Datasets:

Jarmac
/

llama2_bhc_dataset_train_prompt

Dataset card Viewer Files Files and versions Community

Split (1)

train · 68.8k rows

text stringlengths 519 60.4k
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ ___ woman with a history of CAD, sCHF (EF 40-45%), CKD IV-V, IDDM, HTN, and pseudomembranous colitis s/p colectomy with ileostomy was referred to ED for positive blood cx after recent admission ___ for possible viral gastroenteritis and shortness of breath possibly ___ aspiration. Blood cultures drawn ___ grew GPR's today c/w corynebacterium or propionibacterium species and so patient was referred to ED where she endorsed possible subjective fevers, denied CP/SOB, abd pain. While in the ED she had an episode reportedly of leg weakness and vomiting, she tells me it was not so much weakness as pain in her L thigh which now persists, this is a new pain for her. She also says the episode of vomiting was very small, it happened after getting up after urinating and feeling lightheaded.Initial Vitals 16:10 0 97.7 62 150/54 18 96%. Labs: Na 132, K 5.9 (lipemic specimen), hco3 21, BUN 60, Cr 2.9, Glu 204, WBC 7.7 62%N Hgb 10.1. She was given insulin, glucose, calcium, and 1L NS. repeat K was 5.4 with lactate 1.4, EKG unchanged from prior, CXR non-acute with enlarged heart and mild pulm edema. Vitals prior to xfer Today 21:29 0 98.5 71 151/55 20 93% RA with FSG 167. On the floor, says she had cramping in her L thigh which has been intermittent over the past few days, now resolving. Review of Systems: (+) per HPI (-) chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed Moderate cardiomegaly with mild edema. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is again substantial enlargement of the cardiac silhouette with relatively mild vascular congestion. This discordance the raises the possibility of pericardial effusion or cardiomyopathy. Minimal small bilateral pleural effusions with probable atelectatic changes at the bases. CT CHEST W/O CONTRAST showed Bilateral dependent atelectasis. Subtle bilateral ground-glass opacities may represent mild pulmonary edema. No evidence of pneumonia. Moderate cardiomegaly. Coronary artery calcifications. 8 mm splenic hypodensity, likely representing a cyst or hemangioma. The patient was diagnosed with HYPERKALEMIA, BACTEREMIA NOS. At the time of discharge, the patient had Primary: Rhabdomyolysis Hypoxia Adenoviral gastroenteritis bacteremia Secondary: chronic kidney 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>___ ___ speaking woman with a history of CAD, sCHF (EF 40-45%), CKD IV-V, IDDM, HTN, and pseudomembranous colitis s/p colectomy with ileostomy referred for blood cx drawn ___ with corynebacterium vs. proprionobacterium, admitted for hyperkalemia and an episode of vomiting/leg cramps in ED with continued nausea/vomiting, found to have a CK of 35,000 possibly related to statin therapy. #POSITIVE BLOOD CULTURE: The patient was called back after prior admission for GPR's in single cx c/w propionobacterium or corynebacterium growing 6 days after culture was drawn. Given that the patient has no prosthetic valves or devices (only stent from CABG in ___, was afebrile, and had a normal WBC, it was thought that this was very likely a skin contaminant. Patient did have vomiting in the ED and on the floor, however this was determined to be a viral gastroenteritis. Repeat blood cultures from ___ were negative. #RHABDOMYOLYSIS. Patient reported L thigh cramping on admission. CK 35,000 on admission w/ h/o admissions to ___ in ___ and ___ with similar elevations. At these times it seemed to be linked to her fibrate/statin therapy, and this was the working diagnosis on this admission as well. This also explains her elevated AST/LDH as well as her admission hyperkalemia (also in the setting of ___. Her hyperkalemia was normalized w/ insulin/gluc/calcium and Kayexalate. Pravastatin was promptly discontinued, and aggressive IV hydration was begun. When the patient became hypoxic in the setting of CKD and high volume load, fluids were d/c'd. By this time, her CK had trended below 3,000, so this was deemed safe. #HYPOXIA. Likely V/Q mismatch ___ pulmonary edema in the setting of fluids for rhabdomyolsis. No signs of PNA, no suspicion for PE, and given CHF and CKD, as well as clinical exam, edema was a sufficient explanation for the hypoxia. The patient was relatively refractory to to diuresis and the clinical exam was never c/f significant volume overload, so other etiologies, including interstitial disease or a clinically significant decline in cardiac functionm, were entertained. A CT scan demonstrated only ground-glass opacities c/f pulm edema, and the patient's O2 sats improved to baseline prior to discharge. #ADENOVIRUS GASTROENTERITIS. Patient was recently admitted prior to this admission for vomiting which resolved that admission and was thought ___ a viral gastroenteritis. On this admission, initially thought to be related to rhabdomyolysis and resultant lyte abnormalities, but viral cultures returned positive for adenovirus. Remaining stool cx/O+P negative. Norovirus negative. #PYURIA, BACTERIURIA. In the setting of a fever to ___, a UA and urine cultures were sent. Pt remained asymptomatic. She was briefly started on ciprofloxacin, but this was discontinued given lack of symptoms and absence of recurrent fevers. #FOOT PAIN. A few days prior to discharge, Ms. ___ began complaining of b/l burning foot pain. Given her history of diabetes and the quality of the pain, it was thought that this was consistent with diabetic neuropathy. Started low dose gabapentin with symptomatic improvement. #VAGINAL PRURITUS. A few days prior to discharge, Ms. ___ complained of vaginal pruritus w/o dysuria, hematuria, or reported discharge. A pelvic exam demonstrated white cervical discharge concerning for candidiasis. She was treated with a dose of fluconazole. #DM2: Fingersticks on this admission were 100s to 200s, so we continued her 30mg humalog ___ qam and qpm plus sliding scale. #HTN: On amlodipine, metoprolol, hydralazine. BPs were 140s-160s this admission, outpt recommendation had been to increase amlodipine to 10mg so we did uptitrate this med. She remained asymptomatic - no headache, no chest pain, vision changes - during this admission. #CHRONIC ANEMIA: Ms. ___ has a chronic normocytic anemia, with Hgb ___, concerning for anemia of chronic disease. Epo levels were elevated. #CKD IV/V: Patient w/ recently placed left fistula. She continued her phosphate binder, sodium bicarbonate (increased to 1300mg TID on this admission) and vitamin D. Her Cr did rise with diuresis in the setting of her pulmonary edema and was 3.7 on discharge, but this is in keeping with previous values in her chart over the past year. #CAD: Patient was noted to have a lipemic specimen on admission labs. Triglycerides were found to be ~700. Unfortunately, she needed to d/c her statin due to the rhabdomyolsis and had had a previous similar reaction to fenofibrate. We continued her home aspirin, started fish oil, and scheduled her for follow up in Cardiology clinic where she will be evaluated for other lipid-lowering treatments. #HFrEF. Per patient, she suffers from baseline SOB when climbing stairs, does not walk a lot, and spends most of her day in bed. We continued her home metoprolol, Imdur, and hydralazine. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is ___ M with IDDM c/b diabetic retinopathy, nephropathy and likely gastroparesis vs. cannabis hyperemesis syndrome who presents with nausea/vomiting, headaches and blurry vision. Radiology showed Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. CHEST PORT. LINE PLACEMENT showed In comparison with the study of ___, the left central catheter has been removed. There is an placement of a right hemodialysis catheter with the tip in the upper right atrium. No evidence of post procedure pneumothorax. No acute pneumonia or vascular congestion. The patient was diagnosed with Essential (primary) hypertension. The patient was treated with Tunneled dialysis catheter placement ___ Pan-retinal photocoagulation ___. At the time of discharge, the patient had End-stage renal disease Diabetic retinopathy with blindness HTN Insulin Dependent Diabetes Suspected gastroparesis. 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>Pt is ___ M with IDDM c/b diabetic retinopathy, nephropathy and likely gastroparesis who presented with nausea/vomiting, headaches and blurry vision, ultimately started on HD but with persistently erratic BPs. Left AMA due to family emergency, but plans to return to care within ___ hours. # N/V ___ suspected diabetic gastroparesis # Malnutrition Pt with multiple admissions for these symptoms and now presented with the same. Previously thought to be gastroparesis vs. cannabis-hyperemesis syndrome but given worsening renal function, may also represent component of uremia. Symptoms remained poorly controlled despite aggressive medical therapy with multiple antiemetics including reglan, as well as HD to address possibility of uremia. Discharged back on prior home regimen of reglan, although this can be titrated further when he returns to care. Would attempt to miminize his overall pill burden as this is a likely contributing factor. # ESRD now on HD Patient with rapid progression of renal failure in recent months. Worsening renal failure attributed to diabetic nephropathy and renal vascular disease. Due to concern for uremia he was started on HD during the admission. He underwent 4 HD sessions. He was started on sevelamer and nephrocaps. As noted above he left AMA on ___. Fortunately he does have an outpatient HD spot for next week, so after he returns to care and other medical issues are optimized, he has an HD spot and transportation to and from his HD center. As of yet no permanent access plans. He was given careful instructions for care of his line while outside of the hospital. Upon his representation would contact ___ regarding outpatient HD plans. # Bilateral proliferative diabetic and hypertensive retinopathy # Bilateral traction retinal detachment with vitreous hemorrhage # Severe vision loss R>L Pt reports progressive blurry vision over the last 2 weeks. Ophtho was consulted and felt symptoms could be consistent with resolving vitreous hemorrhage. Seen by retinal team on ___iagnosed with severe diabetic retinopathy and he underwent panretinal photocoagulation in the R eye. Per ophtho note plan had also been for photocoagulation of L eye, followed by bilateral vitrectomies as outpatient. Patient left before these plans could be confirmed, so would recommend touching base with Dr. ___ patient ___. Patient very distressed by his vision loss and motivated to pursue ophtho interventions. # HTN Patient with history of poorly controlled hypertension, presented with SBPs in 200s, which was felt to be related to pain, vomiting, and medication nonadherence. He was changed from labetalol to carvedilol for increased adherence and restarted on losartan, as well as his nifedipine and clonidine patch. Home hydralazine was held. Initially it appeared his HTN was better controlled, but in the days prior to discharge his BPs fluctuated from 120s-210s, often higher in the morning and lower in the afternoon and evening. He received intermittent hydralazine PRN. His BP will need to be better controlled before a safe discharge, particularly considering the immediate risk of worsening retinopathy and vision loss. Would also consider inpatient secondary hypertension work-up given his erratic BPs. # IDDM: A1C 7.9% ___. Glucose control has been very labile in the past. ___ was consulted and titrated insulin through the admission. His insulin management was complicated by GI symptoms and poor PO intake. Toward the end of the admission he was typically eating minimal food through the day until the evening/night, when he would eat one or two large meals. His insulin was adjusted accordingly, and his glucose levels were relatively well controlled, but only in the setting of relatively poor nutrition. Upon discharge from his re-admission will need to determine safe plan for insulin at home given his vision loss. He has had some help recently from family but does not expect this long term and wishes to inquire about additional help he can get at home through his insurance (this was not addressed prior to his leaving AMA). Of note his current regimen is 9 units lantus daily plus 5 units humalog for meal coverage four times daily if eating (breakfast, lunch, dinner, second dinner), plus sliding scale. This dosing was overall reduced from his prior, which likely related to renal failure and also poor PO intake. # Anemia Hb: 7.0 on admission, has recently been in the 7___s. No e/o bleeding, likely ___ renal disease. Dropped to 6.7 on ___ s/p 1U pRBC with adequate response. Has not received ESA yet due to poorly controlled HTN. #Leukocytosis WBC normal most of admission but rose just prior to his AMA discharge. No localizing findings or fevers to suggest an infection. Will need further work-up if still present when patient returns to care. #Circumstance of AMA discharge Patient's aunt fell ill and patient left on short notice to see her, but plans to return to ED within ___ hours. No alternative plans were devised to avoid this. Patient also left from the last admission for personal reasons with a plan to return, which he followed through with. He is very concerned about his vision and also recognizes that HD is critical at this point and that he needs to return to address these and other issues. Therefore there was no significant question of his capacity and overall it seemed likely he would return as planned. ======================================= TRANSITIONAL ISSUES: [ ] continue to titrate nausea regimen for suspected gastroparesis [ ] Discuss future access plans/?vein mapping with renal team [ ] touch base with ___ about HD plans [ ] touch base with Dr. ___ ophtho plans [ ] Needs plan for insulin management given vision loss [ ] Titrate BP regimen and consider secondary work-up [ ] Continued titration of insulin regimen [ ] recheck CBC and consider infectious work-up if rising leukocytosis [ ] consider hep B immunization as outpatient [ ] discuss with case management potential home care options given patient's vision loss ======================================= >30 minutes in patient care and coordination of discharge</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old M adm s/p fall ___ feet from rope swing. +head strike, +LOC. Pt was admitted ___ and found to have R sided rib fractures and R small pneumothorax s/p CT placement. Chest tube now discharged. TRAUMA TORSO showed 1. Right lateral ninth, tenth, and eleventh rib fractures with associated small right anterior pneumothorax, and air in the right lateral chest wall. The ninth rib fracture is mildly displaced, and the tenth and eleventh rib fractures are nondisplaced. 2. No evidence of solid organ injury in the abdomen or pelvis. NOTIFICATION: The findings were discussed by Dr. ___ with the trauma team, in person ___ at 4:38 ___, upon discovery of the findings. PA and lateral chest radiographs showed Slight interval increase in the small right pneumothorax. CHEST (PORTABLE AP) showed Right pneumothorax has almost entirely resolved following insertion of a new pleural drainage catheter. Moderate right basal atelectasis is stable. Pneumomediastinum may be present. Left lung is clear aside from mild basal atelectasis. Heart size is normal. CHEST (PORTABLE AP) showed There is minimal if any right pneumothorax, and no pleural effusion, following insertion of a replacement right apical pleural drainage catheter. Moderate right basal atelectasis has not yet resolved. Left lung is fully expanded and clear. Heart size is normal. Portable AP chest radiograph showed No pneumothorax or effusion. CHEST (PORTABLE AP) showed Left pleural drainage catheter has been withdrawn to the level of the right third anterior interspace. I cannot be sure it is actually intra thoracic. Right pneumothorax is tiny. No right pleural effusion. Mild bibasilar atelectasis, slightly greater on the right, unchanged. Normal cardiomediastinal and hilar silhouettes. CHEST (PA, LAT AND OBLIQUES) showed Status post removal of the right-sided chest tube. There is a 1 cm right apical lateral pneumothorax without evidence of tension. Minimal atelectasis at the right lung bases. Unchanged appearance of the left lung and the heart. CHEST (PA AND LAT) showed As compared to the previous image, the extent of the known right pneumothorax is constant. No evidence of tension. Better apparent than on previous images is a slightly displaced fracture of the ninth and tenth rib on the right. Normal appearance of the left lung CHEST (PA AND LAT) showed As compared to the previous radiograph, there is no substantial change in appearance of the approximately 1 cm right apical pneumothorax without evidence of tension. PA and lateral chest radiograph showed Small right apical pneumothorax, overall unchanged. CHEST (PORTABLE AP) showed Traumatic findings of right pneumothorax and right lateral rib fractures are better seen on the concurrent CT of the torso. CT HEAD W/O CONTRAST showed 1. No acute intracranial process. 2. Depressed nasal bone, please correlate for acuity. CT C-SPINE W/O CONTRAST showed No fracture or traumatic malalignment. The patient was diagnosed with FX MULT RIBS NOS-CLOSED, TRAUM PNEUMOTHORAX-CLOSE, FALL-1 LEVEL TO OTH NEC. The patient was treated with 1. Chest tube placement - right side for his pneumothorax - d/c on ___. At the time of discharge, the patient had right-sided rib fractures ___, small right pneumothorax. 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 M adm s/p fall ___ feet from rope swing. +head strike, +LOC. Pt was admitted ___ and found to have R sided rib fractures and R small pneumothorax s/p CT placement. Chest tube now discharged showing a small apical pneumothorax, constant over the course of two days s/p CT removal. Patient main issues during this hospitalization involved: 1. Pain: Patient had a significant amount of pain when he was lying in bed, but no pain when standing or sitting. Several attempts of medication/doses were attempted in order to improve his pain. On HD 6 he was discharge home. By the time of discharge his pain had improved with a combination of Oxycontin, Dilaudid, Tylenol, Lidocaine patch and Baclofen. Patient was discharge home with the following pain meds regimen: - Oxycontin 20 mg am x 4 days - Oxycontin 10mg am x 4 days -> Then pt instructed to take Oxycontin 10mg am/pm for a week. - Dilaudid 2mg Q3-6h PRN for 5 days. Then pt instructed to take either OTC tylenol or Advil - Baclofen 10mg TID for 11 days - Lidocaine patch 2. R side pneumothorax: Patient had a chest tube placed as he was noted to have a slight increase of his right side pneumothorax. His chest tube was initially put on suction with successful improvement of his pneumothorax. After his chest tube was removed patient was noticed to have a small apical pneumothorax, that was closely observed the next couple of days. His pneumothorax was small and stable and we felt it was safe to discharge patient home w close follow up. On HD 6 patient was discharge home. On discharge he was tolerating a regular diet, pain was under better control w PO pain meds, we was ambulating w/o difficult, his chest tube incision was c/d. Patient will follow up with us in clinic in the next couple of weeks. Dr. ___ patient to follow up with oour Nurse ___ in a week but unfortunately she does not have any availability in the next couple of weeks. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o woman with complicated cardiac history, including CAD s/p PCI, Afib, sick sinus syndrome s/p PPM, MV replacement, and severe TR that resulted in significant cardiac ascites presenting with syncopal event on ___. Patient states that she had walked to the restroom and had just sat down on the toilet when she felt like a "sheet was coming over her". She subsequently woke up on the ground and had bruises on her right shoulder and wrist. She is unsure of headstrike. She was not confused when she woke up and noticed that 15 minutes had passed. No incontinence of urine or tongue biting. She decided to "sleep it off" and came in today at the request of her son. She has not experienced any chest pain, HA, palpitations. She has a chronic SOB which is unchanged. She reports having difficulty walk ___ a city block and climing stairs that has been ongoing for the past couple months. She denies any recents fevers, chills, nausea, vomiting, diarrhea, dizziness. Patient states she was seen in ___ to have her pacemaker interrogated and was told battery needed replacement, but has not had that done due to a change in her cardiologist Patient also recently increased lasix dose per PCP ___ 100mg qAM and 80mg qPM. Has not taken for past 3 days in case it may have led to her fall. In the ED, initial vitals were: 97.7 65 144/46 18 100% RA - Labs were significant for: 11.0 5.1 >--< 179 33.7 N:66.9 L:21.3 M:9.6 E:1.2 Bas:0.6 ___: 0.4 137 102 9 --------------< 60 5.2 25 0.8 ___: 24.9 PTT: 40.4 INR: 2.3 K:4.5 Glu:49 Lactate:1.0 - Imaging revealed: CT head with no acute intracranial process. CXR No acute cardiopulmonary process. No significant interval change. - The patient was not given any medication. Cards consult recs: No high rates on interrogation, but PPM at ERI so will require admission for generator change. Please admit to ___ under ___. NPO after midnight. Vitals prior to transfer were: HR 60 137/56 16 97% RA Upon arrival to the floor patient denies any chest pain, SOB, lightheadedness, dizziness Chest: Frontal and lateral views showed No acute cardiopulmonary process. No significant interval change. CT HEAD W/O CONTRAST showed No acute intracranial process. CHEST PORT. LINE PLACEMENT showed In comparison with the study of ___, there is little overall change in the appearance of the dual-channel pacer and leads. Specifically, there is no evidence of pneumothorax. No pneumonia or vascular congestion. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen. Moderate cardiomegaly with mild elongation of the descending aorta. Left pectoral Port-A-Cath. No pleural effusions. No pneumonia, no pulmonary edema. The patient was diagnosed with SYNCOPE AND COLLAPSE. The patient was treated with 1) ___: Pacemaker procedure: Battery at ERI s/p generator replacement. Lower rate was changed to 75 bpm. 2) ___: TTE: Well-seated, normally functioning bileaflet mitral valve prosthesis. Mildly depressed global left ventricular systolic function in the setting of beat-to-beat variability in LVEF secondary to atrial fibrillation. Severe tricuspid regurgitation. Compared with the prior study (images reviewed) of ___, a mild reduction in global left ventricular systolic function is now appreciated. The right ventricle was not able to be accurately accessed. At the time of discharge, the patient had Primary Diagnoses: Sick Sinus Syndrome s/p PPM Cardiac Arrest secondary to Torsade Syncope Atrial Fibrillation Secondary Diagnoses: Diastolic Congestive Heart Failure Anxiety COPD. 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 woman with hx of CAD s/p PCI, Afib, sick sinus syndrome s/p PPM, MV replacement, and severe TR c/b cardiac ascites presented with syncopal event. Etiology of her syncope is unclear; her pacemaker was interrogated and did not show any arrhythmias at home. It was found that the pacemaker had a low battery, so she went for generator change with metronic sensia dual chamber on ___. They tried to place a new RV lead but she had subclavian vein stenosis that prohibited new lead placement. Her hospital course c/b torsades leading to vfib cardiac arrest s/p x1 shock w/ROSC. The torsades was due to long QTC ___ medication error with extra dosing of her dofetilide. She was transferred to the ICU for close monitoring. Her dofetilide was held and she was started on metoprolol 50mg BID to control her atrial fibrillation. Echo showed stable cardiac function. Her INR was elevated at discharge to 4.7; she will have ___ monitor her INR closely after discharge. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female w/ PMHx including Alzheimer's dementia and HLD, RHD, unwitnessed fall possibly down stairs, walked to family holding her right arm with bone exposed. C/o some pain to left forearm. Poor historian given dementia, no other complaints and history obtained from family. At baseline she is mobile on her own, knows her close family, can feed herself (right hand), needs help getting dressed. CHEST (SINGLE VIEW) showed No grossly displaced rib fractures are identified. DX FOREARM AND WRIST showed Open fracture dislocation of the right wrist, with complete volar and radial displacement of the hand and distal radial fragment. Fracture of the ulnar styloid process. Mild cortical irregularity of the radial head, suboptimally evaluated. If there is clinical concern for radial head fracture recommend dedicated elbow radiographs. CT HEAD W/O CONTRAST Q111 CT HEAD showed Atrophy. Otherwise normal study. CT C-SPINE W/O CONTRAST showed 1. Diffuse osteopenia limits evaluation for subtle fractures. 