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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> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o DMII, CAD, and sCHF (LVEF <25% in ___ s/p
recent L salpingoopherectomy (discharged ___ for an enlarged
adnexal mass admitted with tachycardia and abdominal pain. Radiology showed Moderate degenerative change of the left acromioclavicular joint. Radiology showed Persistent cardiomegaly without other acute process seen. Radiology showed No significant interval change in postoperative changes along the
anterior abdomen as well as in the pelvis. Stable small amount of mesenteric
fluid. Mild fullness of the renal collecting systems, but stable. The patient was diagnosed with TACHYCARDIA NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED, URIN TRACT INFECTION NOS, ABN SERUM ENZY LEVEL NEC. At the time of discharge, the patient had Primary
Pyelonephritis
Secondary
? Gastroenteritis. 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>BRIEF HOSPITAL COURSE:
Tachycardia: Ms ___ presented to the ED with tachycardia.
Serial cardiac enzymes were performed, trending down from 0.03
to 0.02. There
# Tachycardia: Ms ___ presented with palpitations found to be
dehydrated and tachycardic in ED following poor p.o intake with
likely demand ischemia with associated mild troponin leak that
trended down (0.03 to 0.02) and EKG not suggestive of myocardial
infarction. Much improved after IVF. HR wnl, patient remained
chest pain free. Her PCP should arrange for an outpatient stress
test. She will continue home services, ___ to review that she is
taking adequate p.o intake.
.
Abdominal pain: pt with diffuse abdominal pain initially, with
pain resolved on discharge. She had also endorsed associated n/v
and found to have UTI. Pain did not appear related to recent
surgery and CT abdomen and pelvis did not reveal any acute bowel
pathology. She was started empirically on IV ciprofloxacin,
switched to nitrofurantoin based on sensitivities from prior
urine cultures. A urine culture performed this hospitalization
was contaminated and she was treated empirically for UTI with
nitrofurantoin for planned 7 day total antibiotic course.
.
# CKI: pt with Cr from 2.1 from 1.0 in setting of n/v and poor
p.o intake leading to dehydration, with ___ likely prerenal in
etiology.Cr improved to 1.2 from 2.1 after receiving intravenous
fluids.
.
# s/p L salpingoopherectomy; pathology shows large cyst. Steri
strips remained in place per ob/gyn. She will f/u with her
gynecologist at ___.
.
# Recent shoulder surgery: continue home physical therapy.
.
# Anemia: pt had 8 point HCT drop from 38 to 30.2 in the setting
of receiving intravenous fluids. This HCT was believed to be
dilutional with subsequent HCT trend showing increase in HCT to
31.8 consistent with this. She should have repeat HCT check on
follow up with her PCP.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ gentleman with high risk MDS
currently on cycle 14 of decitabine, CKD III, chronic pleural
effusions, diastolic heart failure, hypertension, and atrial
tachycardia (previously on amiodarone, not on any
anti-arrhythmics currently) who was recently admitted to ___ for
HCAP and is now readmitted for shortness of breath with sputum
culture from ___ is growing ___ transferred to the ICU for
Afib with RVR on ___ for management, controlled with Dilt drip,
transitioned to metoprolol, and now asymptomatic with normal
hemodynamics, currently followed by ID for positive AFB sputum
however most recent cultures negative and noted for +klebsiella
PNA. CT CHEST W/O CONTRAST showed 1. Progression of multifocal consolidative and ground-glass opacities, since
___ now involving all lobes, differential is broad but includes
multifocal infection, vasculitis. Given the rapid interval progression
cryptogenic organizing pneumonia, is felt to be less likely.
2. Unchanged mediastinal lymphadenopathy.
3. New small bilateral pleural effusions and lower lobe septal thickening,
consistent with background pulmonary edema. Radiology showed Multifocal opacities, mild pulmonary edema, and small bilateral pleural
effusions are stable from ___. No significant interval change. CHEST (PORTABLE AP) showed In comparison with study of ___, there is increasing diffuse bilateral
pulmonary opacifications, most likely reflecting worsening pulmonary edema
with bilateral effusions and compressive basilar atelectasis. In the
appropriate clinical setting, several areas of more coalescent appearance
bilaterally could possibly represent superimposed pneumonia. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had MDS
pneumonia. 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 high risk
MDS and chronic diastolic heart failure recently admitted for
several days of hemoptysis and CT showing ? PNA vs. other
process
found to have a positive AFB smear from ___, who presented to
clinic ___ with fever and SOB, s/p ICU transfer for Afib with
RVR improved with Dilt/metoprolol, now hemodynamically stable in
NSR sputum +klebsiella.
#Afib with RVR: Transferred to ICU on ___ for this, now
converted to sinus and hemodynamically stable since then.
Cardiology following. TTE with no evidence of pericardial
effusion. Resumed home metoprolol with holding parameters.
#Fever/SOB: Recent admission with chest CT ___ showing LL
predominant multifocal consolidations c/f multifocal infection
v.
vasculitis v. COPD v. pulmonary infarcts. He was treated for
HCAP. Sputum sample ___ grew AFB, repeat samples neg now off TB
precautions. Beta glucan level also highly elevated on ___.
However, most recent B-glucan is negative without a clear
therapy. Has had ongoing intermittent productive cough. CT chest
___ shows rapid progression of pulmonary infection. He is
growing klebsiella on his sputum cultures which could certainly
account for his interval change on imaging and it appears to
have
been somewhat high grade as is on three different cultures
despite therapy. Per pulmonary recs, should obtain chest CT 2
weeks after treatment for klebsiella to evaluate for possible
secondary infectious process. If no improvement or significant
residual disease per imaging, bronchoscopy would then be
indicated. Pulmonary also recommended evaluation for aspiration
risk given distribution of disease but this may be difficult to
obtain due to TB precautions.
-crypto antigen in blood and urine histo negative
-ceftazidime (___) then changed to ceftriaxone to
complete 14d course ___, off ___ and vanco since ___
-appreciate ID recs-see note AFB unlikely at this point,
negative
sputums x3
-repeat CT chest 2 weeks after most recent
-weekly fungal markers
-IgG level 796 on ___
#Acute on chronic diastolic heart failure: BNP on admission was
elevated at 4800 and patient was mildly volume overloaded on
exam the afternoon of ___, resumed home lasix. CXR ___
shows
mild pulmonary edema; however, repeat ___ in the setting of
worsening SOB showed progressive pulmonary edema w/ bilateral
effusions. Continues on home regimen of lasix 40mg BID and
baseline crackles at b/l bases.
-Lasix IV x 1 on ___, consider repeat dose if no improvement
-telemetry for continuous 02 monitoring
-monitoring strict I/Os
#Coagulopathy: Likely vit K deficient, received PO vitamin K.
Low suspicion for inhibitor but we checked a mixing study since
if he did have an inhibitor with worsened hemoptysis treatment
would be different.
-vitamin K 5mg x 1 on ___ and ___
-f/u mixing study
-restarted prophylactic heparin daily dosing and when
checking PTT, this should be done peripherally (not from his
port)
#HR MDS: He has been maintained on dacogen for about a year now,
currently on C14 so holding now in the setting of active
infection. Exjade on hold while inpatient.
-transfuse to maintain hgb > 7,
-will need Lasix prn with transfusions
#Acute on chronic kidney disease: CKD stage III attributed to
HTN
and vascular disease. Cr slightly above baseline of 1.4-1.6
though downtrending since admission. Possibly in the setting of
volume overload.
-Lasix as above
-Trend Cr
-Avoid nephrotoxins
-Hold lisinopril
#Hernia: Etiology likely due to previous abdominal surgery in
___ ? incisional-related. No abdominal discomfort or
tenderness.
We will continue to monitor closely
#HTN:
-Continue metoprolol with holding parameters
-Hold lisinopril given acute on chronic renal failure
#CAD: Continue ASA 81
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: SQ heparin daily
# Access: Port
# Communication: ___ (___)
# Code: Full (confirmed)
# Disposition: home, to complete 1wk course of ceftriaxone
outpatient, f/u next week ___ or sooner if issues arise</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx of polycystic kidney disease on transplant waiting list
(listed but inactive until GFR < 20, not on dialysis), currently
stage IV ckd- b/l Cr 2.8-2.9, HTN, HLD and hx of diverticulosis
who presents with flank pain/LLQ pain and hematuria. Radiology showed 0.9 x 0.3 cm ovoid ossific structure along the superior patella may represent
a fracture of indeterminate age. No acute fracture seen elsewhere. No
suprapatellar joint effusion is seen. CT abdomen and pelvis without contrast showed 1. Multicystic enlarged kidneys and multiple hepatic cysts are in keeping with
known polycystic kidney disease. There are new rounded areas of
hyperattenuation in the left upper renal pole which may indicate cyst rupture
with hemorrhagic contents. At least 1 of the previously seen simple appearing
cyst now appears hyperdense. No free fluid.
2. Colonic diverticulosis without acute diverticulitis.
3. No acute fractures are seen The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had PRIMARY:
-Ruptured renal cyst
SECONDARY:
-CKD. 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>___ hx of polycystic kidney disease on transplant waiting list
(listed but inactive until GFR < 20, not on dialysis), currently
stage IV ckd- b/l Cr 2.8-2.9, HTN, HLD and hx of diverticulosis
who presents with flank pain/LLQ pain and hematuria.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with complicated PMH here from dialysis with shaking
chills. She has a long history of recurrent fevers, most
recently with hospitalization ___ for Klebsiella
bacteremia of unknown source. She reports she has not felt right
since she completed her course of cefazolin, which she received
at dialysis on ___, 10 days ago. She reports that she has been
very tired, achy, complains of SOB with DOE, and has had several
fevers to 100. She reported back pain radiating to lower
extremities, associated with lower extremity weakness. Today at
dialysis she became very cold and began having chills/rigors.
Temp 100.0. She completed dialysis, and was given acetaminophen
and either cefazolin or cefepime, then sent to the ED. Patient
denies headache, chest pain, abdominal pain, nausea, vomiting,
diarrhea, urinary symptoms. She has chronic cough which is at
baseline. Denies n/v, states she is tolerating PO. She does
report dental work 4 days prior, a ___ year old crown fell out
and she had it replaced. She reports taking unknown prophylactic
antibiotic. No longer makes urine.
In the ED intial vitals were: 4 98.6 94 146/72 18 98%
- Labs were significant for WBC 6.5, Hct 28.0, K of 4.1, Cre
3.7, Calcium 11.0, phos 3.5. INR 1.3. Lactate 1.9.
- CXR showed small bilateral pleural effusion, no focal
consolidation, pulmonary vasculature pronminant, unchanged from
prior. RUQ large rim calcified structure (c/w known liver cyst) Radiology showed 1. Small bilateral pleural effusions and mild pulmonary vascular congestion.
2. Improved aeration of the right lung base from ___. The patient was diagnosed with FEVER, UNSPECIFIED. At the time of discharge, the patient had Elevated temperatures. 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 PCKD s/p failed transplant on HD MWF,
recurrent fevers due to gram negative bacteremia of unknown
source, who presents from dialysis with rigors and temperature
to 100.0, without localizing infection.
ACTIVE MEDICAL ISSUES:
# Elevated temperature: On admission, pt did not meet SIRS
criteria and was afebrile however she had report temperature to
100.0 ___s rigors at dialysis. In the past, pt has had two
episodes of E. coli bacteremia, and most recently completed a
course on ___ of cefazolin for Klebsiella bacteremia. On
admission, she had few localizing symptoms other than a cough
which is chronic as well as back pain with standing which she
reports is also chronic. She denied abdominal pain, n/v/d. No
headaches or neck pain to suggest CNS infection. CXR did not
show evidence of pneumonia. Blood cultures from ___ at both
dialysis and BI were pending, no growth at discharge. CMV viral
load was also pending. She was empirically treated with
vancomycin (HD protocol) and cefepime. Her antibiotics were
stopped as she had no symptoms, remained afebrile with no
leukocytosis. Her elevated temperature and malaise may represent
viral process rather than overt bacterial infection. Her
antibiotics were stopped on the day prior to discharge, and she
remained stable. She had an appointment to follow up with her
PCP the day after discharge.
# HYPERCALCEMIA: Pt noted to have hypercalcemia due to
hyperparathyroidism in the past. Her calcium on admission was
11.0. An SPEP was checked (given her back pain and malaise)
which is pending at discharge. Her dialysis was also modified as
below.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male with history of cardiomyopathy, A-fib, DM and severe
mid LAD stenosis s/p cath with one DES with presents from PCP
with weakness. Pt states his symptoms started 3 weeks ago and
relates it to his cardiac cath in ___. Described as
progressive weakness with some dizziness associated with
decreased PO intake. He fell last week on the curb last week and
has had persistent pain in his left upper back. He denies recent
fevers/chills, headaches, chest pain, SOB, abdominal pain. He
has had no change in bowel or bladder habits, denies
hematochezia, melena, dysuria or hematuria.
Of note, the patient had an admission in ___ for sepsis
related to infected nephrolithiasis.
In the ED, initial vitals were: 97.7 92 115/73 20 100% RA with
positive orthostatics
Labs notable for: WBC 10.1, AP 133, creatinine 1.3 (baseline
1.2), INR 5.2 with PTT 56.5, ___ 58.7, troponin negative x1,
lactate 2.3. He was bladder scanned and a urine sample was sent
from straight cath, with clean UA.
Imaging notable for: normal CT/CTA head, normal CXR
Patient was given: 3 L NS
Neuro was consulted and recommended: unlikely stroke but neuro
will follow as inpatient.
Vitals prior to transfer: 98.0 84 ___ 98% RA
Decision was made to admit for weakness to Medicine with Dr.
___ as attending.
On the floor initially, the patient was completely oriented and
pleasant, overall comfortable and only complaining of weakness
described before and R thigh pain. otherwise denying chest pain,
shortenss of breath, fevers/chills
##At 03:20, a trigger was called for altered mental status and
Afib with RVR into 150's. Pt had not yet received his home
evening dose of Metoprolol tartrate 50 mg. At that time he was
AOx1, more agitated. He had not received any meds by that time.
Bladder scan at that time was 780 cc despite straight cath in
ED. All AM labs were drawn early with BCx., A Foley was placed
and UA/UCx were sent. Dr. ___ was made aware and will see pt at
8 AM. Radiology showed No acute cardiopulmonary process. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. No CT evidence of acute intracranial abnormality. Please note that MRI
provides greater sensitivity in evaluation of acute infarction.
2. Patent intracranial and neck vasculature without carotid stenosis by NASCET
criteria.
3. Postsurgical changes of the cervical spine, as described, with small fluid
collection at the posterior C1 arch decompression site of uncertain
significance. Recommend clinical correlation.
4. Contiguous ossification of anterior longitudinal ligament consistent with
diffuse idiopathic skeletal hyperostosis.
5. Ossification of the posterior longitudinal ligament causing multilevel
spinal canal stenosis most advanced at C6-C7 where there is severe spinal
canal stenosis.
6. 1 cm right thyroid lobe nodule.
RECOMMENDATION(S): Per the ___ College of Radiology guidelines, thyroid
nodules measuring less than 1.5 cm in patient's greater than ___ years of age
do not necessitate imaging follow-up, in the absence of clinical risk factors.
Recommend clinical correlation for 1 cm right thyroid lobe nodule. RENAL U.S. showed 1. Bilateral non-obstructing renal stones..
2. Massively enlarged prostate. MR HEAD W AND W/O CONTRAST T9112 MR HEAD. showed 1. No evidence of acute or chronic large vascular territorial infarction.
2. Mild chronic small vessel ischemic disease. The patient was diagnosed 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>___ h/o cardiomyopathy, A-fib, DM and severe mid LAD stenosis
s/p cath with DES who presents from PCP with weakness found to
have Afib with RVR, AMS during admission.
# AMS: On admission patient was A&Ox3 but later became A&Ox1 and
agitated. Possible triggers for delirium included urinary
retention (patient could not void spontaneously and was
discharged with foley), constipation. Workup for CVA including
MRI and CT was negative. Workup for infection including renal
u/s, cultures, and UA was negative. Renal u/s showed
non-obstructing stones. On discharge patient was A&Ox3 but very
combative. Questionable component of dementia given history from
wife. He may benefit from cognitive testing by Neurology as an
outpatient for evaluation of dementia.
# BPH with active urinary retention: Bladder scanned on ___ ___
and again had 700+cc urine in bladder. Patient was straight
cath'd multiple times for failure to void. A foley was placed
and he was discharged with a foley with plan to follow up with
urology.
# ___: Most likely post-renal in setting of urinary retention,
but may have component of prerenal due to poor po intake at
home. Creatinine decreased to 1.1 after placement of foley.
# Afib on warfarin: Developed rapid rates to 150's in setting of
missing evening dose of Metoprolol tartrate. Improved to
100's-110's after receiving PO dose of Metoprolol tartrate 50
mg. INR supratherapeutic at 5.2 (pt had been taking ___
daily). NO evidence of bleeding. Warfarin held again on ___ for
INR of 3.6. Per his PCP ___ for patient to re-start
warfarin 5 mg daily on ___.
# Leukocytosis: Mild elevation of WBC to 11.5. UA negative,
renal u/s showed non-obstructing stones. Down-trended to normal
without antibiotics.
CHRONIC ISSUES:
# CAD s/p DES in ___: Continued Aspirin and Plavix,
atorvastatin, losartan.
# dCHF: Euvolemic, home torsemide held due to ___ but then
restarted on d/c.
# DM: Metformin held in setting of elevated lactate, restarted
on d/c.
# H/o gout: Continued home colchicine + probenecid.
Transitional Issues
===================
-Patient discharged on foley due to failure to void. Needs to
followup with urology to discontinue foley.
-INR 3.6 on discharge. Warfarin was held on ___ and
___. Patient should restart Warfarin on ___ at 5mg and
check his INR at home per recommendation of Dr. ___.
-Please follow up 9mm thyroid nodule with thyroid ultrasound.
-History obtained from patient's wife and patient's
combativeness in hospital concerning for early dementia. Please
evaluate with cognitive testing as outpatient with possible
referral to cognitive neurology.
-Please consider downtitrating tramadol and lorazepam given
concern for altered mental status.
-Code Status: Full Code (confirmed)
-Contact: Name of health care proxy: ___
Relationship: wife
Cell phone: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with a history of right
inguinal hernia repair with mesh in ___ who presents with 3
days of right groin pain and a bulge. Patient underwent an
uncomplicated elective open right inguinal hernia repair
(direct) with mesh in ___ ___. Patient reports she
has not had any had any problems since her repair until of
approximately 3 days ago she started to feel a growing bulge on
her right groin with an associated sharp pain. Her pain was the
worst 3 days ago which was constant and worse with movement
especially when walking. She denies any abdominal pain,
distention, nausea or vomiting or change in bowel habits. She
has been eating well with normal bowel movements and has been
passing flatus. She wanted to come to the emergency room then
however she had guests over so that she decided to come into the
emergency room today although the pain had somewhat subsided.
Upon presentation to the emergency room patient was in no acute
distress, had normal vitals, and normal laboratory work-up. Her
inguinal hernia was attempted to be reduced at the bedside by
the emergency room staff however unsuccessful. Patient reports
that her pain is currently approximately 7 out of 10. As
previously mentioned, she does not have any other associated
symptoms. CHEST (PA AND LAT) showed 1 cm nodular opacity projects over the left lung base may represent
atelectasis, pulmonary nodule is not excluded. Recommend outpatient chest CT
for further assessment.
RECOMMENDATION(S): Outpatient chest CT to assess left lung base nodular
opacity. CT ABD AND PELVIS WITH CONTRAST showed 1. Fat containing right inguinal hernia. Mild stranding of the herniated fat.
2. Pancreatic cystic likely reflecting side-branch IPMN, better evaluated on
recent MRCP at which time repeat MRCP in ___ years was recommended. The patient was diagnosed with Right lower quadrant pain. At the time of discharge, the patient had Incarcerated right inguinal hernia. 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 is a ___ year old female with past medical history
significant for thyroid cancer s/p thyroidectomy, IBS,
diverticulosis, and prior repair of a right inguinal hernia in
___ ___. Patient presented to the emergency
department with complaints of abdominal pain and was found to
have right incarcerated inguinal hernia on imaging. Therefore
acute care surgery was consulted for evaluation and management.
The hernia was partially manually reduced at the bedside and she
was admitted to the inpatient unit for operative planning.
Surgical repair of her incarcerated inguinal hernia with acute
care surgery was then offered however the patient declined
surgery during current admission. She reported she wishes to
have surgery completed by Dr. ___ as an outpatient. Risks of
delaying surgery were discussed at length. This included risk of
worsening pain and/or bowel incarceration, and need for emergent
operation that could require bowel resection. She reported she
was accepting of these risks. She was then given the contact
information for Dr. ___ clinic to schedule her
follow up care.
During this hospitalization, the patient voided without
difficulty and ambulated early and frequently. The patient was
adherent with respiratory toilet and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay. At the time of
discharge, the patient was doing well. She was afebrile and her
vital signs were stable. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and her pain was
well controlled. The patient was discharged home without
services. Discharge teaching was completed, and follow up was
reviewed with reported understanding and agreement.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ female with minimal PMH who presents with
watery diarrhea, BRBPR, and abdominal cramping after running a
5K race.
She is a runner and was participating in a 5K race this morning.
Towards the end of the race, she felt like she needed to have a
bowel movement, but did not think much of it. About two hours
later, she had watery diarrhea, which was soon followed by
BRBPR. She felt dehydrated and tried to drink some water and
gatorade, but vomited all of her PO intake, with no visible
blood in her emesis. Since her symptoms started, she has had
constant lower abdominal cramping. She denies any fevers,
chills, headaches, chest pain, SOB, or cough. She has not had
any vaginal bleeding or discharge.
She runs regularly, and this amount of activity is not unusual
for her. She was feeling fine before the run. She denies any
sick contacts. She has never had similar bleeding before. She
does not have easy bruising or problems with excessive bleeding.
She did have one beer after the race, but no alcohol last night.
She takes Ibuprofen almost daily for shin pain, including 400 mg
before the race, and averaging 400-600 mg daily.
Initial vitals in ED triage were T 96.8, HR 64, BP 122/73, and
SpO2 100% on RA. Exam was notable for guaiac positive brown
stool. Her CBC showed WBC 14.7 with 88.3% neutrophils and Hct
40.3 with MCV 85. Her chemistry panel was notable for bicarb 21,
anion gap 14, and lactate 2.6. Her urinalysis and UCG were
negative.
She was given a total of normal saline 3000 ml and Ondansetron 4
mg IV. She continued to have episodes of diarrhea and feel
unwell. She was admitted to Medicine for further management of
BRBPR and diarrhea. Vitals prior to floor transfer were T 97.9,
HR 68, BP 128/76, RR 16, and SpO2 100% on RA.
On reaching the floor, she reported continued lower abdominal
pain, but no other current symptoms. She had a normal formed BM
the day before the race. Radiology showed 1. Mild wall thickening of the ascending colon, which could be due to
underdistention, however in conjunction with subtle adjacent stranding, a very
mild colitis is a consideration.
2. Small amount of free fluid in the pelvis, which is nonspecific, and maybe
physiologic. The patient was diagnosed with DIARRHEA, NONINF GASTROENTERIT NEC, DEHYDRATION. At the time of discharge, the patient had Primary Diagnosis
Hematochezia
Diarrhea. 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 ___ female with minimal PMH who presents with one day
of watery diarrhea, BRBPR, and abdominal cramping after running
a 5K race, of unclear etiology.
# Diarrhea / BRBPR: Pt's symptoms decreased significantly at
discharge, with little to no blood in the stool (which remained
watery). Very likely lower GI in origin (vomitus was
non-bloody). She was hemodynamically stable throughout her
admission, and HCT was stable at 37-40. No clear cause at this
point, though given absence of prior GI disease, epidemiology,
CT scan, conincident nausea/vomiting, and elevated white count,
an infectious colitis seems most likely. EHEC and C.Diff neg.
Potential culprits could be shigella, salmonella, or
campylobacter (cultures pending), though she denies any obvious
exposures and absence of fever would be somewhat atypical. Other
less likely possibilities include IBD (though she is appropriate
age range) or ischemic colitis (she is young, no risk factors -
exercise-associated ischemic colitis has been described but is
rare and the inflammation in her colon is not at a watershed
area). She was given IVF while not taking POs, her nausea was
controlled with Zofran, and her diet was advanced to regular.
She was told to avoid ibuprofen for the time being given risk of
re-bleeding.
# Depression / Anxiety: Currently stable. Her home Sertraline
was continued.
