliber.
8. Stable nonspecific supratentorial white matter FLAIR hyperintensities.
RECOMMENDATION(S): Correlation with CSF analysis, if not recently performed,
as well as consideration of MR spectroscopy and perfusion for further
evaluation of brainstem FLAIR abnormalities, as above. Video oropharyngeal swallow study. showed Penetration with thin liquids. No evidence of aspiration.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services). The patient was diagnosed with Secondary malignant neoplasm of brain, Dizziness and giddiness, Dysarthria and anarthria, Anesthesia of skin. At the time of discharge, the patient had Primary:
Thalamic glioblastoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><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 disease
# Dizziness
These symptoms have been attributed to disease progression as
enhancement on MRI c/w leptomeningeal disease previously.
Radiation necrosis
is unlikely as she is on Avastin. Was started on dexamethasone
recently ___ to determine if she may have any benefit and
this helped w/ nausea, but did not help w/ dysarthria nor
dizziness. Dizziness is provoked by any movement, dysarthria and
dysphagia are worsening from prior admission. MRI as an
inpatient showed stable disease. The patient was continued on
her home medications and instructed to follow-up as an
outpatient to start chemotherapy.
# Dysphagia: Symptoms appeared to be worse on this admission.
Speech and swallow were consulted and recommended a video
swallow, which showed a risk for aspiration. Swallow
recommendations are the following:
1. Diet: thin liquids and moist ground solids until chewing
improves
2. Medications: whole one at a time with thin liquids
3. Swallowing strategies:
-Add a sip of liquid to the bite of food in your mouth if having
trouble initiating the swallow
-Cough and reswallow after every couple of sips of liquid to
clear the airway
4. Oral care: brush teeth ___ times per day and use mouthwash
prior to eating/drinking to decrease risk of pneumonia
5. Remain as physically active as possible to decrease risk of
pneumonia
6. Consider nutritional supplements (e.g. Ensure, Boost) if
chewing and swallowing food is too effortful
# HTN:
Patient significantly hypertensive. Was started on nifedipine at
last admission as was bradycardic with metoprolol. Dose was
increased to 20mg q8h with improvement in blood pressures. Goal
BP <140/90.
# Leukocytosis: Noted to be as high as 26.6 at the time of
discharge. The patient was otherwise asymptomatic. Etiology
unclear.
CHRONIC ISSUES
# Headaches: Improved w/ fioricet on last admission.
# Dyspnea on Exertion: CTA ruled out PE on recent admission and
these symptoms have resolved.
TRANSITIONAL ISSUES
[]goal BP <140/90
[]nifedipine increased from 10mg q8 to 20mg q8; converted to
total of 60mg nifedipine ER daily
[]will need continued outpatient speech and swallow evaluation;
patient sent with prescription
[]speech and swallow recommendations: 1. Diet: thin liquids and
moist ground solids until chewing improves
2. Medications: whole one at a time with thin liquids
3. Swallowing strategies:
-Add a sip of liquid to the bite of food in your mouth if having
trouble initiating the swallow
-Cough and reswallow after every couple of sips of liquid to
clear the airway
4. Oral care: brush teeth ___ times per day and use mouthwash
prior to eating/drinking to decrease risk of pneumonia
5. Remain as physically active as possible to decrease risk of
pneumonia
6. Consider nutritional supplements (e.g. Ensure, Boost) if
chewing and swallowing food is too effortful
[]should check CBC at next neuro-oncology visit on ___ to
ensure leukocytosis is improving
#CODE STATUS: Full code, presumed
#HCP: Name of health care proxy: ___
___ number: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with past medical
history of hypertension, hyperlipidemia, and s/p ascending
aortic
aneurysm repair and single vessel bypass (SVG-PDA) in ___ at
___ who presented to OSH with shortness of breath. He was seen
by Dr. ___ in ___ after CTA chest revealed saccular
outpouching of contrast, 1.1 x 1.8 cm, at the site of his aortic
root repair, not seen on prior imaging studies and concerning
for
pseudoaneurysm, no surgery indicated at that time and plan was
to
follow up with echo. CTA at ___ showed mural thrombus.
Patient transferred to ___ on Heparin gtt for further
evaluation. Cardiac surgery consulted. Carotid Doppler Ultrasound showed No atherosclerotic plaque or hemodynamically significant stenosis of the
bilateral carotid arteries. Radiology showed Normal postoperative appearance.
Esophageal tube ends in stomach fundus, and could be pushed further down. Radiology showed Expected postoperative changes. No pneumothorax. Further advancement of the
gastric tube is recommended to ensure that it lies well beyond the GE
junction. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is no evidence of pneumothorax
or increased pleural effusion. Indeed, the left hemidiaphragmatic contour is
actually more sharply seen on the current study.
Endotracheal tube and nasogastric tube have been removed. Radiology showed The tip of a new right internal jugular central line projects over the mid to
distal SVC. No pneumothorax.
Small bilateral pleural effusions and subjacent atelectasis, left greater than
right. Mild pulmonary edema. CHEST (PORTABLE AP) showed Comparison to ___. The left chest tubes are in stable position.
Correct alignment of the sternal wires, correct position of the right internal
jugular vein catheter. There is no pneumothorax. The right lung basis is
slightly better ventilated than on the previous image. No pulmonary edema.
Stable borderline size of the cardiac silhouette and retrocardiac atelectasis. CHEST (PORTABLE AP) showed Comparison to ___. Status post removal of the left chest tube.
There now is a 2 cm left apical pneumothorax without evidence of tension.
Bleeding along the tract of the tube is noted. Mild retrocardiac atelectasis.
Stable normal appearance of the right lung. Chest radiograph PA and lateral showed Slight increase in left pneumothorax.
Overall unchanged appearance of remaining findings. The patient was diagnosed with Dyspnea, unspecified. The patient was treated with ___
1. Redo sternotomy.
2. Coronary artery bypass grafting x2 with left internal
mammary artery to left anterior descending artery and reverse
saphenous vein graft to the posterior descending artery.
3. Aortic valve replacement with a 29 ___ Ease
pericardial tissue valve, model ___, TFX, serial number is
___.
4. Reconstruction of pericardium with CorMatrix. At the time of discharge, the patient had PRIMARY DIAGNOSES
- Ascending aortic aneurysm pseudoaneurysm
- Severe aortic stenosis
- Moderate aortic regurgitation
SECONDARY DIAGNOSES
- Coronary artery disease
- Hyperlipidemia
- Hypertension
- GERD
- BPH. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ male who had previously underwent an
ascending aortic hemiarch replacement back in ___ for an
aneurysm. He also had a saphenous vein graft to
the posterior descending artery. He presented with shortness of
breath and a CT scan was performed and this demonstrated
possible aortic intramural thrombus of the ascending aorta.
Further workup revealed aortic stenosis. The usual preoperative
work up included Dental clearance, carotid US, and Chest CT.
ON ___ he was taken to the operating room and underwent the
following: 1.Redo sternotomy.2.Coronary artery bypass grafting
x2 with left internal mammary artery to left anterior descending
artery and reverse saphenous vein graft to the posterior
descending artery.3. Aortic valve replacement with a 29 mm
___ Ease
pericardial tissue valve, model ___, TFX, serial number is
___. 4. Reconstruction of pericardium with CorMatrix.
Please see operative report for further surgical details.
He tolerated the procedure well and was transferred to the CVICU
for recovery and invasive monitoring. He required inotropy and
pressor support to augment his hemodynamics postop. FFP, PRBCs
and Protamine were administered for elevated chest tube
drainage. He awoke neurologically intact and weaned to extubate.
He was started on ___, Lasix. He continued to
progress and was transferred to the step down unit for further
recovery. Chest tubes remained in due to elevated drainage.
Pacing wires were discontinued per protocol without incident.
Physical Therapy was consulted for evaluation of strength and
mobility. POD# 4 Chest tubes were discontinued per protocol
without incident. His rhythm went into Atrial fibrillation and
Amiodarone was administered. Anticoagulation was initiated and
will be managed by ___ Medical in ___ as discussed
with ___.
By the time of POD 5 he was ambulating independently, wounds
healing, and pain controlled. He was cleared for discharge to
home with ___ services. All follow up appointments were advised. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p fall 4 days ago. He states that he was in his home while
standing on a stool and fell to the ground. He claims he was not
intoxicated when he fell and has not had a drink since last
___, but his EtOH level on arrival was 45. He
has had multiple admission in the past for alcohol withdrawal.
After his recent fall, he states he presented to an OSH and was
discharge with pain medications. Given persistent pain, he
presented to the ___ ED for further evaluation. FAST exam was
performed which showed no evidence of intra-abdominal free
fluid. Chest radiograph showed No radiographic evidence of traumatic injury. Please note that this is not a
dedicated exam for evaluation of the bones. Correlate with focal exam
findings and obtain dedicated radiographs as needed. CT HEAD W/O CONTRAST showed No acute intracranial process. CT C-SPINE W/O CONTRAST showed 1. No acute fracture or malalignment.
2. Focal prevertebral soft tissue edema anterior to C4 which raises the
possibility of ligamentous injury. If focally tender in this area, MRI could
be obtained if clinically indicated.
NOTIFICATION: The updated findings were discussed with ___, M.D.
by ___, M.D. on the telephone on ___ at 11:17 AM, 2 minutes
after discovery of the findings. CT torso. showed 1. Nondisplaced left ___ and 10th rib fractures with small left chest
wall hematoma and complex effusion likely representing a hemothorax. No
pneumothorax. No other fractures identified.
2. No other acute intrathoracic or intra-abdominal injury. CHEST (PORTABLE AP) showed Comparison to ___. New retrocardiac opacity with air bronchograms,
likely reflecting pneumonia. No pleural effusions. No pulmonary edema.
Borderline size of the cardiac silhouette. C-SPINE NON-TRAUMA ___ VIEWS showed Degenerative changes. No dynamic instability is identified. There is mild
prevertebral soft tissue swelling in the upper cervical spine.
RECOMMENDATION(S): As previously recommended, if concern for ligamentous
injury, recommend MRI. CHEST (PORTABLE AP) showed Comparison to ___. Minimal improvement of the pre-existing
retrocardiac atelectasis. No other relevant change. Borderline size of the
cardiac silhouette. No pulmonary edema, no pleural effusions, no pneumonia.
Known rib fractures are subtle and better appreciated on the CT examination
from ___. The patient was diagnosed with Multiple fractures of ribs, left side, init for clos fx, Traumatic hemothorax, initial encounter, Other fall from one level to another, initial encounter, Alcohol dependence with withdrawal, unspecified, Blood alcohol level of 40-59 mg/100 ml. At the time of discharge, the patient had Rib fractures secondary to Mechanical fall. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ presented to ___ emergency room on ___ after a fall that occurred four days prior to admission. He
was evaluated by trauma surgery and admitted for pain control
and further evaluation. His hospital course was complicated by
agitation secondary to likely alcohol withdrawal. Once evaluated
in the ED, he was transferred to the TSICU for observation.