2. No evidence of fracture or subluxation. 3. Multilevel degenerative disease with spinal canal and neural foraminal narrowing. The patient was diagnosed with Oth intartic fx lower end r radius, init for opn fx type I/2, Fall on same level, unspecified, initial encounter. The patient was treated with ___: I&D, ORIF radius, DRUJ pinning ___, ___.. At the time of discharge, the patient had Right open distal radius fracture and ulnar dislocation. 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 hand surgery team. The patient was found to have an open right distal radius fracture as well as radial ulnar joint dislocation and was admitted to the hand surgery service. The patient was taken to the operating room on ___ for irrigation and debridement of the right wrist as well as operative 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 OT who determined that discharge to home 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 nonweightbearing in the right upper extremity. 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: ACS Consult H&P ___ Radiology showed 1. Findings concerning for small bowel obstruction, potentially of the afferent limb near the jejunojejunostomy, although no definite transition point is identified. No obvious evidence of ischemia or perforation within the limitations of paucity of intra-abdominal fat. Surgical consultation recommended. Additionally, small-bowel follow-through series with Gastrografin may be obtained for further assessment. 2. Slight increase in mild-to-moderate intrahepatic biliary ductal dilatation, which is nonspecific, could further suggest afferent limb obstruction. RECOMMENDATION(S): Recommend small-bowel follow-through series with Gastrografin for further assessment. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 2:49 am, 5 minutes after discovery of the findings. Radiology showed Hyperinflated lungs compatible with emphysema with no acute cardiopulmonary process. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Small posterior falx subdural hematoma extending to the tentorium and adjacent small subarachnoid hemorrhage. 2. Large right occipital parietal scalp hematoma without fracture. NOTIFICATION: Discussed with night resident who accompanied the patient to the ED. CT HEAD W/O CONTRAST Q111 CT HEAD showed Interval increase in size of a posterior falx subdural hematoma extending to the tentorium and now the anterior falx. There has been interval increase in the degree of posterior left parietal subarachnoid hemorrhage as well as new left frontal lobe and possibly posterior right parietal lobe subarachnoid hemorrhage. No midline shift. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 10:41 am, 5 minutes after discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Prominent subdural hemorrhage along the superior falx and left tentorial leaflet and multiple areas of subarachnoid hemorrhage involving in the left frontal and temporal lobes are not significantly changed. 2. Several areas of subarachnoid hemorrhage in the right frontal and temporal lobes are new or increased in prominence. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:15 pm, 5 minutes after discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No evidence of infarction or new intracranial hemorrhage. 2. Redemonstration of prominent subdural hemorrhage along the superior falx and left tentorial membrane, minimally decreased in size compared to prior study. 3. Several areas of subarachnoid hemorrhage in the bilateral frontal and temporal lobes appear slightly less conspicuous than on prior study. 4. Large right parietal subgaleal hematoma appears significantly increased in size compared to prior study, now measuring up to 1.6 cm. HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT showed No comparison. A pelvis over view as well as 2 projections of the left hip are provided. Moderate degenerative changes at the level of both hip joints. No evidence of fracture. Multiple phleboliths project over the pelvis. Mild degenerative changes at the level of the sacroiliac joints. US ABD LIMIT, SINGLE ORGAN showed 5.0 x 1.2 x 2.1 cm collection deep to the inferior aspect of the midline laparotomy site, differential diagnosis includes hematoma or a complex seroma. UNILAT LOWER EXT VEINS showed Moderate to severe soft tissue swelling overlying the right posterior knee. No evidence of deep venous thrombosis in the right lower extremity veins. The patient was diagnosed with Other partial intestinal obstruction, Epigastric pain. The patient was treated with ___, PLACEMENT OF JEJUNOSTOMY. At the time of discharge, the patient had afferent loop obstruction abdominal pain subarachnoid hemorrhage subdural hemorrhage traumatic brain 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>Ms. ___ ___ yo F with hx of total gastrectomy with RNY esophagojejunostomy, D2 lymphadenectomy, and Witzel jejunostomy (since removed) ___ for T2aN0 gastric adenoCA who presented on ___ to ___ ED for acute epigastric pain. CT A/P was obtained which revealed dilated small bowel thought to be consistent with afferent loop obstruction. Acute care surgery was consequently consulted in the ED. Patient was admitted under ACS on ___ for further evaluation and management. Overnight ___ patient fell unwitnessed while getting out of bed, striking head. Non-contrast HCT revealed small left sided subarachnoid and parafalcine subdural hemorrhage. She was evaluated by neurosurgery who did not recommend operative management. The patient had a repeat fall with head strike without associated changes on imaging later in her hospital course. She fortunately did not sustain any ongoing neurologic deficits from either fall. On ___ patient underwent uncomplicated ___ enteroenterostomy and placement of jejunostomy with EBL of 20 mL. She was noted to be stable in the PACU s/p 1 unit pRBC. She was ___ transferred to the floor. On discharge her tube feeds were at goal and she tolerating a (small) clear liquid PO diet. On ___ the renal team was consulted for progressive hyponatremia that initially developed on ___. They felt this was likely SIADH in the setting of subarachnoid hemorrhage and recommended fluid restriction and appropriate workup, with expectation of improvement as intracranial hemorrhage improves. The endocrine service was also consulted and after workup were in agreement this was likely SIADH. They agreed with the renal team's recommendation to restrict PO intake to <1L and to continue trending her sodiums at her rehab facility. There is no place for salt tabs or vaptans at this time. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ y/o male w/ a PMHx of recently diagnosed seizures, GAS meningitis & bacteremia, s/p multiple ENT surgical procedures for source control of mastoiditis/cranial abscess and DRESS ___ anti-epileptics and/or multiple abx received during prior admission who presents from ___ office after having LFTs checked that showed uptrending LFTs. CHEST (PORTABLE AP) showed Left upper extremity PICC terminates in the mid to low SVC. MR HEAD W AND W/O CONTRAST ___ MR HEAD showed Interval decrease in size of the known right temporal abscess with associated decrease in surrounding vasogenic edema. The right dural/pachymeningeal enhancement appear similar to slightly improved compared to prior. Opacification of the right mastoid air cells and middle ear cavity appear similar compared to prior, but no restricted diffusion to suggest abscess formation. The patient was diagnosed with Gen skin eruption due to drugs and meds taken internally, Adverse effect of cephalospor/oth beta-lactm antibiot, init, Oth places as the place of occurrence of the external cause, Acute viral hepatitis, unspecified, Epilepsy, unsp, not intractable, without status epilepticus. 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>SUMMARY STATEMENT Mr. ___ is a ___ with PMHx of childhood asthma and multiple B/L ear infections s/p tympanostomy tubes, right upper molar infection s/p extraction, and a recent hospitalization (___) for GAS meningitis/bacteremia (right mastoiditis s/p multiple surgical interventions for source control) c/b seizures and then DRESS/DILI, who presents with worsening of previously down-trending LFTs. ACUTE ISSUES #Acute liver injury: Concern for reactivation of DRESS syndrome vs. drug-induced liver injury, which can relapse even weeks after in the setting of discontinuation of culprit drug. Unsure which drug was original offending agent, however prior vancomycin, meropenem, and Keppra are all possibilities. Given elevated LFTs, Keppra and meropenem were initially held. The patient's LFTs rapidly began to downtrend. Neurology was consulted and recommended switching patient to lacosamide for seizure prophylaxis. ID was consulted and recommended switching patient to daptomycin for brain abscess. The patient was continued on prednisone, as well as his home calcium and famotidine. #H/O GAS meningitis and temporal abscess: Patient was scheduled for head MRI and ID follow up in the coming week. No recurrence of any symptoms and no fevers. Patient had been taking IV meropenem at home as instructed. Last dose 4PM on ___. The patient was switched to daptomycin without side effects. Repeat MRI brain showed interval decrease in size of the abscess. #Seizures: Initially held Keppra, before switching to lacosamide for seizure prophylaxis. #Leukocytosis: Approximately stable since last admission. Likely from steroids vs. DRESS. No infectious signs or symptoms. TRANSITIONAL ISSUES []New medications: IV Daptomycin 650mg q24h (at least until ID follow up on ___ lacosamide 100 bid (at least until neuro follow up ___ []ID working on re-scheduling outpatient appointment and repeat brain MRI []Patient continued on previously documented prednisone taper (see discharge medications) []Consider re-sending LFTs at upcoming dermatology appointment []OPAT labs: weekly CK, CBC, BUN/Cr #CODE: FULL CODE (presumed) #CONTACT: Father ___ ___</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o female well known to our service who underwent right robotic partial nephrectomy and pyelolithotomy (for a large staghorn calculus) on ___. The renal pelvic tissue was thin and friable due to inflammation from the stone and the closure was poor; she developed a urine leak and was discharged home with Foley catheter, ureteral stent, and surgical drain in place. She was subsequently readmitted ___ - ___ with an infected urinoma for which she had a drain placed by ___. Blood and urine cultures on admission were negative but culture of the purulent material from the urinoma grew multiple organisms; initially only Pseudomonas aeruginosa was speciated and she was sent home on a 14-day course of PO ciprofloxacin. Full speciation/sensitivities were requested on the culture and Enterococcus and E. coli were additionally isolated. CTU with contrast, including delayed imaging showed 1. No evidence of collecting system extravasation. No urinoma. 2. The previously seen right perinephric fluid collection has largely resolved with minimal persistent trace fluid. 3. There is a right double-J ureteral stent and a right posterior approach pigtail catheter at the site of the previous right perinephric fluid collection. The superior pigtail of the double-J ureteral stent is inferior to the obstructed renal pelvis, as before. 4. On delayed imaging, there is a right persistent striated nephrogram without evidence of extravasated contrast. A persistent striated nephrogram, likely secondary to obstruction. A portion of the cortex is nonenhancing at the site of the prior partial nephrectomy. Radiology showed The proximal end of the right double-J ureteral stent is now curled in the expected location of the right renal pelvis and the distal end is curled in the right side of the bladder. A right-sided percutaneous nephrostomy tube is in unchanged position. The patient was diagnosed with Urinary tract infection, site not specified, Fever, unspecified. The patient was treated with ___: right ureteral stent exchange. At the time of discharge, the patient had fever and partial right renal obstruction following robotic pyeloplasty. 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 from the ED on ___ with low grade fevers to 101.3. She was started on broad coverage with vancomycin and Zosyn. Repeat CT scan was obtained with delayed cuts showing no extravasation of contrast from the collecting system, but a moderate sized stone causing upper pole hydronephrosis of the right kidney. As before, the right ureteral stent was quite low and was not draining the upper pole. The decision was made to exchange and reposition the ureteral stent and she was added on for cystoscopy and ureteral stent exchange, which was performed on ___. A glidewire was advanced past the stone into the upper pole and a new ___ Fr x 28 cm stent placed over a wire. Retrograde pyelogram showed the collecting system was intact with trace to no extravasation of contrast. The patient did well postoperatively and remained afebrile throughout her hospital stay aside from the initial night of admission. Her ___ drain was removed on HD 3 (POD 1) and she was discharged home later the same day in good condition. She was given a 10 day course of PO ciprofloxacin and amoxicillin/clavulante and instructed to make an appointment with ___ in ___ weeks, and to call the office in two days to follow up her culture results. She will return for an interval discussion with Dr. ___ further management of the stent and stone.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMHx Primary biliary cirrhosis and autoimmune hepatitis referred to ER for workup of increasing bilirubin and abdominal distension. Radiology showed 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 3 L of fluid were removed. Chest radiograph showed 1. Increased prominence of the bilateral hila since ___ can be concerning for sarcoidosis. 2. Low lung volumes with left basilar opacities, which may be due to atelectasis. However, concurrent pneumonia is difficult to exclude in the appropriate clinical setting. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 2:20 ___, 2 minutes after discovery of the findings. MRI of the Abdomen showed Images are compromised by patient motion. Hepatic cirrhosis. Large volume ascites. Varices. Mild splenomegaly. There is no liver mass. Consider mild cholangitis. Patent portal vein. Multiple pancreatic side-branch IPMNs, some have enlarged, largest 1.1 cm. CT CHEST W/O CONTRAST showed 1. Diffuse bronchial wall thickening may reflect bronchitis. 2. Multiple small nodular opacities measuring 4 mm or less may reflect mild atypical pneumonia or inflammatory changes. Consider follow-up chest CT after resolution of acute illness. 3. Mild bilateral lower lobe atelectasis. 4. Liver cirrhosis with ascites and splenomegaly. Radiology showed 1. Successful transjugular liver biopsy. 2. Portosystemic gradient of 16 mmHg The patient was diagnosed with Cholangitis. The patient was treated with ___: Transjugular hepatic core biopsy. At the time of discharge, the patient had Primary: Primary biliary cirrhosis with autoimmune hepatitis Community acquired pneumonia, suspected bacterial source Secondary: Ascites 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>___ year old woman with PMHx Primary biliary cirrhosis and autoimmune hepatitis referred to ER for workup of increasing bilirubin and abdominal distension concerning for progression of autoimmune hepatitis vs. PBC/cirrhosis progression. Ascites was found on ultrasound and large volume paracentesis was performed with no evidence of SBP. Transjugular liver biopsy was performed showing inflammation consistent with autoimmune hepatitis and toxic metabolic injury. Her course was complicated by pneumonia with fever for which she was treated for community acquired pneumonia. # Primary Billiary Cirrhosis: Child B, MELD 21 on admission. History of varices s/p banding. Decompensated by jaundice, ascites and varices with INR, bilirubin above baseline with unclear etiology. Per history, the patient had been taking azathioprine 75mg daily but only 15 days per month. A transjugular liver biopsy with ___ on ___ pathology showing inflammation consistent with autoimmune hepatitis and toxic metabolic injury. MRCP showed ascites and varices without liver mass. She was continued on ursodiol. Azathioprine was increased to 125mg daily. Prednisone was started for autoimmune hepatitis at 40mg on ___ with concurrent bactrim prophylaxis and calcium/vitamin d supplementation. Her ascites was managed with 3L removed by paracentesis with ___ on ___. When renal function stabilized she was restarted on furosemide 20mg, spironolactone 50mg. She was given furosemide 40mg IV for diuresis during her stay due to lower extremity edema and then transitioned back to home dosing of oral furosemide. There was no evidence of SBP 118 WBC on diagnostic para ___. She was continued on nadolol. # Pneumonia, suspected community acquired bacterial: Most likely due to pulmonary etiology from CAP/Bronchitis. CXR showed possible consolidation in LLL. Chest ct showed bronchial wall thickening and opacities that may reflect pneumonia. She was started on levoquin ___ and spiked fever to 101. She was switched to ceftriaxone and azithromycin ___ with no further fevers. Urine legionella antigen negative. CMV VL was negative. EBV VL, mycoplasma antibodies, quantiferon gold pending at the time of discharge. Ceftriaxone/azithromycin transitioned to levoquin on ___ for a planned two week course to complete ___. # ___: Recent baseline Cr 0.6. Presented with ___ to 0.9 with hyponatremia with a history of recent flu like illness with GI component. Alternatively, she has signs of worsening cirrhotic physiology with worsening abdominal distention now with improving creatinine s/p 62.5g albumin. Feurea: 3.5%, FeNa 0.42% suggestive of pre-renal etiology. Restarted Furosemide and spironolactone without renal impairment. TRANSITIONAL ISSUES ============= #NEW MEDICATIONS - Vitamin D ___ UNIT PO 1X/WEEK (TH) for total of 12 weeks. - Levofloxacin 750 mg PO DAILY (LAST DOSE ___ - PredniSONE 40 mg PO DAILY - Sulfameth/Trimethoprim SS 1 TAB PO DAILY - Calcium Carbonate 500 mg PO BID #CHANGED MEDICATIONS - AzaTHIOprine 125 mg PO/NG DAILY - Ursodiol 500 mg PO BID #STOPPED MEDICATIONS - Alendronate Sodium 70 mg PO QSAT - Budesonide 6 mg PO DAILY (patient was not taking) - please avoid in the future as it puts patient at risk for thrombosis - Ocaliva (obeticholic acid) 5 mg oral DAILY (patient was not taking) - Calcium 500 With D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral DAILY [ ] Added prednisone and increased dose of azathioprine for autoimmune hepatitis. Monitor for response on prednisone and increased dose of azathioprine. MELD 18 on day of discharge. If not improving, then discuss liver transplant (workup started inpatient) [ ] Continue prednisone course for autoimmune hepatitis with Bactrim prophylaxis [ ] Labs for transplant workup were ordered while inpatient [ ] She asked about the possibility of live donor as well [ ] Multiple side-branch IPMN will require follow up imaging [ ] Follow up chest CT to document resolution of opacities after treatment with antibiotics [ ] Optimize diuretics to balance relative hypotension and worsening ascites. Low blood pressures prevented increasing dosing while inpatient. [ ] Continue ergocalciferol 50,000 units weekly for total of 12 weeks for low vitamin D. Switch to ___ units daily after completion of weekly doses [ ] Alendronate stopped because it puts her at risk for esophagitis and bleeding from esophageal varices. Please ensure Endocrinology follow up to discuss alternative medications [ ] Ensure she is taking in no alcohol, including with cooking [ ] Follow up repeat quantiferon gold as first was indeterminate. If repeat is indeterminate will need further workup. # CODE: Full code, confirmed # CONTACT: ___ (boyfriend) ___ # DISCHARGE WEIGHT: 69.13 kg</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ no signficant PMHx fell off roof this morning and suffered open R femur fracture. He slipped on frozen piece of roof and fell 25' to ground, landing on his R side. He denies LOC. Reports headache and pain on R chest wall, R leg. Open fracture w/ exposed femur noted by EMS and pt placed in traction splint. Brought to ___ where he recieved Ancef, tetanus. He has remained alert and oriented. Denies weakness, numbness in RLE. Denies other extremity pain. Radiology showed 1. Tiny right pneumothorax. 2. Old left 4th rib fracture. No other thoracic or abdominal injuries identified. Radiology showed Comminuted bilateral nasal bone, frontal process of the maxilla, and bony nasal septum fractures. No other acute process. Radiology showed Minimal right apical pneumothorax. No cervical spine fracture or traumatic malalignment. Radiology showed Open comminuted fracture of the distal femoral diaphysis with extension to the lateral femoral condyle and articular surface. Radiology showed No acute fracture or dislocation. Radiology showed Limited exam. Possible intra-articular fractures involving the base of the ___ proximal phalanx and head of the ___ metatarsal. Radiology showed 1. Comminuted bilateral nasal bone, frontal processes of the maxilla, and bony nasal septum fractures with associated soft tissue swelling. 2. Periodontal disease and dental caries of several mandibular and maxillary teeth. Radiology showed 1. Mildly displaced distal radial fracture with intra-articular extension. 2. Triquetrial fracture. 3. Widening of the scapholunate interval suggests ligamentous injury with nondisplaced fracture through the waist of the scaphoid. Radiology showed 1. Vertically oriented fracture of the distal radius with intra-articular extension and disruption of the articular surface by 1.3 mm. 2. Small fracture at the dorsal aspect of the triquetrum. 3. Apparent widening of the scapholunate interval, concerning for scapholunate ligament injury. 4. Subtle linear lucency in the waist of the scaphoid concerning for an non-displaced fracture. No radiographic correlate is identified, though this difference could reflect increased sensitivity for CT. The pertinent findings were posted to the critical results dashboard at 5pm on ___. Radiology showed No acute cardiopulmonary process. Radiology showed 1. No pulmonary embolism 2. 5 mm left upper lobe nodule. As per the ___ Pulmonary Nodule Guidelines, followup chest CT is recommended in 12 months for a low risk patient and ___ months for a high risk patient. 3. Tiny right pneumothorax unchanged. The patient was diagnosed with FX FEMUR NOS-OPEN, OTHER FALL. The patient was treated with 1. Right femur ORIF ___, ___ 2. Left wrist ORIF ___, ___. At the time of discharge, the patient had 1. Open right distal femur fracture s/p I&D and ORIF 2. Left distal radius fx/ scaphoid fx/ scapholunate widening s/p ORIF 3. Right metatarsal & ___ phalanx fractures 4. Facial laceration s/p suture repair by plastics. 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 open midshaft femur fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right femur I7D and ORIF, 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. Musculoskeletal: Prior to operation, patient was NWB RLE. After procedure, patient's weight-bearing status was transitioned to WBAT RLE. Throughout the hospitalization, patient worked with physical therapy, who determined that discharge to home with home ___ was most appropriate. His left upper extremity remains NWB in a splint post-op. Two week post-op films were obtained on ___ and staples were removed. Neuro: Post-operatively, patient's pain was controlled by dilaudid PCA and was subsequently transitioned to oxycodone with good effect and adequate pain control. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Hematology: The patient was not transfused blood for acute blood loss anemia. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: A po diet was tolerated well. Patient was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. ID: The patient received perioperative antibiotics. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received enoxaparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on ___, POD ___, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The incision was clean, dry, and intact without evidence of erythema or drainage; the extremity was NVI distally throughout. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. He will follow up in 4 weeks post-discharge, as his two week follow up was done while he was in house. The patient completed his two week course of chemical DVT prophylaxis. All questions were answered prior to discharge and 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 ___ with history of Wilms Tumor s/p chemo/XRT and nephrectomy at age ___, recently diagnosed HCV genotype 1, and chronic EtOH use, referred to ___ for evaluation of new cirrhosis and possible IVC occlusion seen on outpatient MRI. DUPLEX DOPP ABD/PEL showed 1. Coarsened liver may be due to fatty infiltration and/or cirrhosis. Other more advanced forms such as fibrosis/cirrhosis not excluded on this study. 2. No hepatic lesions are identified. However, MRI is more sensitive for detection of small hepatic lesions. 3. Wall-to-wall color flow in the visualized IVC. No evidence of IVC thrombosis seen sonographically. Recommend correlation with prior examinations when they become available or MRV/CTV. 4. Small amount of ascites. 5. Cholelithiasis with no evidence of acute cholecystitis. 6. Mild pelviectasis of the right kidney. Chest: Frontal and lateral views showed Small right pleural effusion. The patient was diagnosed with CIRRHOSIS OF LIVER NOS, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA. The patient was treated with Upper endoscopy (___) Packed red blood cell transfusion (1 unit on ___. At the time of discharge, the patient had PRIMARY DIAGNOSES: HCV cirrhosis Esophagitis Chronic macrocytic 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 ___ with history of Wilms Tumor s/p chemo/XRT and nephrectomy at age ___, recently diagnosed HCV genotype 1, and chronic EtOH use, referred to ___ for evaluation of new cirrhosis and possible IVC occlusion seen on outpatient MRI. # Cirrhosis: Newly diagnosed, likely secondary to HCV and alcohol use. MELD score 10 based on age and admission labs. Outside MRI report initially concerning for ___ but hepatic lesions are not classic for ___ on our review of images here. No history of hepatic encephalopathy. We initiated diuresis with furosemide. Nutrition was consulted for education regarding low sodium diet. A 2L fluid restriction was placed. He had a screening endoscopy which revealed no varices but was notable for esophagitis, for which PPI was started. # Ascites: New onset ascites, no history of paracentesis. This was evaluated with ultrasound but no readily accessible fluid pocket was seen, so paracentesis was deferred. There was low suspicion for SBP in the absence of SIRS/sepsis physiology or abdominal pain. # Hepatitis C: Genotype 1, untreated. Will follow-up outpatient records. ___ need to consider treatment in the future. # Coagulopathy: INR 1.4 on admission, no known source of bleeding but had Hgb 6.5 in the setting of untreated hepatitis C. Plt 158. We administered Heparin SC given platelet count was in the normal range. # Anemia: Hct slowly downtrending since ___. He is symptomatic with fatigue and decreased exercise tolerance. Hct 22.0 (Hgb 6.5) on admission, and macrocytic (MCV 114), likely etiologies include ETOH toxicity vs HCV marrow suppression vs nutritional deficiency. He was transfused 1 unit pRBCs and tolerated this well with appropriate increase in post-transfusion hematocrit. # Hypothyroidism: Continued home levothyroxine. # Asthma: Continued home albuterol inhaler.</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 atrial fibrillation, non-ischemic cardiomyopathy with EF 45% with hx of VT s/p ICD placement who presented with fevers and malaise, admitted from the ED due to hypotension and concern for sepsis. Radiology showed No evidence of pneumonia. Small right pleural effusion. Radiology showed Increased opacities in the left lower lung possibly reflective of lower pleural fluid and overlying atelectasis/consolidation. Radiology showed Left-sided single lead pacemaker with the lead in the right ventricle. Overall no changes prior. Moderate cardiomegaly. No pulmonary edema. Unchanged retrocardiac opacities. No focal consolidation or pneumothorax. The patient was diagnosed with Sepsis, unspecified organism, Fever, unspecified, Bacteremia, Severe sepsis with septic shock, Dyspnea, 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>Mr. ___ is an ___ yo male with history of atrial fibrillation on rivaroxaban, CVA, VT s/p ICD placement, prolonged QT recently initiated on quinidine, non-ischemic cardiomyopathy (EF 45% --> ___, and hypertension with recent admission for Strep bovis bacteremia s/p 6 wks CTX who presented to ___ on ___ with fevers and hypotension initially treated in the ICU and then transferred to the cardiology service with course c/b VT. #Ventricular tachycardia Patient ___ a complex history: Initial episode in ___. S/p secondary prevention single chamber ICD. Recurrence in ___ w/MMVT that required ATP started on amiodarone 200 mg daily, which was increased to 400 mg daily. Amio was later weaned due to concern for a/e. Admitted in ___ with MMVT and EP applied programmed ventricular stimulation via ICD with resolution of VT and he was started on amiodarone IV, which was later d/c due to previous intolerance. Underwent VT ablation on ___ readmitted with bacteremia and he was started on dofetaline, however, his QTc was markedly prolonged on this regimen and so it was discontinued. In follow up, he was started on quinidine as his QT appeared shorter. During this admission, the quinidine was held after QTC was noted to be >500. After discontinuation of quinidine, the pt was noted to have significant burden of VT while in the ICU. EP was consulted. The patient was started on a lidocaine drip and then transitioned to mexiletine 150 mg PO q 8 hours. His QTC remained at 400 ms and he had no more episodes of VT. #Heart failure with reduced ejection fraction Patient ___ a history of non-ischemic cardiomyopathy with reduced EF of 40-45%. Repeat echo during this admission demonstrated worsening of EF ___. Unclear if this new reduction is related to acute illness given fever and hypotension upon admission vs. worsening burden of VT. Because of his hypotension, his losartan and eplerenone was initially held. This was restarted after his blood pressures improved. He was given one dose of 40 mg IV Lasix on ___ given his increased weight (we believe dry weight is 145-150 pounds) and elevated proBNP. His metoprolol succinate was increased from 25 mg to 50 mg daily. Torsemide 5 mg was added upon discharge. Because of reduced EF and symptoms, bIV pacer should be considered as an outpatient. #Hypotension/fevers #Community acquired pneumonia Pt presented with fever and hypotension concerning for sepsis. Because of recent strep bovis bacteremia, ID was consulted. Blood and urine cultures were without growth. Echo was without vegetation. CXR was w/o consolidation although pt noted cough upon admission. He was initially treated with vancomycin and ceftriaxone for CAP, which was changed to ceftriaxone and doxycycline to complete a five day course. With fluid resuscitation and antibiotics, patient's symptoms improved and he remained HDS. #Thrombocytopenia Pt was noted to have thrombocytopenia upon admission. No heparin exposure. With treatment of sepsis, platelets increased and were 143 upon discharge. #Severe MR ___ been evaluated for mitral clip in the past and sx not thought to be related to severe MR. ___ consider re evaluation for mitral clip as an outpatient. #Atrial fibrillation with history of CVA Patient was continued on home rivaroxaban and metoprolol succinate was increased to 50 mg daily. #Psych Continued home lorazepam and mirtazapine TRANSITIONAL ISSUES</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of CLL/SLL with pulmonary parenchymal involvement diagnosed in ___ s/p chemotherapy (last in ___ c/b hypogammaglobulinemia on monthly IVIG and recurrent PNA,bronchiectasis, chronic systolic heart failure (LVEF 40-45% in___), and atrial fibrillation on rivaroxaban (TIA while onwarfarin) who presents with subacute progressively worsening cough and SOB and new hypoxia. CHEST (PA AND LAT) showed Patchy opacities in the lung bases in a region of bronchiectasis, which may reflect pneumonia. CT CHEST W/O CONTRAST showed Diffuse bilateral ground-glass opacification somewhat patchy, could represent pulmonary edema. Atypical pneumonia can have a similar appearance. Small volume mediastinal and hilar adenopathy is unchanged. Right-sided Port-A-Cath with its tip in the right atrium. Radiology showed Subtle bilateral parenchymal opacities appear worse compared to radiograph from ___ however, have subtly improved compared to chest CT from ___. RECOMMENDATION(S): Recommend repeat chest radiograph in ___ weeks to ensure resolution of parenchymal opacities. CHEST (PA AND LAT) showed Comparison to ___. Stable right apical calcifications, 1 of which is nodular in appearance. Stable parenchymal morphology. Stable correct position of the right pectoral Port-A-Cath. Normal size and shape of the cardiac silhouette. The patient was diagnosed with Other pneumonia, unspecified organism, Dyspnea, unspecified. At the time of discharge, the patient had Acute hypoxic respiratory failure Bronchiectasis exacerbation 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>ATIENT SUMMARY ===================== ___ with history of CLL/SLL with pulmonary parenchymal involvement diagnosed in ___ s/p chemotherapy (last in ___ c/b hypogammaglobulinemia on monthly IVIG and recurrent PNA, bronchiectasis, chronic systolic heart failure (LVEF 40-45% in ___, and atrial fibrillation on rivaroxaban (TIA while on warfarin) who presents with subacute progressively worsening cough and SOB and new hypoxia. =============</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with a history of recent babesiosis infection, HTN, HLD, and T2DM, who presented initially with dyspnea on exertion, and is transferred from ___ for "pre-tamponade." He was admitted to ___ from ___ with sepsis, renal failure, and hyperkalemia, where he was noted to have splenomegaly to 15cm, and Babesia Microti PCR positive. He was treated with Atovaquone and Azithromycin. Since then, he has had significant bilateral lower extremity edema, dyspnea on exertion, and orthopnea. These symptoms started 2 weeks ago, but have been improving. Otherwise, he feels well, with no chest pain, nausea, vomiting, or abdominal pain. Earlier today, he presented for routine follow-up TTE, was found to have EF 51%, a small circumferential pericardial effusion with 30% respiratory variation, diastolic RA collapse, dilated IVC suggesting high artery filling pressures with findings suggestive of pre-tamponade physiology. He was subsequently referred to the ER where he had lab testing showing a BNP of 73 troponin of 0.03, normal LFTs, mild anemia with a hemoglobin of 12. Cardiology was consulted there and are recommended transport here. - In the ED initial vitals were: 98.0, 75, 188/88, 17, 94% RA - EKG: NSR, nonspecific ST changes, Low voltage - Labs/studies notable for: WBC 6.3 Hb 11.5 Plt 205 Prst smear negative Cr 1.1 Trop < 0.01 lactate 1.4 Imaging showed: CXR: Opacities at the posterior costophrenic angles could be due to small effusions and atelectasis noting that infection is not excluded. No pulmonary edema. Patient was given: no medications Cardiology was consulted, and recommended admission to ___ for repeat TTE & workup of ___. ID was called, and recommended Atovaquone and Azithro only if patient decompensates, pending smear (which ultimately was negative) Vitals on transfer: 77 147/80 16 96% RA On the floor, he reports no current dyspnea, chest pain/pressure, palpitations, lightheadedness, n/v, fevers, diaphoresis, myalgias, or any other complaints. Radiology showed Opacities at the posterior costophrenic angles could be due to small effusions and atelectasis noting that infection is not excluded. No pulmonary edema. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial abnormality. Tiny chronic left putamen lacune. The patient was diagnosed with Disease of pericardium, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSES: acute on chronic diastolic heart failure hypertension diabetes, insulin dependent GPC bacteremia SECONDARY DIAGNOSES: history of babesiosis history of acute kidney injury, now resolved. 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>Key Information for Outpatient ___ with a history of recent babesiosis infection, HFpEF, HTN, HLD, and T2DM, who presented initially with dyspnea on exertion, and is transferred from ___ for "pre-tamponade," with repeat TTE showing no significant effusion and no tamponade, but clinically he is significantly volume overloaded. Later in the course of his hospital stay he was found to have 2 out of 4 blood cultures that were positive for gram-positive cocci in pairs that ultimately speciated to staph epidermidis. ID was consulted and they felt that as long as he had no growth off of vancomycin for 48 hours, the suspicion for a true infection was low. Blood cultures 48 hours after antibiotic discontinuation remain negative. #HFpEF exacerbation: Presented with history of orthopnea and ___ edema that started at end of his recent hospitalization. This was most likely multifactorial: diastolic dysfunction in setting of HTN, volume resuscuitation and renal failure as well as hypoalbuminemia at last hospitalization. TTE was notable for normal systolic function with Grade II (moderate) left ventricular diastolic dysfunction. His BP was significantly elevated on admission here which may have been exacerbating his diastolic heart failure. Renal failure resolved by this admission. He was diuresed with boluses of 20 IV Lasix with improvement and transitioned to po Lasix 20 mg on discharge due to continued bilateral lower extremity edema. For his hypertensive heart disease, amlodipine was added to his Lisinopril regimen #GPCs on blood cultures x2, suspected contaminant: ___ blood cultures returned positive for staph epidermidis, but patient clinically well (no fever or leukocytosis). He was started on Vancomycin, but this was stopped after 48 hours per ID recommendations, and daily cultures monitored for clearance (several remain pending on day of discharge). His TTE was re-evaluated by cardiology and they did not see any vegetations. He was discharged with a plan to see PCP the day after discharge to follow-up on these blood cultures and obtain new cultures; if cultures from ___ days after stopping ABx remain negative, then this is most likely a contaminant. #Albuminuria: Patient had a alb/cr. ratio in the 4000s range. This is severe proteinuria. He has a history of diabetes on insulin at home so this could be secondary to diabetic nephropathy. We think this was most likely secondary to his underlying diabetic nephropathy and he will see nephrology on discharge for further follow-up ___: Patient developed mild pre-renal ___ after aggressive diuresis. Creatinine returned to baseline of 1.2 on discharge after holding IV diuresis #History of elevated ___: At OSH had elevated ___ 1:1280, speckled pattern. Rheumatology was consulted and recommended to repeat the ___. His overall picture did not fit for a distinct rheumatologic disease and they did not recommend further follow-up</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo RH male with HTN/HLD p/w with acute onset right-sided weakness, clumsiness and dysarthria. The patient went to work ___ around 7 AM and was reportedly feeling well. Works as a ___ and worked through the AM. Around 11 AM the patient appeared diaphoretic, seen by coworkers tripping over objects at work. His boss encouraged him to relax and cool off in the AC. About an hour or so later, he apeared well, speaking normally and walking fine.. Around 2:30 ___ the patient's boss again noticed him appearing very clumsy. He told him to go to the ED. He called his brother to come pick him up and his brother reports that he was dysarthric and falling to the right. After subsequent interviews and clarification the patient reported, that he did not feel well at 11 and never returned to baseline. He reported having dyasrthria around 1 ___ and having a clumsy hand while working on the cars in the afternoon. He then later felt as though his right leg was clumsy as well - around 2:30. Radiology showed No definite change since the study 4 hours prior. Apparent increase in conspicuity of a focal hypodensity in the anterior limb of the left internal capsule could be accounted for by differences in technique. Radiology showed Slow diffusion is identified in the posterior limb of the left internal capsule, likely consistent with an acute ischemic event. There is no evidence of hemorrhagic transformation or mass effect. These findings were discovered and communicated via phone call to Dr. ___ ___ at 17:30 hours on ___ by Dr. ___. Radiology showed No evidence of acute hemorrhage. The patient was diagnosed with TRANS CEREB ISCHEMIA NOS. At the time of discharge, the patient had - Cerebral embolism with infarction Hypertension, Hyperlipidemia, Tobacco 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>Mr. ___ was admitted to the neuroICU after receiving ___ dose tPA (by weight). This was terminated abruptly, after it was learnt that the original onset of his symptoms was well before the first related time of 2PM. He remained hemodynamically stable in the ICU and follow up neuroimaging did not show any hemorrhage in his brain. His examination was significant for profound weakness of the right arm, with gradually improving weakness of the right leg. - He was followed closely by physical therapy throughout his stay who judged him to be a good candidate for acute rehabilitation. At the time of discharge, his physical examination was notable for right arm plegia, slight pyramidal weakness of the right leg, and right facial weakness. - His cholesterol returned elevated and so he was started on a statin. He was also continued on an aspirin, and his BP control required three agents. - He was counseled by our nutritionist about the importance of healthy food choices. - His EKG showed profound elevations of the ST-segment consistent with a J-point elevation. He never had chest pain or chest discomfort. Echo showed LVH, and so he will follow up with cardiology in 6 weeks. - He was quite tearful at the initial presentation, and his motivation and participation was rather poor at times. He was agreeable to starting on a low dose of fluoxetine, with the goals that improving his mood may assist with his overall recovery. His family visited him on numerous occasions during his stay. TRANSITIONAL ISSUES: - We apologize that we were unable to set up his follow up appointments prior to discharge, but they will be set up. We will contact his rehabilitation facility directly to ensure that those are communicated. - HCTZ may need to be uptitrated as needed to control his BPs - Would continue to encourage smoking cessation. While on the floor, he did not require nicotine supplementation</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old male with history of hepatitis C, sleep apnea, peptic ulcer disease, presenting to the ___ ED directly from radiology with an acute right-sided SDH. He reports approximately 1 week of worsening headache. He denies any trauma or minor headstrike. He had an episode of nausea & vomiting 3 days ago, with mild nausea since. His family reports decreased appetitite and general malaise. He was seen in urgent care yesterday and had a scheduled MRI this afternoon which revealed an acute right convexity SDH. He was referred directly to the ED for Neurosurgical evaluation. He is prescribed Aspirin 81mg daily for "general health". He reports taking more Aspirin than prescribed this week (162mg-325mg daily) for headaches. No history of stroke or aneurysm. Today, he does admit to mild headache. Denies visual changes, new numbness or weakness in arms or legs. He does report slight difficulty using his right hand. No difficulties with speech. CT HEAD W/O CONTRAST showed Moderate acute right hemispheric subdural hematoma measuring approximately 1.2 cm in maximal thickness, with mild leftward shift of midline structures. Close interval followup is recommended. CTA HEAD WANDW/O C AND RECONS showed 1. Stable right hemispheric subdural hematoma resulting in 4 mm leftward midline shift. 2. No new hemorrhage. 3. Essentially unremarkable CTA of the head. 4. No evidence of vascular malformation or active contrast extravasation identified. 5. Paranasal sinus disease as described. CT HEAD W/O CONTRAST showed 1. No significant interval change to the right hemispheric subdural hematoma measuring up to 1.5 cm from the inner table. 2. Grossly stable mass effect with associated 6 mm leftward midline shift. 3. Ventricles are stable in size. CHEST (PRE-OP AP ONLY) showed Lungs are fully expanded and clear. Mediastinum in the region of the ascending thoracic aorta is slightly bulged to the right likely due to dilated or tortuous ascending thoracic aorta. Heart is normal size, pulmonary vasculature is not dilated and there is no pleural abnormality. Patient presented for diagnostic catheter angiography. The following vessels were selectively catheterize injected: Right common carotid artery, right internal carotid artery including Three dimensional rotational angiography and postprocessing on separate work station with concurrent physician supervision with images being used for final interpretation, right external carotid artery, right vertebral artery, left common carotid artery including Three dimensional rotational angiography and postprocessing on separate work station with concurrent physician supervision with images being used for final interpretation, left vertebral artery,. ANESTHESIA: ANESTHESIA: Moderate sedation was provided by administrating divided doses of 75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service time of 65 during which the patient's hemodynamic parameters were continuously monitored by an independent trained radiology nurse. 1% lidocaine was injected in the skin and subcutaneous tissues overlying the access site TECHNIQUE: OPERATORS: ___, and Dr. ___ physician performed the procedure. Dr. ___ supervised the trainee during the key components of the procedure and has reviewed and agrees with the trainee's findings. PROCEDURE: Patient was brought to the fluoroscopy suite, ID confirmed via wrist band. The patient is placed supine on the fluoroscopy table in the bilateral groins were prepped and draped in usual sterile manner. Time-out procedure was performed per institutional guidelines. Next the location the right mid femoral head was located using anatomic and radiographic landmarks. 10 cc of lidocaine was infused in the subcutaneous tissue. A micropuncture kit was used to gain access to the right femoral artery, serial dilation was undertaken until a short 5 ___ groin sheath connected to a continuous heparinized saline flush was inserted. A ___ catheter was advanced over the 0.038 glidewire in used to select the innominate followed by the right common carotid artery. Cervical biplane road map imaging was undertaken. Next, under road mapping technique, the right internal carotid artery was selected. Intracranial biplane magnified biplane oblique views along with 3 dimensional rotational angiography and processing a separate 3D workstation was undertaken from this vessel. The catheter was then pulled back into the right common carotid artery, new road map was undertaken, and the right external carotid artery was then selected. Extracranial biplane imaging was then undertaken. Next the catheter was pulled back into the aorta in used to select the right innominate artery followed by the right vertebral artery. ___ lateral views were then undertaken. The catheter was then pulled back and the aorta used to select the left common carotid artery. Intracranial biplane along with cervical biplane imaging was undertaken from this vessel. 