# OCPs: Her home OCP was continued. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o bipolar disorder on lithium, nephrogenic DI,
breast CA sp mastectomy in ___ who initially presented s/p
mechanical fall on ___ and found to have L subcapital femur
fx. She was admitted to ___ service for ORIF, now POD#1. Her
course has been complicated by AMS with slurred speech,
initially concerning for acute CVA but ruled out by head CT.
Lab work has been notable for leukocytosis (WBC 14),
hypernatremia (Na 148, increased from baseline of 145) and
hypercalcemia (Ca ranging ___.
.
Currently, she is somnolent and unable to provide a history. Radiology showed Left subcapital femur fracture. Radiology showed No evidence of acute disease. Large hiatal hernia, as seen
previously. Pinning of the left hip.
Note is made that the radiologist was not attending the procedure.
Three fluoroscopic views obtained during fluoroscopy were brought to our
review. Note is made that the fluoroscopy time of 82.4 seconds was provided.
Internal pinning of the left hip is noted with no immediate complications.
For precise details, please review procedure report. was done. Radiology showed 1. No evidence of large vascular territorial infarction. Study is suboptimal
due to extensive motion artifact.
2. Prominent sulci and ventricles, likely age-related involutional changes. Evaluation of the patient with mental status changes.
COMPARISON: ___ radiograph.
Large hiatal hernia is projecting over the left lower lung behind the cardiac
silhouette. There are bibasal opacities concerning for interval increase of
areas of atelectasis. Infectious process is less likely but cannot be
excluded. Small bilateral pleural effusions are present. Mild vascular
engorgement is seen, might be consistent with interval fluid load on the
patient. was done. Radiology showed Limited study due to patient motion, the patient refused to
continue with the examination. Grossly, there is no evidence of acute
hemorrhagic changes or areas with acute ischemia. Followup examination is
recommended if clinically warranted under conscious sedation. The patient was diagnosed with FX FEMUR INTRCAPS NEC-CL, FALL FROM BED. The patient was treated with ___: Closed reduction with percutaneous pinning of Left
subcapital femur fracture. At the time of discharge, the patient had Left subcapital femur 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>Primary Reason for Hospitalization:
___ yo F with nephrogenic DI, breast CA sp mastectomy in ___,
admitted with hip fracture sp ORIF on ___. Post-op course
complicated with AMS and slurred speech, hypernatremia,
hypecalcemia, and pt was transferred to medicine.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Radiology showed No acute cardiopulmonary process. Radiology showed There is a large amount of colonic stool. Non-specific, nonobstructive gas
pattern. No pneumoperitoneum. CHEST PORT. LINE PLACEMENT showed No vascular access catheter is identified. There is no focal consolidation,
pleural effusion or pneumothorax. The cardiomediastinal silhouette is within
normal limits. There are no acute osseous abnormalities. Healed left rib
fractures are noted. The patient was diagnosed with Anemia, unspecified. The patient was treated with EGD ___
attach
Pertinent Results:
ADMISSION LABS:
================
___ 10:00AM BLOOD WBC-14.6* RBC-2.37* Hgb-5.9* Hct-20.4*
MCV-86 MCH-24.9* MCHC-28.9* RDW-18.3* RDWSD-58.1* Plt ___
___ 10:00AM BLOOD Neuts-83.6* Lymphs-6.2* Monos-9.5
Eos-0.1* Baso-0.3 Im ___ AbsNeut-12.18* AbsLymp-0.90*
AbsMono-1.39* AbsEos-0.02* AbsBaso-0.04
___ 10:00AM BLOOD Glucose-99 UreaN-36* Creat-0.7 Na-139
K-4.4 Cl-106 HCO3-22 AnGap-11
___ 10:00AM BLOOD ALT-9 AlkPhos-114 TotBili-<0.2
___ 10:00AM BLOOD Albumin-3.0* Calcium-7.7* Phos-2.3*
Mg-2.0. 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>BRIEF HOSPITAL COURSE
=====================
___ Hx ___, severe intellectual disability, recurrent
GIBs, unprovoked DVT on rivaroxaban, p/w acute on chronic anemia
I/s/o likely UGIB. Patient underwent unrevealing EGD (___)
with self-resolution of ongoing bleeding, with course
complicated by propofol infiltrate requiring MICU transfer for
observation and generalized seizure in setting of acute illness
and not receiving home medications
TRANSITIONAL ISSUES
===================
[] HEART MURMUR: Holosystolic murmur best heard at apex noted on
exam, please monitor and consider TTE on outpatient basis.
[] ASPIRATION RISK: Patient continues to demonstrate chronic
risk of aspiration. Recommend ongoing precautions as well as
ongoing discussions with guardian regarding the risks of
complications with aspiration
[] PPI: Patient should complete a 12 week twice a day PPI course
for likely UGIB
ACTIVE ISSUES
=============
# UGIB
He presented with coffee-ground emesis with Hgb 5.5 (baseline
___. EGD ___ was unrevealing. Of note, patient has had
extensive GI work up in the past with negative colonoscopy and
capsule studies in past. His bleeding self resolved and he was
started on lansoprazole 30 BID, and he was discharged with GI
follow-up.
# Seizure
# ___ syndrome
Known history ___ Gastaut syndrome. He was continued on
felbamate 1400 big + phenytoin 150 bid + levetiracetam 750 bid
throughout this admission. He had two breakthrough, generalized
seizures during this admission which were treated with IV
lorazepam. Neurology was consulted and this was believed to be
due to difficulty with medication administration in the ED as
well as in the setting of acute illness and no changes were made
to his medication regimen.
#Aspiration Risk: Patient was evaluated by speech and swallow
service and felt to be at baseline swallowing capacity.
# Propofol IV infiltration
# Arm swelling
Midline infiltrated during propofol bolus prior to EGD. He was
transferred in the MICU and toxicology was consulted. There were
no complications.
CHRONIC ISSUES
==============
# Hx unprovoked DVT - his home anticoagulation was resumed by
the time of discharge after short bridge with heparin gtt to
ensure stability after bleed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman with history of NASH cirrhosis s/p DDLT
(___) on cyclosporine and mycophenolate sodium w/ aortic
conduit complicated by biliary stricture s/p stent placement &
multiple PTBD exchanges, who has had multiple hospitalizations
for recurrent cholangitis who presents with fevers Chest Radiograph showed No acute intrathoracic process. Unchanged small right pleural effusion. DUPLEX DOP ABD/PEL LIMITED showed 1. Patent hepatic vasculature.
2. No significant change in fluid collection adjacent to the falciform
ligament when accounting for differences in technique.
3. Stable mild splenomegaly.
4. Right pleural effusion. Radiology showed Successful exchange of existing percutaneous transhepatic biliary drainage
catheters with new 12 ___ internal external biliary catheter.
Successful exchange of subhepatic 8 ___ abscess drain.
RECOMMENDATION(S): 1. The biliary drainage catheter can be capped when the
output is bilious and nonbloody. The patient was diagnosed with Cholangitis. The patient was treated with Cholangiogram and plasty of biliary tree (___). 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 with history of CAD,
hypertension, diabetes mellitus, NASH cirrhosis with DDLT
(___) (on cyclosporine and mycophenolate) with aortic conduit
complicated by biliary strictures s/p stenting and multiple
percutaneous transhepatic biliary drain exchanges with recurrent
cholangitis, pseudomonas bacteremia, on suppressive cipro, VRE
infections, and left hepatic abscess, who presented with fevers,
and elevated ALP concerning for recurrent cholangitis.
ACUTE ISSUES
#Cholangitis: The patient presented with 1 day of fever &
elevated LFTs concerning for recurrent cholangitis. She did not
have abdominal pain, however she denies ever abdominal pain with
her recurrent cholangitis. Fever occurred while on suppressive
cipro. Previous bile cultures grew MDR pseudomonas sensitive
only to cipro & aminoglycosides as well as VRE. RUQ U/S revealed
persistent perihepatic collection, so likely continued source of
infection. The patient's PTBD was uncapped with significant
drainage to bag concerning for PTBD dysfunction. She was started
on high dose ciprofloxacin and linezolid and ultimately
underwent cholangiogram with dilation of biliary stricture and
subsequent improved flow. The patient remained afebrile
throughout her hospitalization. Her PTBD was capped on ___.
Patient did not spike fever overnight, after capping. ID
consulted and recommended to complete a 2 week course of cipro
750mg BID and linezolid ___ BID (last day ___, followed
by return to ___ 500mg daily for suppression.
CHRONIC ISSUES
#Idiopathic cirrhosis s/p DDLT: With aortic conduit (___) and
stenosis of arterial graft of liver. Patient with multiple
complications. Now more stable, though with continued biliary
strictures.
# Anemia: Patient anemic to 6.9 on ___. Given 1U pRBCs. Likely
related to chronic disease/bone marrow suppression given low
retic index. Anemia improved appropriately. Now stable in 8s.
Iron studies consistent with inflammatory picture (high
ferritin, low iron).
TRANSITIONAL ISSUES
[] Labs on ___: CBC, Chemistries, cyclosporine level.
Should be faxed to Dr. ___ ___, Dr. ___
___.
[] discharge antibiotic regimen: ciprofloxacin 750mg q12h,
linezolid ___ q12h (last day ___
[] once initial antibiotic regimen is complete, should stay on
suppressive ciprofloxacin 500mg daily indefinitely
[] follow-up to be scheduled with ___ for PTBD and JP drain
management
[] discharge hemoglobin: 7.7
[] discharge immunosuppression: Mycophenolate Sodium ___ 360 mg
PO BID, CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H
# CODE: FULL CODE (presumed)
# CONTACT: ___ (sister and HCP), ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of cirrhosis (HCV and EtOH, s/p orthotopic
liver transplant ___ with subsequent recurrence of cirrhosis
(s/p treatment with simeprevir/sofosbuvir ___, presents with
___ days of productive cough, hemoptysis, abdominal pain,
nausea, and fever to 103.
His symptoms began ___ with cough productive of white
bloody sputum (not massive hemoptysis), head congestion, and
diarrhea. On ___, he woke up feeling clammy alternating with
feeling hot, and measured a temperature of 103. He also had
dizziness and continued cough with blood-streaked sputum. His
diarrhea improved after taking Immodium. On ___, he developed
vomiting with all POs as well as pain in his "stomach,"
especially his RUQ and RLQ, which was severe and exacerbated by
movement and coughing. He has never had pain of this type
before. He also reported throbbing pain in his chest, which he
thought was due to vomiting. He was reluctant to present to his
PCP or the hospital due to frequent hospitalizations since liver
transplant, but on ___ his symptoms persisted and he presented
to his PCP. He then presented to the ___ ED. Radiology showed Uncomplicated rush non-targeted liver biopsy. Radiology showed Uncomplicated non-targeted liver biopsy. Radiology showed 1. New 6 mmn nodule in the left upper lobe, potentially infectious or
inflammatory in etiology. Numerous additional pulmonary nodules are stable
dating back to ___ and are consistent with a benign etiology given
long-term stability.
2. Mild interstitial edema and small to moderate right pleural effusion.
Enlargement of the right atrium and ventricle with straightening of the
interventricular septum, suggestive of right heart disease.
3. Trace perihepatic stranding and small volume ascites, incompletely
assessed.
4. Wedge-shaped hypodensity at the splenic hilum, likely perfusional defect
related to timing of contrast.
RECOMMENDATION(S): Follow-up CT thorax in 3 months to reassess the left upper
lobe nodule. The patient was diagnosed with ABDOMINAL PAIN UNSPEC SITE. The patient was treated with ___ Transcutaneous liver biopsy
___ Transcutaneous liver biopsy. 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 ___ with a history of cirrhosis (HCV and
EtOH, s/p orthotopic liver transplant ___ with subsequent
recurrence of cirrhosis (s/p treatment with
simeprevir/sofosbuvir ___, who presented to ___ on ___
with ___ days of cough, hemoptysis, abdominal pain, nausea and
fever, found to have subsequent acute liver rejection.
# Acute liver transplant rejection: Patient was admitted to
___ on ___ with fevers to 103, ___ days of productive
cough, hemoptysis, abdominal pain, nausea, and vomiting of all
POs including his immunosuppressive medications. His LFTs were
elevated on admission and continued to increase during his
hospitalization with peak AST of 144 and peak ALT of 148. His
elevated LFTs were concerning for transplant rejection in the
setting of decreased tacrolimus level. CT abdomen was concerning
for an intraparenchymal process. He then underwent liver biopsy
on ___ with confirmed acute liver rejection. Patient was
started on high dose steroids for 5 days along with tacrolimus
and cellcept, but continued to have elevated LFTs. He underwent
repeat liver biopsy on ___ which showed ongoing rejection. He
then received 7 days of anti-thymocyte globulin (ATG) for
steroid resistant rejection. His LFTs improved with ATG
administration to ALT 82 AST 52, and patient was discharged with
planned repeat liver biopsy and hepatology follow up.
___: Patient had mild ___ during his admission. His creatinine
was elevated to creatinine 1.4 above baseline 1.1-1.2. This
stabilized to 1.3 at discharge after fluid administration. His
___ was thought to be secondary to tacrolimus vs hypovolemia.
# Diabetes: Patient had difficult hospital course with regard to
his glycemic control likely due to steroid administration. He
was at times hypoglycemic and hyperglycemic but was not
symptomatic. He was managed with his home 70/30 and an insulin
sliding scale. His insulin was adjusted per ___ consult
recommendations.
# Viral syndrome: Presented with ___ days of productive cough,
hemoptysis, abdominal pain, nausea, and fever to 103. Likely
viral given improvement off antibiotics. Pt had fever of 103
days prior to seeking care and may benefit from prompt
evaluation next time he is febrile, given his immunosuppression.
Team has counseled patient to seek care immediately with future
fevers. He received guaifenisin/dextromethorphan and benzonatate
for symptomatic relief of cough. He receieved a CT scan for
ongoing mild hemoptysis that showed a small nodule that will
need subsequent follow up with pulmonology.
# Hyponatremia: Patient had Na+ that was initially downtrending,
but resolved with IVF. Patient did not have any associated
symptoms.
# Medications: You have the following new or adjusted
medications:
Tacrolimus 3 mg po twice a day
Mycophenolate Mofetil 1000mg twice a day
Prednisone 20 mg po daily
Valganciclovir 450 mg po daily
Fluconazole 400 mg po daily
Insulin dosing now 24 Units in AM and 26 units in ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a hx of pancreatitis and membranous glomerulonephritis
with nephrotic syndrome and recent admission for hyponatremia
who was at clinic appointment, and had an unresponsive episode. CHEST (AP AND LAT) showed No acute intrathoracic process. CT HEAD W/O CONTRAST showed 1. No acute intracranial process.
2. Age advanced involutional change. The patient was diagnosed with SYNCOPE AND COLLAPSE. At the time of discharge, the patient had vasovagal and orthostatic syncope
hyponatremia. 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 membranous nephropathy and nephrotic syndrome with
progressive proteinuria who presents after syncopal episode with
concern for pulselessness.
# Syncope: By symptoms consistent with vasovagal syncope,
borderline orthostatic by vital signs. Received IVF and was
monitored on telemetry. Though unlikely, was ruled out for ACS.
No tachycardia, pleuritic chest pain, leg swelling or hypoxia to
suggest DVT/PE. Felt better day after. Was persistently
borderline orthostatic per BP and HR but w/o symptoms, likely
due to hypoalbuminemic state resulting in relative intravascular
volume depletion. PO intake encouraged upon discharge
# Chest pain: Noted upon admission, not pleuritic, unchanged.
Acute coronary syndrome ruled out. Resolved by HD 1. Etiology
may be muscle soreness/MSK.
# Hyponatremia: Improved with more IVF to 134.
# Membranous nephropathy/nephrotic syndrome: On prednisone and
cyclosporine, recent 24 hr urine with > 6g protein. No
significant edema on exam, BPs ok and renal function stable.
Continued these medications and associated prophylaxis with
atovaquone.
# T2DM: Recent HbA1c 7.2%. Glipizide held at last admission, and
continued to be held during this admission. Trended FSBG while
inpatient as on prednisone, reasonable control achieved on
sliding scale alone. Will continue to hold glipizide upon
discharge as may potentially be contributing to
SIADH/hyponatremia.
# Anemia: Mild and stable. Trended while inpatient with no other
intervention. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is an ___ with a hx of NSCLC (diagnosed ___, recurrent L
pleural effusion, COPD, hyponatremia who presents to the ED
following outpatient CT imaging showing a complex L pleural
effusion. Pt was in her usual state of healthy until two months
ago. She developed dyspnea and presented to ___, where she
was noted to have a LLL mass, L pleural effusion and
hyponatremia. Biopsy and PET scan revealed Stage IV NSCLC. She
was discharged home and underwent thoracentesis as an
outpatient. CHEST (PA AND LAT) showed Opacity in the left mid and lower lung better assessed on CT performed 1 day
prior with malignancy suspected and probable adjacent pneumonia, with small
left pleural effusion. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had Primary Diagnosis
=================
Loculated pleural effusion
Stage IV non-small cell lung cancer
Secondary Diagnosis
====================
Hyponatremia. 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>Transitional Issues
====================
[]titrate morphine to quell patient's air hunger
[]titrate Ativan to quell patient's anxiety
[]titate bowel regimen
Summary Statement
==================
This is an ___ with h/o Stage IV NSCLC (recently diagnosed),
COPD and hyponatremia, admitted for recurrent complex pleural
effusion on CT and leukocytosis concerning
for pleural infection. The patient's effusion was too viscous to
be drained by IP. After the unsuccessful drainage, the patient
requested no more interventions or escalations in care. Her
symptoms were treated with morphine and Ativan as well as
amox/clav to prevent worsening of her likely pleural infection.
She was discharged to ___ with hospice and comfort focused care.
Active Issues
==============
#Left loculated pleural effusion
#Leukocytosis
The patient presented with a loculated appearing pleural
effusion on the left side, leukocytosis to 36,000, and mild
hypoxemia requiring 2L O2. She was seen in the emergency
department by Interventional Pulmonology who attempted bedside
thoracentesis but was unable to extract any fluid due to its
viscosity. Given the patient's malignancy as well as
significant leukocytosis and fevers, her effusion is likely
malignant in nature with possible super-infection. Patient was
initially started on empiric vancomycin and cefepime. Treatment
options were discussed with the patient and her family, and she
decided that she did not want surgical drainage or any further
escalations in her care. Palliative Care was consulted.
Outpatient hospice services were arranged, and she was switched
to p.o. amoxicillin-clavulanate, given p.o. morphine and
lorazepam for air hunger and anxiety, and discharged to ___
___ for ongoing hospice care.
#Goals of care
During the ___ hospital stay, we had an extensive
conversation regarding her goals of care. She noted that she
would not want to be intubated or have chest
compressions done. She initially thought she would want to be
transferred to the ICU for BiPAP but reconsidered and decided
that it would not be within her
goals of care. We discussed the potential of a VATS surgery
which the patient noted she would not be interested in. The
patient was seen by the thoracic surgeons and declined any
further interventions including thoracentesis. The patient would
like her infection treated if possible with po antibiotics. She
was treated with po morhine for air hunger and po Ativan for
anxiety.
#Hyponatremia
Patient has a history of chronic hyponatremia with sodium around
130. Serum sodium here on presentation was 130 with serum
positives of 265 consistent with hypotonic hyponatremia. Urine
electrolytes were not consistent with SIADH. Likely some
component of hypovolemia as the patient received IV fluids as
well as p.o. intake and sodium stabilized. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman who is otherwise healthy presented with
malaise x 1 month and worsening DOE x 1 week to her PCP and was
found to have pancytopenia after basic workup. She was referred
urgently to ___ where labwork showed WBC 0.4 hbg 4.8
and plt 38. She was started on zosyn and then transferred ___
for further evaluation. Radiology showed Vague left lower lobe heterogeneous density, which may represent infection in
the setting of neutropenia vs overlap of structures. If the patient is able,
dedicated PA and lateral views would be helpful for further evaluation. Radiology showed 1. No lymphadenopathy in the chest, abdomen, or pelvis.
2. Several small solid and ground-glass pulmonary nodules, some of which may
be infectious or inflammatory in etiology. Comparison to prior exams may be
helpful, otherwise, these could be followed.
3. Findings suggestive of anemia.
4. Tiny left renal hypodensity, too small to characterize, but could
represent a small cyst or AML.
5. Gallbladder wall edema, a nonspecific finding - while inflammatory change
(cholecystitis) can cause this appearance, as an incidental finding this could
be related to other systemic processes such as underlying hypoalbuminemia, IV
hydration or drug related effects. Radiology showed AP chest compared to ___, read in conjunction with a torso
CT, ___ at 2:30 p.m.:
Moderate generalized interstitial abnormality with mild bibasilar confluence
has progressed substantially over the course of less than an hour, strong
indication that the explanation is pulmonary edema. There is no appreciable
pleural effusion and no pneumothorax. Findings were discussed by telephone
with Dr. ___ at 4:20 p.m., 1 minute after the findings were recognized. Radiology showed Right internal jugular central venous catheter tip in right
atrium for which withdrawal of 4 cm is recommended. Interval improvement of
pulmonary edema.
A wet read of this report was provided to Dr. ___ telephone on ___ at 20:30. Radiology showed 1. Infrasphincteric phlegmon without sphinteric involvement and without
origin from the anal canal. No discrete fistulous tract or drainable fluid
collection is noted.
2. Nonspecific vascular blush is noted about the posterior wall of the vagina
at the level of the introitus. No discrete fistula is seen. Recommend clinical
correlation of this region. Inflammation can have a similar appearance.
3. Small anterior uterine fibroid is noted.
4. Nonspecific mild-to-moderate amount of pelvic free fluid within the
cul-de-sac.
5. Left-sided Tarlov's cyst is seen. Radiology showed Uncomplicated placement of a 13 ___ Hickman catheter
(triple-lumen) via the right internal jugular vein.
The catheter may be used for infusion therapy immediately.
The tip lies in the right atrium. The patient was diagnosed with OTHER PANCYTOPENIA. The patient was treated with ___ Bone Marrow Biopsy
___ Bone Marrow Biopsy. At the time of discharge, the patient had primary: APML, perianal phlegmon
secondary: neutropenia, 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>___ otherwise healthy admitted to the MICU for pancytopenia of
unclear etiology and neutropenic fever, found on bone marrow
biopsy to have new diagnosis of acute promyelocytic leukemia.
# Acute Promyelocytic Leukemia: She presented with pancytopenia
and bone marrow biopsy showed hypercellular marrow with 55%
neoplastic promyelocytes. FISH study confirmed the diagnosis
with the characteristic t(15:17)(q22;q12) translocation. Given
leukopenia on presentation, she is classified as low-risk APML
and treatment consisted of ATRA with arsenic (added on day 10 of
tx). Her WBC went as high as 60 but she never required
dexamethasone (she had no symotoms of differentiation
syndrome)and never required hydrea. Her counts eventually went
down and she became pancytopenic from the chemo. She was
discharged still neutropenic but no signs of active infection no
fevers (Still on cipro and flagyl) and was advised to all if any
fevers
# Neutropenic Fever: Fever on presentation, likely secondary to
tumor fever or perirectal fistula (described below).
Antibiotics initially started were cefepime/Vancomycin. Flagyl
and fluconazole were added on ___ given perirectal fistula and
antibiotic course was eventually switched to cipro and flagyl
while neutropenic.
# Perirectal Enterocutaneous Fistula/Diarrhea: One week of anal
fissure prior to presentation for which she was using
nitroglycerin topical. Onset of diarrhea (cdif negative) as
inpatient resulted in pain and development of perirectal
fisutula. MRI pelvis showed no abscess. Colorectal did not feel
surgery was necessary. Flagyl was added to vanc/cefepime on
___. Her fistula improved with ___ baths and dilaudid for
pain control and antibiotcs were switched to cipro and flagyl.
# Reaction to Transfusion and IV Contrast:
On ___ she developed hypotension and complaints of pain/burning
at the IV site, lightheadedness and chills/rigors, during the
transfusion of the second of two units of PRBCs. This resolved
with steroids, H1/H2 blockers, and fluids. Blood bank did not
believe that this is a typical transfusion reaction,
specifically no evidence of hemolysis. On ___, she developed
respiratory distress and fever to 103 after IV contrast for CT
that resolved with steroids, H1/H2 blockers, and fluids. Future
transfusions and IV gadolinium contrast infusions went smoothly
with premedication (hydrocortisone, tylenol, benadryl). </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PA AND LAT) showed No acute findings. The patient was diagnosed with Chest pain, unspecified. The patient was treated with N. At the time of discharge, the patient had PRIMARY DIAGNOSES
=================
GERD
Chest Pain. 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>TRANSITIONAL ISSUES
===================
[ ] A1C 7.0. Patient on Invokana only. Patient would benefit
from additional oral hypoglycemic to lower A1C further as an
outpatient.