Neuro: On admission, he received a rescue dose of phenobarb
2.5mg/kg for acute alcohol withdrawal. His CIWA scales was rated
from ___. After 24 hours, he was transferred to the floor for
further recovery. On ___ a coded purple was called, and patient
required IV Haldol and transfer to the TSICU for management.
Psychiatry was consulted and determined that he was acutely
delirious. After re evaluation, psychiatry noted much
improvement in patient's delirium and noted that patient can be
discharged if no further medical needs. Pain was initially
managed with a narcotic, but primarily Tylenol.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO, then diet was
sequentially advanced as tolerated
MSK: Per imaging, he had a chest wall hematoma adjacent to a
nondisplaced left ___, and 10th rib fractures. Pain was
managed expectantly. A tertiary exam revealed no new injuries.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up is currently as needed, and should follow up with PCP.
Instructions with understanding verbalized and agreement with
the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female, s/p ___ gastric bypass
surgery in ___ at ___. The patient was
in her usual state of health until approximately 11:30 am
___, today, when she began having ___ non-radiating RUQ and
middle right side abdominal pain. She went to ___ for lunch
and before she started eating the pain worsened to ___. She
has a history of kidney stones and thought this might be a
recurrence so she tried to hydrate with PO fluids. She states
that she urinated x 2, with simultaneous BM and flatus around 12
pm. She continued to hydrate with PO fluids and had more
micturition and flatus. The patient's pain continued at ___
and at around 12 pm she called her PCP who directed her to the
___. She arrived at the ___ at approximately 2:15 pm
where a CT scan wet read showed nephrolithiasis and possible
partial SBO. The patient was given morphine which relieved her
pain to a ___ level and she was sent via ambulance to the ___
___. When she arrived at ___ she had more flatus and her pain
has since been very well controlled.
Ms. ___ had a ___ bypass surgery in ___ which was
complicated on POD 1 with bleeding, possibly from a pre-existing
duodenal ulcer. She was taken back to the OR that day and a
repair was performed which remained laparoscopic, no records are
available. The patient endorses a 40-lbs total weight loss sinc
surgery and no other interval changes. On exam today, she
denies fever, chills, nausea, vomiting, dyspnea, chest pain,
dysuria, weakness or dizziness. She has had no changes in
appetite, temperature intolerance or changes in hair or skin
texture. Radiology showed 1. Interval resolution of previously seen obstruction.
2. Small hiatal hernia. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, HYPOTHYROIDISM NOS, BARIATRIC SURGERY STATUS , HX OF OVARIAN MALIGNANCY. At the time of discharge, the patient had Enteritis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to the bariatric service with
abdominal pain after being transferred from an OSH with a CT
read of possible small bowel obstruction. Due to her ___ en y
gastric bypass, there was concern of an internal hernia and need
for operative intervention. On arrival, she had a nutritional
IV fluids given ("banana bag") which consisted of thiamine and
Vitamin B12. Stat CBC/chem10 and lactate revealed no etiology
of her abdominal pain. She had normal LFTs, lipase, lactate,
and white count. She was started on an IV BID PPI and IVF and
made NPO. She had a repeat CT abdomen with PO contrast to
better evaluate for a small bowel obstruction. There were no
abnormal findings on the CT scan. Her diet was advanced to
stage III which she tolerated well. Nutrition labs were drawn
which revealed iron deficiency. On questioning, she reported
not following up with a nutritionist and not being aware of
having her vitamin levels drawn by her PCP since her ___ en Y
gastric bypass. The importance of having close nutritional
follow up due to her altered anatomy was emphasized, including
following closely Vitamin B1, B12, iron, vitamin D, and folate.
Her primary care physician ___ was also telephoned and
a message was with left with his office to communicate these
recommendations. She had also been taking NSAIDs in the past
and was unaware of their danger with after a gastric bypass, and
the need to avoid NSAIDs was also reinforced.
On the day of discharge, she was tolerating a stage III
bariatric diet. Her pain was well controlled. She was voiding
freely. She was ambulating independently without assistance.
She will follow up with her PCP in one to two weeks.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female w/ PMH HTN,
hypothyroidism, mood disorder with sleep issues, constipation,
history of breast cancer who presents after she was found down. CT C-SPINE W/O CONTRAST showed No fracture or alignment abnormality. Degenerative changes as stated without
critical stenosis. CHEST (SINGLE VIEW) showed No acute intrathoracic process, hiatal hernia. Radiology showed No fracture or dislocation. Possible loose body within the left glenohumeral
joint space. Mild left glenohumeral OA. CT HEAD W/O CONTRAST showed No acute intracranial process. Chronic small vessel disease. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had Fall, altered mental status. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#Found down: Patient with history of falls and dizziness and has
been evaluated by Gerontology at ___ for this. Concern was for
POTS disease because her HR increased >30 with standing. Has not
been worked up for arrhythmia. She is on many medications that
can cause hypotension, will however she was hypertensive on
admission. She also has a murmur on exam that is known but has
not had a recent echo, so one was ordered. It was notable for
mild-mod aortic stenosis. EKG was nonischemic and telemetry not
notable for any arrhythmias. Orthostatics were normal throughout
the admission but the patient felt dizzy with sitting up.
Physical and occupational therapy were consulted and recommended
rehab. On discharge, carvedilol and aldactone were stopped and
her amlodipine and lisinopril were uptitrated, with good control
of BPs.
#Mild Rhabdomyolysis: No evidence of ___, levels elevated to ~5K
on admission.
IVF were continued until CK downtrended to normal.
#Leukocytosis: likely due to stress reaction. No evidence of
infection. Downtrended on recheck.
#Chest pain: Had chest pain episode in ED. On arrival to the
floor she complained of heart burn. Trop neg x 1. ___ trop 0.02
but could be elevated due to rhabdo. No evidence of ischemia on
EKG. Was given Tums and protonix for heartburn.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Chief Complaint: nausea, vomiting, jaundice
Reason for MICU transfer: hypotension after nausea
___ ___ who presented with a 2 month history of
abdominal pain, nausea and vomiting. The patient and her family
reported that she had not been able to eat well and had lost
___ lbs. Her family first noted that she became jaundiced 1
month prior. She denied fevers, chills, diarrhea and
constipation. Her last formed bowel movement had been 2 days
prior. She denied BRBPR. She denied pain radiating to her back. Radiology showed No acute cardiopulmonary process. Radiology showed No acute intracranial abnormality. Radiology showed 1. No fracture or malalignment.
2. Multilevel degenerative changes with multilevel neural foraminal narrowing
due to facet arthrosis.
3. Multiple nodules in the thyroid gland. If clinically indicated, recommend
further evaluation with a thyroid ultrasound. Radiology showed 1. Severely dilated intra- and extra-hepatic biliary ducts without definite
associated mass. Recommend MRCP for further evaluation if there are no
contraindications to MRI. Alternatively, a multiphasic CT of the abdomen
should be performed.
2. Distended gallbladder with cholelithiasis and sludge, but no other
findings to suggest evidence of acute cholecystitis. Radiology showed There is a mass lesion involving the ampullary region which results in severe
dilatation of the intra and extrahepatic biliary tree as well as mild main
pancreatic ductal dilatation. Differential considerations include a
cholangiocarcinoma versus a pancreatic neoplasm. There is no evidence of
distant metastases. Trace ascites is seen.
Incidental hepatic and renal hypodensities, likely cysts as described above.
Incidental pancreatic cystic lesions, most compatible with IPMN. Radiology showed No evidence of acute intracranial process. Radiology showed Left PICC line enters the right internal jugular vein and loops around, coming
down to the level of the right clavicle. The line needs to be withdrawn and
repositined. Radiology showed Uncomplicated repositioning of a right-sided PICC line with the tip now
positioned at the cavoatrial junction.
The line may be used for infusion therapy immediately. Radiology showed 1. Marked intra and extrahepatic biliary dilatation to the level of the distal
CBD.
2.Successful placement of an 8 ___ percutaneous transhepatic biliary drain
throught the obstruction which has been left on free drainage. Radiology showed Nasogastric tube below the diaphragm, with tip likely located in
distal stomach. Right-sided PICC with tip in lower SVC after repositioning.
Left basilar atelectasis. Radiology showed Right PICC line in unchanged position. No pneumothorax or other
complications. Small left pleural effusion. Radiology showed 1. Indeterminate right middle lobe and lower lobe pulmonary nodules. In a
patient with history of prior malignancy, unenhanced CT chest is recommended
in three months to monitor growth pattern and malignant potential.
2. No intrathoracic lymphadenopathy.
3. Pneumobilia, abdominal ascites and pericolonic fluid involving the splenic
flexure are likely related to recent surgery. Hypoattenuation in gallbladder
fossa with intrinsic air is compatible with Surgicel packing, however an
abscess would have a similar appearance and cannot be excluded.
4. Scattered colonic diverticulosis. The patient was diagnosed with JAUNDICE NOS, OBSTRUCTION OF BILE DUCT. The patient was treated with Percutaneous transhepatic cholangiography/biliary decompression
(___)
Exploratory laparotomy with biopsy of periduodenal nodule,
cholecystectomy, Roux-en-Y, choledochojejunostomy and
gastrojejunostomy (___). At the time of discharge, the patient had 1. Metastatic well differentiated adenocarcinoma.
2. Chronic cholecystitis and cholelithiasis.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>At the time of her admission on ___ the patient was
hypotensive and had an elevated WBC to 16 with a left shift.
She was therefore transferred to the ICU for further management.
She was started on zosyn and given Vitamin K and FFP to reverse
her coagulopathy. Due to her hypotension, CT scan was initially
post-poned. Upon stabilization of the patient's blood pressure,
it was decided to proceed with ERCP on ___. ERCP was
unsuccessful due to an obstructing duodenal mass. An NG tube
was placed, and three liters of gastric contents were removed
from her stomach.
At this time, the Hepatobiliary Surgical team was consulted for
evaluation. Upon review of CT Abdomen/Pelvis, it was determined
that the patient had a potentially operable lesion. The patient
was scheduled for an upcoming surgical procedure on ___. For
immediate biliary decompression and relief of the associated
symptoms and abnormal laboratory values, on ___, the patient
underwent percutaneous transhepatic cholangiography with
decompression and drain placement. In the days thereafter, the
patient was noted to have significant improvement in her TBili
laboratory values, and some improvement her jaundiced
appearance. Additionally, on ___, the patient had a PICC line
placed, and TPN was started. The patient was repleted with
intravenous fluids to replace the losses from both her abdominal
drain as well as her NG tube. The patient had notable
improvement in laboratory values and clinical appearance in this
manner, over the following days, leading up to her scheduled
operation on ___.
On ___, the patient underwent an exploratory laparotomy with
biopsy of periduodenal nodule, cholecystectomy, Roux-en-Y,
choledochojejunostomy and gastrojejunostomy, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO with an NG tube, on IV fluids,
on a single-day-course of IV zosyn, with a foley catheter, and
her PTBD in place, and an epidural for pain control. The
patient was hemodynamically stable.