3 dimensional rotational angiography with separate processing on a separate 3D workstation was also undertaken from this vessel. Catheter was then pulled back into the aorta used to select the left subclavian artery, followed by the left vertebral artery. Left vertebral artery injection was undertaken in the intracranial biplane. The catheter was then pulled back into the aorta and then fully removed from the body. No compression pressure was held over the right femoral artery for approximately 25 min until hemostasis was achieved. At the conclusion the procedure, the patient was is neurologic baseline. FINDINGS: Right common carotid artery: Cervical bifurcation is well visualized, there is mild tortuosity at the origin of the right common carotid artery off of the innominate artery. There is no significant carotid stenosis or carotid atheromatous disease. Right internal carotid artery: The distal right ICA, proximal distal MCA and ACA branches are well-visualized. Vessel caliber smooth and tapering, there is no evidence of abnormal early venous drainage, or arteriovenous shunting. There is no evidence of vasculitis or aneurysm formation. Patient is a very prominent ophthalmic artery, however there is no evidence of abnormal anastomoses with the venous circulation, or early draining vein identified. There is however it is normal anastomoses with the external carotid artery circulation. There is no evidence of a dilated superior ophthalmic vein, the timing of normal venous drainage is seen, the cavernous sinus is also seen to be filling. Right external carotid artery: The internal maxillary artery, occipital artery, middle meningeal artery, superior temporal artery are well-visualized. Vessel caliber smooth and tapering. There is no evidence of vasculitis, or abnormal arteriovenous shunting, or abnormal extracranial to intracranial anastomoses. There is no identification of a pathologic early draining vein. Right vertebral artery: The right vertebral artery, right ___, basilar artery, reflux down the left vertebral artery to the ___, basilar artery, bilateral AICA, the, SCA, PCAs are also visualized. Vessel caliber smooth and tapering, there is no identification of aneurysms, or abnormal early venous drainage. There is no identification of abnormal arteriovenous shunting. In the high cervical views, posterior muscular branches along with the posterior meningeal artery are identified off of the right vertebral artery however there is no abnormal fistulous connection to a sinus, or cortical vein. Left common carotid artery: The distal left ICA, proximal distal MCA and ACA branches are well-visualized. This caliber smooth and tapering. There is no evidence of abnormal early venous drainage, or abnormal arteriovenous shunting. No aneurysms are identified. Of the ECA vessels visualized, the STA, middle meningeal, I max are seen. There is no evidence of abnormal arteriovenous shunting or abnormal extracranial to intracranial anastomoses. Left vertebral artery: Origin of the left vertebral artery throughout the cervical plane is visualized. There is no evidence of dissection or abnormal anastomoses. The left vertebral artery, left ___, basilar artery, bilateral at AICA and PCA and SCA is are well-visualized. vessel caliber smooth and tapering. There is no evidence of aneurysm formation, early venous drainage, or abnormal arteriovenous shunting. IMPRESSION: 1. No abnormal arterial malformations identified cause of the patient's a traumatic subdural hemorrhage. Dr. ___ was personally present, an performed the procedure. showed 1. No abnormal arterial malformations identified cause of the patient's a traumatic subdural hemorrhage. Dr. ___ was personally present, an performed the procedure. CT HEAD W/O CONTRAST showed 1. Stable right hemispheric subdural hematoma, measuring up to 15 mm, with layering along the right tentorium, as described. 2. Grossly stable 5 mm leftward midline shift. 3. No new hemorrhage is identified. The patient was diagnosed with HEADACHE. The patient was treated with ___ - cerebral angiogram. At the time of discharge, the patient had ___. 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>On ___, the patient was admitted to from the ED for a SDH. He was neurologically intact and his blood pressure was agressively controlled in the ICU. He was given a unit of platelets for aspirin use. On ___, the patient was neurologically stable. He was transferred to the step down unit. CTA imaging did not show any abnormalities. On ___, the patient underwent diagnostic cerebral angiography which did not show any evidence of vascular lesions/abnormalities. He remained stable neurologically. ON ___, the patient was stable neurologically. Repeat CT imaging was stble. He ambulated in the halls without any difficulty, tolerated a PO diet and was able to void. He was discharged to home in stable condition with follow up instructions.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Pt is a ___ who presents as a transfer from ___ w/ a R trimalleolar ankle fracture. Pt was painting on a ladder when he unfortunately had a fall, landing on his R ankle. He had immediate pain, deformity, and inability to bear weight. He presented to ___, was found to have a R trimalleolar ankle fracture and was transferred to ___ for further management. He reports no pain elsewhere. CT of the right ankle without contrast showed 1. Pilon fracture of the right ankle with a vertically oriented tibial fracture extending to the articular surface of the tibial plafond. Transverse/oblique fractures of the distal fibula and medial malleolus also noted. ANKLE (AP, MORTISE AND LAT) RIGHT showed Intraoperative radiographs. For further details please refer to the operative report in the ___ medical record. Radiology showed Re-demonstration of comminuted distal tibial and fibular fractures without significant change in alignment. No dislocation. Radiology showed Slight interval improvement in alignment of the comminuted distal fibular fracture. No significant interval change in appearance of nondisplaced comminuted intra-articular distal tibial fracture with involvement of the medial malleolus. CHEST (AP AND LAT) showed Low lung volumes with mild patchy bibasilar atelectasis. The patient was diagnosed with Displaced trimalleolar fracture of right lower leg, init, Fall on and from ladder, initial encounter. The patient was treated with external fixator device. At the time of discharge, the patient had ankle 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 an ankle fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for application of an external fixation device, 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 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 touch down weight bearing in the RLE extremity, and will be discharged on aspirin 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 ___ male with history of CAD, hypertension, diabetes, CKD on ___ dialysis last yesterday, presents with back pain radiating to his chest associated with shortness of breath. CHEST (PA AND LAT) showed Increased in conspicuity of the patchy opacities in the lung bases, right greater than left, which may reflect sequela of recurrent aspiration and possible underlying pneumonia. Combination of peripheral unilateral lung nodules and central adenopathy progressing over 2 weeks could be unusual infection or rapidly progressive malignancy such as lymphoma. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Multiple, spiculated, nodules and masses throughout the mid right middle and lower lobes, in a perilymphatic distribution, show minimal surrounding ground-glass with air bronchograms in multiple areas. There are few areas of airway obliteration beyond the subsegmental level. Largest mass is seen in the medial right lung base, measuring 4.1 x 2.2 x 1.6 cm. Neoplastic etiology is favored for these findings, much less likely infectious. Recommend tissue diagnosis for further evaluation. 3. Large right hilar soft tissue adenopathy, likely neoplastic in etiology. This area could also be considered for tissue diagnosis. 4. Multiple additional calcified mediastinal lymph nodes and calcified granulomas throughout the lungs, likely sequela of prior granulomatous disease. RECOMMENDATION(S): Recommend tissue diagnosis of likely neoplastic process in the right lung. The patient was diagnosed with Other chest pain, Dyspnea, unspecified, Chronic kidney disease, unspecified. The patient was treated with MIBI ___. At the time of discharge, the patient had Right sided lung opacities with lymphadenopathy Chest pain, stable coronary artery disease GERD. 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 history of CAD, hypertension, diabetes, CKD on HD MWF, presented with back pain radiating to his chest associated with shortness of breath.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with pmh significant for morbid obesity, OSA, HTN, CAD s/p MI with stenting, gout, who presented to his PCP office for follow evaluation of his serum chemistries which showed worsening renal failure. He went into his PCP's office today for laboratory evaluation. He was referred to the emergency department secondary to the patients elevated creatinine. Patient was recently admitted for hyperkalemia and at that time his lisinopril was held. Upon review of systems, the patient endorses 8 lb weigh loss from his lasix, nausea, dyspepsia, dysphagia for solids, diffuse muscle cramps lasting for a few seconds, right knee pain and back pain. He notes that he has been constipated recently. He denies any chest pain or shortness of breath. Patient denies decreased exercise tolerance. The patient denies PND, orthopnea, ___ swelling. He notes that he has recently stopped his lisinopril 8 days ago. He notes that he has been using nsaid's for pain and he takes no more than 4 in a day. Radiology showed No evidence of acute cardiopulmonary process. Radiology showed 1. No hydronephrosis. 2. The liver is incidentally noted to be diffusely echogenic consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. The patient was diagnosed with CHEST PAIN NOS, MYALGIA AND MYOSITIS NOS, NAUSEA, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with Upper GI endoscopy, exercise stress test, Echocardiogram.. At the time of discharge, the patient had 1. Esophagitis 2. Gastritis 3. Acute kidney injury secondary to dehydration. 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 morbid obesity (BMI 48), DMII, CAD ___ years s/p inferior wall myocardial infarction, OSA on bipap, gout, who presents with acute on chronic renal injury, atypical chest pain, cramps, and dyspepsia for workup of his various sequalae. 1. Rule out acute coronary syndrome: This is a patient with multiple risk factors for UA/NSTEMI. He reported constant cramping throughout his body. This crampy sensation would sometimes be in his legs and other times it would be substernal. This pain "crampy" in nature and would go away in ___ seconds. It was not related to exertion and there were no known factors which would alleviate or exacerbate this condition. Given his TIMI risk score of 3 which represents a 13% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization, he was ruled out for ACS. -Serial EKG were performed. His EKGs were unchanged from prior and there were no signs myocardial ischemia on EKG. -He had two negative troponins. - He was further evaluated with an treadmill EKG which did not show EKG changes concerning for ischemia, nor did it reproduce any angina. -His TTE showed cardiomegaly with normal to mildly depressed ejection fraction. There were no signs of any focal wall motion/valvular anomalies. Given that there were no dynamic EKG changes, with a negative exercise stress, and a normal echo, with negative cardiac enzymes suggests that his chest cramping was not ischemic in nature. 2. Acute on chronic renal failure: The patient presented with a serum creatinine of 2.4. Of note this was unchanged since his previous admission approximately 10 days ago. As part of his work-up, we held his lasix, got a urinalysis, urine electrolytes, renal ultrasound, and formal renal consultation. -By holding the patients lasix his creatinine dropped from 2.3 to 1.6 over the course of two days. -His renal ultrasound showed no pathology or signs of obstruction. (However, it did show a diffusely fatty liver incidentally). -Renal consult suggested that his acute kidney injury was pre-renal in nature and suggested having the patient continue to hold his ACE-I and only take 20mg of lasix once a day instead of BID. -He was discharged with lasix 20mg once a day and follow up with outpatient nephrology. 3.Dyspepsia: The patient complained heartburn, nausea, feeling like he was "throwing up in his mouth," and dysphagia for solids but not liquids. -We stopped his indocin which we felt might be causing irritation of the gastric mucosa. -We also started the patient on a proton pump inhibitor. -GI was consulted an a EGD was performed which showed gastritis. A biopsy was taken for further evaluation. -In addition he was tested for h-pylori. THIS RESULT IS STILL PENDING****** -He has follow up with Dr. ___ as an outpatient. 4. Type 2 DM: While inpatient, we put Mr. ___ on a ___ sliding scale and stopped his metformin secondary to his poor kidney function. As his renal function improved, Dr. ___ that the patient would be safe to resume taking his metformin and ___ as an outpatient. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman with a history of arthritis, hypertension, and diabetes mellitus, seronegative RA - p/w right flank pain. Pt states that flank pain started 1 week ago, gradual onset, she went to ___ clinic and given cipro for UTI. UA at that time showed trace leuks, Since then the pain has progressively worsened now ___ in right flank non-radiating, sharp. No dysuria, hematuria. No bowel changes. Denies f/c/cp/sob/abd pain. Radiology showed No acute cardiopulmonary process. Radiology showed 1. Cholelithiasis without gallbladder wall thickening or pericholecystic fluid. Correlate for clinical signs of cholecystitis. 2. Hepatic steatosis. 3. No acute bowel pathology. 4. Diverticulosis without evidence of active inflammation. 5. No evidence of nephrolithiasis or renal pathology. The patient was diagnosed with Hypo-osmolality and hyponatremia. At the time of discharge, the patient had PRIMARY DIAGNOSIS Flank pain Hyponatremia Seronegative arthritis Hypertension Diabetes Anxiety. 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>Pt is a ___ with history notable for seronegative arthritis, hypertension, diabetes here for severe flank pain x 1 week and oliguria/increased urinary frequency with CTU negative for hydronephrosis or stone concerning, no radiographic evidence for pyelonephritis. UA was negative, UCx without growth on discharge. #Flank pain: GU vs MSK etiology. Patient has been afebrile, without leukocytosis, and questionable urinalysis given contaminant in ED urine sample and outside clinic UA with trace leuks s/p 6 days of cipro. Urinary symptoms point towards GU etiology although imaging is negative. However, pt does have history of seronegative arthritis and has required pred and mtx for pain control. Given that the flank pain radiates down buttocks and upper thighs it was felt her pain was likely MSK. CRP elevated at 7. We treated pain with 1 dose oxycodone 5 mg, patient slept well and on morning of discharge was no longer in pain. On day of discharge, patient denied hip pain, flank pain or difficult urinating. #hyponatremia: notable new hyponatremia to 127, has been low as 131 on prior check given ___ for celecoxib however pt does endorse somewhat low po intake today, urine lytes suggest possible SIADH etiology. Pt given IVF in ED and appears to have worsened. On morning of discharge, Na+ 132 that improved after pain control and PO intake. To follow the hyponateremia, patient is scheduled for repeat Chem10 on ___ with her PCP. #seronegative arthritis: controlled outpatient with pred5 mg and methotrexate injections #hypertension: restarted lisinopril upon discharge. will hold for now given possibility of infection although vitals stable #diabetes: restarted metforming 1000mg #anxiety: continued clonazepam 0.5 prn #nutrition: continued iron sulfate, magnesium oxide, vitamin E, vitamin D, fish oil capsules ====================== Transitional Issues ======================= - Should she remain on meclizine - F/u hyponateremia, ensure sodium is stable - close follow up with rheumatology, primary care - DNR/DNI (confirmed)</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o female transferred from ___ with right parietal occipital edema on head CT concerning for an underlying lesion. She states that she experienced a headache, transient blurred vision and numbness, tingling weakness of the right upper extremity yesterday and occasionally into the left upper extremity over the past two days. These symptoms came on quickly and self resolved both days after several hours. She became concerned and presented to ___ today at which time she underwent a CT of the head which was concerning for a brain lesion. She was transferred to ___ for further evaluation. MR spectroscopy showed Evolution of signal abnormality in the right occipital lobe with corresponding single voxel spectroscopy demonstrating lactate peak. Constellation of findings are most suggestive of evolving infarction in the distribution of the right posterior cerebral artery rather than an underlying malignancy. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Stable right parieto-occipital lobe hypodensity, likely corresponding to evolving subacute infarction. No evidence of intracranial hemorrhage. 2. Patency of the major intracranial vasculature without stenosis, occlusion, or aneurysm. 3. Patency of the bilateral carotid arteries and vertebral arteries, without internal carotid artery stenosis by NASCET criteria. 4. Linear defect of the lateral aspect of the left carotid bulb due to a carotid web, an incidental finding. 5. Probable artifact creating linear filling defect within the lateral margin of the aortic arch, not seen on the recent CT chest ___. 6. Noncalcified plaque resulting in mild luminal narrowing of the proximal left subclavian artery. 7. Moderate centrilobular emphysema. UNILAT UP EXT VEINS US LEFT showed -Occlusive thrombus in the left brachial artery. -No evidence of deep vein thrombosis in the left upper extremity. NOTIFICATION: The findings were discussed by Dr. ___ with ___ on the telephone on ___ at 2:20 pm, 5 minutes after discovery of the findings. CTA torso showed 1. Mild to moderate atherosclerotic disease of the takeoff of the left subclavian artery, left common carotid artery, and right brachiocephalic trunk. There is moderate atherosclerotic disease of the abdominal aorta. There is no evidence of occlusion, thrombus, or a large plaque of the thoracoabdominal aorta and its major branches. 2. Wedge-shaped area of hypoattenuation in the upper pole of the right kidney (series 3:127) which is new as compared to CT abdomen pelvis ___. This could represent infarction or focal pyelonephritis. 3. Heterogeneous enhancement of the left kidney is grossly unchanged from CT abdomen and pelvis ___ and most suggestive of pyelonephritis. Follow-up CT is recommended following treatment to ensure improvement or resolution. 4. Limited evaluation of the arm, but there is an abrupt cutoff in the left brachial artery (series 3: 74-75) with reconstitution of flow distally likely corresponding to focal thrombus seen on left upper extremity ultrasound ___. NOTIFICATION: The findings were discussed by Dr. ___ with NP ___ ___ on the telephone on ___ at 8:56 pm, 5 minutes after discovery of the findings. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Acute to early subacute infarction in the distribution of the right posterior cerebral artery. 2. No evidence of intracranial hemorrhage. No evidence of enhancing mass or abnormal enhancement. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 9:39 am, 2 minutes after discovery of the findings. CT abdomen pelvis with contrast showed 1. Multiple heterogeneous foci of hypoenhancement throughout the left renal cortex with mild stranding, most suggestive of pyelonephritis. Given the absence of a definite malignancy on recent head MR and presence of a markedly elevated WBC, infection remains the likely cause. An infiltrative neoplasm can be considered, but is less likely in this clinical setting. Follow-up CT is recommended following initial treatment to ensure improvement/resolution. 2. No abdominopelvic lymphadenopathy. CT CHEST WITH CONTRAST showed 1. Left pyelonephritis. 2. No evidence of intrathoracic malignancy. 3. Severe centrilobular emphysema. 4. Chronic small airway inflammation. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:41 am, less than 15 minutes after discovery of the findings. The patient was diagnosed with Other specified disorders of brain. At the time of discharge, the patient had Ischemic infarction Occlusive thrombus in the left brachial artery. 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 patient admitted to Neurosurgery for further work up after presenting with LUE paresthesias and blurred vision. Head CT showed right occipital edema concerning for underlying lesion. #Brain lesion/Acute ischemic stroke Brain MRI with and without contrast was done. This showed a non-enhancing lesion concerning for possible PCA infarct. Neurology and Neurooncology were consulted and MRS was ordered, stroke workup ongoing. Patient was started on Atorvastatin per neurology recommendations. TTE was unremarkable. CTA showed patency of the major intracranial vasculature without stenosis, occlusion, or aneurysm and patency of the bilateral carotid arteries and vertebral arteries, without internal carotid artery stenosis by NASCET criteria. MRS ___ suggested evolving infarction in the distribution of the right posterior cerebral artery rather than an underlying malignancy. Neurology was notified and cleared the patient for discharge with follow-up as outpatient including an appointment with Dr. ___ ___ monitor, and TEE. Her home Aspirin 81mg was resumed on ___. Signs and symptoms of stroke were reviewed with the patient and her family with a ___ interpreter present in the room prior to discharge. Due to blood clot found in brachial artery, her Aspirin was stopped and she was transitioned to Lovenox bridge to Coumadin. All questions and concerns regarding imaging results and follow-up plan were answered with the interpreter at this time. #Pyelonephritis/Leukocytosis On admission the patient was noted to have Leukocytosis of 23. She was afebrile and urinalysis was negative. CT torso for metastatic work up showed left pyelonephritis. Urine culture was ordered and Cipro was started after Urine Cx was obtained. MERIT service consulted for evaluation however given that the patient is afebrile and UA negative, recommend following up on urine culture. On ___, urine culture resulted as negative, Cipro discontinued. Patient was monitored closely and denied back pain, urinary symptoms, fevers, chills with ___ interpreter present. She was advised to follow-up with her PCP after discharge. #Occlusive thrombus in the left brachial artery: A LUE ultrasound was done for complaints of general pain in the left bicep/tricep area. The ultrasound showed occlusive thrombus in the left brachial artery. Vascular surgery was consulted and recommended CTA torso including the LUE to evaluate for causes of thrombus such as aortic plaque. The CTA torso showed new wedge shaped lesion in R kidney suggestive of infarct and some atherosclerosis but no clear source. She was started on Lovenox and Warfarin as noted above. Due to concern for hypercoagulable state, associated labs were sent with other arranged to be collected as outpatient. She was directed to follow up with Hematology as outpatient to review lab results. She is ordered for repeat LUE US in 1 month and follow up in ___. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ referred to ED by PCP for volume overload and HTN management. Was seen by PCP last week as new patient (first time seeing an MD in ___ years) with dyspnea on exertion, progressive, over several months. Found to be in Afib with rapid ventricular response and signs of CHF. Started on furosemide, aspirin, metoprolol. Returned to ___ on day of admission for further med titration and to begin anticoagulant. CHEST (PA AND LAT) showed Cardiomegaly, small bilateral pleural effusions, mild pulmonary edema. ABDOMEN US (COMPLETE STUDY) showed 1. Hyperdynamic waveforms noted in the hepatic veins a in the main portal vein suggesting heart failure. 2. Unremarkable appearance of the liver and bile ducts. 3. Large pleural effusions are present. A scant trace of ascites is noted in the abdomen. Radiology showed Please note that this report only contains extracardiac findings. Incidentally noted is a bovine arch. There are moderate bilateral pleural effusions, slightly larger on the right than the left. There is trace perihepatic ascites. There is a 9 mm T2 dark round lesion in the right adrenal gland (1702, 14), which is incompletely evaluated, though statistically a benign lesion such as an adenoma or myelolipoma. The entirety of this Cardiac MRI is reported separately in the Electronic Medical Record (OMR) - Cardiovascular Reports. RECOMMENDATION(S): If indicated, the adrenal nodule could be further evaluated with dedicated imaging. US NECK, SOFT TISSUE showed No evidence of deep vein thrombosis in the left upper extremity. Left subclavian vein is widely patent. RECOMMENDATION(S): If there is concern for arterial stenosis, a separate dedicated ultrasound could be obtained to evaluate the subclavian artery. NOTIFICATION: Findings and recommendation were telephoned to Dr. ___ ___ by ___ on ___ at 10:40am. The patient was diagnosed with ATRIAL FIBRILLATION, CONGESTIVE HEART FAILURE, UNSPEC. The patient was treated with Right and left heart cath ___ TEE without cardioversion ___. At the time of discharge, the patient had Cardiac amyloidosis Atrial fibrillation Left atrial appendage thrombus Heart failure with reduced ejection fraction. 