[ ] Patient started on atorvastatin 40mg daily for ASCVD score
>10% (12%). Please monitor for tolerance.
[ ] Patient with close cardiology follow-up with Dr ___.
Recommend dobutamine stress test to further evaluate cardiac
function.
BRIEF HOSPITAL COURSE
======================
Ms. ___ is a ___ year old woman with history of AFib,
severe asthma, DM, HLD, and iron deficiency anemia who presented
with chest pain during IV iron infusion found to have possible
ST depressions on EKG, without elevated troponins initially
started on heparin gtt. However, patient then described more GI
symptoms with indigestion, belching, N/V, and acid reflux
relieved with Tums and Zofran. Heparin was discontinued and
patient continued to be chest pain free even with
ambulation/exertion, making GERD more likely and cardiac
pathology less of an acute concern.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Neurology at bedside for evaluation after code stroke activation
within: 4 minutes
Time (and date) the patient was last known well: 22:00 on
___ CT HEAD W/O CONTRAST showed 1. No evidence of intracranial hemorrhage.
2. Possible very subtle loss of gray-white differentiation in the left MCA
territory is equivocal but could represent early ischemic changes. Of note
MRI, would be more sensitive for detection of acute ischemic changes.
COMMENT ON ATTENDING REVIEW:
There also appears to be a hyperdense left MCA. Findings are concerning for
acute ischemia. Recommend MRI for further evaluation. Radiology showed No evidence of acute fracture or traumatic malalignment. Of note, the anterior
inferior corner of C7 was not included in the study. If high clinical concern
for lower cervical spine injury, could repeat to include the C7 level. MRI AND MRA BRAIN AND MRA NECK showed Acute infarction in the left caudate putamen and temporal lobe with
hemorrhagic transformation. Lack of flow related enhancement beyond the
proximal left M1 MCA. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the patient has received a Dobbhoff
catheter. The catheter is in correct position in the middle to distal parts of
the stomach. No evidence of complications. The lung volumes have decreased.
Mild fluid overload but no overt pulmonary edema. Video oropharyngeal fluoroscopy swallowing study. showed Aspiration with thin nectar consistency.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations. CT HEAD W/O CONTRAST showed Evolving subacute infarct involving the left basal ganglia and temporal lobe
with stable hemorrhagic transformation. CT ABD AND PELVIS WITH CONTRAST showed 1. No evidence malignancy or in the abdomen or pelvis.
2. CT chest reported separately. Evaluation of the patient with large right MCA
stroke, suspicion for occult malignancy.
COMPARISON: CT of the chest from ___.
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen after administration of IV contrast. Axial images were reviewed in
conjunction with coronal and sagittal reformats.
FINDINGS: Large goiter originating from the left thyroid lobe is
demonstrated, and appears to be overall similar to the prior study except for
one larger or new nodule demonstrated in its lower right portion, 5:7,
approaching 2.2 cm in diameter. The goiter provides pressure of the left and
posterior aspect of the trachea with mild-to-moderate narrowing of the
tracheal lumen. The NG tube tip is in the stomach. Thickening of the distal
esophagus is unchanged, most likely due to small hiatal hernia, unchanged
since the prior study.
No mediastinal, hilar or axillary enlarged lymph nodes demonstrated with small
hilar lymph nodes being unchanged as compared to previous imaging, interval
stability of the aortopulmonic lymph node, approaching 11 mm.
Heart size is enlarged. Predominantly, there is an enlargement of the left
atrium up to 5.6 cm in the anterior posterior diameter. No pleural or
pericardial effusion is present.
Airways are overall patent until the subsegmental level bilaterally.Assessment
of the lung parenchyma reveals biapical scarring. Lingular nodule, 6, 159, is
7.6 x 9 mm, new and although most likely represent atelectasis, should be
reassessed in 10 weeks for documentation of stability and to exclude the
remote possibility of a neoplasm.
No lytic or sclerotic lesions worrisome for infection or neoplasm
demonstrated. Wedge compression fractures are demonstrated at the level of
T8-T10 as well as L2. was done. Radiology showed Aspiration with thin liquid and nectar thick liquids was demonstrated.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations. CT HEAD W/O CONTRAST showed Evolution of Re- demonstrated subacute infarction with hemorrhagic
transformation involving the left basal ganglial and temporal lobe. No new
areas of hemorrhage or large infarction. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT, ATRIAL FIBRILLATION. The patient was treated with NA. At the time of discharge, the patient had - ACUTE ISCHEMIC STROKE with hemorrhagic conversion
- atrial fibrillation
- hypertention
- hyperlipidemia. 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>Transitional Issues:
[ ] Pt needs to have a repeat CT chest in 10 weeks to follow up
her prior CT findings
[ ] Pt is on day 2 of a 7 day course of IV ceftriaxone (started
___
[ ] Pt should continue to undergo speech and swallow evaulation
with the hopes of advancing her diet further.
[ ] Please monitor the patient for urinary retention with
Q-shift bladder scans as this was an issue for the patient early
on the her stay.
Ms. ___ is an ___ yo woman with PMH significant for afib on
coumadin, HLD, depression and hypothyroidism who presented as a
code stroke, found to have a left MCA ischemic stroke with
aphasia and R sided plegia. The patient had hemorrhagic
transformation of the infarct - anticoagulation was held.
Etiology of stroke is likely afib although patient was
supratherapeutic on coumadin (initial INR 3.3). She underwent a
CT of the chest/abd/pelvis to assess for occult malignancy which
was negative. She was initially monitored in the neuro ICU and
remained stable with slow improvement in her sytmptoms. Her
course was complicated by afib with RVR which corrected with
increased doses of metoprolol. She diet was advanced very slowly
with the help of speech therapy. She was started on Dabigatran
on ___ - repeat head CT 48 hours later was stable. HgbA1c 5.7;
LDL 153.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2? ()
Yes - (x) No
(patient therapeutic on coumadin)
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (x) No
(patient therapeutic on coumadin)
4. LDL documented (required for all patients)? (x) Yes (LDL
=153) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
**10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - () N/A</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with low factor 11 levels, now with a 1 day h/o mild RLQ
abdominal pain that initially started in the epigatric area.
She had an outpatient CT scan which was concerning for acute
appendicitis. She denies any fevers, but has had some chills.
She has had some mild nausea, without emesis, as well as
bloating. She denies any other symptoms, and has never had this
type of pain before. She reports that she is currently hungry. CT ABD AND PELVIS WITH CONTRAST showed Acute uncomplicated appendicitis with an appendicolith.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 7:11 pm, 5 minutes
after discovery of the findings. The patient was diagnosed with Unspecified acute appendicitis. At the time of discharge, the patient had Acute Appendicitis. 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 F who presents to the Emergency
Department with epigastric abdominal pain and underwent
outpatient CT scan which was concerning for acute appendicitis.
The patient was hemodynamically stable, afebrile, and white
blood cell count was 5.1. Discussed options of possible
operative intervention versus
non-operative management with the patient. Reviewed risks and
benefits of both options, and patient decided to pursue
non-operative management with antibiotics. On HD2 diet was
advanced to regular with good tolerability. Antibiotics were
transitioned to oral.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. Follow up was scheduled to discuss
future/interval appendectomy. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of HTN, HLD, Depression admitted for pain
control with MRI/CT highly suggestive of metastatic disease,
etiology unknown. MRI of spine done at OSH on ___
revealed multiple lesions c/w mets. Patient also has severe
cutaneous and sub-cutaneous nodules suspicious for malignancy.
Lesions are located over RUQ of abdomen, lower left back, right
inner thigh - states she was told they are lipomas.
Non-painful, non-purulent. + history of subjective fevers and
weight loss. + headaches, + weakness in lower extremities - no
bowel or bladder incontinence or falls. No chest pain,
palpitations, SOB, cough, abdominal pain, N/V/D,
dysuria/hematuria. Regarding health screening, no colonoscopy,
last mammogram in ___.
.
In the ED, VS 98.5 123 167/91 20 98%, pain 6. Given morphine and
ativan. Chem 7, LFTs, CBC WNL except for WBC of 12.0 (N:81.2
L:11.3 M:5.0 E:1.5 Bas:0.9). Lactate 1.4. CT chest/abd/pelvis
performed just prior to arrival to the floor, negative for PE -
previous concerning bony/abdominal wall lesions noted.
.
On the floor, patient triggered for sustained HR in 130's,
asymptommatic, VSS. Pain ___ located in lower back.
Otherwise no complaints. On O2, no subjective SOB. Radiology showed 1. No pulmonary embolism.
2. Left lower lobe spiculated lung mass measuring 4.2 x 5.3 x 7.7 cm,
concerning for a primary lung malignancy. The spiculated mass runs along the
descending thoracic aorta with its linear medial component approximately 8.7
cm in craniocaudal dimension. There are two small right pulmonary nodules,
possibly representing metastases measuring 6 and 2 mm.
3. Osseous metastatic disease with mixed lytic and sclerotic lesions.
4. Enhancing subcutaneous nodules concerning for metastases.
5. Bilateral adrenal nodules, likely metastases.
6. 8mm inter-polar right renal lesion is incompletely evaluated on this
examination. This does not measure fluid density. When clinically
appropriate, further characterization with ultrasound may be beneficial.
Additional simple left renal cyst and too small to characterize lesions.
7. Significant aortic atherosclerotic disease and extensive coronary artery
calcifications. Radiology showed 1. Right occipital calvarium lesion, likely representing bony metastasis.
2. Left frontal parasagittal mass, most likely representing a meningioma.
3. There is no evidence of intraparenchymal metastatic disease and no acute
findings, such as hemorrhage or infarct. The patient was diagnosed with MALIGNANT NEOPLASM NOS, BACKACHE NOS, HYPOTHYROIDISM NOS. The patient was treated with Fine needle aspiration
Radiation therapy. At the time of discharge, the patient had Primary Diagnosis: Metastatic lung cancer
Secondary Diagonsis:
Hypertension
Low Back Pain
Depression
Hypothyroidism
Eczema
Hyperlipidemia. 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 history of anxiety and hypertension admitted with
worsening back pain in setting of concerning lesions on MRI/CT
for metastases. Hospital course was notable for diagnosis of
metastatic nonsmall cell carcinoma of the lung and radiation
therapy to metastatic bone lesions.
.
#Metastasic nonsmall cell lung cancer: Presented with widely
metastatic cancer with lesions in the lung, adrenals, skin as
well as diffuse bony disease. FNA of the RUQ subcutaneous nodule
demonstrated poorly differentiated non-small cell lung cancer.
Hematology oncology was consulted who recommended outpatient
oncology follow up which has been scheduled for ___. During this admission, she underwent mapping and
palliative XRT to the rib/sternum and L fibula/ilium. MRI of the
brain showed mets to the skulls, a meningioma, without
intraparenchymal disease.
.
# Bone Pain: From metastatic disease. She was started on
standing oxycontin and acetaminophen as well as prn oxycodone
and ibuprofen for pain control. She was additionally given a
lidocaine patch for her sternal pain. Her pain medications were
titrated until she was no longer requesting all of her prns and
was sleeping comfortably through the night. She appeared
comfortable on daily examinations and would only say her pain
was not well controlled if directly asked. She was discharged on
oral and topical pain control and advised to contact her PCP
___ Oncologist should she require adjustments to her home
pain medication regimen.
.
# Hypoxia: On admission, she was noted to be hypoxic, likely
related to her baseline decreased lung function (chronic
smoker), NSCLC with possible associated atelectesis, and
possibly decreased inspiratory volumes ___ sternum and rib pain
(bony metastasis). Physical therapy worked with the patient and
noted she was 84% on room air when sitting. She was discharged
on home oxygen ___ at rest.
.
# Tachycardia - She had sinus tachycardia on admission. CTA did
not show PE. Her tachycardia was believed to be from pain and
anxiety, possible hypermetabolic state ___ cancer. She was
started on pain control as above and her lisinopril was switched
to propanolol TID both for pain control and possibly better
control of her anxiety symptoms.
.
# Social Issues/Depression: The patient and brother are having a
very difficult time dealing with her new diagnosis and reduced
functional status. The patient has been nervous about being
discharged home, but physical therapy felt that she did not
require rehab and she has been arranged to have services at home
(she will be staying with a family friend). ___, her
brother has been staying at a local hotel and they have been
resistant to her going there. She lives in ___ but
was not interested in having her care in ME. Lastly, Ms.
___ was given the number for psychiatry as she is having a
difficult time coping with her diagnosis and speaking to someone
or starting on antidepressants may help her.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ORTHOPAEDIC SURGERY CONSULT NOTE Radiology showed 1. No acute cardiopulmonary process.
2. Angulated appearance of the left lateral third rib, which could be acute in
nature. Correlation with prior imaging or dedicated rib series is recommended
as clinically indicated.
3. Other chronic appearing rib deformities as described above. Radiology showed Pelvic fractures as seen on prior CT. CT CHEST W/O CONTRAST showed 1. Minimally displaced fractures at right lateral 4, 5, and 6 ribs are of
unknown chronicity but likely chronic. To be correlated clinically.
2. 2 pulmonary nodules measuring up to 10 mm are identified in the right lower
lobe. Please see recommendation below.
3. Mild pulmonary emphysema.
4. Bilateral gynecomastia.
RECOMMENDATION(S):
1. For incidentally detected multiple solid pulmonary nodules bigger than
8mm, a CT follow-up in 3 to 6 months is recommended in a low-risk patient,
with an optional CT follow-up in 18 to 24 months. In a high-risk patient, both
a CT follow-up in 3 to 6 months and in 18 to 24 months is recommended.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___ Radiology showed Bilateral superior and inferior pubic ramus fractures with comminuted right
acetabular fracture and pelvic sidewall hematoma. PELVIS (AP, INLET AND OUTLET) showed Multiple intraoperative images were obtained during right acetabular fracture
ORIF. Please refer to operative report for further details. The patient was diagnosed with Oth fracture of right pubis, init encntr for closed fracture, Unspecified fall, initial encounter. The patient was treated with Open reduction and internal fixation of right acetabular
fracture; ___ ___.. At the time of discharge, the patient had right, closed acetabular 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>Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right acetabular fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable. The patient was monitored for
withdrawal on a CIWA scale given his history of ethanol use and
required no pharmacologic measures for withdrawal and showed no
hemodynamic instability secondary to withdrawal.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing in the right lower extremity
extremity, and will be discharged on enoxaparin for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a nice ___ year old man with a history of coronary
artery disease, diabetes mellitus, hyperlipidemia, hypertension,
and prior NSTEMI. He was admitted to ___ for type
I NSTEMI, found to have 3 vessel CAD with 90% thrombotic
stenosis of proximal RCA s/p POBA to proximal and mid-RCA with
plans for future CABG, who was discharged from ___
___ and
now presents with unstable angina. He initially presented to
___ on ___, with chest pain and found
to have NSTEMI. Cardiac cath ___ was notable for 3 vessel CAD
(90% stenosis RI, 90% stenosis in distal LAD, 80% stenosis in
OM1, 70% stenosis in mid LCx, 90% stenosis in proximal RCA, 70%
mid-RCA, and sub-occlusive stenosis in distal RCA). He underwent
balloon angioplasty of proximal and mid RCA, with plan for CABG
in ___ weeks. He was discharged from ___ on ___.
Since then, he had been doing well and was chest pain free until
this morning at around 6:30AM. He reports recurrence of
intermittent left-sided, chest pressure at rest with radiation
to
R arm and axilla and associated shortness of breath. This is
similar to prior NSTEMI symptoms. On EMS arrival, he was treated
with ASA 324mg and SL nitro with improvement in symptoms. He was
taken to ___, where EKG was notable for T wave
inversions in inferior leads and elevated Trop I of 1.17
(although decreased from prior 6.69 on ___, 16.60 ___. CHEST (PRE-OP PA AND LAT) showed In comparison with the outside studies of ___, there is little
overall change. Cardiomediastinal silhouette is within normal limits. There
is diffuse prominence of reticular markings bilaterally, with hyperexpansion
of the lungs and flattening hemidiaphragms, worrisome for chronic fibrotic
interstitial lung disease. No evidence of acute focal consolidation or
definite vascular congestion.
Large hiatal hernia is seen. VEIN MAPPING-Lower extremities showed The great and small saphenous veins are patent bilaterally. Please see
digitized image on PACS for formal sequential measurements. CHEST PORT. LINE PLACEMENT showed Trace right apical pneumothorax
Left lower lobe atelectasis and small pleural effusion. CHEST (PORTABLE AP) showed In comparison with the study of ___, the endotracheal tube and
nasogastric tube have been removed. Left chest tube remains in place and any
residual pneumothorax would be extremely small.
Little overall change in the appearance of the heart and lungs. CHEST (PORTABLE AP) showed Comparison to ___. With the chest tubes on waterseal, there is now
a 1 cm right apical pneumothorax. No evidence of tension. No change in
appearance of the lung parenchyma and the heart. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___ through ___.
Mild postoperative pulmonary edema after ___ has improved since ___.
No pneumothorax. Small left pleural effusion is stable or improved. Left
lower lobe atelectasis is moderate. Normal postoperative appearance the
cardiomediastinal silhouette. Heavy asbestos related calcified pleural plaque
noted.
Right jugular line ends in the low SVC. Midline and at least one pleural
drain in place. CHEST (PORTABLE AP) showed Lungs are low volume with stable interstitial edema. Right IJ line is
unchanged. Patchy parenchymal opacity in the left lower lobe is unchanged.
Lungs are low in volume. Small bilateral effusions left greater than right
are stable. No pneumothorax. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___ through ___.
Mild pulmonary edema unchanged since ___. Small left pleural effusion is
likely. No pneumothorax. Normal postoperative appearance cardiomediastinal
silhouette.
Heavy asbestos related pleural calcification.
Right jugular line ends in the low SVC. Chest radiograph, portable AP upright. showed No short-term change in very small right apical pneumothorax. CHEST (PA AND LAT) showed Right internal jugular line tip terminates at the level of mid to lower SVC.
Heart size and mediastinum are stable. Left sided pacemaker leads terminate
in right atrium and right ventricle. There is interval improvement in
pulmonary edema and better aeration of the lung fields.
Bilateral basal opacities and interstitial lung disease as well as calcified
pleural plaques are re-demonstrated. The patient was diagnosed with Chest pain, unspecified, Athscl heart disease of native coronary artery w/o ang pctrs. The patient was treated with ___ - Aortic valve replacement with 25 mm Epic supra
valve. Coronary artery bypass grafting x 3, left internal
mammary artery graft to left anterior descending, reverse
saphenous vein grafts to the ramus intermedius and the posterior
descending artery.. At the time of discharge, the patient had Coronary Artery Disease
- IDDM
- Hypertension
- Dyslipidemia
- Glaucoma
- Prostatic CA s/p XRT
- Basal cell carcinoma
Past Surgical History:
- s/p MOHs surgery (___)
- left inguinal hernia repair (strangulated per pt but no bowel
resected)
Past Cardiac Procedures:
- CAD s/p proximal LAD PCI (___) after positive stress test for
angina symptoms
- NSTEMI (___) with coronary angiogram showing 3 vessel CAD
(90% RI, 90% distal LAD, 90% ___ RCA s/p POBA. 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>He was admitted on ___ and underwent routine preoperative
testing and evaluation. He remained stable and was taken to the
operating room on ___. He underwent aortic valve
replacement and coronary artery bypass grafting x 3. Please see
operative note for full details. He tolerated the procedure well
and was transferred to the CVICU in stable condition for
recovery and invasive monitoring.
He weaned from sedation, awoke neurologically intact and was
extubated on POD 1. He was weaned from vasopressor support. Beta
blocker was initiated and he was diuresed toward his
preoperative weight. He remained hemodynamically stable and was
transferred to the telemetry floor for further recovery. He was
started on
beta blockers, though these were ultimately held. He was
initially A-V paced, though eventually the atrial lead stopped
sensing and pacing. On ___ he had ___lock,
each 7 seconds in duration. He reportedly had loss of
consciousness with one of these events. EP was consulted and he
underwent PPM placement on ___. He developed delirium
following this procedure. Geriatrics was consulted. Olanzapine
initiated with good effect. Delirium resolved and olanzapine
discontinued. Beta blocker resumed.
He was evaluated by the physical therapy service for assistance
with strength and mobility. By the time of discharge on POD 7 he
was ambulating freely, the wound was healing, and pain was
controlled with oral analgesics. He was discharged home in good
condition with appropriate follow up instructions.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F w/ hx of HTN, LHD and recent C2 decompression with
C1-C3 laminectomy/fusion on ___ who was sent in from rehab
facility due to altered mental status. Pt was in her usual state
of health until this morning when she was found to be confused.
Pt does promote feeling confused at the time. She and the
facility both deny a recent hx of fever, chills, or any
constitutional symptoms. She has been constipated and promotes
___ lower abdominal pain over this time. No hx of diarrhea. She
did have episode of hematuria yesterday but denies any dysuria
or increase freq. Denies any CP, lH, dizziness, or SOB. No pain
at surgical site. Denies any weakness. Continues to have b/l
lower extremity numbness which she says is her baseline and
unchanged.
In the ED, initial vitals were: 97.4 68 118/51 24 97%. She was
noted to be A&Ox3 but agitated. Labs were notable for UA with
pyuria, mod bacteria, large ___, blood, and nitrites. No
leukocytosis on CBC with stable H/H. Chem 7 notable for K+ of
5.5. A CT head was normal. CXR was normal. She was started on
CTX for UTI.
On the floor, she no longer feels confused and has no concerns.
She continues to promote mild lower abdominal/suprapubic
discomfort. Radiology showed Minimal left basilar atelectasis. Radiology showed No evidence of acute intracranial abnormality. MRI is more sensitive in the
detection of acute stroke. The patient was diagnosed with URIN TRACT INFECTION NOS, HYPERTENSION NOS. At the time of discharge, the patient had Primary Diagnosis:
Urinary Tract Infection
Toxic Metabolic Encephalopathy
Stage 1 Sacral decubitus
Secondary Diagnosis
Status Post C1-C3 laminectomy/fusion. 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 a history of HTN, hyperlipidemia and recent C2
decompression with C1-C3 laminectomy/fusion on ___ who was sent
in from rehab facility due to altered mental status and was
found to have urinary tract infection.
# Altered mental status: Patient presented with AMS which
resolved by the time of admission. Most likely secondary to
urinary tract infection and large doses of narcotics and
diazepam following surgery. Patient remained A&Ox3 entire
admission. Previously prescribed oxycodone was discontinued and
she was transitioned to standing tylenol with as needed
tramadol. She will also use ibuprofen as needed on a full
stomach. The risk of NSAIDS were discussed with patient but she
notes they offer the greatest relief. She was guaiac negative
this admission. Hematocrit should be monitored closely while
taking this medication. Patient should not take aspirin while
taking NSAIDS.
#UTI: Urine analysis was strongly suggestive of infection with
moderate bacteria and large ___ and nitrites. Urine culture grew
pansensitive entercocci. She was treated with a 7 day ___ of
amoxacillin for sensitive enterococcus. Infection most likely
secondary to foley placements during recent hospitalizations.
#Hx of C2 decompression with C1-C3 laminectomy/fusion: Incision
appeared clean and without signs of infection. Patient noted
extreme discomfort with ___ j collar. She was evaluated by
orthopedics who arranged for a new, smaller collar. Patient's
pain regimen was modified this admission by holding oxycodone
and adding tramadol due to AMS. She will also take ibuprofen as
needed (risks and side effects discussed). She will continue to
follow up with ortho as an outpatient. Patient deferred going
back to a rehab facility and will continue ___ at home.
#Weakness: Rehab facility noted weakness prior to admission but
patient found to have ___ strength on exam without focal
deficits. Neuro evaluated earlier this week without concern. MRI
without new findings.