On POD#1 (___), she continued to have the epidural for pain
control. She therefore continued to have a foley catheter. She
required aggressive IV fluid hydration post-operatively, which
she responded well to, as gauged by her urine output and vitals,
which remained hemodynamically stable and normal throughout. Her
TPN was held on this day, and she remained NPO with her NGT n
place.
On POD#2 (___), her pain remained well-controlled with the
epidural. Due to a hematocrit of 23, she was transfused 2 units
of Packed Red Blood Cells on this day. Through follow-up of
post-transfusion hematocrit, it was determined that she had
responded well to this step. She worked on ambulating with
Physical Therapy on this day. Her NG tube and foley catheter
were maintained, and she remained NPO. TPN was restarted on this
day.
On POD#3 (___), she continued to have good pain control with the
epidural. Her foley catheter was therefore also maintained. Her
NGT was clamped on this day, and residuals were checked every
four hours. She consequently also remained NPO. She ambulated
twice with Physical Therapy.
On POD#4 (___), she continued to have good pain control with the
epidural. Her foley catheter was also maintained. Her NGT was
removed, and she was permitted to have sips of liquids, which
she tolerated well. She ambulated with Physical Therapy.
On POD#5 (___), the patient's epidural was removed, and she was
transitioned to oral pain medications, which she tolerated well.
Diet was advanced to clears, in addition to having TPN, which
she also tolerated well. She continued to ambulate multiple
times per day. The foley catheter was removed, and she voided
successfully.
On POD#6 (___), the patient's PTBD drain was removed. She was
advanced to full liquids, which she tolerated well. She was
continued on TPN. She continued to ambulate multiple times
daily, with physical therapy.
On POD#7 (___), the patient was continued on TPN, and Enlive
supplementation was added to her full liquid diet. Her pain was
well controlled with oral medications. She continued to ambulate
frequently and regularly.
On POD#8 (___), per recommendations by Hematology/Oncology, a
CT Chest was obtained for staging purposes. She was continued on
TPN, but the volume was decreased to half. She continued to have
good pain control, tolerating full liquids, and ambulating
regularly.
On POD#9 (___), she was advanced to a regular diet with Enlive
supplementation, and continued on half-volume TPN. She continued
to ambulate regularly, and have good pain control.
On POD#10 (___), she was maintained on half-volume TPN, regular
diet with Enlive supplementation, ambulating regularly, working
with ___.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. *********Staples were removed, and steri-strips
placed.***** The patient was discharged home without/with
services.***** The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y.o male with significant Pmhx of bipolar diorder,
depression, osteoarthritis, and DVT/PE s/p IVC filter,
currently on coumadin, who presents from his nursing home s/p
fall on his face/and right side after tripping on a table.
Patient reports that he had recent increase in dose of his
pscyhiatric medications and since then he has felt increased
dizziness and a little more trouble ambulating. He is
experiencing ___ headache located in the right temple without
radiation, associated with no vision changes, recent
nausea/vomiting, limb weakness, confusion. Radiology showed Mildly artifact-limited study. Previously seen focus of left
frontal cortical hyperdensity is no longer present on the current examination.
Apparent foci of hyperdensity now project over different portions of the
frontal cortex bilaterally, almost certainly artifactual.
The artifacts are in part related to the protective goggles over the patient's
eyes. If additional imaging is desired, the patient should be rescanned with
his neck flexed, so that the goggles would not project over the frontal lobes. The patient was diagnosed with HEAD INJURY UNSPECIFIED, NAUSEA WITH VOMITING, UNSPECIFIED FALL. The patient was treated with EGD ___. At the time of discharge, the patient had Primary: Mechanical Fall
Erosive gastritis
Secondary: Bipolar disorder
Gastroesophageal reflux disorder
History of deep venous thrombosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y.o male with significant Pmhx of bipolar diorder,
depression, osteoarthritis, and DVT/PE s/p IVC filter, on
coumadin, who presents from his nursing home s/p mechanical fall
on his right side of his head and hemetemesis.
# GI Bleed: He reported multiple episodes of non-bloody emesis
prior to emesis with frank blood, and the coffee-ground emesis.
Additionally, he was found to be guaiac positive on admission.
He was admitted to the MICU for close monitoring and
observation. There, he was initially started on a PPI drip, and
he was evaluated by GI, who recommended inpatient EGD. He was HD
stable, his crit was stable, and did not have any additional
episodes of vomiting. He was transitioned to IV PPI BID, which
he tolerated well. He underwent EGD which showed erosive
gastritis and duodenitis, as well as a large amount of food in
the stomach. GI recommended repeat EGD in 8 weeks, double dose
PPI PO, and an outpatient gastric emptying study.
#Reported Dyspnea- He reported dyspnea prior to admission,
although this was not an active issue during this
hospitalization. He appeared euvolemic on admission with no
evidence of wheezing or acute heart failure on exam. No
infiltrate on CXR or fevers/chills to suggest pneumonia. Mild
pulm edema on CXR better than ___, and stable on room air. He
was diuresed with lasix, and restarted on his home regimen. He
maintained excellent oxygen saturations throughout this
hospitalization.
# Lightheadedness: Complained of lightheadedness/dizziness on
muptiple days prior to admission. Exact etiology was unclear,
but most likely secondary to medication side-effects. There were
no focal signs to suggest TIA or CVA, and head CT was normal. He
was not orthostatic while on the medicine floor.
#Bipolar disease- Stable on this admission. He was maintained on
his home regmine of divalproex, doxepin, clonazepam, wellbutrin,
paxil and quetiapine.
#Hx PE/DVT- In the setting of GI bleed, his home coumadin was
held, and he was given 10 mg FFP for reversal, prior to EGD. His
INR on discharge was 1.8.
#GERD- Well controlled on omeprazole. He denied any abdominal
pain or reflux symptoms. In the setting of GIB (see above) he
was on PPI drip, and transitioned to IV PPI BID. He was
discharged on PO PPI BID, with close GI follow-up.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/CLL, pure red cell aplasia, dCHF and A-fib present
presents with fatigue x 2 weeks. Pt admitted from ___ to
medicine for fatigue and ___ and ___ ___ w/dyspnea, cough,
increasing pleural effusion with pneumonia. Patient was
discharged the first hosptial visit on Metalozone for increasing
edema. Patient was readmitted with Cr 3.7 (baseline ~ 1.6 -
1.9), metalozone was held and Cr improved to 3.2 and patient was
discharged. On repeat lab draw today, Cr still 3.2 so patient
was referred to ED.
Patient reports continued to feel fatigued. Reports 19lb weight
loss since ___. No night sweats. Denies chest pain, SOB,
cough, fever, chills, nausea, vomiting, diarhea. Leg swelling
improved from baseline. No blood in stool.
In the ED, initial vitals were: 97.5 75 100/48 18 100% 0
- Labs were significant for Na 127, Cr 2.7 (2.0 on ___, up to
3.7 on ___ , BUN 77, Hgb/Hct 8.___.1 (at baseline). Coags and
UA were normal, however 21 casts noted.
- Imaging revealed CXR - no fluid overload. Bilateral pleural
effusions
- The patient was not given medications, started on 75cc/hr IVF.
Vitals prior to transfer were: 78 118/78 23 Nasal Cannula
Upon arrival to the floor, patient reports fatigue no other
complaints. Radiology showed Similar appearance of the bilateral small pleural effusions. CHEST (PORTABLE AP) showed As compared to ___ chest radiograph, bilateral pleural effusions and
adjacent basilar atelectasis have slightly worsened. The right pleural
effusion is now moderate, in the left is small to moderate. No other relevant
changes. . The patient was diagnosed with RENAL & URETERAL DIS NOS, OTHER MALAISE AND FATIGUE. At the time of discharge, the patient had Primary Diagnosis:
- Acute on Chronic Kidney Injury
Secondary Diagnoses:
- Acute on Chronic Diastolic Heart Failure
- Atrial fibrillation
- Coronary artery disease
- Chronic Lymphocytic Leukemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>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.
================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: 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. Chest: Frontal and lateral views showed No focal consolidation to suggest pneumonia. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial process. If there is high clinical concern for
encephalitis, further evaluation may be performed with MRI brain with contrast CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS showed 1. There is moderate mucosal thickening of the bilateral ethmoid air cells and
left maxillary sinus with partial opacification of the left maxillary sinus
which may represent sinus disease in the appropriate clinical setting.
2. There is opacification of the left infundibulum.
3. Polypoid soft tissue in the left maxillary sinus may represent sinus
polyposis.
4. The bilateral orbits are unremarkable. CT CHEST W/O CONTRAST showed 1. Multiple lucent lesions scattered throughout the axial skeleton are
concerning for myelomatous involvement. Several of the lesions including
dominant lesions in the T6 and T7 vertebral bodies, which were not FDG avid on
the prior PET-CT appear grossly unchanged. A probable lesion in the medial
aspect of the right clavicle, appears new from PET-CT ___ and is
concerning for new or worsening myelomatous involvement.
2. Small pulmonary nodules measure up to 2 mm, not definitely seen on PET-CT
___, possibly due to poor resolution. Recommend ___ month interval
follow-up to assess for stability.
3. Assessment is moderately limited by respiratory motion, but no definite
evidence of pneumonia or bronchitis. The patient was diagnosed with Weakness. At the time of discharge, the patient had Febrile illness
Acute metabolic encephalopathy
Multiple myeloma
Anemia and thrombocytopenia
CAD s/p CABG
Demand ischemia
Diabetes mellitus
Weakness
Fall
Conjunctivitis
Essential hypertension
Hyperlipidemia
Gout
Actinic keratosis:. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ man with history of CAD s/p CABG,
HTN, HLD, DMII, multiple myeloma s/p auto SCT currently on
pomalidomide/daratumumab presenting with weakness and fever.
#Fever
#Sinusitis
Patient recently was admitted to BID-M for neutropenic fever
with extensive evaluation without source identification. Patient
was treated with 10 day course of empiric vancomycin/cefepime.
He re-presented with recurrent fever. No clear localizing signs
or symptoms of infection other than cough and possible
conjunctivitis. CXR was without focal infiltrate. CT chest
showed no pneumonia. CT sinus showed possible sinusitis. Patient
did have loose stools prior to admission, but they were
self-limiting. Infectious disease and oncology were consulted to
help advise investigation and management. Patient was treated
with empiric broad spectrum antibiotics with IV vancomycin, IV
cefepime, and IV metronidazole, then transitioned to PO
levofloxacin and flagyl on ___ once it was determined that he
likely had viral URI +/- superimposed bacterial
conjunctivitis/sinusitis. He remained stable on this regimen and
was discharged on levofloxacin and metronidazole to complete a
14-day total course on ___.
# Acute metabolic encephalopathy
Delirium, febrile effects related to immunotherapy versus
infection. Infectious workup and management as above. His
encephalopathy resolved with the aforementioned treatment.