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: ___ with no recent PMH, referred by PCP for management of CHF and A-fib with RVR after pt stopped outpatient therapy. Volume overloaded on exam, EF ___, severe LVH, low E'. Concern for infiltrative cardiomyopathy. #Dyspnea on exertion/CHF/Cardiac amyloidosis: The patient's findings are most consistent with congestive heart failure. On admission, the patient had crackles, pitting edema, elevated JVD, positive Kussmaul sign, and S3 on exam. A chest xray showed mild pulmonary edema. ProBNP 4281. The patient had no chest pain to suggest an acute etiology, and EKG and troponins did not suggest ACS. A TTE on ___ showed an EF ___, severe LVH, low E', with findings suspicious for infiltrative cardiomyopathy. Our heme-onc team was consulted, and serum and urine labs for infiltrative disease (SPEP, UPEP, uric acid, LDH, wuantitative immunoglobulins, iron studies, beta 2 microglobulin) were unremarkable. A cardiac MRI was done ___ that showed nulling consistent with amyloid deposition. A right heart cath/left heart cath was done with biopsies ___. Biopsies were positive for amyloid deposition. Samples were sent to an outside lab for mass spec typing. In addition, the right heart cath/left heart cath showed 2 vessel disease, elevated RH and LH filling pressures, and elevated PASP. No intervention was done for the coronary disease. With regards to treatment of the patient's CHF, he was aggressively diuresed and discharged on PO lasix 20mg. We also started aspirin and high-intensity atorvastatin for his newly-diagnosed CAD. Metoprolol started at his recent outpatient visit was continued. His blood pressure was controlled with lisinopil 2.5mg, and he was discharged on the same medication. The patient's symptoms improved dramatically and he was ready for discharge on ___. A follow-up appointment was made in the heart failure clinic. We are awaiting the results of his amyloid typing. #Afib with RVR: diagnosed at recent outpatient appointment, had on admission in the setting of not tolerating metoprolol prescribed by PCP. The patient's RVR was initially controlled in the ED with diltiazem. During the admission his rate was controlled with metoprolol, with a goal rate in the 80___s-90's. We did not want the rate to be slower because of the patient's infiltrative cardiomyopathy. A TTE with cardioversion was planned. On ___, the TTE showed clot in left atrial appendage, so no cardioversion was performed. The patient's CHADS2 score is 3 (CHF, HTN, DM). The patient was anticoagulated with a heparin drip as an inpatient, and he was switched to warfarin with a lovenox bridge prior to discharge. The patient was discharged with lovenox training and a follow-up appointment in the ___ clinic for warfain management. #DM: This is a new diagnosis for the patient, with A1C 6.8% at recent PCP ___. We controlled his glucose with diet only and his fingersticks were well-controlled. The patient was seen by a dietician during this admission. #Creatinine elevation on admission: The patient's creatinine was 1.3 on admission. The patient's baseline is unknown. The etiology of this presumed bump was unclear. Chemistries were trended and Cr quickly dropped to 0.9, and was stable at 0.9-1.0. # Transaminitis: The patinet had a mild transaminitis on admission. The etiolog was unclear. A RUQ ultrasound on ___ showed unremarkable liver and bile ducts. On repeat labs the transaminases improved slightly, but alk phos remained elevated at 245. *Transitional Issues* [ ] Dry weight 66.7 kg [ ] Continued monitoring of INR and warfarin dose (started ___ [ ] follow-up final tissue biopsy for specific amyloid type, refer to specialist as appropriate [ ] continued management of diuretics, monitor electrolyte levels. [ ] will need stress test as outpatient</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M s/p fall 2 days ago, found unresponsive. CTH with 1.2cm right frontoparietal aSDH, 9mm MLS. EtOH 303. Confused, intoxicated, but full strength. Radiology showed No acute cardiopulmonary process. Radiology showed 1. Slight increase in right subdural hematoma with stable 9 mm of midline shift. No sign of downward herniation. 2. Small amount of subarachnoid blood in the right sylvian fissure. Radiology showed Degenerate changes without evidence of acute fracture. Radiology showed 1. No intra-abdominal or intrathoracic solid organ injury. 2. Minimally displaced fractures of the posterior left ___ and 12th ribs. 3. Fatty liver. 4. Mildly dilated right ureter, perhaps due to reflux, although non-specific in nature. 5. Cholelithiasis without cholecystitis Radiology showed 1. Slightly decreased right convexity subdural hematoma s/p craniotomy. Slightly decreased associated mass effect. 2. Nondisplaced right parietal bone fracture extending into the squamous temporal bone, without petrous involvement. Radiology showed Interval increase in right subdural hematoma with increased leftward shift of midline structures and subfalcine herniation. Findings were discussed with ___ by Dr. ___ telephone at 10:45 AM on ___. Radiology showed Increasing size of right frontoparietal subdural hematoma with increased mass effect resulting in increased subfalcine herniation and concern for downward transtentorial herniation. Dr. ___ communicated the above results to Dr. ___ at 6:41 p.m. on ___, immediately after discovery. Findings were known to the surgical team and patient was being sent emergently to the operating room for decompression. Radiology showed Interval placement of a right-sided drain status post evacuation of subdural contents with overall decreasing shift of the midline structures. Radiology showed Endotracheal tube has been advanced approximately 1-1.5 cm and now terminates approximately 2.4 cm above the level of the carina. Clear lungs. Radiology showed Interval increase of the right subdural hematoma with more blood identified along the anterior and posterior convexity. There is increase in associated mass effect and compression of the ventricles. Radiology showed AP chest compared to ___: ET tube and nasogastric tube in standard placements respectively. No pneumothorax, pleural effusion or atelectasis. Lungs clear. Heart size normal. Radiology showed No significant change in right subdural hematoma, mass effect or leftward shift of midline structures since ___. External drain in appropriate and stable position. Radiology showed No significant change in postoperative appearance of right subdural hematoma and degree of local mass effect and subfalcine herniation. Radiology showed No evidence of DVT in the right or left lower extremity. Radiology showed Interval removal of right frontal approach drain with slight increase in pneumocephalus overlying the right frontal convexity. No other significant change in the appearance of right subdural hematoma and degree of local mass effect. The patient was diagnosed with SUBARACHNOID HEM-NO COMA, ACCIDENT NOS. The patient was treated with ___ Right Craniotomy for evacuation of Subdural Hematoma ___ Right Craniotomy for re-evacuation of Subdural Hematoma. At the time of discharge, the patient had Subdural Hematoma. 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 presented to ___ and was admitted to the ___ care unit for close neurological monitoring and care. Plan was made that he would undergo surgery on ___ for evacuation of his right subdural hematoma. Initially upon admission he was intoxicated and unable to provide informed cosnent for surgery and a repeat CT head was stable. On ___ he was awake alert and oriented x 3, understood his current condition, and was able to provide informed consent for surgery. he was taken to the oeprating for for evacuation of his right subdural hematoma via right sided craniotomy. he toerlated the procedure well was extubated in teh oeprating room and transferred to the ICU post-operatively for further monitoring and care. He underwent a post-operative CT head that showed decreased right subdural hematoma with decrease in midline shift. He remained stable overngiht into ___ and on mornign rounds he was noted to have increased somnolence and difficulty with teh date. A CT scan of the head was done which showed increased blood products and increased midline shift. He was closely monitored following this but given a change in neurologic status, returned to the operating room for a re-evacuation of the subdural hematoma on the right. He remained intubated s/p the procedure and returned to the ICU for close monitoring. On ___, the patient's examination waxed and waned overnight. The subgaleal drain output was 40cc since the OR and the Subdural drain output was 35cc since the OR. The patient was actively withdrawing from alcohol and was requiring additional doses of Ativan per CIWA scale. On ___, the patient remained intubated as he was withdrawing and requiring increased benzodiazpines. He received a Phenobarbitol bolus for withdrawal symptoms. The subdural drain and subgaleal drains remained in place for continued drainage. Antibiotic coverage continued as the drains remained in place. The non-contrast head CT shows a stable bleed with slight improvement in midline shift and pneumocephalus. On ___, the subgaleal drain was removed and 2 staples were placed for closure. He continued with intermittent fevers. The sputum gram stain showed gram positive rods; the culture remains pending at this time. He continues to receive Phenobarbitol for etoh withdrawal. The non-contrast head CT obtained today showed stable post op changes and subdural drain in place with stable fluid collection. Subgaleal drain removed, 2 staples placed at drain site. Temp, sputum gram stain shows 1+ GPRs, pending culture. Receiving Phenobarb bolus for etoh withdrawal. On ___, he remained intubated and received phenobarbitol boluses for his withdrawl. Head CT was performed and was stable. His subdural drain was removed, two staples were placed. On ___, a non-contrast head CT was performed and was stable. He was extubated. His CDiff culture was positive and he was started Flagyl 500mg PO TID. On ___, Mr. ___ underwent a bedside speech & swallow evaluation which he passed. On ___, the patient was neurologically and hemodynamically intact and was stable for floor transfer, but due to his Phenobarbital taper he remained in the ICU for close monitoring. ___, the patient remained neurologically and hemodynamically stable and was trasfered to the floor in stable condition. His staples were removed, incision healing well. On ___ he was walking with ___ and did well. later in the day he fell OOB, did not strike head and did not require imaging or workup. He was awaiting placement. Later int eh evenign he reported difficulty urinating with a burning sensation. A UA was sent which was not overtly concerning for UTI. HE remaiend stable into ___. He was screened and accepted to the ___ for rehab. Plans were made for discharge, he was given instructions for followup, and all questions were answered. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male with HTN, dCHF (EF >55% ___, recurrent MRSA infections, TURP, CKD stage 3 (baseline 1.5-1.7), h/o L leg split-thickness skin graft and chronic LLE lymphedema and pannus edema who presents to emergency Department with SOB and ___ ulcer. Patient states that on ___ he developed an allergic reaction with severe swelling and hives and shortness of breath. He decided to go off his medications for this allergic reaction and since then he is not taking any of his medications. He since has also stopped taking his oxygen at home because he felt like he had an allertic reaction to it. He is coming in to the emergency room today because he felt like he had difficulty ambulating in the setting worsening left ankle pain as well as increased shortness of breath. He has not been able to take any of his Medication for fear of an allergic reaction. In the ED, initial vitals were: 99.5 88 135/43 26 88% RA - Labs were significant for H&H ___, WBC of 8.4, Chem 7 significant for BUN/Cr of ___. Tnt <0.01, BNP of 1243, UA without infection. - Imaging w/ chest xray showed Cardiomegaly with pulmonary vascular congestion. - The patient was given 80 IV lasix, 25 mg of Carvedilol, 800 mg of Ibuprofen, and Tylenol. Vitals prior to transfer were: Upon arrival to the floor, pt states he is not far from baseline. He speaks in full sentences but states he has had to sleep upright for the last two weeks (coinsides with stopping all medications). He denies cough, chest pain, fevers/chills. He states ___ edema and chronic venous stasis is at baseline. No changes in pannus. REVIEW OF SYSTEMS: (+) 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 arthralgias or myalgias. CHEST (PORTABLE AP) showed Cardiomegaly with pulmonary vascular congestion. CHEST (PORTABLE AP) showed Since ___, cardiomegaly is accompanied by worsening pulmonary vascular congestion and mild interstitial edema. No definite areas of consolidation to suggest a site of infectious pneumonia. Radiology showed Mild pulmonary edema, mild cardiomegaly. RENAL U.S. showed 1. No evidence of hydronephrosis, stones or obstruction. 2. Collapsed urinary bladder, though visualization limited secondary to body habitus. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPOXEMIA. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Diastolic heart failure exacerbation Acute on chronic kidney disease SECONDARY DIAGNOSIS: Moderate Aortic Stenosis Hypertensive Urgency Bronchitis Gout flare Contact Dermatitis Adjustment reaction. 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 male with HTN, dCHF (EF >55% ___, recurrent MRSA infections, TURP, CKD stage 3, h/o L leg split-thickness skin graft and chronic LLE lymphedema and pannus edema who presents with heart failure exacerbation in the setting of medication nonadherence and increased LLE pain consistent with gout flare. # dCHF exacerbation Presenting with orthopnea in the setting of medication nonadherence, BNP 1243 and CXR with pulmonary edema indicating CHF exacerbation. No pulmonary infiltrate to suggest PNA and no increased cough to suggest Asthma/COPD exacerbation on admit. Ruled out amyloidosis as FreeKap 46.4, FreeLam 44.2, Fr K/L 1.05. HA1c 5.9%. Diuresed with goal net negative ___ L daily. Home Torsemide 80 daily. Received multiple IV boluses for 100mg lasix followed by several days of a 10cc/hr Lasix drip with significant UOP. Held two days in the setting ___ on CKD. Switched ___ to Torsemide 40 daily with new even UOP/weight. On home O2 of ___. In terms of optimizing antihypertensives, we would prefer that he take carvedilol to improve cardiac function, but Mr. ___ believes that he is allergic so is refusing to take carvedilol. Consider further discussion outpatient. BPs have been stable on maximum amlodipine 10mg daily. Discharged on 40mg torsemide PO daily. # ___ on CKD stage 3: Baseline 1.5-1.7. Creatinine 1.4 on admit > up to 2.5 ___ > down to 1.8 ___. ___ likely secondary to overdiuresis given FeUrea 20; unremarkable renal ultrasound, and higher dose of losartan. Improved with holding PO Torsemide and losartan (and with avoiding the significant amounts of ibuprofen that patient takes at home). Restarted torsemide ___ with continued improvement in creatinine down to 1.8. # Leg and back pain H/o of gout; likely also with radiculopathy and msk pain. Completed a course of steroids for his gout without significant improvement in pain, though also on Lasix drip which will exacerbate gout further. States that ibuprofen is the only thing that cures his pain; however, given his cardiac and renal function, he should not be on NSAIDs, which has been discussed with the patient at length. Encouraged to participate in Physical therapy as this would help improve radiculopathy or arthritis. Started on gabapentin and lidocaine patch. Started on 1gm acetaminophen PO q6hours with significant improvement in pain. Also attributes improvement to cyclobenzaprine. Will switch to acetaminophen to 650 q6hrs prn outpatient. Will continue cyclobenzaprine and lidocaine patch PRN for pain. B12 WNL; waiting for Methylmalonic acid lab for neuropathy workup. Consider further workup outpatient. # Gout acute gout flare in the setting of diuresis; currently in a hyperuremic state (Uric acid level 11.8). Pt takes 800 mg of ibuprofen TID at home; advised to stop dt CAD and CKD. Pt states they have confirmed gout by arthrocentesis, but no results in OMR. Appreciate rheum rec for methylpred taper and allopurinol. Completed methylpred taper 60 ___ & ___ > decreased by 10mg per day until completion on ___. Started allopurinol ___ daily ___ and will continue outpatient. #HTN: BP to 170s on admit > well controlled on amlodipine 10mg while inpatient. For cardiac function, would prefer that patient is on carvedilol or losartan; however, he states that he is allergic. Patient also refused labetolol as he only wants to be on one antihyprtensive. While not the ideal regimen for his heart failure, his BPs are stable on amlodipine 10mg daily. continuing home amlodipine 10mg tablet daily. # Adjustment reaction; Personality disorder (schitotypal vs narcissistic); Autism spectrum disorder Patient with concrete thinking and limited health literacy leading to fear of medications and medical care. For example: believes that ibuprofen and "15 cherries" will cure his gout. Also with some paranoia about health and people coming into his home. Appreciate psych recs to focus on immediate needs with patient and to communicate concrete and concise informant about treatment plan # Leukocytosis: Leukocytosis now resolved. WBC increased in the setting of acute gout flare. Patient believes that he is having an allergic reaction to the medications we are giving him; however, no signs of systemic allergic reaction on exam. In terms of infectious workup, Blood cultures with NGTD. Started on ceft/vanc ___ for presumed LLE cellulitis initially; however appears more like chronic venous stasis with lymphedema and gout, so ceft/vanc stopped ___. With some cough productive of green/yellow phlegm ___ with sinus congestion. CXR difficult to assess, but no clear infiltrate. Suspected bronchitis. Completed 5 day course of Azithromycin. Blood cultures with NGTD. Cough and leukocytosis resolved on discharge. # Rash face/chest and Aphthous oral ulcers; Patient concerned about allergic reaction. Evaluated by dermatology and count only to have contact dermatitis and aphthous oral ulcers. ___ seek allergy testing outpatient. Derm recommendations below; however, patient did not feel better with creams or ace bandage wrappings. HSV culture preliminary negative. - Face rash: 2.5% hydrocortisone BID PRN - Truck rash: triamcinolone 0.1% cream BID PRN - Pruritis: fexofenadine 60mg BID - Lower extremities: aquafor TID > kerlex and ace bandages - LLE ulcer eschar: collagenase and xeroform - Aphthous ulcers: HSV culture, viscous lidocaine - Nose irritation: nasal saline QID PRN #Moderate Aortic Stenosis Peak velocity 4.4, Mean gradient 45. Likely complicating HF exacerbation. Outpatient follow up with Dr. ___. #CAD H/o ?NSTEMI without intervention. Continue clopidogrel 75 mg (Asa allergy). Discussed need to avoid NSAIDs given CAD and CKD. #Asthma/OSA Has both restrictive and obstructive PFTs from ___. Pt has some inspiratory or expiratory wheezes on exam after lungs cleared from pulmonary edema, unlikely to have exacerbation though required home albuterol at times throughout hospitalization. Continue 2 puffs alb 4x daily PRN; continued nebs PRN. ___ Edema chronic venous stasis and lymphedema with acute gout flare. Treatment with Lasix as above with improvement. Derm recommendations to treat LEs and Panus with aquafor TID > kerlex and ace bandages, but patient felt that this increased his pain. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old gentleman with hx of malrotation s/p surgery who presents with abdominal pain. Radiology showed No bowel obstruction. Congenitally malrotated bowel is unchanged in configuration to prior CT. No acute abdominopelvic process. The patient was diagnosed with Vomiting, unspecified. At the time of discharge, the patient had PRIMARY: Abdominal Pain Secondary: Intestinal Malrotation. 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 hx of malrotation of gut s/p surgical intervention presents with nausea, vomiting, abdominal pain x1 week. CT scan negative for any acute process. Pt initially had leukocytosis w/ left shift, and WBCs in the UA. Pt was tested for HIV, GC/chlamydia, which are pending on discharge. Pt was given IV fluids and Zofran with resolution of symptoms. Pt tolerated full PO diet and his symptoms improved, and he was stable for discharge home. #Abdominal Pain/Nausea/Vomiting No clear source for patient's GI symptoms. Possible that patient has cyclic vomiting syndrome given patient has chronic hx of nausea/vomiting and has been symptom free for several months, and pt also has hx of migraines which is associated with ___. Also suspect patient may have some sort of gastroparesis given hx of slow motility on gastric emptying study, possibly related to his hx of malrotation. With history of marijuana use, was intrigued at the possibility of cannabis hyperemesis syndrome. However, pt does not endorse any behavioral shower relief and pt stopped using marijuana for 5 days now without resolution of symptoms. Given normal CT scan unchanged from before, no concern for bowel obstruction, IBD, or acute process. Does not appear to be infectious gastroenteritis given only 1 episode of diarrhea. No acute electrolyte abnormalities is reassuring. Pt with leukocytosis w/ left shift on admission and WBCs in the UA. Pt endorses high risk sexual activity and at risk for STI, which could have precipitated his GI symptoms. Pt was tested for HIV, GC/chlamydia, which are pending on discharge. Pt was given IV fluids and Zofran with resolution of symptoms. Pt tolerated full PO diet and his symptoms improved, and he was stable for discharge home. Consider gastric emptying study to assess for motility issues #High risk sexual activity Pt was tested for HIV, GC/chlamydia, which are pending on discharge. Patient was encouraged to engage in safe sex practice TRANSITIONAL ISSUES ============================ -f/u patient's GI symptoms. Consider getting a gastric emptying study to assess for motility issues. -f/u Urine GC/chlamydia. Treat if positive -f/u HIV ab test -encourage safe sex practice #Code Status: Full Code #Emergency Contact/HCP: ___ (Father) ___, ___ (Mother) ___</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with PMH of HTN and history of osteomyelitis of the R foot presenting to the ED with c/o worsening L foot infection. She presents with swelling and erythema of the left great toe and dorsum of foot. 2 weeks ago noticed a blister on the tip of her left great toe. She saw her podiatrist who did a debridement and put her on antibiotics. Xrays taken several weeks ago were negative of signs of osteo of the L hallux. The wound improved but did not completely resolve. On ___, she noticed redness and swelling of the great toe that subsequently spread to the dorsum of her foot and became warm. She does not have any pain in the area but is neuropathic. She denies fevers, nausea, vomiting or other systemic symptoms of infection. Radiology showed Findings highly worrisome for acute osteomyelitis of the distal aspect of the first distal phalanx; lucency through the distal aspect of the first distal phalanx, worrisome for acute osteomyelitis. Additional region of lucency just proximal to this appears to have subtle sclerotic margins and may not be acute. A bandage overlies the first toe and there is underlying ulceration and possibly soft tissue gas. The patient was diagnosed with Local infection of the skin and subcutaneous tissue, unsp. At the time of discharge, the patient had L Foot Infection. 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 was admitted to the podiatric surgery service from the ED on ___ for a Left foot infection. On admission, she was started on broad spectrum antibiotics and monitored for improvement. The patient remained afebrile with stable vital signs. Her WBC count normalized. Her pain was well controlled oral pain medication on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. She was placed on clindamycin and ciprofloxacin while hospitalized and discharged with oral antibiotics. Her intake and output were closely monitored and noted to be adequtae. The patient refused subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged. The patient was subsequently discharged to home on HD3 with plan for her to go to the OR on ___ for outpatient surgery. The planned procedure is a partial Left Hallux amputation. 