#Anemia: Most likely secondary to chronic disease with high
ferritin and low TIBC. Guaiac negative this admission. Has been
downtrending over the last several admissions and should be
monitored going forth. Recommend outpatient hematocrit within
the next ___ days to ensure stability.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ yo female past medical history significant for
Bechets vasculitis (on cyclophosphamide and prednisone) admitted
to ___ following concern for epidural abscess in setting of
increased low back pain following and LP
done approximately 3 weeks prior. The LP was done to r/o
Guillain
___ syndrome. Further review of imaging showed no evidence of
epidural abscess, however there is evidence of a subacute
fracture of L4 vertebral body height loss and mild spinal
stenosis. A chronic fracture at S1 was also observed. Plan to
brace ___ for management of the compression fracture. CHEST (AP AND LAT) showed No acute intrathoracic process. MRI lumbar spine without and with intravenous contrast showed 1. Subacute fracture of L4 with mild to moderate vertebral body height loss
and mild spinal canal stenosis. Enhancement of the anterior epidural space at
L4 is either due to prominence of the venous plexus or a small epidural
hematoma. Recommend CT scan for further evaluation
2. Chronic fracture of S1 without height loss.
NOTIFICATION: The discrepancy between the wet read and final read was
discussed with ___ of the Neurosurgery service at approximately
11:00 ___. The patient was diagnosed with INTRASPINAL ABSCESS. At the time of discharge, the patient had Subacute L4 compression fracture with no canal compromise
Pain. 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 neurosurgery. Further review of the
MRI showed no abscess and Neurosurgery was not concerned for
epidural hematoma. A subacute L4 compression fracture was noted
and a Aspen quick draw brace was ordered. Patient complained of
pain and required IV Dilaudid Q2hrs. Neurology continued to
follow. On HD 2, a social work consulted was called for patient
coping. Pain services was consulted and recommendations were
made after speaking with the ___ pain MD. ___ was
curbsided and felt that any steroid recommendations could be
made outpatient by the ___ rheumatologist. Neurology
signed off. Physical therapy worked with the patient and cleared
her for home. Patient refusing discharge until pain management
rediscussed. A pain managment was made and agreed upon.
On ___ IV dilaudid was discontinued. Her pain was well
controlled on oral pain regimen. She was discharged home with
instructions for follow and pain managment. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo W with no psychiatric hx, MMP, including s/p R. MCA
stroke, CAD, DM, COPD, recent TKR, was sent from ___ at
___ for a change in mental status. Per
records from rehab, on ___ at 8 am pt requested to go home,was
refusing exam, medications, and when she was told that she
needed to wait for MD to see her she called ___. In addition,
she was screaming, verbally abusive and combative with staff.
Expressed paranoia that "you are just using my Medicare". Pt
sent to ED for eval.
In ED pt seen by psych. Was pleasant and cooperative. Did not
remember above incident.
On arrival to floor pt again pleasant and cooperative. Does not
know why she was brought to hospital. States she needs to go
home so she can pay her rent. No complaints. Radiology showed 1. No acute intracranial process.
2. Encephalomalacia from prior right MCA territorial infarct.
3. Extensive sinus disease as above appears acute. Radiology showed No significant change compared to prior study with
redemonstration of mild hyperinflation and global increased interstitial
markings most compatible with emphysema. Radiology showed No fracture. Revision total arthroplasty in place without
hardware complication. The patient was diagnosed with URIN TRACT INFECTION NOS, SEMICOMA/STUPOR, HYPERTENSION NOS. At the time of discharge, the patient had Primary:
Delirium
Urinary Tract Infection
Secondary
Rheumatoid Arthritis
-CAD s/p RCA stent ___, patent on ___ cath
-mild dCHF (EF 60% in ___
-COPD (2L NC at night only)
-CVA ___ (left sided weakness, speech affected)
-PVD/PAD
-DM type 2
-HTN
-AAA (MRI ___- 3.4cm, ___ 3.5cm)
-Right lacunar infarct (___) - on coumadin, then stopped ___
-erosive gastritis, angiodysplasia (Normal EGD ___
-diverticulosis, angioectasias on CSPY ___
-migraines manifest as left facial numbness
-Lumbar stenosis and cervical spondylosis, C5-7 radiculopathy
-OSA
-Neurologic bladder on daily bactrim per urol
-Depression/Anxiety
-Recurrent UTIs
-Anemia
-Hyponatremia (baseline Na low 130s)
-Right total knee 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>A/P: ___ yo W with MMP but no psychiatric hx, sent from ___ at
___ for a change in mental status and
resistance to care. This is most like secondary to a UTI.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant ___ w/ HTN, non-ischemic CMY (LVEF
45-50% TTE ___, LBBB, and recently diagnosed NSCLC (___) w/
brain mets s/p CK, on ___, course c/b afib
w/
RVR requiring ICU, subsegmental PE now on enoxaparin, who p/w
persistent n/v after her C8 on ___. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. A 1.4 x 1.3 cm rim enhancing metastasis in the left cerebellar hemisphere
has increased in size, previously 1.2 x 1.1 cm. Smaller enhancing metastases
in the left cerebellar hemisphere and lateral right temporal lobe are
unchanged. No new intra-axial lesions identified.
2. Metastatic infiltration of the left sphenoid wing and left frontal bone has
increased since the prior examination. Evidence of adjacent left temporalis
muscle involvement is new. Extensive left cerebral pachymeningeal thickening
and enhancement is not appreciably changed. CT ABD AND PELVIS WITH CONTRAST showed 1. No evidence of acute intra-abdominal process.
2. Sclerotic lesions in the L4 vertebral body and right iliac bone consistent
with known metastases.
3. Please refer to separate report of CT chest performed on the same day for
description of the thoracic findings. CT CHEST W/CONTRAST showed Progressive right upper lobe collapse since PET-CT on ___ due to
persistent obliteration of the right upper lobe bronchus by the likely growth
of the large right hilar mass. There may be a component of postobstructive
pneumonia.
Several scattered lung nodules are relatively unchanged in size since ___.
No new or growing lymphadenopathy or osseous lesions. The patient was diagnosed with Adult failure to thrive. At the time of discharge, the patient had Nausea and vomiting
Pancytopenia due to chemotherapy
Febrile neutropenia
Preseptal cellulitis
Hypocalcemia
Hypophosphatemia
Metastatic non small cell 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>___ is a ___ year old woman with HTN, non-ischemic
CMY (LVEF 45-50% TTE ___, LBBB, and recently diagnosed NSCLC
(___) w/ brain mets s/p CK, on ___, prior
course c/b afib w/ RVR requiring ICU, subsegmental PE now on
enoxaparin, who p/w persistent N/V after her C8 on ___, found
to have likely L preseptal cellulitis, neutropenia,
hypocalcemia, hypophosphatemia, and mild progression of disease
on re-staging scans.
# Nausea, Vomiting, Dehydration, Weakness
# Pancytopenia / moderate neutropenia
# Severe malnutrition
Patient presented with nausea, vomiting, and poor PO intake
during cycle 8 of chemotherapy. Symptoms improved with
supportive treatment, so suspect they were primarily driven by
chemotherapy, although likely also has some baseline symptoms
from malignancy as well. Low suspicion for pembro-related
autoimmune hypophysitis based on cortisol and TSH. By discharge
was tolerating regular diet with PRN PO antiemetics. Also
changed dronabinol from PRN to scheduled per oncology
recommendations, as this has helped with appetite. Seen by
nutrition and given suppleents.
#Borderline febrile neutropenia
#Pancytopenia
#Suspected L preseptal cellulitis
Developed periorbital erythema and edema within 24 hours prior
to arrival on the floor, suspected to be preseptal cellulitis.
Exam/history reassuring against orbital involvement. Had temp to
100.5x1 overnight ___ and then developed severe neutropenia
___ with nadir ANC in 300s. ANC >500 since ___. Continued on
vanc/cefepime through discharge, and then then transitioned to
bactrim/amoxicillin to complete 7 day course from recovery of
ANC (___). Periorbital erythema improved rapidly on
treatment.
# NSCLC - progressive
Treatment history as per above, currently cycle 8 of
chemotherapy. Unfortunately CT C/A/P and MRI brain notable for
mild progression of one cerebellar met and left scalp/bony met,
as well as progression of primary with worsening
post-obstructive atelectasis. Other disease mostly stable. She
has a persistent cough and intermittent headache. As noted
above, it is unclear to what degree nausea/vomiting and poor PO
intake have been related to her mets vs chemo. Discussed with
medical oncology, neurooncology, and radiation oncology during
the admission, and Dr. ___ oncology met with patient to
discuss goals and future plans. Patient is uncertain whether she
will consider any second line chemotherapy. She will be
following up closely in oncology, neurooncology, and rad-onc.
Steroids were considered for symptoms, but ultimately not given
since her symptoms were mostly resolved and since per rad-onc
her lack of edema makes steroids less likely to help.
# Hypocalcemia:
Severe hypocalcemia initially, likely from zometa ___.
Initially required IV repletion. Trialed on higher doses of tums
1000 mg PO TID and calcium levels were maintained in the
low-normal range.
# Hypophosphatemia:
Moderate hypophosphatemia likely from zometa, improved with
neutraphos. Stopped neutraphos ___, and phos levels remained
stable.
# Afib/HTN/cardiomyopathy:
- continued on home metoprolol (fractionated) and amiodarone;
metoprolol intermittently being held for soft BP, so discharged
on 25 mg instead of 50 mg
# Subsegmental PE:
Lovenox continued however the dose was reduced from ___ID
to ___ID based on her weight of ~60 kg.
# ___: PPI continued
# Headaches: overall improved
# free T4 elevation
TSH lower normal range. Would recheck as outpatient
===================================
===================================
TRANSITIONAL ISSUES
- needs close monitoring of calcium and phos
- has follow-up in neuroonc, rad-onc, and onc
- recheck thyroid studies as outpatient
===================================
===================================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with h/o CAD, CHF, a-fib, AVR, ? prior CVA, DM, HTN, HLD
and recent admission (___) for MSSA bacteremia that
was c/b ___ felt to be due to AIN at the time, requiring 2
sessions of HD, prednisone tx (Cr improving at d/c), NSTEMI,
possible stroke or recrudescence of an old infarct, afib w/ RVR
requiring CV and a new onset rash at time of discharge who is
brought from the ___ for an evaluation of worsening ___ edema,
worsening rash and confusion. Radiology showed Low lung volumes. Cardiomegaly without pulmonary edema. Radiology showed 1. No acute intracranial process.
2. Chronic atrophy, microvascular changes, and multifocal infarcts.
3. Mild pansinus mucosal thickening, with resolution of prior left sphenoid
air-fluid level. Color Doppler and pulse-wave Doppler images were
obtained. Note is made that this is a very limited study of the right kidney
only as the patient declined the completion of the exam. This exam is also
limited due to the patient's inability to hold his breath. Arterial waveforms
are seen in the main right renal artery and in the intraparenchymal arteries
of the right kidney. No antegrade diastolic flow can be seen on these
waveforms; however, it is unclear whether this finding is related to the
technically limited nature of this exam. Venous flow is seen in the main
right renal vein.
IMPRESSION:
1. No hydronephrosis. Two simple left renal cysts.
2. Arterial and venous flow is seen in the right kidney; however, the Doppler
examination is limited as the patient is unable to hold his breath. Note is
made that the patient declined to complete the Doppler examination and
consequently the exam is very limited and no Doppler images were obtained of
the left kidney. showed 1. No hydronephrosis. Two simple left renal cysts.
2. Arterial and venous flow is seen in the right kidney; however, the Doppler
examination is limited as the patient is unable to hold his breath. Note is
made that the patient declined to complete the Doppler examination and
consequently the exam is very limited and no Doppler images were obtained of
the left kidney. Radiology showed Successful insertion of a ___ temporary dialysis catheter
in the left internal jugular vein with tip in the lower SVC. The line is
ready for use. Radiology showed Moderate left tibial disease. The patient was diagnosed with OTHER FLUID OVERLOAD, NONSPECIF SKIN ERUPT NEC, ACUTE KIDNEY FAILURE, UNSPECIFIED. The patient was treated with temporary HD line placement under general anesthesia. At the time of discharge, the patient had Primary: Acute on chronic kidney disease, acute interstitial
nephritis, Uremia, Vasculitic skin rash
Secondary: Coronary artery disease, diabetes, hyperthyroidism. 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 ___ gentleman with recent admission
___ for post-procedure MSSA bacteremia that was
complicated by presumed Nafcillin-induced AIN requiring
temporary HD, who re-presented on ___ with renal failure
requiring HD, confusion that continued despite HD, and worsened
petechial leg rash. During his stay, he underwent hemodialysis.
His mental status cleared throughout the admission and he no
longer required dialysis and will be followed by nephrology. He
was discharged to ___ on the ___.
ACTIVE ISSUES
#. ___ on CKD: requiring HD but resolving.
Presumed to be AIN (though diagnosis not ___ certain and he was
a poor candidate for renal biopsy) vs. sequelae of cholesterol
emboli (though his cardiac cath was more than a month prior).
Never had a very active sediment to suggest RPGN. Opthomology
did a dilated fundoscopic exam and did not see cholesterol
emboli. Dermatology did not biopsy the skin. On admission, he
underwent temporart HD line placement and underwent HD. Line
was removed at discharge and patient was to follow up with renal
at discharge and Dr. ___. He was discharged on 10mg
prednisone with intention to decrease with renal follow up.
#. Altered mental status: continued delirium.
Very disoriented, intermittently agitated. At first, it seemed
likely that this was all related to uremia but per Nephrology he
should have cleared by now. No clear infectious etiology to
blame (UCx negative ___, BCx from admission negative,
CXR ___ negative, C.diff pending). CT head negative for
bleed. Did have very suppressed TSH on last hospitalization and
he is on Amiodarone, but hyperthyroidism causing delirium is
less likely without other systemic manifestations. C.diff
negative. B12 and Folate unrevealing. RPR and HIV negative.
#. Leukocytosis: no obvious infection.
He did complete a course of Vancomycin for MSSA bacteremia, but
he had a rising leukocytosis up to 25.9 on ___ so Vanc was
restarted from ___ (stopped per ID recs). Prednisone or
drug reaction could possibly explain leukocytosis. Resolved to
9 on discharge. Cultures all negative at time of discharge.
#. Leg rash: ?vasculitis.
Upon prior discharge, the patient had a rash thought to be from
Nafcillin-related AIN which appeared to be resolving, but it
worsened as an outpatient. Per Dermatology, appearance
consistent with vasculitis and he is already on Prednisone for
AIN so would not necessarily biopsy. Other etiologies include
purpura from platelet dysfunction (Plavix and uremia). Patient
was continued on topical Clobetasol per Derm recs but patient
was refusing.
#. Cool feet: per Vascular, unlikely ischemic.
Has non-palpable DPs (but Dopplerable and other pulses
palpable), and occasional foot pain. Ulcerations on bilateral
dorsum of feet. Per Vascular Surgery, unlikely to be ischemic
in origin.
#. DM2: on insulin. Exacerbated by steroids and patient eating
secret cookies in room. Has had issues with hypoglycemia, much
improved with ___ recs. We appreciated ___ recs.
#. Hypothyroidism: on replacement.
TFTs on last admission showed hyperthyroidism; Synthroid dose is
low so this may be due to Amiodarone. Held Synthroid for now
-recheck TSH ___
INACTIVE ISSUES
#. CAD s/p DES to LAD and distal PDA 1 month ago: stable.
Patient was cotinued on ASA, Plavix, Metoprolol, Atorvastatin
#. Afib: rate controlled. Held anticoagulation for line
placement, but restarted at discharge. Given PFO and afib and
prior strokes, is on lifelong Warfarin. We continued
Metoprolol, Amiodarone
#. CVD: with intermittent facial droop/dysarthria.
Concern for prior CVAs based on imaging (multifocal
ncephalomalacia, of which a prominent example involves the left
temporo-occipital region). Facial droop seems to correlate with
times of severe confusion. We continued ASA/Plavix
TRANSITIONAL ISSUES
CODE STATUS: DNR/DNI
EMERGENCY CONTACT: ___ ___ ___
(daughter) ___
-Recheck TSH ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o M with chronic AF (on dabigatran) and prior TIA, sent to
ED from ___ clinic for abnormal holter findings with tachy-brady
syndrome. Radiology showed No acute cardiopulmonary process. Radiology showed PA and lateral chest compared to ___:
Transvenous right ventricular pacer lead tip projects over the anterior wall
of the right ventricle, continuous from the left pectoral generator. There is
no pneumothorax, mediastinal widening or appreciable pleural effusion. Lungs
are clear and the heart size is normal. The patient was diagnosed with PAROX VENTRIC TACHYCARD, SYNCOPE AND COLLAPSE. The patient was treated with Pacemaker placement. At the time of discharge, the patient had Pacemaker
Tachy-brady syndrome
atrial fibrillation. 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 permanent atrial
fibrillation with recent syncopal episode and holter showing
evidence of tachy-___ syndrome.
# Tachy- ___ syndrome: Patient with permanent afib and recent
syncopal episode during exertion. Holter monitor showing afib
with rates ranging from ___. Admitted to the hospital for
RV single lead PPM. Course was unremarkable. Post-op he
continues to be in afib with ventricular rates in the 70-80s and
intermittent pacing (threshold 50). Diltiazem 180mg daily
started to help avoid extreme tachycardia with exertion. He
will continue dabigatran for stroke prevention. Keflex for 2
days for prophylaxis. Follow up in device clinic.
# Hypercholesterolemia: simvastatin decreased from 20mg to 10mg
daily due to interaction with diltiazem. lipids need to be
rechecked as outpatient.
# Transitional issues:
- code status: full code
- recheck lipid panel given simvastatin reduced due to
interaction with dilt. consider switching to different statin.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with past medical history of atrial
fibrillation, on Coumadin, CKD stage IV, and heart failure with
a preserved ejection fraction, spinal stenosis presents with
several days of feeling unwell, fatigue, bilateral leg aches,
new onset of nonbloody diarrhea one day prior to admission. PA and lateral chest radiographs showed Mild pulmonary edema with mild cardiomegaly. The patient was diagnosed with Anemia, unspecified. 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 female with h/o afib s/p cardioversion in ___, CHF with
preserved EF, CKD, spinal stenosis presenting with diarrhea of 1
day's duration and lightheadedness, weakness. Afebrile and with
stable vital signs, initial evaluation significant for anemia at
Hgb 7.6 (baseline ___, mild Cr elevation at 1.9 (baseline
1.5-1.8), and mild pulmonary edema on CXR. She received gentle
IV hydration in ED and remained hemodynamically stable. Based on
the short time course and relatively benign clinical status, her
diarrhea was most consistent with a viral gastroenteritis. Mild
___ was thought to be ___ to volume depletion, while anemia may
be related to known thalassemia, iron deficiency, and CKD (no
symptoms of bleeding, stool guaiac negative). Received 20 mg IV
Lasix for mild volume overload on exam. While admitted the
patient was able to take good PO. Hgb came up to 8.1 without
transfusion and Cr downtrended to 1.7. Because the patient had
no further episodes of diarrhea while admitted and because she
was able to ambulate with ___, she was determined to be stable to
be discharged.
Transitional Issues
===============================
[] Please consider repeating CBC, chem to ensure that anemia and
Cr continue to be at baseline
[] Furosemide and lisinopril were initially held in the setting
___ but were restarted on discharge at regular home doses
# CONTACT: sister ___ ___
# CODE: DNR/DNI</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ male with a history of hypertension who
was transferred from an outside hospital with a left tibia and
fibula fracture. He was reduced and splinted at the outside
hospital before being transferred. He was at work when he fell
backwards and a utility pole fell onto his left tibia. No head
strike or LOC. He was transferred here for further management.
He denies any numbness or tingling into the left foot or pain
elsewhere. TIB/FIB (AP AND LAT) LEFT showed Transverse fracture of the distal diaphysis of the tibia with half bone width
lateral translation of the distal fracture fragment and mild apex anterior
angulation.
Comminuted fracture of the distal fibula with 1.6 cm overriding at the
midshaft. Left tibia-fibula intraoperative radiographs showed Intraoperative images were obtained during ORIF. Please refer to the
operative note for details of the procedure. The patient was diagnosed with Displaced comminuted fracture of shaft of left tibia, init, Oth cause of strike by thrown, projected or fall obj, init. The patient was treated with placement of left tibial IM nail ___. At the time of discharge, the patient had left tibia 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 left tibia and fibula fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left tibial IM nail, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
without services was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
will be discharged on aspirin 325mg daily for 4 weeks for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with MMP including nephrolithiasis, CKD who was found to
be in ARF with creatinine to 3.4 in PCP's office. Sent to ED.
Known 1.2 cm L UPJ stone with hydronephrosis. No flank pain. No
fevers/chills/n/v. Urology was consulted. Radiology showed No definite kidney stones. The study is limited by patient body habitus.
Ileus. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, CALCULUS OF KIDNEY. The patient was treated with CYSTOSCOPY, BILATERAL RPG W/ LEFT LASER LITHO AND URETERAL STENT
PLACEMENT. At the time of discharge, the patient had Nephrolithiasis, obstructing
Acute renal failure. 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 ___ male with a long
history of uric acid and calcium oxalate nephrolithiasis. He
sought a second opinion from me on ___. I noted that he
had approximately 1.5 to 2 cm of left ureteropelvic junction
stone and was in acute on chronic renal failure with a
creatinine of 3.1 with his last baseline creatinine being
1.9. I urged him to come to our emergency department, and he
ultimately presented on ___ to our ED. His
creatinine was again noted to be 3.1 with a potassium of 4.8.
Plans were made to bring him to the operating room for
retrograde pyelography on the right to delineate the anatomy
of what appears to be a complex right calyceal diverticulum
with stones as well as to place a left ureteral stent and
potentially treat his left proximal ureteral stones.
He was admitted from the emergency room and prepped for
operative intervention. He was taken to the operating room where
he underwent cystoscopy, bilateral retrograde pyelograms with
interpretation,
left ureteroscopy and laser lithotripsy of left ureteral calculi
and finally left ureteral stent placement. Foley catheter was
placed for urine output monitoring. He was recovered and taken
to the PACU and subsequently transferred back to the general
surgical floor where he remained overnight. See the detailed
operative note for full details. His pain was well controlled on
the general surgical floor and on postoperative day one, his
foley catheter was removed. After voiding he was discharged
home. His post-operative course was unremarkable. Postoperative
labs reflected improved creatinine and improvement in his acute
kidney injury. He was discharged home with explicit instructions
to return for ureteral stent removal and further intervention as
necessary. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ with h/o CAD and ischemic cardiomyopathy who
presents with chest pain. Reports the pain started while she was
in bed at 3AM on ___. She describes the pain as piercing L
parasternal pain and experienced 4 quick episodes. The pain went
away when she called EMS at 5 AM. Denies nausea, vomiting or
SOB. No pleuritic component. Denies cough. Patient did receive
full-dose ASA prior to transfer. MRI AND MRA BRAIN AND MRA NECK showed 1. Subtle focus of slowed diffusion adjacent to the cortex of the right
parietal lobe is concerning for a focus of infarction.
2. Small micro-hemorrhage in the right temporal lobe series 16, image 11 is
likely subacute.
3. Diffuse bifrontal and right frontoparietal T2 and FLAIR hyperintensities is
consistent with patient's known encephalomalacia.
NOTIFICATION: Findings were discussed with Dr. ___ by Dr. ___ by phone
at 4:30p on the day of the exam. The patient was diagnosed with CHEST PAIN NOS. At the time of discharge, the patient had Primary diagnosis: Atypical chest pain, CVA
Secondary diagnosis: ischemic cardiomyopathy. 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 h/o CAD, ischemic cardiomyopathy presents with chest
pain.
.
>> Acute Issues:
# Chest pain: This patient has a history of CAD s/p MI in
___. During her hospitalization, she had two sets of
negative cardiac enzymes and EKG showed non specific ST changes,
unchanged from last EKGs. Due to her negative cardiac enzymes,
unchanged EKG, and brevity of symptoms before presentation
without recurrence, patient will follow up as an outpatient for
catheterization. Patient was discharged on all of her home
medications. The cardiology fellow spoke to pt's OP cardiologist
who agreed to plan for OP cath.
.
# Hypotension: The patient's SBPs went into the ___ on
arrival to floor. She received 250 cc bolus NS and her SBP
responded appropriately (SBPs in 100s-110s). This was most
likely due to hypovolemia and antiHTn meds given at BIN before
transfer. Through rest of the hospital course, her SBPs remains
in the 110s-120s and she remained asymptomatic (no dizziness,
lightheadedness). Home metop and lasix were restarted without
issue.
.
# Neuro deficits: On examination of the patient on admission, it
was noted that she had dysarthria, facial asymmetry, and mild
ptosis. The stroke team was consulted and she received an MRI
and MRA head/neck. These images revealed small micro-hemorrhage
in the right temporal lobe and subtle focus of slowed diffusion
adjacent to the cortex of the right parietal lobe, concerning
for a focus of infarction. She got a TTE which showed: Moderate
left ventricular dilatation with moderate to severe regional
variation c/w multivessel CAD, Normal right ventricular cavity
size and systolic function, Right ventricle not well-visualized,
Mild mitral and aortic regurgitation, and No cardiac source of
embolism identified. She got HbA1c (6.9) and lipid levels drawn
(Chol 142, LDL 60). Neurology believes that her dysarthria is
readily explained by her penetrating arttery brain lesions and
her prior stroke and her long term use of antipsychotics and
there is no evidence of recent brain ischemia. Neurology thought
anticoagulation may be appropriate for the patient, but deferred
to cardiology. Cardiology attending did not feel as though
anticoagulation is indicated.