# Multiple myeloma
# Anemia/thrombocytopenia: Currently receiving treatment with
daratumumab/pomalidomide. Intention had been to hold
pomalidomide, but patient took 2 doses since recent discharge.
Held daratumumab/pomalidomide but per Atrius onc. He will see
his oncologist Dr. ___ on ___ to discuss resuming therapy.
He received 1 U pRBC for symptomatic anemia and Hgb <7.
# CAD s/p CABG
# Demand ischemia: Patient with mild troponin elevation on
admission, likely represents mild demand in setting of acute
illness. Patient is asymptomatic and EKG was without acute
ischemic changes. His home cardiac medications were resumed.
# DMII: Labile blood sugars in setting of recent dexamethasone
use. His home medications were resumed
# Weakness
# Fall
Patient with global weakness in setting of febrile illness,
labile blood sugars, and multiple myeloma on new immunotherapy
regimen. ___ worked with the patient, and his mobility progressed
to where they felt he would be safe to return home with home ___.
# Conjunctivitis (viral versus bacterial): Patient had scant
purulent discharge in left eye in ED and started on
erythromycin. He completed 7 days of erythromycin ointment.
# Gout: No evidence of acute flare.
Mr. ___ was seen and examined on the day of discharge and is
clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: 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 and dyspnea, sent in by PCP.
She developed malaise and fatigue a few days ago, and yesterday
(___) she developed a fever with Tmax of 100.8 (axillary).
This was associated with some dyspnea on mild exertion,
generalized fatigue/weakness, and decreased appetite. This
morning, she was afebrile, but had a productive cough (mostly
clear sputum; question of some sputum with a speck of blood). CTA chest. showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Concern for right lower and middle lobe pneumonia superimposed on
atelectasis.
3. Mild pulmonary edema with small right and trace left pleural effusion.
4. Few new scattered 3mm pulmonary nodules, in the setting of edema and
possible right lower lobe pneumonia/aspiration pneumonia is of uncertain
significance and etiology.
5. No significant change in a 3.4 cm left lower lobe mass with fiducial
markers.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 4:35 ___, 15 minutes after discovery of the
findings. CHEST (PORTABLE AP) showed 1. Marked interval worsening of CHF findings. Worsening left lower lobe
collapse and/or consolidation.
2. Please note that the ___ chest CT referred to concern for right
lower and middle lobe pneumonia, which could be obscured by CHF findings on
the current study.
3. Left base mass with 2 fiducials again noted. CHEST (PORTABLE AP) showed As above. CHEST PORT. LINE PLACEMENT showed In comparison with the study of ___, there has been placement right
subclavian PICC line that extends into the jugular system. Little change in
the appearance of the heart and lungs. DX CHEST PORTABLE PICC LINE PLACEMENT showed The right PICC line continues to be malpositioned in the right internal
jugular vein. No other changes are noted. No pneumothorax or other
complications. UNILAT LOWER EXT VEINS RIGHT showed 1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. 4.0 cm ___ cyst in the right popliteal fossa. CHEST (PA AND LAT) showed In comparison with the study of ___, the malpositioned PICC line is been
removed. There again are very low lung volumes with elevation of the right
hemi diaphragm and a mass with fiducial seeds at the left base. The pulmonary
vascularity may still be mildly elevated. CHEST (PA AND LAT) showed Left lower lobe opacity is most likely atelectasis. In the appropriate
clinical setting, pneumonia cannot be excluded, but this is thought to be less
likely. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. At the time of discharge, the patient had Pneumonia
Atrial fibrillation - new dx
Mild diastolic dysfunction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with history notable for
HTN and endometrial cancer with oligometastasis to the left lung
status post TAH-BSO in ___ and radiation in ___,
presenting with fever to Tmax 100.8 (at home) and dyspnea, sent
in by PCP, found to have RML and RLL pneumonia. She was
initially treated on the general medicine floor, subsequently
transferred to the ICU for hypercarbic respiratory failure. She
was never intubated and monitored closely with improvement in
respriatory status with continued treatment of pna. She was
transferred back to the general medicine floor, where she
remained well, breathing comfortably.
# Pneumonia: Presented with SOB, hypoxia, and tachypnea. CTA
with concern for lower and middle lobe pneumonia superimposed on
atelectasis. She was initially treated broadly for HCAP, then
transitioned to ceftriaxone and azithromycin for treatment of
CAP. On ___, patient was noted to have worsening delirium
and increased somnolence, in the setting of sustained tachypnea
and hypercarbia. She was transferred to the ICU and started on
BiPAP. Hypercarbia resolved and she was considered well enough
to transfer to medicine. On the floor she remained afebrile
without leukocytosis. She was transitioned to RA and breathing
comfortably, sats in the early ___. She completed 8 days of abx
(initally vanc/cefepime, narrowed to CTX/azithro) for CAP.
Of note, vancomycin was re-started on the afternoon of ___
given blood culture showing GPCs but DC'd later as this was
ultimately felt to be a contaminant.
# Atrial fibrillation with RVR: Afib with RVR to the 130s was
noted incidentally on telemetry in the ED on ___. In the
MICU afib with RVR was observed again, and she was started on po
diltiazem. Asymptomatic during episodes. She has a CHADS2-vasc
of 4 and intermittent afib. She was started on warfarin with
lovenox bridge.
#Volume overload: Concern for mild diastolic heart dysfunction.
CT and CXR with evidence of mild pulmonary edema. Underwent IV
and PO diuresis. On discharge, on 1L supplemental O2. O2
requirement most likely thought to be from underlying lung
disease from metastatic cancer to lung and subsequent radiation,
as well as resolving pneumonia.
# Hypertension
Continued home nifedipine with holding parameters for SBP<100 or
DBP<40.
# Hyperlipidemia
Continued home lipitor.
# Chronic back pain ___ spinal stenosis
Continued home gabapentin, but held Tylenol out of concern that
tylenol would mask her fevers. Tylenol was restarted upon
discharge.
# Risk of CAD
Aspirin continued this admission.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ nursing home dwelling male with past medical history
HTN, HLD, DM, BPH, dementia, BPH and indwelling Foley with
recent
treatment for urinary tract infection on ciprofloxacin presents
with worsening lethargy per family. CHEST (PA AND LAT) showed Ill-defined opacity right lobe is nonspecific and could represent atelectasis
or pneumonia, in the right clinical setting. CT HEAD W/O CONTRAST showed No acute intracranial abnormality on noncontrast head CT. CT abdomen and pelvis without intravenous contrast. showed 1. No acute abnormality in the abdomen or pelvis. Specifically, no evidence
of a fluid collection or obstruction in the abdomen or pelvis. Appendix not
visualized but no secondary sign of acute appendicitis.
2. Bladder wall thickening likely due to bladder outlet obstruction from the
enlarged prostate. Cystitis cannot be ruled out. Radiology showed Mild left basilar opacity is likely secondary to atelectasis, however a
superimposed infectious process can't be excluded. No evidence of a pleural
effusion or pneumothorax.
Interval improvement of the previously seen mild pulmonary edema with mild
residual pulmonary vascular congestion. The patient was diagnosed with Urinary tract infection, site not specified, Sepsis, unspecified organism, Non-ST elevation (NSTEMI) myocardial infarction. At the time of discharge, the patient had PRIMARY DIAGNOSES:
Urinary Tract Infection
Dementia
Altered Mental Status
NSTEMI, type II
Acute kidney injury
SECONDARY DIAGNOSES:
Hypertension
Diabetes Mellitus
Hypothyroidism
Depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>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.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old man with a history of HBV, HCV
cirrhosis with gastric varices, portal hypertension and
splenomegaly, as well as type I DM and recurrent DLBCL s/p CHOP,
EPOCH and Rituxan who presented to the ER after sustaining a
fall and landing on his left knee. He states that he was walking
across his tile kitchen wearing his diabetic sneakers and
tripped over his feet. He landed with his left knee on the tile.
He was on the floor unable to get up for about 10 minutes. He
denies dizziness, lightheadedness, chest pain, shortness of
breath, loss of consciousness or head trauma. He remembers the
entire event. He waited until his son was able to help him and
came to the ER for pain and inability to ambulate. Of note, he
denies recent memory changes, difficulty concentrating, changes
in speaking or swallowing, focal weakness or numbness. He notes
a bizzare sound in his hear (a whoozing noise) which occurs only
in his right ear every few days and lasts for a moment. He
denies headaches or ear pain. Radiology showed No acute cardiopulmonary process. Radiology showed Acute nondisplaced transverse fracture of the patella with large
joint effusion. Radiology showed New 1.3 cm right temporal hyperdense lesion suspicious for
malignancy, possibly metastasis given this patient's history of lymphoma.
Further characterization with MR is recommended.
These findings were discovered at 12:01 pm and communicated via phone call to
Dr. ___ by Dr. ___ at 12:51 pm. on ___. Radiology showed 1.9 cm inhomogeneously enhancing mass with internal enhancement and a small
amount of peripheral hemorrhage seen in the right temporal lobe with
surrounding vasogenic edema. This mass most likely arises from an extra-axial
location. It does not have the typical characteristics of lymphoma as
lymphoma lesions tend to be homogeneous and demonstrate slow diffusion.
Abscess was also considered, however usually abscess also demonstrates slow
diffusion. As the masses likely extra-axial, a glioma less likely.
Thus, more likely differential for this mass include aggressive meningioma or
metastatic disease.
The findings were discussed with ___ by ___ telephone at 5:45pm on
___, 20 minutes after discovery. Radiology showed 1. Gallbladder sludge. No concerning gallbladder mass.
2. No intra or extrahepatic bile duct dilation. No ductal stones.
3. Extensive soft tissue throughout the right perinephric space and
retroperitoneum, with compression of the IVC, in keeping with known history of
lymphoma, corresponding to FDG avid soft tissue lesion on the PET-CT from ___.
4. Stable moderate right hydronephrosis with delayed contrast excretion from a
head MRI examination on ___.
5. Mild bibasilar atelectasis.
6. Cirrhotic liver. Trace perihepatic ascites, mild splenomegaly, diffuse
anasarca, and mild gallbladder wall edema likely secondary to chronic liver
disease. Radiology showed AP chest compared to ___:
Consolidation in the right upper lobe marginated by the major fissure is
probably pneumonia. ___ a second region of pneumonia in the right lower
lobe or fissural pleural fluid. Heart is top normal size and pulmonary
vasculature is still engorged, but as yet no pulmonary edema. Left pleural
effusion. Left subclavian infusion port ends low in the SVC. No
pneumothorax. Dr. ___ was paged at 1:15 p.m. and we discussed the findings
by telephone. The patient was diagnosed with FRACTURE PATELLA-CLOSED, UNSPECIFIED FALL, BRAIN CONDITION NOS. The patient was treated with Palliative radiation
Cyber Knife. At the time of discharge, the patient had Primary:
Diffuse Large B cell lymphoma
Left patellar fracture
HCAP pneumonia
___ ulcer/cellulitis
Secondary:
Chronic pain
Diabetes Mellitus I
Hyponatremia
Thrombocytopenia
Anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old man with recurrent DLBCL, DM1 and
cirrhosis who presents after a mechanical fall and is found to
have a patellar fracture of the left knee. He incidentally was
found to have a 1.6 cm mass in the right temporal area, highly
suspicious for malignancy now with evidence of extensive
lymphoma progression.