>>Chronic Issues
# CHF: patient has known ischemic cardiomyopathy, with most
recent ECHO showing EF ___ and severe regional left
ventricular systolic dysfunction with global hypokinesis and
akinesis of the septum, apex, distal two thirds of the inferior
wall. She presented with a proBNP 3707, but lower than her
baseline of >4000. Patient's lungs clear, however patient does
have elevated JVP. Her heart failure medications were held for a
day due to hypotension, but were resumed during the hospital
course and she maintained hemodynamic stability.
# DM: The patient's glucose was monitored qAHCS and she was put
on an ISS. Her HbA1C was 6.9. She was discharged on her home
diabetic medications.
>>Transitional issues:
- Patient will go to rehab on DC for ___ and OT
- needs to follow up with cardiologist to plan for outpatient
cath
- She should follow up with psychiatrist (or PCP if she does not
have a psychiatrist) to discuss her antipsychotic medications
and doses. Neuro recommends that she decrease her antipsychotic
meds as it may be exacerbating her neuro symptoms.
- Please consider restarting lisinopril as an outpt if BPs will
tolerate</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: from Dr. ___ note:
___ is a ___ F with h/o autism and epilepsy who is
transferred from ___ after having 2
breakthrough seizures today. The patient was at her group home
earlier today eating lunch when she had a generalized tonic
clonic seizure. She was brought to ___ and
subsequently discharged back to her group home. Later in the
evening while eating dinner, the patient had a second
genearlized tonic clonic seizure. She was sitting in a chair
eating and fell to the ground. The event is reported to have
lasted 5 minutes, but her mother is not sure if the actual
seizure event lasted this long or she perhaps had a shorter
seizure and was post ictal afterwards. She was again taken to
___ where she was given a dose of lorazepam and
transferred to ___. The patient is non-verbal at baseline. Radiology showed No evidence of pneumonia. The patient was diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY. At the time of discharge, the patient had epilepsy
autism. 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>___ was admitted to the Neurology floor in stable
condition. A workup for infectious etiologies was negative. A
zonisamide level was sent and is pending. She underwent extended
routine EEG monitoring with no evidene of seizure activity. Her
mental status returned to baseline. After consultation with Dr.
___ AED regimen was left unchanged and she will
continue zonisamide 700 mg monotherapy. She was discharged to
the care of her parents to return to her group home.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with h/o IVDU c/b endocarditis
s/p mitral valve replacement in ___, with recurrent prosthetic
valve endocarditis in ___ and ___, presenting with
intermittent
substernal chest pain, fatigue, and malaise in setting of recent
IV cocaine use. History was obtained directly from the patient
but was somewhat limited by his poor memory and difficulty
describing symptoms. CHEST (PA AND LAT) showed No acute intrathoracic process. CTA CHEST showed No pulmonary emboli.
The pulmonary artery is mildly enlarged, pulmonary arterial hypertension
should be excluded.
No pneumonia. No suspicious pulmonary nodules or masses.
Mild, but diffuse bronchial wall thickening is nonspecific, most likely
reflecting underlying bronchial inflammation. The patient was diagnosed with Chest pain, unspecified, Other fatigue. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
==================
Cocaine use
SECONDARY DIAGNOSIS:
====================
History of intravenous drug use complicated by endocarditis
status-post mitral valve replacement
Recurrent prosthetic valve endocarditis. 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 h/o IVDU and recurrent endocarditis involving
bioprosthetic mitral valve, presenting with intermittent central
chest pain, fatigue, and malaise after recent heavy cocaine use.
Currently pain free and hemodynamically stable. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMHx hypothyroidism, ___ disorder (___) presents
after having been found down for up to 36 hours in his
apartment. Difficult to obtain details from the patient who is
oriented x 3 but confused as to day of week. Upon further
review, the patient notes that he was walking in his house when
he might have slipped on the sawdust in his house which is
undergoing construction. Limited history possible at the time of
assessment given the patient's hoarse voice. Information
corroborated with the patient's son. Son notes that there is at
least 36 hours of elapsed time during which his father was
unaccounted. He advised neighbors and police who entered the
house to find the patient down.
Vitals upon arrival to ED, 97.6 86 127/76 16 100% . Underwent CT
C-spine which revealed pre vertebral edema without fracture;
NCHCT without acute intracranial process; TSH 16; fT4 5.1; CK
2193.; SCr 0.8; lactate 1.8. Received 2L IVF and transferred to
the floor. Radiology showed Left-sided rib fractures as above, some of which appear old,
others of which may be subacute. Non-displaced fracture of the lateral right
eighth to ninth ribs of indeterminate age not excluded. Please correlate
clinically.
Slight irregularity along the inferomedial aspect of the right femoral neck,
correlate with site of pain and dedicated imaging of the right hip. Radiology showed No acute intracranial abnormality. Radiology showed 1. Prevertebral/retropharyngeal edema anterior to the C1-C4/C5 cervical spine,
non-specific but ligamentous injury not excluded. Recommend further
evaluation and clinical correlation with MRI.
2. Left 5 mm apical lung nodule. Recommend CT imaging to assess stability in
___ months if patient is at high risk for lung cancer, otherwise in 12
months.
Findings were discussed with Dr. ___ by Dr. ___ telephone at
approximately 1:30 p.m. on ___ immediately following wet read
change. Radiology showed Mild loss of height of the C6 vertebral body with associated STIR
hyperintensity consistent with marrow edema from trauma or degenerative
change. Mild prevertebral edema has slightly diminished compared to the
previous study CT examination. There is no evidence for ligamentous
disruption.
Multilevel degenerative changes as described above with disc bulging indenting
the cord from C2-3 to C4-5 levels without frank cord compression or abnormal
signal within the cervical cord. The patient was diagnosed with DEHYDRATION, RHABDOMYOLYSIS. At the time of discharge, the patient had PRIMARY DIAGNOSES:
RETROPHARYNGEAL EDEMA
___ DISEASE
RHABDOMYOLYSIS
DEHYDRATION
SECONDARY DIAGNOSES:
HYPOTHYROIDISM. 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>___ PMHx hypothyroidism, ___ disorder (Dx ___, and
recent falls who presented after been having been found down in
his apartment for up to 36 hours. Noted to have mild
rhabodomyolysis and C1-C4 prevertebral edema due to cervical
trauma without evidence of fracture or ligamenetal injury.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male with advanced prostate cancer, with suprapubic
catheter and home hospice care for past month presents with
right groin/pelvic pain and renal failure. Radiology showed New bilateral hydronephrosis, mild on the right and mild to
moderate on the left. The urinary bladder could not be assessed.
Results were discussed via telephone with ___ by Dr. ___ on ___ at 4:32 p.m. Radiology showed 1. Technically successful placement of bilateral 8 ___ nephrostomy tube.
2. Tortuous distal left ureter consistent with extrinsic compression. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, SECOND MALIG NEO GENITAL, HX-PROSTATIC MALIGNANCY, HYPERTENSION NOS. The patient was treated with bilateral percutaneous nephrostomy tube placement. At the time of discharge, the patient had Renal failure due to post obstructive uropathy
Advanced prostate cancer
Constipation. 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># Renal failure- due to post-renal obstruction ___ tumor
invasion of bladder wall. Discussed with patient and wife prior
to obtaining ultrasound. IVF overnight did not improve
creatinine. ___ consulted for bilateral nephrostomy tube
placement to relieve obstruction as a palliative procedure to
extend his quality of life. Attempt was made to internalize the
tubes, but ___ unable to do so, so external tubes with collection
bags were means of decompression. His hospice nurse has
experience caring for patients with percutaneous nephrostomy
tubes, and should they cause discomfort at home, they can be
removed. Following placement, creatinine improved from 4.6 to
1.1 on the day of discharge.
++ Nephrostomy tube care, wash with ___ saline and ___ hydrogen
peroxide and cover with dressing daily. Flush with ___ NS if
bloody or clogged.
++ suprapubic tube care-wash with ___ saline and ___ hydrogen
peroxide and cover with dressing daily. Flush with 30cc saline
if bloody or clogged.
# Advanced pancreatic cancer-the patient wishes to pursue only
palliative therapy. Symptoms were well controlled with morphine
5 mg IV Q3H PRN. With input from palliative care, regimen was
converted to MS ___ 30 mg BID and MSIR ___ Q3hrs.
However, this regimen again proved challenging as pt would go
from periods of confusion to severe pain. Therefore, the patient
was converted to a fentanyl patch at 25mcg q72hrs and continued
to use MSIR for breakthrough pain. AT a dose of ___ Q3hrs
prn. Difficulty balance as pt often with pain using 15mg and
somewhat confused/sedated with 30mg. Pt should get 30mg MS ___
___. Can trial ___ at intervals during the day, depending on
symptoms. Could also uptitrate fentanyl patch. Pyridium was
discontinued given significant anti-cholinergic effect that was
likely exacerbating constipation. However, the urology team felt
that pt was having bladder spasms and pt was started on
oxybutynin therapy TID with good effect and improvement in
spasms.
# Fever- treated at home with levofloxacin for empiric UTI
coverage. Ceftriaxone continued initially on admission.
Initial urine culture from chronic suprapubic catheter was
indeterminate, repeat cultures from each nephrostomy tube were
negative. However, pt with another low grade temperature on ___
and culture was sent from suprapubic tube which showed mixed
flora. Antibiotics were discontinued.
.
# Constipation- pt given an aggressive bowel regimen, with
enemas, which relieved constipation.
.
#anemia/thrombocytosis, leukocytosis-felt to be related to above
process. No signs of C.diff, or PNA.
# HTN- continued amlodipine
.
# FEN- IVF, replete lytes, regular diet
# Contact- patient, wife ___ ___
# Code- DNR/DNI
.
Transitional care
1.continue titration of pain medication prn. Pt currently on
25mcg fentanyl patch and MSIR ___ Q3hrs pain. Occasionally
15mg works, occasionally needs 30mg. Would give 30mg ___. 30mg
occasionally too sedating. Could also uptitrate fentanyl patch
prn.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: REASON FOR CONSULTATION: headache, vomiting
HPI:
Mr. ___ is a ___ man with past medical history of
HTN, HLD, poorly controlled DM, CAD, and recent admission for
right ICA and MCA occlusion s/p TPA, ICA stent placement, and
thrombectomy with TICI3 reperfusion with ___ hemorrhagic
transformation who presented as a transfer from ___ for severe
headache, nausea and vomiting. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Evolving right putaminal and adjacent white matter hematoma with edema and
mass-effect. The edema appears unchanged to slightly more prominent compared
to ___ but markedly increased since ___.
2. Limited view of the neck due to bolus timing. The vertebral and internal
carotid arteries appear patent but are not well characterized.
3. Right carotid stent in place with apparent patency of the vessel. MR HEAD W/O CONTRAST ___ MR HEAD showed 1. Evolution of the right putamen hematoma with surrounding edema, unchanged
from the most recent prior CT but increased from initial presentation.
2. No significant change of mild 1-2 mm leftward midline shift with partial
effacement of the right lateral ventricle and mild asymmetric prominence of
the temporal horn of the right lateral ventricle.
3. No new intracranial abnormality identified. The patient was diagnosed with Headache. At the time of discharge, the patient had Sequelae of Right MCA stroke with hemorrhagic transformation
___ edema. 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>HOSPITAL COURSE:
___ man with past medical history of HTN, HLD, poorly
controlled DM, CAD, and recent admission for right ICA and MCA
occlusion s/p TPA, ICA stent placement, and thrombectomy with
TICI3 reperfusion with ___ hemorrhagic transformation who
presented as a transfer from ___ for severe headache, nausea and
vomiting. At ___, neurological exam stable. On imaging, no new
hemorrhage but had increased ___ edema around the
known old hemorrhage. Patient was observed and had spontaneous
resolution of symptoms with stable neurological exam. He was
found to have Enterococcus UTI, treated initially with IV
Ceftriaxone, then narrowed to IV ampicillin and discharged to
Rehab on oral amoxicillin.
=======================================
## Headache, known Right MCA stroke with hemorrhagic
transformation:
On arrival to ___, patient reported that he had mild headache
over the past few days. It became worse day before admission &
improved with Tylenol. He then vomited once. He had no
complaints when evaluated in the ED, specially no headache. On
initial presentation, his exam was largely stable from most
recent documented discharge physical exam with stable left
hemiparesis, dysarthria, left facial droop. New findings on
initial exam were decreased sensation to light touch and
pinprick in the left side of his face in the V2 and V3
distribution, in addition to decreased light touch and pinprick
in his left upper extremity compared to the right upper
extremity. On repeat exam in ED, his sensory exam was noted to
be symmetric without any difficulty to light touch, exam was
thus essentially unchanged from discharge exam after previous
hospitalization: VSS. Awake & alert. ___ seem intact. +
flattening of L NLF. No field cut. + pronation of L UE. L
hemiparesis (___) w/ increased tone. L sided hyperreflexia.
Sensations intact.
CT head showed stable left basal ganglia hemorrhagic
transformation with increased surrounding hypodensity
___ edema) resulting in increased effacement of
the R lateral ventricle and 1-2 mm midline shift. CTA showed
patent R ICA stent; scattered calcifications in the ICAs, and
narrowing of R ___.
He was thus admitted for observation due to increased ICP due to
increased ___ edema. Given resolution of symptoms
and stable exam, hyperosmolar therapy was not given. He remained
stable during the hospitalization. Overall exam is largely
stable from most recent documented discharge physical exam with
stable left hemiparesis, dysarthria, left facial droop. We
continued aspirin (81 mg) and Plavix given his ICA stent. Repeat
___ evaluation was done, and ___ rehab was recommended,
therefore patient was discharged to ___ rehab on ___.
[ ] continue aspirin 81 mg and Plavix
[ ] continue atorvastatin 80 mg
##Enterococcus UTI:
He was found to have Enterococcus UTI, treated initially with IV
Ceftriaxone (___), then narrowed to IV ampicillin
(___) and discharged to Rehab on oral amoxicillin 500 mg
TID till ___ (for a total 7 day course).
============================================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman
with a PMH of HIV, HCV, IVDU, chronic pain admitted from ___
to ___ with MRSA vertebral osteomyelitis, paraspinal abscess
and arachnoiditis/meningeal enhancement.
.
The patient presented on her PREVIOUS Admission to an OSH with
severe lumbar pain. An LP was performed and showed WBC 59K with
cultures growing MRSA. Blood cultures also grew MRSA. MRI was
performed after the LP showed a 3.1 x 1.6 cm abscess in the
right paraspinal musculature at the L3-5 level with involvement
of the right L4-5 facet joint and the L4 spinous process with
additional
leptomeningeal enhancement. It was unclear if the LP fluid that
was obtained was from the abscess or from the spinal fluid,
given the close proximity and the unknown presence of abscess at
the time of LP. The patient was given
vancomycin, ceftriaxone and acyclovir and was transfered to
___. On arrival to ___ she was intubated due to altered
mental status.
.
Neurosurgery evaluated the patient and she underwent ___ guided
drainage of her paraspinal abscess, cultures also grew MRSA. She
was continued on vancomycin alone. She was taken back for repeat
___ guided drainage of her abscess on ___ with and a drain
was removed prior to discharge. TTE revealed no
vegetations. She was discharged on vancomycin with a planned
prolonged duration of therapy. Her ID follow up was transitioned
to her PCP prior to discharge.
.
After discharge her ___ abscess fluid grew AFB with speciation
pending. Due to this, and a truncal rash, she was referred back
to the ___ for admission ___ Radiology showed No acute cardiopulmonary process. The patient was diagnosed with OTHER NONSPECIFIC FX ON EXAM. At the time of discharge, the patient had Tuberculosis rule out. 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>___ pmHx HIV, HCV, IVDA who recently was discharged with
epidural abscess who p/w concern for Tb and with ___ rash ?drug
related
# AFB+ Abscess Cx: Patient with growth of AFB on abscess that
previously was known positive for MRSA. Patient was admitted
from rehab for r/o Tb.
- 3 induced sputums with AFB sputum was smear negative on gram
stain
- Dr. ___ with ID will f/u State lab to return
speciation and contact patient
# MRSA Abscess: Patient on extended course of Vancomycin s/p
multiple drainages of epidural abscess. Derm consulted, felt
rash was due to Vanco and this was stopped. Daptomycin was
started at the recommendation of ID. She declined the
opportunity to go to rehab for continued abx with Daptomycin,
so PICC line was removed give hx of IVDU and pt was d/c with 4
weeks of linezolid ___ PO BID. She will f/u with Dr. ___ in
___ for weekly CBC, CMP, ESR, CRP and
LFTs. She will also f/u at ___ in ___ clinic in 4 weeks.
# Transaminitis: LFTs slightly elevated, trending up. Risk for
hepatitis due to IVDA as well as known Hep C. Could be due to
medications. Hep B surface antigen was negative.
# Normocytic Anemia: Hct 33 on admission, stable at this level
during last admission. Iron studies normal.
# HIV: Low CD4 count measured here thought to be secondary to
acute illness (171 on ___. ID did not feel prophylactic
bactrim was indicated at that time. CD4 ___. She was
contniued on home truvada and raltegravir.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ yo F with a PMHx of gastric by pass, depression
with recent suicide attempt and was at ___ on a
___ after a reported alcohol and clonodine overdose who
was transfered for c/o abdominal pain X5 days.
.
Patient was seen at ___ for similar complaints and
had a CT was was reportedly normal. Her intial evalaution there
was for OD with 40-60 clonodine tablets while drinking alcohol.
She was intially admitted to the ICU for close monitoring. She
had self limiting bradycardia and hypotension at ___.
LFT's and lipase also wnl. At that time, reports last normal BM
was 5 days ago and since has only had small stools. Was
medically cleared and sent to ___, sent to ___ ___ for
continued abdominal pain.
.
In our ED, VSS. Rectal exam done in ED showed hard dark stool
in rectal vault, guaiac negative without CVA tenderness. The
patient was teary in the ED and anxious due husbands death ___
years ago from complications of gastric bypass. Enemas given
with moderate amounts of BM after. Patient placed on 1:1 sitter
and sent to the floor.
.
On the floor the patient reports that she began to have sharp
pains in her abdomen about 1 month ago. Theses pains got worse
in intensity and duration shortly after her overdose 5 days ago.
The pains prior to her OD lasted seconds and now they are
lasting minutes to hours. The pains are usually related to po
intake. The patient also reports constipation X5 days that was
releived by an enema in the ED. The patient has never had an
EGD and had a colonoscopy at ___ in ___ of this
year due to LGIB which was thought to be due to a bleeding
polyp. The polyp was removed and the bleed stopped. The
patient does reported black stools recently but her medications
on transfer included iron. The patient denies a h/o
pancreatitis or ulcers. The patient has had multiple suicide
attempts in the past, most recently ___ when she was
inpatient. The suicide attempts were in the setting of alcohol
abuse. Denies current HI or SI.
.
10 point ROS is otherwise negative except above
. Radiology showed 1. Nonspecific bowel gas pattern without definite evidence of obstruction.
2. 5-mm nodular opacity overlying the left base should be further evaluated
with conventional chest radiographs.
Findings were communicated via phone call by Dr. ___ to Dr. ___
___ on ___ at 0756 am. Radiology showed 1) No acute pulmonary process identified.
2) No free air detected beneath the diaphragm. Radiology showed 1. Large quantity of oral contrast material within the excluded stomach,
without clear evidence of reflux via the pancreatobiliary limb, indicating a
likely communication between the gastric pouch and excluded stomach. Further
evaluation could be performed with direct visualization or an upper GI barium
study.
3. Extrahepatic and central intrahepatic biliary ductal dilation, without
evidence of an obstructing lesion, a finding that can be seen in patients who
have undergone prior cholecystectomy, although correlation with right upper
quadrant abdominal pain and LFT's is recommended. Further evaluation could be
performed with MRCP, if clinically indicated.
3. Possible hepatic steatosis.
4. Mild splenomegaly.
Updated findings were discussed with Dr. ___ by Dr. ___ at 6:56
p.m. via telephone on the day of the study. The patient was diagnosed with ABDOMINAL PAIN PERIUMBILIC, UNSPECIFIED CONSTIPATION. The patient was treated with EGD. At the time of discharge, the patient had Marginal ulcer near the g-j anastomosis
Gastro-gastric fistula
Depression
Anxiety
SVT. 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 ___ yo F with a PMHx of gastric by pass, idiopathic
intermittent abdominal pain who initially p/t ___
for a clonidine and alcohol overdose, course c/b self limiting
bradycardia and hypotension, transferred to ___ for
psychiatric treatment now transferred to ___ for further
evaluation of about 5 days of RUQ abdominal pain with prior
normal imaging and labs, found to have h. pylori with an
anastomotic ulcer and a gastro-gastric fistula
.
# Gastro-gastric fistula
The patient was evaluated by the ___ surgery team and they
recommended a GI evaluation for further work up. The patient
got an EGD on ___ which showed a marginal ulcer at the g-j
anastomosis and a gastro-gastric fistula which was not amenable
to endoscopic therapy due to the size of the fistula. The
patient was also found to have h. pylori serology. These
findings were discussed with the ___ surgery team and they
felt as though a trial of medical therapy was appropriate with
follow up as an outpatient in ___ weeks. The patient was
agreeable to this and will follow up initially at ___,
although her surgery was done else where.
.
# marginal ulcer in the setting of h. pylori positive serology
A component of the patients pain is also likely due to her ulcer
found on EGD. The patients h/o overdose, alcohol use and h/o
gastric bypass puts her at risk for ulcers and fistulas. The
patients h. pylori serology also came back positive. Her Hgb
was stable during this hospitalization. She will be treated
with quadruple therapy for this with omeprazole 20 BID, bismuth
525 QID, metronidazole 250 QID and doxycycline 100 Q12H for 14
day course (start date is ___ ending ___. This is a
non-conventional regimen due to the patients allergies to pcn
and biaxin (rash) and unavailability of tetracycline at ___.
This issues was discussed with both pharmacy and ID and they
agreed with this regimen. The patients abdominal pain
associated with both her ulcer and fistula were an ongoing
problem in house but did improved and she was able to tolerate a
bariatric diet. She was initially on Dilaudid IV and was
eventually transitioned to oxycodone. Given the patient has
issues with alcohol in past, narcotics should attempt to be
weaned off as her symptoms resolve. The patient had times when
she appears very comfortable and other times where she is in
tears. Her pain has been relatively well controlled for the
past several days on Carafate 1 g QID, oxycodone 15 Q3H prn and
tylenol ___ Q8H standing. Tramadol can also be considered as
the patient is attempting to come off narcotics. There is a
small risk of serotonin syndrome with her current medication
regimen, but pharmacy indicated that this is not a
contra-indication to using this medication.
.
# SVT with episode of symptoms in house
The patient has a known h/o SVT and has had a prior evaluation
by a Cardiologist who suggested a possible ablation in the
future. Anxiety related to pain and her condition seemed to
drive the onset of SVT (which appeared to be AVNRT by EKG). Her
symptoms terminated with vagal maneuvers. The patient was
attempted to be started on metoprolol 12.5 BID, but she had
borderline bradycardia, so this was deferred. She should follow
up with a Cardiologist as an outpatient. Serial cardiac enzymes
were negative following this episode.
.
# Anxiety/Depression with recent suicide attempt with clonidine
and alcohol
The patient has a history in the past of suicide attempts and
alcohol abuse. The patient denies active SI or HI while in
house here. She was followed by psychiatry and had a 1:1 sitter
for the duration of her stay. She had mood lability and was
often tearful during medical evaluations, specifically about her
deceased husband. Much of her anxiety was in regards to having
her pain treated.
.
# Transitional Issues
[] follow up with Bariatric Surgery at ___ in ___ weeks for
further management of her gastro-gastric fistula and
consideration of surgical management
[] complete her 14 day course of antibiotics for her h. pylori
positive ulcer and follow up with her PCP and confirm
eradication with a urea breath test, fecal antigen test, or
upper endoscopy performed four weeks or more after completion of
therapy
[] follow up with Cardiology regarding further management of her
SVT
[] further management and outpatient Psyc services per inpatient
Psyc at ___
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with history of ESRD from T2DM s/p renal transplant
___, complicated by chronic rejection, currently on Rituxan),
Afib on Coumadin, CAD s/p CABG, TIA, Roux-en-Y bypass,
hypertension, recent admission for diastolic CHF exacerbation,
presenting with dyspnea. Patient reports that after discharge
from recent hospitalization, she felt well and without cough.