ACTIVE ISSUES
=============
# HCAP Pneumonia
CXR on ___ was suggestive of a RUL pneumonia and given that
he had been hospitalized since ___, he was treated for an
HCAP with Cefepime and Vancomycin with plan for a 14 day course
to end through ___. He did not have fevers and was
not symptomatic. His Vancomycin levels were difficult to
control, with Vanc trough of 42 on the day prior to discharge
(at which point Vancomycin was discontinued) and 25.8 on the day
of discharge with evidence ___ (resolved s/p discontinuation
of Vanc). Given that he was clinically asympomtatic from a
pulmonary status and elevated Vancomycin levels his Vancomycin
was discontinued. He will continue to take Cefipime through
___, to complete a 2 week course.
# RLE ulcer
Patient was admitted with a known RLE ulcer which was evaluated
and treated per wound care. However, on ___, given his
neutropenia, there was concern for cellulitis and he began
treatment with Vancomycin (day ___ with plan for a 14
day course through ___. His Vancomycin levels were
difficult to control. His trough was 1.7 on Vancomycin 750 BID
and subsequently 42.3 on Vancomycin 1g BID. Given elevated
trough, as well as evidence of ___, his Vancomycin was
discontinued. His RLE wound was much improved on day of
discharge without evidence of infection and his Vancomycin was
discontinued as noted without plans to restart.
# DLBCL
MRI abdomen as well as PET CT showing evidence of progression of
disease. He is now s/p palliative chemo with cytoxan/etoposide
on ___ and palliative radiation therapy on ___. S/p
rituxan on ___. Methadone was converted to TID dosing for
pain control (methadone 30mg PO TID) and dilaudid was used for
breakthrough pain. He initially required IV dilaudid for pain
control and as his pain decreased after chemo/radiation, he was
transitioned to PO dilaudid. However, he subsequently endorsed
poorly controlled pain with dilaudid ___ PO Q4H PRN and
required 0.25 mg IV for breakthrough. He was started on Ativan
0.5 mg PRN pain/agitation which proved to be effective for
symptom control. Home dose acyclovir was continued as ppx.
# Type I DM
Patient has a known history of type I diabetes. He was followed
by ___ throughout his hospitalization. He had several issues
with both hypoglycemia and hyperglycemia. Ultimately he is
discharged on the following regimen:
- Lantus 11 units QAM
- Humalog sliding scale for goal glucose <300
Breakfast Lunch Dinner Bedtime
71-150 0 0 0 0
151-200 3 3 3 0
___ 5 5 5 1
301-350 6 6 6 2
351-400 7 7 7 2
- He does have a tendency to fall asleep during his meals and it
is thus advised to give him his Humalog after he finishes his
meal to prevent hypoglycemia
# Hyperbilirubinemia: Initially presented with
hyperbilirubinemia, likely related to pRBC transfusion and
resolved.
# Hyponatremia
Patient had hyponatremia to 132 in the setting of hyperglycemia.
Most likely a pseudohyponatremia. Resolved with better control
of his blood glucose levels.
# Thrombocytopenia
Patient has baseline thrombocytopenia-acute drop likely due to
cirrhosis versus lymphoma versus chemo. There was initial
concern for HIT and heparin products were discontinued, however,
platelets dropped after stopping heparin products, making HIT
less likely. Most likely due to chemo and demonstrated slow
improvement throughout his hospitalization.
# Anemia
Patient anemic at baseline (likely multifactorial) now with
acute decrease in Hct, likely due to chemo. Patient was
transfused for Hct<21. His blood counts remained stable
throughout his hospital stay.
# Abdominal pain
Likely due to lymphoma, treated with pain regimen as noted
above.
# Brain mass
Incidentally found on Head CT after fall. Better seen with brain
MRI. Per radiology, the mass did not appear to look like
lymphoma- however it is possible given his extensive disease
progression. Unlikely to be meningioma given that it was not
seen in ___. He received cyber knife treatment once on
___.
# HBV/HCV Cirrhosis
Patient has a known history of hepatitis B and hepatitis C.
Hepatitis B viral load was negative on this admission. His home
dose lamivudine and nadolol were continued during this
admission. The patient intermittantly took lactulose but was
difficult to maintain complete compliance.
# Scrotal swelling
Ascities and scrotal swelling malignant versus due to cirrhosis.
He was treated with lasix 40mg PO daily; however, swelling with
minimal improvement during hospital stay. Will continue on
Lasix. On the day prior to discharge he had low urine output,
and was bladder scanned for >500 cc (likely largely ___ to
narcotic use). He was straight catheterized. He may require
intermittent straight catheterization during his rehabilitation
stay.
# Prolonged QTc
QTc 502 on EKG on ___. From reviewing past EKGs, looks as
though this has been ongoing. Most likely due to his methadone.
QTc was monitored weekly throughout his admission. Qtc 473 on
___.
# ___
Was likely in the setting of hyperuricemia. He was started on
Allopurinol and his renal function resolved back to baseline. He
had another episode ___ in the setting of Vanc trough of
42.3. He was given IVF, Vancomycin discontinued, and his ___
resolved.
# Hyperuricemia
After receiving chemotherapy, patient noted to have
hyperuricemia. Uric acid found to be around 11 and he received
rasburicase on ___. He was also maintained on allopurinol
___ PO daily.
# L knee patellar fracture s/p Mechanical Fall
Patient was evaluated by orthopedic surgery who recommended
conservative treatment with immobilization and pain control.
Patient worked with physical therapy while hospitalized. He will
be discharged with a knee immobilizer.
# Hx of substance abuse
Patient was admitted on maintenance methadone 90mg PO daily.
However, this home dose methadone was transitioned to 30mg PO
TID to be used as pain control instead of as maintenance
methadone.
TRANSITIONAL ISSUES
===================
- Patient to follow up with Dr. ___ on ___
- Please continue patient on Lantus and ISS as noted above
- Please change wound dressing daily
- Patient OK to weight bear as tolerated on left knee with left
knee immobilizer
- Patient to continue on Cefipime Q12 hours through ___ to complete a 2 week course</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo RHF with alcoholic cirrhosis c/b portal
vein HTN, esophageal varices s/p TIPS ___, encephalopathy on
lactulose, T2DM, and cervical stenosis who initially presented
to
___ this morning for altered mental status and
transferred to ___ after found to have right frontal IPH. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Patent TIPS. Of note, the measurements for the proximal tips are
inadequately obtained as the patient was unable to hold her breath. The
velocities within the mid and the distal tips are within normal range.
2. Portal vein is patent.
3. Cirrhotic liver morphology with stable splenomegaly. No ascites.
4. Cholelithiasis without sonographic evidence of acute cholecystitis. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Redemonstration of the right inferior frontal lobe intraparenchymal
hematoma, with surrounding edema. This is unchanged in appearance. No new
intracranial hemorrhage.
2. Patent circle of ___ without definite evidence of stenosis,occlusion,or
aneurysm.
3. Patent bilateral cervical carotid and vertebral arteries without definite
evidence of stenosis, occlusion, or dissection.
4. Multiple pulmonary nodules measuring up to 4 mm in the right apex.
For incidentally detected multiple solid pulmonary nodules smaller than 6mm,
no CT follow-up is recommended in a low-risk patient, and an optional CT
follow-up in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___ UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins.
Extensive calcified atherosclerotic plaque, particularly in the common femoral
artery. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Examination is moderately motion degraded.
2. Approximately 2.8 cm right frontal intraparenchymal hematoma with
associated surrounding edema, grossly stable in size compared to the prior CT
head examination.
3. No new areas of intracranial hemorrhage or evidence of acute to subacute
infarction.
4. Within limits of study, no definite evidence of enhancing mass. Please
note that a enhancing intracranial mass in region of right frontal
intraparenchymal hemorrhage is not excluded on the basis of this examination.
Recommend follow-up imaging to resolution.
5. Paranasal sinus disease, as detailed above.
RECOMMENDATION(S): Within limits of study, no definite evidence of enhancing
mass. Please note that a enhancing intracranial mass in region of right
frontal intraparenchymal hemorrhage is not excluded on the basis of this
examination. Recommend follow-up imaging to resolution. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Grossly stable right frontal lobe intraparenchymal hematoma, with
surrounding edema and no definite midline shift.
2. Paranasal sinus disease , as described. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had intraparenchymal hemorrhage. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman past medical history
of alcoholic cirrhosis c/b portal vein HTN, encephalopathy
esophageal varices, s/p TIPS ___, T2DM, cervical stenosis with
a right frontal intraparenchymal hemorrhage.
#Right frontal IPH
Mic___ initially presented to ___ ___ after being
found on the ground by her daughter confused and less responsive
and left sided weakness. She was found to have a right frontal
IPH on CTH and was subsequently transferred to ___ for further
evaluation. All antiplatelets and anticoagulants were held. In
the ___, she transiently required a nicardipine gtt to maintain
SBP <150 but this was quickly titrated off. She was given 1 ___ in the ___, and on repeat CBC platelets decreased to
35; another unit of platelets were given for goal platelet count
>50. Patient was clinically improving, and admitted to the ___
for Q2H neuro checks for close monitoring given
thrombocytopenia. Her platelets were trended Q6H for 24 hours,
and she required no further platelet transfusions. CTA H&N
negative for stenosis, occlusion, dissection. CTH was repeated
___ and was stable. MRI stable with 2.8 cm hematoma in R
frontal lobe, and otherwise negative.
Etiology of stroke thought to be secondary to coagulopathy,
could also consider hypertensive etiology. We will plan to
follow up in stroke neurology clinic for repeat MRI to evaluate
for resolution of hemorrhage.
#Thrombocytopenia
Thought to be secondary to coagulopathy. She received a total of
2U of platelets and required no further transfusions. Discussed
case with hematology, who recommended no further workup or
intervention. Also discussed with hepatology, who recommended
continuing to hold SSRI as these medications can worsen a
coagulopathy.
#Hypertension
She was on a tight BP control, with goal SBP <140. We continued
home spironolactone 25 qDaily, and captopril increased from 6.25
TID to 12.5 TID. This medication can be switched to long acting
once per day prior to discharge.
#Trop 0.03 on admisison
Trended down, thought to be secondary to demand. No complaints
of chest pain. EKG with no acute findings.
#DM
A1c 7.9. Patient was put on sliding scale insulin for tight
blood sugar control, and this should be continued at rehab. Her
home lantus dose was cut by 50%, and this should be increased as
needed.