About a week ago she noticed increased dyspnea both on exertion
and at rest. Today she started wheezing. Her husband has a pulse
oximeter which showed sats lower ___ on RA. Consulted with their
PCP who recommended she come to the ED for evaluation.
In the ED, initial vitals were: 97.8 91 136/69 18 92% RA
- Exam notable for:
Crackles bilateral lung bases
Bilateral lower extremity edema, left greater than right, at
baseline per patient
- Labs notable for:
Cr 2.1
INR 3.9
BNP 11k
WBC 11.1
Top 0.03 with MB of 3
- Imaging was notable for:
CXR PA & LAT
Stable mild cardiomegaly and central pulmonary vascular
congestion without frank pulmonary edema or focal consolidation.
Renal US
1. Persistent elevated intrarenal artery resistive indices,
overall slightly increased compared to prior (0.82 to 0.87 today
compared to 0.77-0.82 prior study).
2. No hydronephrosis.
- Transplant nephrology was consulted:
- Concern for dCHF exacerbation, OK for diuresis, can use 40mg
IV Lasix.
- If any infectious symptoms, would obtain flu swab
- Renal transplant ultrasound unchanged from prior
- INR elevated, hold warfarin
- Continue home IS in the ED: mycophenolate sodium 360mg QID,
prednisone 5mg daily, tacrolimus 2mg q12h. Check AM tacrolimus
trough.
- Continue home ppx: valganciclovir 450mg daily, dapsone 100mg
daily
- Patient was given: ___ 21:34 IV Furosemide 40 mg
- Vitals prior to transfer: 99.2 86 151/83 22 95% Nasal Cannula
Upon arrival to the floor, patient reports she has been taking
home Lasix as prescribed. Her tacrolimus has been increased to
2mg bid by her nurse manager. She denies history of asthma. No
chest pain, fevers, dysuria. She has been urinating ___ times
daily, which is normal for her. Leg swelling has recently
increased.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative. Radiology showed Stable mild cardiomegaly and central pulmonary vascular congestion without
frank pulmonary edema or focal consolidation. RENAL U.S. showed 1. Persistent elevated intrarenal artery resistive indices, overall slightly
increased compared to prior (0.82 to 0.87 today compared to 0.77-0.82 prior
study).
2. No hydronephrosis. The patient was diagnosed with Heart failure, unspecified, Acute pulmonary edema. At the time of discharge, the patient had Flu
Acute on chronic diastolic heart failure. 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 ___ with PMH significant for LRRT ___ and
recent diagnosis of humoral rejection s/p IVIG and rituximab who
presented with dyspnea, cough, wheezing, and hypoxemia. BNP was
elevated to 11,000 and patient had evidence of mild fluid
overload on exam. Additionally, she tested positive for
influenza A. She was diuresed with IV lasix, ultimately with a
lasix ggt at 5mg/hr. She was also started on oseltamivir 30mg
q12h for treatment of influenza and duonebs. Her respiratory
status improved significantly and she was stable on room air on
the day of discharge with ambulatory sat in 92-94% range. Her
tacro level was at 4.8, so her tacro was increased from 2g q12h
to 3.5g BID. She was discharged on her home dose of diuretics
with plan to continue Tamiflu 30mg q12 for 5 day course to end
on ___. She will need repeat labs drawn on ___ at her
follow-up appointment with transplant nephrology.
#Acute on chronic HFpEF (EF 65-70%)
#Acute hypoxic respiratory failure ___ influenza A infection
BNP was elevated at admission to 11k, likely acute on chronic
diastolic HF ___ influenza infection. She was diuresed with
Lasix intravenous bolus and placed on a Lasix ggt at 5mg/hr. Her
respiratory status improved and she was transitioned back to
Lasix 40mg PO BID. She was also found to have influenza A
infection that was likely contributing to acute hypoxic
respiratory failure. Patient was placed on Tamiflu 30mg q12h
(renal dosing) and she had duonebs standing. Her respiratory
status improved significantly and she was stable on room air
after requiring 3L O2 at admission. Ambulatory O2 sat ranged
from 92-94% on the day of discharge. Will be discharged on
albuterol inhaler. 5 day course of Tamiflu will end on ___
(renally dosed to 30mg q12h)
-preload: lasix 40mg BID
-NHBK: c/w carvedilol
-afterload: c/w hydralazine</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo F with PMH significant for HLD, CAD s/p
CABG
and multivessel PCI, GERD, HTN, DM initially presenting with
right upper abdominal pain. Patient was in her normal state of
health until approximately 2 days prior to admission when she
began experiencing abdominal pain in her RUQ. This pain
progressed through the day prior to admission, described as a
burning pain that was constant and occasionally sharp. The pain
did not radiate, and was associated with nausea, providing her
with minimal appetite. On the day prior to admission, she
attempted to drink Sprite and eat bread, though had an episode
of
bilious yellow emesis afterwards. She denied any associated
fevers, though did note chills. She also endorsed 5 episodes of
watery brown diarrhea. MRCP showed 1. Findings of acute gangrenous cholecystitis with a percutaneous
cholecystostomy tube appearing well positioned. There is persistent mild
distension of the gallbladder lumen and new perihepatic ascites, which raises
concern for a leak around the tube or tube obstruction. Correlation with tube
output is recommended and confirmation of placement by injection of contrast
under fluoroscopy could be considered.
2. No choledocholithiasis. Mild extrahepatic biliary ductal dilatation
attributable to a periampullary duodenal diverticulum.
3. Mild hepatic steatosis. Radiology showed Successful ultrasound-guided placement of ___ pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation. T-TUBE CHOLANGIO (POST-OP) showed Patent cystic duct with contrast passing into the common bile duct. No
definite evidence of leak. The patient was diagnosed with Calculus of gallbladder w/o cholecystitis w/o obstruction, Unspecified abdominal pain. The patient was treated with Percutaneous cholecystostomy on ___ by Interventional
Radiology. At the time of discharge, the patient had ===================
PRIMARY DIAGNOSIS
===================
Acute cholecystitis
===================
SECONDARY DIAGNOSIS
===================
Coronary artery disease
Type 2 diabetes
Hypertension. 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>P - Patient summary statement for admission
===========================================
___ with PMH of HLD, CAD s/p CABG and multiple PCI, GERD, HTN,
DM presenting with RUQ abdominal pain, nausea, and vomiting.
A - Acute medical/surgical issues addressed
===========================================
# Acute cholecystitis
Patient presented with acute onset progressive RUQ pain, fevers,
and leukocytosis consistent with acute cholecystitis. Initially
tachycardic to HR 110s but otherwise HDS and reassuringly, LFTs
and lipase wnl. ___ performed percutaneous cholecystostomy on
___. She was kept NPO, received IVF resuscitation and IV
morphine and acetaminophen for pain control, and was initially
treated with Unasyn. Bile culture from cholecystostomy grew E.
coli resistant to ampicillin and intermediate resistance to
Unasyn. ___ MRCP demonstrated acute gangrenous cholecystitis
without choledocolithiasis. New perihepatic ascites was noted on
MRCP, however ___ tube study did not show definite evidence of
leak. Afebrile since the morning of ___, when she was switched
from Unasyn to Zosyn. Clinically improved on conservative
management with decreased pain (last dose of morphine on ___
am) and improvement in leukocytosis and tachycardia. On day of
discharge she was tolerating full PO diet without issue and she
was transitioned from Zosyn to Bactrim on ___ with plan to
continue Bactrim until cholecystectomy. Surgery (ACS) evaluated
patient and recommended continuing conservative management
followed by cholecystectomy as outpatient after acute infection
is cleared. Physical Therapy evaluated patient and recommended
___ rehab.
# CAD
Pt has an extensive history of CAD with chronic stable angina
s/p CABG in ___, and most recently DES to PL in ___.
Positive cardiac stress test (___). Patient follows with Dr.
___ was evaluated in the ED by Cardiology. She has chronic
exertional angina but reassuringly EKG with no interval change
and trop negative this admission. At last appointment with Dr.
___ was discussion regarding possible diagnostic
angiogram if symptoms worsened. Exertion at level of ___ METS
brings on typical angina. Cardiology was consulted when surgical
intervention during this admission was being considered,
recommended holding clopidogrel for 3 days prior to
cholecystectomy if warranted. Home clopidogrel 75mg QD was
initially while surgical intervention during this admission was
considered, then restarted on ___ as clinical status improved.
Continued home ASA, simvastatin, fractionated home metoprolol.
Home Lasix was held ___ infection and relative hypotension.
# IDDM
On home Humalog ___ 95 units SC daily. While NPO she was given
50U Lantus qhs with HISS.
C - Chronic issues pertinent to admission
===========================================
#HTN
Continued home metoprolol tartrate 25mg Q6H (fractionated). Home
isosorbide mononitrate and lasix held in setting of infection
and SBPs ___.
#HLD
Continued home simvastatin 5mg po daily.
#GERD
Continued home ranitidine 300mg po daily.
#Vitamin D Deficiency
On home 50,000 ergocalciferol q2 weeks.
#Chronic Pain
#Diffuse Osteoarthritis
Continued home tramadol 50mg po TID. Continued gabapentin 300mg
po am and afternoon and gabapentin 900mg po qhs. Vitamin D
supplementation as above. Home Vicodin held while patient
received morphine.
#Asthma
#Allergic Rhinitis
Continued albuterol inhalers prn and home cetirizine.
#Depression
Continued venlafaxine 150mg po daily
T - Transitional Issues
===========================================
[] Plan for cholecystectomy after acute infection: We will
continue antibiotic treatment with Bactrim (sensitive on bile
culture) until patient follows up with surgery in clinic. Per
surgery team, will arrange follow-up in ___ weeks and likely
plan for surgery in ___ weeks. Percutaneous cholecystostomy
tube management per surgery team.
[] Clarify plan with Cardiology regarding how long to hold
Plavix prior to cholecystectomy. Patient has follow-up
appointment on ___ during which a plan should be made
detailing went to stop Plavix prior to surgery.
[] F/u BP and electrolytes in 1 week: home isosorbide
mononitrate, Lasix 20mg QD and potassium repletion 20mEq QD held
this admission in setting of infection and SBPs ___
restart as tolerated.
[] F/u blood glucose levels, insulin regimen: on home Humalog
___ 95 units SC daily, has been getting 50U glargine QHS
during this admission while mostly NPO. FSBGs mostly in
100s-200s, but had a BG of 409 the morning of discharge after
having breakfast. Would recommend uptitrating towards home dose
prn as PO intake increases.
[] Consider changing to high intensity statin if able given
significant cardiovascular disease.
#CODE: Full, confirmed
#CONTACT: ___ (husband) ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male presented after a fall tonight. He was recently
diagnosed with a large cerebellar mass which he has been
symptomatic from, with double vision and ataxia. The fall
occurred after he had difficulty judging where a step was. Per
the patient, after he had a MRI demonstrating a large right
mostly cystic cerebellar lesion which extends into the
cerebellar
pontine angle, he has been attempting to establish care with a
neurosurgeon. The patient has been symptomatic since ___ of
this
year with right facial numbness, diplopia, and ataxia. He
endorses a number of recent frequent falls. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. No evidence of dissection, occlusion, stenosis, or aneurysm formation
within the great vessels of the head or neck.
2. Re-demonstration of a hypodense mass at the right cerebellopontine angle
measures 4 cm x 3 cm and is pressing upon the brainstem, compatible with
likely vestibular schwannoma as visualized on prior MR from ___.
3. Basilar artery and right vertebral artery appear closely adjacent to the
previously characterized mass, however neither appears to be encased by the
mass. The patient was diagnosed with Disorder of brain, unspecified, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had right cerebellopontine angle mass
Bilateral partial ___ nerve palsy. 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 to neurosurgery service after a fall
with large cystic cerebellopontine angle mass.
#CPA mass
He was started on Decadron for cerebral edema. He underwent CTA
for operative planning. Ophthalmology evaluated patient and
findings were consistent with bilateral ___ nerve compression,
causing his diplopia. Given the mass location, Dr. ___
___ transfer to ___, Dr. ___. Patient and HCP
were updated and in agreement. An Audiogram was done on ___
prior to transfer to ___.
#Dysphagia
SLP evaluated patient and he was found to have intermittent
aspiration with thin liquids. He was put on nectar thick diet. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ well known to surgical service, with history of
multiple SBOs s/p exploratory laparotomies for the same (last
one
___ who presents with diffuse abdominal pain associated with
several episodes of nausea and one episode of bilious emesis. Of
note, admitted to ___ surgical service on ___ for same
issue. Treated with conservative measures and was discharged
home
with normal return of bowel function and tolerating regular
diet. Radiology showed High-grade small-bowel obstruction with a transition point in the right lower
quadrant.
These findings were discussed with Dr. ___ by Dr. ___ at 2:15
a.m. on ___ in person at the time of discovery. Radiology showed Continued small-bowel obstruction with worsening dilatation of
small bowel loop in the mid abdomen. Radiology showed No significant change compared with ___. Possible small right
effusion. Otherwise, no acute pulmonary process identified. The patient was diagnosed with INTESTINAL OBSTRUCT NOS. The patient was treated with Exploratory laparotomy/ lysis of adhesions. 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>The patient presented to the ___ ED on ___, two days out
from prior discharge due to intermittent chronic abdominal pain,
cramping and increaing nausea. An NG tube was placed and CT
abdomen/pelvis showed high grade small bowel obstruction. She
was subsequently admitted to the ___ surgery service
and treated intially with bowel rest, NG tube and TPN. Given her
reoccurrance and the fact she was not showing signs of
improvement she ultimately underwent an exploratory laparotomy
with Dr. ___.
GI: She was made NPO and IV fluids were initiated. Nausea was
treated with IV ondasetron and ativan. Due to poor nutritional
status a PICC line was placed and patient was placed on TPN. Her
diet was advanced as her bowel function returned slowly until
she was placed on a regular diet on POD10, which she tolerated
well. She was tolerating a regular diet at discharge on POD11,
passing flatus and stool.
CV: Vital signs were routinely monitored and the patient
remained hemodynamically stable
Pulm: There were no respiratory issues. Extubated after surgery
without issues.
Neuro: Pain was controlled with IV morphine and acetaminophen.
She was transitioned to PO medications upon d/c.
GU: Foley ___ was placed upon admission for urinary output
monitoring and discontinued; the patient returned to straight
caths for neurogenic bladder which she had been preforming at
home. She did have a urine analysis and urine culture performed
as there was residue seen on the foley cathater tubing, but no
urinary tract infection was found to be treated.
PPX: The patient received subq heparin and wore SCDs.
--------------------</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 a past medical history
of Type 1 diabetes on insulin, ESRD on HD (___), and
gastroparesis with history ___ tears who presents
with abdominal pain, nausea, and dark brown emesis. Pt was
recently discharged from ___ on ___ for hematemesis vs
hemoptysis and gastroparesis and her abdominal pain had been
controlled. Since her discharge, she went to HD on ___ and
was feeling well through the weekend. This morning, the patient
awoke complaining of severe ___ epigastric pain. She also was
vomiting with small amounts of dark-brown emesis and unsure if
"coffee-ground" appearance. She reports taking her medications
including her insulin up until yesterday, though did not take
her insulin this morning as she was feeling ill. Radiology showed 1. Right central venous catheter with tip in the upper right atrium. No
pneumothorax.
2. Severe pulmonary edema, significantly worsened since the previous exam.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 2:05 ___. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormalities resolved pulmonary edema The patient was diagnosed with DIAB HYPEROSM COMA IDDM, DIAB NEURO MANIF IDDM, GASTROPARESIS, GASTROINTEST HEMORR NOS, RENAL FAILURE, UNSPECIFIED. The patient was treated with R IJ placement. At the time of discharge, the patient had PRIMARY:
1. hyperglycemia
2. insulin dependent diabetes mellitus
3. end stage renal disease, on hemodialysis
4. hypertension
5. gastroparesis
6. abdominal pain. 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 a history of poorly controlled
T1DM, ESRD on HD, and gastroparesis who presented with
hemoptemesis, nausea, vomiting, and abdominal pain found to have
elevated blood sugars in and acidosis, most consistent with HHS. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo woman with multiple cardiovascular risk
factors (HLD, pre-DM, Fhx, ongoing cig smoking), CAD s/p stent
with prior MI in ___, CVAs x2 including left occipital stroke
in ___, lung CA s/p chemotherapy and surgery, atypical chest
pain, who presents with headache and chest pain. CHEST (PA AND LAT) showed No acute intrathoracic process. CT HEAD W/O CONTRAST showed 1. No acute intracranial abnormality. Specifically no acute intracranial
hemorrhage or territorial infarct.
2. Nonspecific white matter hypodensities are unchanged and commonly seen in
setting of chronic microangiopathy in a patient of this age.
3. If there remains high clinical suspicion for infarct, MRI would be more
sensitive if there no contraindications. The patient was diagnosed with Other chest pain, Headache. The patient was treated with Cardiac catheterization (no stents placed). At the time of discharge, the patient had Primary Diagnosis:
1. Unstable Angina
Secondary Diagnosis:
2. 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 ___ year old woman with multiple cardiovascular
risk factors (HLD, pre-DM, Fhx, ongoing cig smoking), CAD s/p
stent with prior MI in ___, CVAs x2 including left occipital
stroke in ___, lung CA s/p chemotherapy and surgery, atypical
chest pain, who presents with headache and chest pain found to
have a normal EKG and negative troponins.
# Chest pain: Given her normal EKG, negative troponins, and
history of atypical CP with a negative workup, and reproducible
chest pain on palpation, an acute coronary process was
considered unlikely during her presentation. We started her on
naproxen, continued her home aspirin, and continued to monitor
her clinically. However, she complained of chest pain on
hospital day one and had a negative EKG and negative troponins.
Cardiology was consulted and recommended cardiac
catheterization. The cardiac catheterization was unchanged from
her prior evaluation and a cardiac etiology for her chest pain
was felt to be unlikely.
# Headache: She had a CT head that showed no acute intracranial
abnormality. We continued her home Oxycodone-Acetaminophen
(5mg-325mg) ___ and avoided IV opioids after she had transient
opioid-induced delirium. Her headache had resolved prior to
discharge.
# Opioid-induced transient delirium: During her hospitalization,
she had an episode of pin-point pupils, slurred speech,
somnolence, decreased respiratory rate to ___ breathes per
minute, and dry mouth which was likely secondary to receiving
oxycodone and IV morphine. She was hemodynamically stable,
satting well on room air, and mentating during the episode and
was without focal neurological signs with unchanged baseline
weakness in her right upper and right lower extremity. She was
back to her baseline within 30 minutes of the episode. We held
IV pain medications and she did not have any similar episodes
before she was discharged.
# H/o stent and CVA: We continued her home clopidogrel.
# Cardiovascular risk factors: We continued her home aspirin and
atorvastatin.
# GERD: We continued her home pantoprazole.
# Hypothyroidism: We continued her home levothyroxine.
# Chronic back pain: We continued her home gabapentin 600mg and
oxycodone-acetaminophen.
# Insomnia: We held her home TraZODone 150 mg and gave her
trazodone 50mg PRN instead. We held her home melatonin.
# Allergies: We held her home hydrOXYzine and cetirizine.
# ?Asthma: We held her ProAir HFA (albuterol sulfate).
# Vitamins: We continued her home multivitamins, cyanocobalamin,
and held her home fish Oil.
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (sister, HCP) ___
TRANSITIONAL ISSUES
[] Follow-up with cardiologist Dr. ___. Consider
starting low-dose beta blocker (ie. Lopressor 12.5mg BID) if her
blood pressures allow.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o female with HCV s/p treatment, EtOH
cirrhosis c/b ascites, varices, and HE, and recent admission for
alcoholic hepatitis who presents as a transfer for c/f portal
vein thrombosis. CHEST (PORTABLE AP) showed No acute cardiopulmonary process. MRI of the Abdomen showed Cirrhosis, portal hypertension and splenomegaly without any evidence of portal
vein thrombosis.
Newly developed liver steatosis, not present on ___.
Mild to moderate ascites.
Very small low suspicious liver lesion in the lateral segments which is
amenable to consideration of attention in followup. Ultrasound-guided diagnostic paracentesis showed 1. Technically successful ultrasound guided diagnostic paracentesis.
2. 20 cc of fluid were removed and sent for requested analysis. Radiology showed 1. Mildly distended loops of small bowel with air-fluid levels most likely
consistent with mild ileus. ULTRASOUND-GUIDED DIAGNOSTIC AND THERAPEUTIC PARACENTESIS showed 1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 2.75 L of clear, straw-colored fluid were removed and sent for requested
analysis. The patient was diagnosed with Portal vein thrombosis, Alcoholic hepatitis without ascites. The patient was treated with EGD with dobhoff placement ___
Diagnostic paracentesis ___
Diagnsotic paracentesis ___. At the time of discharge, the patient had Primary diagnosis:
====================
Alcoholic hepatitis
Alcohol use disorder
Secondary Diagnosis:
======================
Ileus
HCV/ alcoholic cirrhosis
Prolonged Qtc
Thrombocytopenia. 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 ___ y/o female with HCV s/p treatment, EtOH
cirrhosis c/b ascites, varices, and HE, and recent admission for
alcoholic hepatitis who presented as a transfer w/ concern for
PVT but was found not to have PVT by MRI and found to have
worsening alcoholic hepatitis.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ male with no significant past medical history who
presented as transfer from ___ due to abnormal
CTA chest. Radiology showed Technically successful CT-guided biopsy of the left lower lobe lung
mass/consolidation. No immediate complications. Chest radiograph, portable AP upright. showed No evidence of pneumothorax. The patient was diagnosed with Pneumonia, unspecified organism. The patient was treated with ___ CT-guided left lower lobe lung mass/consolidation
biopsy.. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Lung mass
Back pain
Sinus tachycardia. 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 ___ with no significant past medical
history who presented to OSH with pleuritic back pain, found to
have abnormalities with lung mass on CTA chest, transferred to
___ for further workup, ultimately underwent lung biopsy for
suspected malignancy vs infection.
#Left lower lobe peripheral lung mass
#Pleuritic back pain
Patient presented with back pain increased with inspiration. CTA
performed at ___ showed a left lower lobe peripheral lung
mass with surrounding ground-glass opacity. Differential
included bronchoalveolar carcinoma, fungal infection, atypical
bacterial infection. No family history of lung cancers at young
age. He does smoke marijuana on a daily basis. He was treated
initially with CTX/azithromycin which was stopped at ___.
Pulmonary and ___ were consulted. Patient underwent CT guided
percutaneous lung biopsy targeting the left lower lobe mass on
___ after multidisciplinary discussions. CXR after the
procedure showed no pneumothorax. His pathology and other
results will be followed by the pulmonary team, followup to be
arranged after discharge. He should have an appointment within
the next 4 weeks.
# Sinus Tachycardia
He had sinus tach in 100s to 110s intermittently. CTA did not
show any PE. Likely there was an element of pain and anxiety
contributing. He received 25 mg Hydroxyzine with a calming
effect.
# Normocytic anemia
Hb 12.8 on HD 3, possibly in setting of receiving IVF, would
recheck as an outpatient.
TRANSITIONAL ISSUES:
==================
[] f/u biopsy micro and path </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with relapsing remitting
multiple sclerosis who presents with vision changes. MRI BRAIN AND ORBITS PT4 MR ___ showed 1. Interval development of multiple lesions demonstrating hyperintense FLAIR
signal abnormality compatible with multiple sclerosis, with majority
demonstrating abnormal enhancement and slow diffusion suggestive of an acute
process. The largest of these lesion is involving the left calcarine cortex
and optic radiation tracks, likely attributing to patient's symptomology.
2. No evidence of optic neuritis. The patient was diagnosed with Multiple sclerosis. At the time of discharge, the patient had Multiple sclerosis flare. 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>___ presented with one week of right-sided visual
artifacts and difficulty seeing on the right. She was found to
have a right homonymous hemianopsia. MRI brain showed multifocal
FLAIR hyperintensities with contrast enhancement, consistent
with an acute MS flare. She was treated with IV
methylprednisolone. She received three doses as an inpatient and
will complete two doses as home infusion. She will follow up
with her outpatient neurologist to start long term MS therapy.
Her course was otherwise notable for headache which responded to
tramadol and mildly elevated blood sugars while on prednisone.
Her home medications for headache, depression and anxiety were
continued.