#Pulmonary nodules
Incidental finding of pulmonary nodules on CTA H&N. "Multiple
pulmonary nodules measuring up to 4 mm in the right apex.For
incidentally detected multiple solid pulmonary nodules smaller
than 6mm, no CT follow-up is recommended in a low-risk patient,
and an optional CT follow-up in 12 months is recommended in a
high-risk patient. See the ___ ___ Guidelines
for the Management of Pulmonary</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ old man with no significant past
medical history who presents with transient facial droop and
right-sided weakness. MRI AND MRA BRAIN PT12 MR HEAD showed 1. A couple of punctate foci of hyperintense DWI signal in the left parietal
cortex without definite correlate on ADC, T2 or FLAIR imaging. These lesions
most likely represent tiny hyperacute infarcts, but in the differential
consider the fact that these lesions may be artifactual in nature.
2. Periventricular and deep white matter T2 and FLAIR hyperintensities are
nonspecific but most likely related to microangiopathy.
3. Bilateral maxillary sinus mucosal thickening.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 1:53 pm, 5 minutes after
discovery of the findings. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. MRI of the Pelvis showed 1. No evidence of deep vein thrombosis in the pelvis.
2. Enlarged prostate The patient was diagnosed with Cerebral infarction, unspecified. At the time of discharge, the patient had Transient ischemic attacks. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ without significant past medical history admitted with
transient right-sided facial droop, speech difficulty, upper
extremity weakness, and sensory disturbance, found on CTA at
___ to have left M2 occlusion prior to transfer to
___. Symptoms resolved on arrival to ___, although
examination notable for subtle right-sided weakness in the
distal upper > proximal lower extremities. MRI brain revealed
small left parietal infarcts suggestive of a cardioembolic
origin, although no paroxysmal atrial fibrillation noted on
telemetry during the admission. Due to intracranial artery
stenosis noted on vascular imaging, patient was started on
aspirin 81 mg daily and atorvastatin 80 mg daily. TTE revealed a
PFO, but there were no DVTs on MRA pelvis ___ US. Patient was
discharged with ___ and ___ follow up with Dr. ___.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = 123) - () No
5. Intensive statin therapy administered? () Yes - () No [if
LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? () Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ y/o woman with history of HFpEF, paroxysmal
atrial fibrillation, and HTN who presents with 2 months of
worsening shortness of breath. History was obtained in part from
records due to patient's poor memory, but key details were
confirmed with the patient.
Patient and providers report ___ gradual worsening of symptoms
over the past ~2 months. Patient reports strict adherence to her
diuretics, 1500cc fluid restriction, and low-sodium diet at
home, but she has nonetheless experienced worsening SOB as well
as ___ edema. She is now only able to walk about 4 steps before
becoming short of breath. Her dry weight is around 150 lbs but
she does not weight herself regularly. No orthopnea or PND. No
chest pain, palpitations, diaphoresis, or dizziness.
Patient was advised by her cardiologist to come into the CDAC
over the last month for IV diuresis but declined. Today she
noted new dysuria and vaginal itching and decided to come to the
ED for these reasons. Of note, patient has a h/o recurrent UTIs
and just completed a 7-day course of amox/clav today. She denies
fevers, chills, rhinorrhea, cough, chest pain, N/V/D/abdominal
pain, or rashes.
In the ED, patient was afebrile and hemodynamically stable on
room air. Exam, CXR, and BNP were consistent with heart failure
exacerbation. EKG showed afib vs. flutter in ___ with no
ischemic changes, and trop was negative. Cardiology was
consulted and recommended admission for IV diuresis. CHEST (PA AND LAT) showed Moderate interstitial pulmonary edema with small bilateral pleural effusions
and bibasilar atelectasis. Radiology showed Improved pulmonary edema. The patient was diagnosed with Dyspnea, unspecified. The patient was treated with ___ ___. At the time of discharge, the patient had PRIMARY
=======
Atrial fibrillation s/p DVVC
Acute on chronic heart failure exacerbation
SECONDARY
=========
HTN
Mild Cognitive Impairment
Conjunctivitis
Urinary retention. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms ___ is an ___ with HFpEF, AF, HTN, p/w with progressive
SOB, ___ edema found to have CHF exacerbation, s/p IV Lasix
diuresis w/improvement in Sx, s/p ___ (___) of AF to sinus
rhythm
# Acute on chronic HFpEF
Pt had gradual progression of Sx over weeks-months, had declined
CDAC admission earlier for IV diuresis, found to have volume
overload, s/p IV Lasix diuresis. Repeat TTE similar to prior
(symmetric LVH, mild AS, mild pulm HTN, EF >65%). After
discussion with outpt Cardiologist Dr ___ for ___ of
AF to assist with CHF management, increased home Amio to BID but
discharging on once a day due to bradycardia in sinus rhythm.
Admission weight (69.1 kg 152.34 . D/c weight 62.69 kg (138.2
lbs). Restarted home Losartan as tolerated. DC'd on atorvastatin
10 mg daily, losartan 100mg daily , propranolol 10 mg (also has
tremors) BID, Bumetanide 3 mg daily
# Paroxysmal AFib vs Flutter
Pt has been in persistent AFib vs flutter since at least ___,
was initially c/w home Amiodarone + Propranolol. Previous ___
in ___. After discussion w/ outpatient Cardiologist Dr
___ (___) was performed but reverted to Aflutter on ___
and then s/p ___ (___) and returned to sinus rhythm before
discharge. Increased home Amiodarone from 200mg qd to 200mg BID
during most of her stay but now being discharged on amiodarone
200 mg daily, home rivaroxaban 15 mg daily, propranolol 10 mg
BID
# Urinary Retention
Had multiple PVRs >500cc but continued to urinate 100-200ccs
every ___ hours. UA wnl. CTs in two occasions in ___ and ___
showing distended bladder (763 ccs, 528.3 cc) and occupying the
space and creating a 4.5 cm hypodense structure posterior to the
bladder. A pelvic ultrasound had been recommended at that time,
which the patient declined. At this point she should have
outpatient urology follow up for consideration of any further
workup. A foley catheter was not placed at discharge as she was
asymptomatic without UTI ___ at time of discharge.
-F/u outpatient if patient wishes to work up
# Dysuria and pyuria
# Vaginal itching (resolved)
Patient completed a 7d course Augmentin for chalazion on day of
admission, s/p CTX & fluconazole in ED with c/f UTI vs
vaginitis. Started Nystatin w/improvement in Sx. UA w/pyuria,
though UCx was neg, no further Abx given
#Chest rash: related to pads from ___, improving.
CHRONIC ISSUES
==============
# Mild Cognitive Impairment: Alert and oriented but with poor
short-term memory and attention
# Tremor: Pt with baseline tremor, c/w home Propranolol
# ?Viral conjunctivitis: per pt, eye drops stopped per outpt
Optho, started frequent warm compresses w/improvement in Sx.
Gave artificial tears.
# HTN: slowly increased Losartan back to home dose, held home
amlodipine
# CONTACT: HCP: Proxy name: ___ (daughter) Phone:
___
TRANSITIONAL ISSUES
===================
[ ] Re-check EKG to determine if she is still in sinus in
cardiology f/u in 1w
[ ] Patient discharged with ___ of Hearts monitor, please
consider adjusting amiodarone dose based on her afib burden.
[ ] Stopped home amlodipine during admission due to soft BPs.
[ ] Discharge diuretic dose is 3mg Bumex daily
[ ] Monitor weights and titrate bumex (dry weight 62.69 kg
(138.2 lbs))
[ ] Patient had urine retention, which is likely chronic. She
should be seen by urology as an outpatient for further
evaluation. Please arrange this. She had a pelvic finding on
prior abdominal CT imaging where a mass could not be excluded
posterior to the bladder, but refused further follow up. This
could be addressed with pelvic ultrasound.
[ ] repeat chem 10 panel in ___ days to ensure stable. Cr at
discharge 1.2
Discharge weight: 62.69 kg (138.2 lbs)
>30 minutes spent on discharge planning/coordination of care</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man who is nearly 3 months
status post VATS right lower lobe lobectomy for lung cancer,
with
a complicated postoperative course including ARDS requiring
prolonged intubation ultimately tracheostomy and a right
pneumothorax requiring a chest tube, presents from rehab with
concern for worsening pneumothorax. When the patient left the
hospital from his last admission, he had a moderate right-sided
pneumothorax with a pleural effusion at the lung base. This is
been followed at rehab with serial chest x-rays. On today's
chest x-ray, the pleural effusion had resolved however the
pneumothorax remained and was questionably enlarged. Therefore
the patient was sent to the ___
emergency department for further evaluation. CHEST (PORTABLE AP) showed Status post right pigtail catheter placement without significant interval
change in moderate right hydro pneumothorax.
Chronic severe infiltrative lung disease.
Size of tracheostomy tube should be re-evaluated clinically. CHEST (PORTABLE AP) showed Tracheostomy is in place. Right PICC line tip is at the level of lower SVC.
Right pigtail catheter is in place. Pneumothorax is moderate to large,
unchanged. Interstitial opacities have substantially progressed in the
interim concerning for progression of interstitial edema. CHEST (PORTABLE AP) showed Unchanged size of a large right pneumothorax. No evidence of tension. CHEST (PORTABLE AP) showed Moderate right-sided pneumothorax with apical and basilar components is
unchanged. Right-sided pigtail catheter is in place. Right PICC line
projects to the cavoatrial junction and is also unchanged. Tracheostomy tube
is also unchanged. Interstitial abnormality bilaterally left greater than
right could represent a combination of pneumonia and edema. CHEST (PORTABLE AP) showed Unchanged size of large right pneumothorax. Mild interval worsening of
underlying parenchymal process at the left lung base. CT CHEST W/O CONTRAST showed 1. Small to moderate hydropneumothorax with some possibly loculated
components. There is no obvious bronchopleural fistula.
2. Post right lower lobectomy. Consolidations in the left lower lobe and
lingula are concerning for pneumonia, significantly progressed since ___.
3. The previously seen large right chest wall hematoma appears significantly
decreased in size, now measuring 6.5 x 1.9 cm.
4. Post tracheostomy. Secretions are seen in the right main bronchus extending
into the subsegmental bronchi of the right lower lobe
5. There is diffuse lower lobe predominance of interstitial reticulation and
honeycombing, compatible with biopsy proven UIP. CHEST (PORTABLE AP) showed Lungs are low volume with mild improvement in the interstitial abnormality
which most likely represents improving edema. The residual opacity
bilaterally is consistent with known interstitial lung disease. The moderate
right pleural effusion is unchanged. Right-sided pigtail catheter and
right-sided PICC line are unchanged. Tracheostomy tube remains in place.
Cardiomediastinal silhouette is stable. There is a stable small right pleural
effusion. CHEST (PORTABLE AP) showed Unchanged small right apical and basal pneumothorax.