She was discharged with a peripheral IV in place for the purpose
of her home IV infusions.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with history notable for
prostate cancer s/p XRT, complex renal cysts, colonic tubular
adenoma, and ___ esophagus who was recently found to have
a liver mass biopsied to be adenocarcinoma with markers not
consistent with colonic or lung origin who presented from the
___ clinic with fevers and a left biliary tube leak. CT scan of the abdomen and pelvis. showed 1. At least 3 new hypodensities noted within the liver, 1 of which is adjacent
to the recently inserted left-sided biliary drainage catheter with additional
months in segment ___ and segment 7 respectively, likely represent bilomas.
These do not have enhancement pattern suggestive of cholangitic abscesses.
2. Residual dilatation of the intrahepatic biliary ducts as described above,
post placement of bilateral internal external percutaneous biliary drains.
Underlying cholangitis cannot be excluded.
3. Right lower lobe subsegmental consolidation as detailed above, concerning
for focal aspiration pneumonitis.
4. The large heterogeneously enhancing mass in the right lobe of the liver
compatible with the known tumor appears more solid on today's exam. There is
an exophytic component of the tumor that appears to be invading the hepatic
flexure of the colon, there is however no bowel obstruction.
5. Revisualization of the solid 1.7 cm renal lesion within the right kidney,
suspicious for renal cell carcinoma.
6. Stable lucency at the T12 vertebral body, which should eventually be
evaluated with a bone scan as previously recommended.
NOTIFICATION: The treating Hematology/Oncology Team was made aware of the
findings at 12:10 On ___. CHEST (PORTABLE AP) showed 1. Stable elevation the right hemidiaphragm.
2. PICC line positioned appropriately.
3. Biliary drainage catheters overlie the right upper quadrant.
4. No signs of pneumonia. Radiology showed 1. Occluded left PTBD.
2. Successful exchange for new bilateral 10 ___ PTBDs. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen. Elevation
of the hemidiaphragm with subsequent right basilar atelectasis. The
ventilated lung parenchyma shows no evidence of pneumonia, pulmonary edema or
pleural effusions. Unchanged silhouette The patient was diagnosed with CHOLANGITIS. The patient was treated with ___ Billiary drain placement and replacement. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
SEPTIC SHOCK
BILLIARY OBSTRUCTION
CHOLANGITIS
SECONDARY DIAGNOSIS:
ADENOCARCINOMA IN LIVER (UNKNOWN PRIMARY). 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 gentleman with a history of
adenocarcinoma of unknown primary causing biliary obstruction
now s/p biliary drain placement x2 during his prior admission,
who is admitted to the MICU with septic shock secondary to
cholangitis/infected bilomas.
# Septic shock: Cholangitis vs infected bilomas. Biliary
obstruction likely caused by adenocarcinoma. Patient presented
with hypotension requiring pressors, tachycardia, leukocytosis,
and fever. He was found to have new bilomas on CT imaging.
Recent blood cultures from ___ revealed VRE in ___
bottles. Blood Cx at ___ grew pseudomonas sensitive to zosyn.
Given linezolid and zosyn (first dose ___. Pressures
improved with IVF, pt required pressors only briefly during ___
procedure for replacement of billiary drains (see bellow).
#Billiary Obstruction: Secondary to adenocarcinoma. Billiary
drains placed, found to be clogged, replaced on ___. During
procedure, SBP was in the ___, patient responded to brief
administration of phenylephrine. Did not require pressors on
floor after procedure. LFTs downtrending.
#Adenocarcinoma: Based on path markers is not of colon or lung
origin. Mass causing biliary obstruction with increased total
bilirubin. He will be seen for follow up in Liver Tumor MDC on
___ by hepatology, medical oncology, and interventional
radioloty where consideration will be given to systemic
chemotherapy.
# Anemia: Normocytic anemia. Patient recieved 1u pRBC with
appropriate response. Hemolysis labs negative. Iron studies
consistant with anemia of chronic disease.
TRANSITIONAL ISSUES
- Continue linezold/zosyn for at least 2 week course (day 1:
___ - ___ for VRE bacteremia and pseudomonas bacteremia
- Please obtain weekly CBC/differential with BUN/creatinine
while patient is on linezolid
- Please obtain infectious disease input regarding course of
antibiotics
- Call ___ rehab ___ to follow up blood cultures
with VRE & ___, MD ___
- Patient was discharged with 2 biliary drains drained to
gravity. Please let interventional radiology know if patient has
any pain, tenderness, redness, or unusual discharge at the drain
or around the drain site.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of crohns disease and collagenous colitis s/p
colectomy, chronic abdominal pain on narcotics, history of
multiple previous central lines complicated by possible ___
syndrome presenting with increasing watery diarrhea over the
last month. Pt presented today after she had difficulty walking
up stairs as she was too weak to climb. She promoted
palpipations, lh, and dizziness at tis time. In terms of her
diarrea, she has chronic watery stools which have increased in
freq over the last several weeks. She promotes having ___
loose bm daily. Often times notes bright red blood in them. She
did travel to ___ in early ___ after which symptoms
worsened. Infectious work up on ___ as an outpatient was
unrevealing. She completed a course of cipro/flagyl without
improvement in symptoms. Patient denies any fevers or chills.
She denies any chest pain. Does promote shortness of breath with
exertion. She denies any urinary symptoms. Pt believes symptoms
are secondary to crohns flare. Radiology showed No acute intrathoracic process. Radiology showed 1. Status post total colectomy. Mild dilatation of the ileoanal J-pouch
without evidence of obstruction.
2. Unchanged wide-mouth ventral hernia containing small bowel without evidence
of strangulation.
3. Unchanged perisplenic and adnexal cystic structures.
4. Unchanged presacral soft tissue thickening which is likely postoperative in
nature. Radiology showed 1. Assessment of the superior vena cava is slightly limited by the indwelling
stent however the vessel opacifies well with no direct or secondary evidence
of SVC thrombosis.
2. Slightly prominent nodes within the lower neck which are
unchanged/borderline enlarged when compared to the prior CT. Further
assessment with ultrasound could be performed if clinically relevant. Radiology showed Area of swelling contains only normal fat, without
lymphadenopathy or other mass. Lipodystrophy should be considered as a
potential etiology. The patient was diagnosed with DEHYDRATION. At the time of discharge, the patient had Chronic Diarrhea
Acute Kidney Injury. 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>___ female with a hx of crohns disease and collagenous colitis
s/p colectomy, ___ syndrome s/p stenting to ___, depression
who presents with acute on chronic abdominal pain, diarrhea, and
swelling of left face with MRV not showing signs of ___
syndrome.
#Diarrhea/abdominal pain: Acute on chronic for last 4 weeks. Has
baseline malabsorption/diarrhea secondary to collagenous colitis
and colectomy. Given that patient has had ___ BMs daily, this
appears more likely to be part of chronic diarrhea state ___ to
colectomy rather than crohn's flare. Stool studies as noted
below pending. Patient was previously prescribed tincture of
opium, however she had not started it. She was started on
tincture of opium and did well as a result. Once she started on
___, she did not have issues with ___ (despite being NPO and not
receiving IVF for ~20 hours for her imaging study). She has
follow up appointment with ___ in ___ who has been
following her for her chronic abdominal pain and diarrhea.
#Soft tissue swelling: Patient presented with worsening neck and
supraclavicular swelling which was concerning for ___ syndrome
given that patient has hx of subclavian stenosis s/p stent. MRV
did not reveal vascular source of neck swelling and plethora,
this was originally thought to be ___ lymph node enlargement so
an ultrasound was performed which only showed prominent
subcutaneous fat.
___ Syndrome: First dx in ___ and has been difficult to
manage. Thought to be ___ to frequent central line placement. In
___ a stent was placed in ___ but quickly clotted but
revascularized following in-stent balooon angioplasty. ___ has
been well controlled this then. However, INR has proven
difficult to control given frequent diarrhea, poor intestinal
absoprtion, poor diet, and alcohol use. Target INR 2.5-3.5 given
history of recurrent thromboembolic disease. On PE, pt does have
L>R facial swelling which she says is consistent with previous
IJ clots, however MRV was unrevealing. Started Lovenox on
___ to bridge INR (see below for anticoagulation)
-warfarin 12mg PO daily with follow up with ___
clinic
-after compromising with patient, will bridge INR with 1.5mg/kg
lovenox until INR>2, then may discontinue
___: Patient presented with Cr 2.5 from baseline 1. Most
likely prerenal from poor po intake and recent exacerbation of
diarrhea. Patient was resuscitated with IVF and started on ___
as noted above. Patient was encouraged to take PO liquids and
did well.
#Depression: Pt has long standing depression. While denies SI,
has made overtures that she would consider hurting herself.
-continue with SSRI
-patient should follow up with her PCP regarding her depression</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ with history of atrial fibrillation on Coumadin
(chads2 4), HFpEF (LVEF 63% ___, hypertension, and T2DM who
presents with weakness in setting of hypoglycemia.
History is limited by patient participation. Patient by report
had not been feeling well since early this weak, he describes
overall weakness as well as some low-level nausea. He also
endorses a recent headache. A concerned neighbor called for EMS
and patient was brought to ___ ED for further evaluation and
treatment.
In the ED, initial vital signs were: 97.8 80 139/88 18 99% RA
- Labs were notable for:
INR >13.1 -> 11.6
PTT 107.5
___ 150
Prolatctin 7.7
Mg 1.5
VBG ___
UA: 46RBCs, 30 Prot, 300 Glu
Upon arrival, patient was noted to be quite lethargic and slow
to respond. Head imaging subsequently obtained showed a 3.5x
1.3cm hyperdensity in the sella eroding into the sphenoid sinus
(see below). Neurosurgery was consulted and recommended INR
reversal and admission to medicine for further work-up, no acute
indication for surgical intervention.
- Studies performed include:
MRI BRAIN
1. Study was prematurely aborted due to significant pain and
claustrophobia experienced by the patient.
2. Large expansile pituitary mass that erodes the sphenoid
sinuses anteriorly, suspicious for a probably hemorrhagic
invasive macroadenoma.
3. Additional 5.5 x 1.1 cm plaque-like lesion extending from
the prepontine cistern inferiorly to the foramen magnum is
likely a separate entity, may represent a meningioma.
4. MRI brain with contrast is required for further
characterization of both findings.
NCCTH
1. 3.5 x 1.3 cm hyperdense expansile mass in the sella eroding
through the roof of the sphenoid sinus, which may reflect a
pituitary mass. Dedicated MRI the sella is recommended for
further characterization.
2. No intracranial hemorrhage.
3. Paranasal sinus disease. Please correlate with clinical
findings.
CXR
INDINGS:
Cardiac silhouette size is moderately enlarged but similar
compared to the prior exam. The mediastinal and hilar contours
are not substantially changed in the interval. Mild pulmonary
vascular congestion is similar to the prior exam. There is no
focal consolidation, pleural effusion, or pneumothorax is
detected. There are no acute osseous abnormalities visualized.
IMPRESSION:
Similar mild pulmonary vascular congestion.
- Patient was given:
___ 12:44 PO/NG Phytonadione 5 mg
___ 14:57 PO Lorazepam 1 mg
___ 19:30 IV Phytonadione 5 mg
___ 19:30 IV Kcentra
___ 19:42 SC Insulin 8 Units
___ 20:05 IV Kcentra 4 Units
___ 21:45 IV LORazepam
___ 22:32 SC Insulin 5 Units
___ 22:32 PO Pravastatin 80 mg
___ 22:32 PO Omeprazole 20 mg
___ 23:04 IV Magnesium Sulfate
___ 00:07 IV Magnesium Sulfate 2 gm
- Vitals on transfer: 98.0 94 161/100 20 98% RA
Upon arrival to the floor, the patient is slow with his
responses. He is able to say ___ and eventually says
___ He says he is at the hospital because of
'low...something.' He denies any acute complaints. No headaches.
He does endorse chronic blurry vision in his L eye for the past
___. Patient says that he manages all of his medications by
himself, though is unable to name any of them. He is not sure
what dose of Coumadin he takes, but is sure that he has been
taking it. 10-point ROS is limited by patient
participation/mental status. CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD showed 1. Re-demonstration of the precontrast hyperdense pituitary macroadenoma which
shows fairly diffuse enhancement postcontrast. No new enhancing lesions. No
compromise of the ICAs.
2. The macro adenoma extends into the sphenoid sinus below with associated
mucosal thickening/air-fluid level in the left sphenoid sinus. Please note
that a CSF leak cannot be excluded, but this may also be due to retained mucus
in the sinus due to narrowing of the left sign and ostium.
3. No significant stenosis by NASCET criteria of the imaged carotid arteries. MR HEAD W AND W/O CONTRAST showed 1. Motion limited exam.
2. Large lobulated sellar mass invading the medial portions of bilateral
sphenoid sinuses, with mild extension to the left cavernous sinus and abutment
of the left ICA without evidence for narrowing, and with mild retro clival
extension. Subacute blood products in the left superior sellar component of
the mass.
3. In addition to the mild retro clival extension of the sellar mass, there is
a larger retro clival nonenhancing signal abnormality from the dorsum sellae
to the top of the dens, with small amount of layering subacute blood products
at the level of the craniocervical junction. Given the presence of subacute
blood products in the sellar mass, this may represent a chronic hematoma.
4. While the retro clival abnormality compatible with hematoma effaces the
prepontine and pre medullary cisterns, there is no compression of the
brainstem and no significant mass effect on the cervicomedullary junction. The patient was diagnosed with Other specified disorders of brain. At the time of discharge, the patient had likely pituitary macroadenoma
Hypoglycemia
supratherapeutic INR
atrial fibrillation
type II diabetes
Hypertension. 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>BRIEF SUMMARY
=============
Mr. ___ is a ___ with history of atrial fibrillation on
Coumadin (chads2 4), HFpEF (LVEF 63% ___, hypertension, and
T2DM who presented with weakness in setting of hypoglycemia,
subsequently found to have new pituitary mass concerning for a
pituitary macroadenoma.
# Expansile sellar mass concerning for pituitary macroadenoma:
Initially presented to ED with weakness and hypoglycemia. He was
noted to be lethargic upon presentation, and a CT head showed a
3.5x1.3 cm hyperdensity in the sella eroding into the sphenoid
sinus. Neurosurgery was consulted, and felt that there was no
need for inpatient surgical intervention, currently no focal
neurologic findings. ENT was consulted, and will coordinate with
neurosurgery for surgical management as an outpatient. He was
discharged to follow up as above.
# Supratherapeutic INR: INR >13 on admission, unclear etiology.
___ be due to inapprpropriate med administration in the setting
of confusion. He received vitamin K and Kcentra in the ED, with
normalization of his INR given concern for bleeding into the
suprasellar mass. His warfarin was held, and once cleared by
neurosurgery was transitioned to ___ to bridge and restarted
on warfarin. He was discharged on his prior dose of warfarin
with strict instructions to follow up for INR checks and with
his PCP.
# Hypocortisolemia:
# subacute confusion: Patient with a few weeks of new confusion,
may be related to neuroendocrine deficit secondary to mass.
Endocrine was consulted and recommended sending testing for the
HPA axis. He was found to have low testosterone and low AM
cortisol. IGF-1 and ACTH were normal. He was started on
hydrocortisone 20 mg QAM and 10 mg QPM with improvement in
mental status. Low testosterone level was not treated.
# Hypoglycemia: Patient with report of hypoglycemia when EMS
arrived. No hypoglycemia in house. His glargine initially at 16
units BID, then increased to 18 units BID but he had borderline
low blood sugars so this was reduced back to 16u BID at
discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman with HTN and DM who presented from her
assisted living facility with acute onset left leg and face
weakness with slurred speech at 12:00 noon today. She was
walking
with her rollator when she suddenly started dragging the left
leg
behind her and her speech sounded slurred. She was helped into
bed (required 2 aides, normally she is able to do this alone)
then slept for 1.5 hours. When she awoke, she continued to have
left leg weakness therefore she was sent to the ED. Upon
arrival,
BP elevated to 182/63 but came down without intervention. Her
daughter met her in the ED and at that time, symptoms had
resolved. She noticed some tremulousness of the hands and word
finding difficulties slightly worse than usual, but otherwise
appeared well with no clear weakness or numbness and without
slurred speech. CT/ CTA revealed hypodensity in the R basal
ganglia and no significant vascular abnormalities.
Toxic/metabolic/infectious workup was negative. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Focal areas of slow diffusion consistent with acute infarcts in the right
putamen and body of the right caudate nucleus as described above.
2. T2/FLAIR hyperintensities in the subcortical white matter suggests chronic
microvascular ischemic changes.
NOTIFICATION: The findings were discussed by Dr. ___ with
Dr. ___ on the ___ ___ at 10:09 am, 10 minutes after discovery
of the findings. The patient was diagnosed with Disorientation, unspecified, Hypokalemia, Altered mental status, unspecified. At the time of discharge, the patient had acute ischemic 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>___ woman with a history of HTN and DM presented with
acute onset left-sided weakness and slurred speech that lasted
for 2 hours before resolving spontaneously prior to presentation
to the hospital. She was admitted to the stroke service. CT head
showed hypodensity in the right basal ganglia. MRI brain w/o
contrast confirmed small acute infarct in the right putamen and
as well as the body of the right caudate nucleus. Her stroke was
most likely secondary to small vessel disease given the location
and her risk factors. We did consider this a failure of ASA. Her
home aspirin was stopped, and she was started on Plavix 75 mg
daily. She had mild weakness on the L side in an upper motor
neuron pattern distribution. ___ assessed and felt that she was
able to be discharged home with home ___. She passed her swallow
evaluation. TTE not done as this was felt to be small vessel
etiology.
Her stroke risk factors include the following:
1) DM: A1c 5.5%
2) intra and extra cranial calcifications noted on CTA
3) Hyperlipidemia: LDL 173, started on atoravastatin 80
#
CKD--Cr 1.4 on admission, 1.2 on discharge (baseline).
TRANSITIONAL ISSUES
stroke - follow up in stroke clinic in ___ months. Stopped
aspirin, started Plavix 75 mg daily this admission. Increased
atorvastatin to 80 mg qhs.
DM - continue glycemic control
HTN - continue blood pressure control
Consider outpatient Echo
Home ___
TSH pending at the time of discharge</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o M ___ with ___ duodenal ulcer in ___ (NSAID
induced per patient), s/p H. pylori eradication ___, p/w 3 days
of RLQ pain and BRBPR. No nausea, vomiting, hematemesis or
melena. No history of abdominal surgeries. Patient reports that
he had BRBPR and intermittent diarrhea and constipatino x 2
months. Presented to OSH 2 months ago, had KUB, and was given
stool softeners. Symptoms continued, and started having ___
diarrhea, so he had colonoscopy 3 weeks ago with Dr. ___
___ affiliate). He was told he has "cancer" of some kind, but
was supposed to discuss details with Dr. ___ ___. No
fevers/chills at home, currently ___ diarrhea/day. No sick
contacts at work or home, no recent travel. Radiology showed 1. Extensive bowel wall edema, surrounding inflammatory changes, and
associated trace acites in the distal and terminal ileum. Additionally, there
is some inflammatory changes in the cecum at the level of the ileocecal valve.
This is most consistent with an enteritis, either inflammatory or infectious.
2. Normal appendix. Radiology showed No acute cardiopulmonary radiographic abnormality. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. The patient was treated with Open Right Hemicolectomy. At the time of discharge, the patient had Right Sided Colon 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>Mr. ___ was initially admitted to the ___ medical service
from the emergency department:
___ y/o M with h/o remote duodenal ulcer, presents with abdominal
pain, BRBPR x2 months, CT showing cecal and terminal ileum
inflammation.
# Colon Mass: Presented with RLQ abdominal pain and BRBPR. Per
discussion with outpatient GI doctor, he has colonoscopic
evidence of a large apple-core mass in the ascending colon.
Biopsies were taken of this lesion, which were consistent with a
poorly-differentiated colon primary. CT showed evidence of
thickening and inflammation in this region. Colorectal surgery
recommended resection of this lesion, especially in the setting
of anemia.
# Anemia: Baseline Hct appears to be in the mid 40's as of ___, but on admission it was down to 32, and continued to drift
down during his time on medicine. Given the presence of a large
colon mass, this is the likely source of blood loss.
The patient was transferred to the colorectal surgery inpatient
surgery pre-operativly. His CEA was 21. Right open colectomy was
preformed on ___. The patient tolerated this
procedure well and recovered on ___ 5. Post-operative day
one, the patient was given intrvenous pain medications and
fluids. All post-operative laboratory values were stable. He
ambulated without issue with god pain control. Clear liquids
were tolerated well. The foley catheter was removed at midnight.
The patient was able to voisd without issue on post-operative
day two. In the late morning of ___ day two, the
patient reported passing flatus. His diet was advanced to
regular which was tolerated well. All pain medications were
transitioned to pills. The patient was requiring minimal
narcotic medications. On the morning of post-operative day
three, the patient was stable and tolerated breakfast. He
continued to pass flatus. He was meeting all discharge criteria
and was discharged home in the care of his supportive wife. All
follow-up instructions were given to the patient. The pateint
had access to a ___ inerpreter throughout his
hospitalization however, he understands ___ well. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ G6P3 @ 10w2d by LMP (LMP ___ which makes
___ ___ although states she was given ___ of ___ with
h/o chronic abdominal pain, longstanding narcotic use, adrenal
insufficiency (per notes likely secondary to chronic narcotic
use) who presents to the ED with multiple complaints including
abdominal pain, nausea/vomiting and right facial numbness. Seen
by Neurology for evaluation of right facial numbness and
multiple
other neurologic complaints. Per their initial impression, most
c/w functional, have not yet recommended imaging. OBGYN
consulted
re: abdominal pain/nausea/vomiting in the setting of early
pregnancy. Radiology showed There is a Dobbhoff tube which is too high, with the distal tip in the mid to
lower esophagus. This should be advanced at least 20-25 cm or removed.
Cardiomediastinal silhouette is within normal limits. There are no focal
consolidations, pleural effusion, or pulmonary edema. There are no
pneumothoraces. Radiology showed The Dobbhoff tube has been advanced with the distal tip well within the body
of the stomach, appropriately sited. Heart size is within normal limits.
There are no focal consolidations, pleural effusion, or pulmonary edema. There
are no pneumothoraces. The patient was diagnosed with OTH CURR COND-ANTEPARTUM, CHEST PAIN NOS, SKIN SENSATION DISTURB. At the time of discharge, the patient had Nausea and vomiting of pregnancy. 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 is a ___ year old G6P3 who was admitted to the hospital
on ___ given persistent nausea in early pregnancy. Her
hospital course was notable for several other issues below:
1. Persistent nausea/abdominal pain: On admission patient had
reported a 10 pound weight loss over several weeks, as well as
vomiting at home. Initial diagnostic evaluation was negative for
concerning etiologies of nausea/pain. She had a negative
ultrasound for adnexal pathology, normal white blood count
making appendicitis or other infectious etiologies unlikely, and
a normal urinalysis making kidney stones or urinary tract
infection unlikely. Her nausea was felt to be consistent with a
combination of nausea of pregnancy and long-standing nausea. In
the hospital, she was initially managed with oral zofran and
fluids and intermittently was able to tolerate oral intake. Her
pain was managed with her normal doses of narcotics (see problem
below). By hospital day 4, however she was unable to tolerate
oral intake due to nausea and abdominal pain induced by nausea.
She requested IV ativan use in order to eat and received a few
doses of this with good ability to eat. Additional services were
consulted to evaluate alternative reasons for the patient's
persistent nausea. Endocrinology was consulted due to history of
adrenal insufficiency, and while her steroid dose was increased
to stress dosages, this did not improve her ability to take oral
intake. Psychiatry was also consulted, due to history of
somatization disorder, and her presentation was felt to be
consistent with this. There was no intrinsically medical reason
identified for persistent nausea. Because she was able to
tolerate some oral intake, she was switched to oral ativan which
she initially declined. She declined all other oral medications,
despite demonstrated ability to tolerate oral intake and
requested IV ativan in exchange for eating. This request was not
met, and patient unable to consistently provide herself with
nutrition for another 2 days, although she was able to take oral
ativan and dilaudid. Per recommendation from hospital
nutritionist, decision was made to proceed with enteral feeding
through a feeding tube. Thus, on hospital day 7 (___), a
Dobhoff tube was placed in a two step fashion in the patient's
stomach. Appropriate location was confirmed with a chest x-ray
and enteral feeding was started. The patient was able to
tolerate enteral feeding without any vomiting, and she was
passing gas and having bowel movements. Plan was made to proceed
with enteral feeding as an outpatient, however given patient's
insurance, outpatient tube feeding was not possible. On hospital
day 10, tube feedings were cycled overnight, which patient
tolerated well, and attempts were made for patient to eat and
drink around the tube. Patient did overall well with this on
hospital days ___. Tube feeding was decreased on hospital day
14, and plan was made to stop tube feeding on hospital day ___
(___) with plan for removal on ___. However, patient
reported being unable to eat and she had lost 3 kg over ___ days
by hospital day 16 (___) and thus tube feeding was
restarted. On hospital day 17, team decided that tube feeding
was counter-productive to goals of care for patient (to go
home). Since patient had demonstrated ability to eat, and tube
was felt to be limiting ability to eat, plan was made with
patient approval for trial of feeding without feeding tube. The
feeding tube was thus removed. On hospital day 17, patient able
to eat and drink and thus decision was made for trial of home
with close outpatient ___. Of note, she was discharged on
a week's worth of oral ativan (7 days x three times daily), as
well as zofran, doxylamine, pepcid, and vitamin b6 to optimize
ability to tolerate oral feeding. Of note, ativan is not a
standard anti-emetic in pregnancy, and thus this medication was
provided for initial optimization, but it was made clear to
patient this would not be a continuing medication provided by
obstetric service in pregnancy.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: (Patient is non-verbal with severe dementia, all information is
from ___)
.