Interval increase in reticular opacities possibly reflecting pulmonary edema. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are
stable, as is the cardiomediastinal silhouette. The patient has taken a
better inspiration with continued extensive reticular changes and right
pleural effusion. Specifically, there is hazy opacification in the right
apical region consistent with pleural fluid replacing the prior pneumothorax. The patient was diagnosed with Pneumothorax, unspecified. The patient was treated with ___
Right pleural pigtail catheter placement. At the time of discharge, the patient had Respiratory failure
Trapped right lung. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was evaluated by the Thoracic Surgery service in
the Emergency Room and a right pleural pigtail catheter was
placed to evacuate his right pneumothorax. He was then admitted
to the ___ for vent management as well as management of his
pigtail catheter. Most recently at rehab he had been able to
tolerate a trach collar during the day and PSV overnight. He
felt that his dyspnea improved following placement of the
pigtail catheter but on xray, the pneumothorax was the same.
There was no air leak from his pigtail catheter.
The Pulmonary service was consulted to comment on his fibrotic
lung disease which was confirmed on pathology (UIP). After the
patient's initial roughly
1-month Prednisone taper, he was not on prolonged steroids. They
felt that he didn't have clinical evidence of an ILD flare, and
CT imaging did not demonstrate progressive fibrosis or ground
glass in a pattern consistent with flaring. However, he did have
significant LLL consolidation and mucus plugging; pulmonary
hygiene and mucus clearance is key to help with vent weaning.
They also felt that his remaining R lung has less parenchymal
abnormality than his L lung and his oxygenation would
significantly be affected by any pleural process that impairs R
lung ventilation. They recommended starting albuterol nebs q6hr
with dedicated coughing and airway
clearance after, starting start Mucinex ___ mg BID. They will
also arrange outpatient pulmonary follow-up for consideration of
pirfenidone.
Mr. ___ was able to be weaned off the ventilator and has
been on a 60% trach collar for the last 72 hours. His pigtail
catheter was removed on ___ and he denies any change on his
baseline dyspnea. He was evaluated by the Speech and Swallow
therapist and cleared for use of a passey muir valve for ___
minute spurts with supervision.
His tube feedings were changed to Osmolite 1.5 from Jevity 1.2
due to loose bowel movements. All stool studies have been
negative including C diff, banana flakes have been added and the
beneprotein has been stopped.
Cardiology was also consulted to comment on his PAF with RVR and
they recommended titrating up his Metoprolol to 37.5 q 6 hrs,
continuing his diltiazem at 60 mg q 6 hrs and if needed for rate
control, possibly adding digoxin. Currently with his Metoprolol
at 37.5 mg q 6 hrs his rate is better controlled.
Anticoagulation was also discussed and deferred given his ___
sore is 1 and prior chest wall hematoma.
Mr. ___ is gradually getting stronger and now off the
ventilator but still needs more physical therapy as well as SLP
before returning home. He was discharged back to rehab on
___ and will follow up with Dr. ___ in 4 weeks.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ otherwise healthy who was playing football today and
suffered
a hyperextension injury to the R knee. Immediate onset of pain,
swelling, and inability to bear weight. No injuries elsewhere.
Denies numbness or tingling distally. CT RIGHT LOWER EXTREMITY WITHOUT CONTRAST showed 1. Comminuted, depressed lateral tibial plateau fracture as described above
with approximatly 1.3 cm of depression.
2. Secondary lipohemarthrosis and intraarticular air locule, most likely
traumatic. Radiology showed As above. The patient was diagnosed with FX UPPER END TIBIA-CLOSE, OTHER OVEREXERTION AND STRENUOUS AND REPETIVE MOVEMENTS OR LOADS, ACTIVITIES INVOLVING AMERICAN TACKLE FOOTBALL. The patient was treated with Right tibial plateau open reduction and internal fixation. At the time of discharge, the patient had Right tibial plateau fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is nonweightbearing in the right
lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with a history of CAD s/p
CABG in ___, PCI in ___ and ___, AS s/p AVR in ___, atrial
fibrillation, permanent pacemaker, chronic angina, hypertension,
and hyperlipidemia who presented with worsening SOB and an
episode of anginal symptoms, nausea, and pallor. Patient reports
he first began feeling unwell a month ago after undergoing ___
surgery complicated by bleeding. He states neither his coumadin
nor aspirin were stopped due to this event. Since then he began
to notice his functional capacity was becoming reduced,
especially one week PTA when he began noticing increased
fatigue, SOB and chest pain with less exertion. He contacted his
cardiologist, Dr. ___ suggested that he start Lasix 20
mg daily on ___ which he did not start because he
was concerned about the side effects. He reports he is usually
able to walk ~ ___ mile before having to stop because of chest
pain and SOB. He takes nitroglycerin daily for anginal symptoms.
Of note, a recent cardiology note from ___ states he reports not
exerting himself or doing much activity because he is afraid
something might happen. Five days PTA he experienced an episode
of SOB after walking ___ feet, and had to rest for ___
minutes. On the day of admission he reports starting to have
breakfast with a friend when he suddenly felt nauseous x4 but
never vomited. He also reports anginal symptoms during this
episode, but no worse than baseline, moderate SOB, pallor, and a
general sense of feeling unwell. He denies diaphoresis, or
radiating pain. He denied PND, and orthopnea. His wife reports
noting worsened peripheral edema over the past days PTA. The patient was diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE, PNEUMONIA,ORGANISM UNSPECIFIED, HYPOSMOLALITY/HYPONATREMIA. The patient was treated with ___ Cardiac catheterization. At the time of discharge, the patient had Primary: acute systolic heart failure, coronary artery disease
Secondary: aortic valve replacement. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year-old-male with a history of CAD s/p CABG in ___, PCI in
___ and ___, AS s/p AVR in ___, atrial fibrillation on
coumadin, permanent pacemaker, chronic angina, hypertension, and
hyperlipidemia presenting with dyspnea found to have new
systolic CHF (EF ___ and aortic valve lesion and new
hyponatremia, now s/p POBA to ___.
# New-Onset Systolic CHF EF ___: Patient presented with
symptoms of new onset heart failure. TTE showed severe regional
LV systolic dysfunction (EF ___ with akinesis of the
inferior wall, hypokinesis of the lateral and anterior walls
with preservation of the septum which appeared to be new.
Cardiac cath performed on ___ with successful angioplasty of
subtotal occulusion of the left circumflex at the site of the
bare metal stent. Otherwise the LIMA to LAD was patient, mid
RCA occluded with collateral flow. Patient was diuresed with
lasix, discharge weight 76.6kg. He was also started on
lisinopril and metoprolol.
# Aortic Valve s/p AVR: ___ at OSH showing possibly thrombus or
endocarditis of mechanical prosthetic aortic valve. TEE
performed on ___ showed no evidence of vegetation or thombus.
Further no evidence of endocarditis on exam and blood cultures
negative. Patient initially received Vitamin K. He was started
on a heparin drip that was continued until INR was therapeutic
(>2.5).
# Coronary artery disease: Patient has known CAD s/p CABG in
___ ___ to LAD, SVG to RCA (known to be occluded) and SVG to
OM (known to be occluded), also BMS to Left circumflex/OM.
Patient presented with new wall motion abnormalities on ECHO as
described above, EKG without evidence of ischemia, Troponins
elevated with flat CK-MB. Cardiac cath performed ___ as above
with successful angioplasty of LCx stent. Patient continued on
aspirin, ranexa and statin.
# Hyponatremia: Patient presented with hypervolemic
hyponatremia, sodium of 119 and was asymptomatic. Sodium
improved with diuresis to 132.
# HLD: Patient continued on simvastatin. Consider rechecking as
outpatient.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of COPD, tobacco abuse, atrial fibrillation on
coumadin, hypercholesterolemia, stage IV CKD presenting with
worsening shortness of breath, productive cough of white/yellow
phlegm over the past 2 days. He denies any fever or chills. No
chest pain or pressure. No abdominal pain. No recent
hospitalizations. Is not on home oxygen and his normal oxygen
saturation is around 93-95%? but once recently it has been as
low as 88%at his cardiologist's office. + sick contacts in his
dtr and grand dtr who both had URI sx. He has had diarrhea 2x in
the course of hte past month. Prior to the development of this
cough he felt well. He has chronic incontinence since his TURP
and does not report dysuria. He does not have a pulmonologist.
+ rhinorrhea and sratchy throat. He has noticed that he does
wake up sob and has to sleep on 3 pillows for the past year. He
has noticed that he does need to take naps after dinner and he
also takes a nap in the daytime.
.
He has had recent life stressors as he in the process of selling
his 3 family home and moving into an ALF at ___. He is
happy because he is getting a higher ___ for his home than he
asked for. Wife of ___ years has been declining per PCP's recent
note however.
.
In ER: (Triage Vitals:0 98.4 60 164/108 26 99% 6L neb)
Meds Given:
methylprednisone 125 mg IV, kayexelate 30 gm, levofloxacin 750
mg IV
Fluids given: none
Radiology Studies: CXR
consults called. none
Admission VS: 98.8, 60, 157/59, 20, 93% 3LNC Radiology showed Findings concerning for multifocal pneumonia. Recommend
treatment and followup to resolution.
emphysema
chk after edma rx
mild cardiomegaly Chest PA and lateral. showed Improvement of previously diagnosed exacerbation of COPD, patient
with multiple focal parenchymal infiltrates.
The present chest findings are similar to what was noted on a more remote
examination of ___. The patient was diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, CARDIAC PACEMAKER STATUS. At the time of discharge, the patient had Pneumonia
COPD exacerbation
Hypoxemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx of COPD, tobacco use (ongoing), atrial fibrillation
on coumadin, hypercholesterolemia, stage IV CKD presenting with
worsening shortness of breath, productive cough of white/yellow
phlegm found to have multifocal infiltrates consistent with PNA
and COPD exacerbation.
.
## Community-acquired pneumonia: Admission CXR showed multifocal
infiltrates supportive of pneumonia. He completed 7 days of
Levofloxacin symptomatic improvement. Repeat CXR prior to
discharge showed significant regression of the infiltrates noted
on initial CXR.
.
## COPD exacerbation: Symptoms improved with antibiotics as
above as well as 5-day course of Prednisone 40mg daily and
nebulizers. He was discharged home with rx for a nebulizer
machine and Albuterol nebs. He still had mild wheezing on
discharge but overall improved.
.
## Hypoxemia: Patient is not usually on home oxygen and his
normal oxygen saturation is around 93-95% on room air with one
recent finding as low as 88% at his cardiologist's office. Here,
he initially required 3L NC to maintain sats in the low ___.
Despite multiple attempts, he could not be weaned off oxygen
completely. He had consistent desaturation to 85-88% on room air
with ambulation. Therefore, he was discharged on continuous ___
O2 and set up with ___. Repeat CXR prior to discharge showed
improvement of pneumonia and also was not remarkable for volume
overload to account for the persistent hypoxemia.
.
## Tobacco dependence: He was maintained on a Nicotine patch
with good effect. He was told that he cannot smoke now that he
is on supplemental oxygen.
.
The remainder of his medical issues were stable during this
admission.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with recent dx of adenocarcinoma of the lung who presents as
transfer from ___ with SOB found to have PE.