___ with history of severe vascular dementia (non-verbal at
baseline), lives in a nursing home who presents with 1 day of
nausea/vomiting. She vomited brown liquid today x3 with 2
episodes of diarrhea (per EMS report). Pt non-verbal and can not
communicate symptoms or story. In ED Labs notable for lactate
2.1, K 6.5, Na 147, Cr 3.6. Trop 0.03. WBC 21 with 92% neuts.
HCT 43, Plt 241. INR 1.0, PTT 25. EKG showed no peaked T waves.
Pt given 30 kayexelate but drank very little of it. CT abd
showed: dilated small bowel loops, 3.3cm, ___oncern for possible obstruction caused by internal hernia. No
evid of bowel ischemia. NGT placed. Pt given vanc and zosyn.
Power of attorney decided against surgical intervention and
ultimately decided to transition to comfort measures only.
.
Patient currently appears comfortable and is in no acute
distress.
.
REVIEW OF SYSTEMS:
can not obtain Radiology showed Nasogastric tube coils in the fundus and terminates in the
gastric body. The patient was diagnosed with INTESTINAL OBSTRUCT NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED, DEHYDRATION, HYPERKALEMIA, ARTERIOSCLER DEMENT NOS, CEREBRAL ATHEROSCLEROSIS. At the time of discharge, the patient had Small Bowel Obstruction
Hyperkalemia. 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>PRIMARY REASON FOR ADMISSION
___ F with severe dementia who presents with emesis with CT
showing SBO, pt is admitted for for medical management of SBO,
acute renal failure, hyperkalemia, leukocytosis. After
discussion with patient's power of attorney, pt was made comfort
measures only.
.
# Small bowel obstruction: Patient was admitted with emesis. CT
scan demonstrated SBO with at least 2 transition points likely
___ internal hernia with a closed loop. Initially NG tube was
placed and patient was evaluated by surgery regarding possible
intervention. In discussion with the patients HCP/power of
attorney the decision was made not to persue surgical
intervention. She was latter made comfort measurues only the
the NG tube was removed. She was symptomatically managed with
PRN morphine, zofran and ativan.
.
#Leukocytosis: Pt was notes to have a leukocytosis on admission
with a predominance of neutrophils. Differential includes:
urinary vs GI source. CXR also concerning for a possible
pneumonia. The patient was covered broadly for gram neg, gram
pos, anaerobes in ED with vanco and zosyn. Antibioitic were
discontinued when care was transitioned to comfort measures.
.
#Severe Sepsis: On admission met patient was tachycardic with a
leukocytosis, likely source being urinary or GI, meeting
criteria for sepsis. Lactate 2.1 (>2.0) suggesting severe
sepsis. MAP>60 therefore patient did not meet criteria for
septic shock. As above the patient was initially started on
antibiotics as well as IVF these were discontinued.
.
#Hypernatremia: Na 147, pt is 1.8 L free water deficit. Likely
from poor access to water.
.
# ARF: Initialy Cr 3.6. Likey pre-renal in setting of sepsis,
emesis, SBO, poor access to water and hydration. ATN also
considered, possibly preceeded by a pre-renal state. Given 3 L
in the ED. Acute renal failure likely explains hyperkalemia.
.
#Hyperkalemia: K 6.5, confirmed on green top. Likely from ARF.
EKG with no peaked T waves, narrow QRS, no EKG signs of
hyperkalemia right now. However, pt not able to take kayexelate
since she has SBO and not able to excrete K through bowel
movements. K will likely increase and cause arrtyhmias. Power of
attorney is aware, he wants patient to be CMO, he explained that
he does not want any dialysis.
.
# ? Lung mass: Patient noted to have possible RUL mass on CXR
concerning for malignancy. CT was recommended for further
evaluation. However this was not done given patients poor
prognosis from other active medical issues.
.
#Comfort Measures Only: Patient's power of attorney requests
that patient be CMO. Wants goal of care to focus on comfort
only. He does not want any surgeries, no tubes, no HD. Given
patients rising K, she is at risk for arrythmias. Also at risk
for hypotension in the setting of possible sepsis. Pt
unfortunately not able to verbalize any pain or discomfort. She
was given PRN morphine for pain. All vitals and lab draws were
held. In dsicussion with the power of attorny the decision was
made to transition her to hospice care at her home facility.
.
TRANSITIONAL ISSUES
- As above patient should be treated with comfort measures only
- Patient will receive hospice care at her home facility</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs ___ is a ___ with CLL, secondary ITP on Prednisone and
recently started on Rituxan, HTN, HL, carotid artery stenosis,
likely CAD s/p recent demand-type NSTEMI with TTE showing
regional WMAs c/w CAD and increased LVEDP, who presents with
dyspnea on exertion. Chest radiograph showed Increased interstitial prominence due to mild to moderate pulmonary edema or
potentially atypical infection. Small right pleural effusion. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism to the segmental level or aortic
abnormality.
2. Mild to moderate asymmetric pulmonary edema with bilateral small to
moderate pleural effusions and moderate cardiomegaly.
3. Multiple prominent mediastinal lymph nodes, measuring up to 1.0 cm.
Suspected but not well assessed subcarinal nodes which are likely enlarged. The patient was diagnosed with 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>This is a ___ with CLL, secondary ITP on prednisone and recently
started on Rituxan, HTN, HL, carotid artery stenosis, likely CAD
s/p recent demand-type NSTEMI with TTE showing regional WMAs c/w
CAD and increased LVEDP, who presents with dyspnea on exertion
consistent with pulmonary edema. Course complicated by
acute-left sided weakness and neglect concerning for CVA vs.
TIA.
Active Problems -
# Dyspnea on exertion and
# Acute hypoxic respiratory failure, likely due to
# Pulmonary edema with bilateral pleural effusions, likely due
to
# Acute diastolic CHF: Her story is fairly consistent with acute
diastolic CHF, with recent admission where she received fluids
initially but also had NSTEMI and TTE showing some LV overload
(BNP at that time was quite elevated as well). She has history
of fluid overload requiring diuresis in context of platelet
transfusion. Last admission she was discharged only on home
HCTZ, which may have been inadequate to maintain euvolemia.
Prednisone also likely contributed to fluid retention, and
recently she received her Rituxan infusion ___, after which she
began developing shortness of breath. During her
hospitalization, she received a total of 100 mg IV Lasix (doses
of 40 mg, 40 mg, and finally 20 mg IV on ___ with improvement
in her symptoms. She is no longer requiring additional O2.
Goal is to continue gentle diuresis with aim of -500cc/24 hours.
Her oncologist is aware that she will likely need Lasix with
her next Rituximab infusion.
# Acute left-sided weakness and left gaze neglect - occurred the
morning of ___, along with noted dysarthria. Upon assessment
by the neurology team, her symptoms had resolved but upon
reassessment several hours later, her symptoms recurred (see
discharge exam) raising concern for a flow-limiting lesion,
especially in light of her carotid artery stenosis on the right.
Her symptoms resolved with laying flat and improvement of her
SBPs to the 140s (she has been otherwise in the 100s-120s).
Neurology recommends an MRI here along with vascular surgery
consult to discuss CEA, however patient and her family prefer to
transfer to the ___ as her vascular surgeon is there. Therefore
no studies were performed here prior to transfer, except for a
lipid profile (at goal), hemoglobin A1C (at goal), and TSH
(wnl). She was on ASA every other day due to her ITP; after
discussion with her oncologist, she was changed to daily
aspirin. She is on a statin.
# CLL, ITP - followed by Dr. ___. Recently
admitted in ___ with steroid-resistant ITP, so was started
on Rituximab for a planned 4 doses over 4 weeks. Her Rituximab
will be held this week per her oncologist given acute medical
issues. She will need Lasix with future infusions as noted
above. Her baseline WBC is in the low ___ platelets in
the ___ is good for her. She is on prednisone 20 mg daily for
her ITP.
# CAD, recent NSTEMI type 2 - during recent admission in ___,
she sustained a type II NSTEMI (no EKG changes, peak Troponin at
OSH 1.5) felt to be in the setting of hypotension from
dehydration due to norovirus. TTE showed WMA c/w underlying CAD
and preserved systolic function. Her troponins trended down and
then back up here to 0.28, likely from fluid overload. She had
no EKG changes or symptoms. She is on aspirin, BB, and ACE-I
(latter two which may need to be held to allow for permissive
hypertension given concern for CVA).
# Sinus tachycardia - HR in the ___ here, likely related to
hypoxia and volume overload. Improved to ___ prior to d/c with
improvement of hypovolemia.
# GERD - on PPI.
Patient is full code.
HCP: ___
Relationship: Daughter
Phone number: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx of multiple UTIs and neurogenic bladder, seizure
disorder, and chronic constipation on standing bowel regimen
presents from nursing home with 1 day of fever to 101.8 on
___. Of note, patient reported eating impressive ___
meal on ___ with eggs ___ and some dairy, and endorse
emesis thereafter associated with meal. She reprots since then
she has felt well, with no abdominal pain, chills, chest pain,
shortness of breath, or back pain or dysuria. Yesterday, she
felt a little warm, and temperature was 101.7. She was brought
to the ED given her history of recurrent UTIs, including history
VRE. Per patient, she spoke gibberish yesterday night, which
"usually happens with my UTI's". Radiology showed No definite pneumonia, though given the baseline abnormality in the right lung
base, an acute process is difficult to exclude. If indicated, short term
followup chest radiographs or CT could be obtained. The patient was diagnosed with URIN TRACT INFECTION NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS
UTI. 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>Mrs. ___ is a ___ year old woman with neurogenic bladder
complicated by multiple urinary tract infections presenting with
fever, mental status change, increased urinary urgency with
leukocytes and white blood cells on urinalysis. Given patient's
history of chronic UTIs and the clinical presentation the most
likely diagnosis is UTI.
# UTI: Patient has a history of recurrent UTI's in setting of
neurogenic bladder, and comes in with fever, dysuria and grossly
positive U/A. On admission she was empirically started on
vancomycin and zosyn for UTI after review of her prior culture
date. Given microbiological history, and patients allergy to
linezolid, she was transitioned to daptomycin for gram positive
and meropenem for gram negative coverage ___. In house,
Ms ___ symptomatically improved. Urine culture taken before
abx administration on ___ showed fecal contamination, so
patient was empirically narrowed to ciprofloxacin based on her
prior urinary tract infection of Morganella morganii sensitive
to Ciprofloxacin. Patient was monitored for a an additional
48hrs on ciprofloxacin alone to assure she remained afebrile and
symptom free. On ciprofloxacin she continued to feel improved,
mentoring at baseline and was d/ced back to rehab on ___ with
plan to discontinue antibiotics on the evening of ___.
# Frontal maxillary sinus tenderness: Nasal exam unconcerning
for acute bacterial sinusitis (no purulent dischagre or focal
tenderness but rather B/L frontal sinus tenderness). Of note,
patient is on guaifenesine at nursing home for "nasal
congestion". It appears patient has been using afrin off and on,
making rebound congestion possbility. She was trialed on
fluticasone with good response.
# Constipation: home constipation regimen: bisacodyl pr, fleet
enema prn, milk of magnesium, senna. will continue. One time
episode emesis ___ concerning for possible obstruction though
patient passing gas. She had a BM ___ without issue.
# Hx HIT: No heparin products used in house. Use fondaparinoux. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old female who presents to ___ on ___ with a mild TBI. CTA HEAD WANDW/O C AND RECONS showed 1. Unchanged findings of a large frontal intraparenchymal hemorrhage with
surrounding edema, local mass effect, and rightward bowing of the anterior
falx.
2. New, layering intraventricular hemorrhage within the bilateral occipital
horns.
3. Stable appearance of a small subdural hematoma along the anterior left
temporal and frontal lobes.
4. No new or additional sites of acute intracranial hemorrhage. No evidence
for acute vascular territorial infarction by CT.
5. Patent intracranial vasculature without high-grade stenosis, occlusion, or
aneurysm greater than 3 mm.
6. Additional findings, as above. MR HEAD W AND W/O CONTRAST ___ MR HEAD showed 1. 5.9 cm left frontal intraparenchymal hematoma appears slightly increased in
size compared to 1 day ago. No definitive underlying enhancing mass lesion is
identified. Recommend repeat examination after resolution of hematoma for
better evaluation of any underlying lesion.
2. Ventricular size similar. Rightward midline shift of the left frontal lobe
is also similar.
3. Additional findings as described above.
RECOMMENDATION(S): Consider follow-up imaging after resolution of hematoma
for better evaluation of any underlying lesion. CHEST (PORTABLE AP) showed No previous images. There are low lung volumes that accentuate the prominence
of the transverse diameter of the heart. The minimal if any vascular
congestion. No evidence of pleural effusion or acute focal pneumonia. The patient was diagnosed with Traum subrac hem w/o loss of consciousness, init, Fall on same level due to ice and snow, initial encounter. 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>#IPH with cerebral edema
The patient was admitted from the emergency department to the
neuro intensive care unit where she was started on Mannitol
therapy. A bolus of Decadron was given but then shortly after
discontinued. She was started on Keppra for seizure prophylaxis.
A CTA was performed which demonstrated a stable large left
frontal intraparenchymal hemorrhage with edema. There was no
evidence of vascular abnormalities. An MRI was also ordered due
to concerns for an underlying lesion given the location, size,
and morphology of the bleed which was negative to underlying
lesion with recommendations to repeat in 6 weeks. She remained
stable and was transferred to ___ on ___ where the mannitol
was weaned to off. Neurology was consulted who recommended
follow-up in the stroke neurology clinic with repeat MRI to
re-evaluate for underlying lesion and follow-up in ___ clinic if
needed after discharge. Patient was evaluated by ___ and OT who
recommended rehab. She remained neurologically stable and was
transferred to the neuro floor. Her electrolytes were repleted
PRN and she was given a small fluid bolus for slightly elevated
BUN with improvement.
#Hypertension
Patient's home atenolol 25mg was switched to metoprolol tartrate
12.5mg BID. In order to maintain SBP goal <160 the dose was
increased to metoprolol tartrate 25mg BID. The patient tolerated
this well and blood pressure was maintained at goal. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year-old female with h/o migraines and left trigeminal
neuralgia who underwent a left posterior fossa craniotomy for
decompression on ___. The procedure was uncomplicated and
she was discharged home on POD#3 in stable condition after a
routine post-operative course. Decadron was tapered and
discontinued on ___. She was seen in outpatient clinic on
___ for suture removal with complaints of left ear fullness,
which has been persistent since that time. Also admits to
muffled hearing and a crackling sensation. Denies pulsating pain
or ringing in ears. No drainage from ear. No inner ear pain. She
does admit to left-sided facial pain since yesterday, different
from her pre-operative TGN pain, and headache since this
morning. Also complains of dizziness and a feeling of "leaning
to the left". Denies fever/chills, redness/drainage from her
surgical wound. CT HEAD WITHOUT CONTRAST showed No acute intracranial abnormalities are identified. Changes from prior no
velocity compression are identified on the left side. Scratch previous
embolization is noted. MR HEAD W AND W/O CONTRAST showed 1. Posterior fossa craniectomy and cranioplasty with fluid subjacent to the
craniotomy site. This may represent postoperative change although all
pseudomeningocele is not excluded.
2. Left mastoid effusion.The bony margins are better delineated on prior CT
dated ___ when there was no evidence of focal dehiscence at the floor
of the middle cranial fossa The patient was diagnosed with HEADACHE, TINNITUS NOS. At the time of discharge, the patient had Mastoid effusion
Migraine
TMJ. 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 Neurosurgical Service for further
evaluation of left ear fullness, headache, & dizziness on ___
s/p left posterior fossa craniotomy for TGN. The patient's pain
was well controlled with Tylenol and oxycodone. Head CT was
reported to show no acute intracranial findings, but was notable
for fluid in the mastoid. Her CRP on admission was 11.2. ENT
service was consulted for concern of possible CSF leak or
mastoiditis. Imaging was reviewed and felt to represent fluid in
the mastoid with no evidence of bony destruction or coalescent
mastoiditis. Recommendations were made to obtain MRI and pursue
treatment of other possible contributing factors including
migraines and TMJ. An MRI Head was performed on ___ which
showed postoperative changes s/p posterior fossa craniectomy and
left mastoid effusion.
The hospital course was otherwise remarkable. The patient
remained afebrile and neurologically intact. She continues to
have left sided head pressure and ear fullness with decreased
hearing on the left. Based on the imaging and overall clinical
picture, decision was made to discharge the patient home on a
steroid taper, with instructions to follow up closely with ENT
(Dr. ___ and neurosurgery (Dr. ___. A thorough
discussion was had with the patient regarding the expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient expressed readiness for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of HTN and vasovagal syncope as well as prior
constipation and N/V following prior non-abdominal surgeries who
presents with constipation, N/V, and abdominal pain following L
thumb surgery on ___. Pt fell in the setting of increasing
pain following surgery, but daughter was present and denies LOC.
Pt reoprts history of vasovagal syncope in past. Pt reports that
she has become constipated and not had BM since surgery 5 days
ago. During that time has developed nausea and frequent vomiting
(green color), with poor po intake. Has also developed abdominal
pain. She reports these symptoms are similar to her course
following knee surgeries last year (pt was in rehab at the
time), although did not have abdominal pain in the past. Per
daughter, pt's 'GI system completely shuts down' and may take
weeks to recover. At home, she has been on scopolamine patch and
zofran. Began taking vidocine after fall, and then tramadol. No
known recent antibiotics or sick contacts. Pt denies fevers,
SOB, cp. Radiology showed 1. Diffuse bowel wall thickening throughout the colon with adjacent fat
stranding, with sparing of the distal sigmoid colon and rectum, consistent
with pancolitis, either infectious or inflammatory in etiology.
2. Small amount of ascites in the abdomen and pelvis. The patient was diagnosed with ABDOMINAL PAIN UNSPEC SITE, NAUSEA WITH VOMITING, UNSPECIFIED CONSTIPATION, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with Sigmoidoscopy (___). At the time of discharge, the patient had Ischemic colitis
___, likely pre-renal
HTN
HLD
Overactive bladder. 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 history of HTN and vasovagal syncope as well as prior
constipation and N/V following prior non-abdominal surgeries who
presents with constipation, N/V, and abdominal pain following L
thumb surgery on ___, found to have pancolitis on CT and
findings consistent with ischemic colitis on sigmoidoscopy.
#Ischemic colitis: Pt with symptoms of N/V, constipation,
abdominal pain, and poor po. Pt was given 1 dose metronidazole
in ED. CT shows pancolitis with sparing of distal colon and
sigmoid. Inflammatory markers elevated. Underwent sigmoidoscopy
with findings consistent with ischemic colitis; with biopsies
taken. Possibly due to hypotension during recent surgery. Pt
symptoms improved during admission, and leukocytosis resolved.
Pain was treated with tylenol; opiates avoided due to potential
to slow bowel transit. Pt was treated with bowel regimen for
constipation; per GI stimulating laxatives were avoided. Pt was
placed on low residue diet and was tolerating po prior to
discharge. Amlodipine was discontinued given desire to avoid
further hypotension, with goal SBP>120. Pt to avoid NSAIDs,
continue low residue diet, use colace and miralax prn
constipation; po hydration encouraged. Will follow up with GI in
___ week for full colonoscopy.
#HTN: Given ischemic colitis, goal SBP >120. Amlodipine was
discontinued. Home lisinopril and metoprolol were continued.
Also remained on asprin 325mg.
___, likely pre-renal: Recent baseline creatinine 0.8-1.0.
Creatinine elevated at 1.2 on admission. Likely prerenal in
setting of poor po, BUN:cr >20. Creatinine returned to baseline
after IV fluids.
#Hyponatremia: Possibly hypovolemic hyponatremia in setting of
poor po intake. Improved following IVF.
#HLD: Continued on pravastatin.
#Overactive bladder: Home oxybutynin was held during admission
given potential effect on constipation; was restarted at
discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old man with h/o hyperlipidemia, bipolar disorder, and
hypothyroidism who presents with chest pain. Radiology showed No acute intrathoracic process. The patient was diagnosed with INTERMED CORONARY SYND. The patient was treated with Coronary angiography ___ with placement of bare metal stent
to OM1. At the time of discharge, the patient had Primary:
- ST Elevation Myocardial Infarction, posterior
Secondary:
- Coronary artery disease
- Hyperlipidemia
- Hypothyroidism
- Bipolar disorder. 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 ___ yo M with a history of hyperlipidemia, but no
known history of CAD who presented with ongoing substernal chest
pain found to have elevated cardiac biomarkers and ECG showing
ST depressions in V2-V4 concerning for posterior STEMI (vs.
anterior ischemia), now s/p coronary angiography with bare metal
stent deployment in OM1.
# STEMI/CAD: Patient presented with posterior STEMI (peak CKMB
89) found to have occlusion in OM branch now s/p BMS placement.
Patient also found to have 2 vessel CAD that was not intervened
on. ___ had 40% stenosis in distal segment, and LAD had
adjacent ostial and proximal 70-80% stenosis. Patient's risk
factors for CAD include hyperlipidemia and family history.
Echocardiogram showed some focal areas of hypokinesis but
overall EF relatively preserved at 50-55% with no clinical
evidence of heart failure.
- Patient should have an Imaging Stress Test in ___ weeks as
outpatient to evaluate if the residual LAD disease is
significant and warrants further intervention. He was scheduled
to follow-up with ___ in cardiology at ___.
- Started on prasugrel for at least one month (ideal 12 months)
- Started ASA 325 mg
- Changed home lovastatin to atorvastatin 80 mg
- Started Metoprolol Succinate 25 mg Daily for post-MI secondary
prophylaxis
- Started Lisinopril 2.5mg, this can be uptitrated as an
outpatient as BP tolerates
- Patient was given information and contact numbers for cardiac
rehabilitation programs near him.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ M w/ PMH cholangiocarcinoma s/p R
hepatectomy,
extraehaptic bile duct rsxn w/ RNY HJ ___ for
cholanagiocarcinoma p/w incisional hernia, pain, nausea and
obstipation x 12 hrs. He reports that he saw Dr. ___ in clinic
___ and had begun to develop obstipation, nausea the day
prior to clinic visit that self-resolved. Planned for elective
incisional hernia repair, and was going to hear from surgical
services this week re: timing of surgery. By ___ was
feeling great. ___ am, however, he developed abdominal pain
at his hernia, the hernia was "popping out" and he also
developed nausea, burping, obstipation. He had no emesis yet.
In ED,
received IVF, antiemetic and pain control and is now feeling
better, but hernia still bothering him and is "stuck out." No
other complaints on ROS. ABDOMEN US (COMPLETE STUDY) showed 1. Small volume ascites. No evidence of varices.
2. A small amount of pneumobilia is consistent with prior
hepaticojejunostomy.
3. Splenomegaly is mild. The patient was diagnosed with Other and unsp ventral hernia with obstruction, w/o gangrene. At the time of discharge, the patient had Incarcerated incisional hernia. 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 with history of incisional hernia was admitted to
the General Surgical Service for evaluation of severe abdominal
pain. In ED patient was found to have incarcerated hernia,
which was manually reduced. After patient's hernia was reduced,
patient's diet was advanced to regular and was well tolerated.
On HD 2, patient underwent abdominal US as part of pre-operative
evaluation. Ultrasound revealed small volume ascites without
evidence of varices. Patient continue to tolerated regular diet,
he was able to move his bowels, and he denied abdominal pain.
Patient was discharged home in stable condition. Prior his
discharge, he was scheduled to see his Hepatologis for pre-op
evaluation.
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 instructions with understanding verbalized and
agreement with the discharge plan.</s> |