The patient was recently admitted to ___ where he underwent a
supraclavicular node bx which was positive for adeno carcinoma
(seep path report below). He was also being treated for a RUL
PNA with amoxicillin and axithromycin. He represented to ___
today for worsening SOB and CTA showed PE. He was transferred to
___ for evaluation for lysis.
In the ED, initial vitals pain ___, T 99.1, HR 90, BP 149/70,
RR 18, 92%RA. No exam documented on ED dash. Labs notable for
unremarkable CBC, Chemistry with Bicarb 19, BUN/Cr ___.
Troponin and BNP negative. Blood cx obtained. Imaging notable
for subsegmental PE, large R effusion and a possible RUL
post-obstructive PNA. Patient was continued on a heparin gtt,
given 1L NS and 2gm Cefpepime. He was ordered for vancomycin but
did not receive it.
Cardiology was consulted for consideration of MASCOT
activation. Given his clinical and hemodynamic stability,
negative troponin and BNP MASCOT was not activated and he was
maintained on a heparin gtt.
On arrival to the floor, pt confirms the above history. In
brief, he reports that he was discharged from ___ on ___ and
worked ___ of this week. ___ he developed
worsening cough and SOB and took ___. His sputum is
occasionally blood tinged. He also found out about the results
of his biopsy this week and was scheduled for a PET-CT on
___ with a plan to f/u with oncology for treatment options
after. He also reports drenching night sweats and chills at
home. He has never been lightheaded. He has some chest
discomfort that has been present for several weeks.
REVIEW OF SYSTEMS: No changes in vision or hearing, no changes
in balance. No palpitations. No nausea or vomiting. No diarrhea
or constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits. CHEST (PORTABLE AP) showed In comparison to outside chest x-ray of ___, a right pleural
effusion has decreased in size, with no visible pneumothorax following recent
thoracentesis. Extensive consolidation and atelectasis predominantly
involving the right upper and middle lobes is likely post obstructive from a
right juxta hilar mass more fully evaluated by outside CT of ___.
Bulky intrathoracic lymphadenopathy is also more fully characterized on that
study. CT CHEST W/CONTRAST showed Massive perihilar lung mass, with bronchial, vascular, and mediastinal
invasion, severe ipsilateral and contralateral lymphadenopathy, obstructive
pneumonia, pleural implants, pleural effusion, postobstructive pneumonia, and
propagation of the process along the bronchi. Known pulmonary embolism.
Suspicious 1 cm right adrenal mass. No evidence of metastatic bone disease. CHEST (PA AND LAT) showed Comparison to ___. Minimal improvement of the large consolidation
in the right lung apex. The paramediastinal consolidations as well as the
enlargement of the right hilus and of the left hilus are stable. No new
parenchymal opacities. Stable borderline size of the cardiac silhouette.
Minimal right pleural effusion. The patient was diagnosed with Pneumonia, unspecified organism. The patient was treated with Thoracentesis ___. At the time of discharge, the patient had Primary diagnosis:
Malignant pleural effusion
HCAP
Adenocarcinoma of the lung
Pulmonary embolism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o M with recent diagnosis of lung adenocarcinoma who
presented as a transfer from ___ with SOB,
found to have bilateral PE's, recurrent malignant right sided
pleural effusion, and post-obstructive pneumonia.
#Acute pulmonary embolism without cor pulmonale: Patient
presented to ___ on ___ with SOB and chest pressure and found
to have bilateral subsegmental PE's on imaging. Hypercoaguable
state secondary to malignancy. Was transferred to ___ for
management and further work-up. On admission to ___, he denied
chest pain or dyspnea and his vitals were stable. His cardiac
workup was negative with unremarkable EKG and negative
troponins. He received heparin on admission and was transitioned
to lovenox. Discharged on lovenox 90mg SC q12h to continue
indefinitely.
#Malignant pleural effusion: On presentation to ___, patient was
found to have a right-sided pleural effusion on imaging. Prior
to this, he had recently undergone a US-guided thoracentesis on
___ at ___ with 60cc fluid drained. Pleural fluid cytology
results were positive for malignant cells. Based on history, was
likely a re-accumulated malignant effusion but there was also
concern for a parapneumonic effusion given the patient's recent
h/o of pneumonia. IP performed a thoracentesis on ___ and 2L
were drained from right pleural effusion. Cultures negative at
both outside hospital and during this hospitalization. Fluid
results were consistent with exudative effusion, cytology
confirmed the presence of malignant cells. Patient was weaned
from 2L oxygen to RA without issues. A repeat CXR on ___ showed
mild right sided pleural effusion, but much improved from
admission. Patient was discharged on oxycodone 5mg and an
outpatient ___ with IP scheduled for ___. He was
counseled on the warning signs which should prompt emergent
re-evaluation such as dyspnea, fever, worsening chest pain,
hemoptysis.
#HCAP: Prior to admission on ___, patient had been treated for
CAP at ___ and completed a ___ day course of Augmentin and
Azithromycin on ___. He represented to ___ on ___ with
productive cough, SOB and fevers/chills. Had CXR and CT torso.
CXR showed evidence of postobstructive pneumonitis in the right
upper lobe with partial
collapse of the right upper lobe. Upon admission to ___, he
was started on vancomycin/cefepime given concern for HCAP(start
date ___. MRSA, legionella, sputum and blood cultures sent.
Sputum culture was not valid and remaining cultures were
negative. Legionella was negative. Patient was switched to
Augmentin PO on ___ to complete a 2 week course to end ___.
He received ipatroprium and albuterol nebs PRN, guaifenesin
600mg BID for management of respiratory sxs, and given a flutter
valve.
#Pain control: Had significant pain secondary to cancer, pleural
effusion, recent procedure. While inpatient his pain management
was oxycodone 5 mg mild pain, oxycodone 10 mg moderate pain,
dilaudid 0.5 mg IV severe pain. He was discharged on
oxycodone 5 mg q3h pain x1 week and bowel regimen with ___
with PCP.
#Stage IV lung adenocarcinoma: Recently diagnosed with
adenocarcinoma with positive lymph node, invasion of mediastinum
and malignant pleural effusion. Cytology was positive for
malignancy at ___ and again on this hospitalization. A recent CT
chest with contrast demonstrated invasion into mediastinum,
vasculature and bronchial tree. CT also showed evidence of
adrenal mass with concern for a possible met. Given malignant
effusion, patient has stage 4. A bone scan on ___ was negative
for bone metastases. The patient has decided to establish care
at ___ and has scheduled an outpatient appt on ___. Summary of
hospital course will be faxed to ___. Imaging results given to
patient in a CD</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ M with a h/o hypertension,
hyperlipidemia and cerebral palsy (has baseline tone increase on
left with some fine motor difficulties on that side) who has
been
seen in the Cognitive Neurology Clinic by Dr. ___ a ___
year history of progressive irritability and memory issues. As
part of his work up he had a MRI of the brain that showed an
acute left occipital stroke in addition to older
encephalomalacia. He is therefore sent into the ED for admission
for stroke work up. CTA HEAD WANDW/O C AND RECONS showed 1. No evidence of acute infarction. Chronic infarction in the right frontal
and parietal lobe.
2. Periventricular white matter low attenuation which is nonspecific but
likely on the basis of chronic small vessel ischemic disease.
3. Unremarkable MRA of the head without evidence of stenosis, occlusion, or
vascular malformation.
4. Stenosis at the origin of the left vertebral artery. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT, HYPERTENSION NOS. At the time of discharge, the patient had acute ischemic right occipital stroke. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old man man with a history of cerebral
palsy and recent cognitive decline who was found to have an
incidental acute right occipital stroke on his MRI obtained for
cognitive workup. He has no new deficits and is asymptomatic.
Etiology is unclear.
# Acute Stroke: CTA of the head and neck showed patent vessels
and small outpouching of basilar which is likely incidental. He
was switched from Plavix 75mg daily from aspirin for secondary
prevention. He was monitored on tele for afib. His atorvastatin
dose increased from 40mg to 80mg daily. Echo did not reveal
cardiac source. A1c was 5.6% and LDL was 107. No etiology of his
stroke was found and he was discharged with plan for ___
___ to monitor for afib.
# Hypertension: Lisinopril and chlorthalidone were held to allow
for permissive hypertension but were restarted prior to
discharge.
# Cognitive Decline: continued his B-12 for replacement. He will
follow up in neurology clinic for further management.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx DM2 on insulin, CAD, OSA who presents for evaluation of
fatigue and lightheadedness for the last couple weeks. CTA chest and CT abdomen and pelvis. showed 1. No evidence of pulmonary embolism to the segmental level.
2. Interval increase in retroperitoneal and mediastinal lymphadenopathy,
compared to ___, raising the possibility of chronic lymphocytic leukemia.
Interval stability to minimal increase in pelvic lymphadenopathy. If biopsy
is to be considered, an enlarged right external iliac node (304:73) may be
amenable to sampling.
3. Moderate bilateral pleural effusions with associated atelectasis.
4. Diffuse, moderate bronchial wall thickening, most prominent within the
bilateral lower lobes, suggestive of inflammation.
5. Cholelithiasis, without evidence of acute cholecystitis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 4:01 pm, 1 minutes after discovery of
the findings. The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had Primary:
--------------
Pulmonary Hypertension
lower extremity edema, bilateral
weakness
lymphadenopathy
bilateral pleural effusions
thickened bronchial walls
Secondary:
--------------
insulin dependent diabetes mellitus
coronary artery disease with stent placed in past
obesity
sleep apnea. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>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. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with remote history of small bowel resection and ?right
colectomy with ileocolic anastomosis recently admitted to ___ colorectal surgery service ___ to ___ with a
complete obstruction at the site of his prior anastomosis for
which he underwent an exploratory laparotomy, extensive LOA,
ileocolectomy with new ileocolic anastomosis formation, and
incicisional hernia repair with Dr. ___ on ___. He now
re-presents to ___ in transfer from ___ with
bilious emesis similar to his prior obstruction and a CT scan
showing SBO with tapering/transition at a loop that runs near
his
RLQ anastomosis where he has significant ___
inflammation, also with enteritis of the small bowel distal to
the transition point. Patient states he hasn't passed gas in a
couple days, has been having waves of abdominal pain since
yesterday that are relieved when he vomits brown/green
non-bloody
fluid, and that his last BM was last night and was black and
liquidy (says he has been having black liquidy stools for most
of
his time at the rehab since being discharged from ___. Last
meal was ___ from the best he can remember. Chest: Frontal and lateral views showed 1. Enteric tube is seen extending to the left upper quadrant with tip out of
view of the image. Moderate to large amount of gas is seen within the stomach.
2. No acute cardiopulmonary process. The patient was diagnosed with Unspecified abdominal pain. At the time of discharge, the patient had Small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ presented to the ED of ___ on ___ for
management of small bowel obstruction. He was admitted to the
colorectal surgery unit for further management. </s> |
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