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: ___ year old, previously healthy, ___ speaking male who presents to emergency room s/p facial trauma. Per ED notes, patient fell from 10 to 12 feet while at work lifting hay. This story was corroborated by his coworker. There was no loss of consciousness, or inciting event noted. Per patient he denies experiencing any new onset headache, dizziness, changes in vision, heart palpitations, or lightheadedness prior to the fall. He states that he hit his face first and got up woozy, but finds it difficult to recall events afterwards. He was taken to ___ for evaluation, where a CT Head was significant for a Left orbital floor fracture, and pneumocephalus. No intracranial bleed or hematoma was noted. He was then transferred to ___ hemodynamically stable for further evaluation. Currently he complains about left face pain, and right knee pain. No nausea, vomiting, fatigue, malaise, signs of increased intracranial pressure, or signs of CSF leak. Radiology showed No fracture. CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD showed 1. Allowing for normal anatomic variations, unremarkable head CTA. 2. No acute intra infarct or hemorrhage. 3. Multiple fractures involving the calvarium with slight interval progression of intracranial pneumocephalus as described above. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Decrease in pneumocephalus with no significant change in multiple facial fractures with blood products within the left maxillary sinus, right sphenoid sinus, and ethmoidal air cells. 2. Progression of left optic nerve deformity by the lateral orbital wall fracture. NOTIFICATION: The findings were discussed by Dr. ___ with ___ on the telephone on ___ at 6:22 AM, minutes after discovery of the findings. CT ORBITS, SELLA AND IAC W/ CONTRAST Q1215 CT HEADSUB showed 1. Minimally displaced left squamus temporal bone fracture with multiple facial fractures better characterized on prior head CT, including left lateral and medial maxillary wall, and left zygomatic arch fractures with hemorrhage in the left maxillary sinus, right sphenoid sinus and ethmoidal air cells. 2. Otherwise normal temporal bone CT. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Decreased pneumocephalus without significant change in multiple facial fractures with blood products within the right sphenoid sinus and ethmoidal air cells. 2. Persistent left optic nerve deformity by the lateral orbital wall fracture. The patient was diagnosed with Oth fracture of base of skull, init for clos fx, Unsp intracranial injury w/o loss of consciousness, init, Fracture of orbital floor, init encntr for closed fracture, Maxillary fracture, unspecified side, init, Other specified disorders of brain, Other fall from one level to another, 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>Mr. ___ was admitted to the ICU after his fall of ___ feet because his imaging findings included pneumocephalus as well as multiple facial fractures, for which neurosurgery, plastic surgery, and ENT were consulted. N: There was a concern for possible CSF leak, and he required q1h neuro checks. A CTA was obtained on HD2 that did not show any signs of bleeding, and he was AOx3 and neuro intact throughout his entire hospitalization. He was originally kept flat for 48 hours, and then sat up to assess for CSF leak. none was identified and he was allowed to space out his neuro checks. Repeat CT head 48 hours after admission showed improved pneumocephalus, and there continued to be no signs of a leak. The following day his neuro checks were spaced out and he continued to be neuro intact, so he was transferred to the floor. CV: no issues with his blood pressure throughout his hospital stay. P: GI: </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with history of CAD on plavix, hip fracture, hypertension, bradycardia and falls presenting after a recurrent fall. Patient cannot give a history as she does not remember the event but was found on the floor of her room at ___ and had a hematoma on her head. The fall was unwitnessed. Patient is confused at baseline. Denies any pain, lightheadedness, headache, worsening confusion, difficulty speaking, shortness of breath, chest pain, abdominal pain and dysuria. She says she feels fine but knows she is here because of a fall. CHEST (PA AND LAT) showed Normal chest radiograph. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Possible single focus of subarachnoid hemorrhage in a left frontal sulcus, versus motion artifact. No other evidence for intracranial hemorrhage. 2. No edema or CT evidence for an acute major vascular territorial infarction. RECOMMENDATION(S): Repeated head CT for reassessment of the questionable small focus of subarachnoid hemorrhage. NOTIFICATION: The final interpretation and recommendation for repeat head CT were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 10:06 am, 5 minutes after discovery of the findings. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed No evidence for a fracture. No subluxation. CT HEAD W/O CONTRAST showed Small focus of subarachnoid hemorrhage in a left frontal sulcus is stable in size with decreased density. No new intracranial hemorrhage. The patient was diagnosed with Urinary tract infection, site not specified. At the time of discharge, the patient had # mechanical fall # recurrent UTI # urinary retention # Subarachnoid 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 ___ female with the past medical history and findings noted above who presents after an unwitnessed fall. # Unwitnessed Fall # Forehead hematoma Fall unwitnessed (found lying on the floor in her room) but bruise on forehead suggests headstrike. Pt does not recall the event. CT head/neck with no intracranial abnormality. While patient with history of 4:1 flutter, ECGs at baseline with HRs in ___ and no documented events on tele > 48h. Cardiac enzymes negative. No murmur on exam nor history of DOE to raise concern for valvulopathy-mediated syncope. Noted to have borderline low BPs so home amlodipine discontinued. Collateral obtained from nursing staff at ___ and story seems consistent with mechanical fall as patient noted to be impulsive with poor situational awareness. Recommend continued rehab and fall precautions on return. Unclear if UTI (see below) contributed in fall risk. # SAH: CT scan with very small SAH without mass effect or focal neuro symptoms. She was evaluated by neurosurgery who concluded that there was no need for intervention or follow up imaging. Plavix was held and should not be given for at least two weeks. However, given risk of recurrent falls, decision made to hold indefinitely. Physician at ___ agrees. #UTI #Urinary retention: UA on admission with pyuria with WBCs greater than assay. UCx growing mixed flora. Treated with CFTX. Subsequently found to be retaining urine and thus bladder placed. She was unable to undergo CIC due to agitation with this, so foley left in place. Given contaminated initial UCx, repeat obtained. UA with significant reduction in pyuria indication response to CFTX so she was transitioned to PO cefpodoxime to complete a seven day course through ___. She will need a voiding trial at ___ with PVRs closely monitored to determine need for CIC versus chronic foley if not voiding spontaneously. #Aflutter 4:1 block on ECG and tele with HRs stable in ___. No documented bradycardia/tachycardia or other arrhythmia. Continued BB. Patient not on anticoagulation and this was not started in setting of SAH, however, given history of repeated falls, likely risks > benefits. # Hypertension: Borderline low BPs noted. Imdur and amlodipine held. BB continued. # Subacute cognitive decline: Per discussion with ___ staff, patient with intermittent confusion and cognitive decline over past month since arrival. Likely had been declining even longer. Consistent with progressive dementia. # Type II diabetes: Diet controlled. No issues. #Carotid stenosis: Continued on statin but. Last U/S in ___ with only mild stenosis. Plavix discontinued in setting of SAH, with plan to not resume per discussion with PCP at ___. # Hypothyroidism. - continued synthroid 88 mcg # Neuropathy - continued gabapentin. TRANSITIONAL ISSUES: =================== [] Discharged with indwelling foley. Recommend voiding trial with monitoring of PVRs. ___ require CIC if not spontaneously voiding. [] Recommend NOT resuming Plavix due to high fall risk. > 30 mins spent planning discharge</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with the past medical history of polymyalgia rheumatica, arthritis, bursitis, HTN, hypothyroidism, fibromyalgia, chronic abdominal pain with dyspepsia, osteopenia, and spinal stenosis s/p recent lumbar laminectomy and posterior spinal fusion on ___ by Dr. ___, presenting with bilateral hip pain. History is obtained from the patient as well as the nursing supervisor at her facility. BILAT HIPS (AP, LAT, AND PELVIS) 5 OR MORE VIEWS showed 1. No acute fracture, dislocation, or radiographic evidence of inflammatory arthropathy. 2. Mild degenerative changes of the bilateral hips, which have not significantly progressed compared to most recent prior radiographs and MRI. ULTRASOUND-GUIDED THERAPEUTIC STEROID/ANALGESIC INJECTION OF THE RIGHT AND LEFT GREATER TROCHANTERIC BURSA showed Technically successful and uncomplicated ultrasound-guided injection of anesthetic and steroid into the greater trochanteric bursa bilaterally. I Dr. ___ personally supervised the Resident/Fellow during the key components of the above procedure and I have reviewed and agree with the Resident/Fellow findings/dictation. The patient was diagnosed with Other acute postprocedural pain. The patient was treated with Bilateral Trochanteric Bursa Steroid Injections (___). At the time of discharge, the patient had Bilateral Trochanteric Bursitis Inability to Ambulate Elevated CRP Thrombocytosis Pseudohyperkalemia. 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 ___ woman with history of PMR (on chronic prednisone), hypothyroidism, fibromyalgia, chronic abdominal pain with dyspepsia, and spinal stenosis s/p recent lumbar laminectomy and posterior spinal fusion on ___ by Dr. ___, admitted with bilateral hip pain thought to be from trochanteric bursisitis, superimposed on her postoperative pains, with inability to ambulate. # Bilateral hip pain # Trochanteric Bursitis # Inability to ambulate: Patient evaluated by spine in the ED who felt that there was low concern for infection given clean appearance of surgical site and for lack of neurologic symptoms. They recommended against imaging at that time. There was initially concern for a flare of PMR based on elevated CRP and patient was started on higher dose steroids. However, rheumatology consult felt symptoms were more consistent with bilateral trochanteric bursitis. Steroids were returned to ___ dosing and patient underwent bilateral trochanteric bursitis injection. With treatment, her symptoms improved significantly and she was able to walk to the chair with assistance from nursing. # Spinal Stenosis, s/p # Recent lumbar laminectomy and posterior spinal fusion: Orthopedics saw in ED, low concern for infection given appearance of surgical site and for lack of neuro symptoms. Recommended against imaging. Patient remained without concerning neurologic features for the duration of her hospital course. Strength was ___ in bilateral lower extremities throughout on discharge. Per discussion with Dr. ___ surgeon), aspirin 81mg was started at discharge to prevent clotting and SC heparin stopped. Please continue for 1 month post-operatively. # Thrombocytosis # Elevated CRP: Patient admitted with elevated CRP and thrombocytosis (950) which may have been related to recent spinal surgery. Thrombocytosis improved over course of admission suggesting resolving process. # Hyperkalemia: Serum potassium was initially elevated to 5.6. There was a large discrepancy between plasma and serum potassium which was suspected due to pseudohyperkalemia in the setting of thrombocytosis (>900). # Polypharmacy: Patient on high doses of narcotic pain meds, benzodiazepines and muscle relaxants concerning given patient's age. Discussed extensively with patient who is amenable to weaning her medications as her post-operative course improves. Please work with patient to wean narcotic pain medications as able given ongoing improvement in her pain post-operatively. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o morbid obesity, obesity hypoventillation on chronic 02, not compliant with nocturnal bipap, diastolic CHF, current resident at ___ since ___ who is transferred from ___ for evaluation of scrotal cellulitis with question of ___ Gangrene. Urology at ___ evaluated patient and there is no signs of necrotizing infection either clinically or with evaluation with CT pelvis performed at ___. Patient has not had fevers. He is poor historian other than remarking on recent chills. Has had issues with chronic scrotal swelling. SNF progress note by Dr. ___ on ___ documents: acute diastolic heart failure with significant scrotal edema for which physician ordered scrotal elevation, increased lasix dose to 80mg and use of zaroxolyn 2.5mg every other day. Scrotum is mildly tender Radiology showed Extensive subcutaneous and scrotal edema and fluid without CT evidence for subcutaneous gas. Based on discussion with Dr. ___ by Dr. ___ prior to performing this CT, the clinical team is aware of these findings and the possibility of early ___ gangrene in the absence of subcutaneous gas. Radiology showed No evidence of deep vein thrombosis in the left lower extremity. The patient was diagnosed with EDEMA, MALE GENITAL ORGN. At the time of discharge, the patient had morbid obesity scrotal cellulitis and edema obesity hypoventillation. 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 morbid obesity, obesity hypoventillation on chronic 02, not compliant with nocturnal bipap, diastolic CHF, current resident at ___ since ___ who is transferred from ___ for evaluation of scrotal cellulitis. He does not have ___ gangrene or evidence of necrotizing soft tissue infection. His obesity, poor skin hygeine, likely diastolic CHF and pulmonary hypertension, and limited mobility all lead to accumulation of scrotal edema. # Scrotal cellulitis: he received: local skin care, scrotal elevation, IV vancomycin and IV ceftriaxone to cover strep and MRSA organisms (and some GNR coverage). Urology followed. Patient did well and was transitioned to Keflex and Bactrim to end on ___. He has an inverted penis and Foley catheter will need to remain in place until a voiding trial is performed at ___. Please see below for wound care recs. Emphasis is placed on skin care in the scrotal/inguinal region, and the urethral meatus should be cleaned daily. The patient is encouraged to walk at least three times daily. While in the bed or chair, the scrotum should be elevated to help limit the amount of edema. Tramadol was used for pain control. # Chronic hypercarbic respiratory acidosis with metabolic alkalsosis due to obesity hypoventilation and likely OSA --SNF notes document non-compliance with nocturnal bipap. He remained on nocturnal Bipap and 02 titrated to keep sats >88, below 98%. It is imperative that he continue to receive BiPAP nightly. # Diastolic CHF, chronic and pulm hypertension: suspected --continued PO lasix 100mg weight stable # Low back rash- resolving dermatitis vs. resolving shingles. No new lesions, all crusted over. Outside window of benefit with antiretrovirals, and asymptomatic. Need to continue to monitor skin for new lesions (no other rash, only in right S2 dermatome in the right gluteal cleft). If new lesions develop, would consider valacyclovir 1000 mg TID. # HTN: amlodipine # Diabetes: continue lantus and SS insulin, held glimiperide and metformin, and restarted metformin at discharge. #Hyperlipidemia: simvastatin #anxiety/depression: fluoxetine Heparin SC diabetic diet Full code</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ female with history of poor oral dentition who presents from OSH with diagnosis of Ludwig's angina.She has had progressive pain and swelling of her left face and neck for the past few days and at OSH was found on CT neck showed periapical abscess of her remaining left mandibular molar withsurrounding cellulitis extending into the parapharyngeal space,and to a lesser extent the retropharyngeal space. She was transferred on RA, received zosyn at OSH. On presentation patient was unable to speak in full sentences and had difficulty handling secretions. The decision was made to intubate in the ED to secure airway and plan for OR with OMFS for incision and drainage of deep neck/facial infection. Radiology showed Endotracheal tube tip is 5.3 cm from the carina. CHEST (PORTABLE AP) showed Compared to chest radiographs ___. Lungs clear. Heart size normal. No pleural abnormality. ET tube in standard placement. Nasogastric tube ends in the stomach. Chest AP view. showed The ET tube, NG tube have been removed in the interim. Lungs are low volume with bibasilar atelectasis. Cardiomediastinal silhouette is unremarkable. There is no pleural effusion. No pneumothorax is see The patient was diagnosed with Cellulitis and abscess of mouth. The patient was treated with ___: extra/intraoral I&D of deep neck space. At the time of discharge, the patient had Ludwig's angina. 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. ___ presented to ___ ED on ___ with Ludwig's angina. She was intubated in the ED for respiratory distress and secretions. She was taken emergently to the operating room on ___ by OMFS. Please see OP Note for more details regarding the procedure. Patient was kept intubated for 1 days and was successfully extubated on POD1. She was kept on Unasyn until ___ when she was transitioned to PO Augmentin. ___ drains were removed on ___. She was discharged home on ___. At the time of discharge, she was tolerating a regular diet, ambulating independently, voiding spontaneously, and pain was well-controlled with oral medications. She was discharged with instructions to follow up in clinic with ___ next ___. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old woman with extensive stage small cell lung cancer currently on carboplatin and etoposide + radiation who is admitted from the ED with profound weakness and dyspnea. CHEST (AP AND LAT) showed No radiographic findings to suggest pneumonia. Interval decrease in size of right upper lobe lung mass compatible with known malignancy. The patient was diagnosed with Weakness. At the time of discharge, the patient had #Localized Herpes Zoster. 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 extensive stage small cell lung cancer on carboplatin and etoposide with concurrent radiation who presented from Radiation Oncology with weakness and dyspnea, most likely I/s/o chemoradiation, subsequently found to have Herpes Zoster. # Herpes Zoster While inpatient, developed pain of L forehead, and subsequent vesicles in V1 distribution. Slight redness and pruritis of chest and back. ID & Derm consulted and felt these represented radiation changes and not disseminated zoster. Started valacyclovir for planned 14 day course given immunosuppression (through ___. Consulted ophthalmology for evaluation given V1 distribution and complaint of fuzzy vision in L eye; no evidence of zoster retinitis, and normal visual acuity, however noted incidental lesion as below. # Subretinal Lesion ___ disk-diameter subretinal lesion noted at 5 o'clock next to L optic nerve during ophthalmologic evaluation which was thought consistent with choroidal metastasis v. granuloma v. other inflammatory lesion. Recommended neuroimaging if possible with thin orbital cuts with contrast; however, given patient is declining recommended follow-up with Atrius ophthalmology within 1 week of discharge with OCT, visual field and ultrasound. # Weakness # Debility # Tremor Presented with weakness I/s/o chemoradiation. Infectious findings negative apart from VZV as above. Intention tremor noted which has been present for some time. TSH & cortisol normal. Patient declined all CNS imaging. Evaluated by ___ and deemed to be below baseline, but likely primarily due to fatigue; recommended home with home ___ but patient declined home services. CHRONIC ISSUES ============== # COPD Dyspnea likely due to known COPD. Improved with standing duonebs and continuation of home inhalers. # Extensive-Stage SCLC Followed by Dr. ___ at ___. Currently on treatment break after 3 cycles and conclusion of radiation; will repeat PET in 1 month. >30 min were spent in discharge coordination and counseling TRANSITIONAL ISSUES =================== [ ] Needs ophthalmology f/u within 1 week of discharge to evaluate heaped-up lesion near L optic disk. [ ] Should continue valacyclovir for 14 day total course (through ___</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is a ___, PMH significant for obesity s/p RNYGB, depression, abuse, presented to ___ today after an assault by her boyfriend. Patient relays that she was shoved by her assailant, causing her to land on the railroad track. There were no head strikes or loss of consciousness. She was brought to ___ where she was found to have right sided chest right fractures with associated pneumothorax. Symptoms are as expected with pleuretic chest pain, without dyspnea at first. She therefore declined placement of chest tube despite the moderately sized pneumothorax. Patient was subsequently transferred to ___ for trauma evaluation. Radiology showed 1. The right pigtail catheter has changed in position, and some of the side ports are now external to the pleural space. Associated accumulation of a small right pleural effusion and worsening right lower lobe atelectasis. 2. Minimal subcutaneous emphysema of the soft tissues overlying the lateral right seventh and eighth rib fractures. RECOMMENDATION(S): Discussed findings with ___ at 11:45 via telephone conversation (___). The impression and recommendation above was entered by Dr. ___ on ___ at 11:47 into the Department of Radiology critical communications system for direct communication to the referring provider. CHEST (PA AND LAT) showed Comparison to ___, 10:23. The drained pleural effusion on the right has further decreased in extent. There is no evidence for the presence of a right pneumothorax. Stable appearance of the heart and of the left lung. CHEST (PA AND LAT) showed Comparison to ___. The right pigtail catheter is in unchanged position. There is no evidence for the presence of a right pneumothorax. The right pleural effusion has not Re occurred. Stable normal appearance of the cardiac silhouette and of the left lung. CHEST (PA AND LAT) showed In comparison with the study of ___, with the chest tube on water seal, there is no evidence of pneumothorax. Mild opacification at the right base laterally is essentially unchanged. The remainder the study is stable. Radiology showed There is a right basilar pigtail catheter. There is a tiny pleural effusion versus scarring which is unchanged. Lungs are grossly clear. Heart size is within normal limits. No pneumothoraces are seen. There are no pneumothoraces. Radiology showed Cardiomediastinal silhouette is within normal limits. No pneumothoraces are seen. There is likely a small right-sided pleural effusion and there is some increased soft tissue density, likely related to the prior pleural catheter entry site. There is no overt pulmonary edema. Radiology showed The right basilar pigtail catheter has been removed. No pneumothoraces are seen. Heart size is within normal limits. Lungs are clear without focal consolidation or overt pulmonary edema There is some increase soft tissue density at the right costophrenic angle at the insertion of the previous pleural catheter. The patient was diagnosed with Traumatic pneumothorax, initial encounter, Asslt by strike agnst or bumped into by another person, init. The patient was treated with 1. pigtail chest tube placement. At the time of discharge, the patient had 1. right pneumothorax 2. right pleural effusion. 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 was admitted to our trauma surgery service after being transferred from an outside hospital for management of a right pneumothorax s/p assault. CXR also showed associated right pleural effusion. She had a pigtail catheter placed in the emergency room that was then replaced the following day when it was noted to have migrated into an incorrect position on chest X-ray. Subsequently, daily chest radiographs showed resolution of her pneumothorax, so her chest tube was transitioned from suction to water seal. However, her chest tube output remained high, suggesting persistent pleural effusion so her chest tube was kept to water seal until this output decreased to <100cc/day, when the chest tube was pulled and post-pull X-ray showed no recurrent pneumothorax. Her respiratory status remained stable throughout her stay and her pain control regimen was optimized prior to discharge. allowing for adequate respiratory effort with use of incentive spirometry. She was discharged home in stable condition. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with history of myeloproliferative disorder, cerebrovascular accident x2 (___), esophageal varices complicated by remote gastrointestinal bleed with splenorenal shunt status post splenectomy, gastritis, and L1 fracture (___) who presents with subjective weakness. She was in her usual state of health until approximately 4 weeks prior to admission, when she developed subjective generalized weakness and fatigue, which she attributed, at least in part, to continued recovery from recent L1 fracture, with progression over that period. Although she is not bedbound, she ambulates minimally around the house and rarely leaves. She is not limited by lightheadedness, chest pain, dyspnea on exertion, or low back pain (reports well-controlled and weaned from TLSO brace to lumbar corset), but rather by fatigue. She has no difficulty brushing her hair or rising from a chair without support, though she does require a walker for assistance with ambulation. Over the same period, she notes persistent loose stools, consistent in frequency with baseline attributable to irritable bowel syndrome; she does endorse occasionally grossly bloody stools due to hemorrhoids, as well as rarely melanotic stools less than once a month. She denies bleeding from any other orifice. Her appetite has been poor in general, and she recalls a few-pound unintentional weight loss over an uncertain period (weeks), though her appetite is robust at this moment. Ultimately persuaded by her family, she notes that she was reluctant to see her primary care provider until the day prior to admission, when urinalysis/urine culture were positive for E. coli at ___. Despite 3 doses of nitrofurantoin, she remains weaker than expected. She denies fevers/chills, abdominal pain, or dysuria/hematuria. Radiology showed Small bilateral pleural effusions, right greater than left. Subtle opacity at the right lung base is concerning for pneumonia. The patient was diagnosed with ANEMIA NOS, OTHER MALAISE AND FATIGUE, HYPERTENSION NOS. The patient was treated with Colonoscopy Video capsule endoscopy. 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 history of myeloproliferative disorder, cerebrovascular accident x2 (___), esophageal varices complicated by remote gastrointestinal bleed with splenorenal shunt status post splenectomy, and L1 fracture (___) who presented with subjective weakness.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo G1 at 24 weeks 2 days w mild intermittent asthma who presents with three days of fevers, chough, and malaise. CHEST (SINGLE VIEW) showed No acute cardiopulmonary process. The patient was diagnosed with Oth pregnancy related conditions, second trimester, Fever, unspecified, Myalgia, unspecified site, Diseases of the resp sys comp pregnancy, second trimester, Other pneumonia, unspecified organism, 24 weeks gestation of pregnancy. At the time of discharge, the patient had Influenza A. 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 G1 with a history of mild intermittent asthma who was admitted with flu like symptoms and a positive influenza A culture on ___. Regarding her influenza A, she presented to triage for history of three days of fevers and cough. Her Tmax was 103 at home. Her last febrile episode was 101.2 (___). A WBC returned as 7.4 with 83% neutrophilic left shift. A UA showed large Leukocytes and ketones and a urine culture was obtained. She had a rapid flu test which returned positive for Influenza A. A chest xray was obtained, which returned negative. She received a IV hydration via a initial 2 liter fluid bolus and was continued on IV fluids until tolerating PO. She was given acetaminophen 1g Q6H for fevers and pain and started on Tamiflu 75mg BID for a planned 5 day course. She did not continue the azithromycin. In the evening of ___, patient was tolerating a regular diet. She had normal bladder and bowel function. The patient remained afebrile throughout the end of the day on ___ and ___, but did continue to have tachycardia to the 130s. An ECG showed sinus tachycardia on ___. Her tachycardia improved to the low 100s on ___ with improved po and IV hydration. She had good fetal movement and no signs or symptoms of preterm labor. Her fetal heart tracing was reassuring throughout her hospital stay. By hospital day 3, patient was tolerating a regular diet, ambulating and voiding without issue. She had a sore throat so a throat swab was sent.This was negative for strep. She was discharged to home with close follow up on hospital day #3. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year-old female with the history below who presented to the ED today complaining of dyspnea. She reported 3 dd of cough, increased sputum production, URI symptoms, and her sob became worse last night. In the ED she was found to have hypoxemia (ra sat high ___. CXR had some ? atypical infiltrate. She was given azith, pred, neb, and improved. She was admitted. CHEST (PA AND LAT) showed Compared to chest radiographs ___. Mild interstitial abnormality is new, either edema or atypical pneumonia. There is no consolidation to suggest bacterial pneumonia. Heart size is normal though increased compared to ___. No pleural effusion. The patient was diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation. At the time of discharge, the patient had AECOPD. 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>AECOPD, likely due to viral URI. Flu neg. Stable. Improved rapidly with nebs, abx, and prednisone. Ambulatory sats normal on room air, felt much better by HD 3, evaluated by ___ and felt safe for home no services from a mobility standpoint. Encouraged smoking cessation repeatedly to pt. Gave nicoderm patch Hx mult cancers, ? in remission, due for surveillance in onc f/u ___. No acute issues on this front evident during this hospitalization Chronic back pain on high dose opiates: cont ms contin. We do not have fentora. Discussed with pharmacy, who recommended dilaudid po ___ mg q 3 h prn pain while hospitalized, which worked well for pain control without sedation</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ year-old R-handed woman with PMHx of HTN, HL, possible epilepsy and spinal stenosis who presents with multiple falls. Pt reports that starting ___ years ago she began to have intermittent slurring of her speech (___) and stiffening of her legs (1x/month) that would always resolve within 10 mins. She would also occasionally have difficulty with writing "my handwriting would become chicken scratch", which would also resolve within 10 mins. These episodes were thought to be seizures, but she has had multiple LTM admissions (most recently at ___ in ___ that did not capture any of these events and did not find any EEG abnormalities. She had an EEG done in ___ in ___ where the "thought they saw some changes in the temporal lobe". She was initially put on dilantin, but this gave her a rash and so she was switched to different medications. She is followed by Dr. ___ here at ___, and in ___, she was referred to Dr. ___ consultation on if the above events could be TIAs. He reviewed her OSH MRI and determined that both hx and imaging were not c/w strokes or TIA's. Pt then feel in Novemeber onto her head on the R side where her glasses broke and lacerated her R forehead. Pt reports that she felt like she got a "sudden push" from behind in the middle of her back that propelled her forwards associated with stiff legs. She was unable to get herself up on her own, so she had an ambulance come and take her to ___. ___, where a CT head was done that was negative for acute process. She saw Dr. ___ at the end of ___ and she was changed from generic keppra to brandname keppra (which was actually started by the patient in the middle of ___. She then had some sensation of her legs stiffening in the beginning of ___, but these were c/w her prior episodes where it disappeared within 10 mins. She saw Dr. ___ again in early ___ who put her on trileptal with the plan to uptitrate the trileptal and wean off the keppra. Pt increased her trileptal dose yesterday from 300mg BID to ___ QAM and 450mg QPM. . Yesterday pt woke up feeling fine, got out of bed, ate breakfast, but then at around 8am was walking into the kitchen and fell, hitting her L hand and L forehead. She reports that she had the same sensation of being propelled forwards with stiff legs as she did in ___. However, the leg stiffness lasted for 1.5hrs this time. She was able to get over to a chair and allow it to subside. She reports that she started to feel mildly nauseated at this time, but did not vomit. She denies any associated H/A, numbness/tingling, vision disturbance, difficulty with speech production or comprehension, weakness, vertigo or any other associated sx at that time. She then "puttered around the house" and went to make lunch at around noon and "felt the stiffness coming on" along with a sensation of feeling off-balance (but not vertiginous), and she was able to make it to a couch. Again the sensation of stiff legs lasted for 1.5 hours. She got up after it dissipated and ate lunch, but then at 6pm when she went to have dinner she felt the stiffening again and her husband was able to help her get to the couch. This episode of stiffening lasted 3 hours, but did eventually go away and she was able to sleep. . This morning, she woke up, and got out of bed, but as soon as she took a few steps away from the bes, she felt both legs stiffen. She was able to walk over to the couch, where she stayed until 1:30pm. Her daughter came to visit, and noticed that when the pt tried to eat soup her arm appeared too stiff to lift the soup to her mouth. Also, when the daughter tried to take the spoon out of her mother's hand she had to "pry it out of her hand", as pt's hand was "clasped" around the spoon. Pt was also having slurred (but appropriate) and mumbled speech at this time, that was similar to her prior events of slurred speech. Pt's husband and daughter felt that the stiffness was too severe to attempt to get the patient downstairs and into the car themselves so they called ___ to be taken to the ED. Her sx had resolved by the time she got to the ED. . In the ED, pt's daughter noted that the pt had another episode of slurred speech, but that this was more subtle and lasted for only a few mins. . On neuro ROS, the pt denies current headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. . On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. 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 arthralgias or myalgias. Denies rash. Radiology showed No acute intrathoracic process. Radiology showed No acute intracranial process. Recurrent fall. AP, lateral, and flexion position of the cervical spine were reviewed. There are extensive degenerative changes demonstrated, as well as diffuse osteopenia. Alignment is preserved. For precise details, please review MRI of the cervical spine obtained the same day earlier. was done. Radiology showed Mild degenerative changes as described. No evidence of significant canal compromise or cord compression. No cord signal abnormality. Apparent prominent veins in the bilateral occipital lobes. Consider MRI of the brain for further evaluation. The patient was diagnosed with OTHER MALAISE AND FATIGUE, HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL, CHEST PAIN NOS. At the time of discharge, the patient had Cervical Spondylosis. 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 HTN, HL, recurrent falls p/w similar episodes of recurrent falls with leg stiffening, being "propelled forwards", and occasionally mild slurring of speech without any impairment of consciousness. [] Falls - The patient has signs of myelopathy on examination with weakness and brisk reflexes but no significant sensory changes. She has cervical spinal canal stenosis on MRI. This is most consistent with cervical spondylosis with myelopathy. She was treated with a soft cervical collar. A spine consult was obtained and there was no recommendation for surgical intervention. She will follow up in the ___ further management. [] ? Seizures - She was monitored on 24h cvEEG monitoring and had several typical events without any EEG correlate. She was advised to taper off her Keppra and Trileptal slowly and to follow up in the epilepsy clinic for further management. Physical therapy and occupational therapy evaluated the patient while admitted and cleared her for discharge home with outpatient ___. </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 history of multiple myeloma diagnosed ___ currently undergoing radiation therapy for L5 plasmacytoma presenting today with chief complaint of new fevers, chills and body aches (tmax 101.1 on morning of admission) and fatigue. She completed a 2 week dexamethasone course on ___. She has yet to receive chemotherapy treatment though feels very anxious and emotional regarding the prospect of chemotherapy. Overnight she began feeling feverish with chills and took 2 Tylenol. She again felt feverish this morning and had a fever to 101.1. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with FEVER, UNSPECIFIED. At the time of discharge, the patient had Fever and fatigue. 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 a history of multiple myeloma diagnosed ___ currently undergoing radiation therapy for L5 plasmacytoma presenting with chief complaint of fever, chills, and body aches. Fever: Ms. ___ presented with a fever to 101.2 on the morning of admission though had no subsequent fevers. The etiology of her fevers is unclear without localizing source on history or physical exam. She was afebrile throughout her hospitalization. She was initially started on Vancomycin and Cefipime for neutropenic fever. Antibiotics were discontinued on hospital day #2. She was monitored for 24 hours after discontinuation of antibiotics without recurrence of fever. She was not neutropenic during her hospital stay. Urine culture was negative. Blood cultures revealed no growth. CMV DNA was negative though EBV and HHV6 results were pending on discharge. She was counseled on the importance of returning to the hospital if her fever returns and she expressed understanding. Plasmacytoma and back/leg pain: Ms. ___ is currently undergoing radiation therapy for L5 plasmacytoma causing nerve root compression with palliative radiotherapy to L4-S1. She has not yet started chemotherapy due to personal hesitation and anxiety. She received 2 radiation treatments during her hospital stay and is scheduled for her last fraction on ___. She ambulated without difficulty during her hospital stay without change in lower extremity strength, no bowel or bladder incontinence, and denied lower extremity pain. She will continue with radiotherapy to L4-S1 as noted above. She will follow up with Heme/Onc in clinic to further discuss systemic therapy on ___. Rash: Ms. ___ presented with isolated 1-2 mm erythematous non-confluent, non-pruritic macules on her cheeks bilaterally on hospital day #3. Possibly viral vs drug related, and improved prior to discharge. FEN: Regular diet, gluten free Prophylaxis: DVT prophylaxis with heparin- patient refused heparin during her hospital stay. Ambulated daily. Pain: Oxycodone PRN. Avoided Tylenol to assess for fevers. Bowel regimen: Senna and Colace </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F with a history of angioedema, known 3 VD (was being evaluated as outpt for CABG), MI ___ and recent CCU admission ___ for STEMI when she received DES x2 to the LAD, POBA of LCX and was diagnosed with acute sCHF with 35%EF with dyspnea. Radiology showed Severe pulmonary edema. The patient was diagnosed with PULM EMBOLISM/INFARCT. At the time of discharge, the patient had Acute on chronic systolic heart failure ST elevation myocardial infarction Acute Kidney Injury Leukocytosis. 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 CAD and known 3VD s/p recent hospitalization ___ for STEMI who presents with dyspnea, pulmonary edema and 2 lb weight gain suggestive of decompensated heart failure.</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 past medical history of T1DM, retinopathy, neuropathy, Charcot foot, ESRD s/p SCD kidney transplantation in ___, repeated skin cancers related to immune suppression, hx of Hep C (undetectable vital load in ___, HTN, who came to the ED with weight gain, swelling over face and legs. Chest: Frontal and lateral views showed Streaky left upper lung opacity is similar compared to ___ ___ be chronic. Small bilateral pleural effusions. Possible mild pulmonary edema superimposed on chronic lung changes. RENAL TRANSPLANT U.S. showed 1. Redemonstration of moderate renal transplant hydronephrosis. Small amount of perinephric free fluid. 2. Patent renal transplant vasculature. Resistive indices range from 0.6-0.8. CT abdomen and pelvis. showed 1. Moderate hydronephrosis of the right lower quadrant transplant kidney, as seen on prior ultrasound. 2. Stable, 3 mm nonobstructing stone within the upper pole of the transplant kidney. 3. Small, bilateral pleural effusions. 4. Trabeculated bladder wall, likely secondary to chronic outlet obstruction. 5. 3 mm pulmonary nodule of the right lower lobe, for which no dedicated CT follow-up is recommended. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and an optional CT 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: ___ The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had Primary: Acute kidney injury on chronic kidney disease Lower extremity edema Secondary: ESRD s/p renal transplant Iron deficiency 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 past medical history of T1DM, retinopathy, neuropathy, Charcot foot, ESRD s/p SCD kidney transplantation in ___, repeated skin cancers related to immune suppression, hx of Hep C (undetectable vital load in ___, HTN, who came to the ED with weight gain, swelling over face and legs. ACTIVE ISSUES ============= # Weight gain # Bilateral lower extremities edema # Pulmonary congestion on CXR Patient presented with reported weight gain of ___ lbs over 5 days along with new bilateral lower extremity edema. Patient reassuringly asymptomatic with no dyspnea or chest pain. BNP elevated to 3200 with negative troponin. No evidence of cirrhosis on CT A/P. Patient received 40 IV Lasix in the ED with some improvement in ___ edema. Echocardiogram performed with normal systolic function, notably with enlarged left atrial and mildly elevated pulmonary artery systolic pressure to 27. Given hemodynamic stability, and reassuring volume exam with only mild edema of lower extremities, patient started on oral diuretic of torsemide. # ESRD s/p SCD kidney transplantation in ___: # ___ on CKD: Cr. 1.8 on admission, up from baseline of 1.3-1.5. Renal transplant U/S demonstrated moderate hydronephrosis stable from prior with patent transplant vasculature. Of note, patient underwent renal biopsy on ___, which demonstrates diabetic nephropathy with nodular glomerulosclerosis. UA demonstrated proteinuria with Pr/Cr ratio of 1.6. Creatinine improved to 1.6 and then on repeat 1.8, which notably in setting of supratherapeutic tacrolimus. # Anemia Hgb 9.0, on repeat 9.5. MCV wnl. Iron studies with low serum iron, but otherwise unremarkable. Baseline appears to be ___. Stool guaiac was negative. Last colonoscopy in our system ___. Due for repeat. Started on PO iron. # Incidental lung finding: 3 mm pulmonary nodule of the right lower lobe, for which no dedicated CT follow-up is recommended. RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and an optional CT in 12 months is recommended in a high-risk patient. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ transferred from ___ with chest pain found to have NSTEMI. Patient was in his USOH until 1am on ___, when he developed the acute onset of ___ burning substernal chest and back pain that awoke him from sleep. He had no associated SOB, N/V/D or diarphoresis. He noted the pain somewhat improved by later that morning, but he continued to have a ___ 'ache' substernally. He then presented to ___, where he was given ASA 325 and nitro 0.4 x 3 without effect. He then received morphine 5mg at 1830 which caused bradycardia to the ___ with a BP of 79/40. He was placed in ___ and given IVF with return of vital signs. OSH labs were notable for trop of 1.0, CKMB of 76.4, INR 1.1, HCT 39.7, and plt 165. He was then transferred for further management. In the ___ intial vitals were pain 2, T 98.7, HR 65, BP 116/67, RR 20, O2 99%3LNC. EKG was notable for qwaves V5-V6,I, and AVL with TWI in I and AVL. Initial labs were notable for troponin of 1.35. CXR showed mediastinum of ~8cm and signficant subcutaneous tissue. Patient received plavix 300mg and started on a heparin gtt before admission to cardiology for futher management. On the floor, patient reports he is chest pain free. He denies recent fevers or chills. No shortness of breath or cough. He denies orthopnea or PND. No recent nausea, vomiting or diarrhea. No symptoms of claudication. He does have baseline urinary urgency and some left elbow pain. Review of systems otherwise unremarkable. Radiology showed Normal mediastinum. The patient was diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE. The patient was treated with Cardiac catheterization ___. At the time of discharge, the patient had NSTEMI: 100% occlusion of left circumflex artery, s/p DES ___. 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 PMHx of BPH who was transferred from ___ with chest pain found to have NSTEMI. # NSTEMI Patient with presentation c/w late NSTEMI with positive cardiac enzymes without ST elevations. He was maintained on heparin gtt. Mild persistent chest pain, evaluated by cards in ___ and underwent LCH on ___. He was found to have extensive thrombus in LCX and underwent thrombectomy, balloon dilatation and placement of ___. He was maintained on metoprolol, atorvastatin and lisinopril, plavix and full dose aspirin. # PUMP: TTE showed depressed EF 50-55%. No clinical signs of heart failure; pt remained euvolemic. # RHYTHM: NSR on Telemetry # BPH: Con't Terazosin and finasteride</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of CKD on dialysis, CAD, diastolic CHF, and diabetes presents with respiratory distress. Patient noted to have significant cough and feeling generally unwell. DNR/DNI status confirmed. No reports of vomiting, chest pain, abdominal pain, leg swelling, rash, dysuria. Radiology showed Interval progression of the parenchymal opacity in the left mid lung worrisome for pneumonia. CT abdomen pelvis without contrast showed 1. Multifocal pneumonia. 2. No evidence of colitis or other acute intra-abdominal process. 3. Extensive atherosclerotic disease, including severe calcification of the celiac axis and SMA. 4. Extensive multilevel degenerative changes of the imaged spine, not significantly changed compared to ___. Radiology showed Persisting multifocal pneumonia as described above. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had Primary Influenza Health-care associated pneumonia New-onset atrial fibrillation Chronic Kidney Disease Stage 4 Secondary Chronic heart failure with preserved EF Coronary artery disease Hyperlipidemia Seizure disorder Glaucoma GERD 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>___ with history of CKD on dialysis, CAD, seizures, and HFpEF who presented with respiratory distress and was found to have multifocal pneumonia and influenza, with likely new onset AF in the setting of infection. #Influenza/Pnemonia: Patient was treated with a 5 day course of Tamiflu (___) and started on coverage for HCAP with an 8 day course of levofloxacin 500 mg q48h (end ___. Patient required ___ O2 and improvement in her symptoms and oxygen status was noted with treatment. #Atrial fibrillation- Patient was noted to have intermittent episodes of Afib during this hospitalization, with no prior diagnosis previously. Patient was started on carvedilol 12.5 mg BID given patient's hypertension. Regarding anticoagulation, patient's cardiologist was contacted and recommended deferring anticoagulation given likely provoked AF in the setting of acute illness and the fact that patient is already of dual antiplatelet therapy. Patient was discharged with ___ of hearts monitor at discharge with plans to follow-up with Dr. ___. # TTE performed ___ showed: Symmetric LVH with normal global and regional biventricular systolic function. Moderate to severe mitral regurgitation. Moderate to severe tricuspid regurgitation. At least moderate pulmonary hypertnesion. #HTN- Patient was found to be persistently hypertensive so her dose of imdur was increased to 60 mg daily. Patient was also started on carvedilol 12.5 mg BID. Discharge BP: 124/64. # CKD Stage 4- Patient received HD on MWF. # Diastolic CHF (EF ~60%): Patient with no e/o heart failure clinically. BNP likely elevated in setting of CKD. Patient's isosorbide mononitrate was increased to 60 mg daily. Patient was also started on carvedilol 12.5 mg BID as above. # CAD/HLD with history of bypass ___ years ago. Patient was continued on home doses of atorvastatin, plavix, aspirin. Imdur increased to 60 mg daily. Carvedilol was added as above. # Seizure history: Patient has a history of seizures during times of infection per patient's daughter that manifest as rhythmic jerking of the arms and legs. No evidence of these seizures during this admission. Patient was continued on keppra 500 mg BID and keppra 500 mg tablet ___ after each HD session. # Glaucoma- Patient was continued on latanoprost 0.005 % drops (ophthalmic) # GERD- Continued famotidine 20 mg q24h # Depression- Continued celexa 20 mg daily</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ man with a history of atrial fibrillation, CAD s/p multiple stents and recent 3V CABG ___, ___ w/ LVEF 22% (___), CKD, cirrhosis s/p liver transplant (___) on tacro, IDDM, and peripheral arterial disease s/p multiple stents, who presents to the ED after transfer from an outside hospital for first time seizure at rehab. History is obtained from prior documentation, as he is unable to provide any history. Radiology showed Lungs are low volume with no evidence of pneumonia. There are old healed right-sided rib fractures. Cardiomediastinal silhouette is stable. Vascular calcifications again seen. Previously visualized right IJ line has been removed in the interim. There is no pleural effusion. No pneumothorax is seen The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus. At the time of discharge, the patient had Primary Diagnoses =================== Seizure Hypocalcemia Vitamin D deficiency Secondary Diagnoses ==================== S/p Liver Transplant Transaminitis Delirium. 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 ==================== [ ] Furosemide and potassium supplementation - held in the setting of ___, hypocalcemia. Can be restarted on an outpatient basis [ ] Seizure precautions - given history of seizure patient should not drive (per state laws), operate heavy machinery, bath alone, swim, or climb ladders for 6 months or until cleared by his primary care physician. [ ] Transaminitis - attributed to amiodarone, though should be followed up in the future to ensure stabilization [ ] Alcohol use - evidence of alcohol use even since his liver transplant. Alcohol use counseling should be considered in the outpatient setting. [ ] Electrolyte abnormalities - calcium, magnesium, and vitamin D should be check periodically to ensure they are within adequate levels and repleted prn. [ ] Please check CMP on ___ and replete as indicated [ ] Is on warfarin for atrial fibrillation. Was changed from rivaroxaban on his last hospitalization ___ discharge) to warfarin. Unclear based on notes the reasoning for the transition. Will continue warfarin but should be evaluated by PCP or cardiology regarding restarting rivaroxaban. [ ] On discharge from rehab, please connect patient to ___ ___ clinic. Per ___ clinic, cannot establish care with their services until after discharge from rehab. [ ] New medications: thiamine 100mg daily, folic acid 1mg daily, vitamin D 2000IU daily ___ year old male with CAD s/p multiple stents and recent 3v CABG ___, EtOH cirrhosis s/p OLT in ___ on tacrolimus, atrial fibrillation on warfarin, HFrEF, CKD, IDDM, and PAD presented from rehab center with new onset tonic-clonic seizure x1 and severe hypocalcemia secondary to vitamin D deficiency. # Seizure Patient presented from rehab center after sustaining a tonic-clonic seizure. A work up, including head CT, was negative. The patient was noted to be severely hypocalcemic, which is thought to have precipitated his seizures. Neurology was consulted, who felt that the hypocalcemia was sufficient to explain the seizures and recommended against EEG and anti-epileptic medications. Mr. ___ did not suffer any further seizures after the initial episode. # Severe hypocalcemia Presented to OSH with calcium reportedly 5.1. A thorough work up revealed vitamin D deficiency as well as hypomagnesemia, which were felt to be the causes of his hypocalcemia. Notably, PTH was within normal range. Calcium, vitamin D, and magnesium were all repleted to appropriate levels, and the patient was started on PO repletion for discharge. # AMS The patient suffered from altered mental status throughout his hospital course, remarkable for waxing and waning features and altered sleep-wake cycle most indicative of hospital-acquired delirium. Other causes of AMS were also entertained, most notably ___'s encephalopathy and hepatic encephalopathy in the setting of his extensive alcohol abuse history. Ultimately, it was felt that his presentation was not consistent with ___'s encephalopathy (no nystagmus or evidence of cerebellar dysfunction) or hepatic encephalopathy (no asterixis). However, given relatively low impact of vitamin supplementation and risk of Wernicke's, started patient on thiamine supplementation per neurology recommendation. # Alcohol use Patient had varying reports of the last time he had alcohol, but collateral acquired from his brother indicated that the patient had been drinking significant amounts of alcohol since 6 months after his liver transplant in ___. Given his history of alcohol use, he was started on MVI, thiamine, and folate. # ___ on CKD Patient's baseline Cr appeared to be around 1.0-1.1, but his Cr was lower on admission. It uptrended on ___ to 1.4, which was thoguht to be secondary to hypovolemia given patient his was significantly net negative based on I/Os. His Cr returned to his presentation levels with increased fluid intake and kidney function remained stable for the remainder of his hospital stay. Of note, his home Lasix was held in the setting of his ___ and should be resumed on an outpatient basis. # Transaminitis # OLT ___ Mildly elevated AST/ALT to the ___ on admission. Patient was started on amiodarone on previous hospitalization in ___ for atrial fibrillation, which was the suspected etiology of his transaminitis. On exam, the patient had a nontender RUQ and no evidence of cholestasis on labs. His tacrolimus levels were monitored, and no dose adjustments were necessary to keep within goal ___ per hepatology). Chronic/Stable Medical Issues ============================== # Atrial fibrillation - Continued amiodarone - Continued warfarin # CAD s/p stenting, 3v CABG - Continued ASA 81mg - Continued atorvastatin 80mg daily - Continued imdur 30mg daily # HFrEF EF 22% ___ in setting of hospitalization for CABG - Held Lasix 20mg daily given hypocalcemia, ___ - Continued lisinopril 10mg - Continued metoprolol succinate 25mg daily # IDDM - Continued home regimen of lantus and Humalog SSI # PAD s/p stenting - Continued ASA, statin</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with the past medical history notable for PE at 7wks gestation (___), IVC clot 2wks post-partum s/p catheter-directed thrombolysis and IVC filter s/p removal, and submassive PE in ___ who presented to the emergency department for evaluation of pleurtic chest pain. She was seen at ___ where she was found to have bilateral PEs with evidence of right heart strain. She was started on TPA and received a total of 5 mg during transfer and this was DC'd upon arrival to ___. CT HEAD W/O CONTRAST showed No acute intracranial process. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. The patient was diagnosed with Other pulmonary embolism without acute cor pulmonale. At the time of discharge, the patient had Acute 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>___ woman with h/o PE at 7 wks gestation (___), IVC clot 2 wks post-partum s/p catheter-directed thrombolysis and IVC filter s/p removal, and submassive PE in ___ who presented to the emergency department for evaluation of pleurtic chest pain, found to have recurrent bilateral pulmonary embolism with right heart strain despite rivaroxaban. # Acute submassive PE: # Chronic VTE: The patient has a history of recurrent VTE and presents with a recurrent PE despite AC with rivaroxaban. She denies missing any doses. She follows with hematology who in their last note wrote: "Pt has a history of peripartum PE/IVC thrombus without identified contributing hypercoaguable syndrome (negative APL abs, AT antigen repeatedly normal). Her IVC filter was removed ___. She was treated with 6 mo therapeutic AC (warfarin -> Xarelto) then transitioned to ppx ASA 81mg daily on which she developed a LLL segmental PE (neg trop, BNP) and normal TTE. During that hospitalization, she underwent a repeat CTA chest 5 days after the diagnostic study which revealed no change in her exam. She was started on rivaroxaban 20 mg twice daily" She was transitioned to once daily rivaroxaban. At that time (___) hematology recommended lifelong anticoagulation. They noted "She does not have Antithrombin deficiency nor any identified hypercoagulability syndrome, though it is clear that she remains at high risk of recurrent thrombosis. Her APLS testing is negative, so she is safe to be anticoagulated with rivaroxaban." She missed her most resent hematology follow-up appointment in ___ of this year. - TTE reviewed, re-assuring - LENIs negative - Appreciate Hematology and MASCOT consult recommendations - Placed on Lovenox ___ q12. ___ cont on DC and have patient follow up with Dr. ___ - ___ repeat anticardiolipin and B2 glycoprotein testing - PENDING on DC - Hold home Rivaroxiban. - Pain control with acetaminophen 1000mg PO Q6H PRN. - Avoid NSAIDS for now if possible # Migraine Headaches: -Monitor</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH ESRD due to lithium toxicity s/p LRRT ___ years ago on azathioprine, prednisone, and tacrolimus, baseline creatinine ~0.9, IBS with chronic diarrhea, OSA on CPAP and 2L O2 at night, anemia, HTN, severe bipolar disorder, presenting with nausea (no vomiting), RLQ/vague abdominal pain, and diarrhea for the past week, with one day of confusion/delirium. Radiology showed Low lung volumes. No evidence of acute cardiopulmonary process. RENAL TRANSPLANT U.S. showed Normal renal transplant ultrasound. CT abdomen pelvis showed Optimal evaluation of organ pathology and vasculature is limited without the benefit of intravenous contrast. Within this limitation, acute uncomplicated diverticulitis involving a short segment of the descending colon, located in the left lower quadrant. No surrounding drainable fluid collection. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:08 pm, 5 minutes after discovery of the findings. The patient was diagnosed with Unspecified abdominal pain. At the time of discharge, the patient had Diverticulitis. 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 ___ yo woman with a history of ESRD due to lithium toxicity s/p LRRT ___ years ago on azathioprine, prednisone, and tacrolimus, baseline creatinine ~0.9, IBS with chronic diarrhea, OSA on CPAP, anemia, HTN, severe bipolar disorder, presenting with nausea (no vomiting), RLQ/vague abdominal pain, and diarrhea for the past week, with one day of confusion/delirium, found to have acute uncomplicated diverticulosis on CTU, which was successfully managed medically. # Acute uncomplicated diverticulitis # Nausea / abdominal pain # Toxic Metabolic Encephalopathy Patient presented with nausea, abdominal pain, and 1 day of confusion. CTU in the ED showed acute uncomplicated diverticulitis, which would explain symptoms. Renal was consulted regarding her immunosuppressive medications and recommended continuation of her regimen as she was relatively stable and not septic. She was started on IV cipro and PO flagyl, and was advanced to PO cipro on ___. She was initially NPO, but by ___ she was tolerating some clears, and her diet was advanced thereafter. By the day of discharge she was feeling like herself and was able to walk with her walker. By ___ she is tolerating diet well. Per ___ evaluation, she will need rehab, anticipate this will be less than 30 day stay. # ___ - Resolved. # ESRD s/p LRRT in ___ Patient w/ ___ to 1.3 from baseline 0.9. Likely pre-renal in the setting of dehydration/ diverticulosis as above. S/p 2L NS in ED and MIVF overnight ___ ___ resolved. Urine Cx negative. Tacro level 8.5 on ___, dose was decreased to 2mg bid (from home dose of 4mg BID), level was 10.2 on ___, thus dose was dropped to 1mg. Recheck of level on ___ was 6.7. Tacro level likely elevated in the setting of diarrhea. Continued other home meds: prednisone 5mg daily, and azathioprine 75mg daily. Recheck on ___ tacro level was 4.7, and she is being discharged, so final discharge dose will be 2mg BID. IMPORTANT She will need tacro level checked on ___ and fax the labwork to ___. # Tertiary hyperparathyroidism # Hypercalcemia Known history, followed by endocrine. She is on alendronate weekly (was not dosed while inpt). Continued cinacalcet. Held cholecalciferol. # Diarrhea # IBS Per patient, daughter, and medical records review, diarrhea appears to be chronic ISO IBS. C. diff was checked and was negative. (has history of infection in ___ and was checked again in ___, was negative). Imodium was given for sx relief. # Severe bipolar disorder Continued divalproex, lamotrigine, aripiprazole, venlafaxine. Of note, her med doses were incorrectly recoded on her pre-admission med list. The doses were adjusted and corrected on ___ by our pharmacy team. # HTN She was briefly on metoprolol after she was stabilized from an infectious standpoint, however it was discovered that her home medication list was incorrect, thus this was discontinued. # OSA Uses CPAP and 2L O2 at night. These were continued inpt. __________________________________</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CT abdomen and pelvis with contrast showed 1. A lower anterior abdominal wall peripherally enhancing fluid collection containing locules of air is decreased in size from prior, currently measuring up to 9.6 cm, compared with 14.2 cm previously, however is again concerning for infected seroma/abscess. This would be amenable to percutaneous drainage if desired. 2. A 2.7 cm left adrenal lesion is not significantly changed from prior, however is again incompletely characterized. Recommend correlation with prior imaging if available, or outpatient MRI/CT adrenal for further characterization if no prior imaging is available. 3. Hepatic steatosis. RECOMMENDATION(S): Recommend correlation with prior imaging if available, or outpatient MRI/CT adrenal for further characterization of a left adrenal lesion if no prior imaging is available. Radiology showed Right-sided PICC line at the appropriate position. Ultrasound-guided collection drainage. showed Successful US-guided placement of ___ pigtail catheter into the collection. Sample was sent for microbiology evaluation. The patient was diagnosed with Cellulitis of abdominal wall. The patient was treated with ___ drainage of pelvic fluid collection Physical Exam: Discharge physical exam Vitals: VSS Gen: NAD, A&O x 3 CV: RRR Resp: no acute respiratory distress Abd: soft, minimally tender, mildly erythematous around the drain site improved from admission, no induration or fluctuance noted, no rebound/guarding, RLQ JP drain intact with serosanguinous fluid Ext: no TTP Pertinent Results: ___ 12:24PM BLOOD Hct-36.2# ___ 05:32AM BLOOD WBC-5.7 RBC-3.22* Hgb-9.6* Hct-28.6* MCV-89 MCH-29.8 MCHC-33.6 RDW-13.5 RDWSD-44.0 Plt ___ ___ 03:40AM BLOOD WBC-7.1 RBC-4.04 Hgb-11.7 Hct-35.4 MCV-88 MCH-29.0 MCHC-33.1 RDW-13.5 RDWSD-43.5 Plt ___ ___ 04:00AM BLOOD WBC-7.7 RBC-3.84* Hgb-11.0* Hct-33.7* MCV-88 MCH-28.6 MCHC-32.6 RDW-13.8 RDWSD-44.0 Plt ___ ___ 05:13AM BLOOD WBC-7.8 RBC-4.27 Hgb-12.3 Hct-37.5 MCV-88 MCH-28.8 MCHC-32.8 RDW-14.0 RDWSD-45.2 Plt ___ ___ 07:33AM BLOOD WBC-9.6 RBC-3.92 Hgb-11.4 Hct-34.6 MCV-88 MCH-29.1 MCHC-32.9 RDW-14.4 RDWSD-46.1 Plt ___ ___ 10:00PM BLOOD WBC-12.5* RBC-4.14 Hgb-11.9 Hct-36.8 MCV-89 MCH-28.7 MCHC-32.3 RDW-14.3 RDWSD-46.1 Plt ___ ___ 05:32AM BLOOD Neuts-49 Bands-0 ___ Monos-13 Eos-2 Baso-0 ___ Myelos-0 AbsNeut-2.79 AbsLymp-2.05 AbsMono-0.74 AbsEos-0.11 AbsBaso-0.00* ___ 03:40AM BLOOD Neuts-58 Bands-0 ___ Monos-8 Eos-4 Baso-1 Atyps-3* ___ Myelos-0 AbsNeut-4.12 AbsLymp-2.06 AbsMono-0.57 AbsEos-0.28 AbsBaso-0.07 ___ 04:00AM BLOOD Neuts-53.4 ___ Monos-9.8 Eos-4.9 Baso-0.4 Im ___ AbsNeut-4.11 AbsLymp-2.39 AbsMono-0.75 AbsEos-0.38 AbsBaso-0.03 ___ 05:13AM BLOOD Neuts-52.2 ___ Monos-9.1 Eos-4.9 Baso-0.4 Im ___ AbsNeut-4.07 AbsLymp-2.57 AbsMono-0.71 AbsEos-0.38 AbsBaso-0.03 ___ 07:33AM BLOOD Neuts-46.2 ___ Monos-9.6 Eos-5.9 Baso-0.4 Im ___ AbsNeut-4.41 AbsLymp-3.57 AbsMono-0.92* AbsEos-0.56* AbsBaso-0.04 ___ 10:00PM BLOOD Neuts-53.8 ___ Monos-8.9 Eos-5.0 Baso-0.6 Im ___ AbsNeut-6.71* AbsLymp-3.87* AbsMono-1.11* AbsEos-0.63* AbsBaso-0.08 ___ 07:33AM BLOOD ___ PTT-31.7 ___ ___ 10:00PM BLOOD Glucose-179* UreaN-13 Creat-0.7 Na-138 K-4.0 Cl-103 HCO3-22 AnGap-17 ___ 12:24PM BLOOD CK(CPK)-50 ___ 04:00AM BLOOD ALT-38 AST-20 ___ 12:24PM BLOOD CRP-3.6 ___ 10:21PM BLOOD Lactate-1.8. At the time of discharge, the patient had Cellulitis and pelvic abscess. 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>On ___, Ms. ___ was admitted to the Gynecology service for pelvic subcutaneous fluid collection concerning for abscess vs. seroma. CT scan showed "1. A lower anterior abdominal wall peripherally enhancing fluid collection containing locules of air is decreased in size from prior, currently measuring up to 9.6 cm, compared with 14.2 cm previously, however is again concerning for infected seroma/abscess. This would be amenable to percutaneous drainage if desired. 2. A 2.7 cm left adrenal lesion is not significantly changed from prior, however is again incompletely characterized. Recommend correlation with prior imaging if available, or outpatient MRI/CT adrenal for further characterization if no prior imaging is available. 3. Hepatic steatosis." She was initially continued on her home antibiotics, IV daptomycin and oral doxycycline. She was given IV dilaudid and tylenol for pain. She remained afebrile with normal vital signs, and labs initially demonstrated a mild leukocytosis of 12.5. She underwent ___ drainage of the pelvic subcutaneous fluid collection, during which 60cc of cloudy fluid was drained and a pigtail catheter was placed for continuous drainage. Fluid gram stain was negative, with sparse enterococcus growth, and fluid creatinine were normal, no anaerobes or acid-fast bacilli were seen. She was seen by the Infectious Disease team who recommended transitioning to IV flagyl and ceftazapime, with continuation of her IV daptomycin. She experienced some urinary urgency, and had a UA which was normal, and UCx negative. She was given pyridium for her symptoms. For her type 2 diabetes, her home metformin and glipizide were held, and she was placed on an insulin sliding scale and her blood glucose was closely monitored. For her bipolar disorder, and COPD/asthma, she was continue on her home medications. From ___, she continued to improve clinically. Drain output was 50cc daily. She continued to have no leukocytosis and no bandemia. She remained afebrile. Her abdominal exam was also noted to improve with decreasing erythema and induration. On ___, her CBC was noted to have an HCT drop from 35.6 to 28.6. Her exam was benign with stable VS, low suspicion for active intraabdominal bleeding. HCT was repeated 6 hours later and was stable at 36.2. Her drain output also decreased to 30cc. Due to her clinical improvement, per ID team she was continued on Daptomycin and transitioned to PO flagyl and levaquin through ___. CRP, CK, ESR were all drawn for daptomycin monitoring which were all normal. EKG was also obtained which did not show any evidence of QTc prolongation. She was also restarted on her home metformin and glipizide. Her ___ remained stable between 130-200. By ___, she had improved clinically and was discharged to home in stable condition with home nursing set up for IV ABX infusion as well as drain care and outpatient follow-up as scheduled. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ F with ___ biopsied Right neck & Left upper forehead mass. Oncology fellow was called by Pathology regarding her tissue biopsy returning as DLBCL. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed 1. Interval resection of large right supraclavicular mass with postoperative changes in the resection bed. 2. Multiple soft tissue masses, as detailed above, almost all of which have increased in size from CT neck ___. The largest mass is abutting the right sternohyoid muscle at the level of the thyroid now measures 1.7 x 2.2 x 2.9 cm, previously measuring 1.2 x 1.4 x 2.4 cm on CT neck ___. CT abdomen/pelvis showed 1. Numerous soft tissue nodules within the subcutaneous fat and anterior abdominal wall measure up to 18 x 9 mm as described in the findings. These are uncertain in etiology, possibly lymphomatous. However, alternative etiologies such as melanoma should be considered. Recommend percutaneous sampling. 2. No splenomegaly or lymphadenopathy in the abdomen or pelvis. CT CHEST W/CONTRAST showed Multiple subcutaneous soft tissue nodules/lymph nodes, with a few lymph nodes in the superior chest subcutaneous tissue appear mildly increased in size compared to prior CT neck done ___. Suspicious pericardial, pleural (intercostal) and a few internal mammary lymph nodes, but no pathologically enlarged superior mediastinal lymph nodes. No conclusive findings to suggest pulmonary involvement. Moderate aortic valve calcification. Mild coronary artery calcification. For neck, abdomen and pelvis findings please refer to their respective reports. Radiology showed Successful placement of a double lumen chest power Port-a-cath via the left internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. The patient was diagnosed with Oth types of foliclar lymph, nodes of head, face, and neck. At the time of discharge, the patient had Primary Diagnosis: ============================ -Diffuse large B-cell lymphoma Secondary Diagnosis: =========================== -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>Ms. ___ is a ___ woman w/ prior lymphoma in ___ treated w/ 6 cycles CHOP found to have DLBCL admitted for staging and determination of treatment. #DLBCL, germinal center type: R supraclavicular mass removed by plastic surgery with pathology showing follicular lymphoma w/ transformation to DLBCL. Cytogenetics positive for IGH/BCL2 and rearrangement of BCL6, negative for MYC. Several nodules on R neck, R axilla, nape of neck, and lower back. Underwent CT head/neck/torso for staging which showed subcutaneous nodules in neck, chest, abdomen. Also had TTE given plan for anthracycline therapy with EPOCH-R which showed no cardiomyopathy (LVEF >55%). Started on allopurinol to prevent tumor lysis given uric acid 7.8. The patient completed EPOCH-R (5 day cycle), tolerated well with minimal nausea, and resulting shrinkage of subcutaneous nodules. Patient to return to clinic on ___ for neulasta, and again on ___ w/ Dr ___ further management of DLBCL. #Lower extremity Edema: #Weight gain: Patient w/ 10 lb increase in weight and development of lower extremity edema iso prednisone as well as IV hydration for chemotherapy. Gentle IV diuresis in house with some improvement. Patient weight on discharge 165.8 (dry weight 157.7). The patient's volume status is expected to improve once discharged as she will no longer be receiving IVF or pred and given her good kidney function. Patient to have close follow up for further management. #INSOMNIA: Likely iso pred and anxiety. Improved w/ diphenhydramine + ramelteon + lorazepam PRN. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ y/o male PMHx of carotid stenosis s/p CEA, Left femoral endarterectomy and left common iliac artery stent, claudication, HLD, HTN, DM, CKD III, C diff colitis (___), pancreatitis ___ ETOH s/p x3 debridements, who presents to ___ after multiple episodes of coffee ground emesis, nonbloody diarrhea, and increasing abdominal pain beginning ___. CT abdomen/pelvis obtained while in ED showed portal venous gas and pneumatosis in the duodenum and jejunum in concerning for bowel necrosis. CHEST (PORTABLE AP) was done. CT ABD AND PELVIS WITH CONTRAST showed 1. Extensive portal venous gas and pneumatosis in the duodenum and long segment of the jejunum in the right abdomen which is nonenhancing and highly concerning for bowel necrosis. No pneumoperitoneum. No central occlusion of the mesenteric arteries although there is severe atherosclerotic calcification and narrowing at their origin in both the celiac axis, SMA, and their branches. The ileum and colon appears spared. 2. Heterogeneous hepatic parenchyma with areas of hypoenhancement in the right hepatic lobe which could suggest infarction. 3. Distended stomach with fluid-filled dilated partially visualized thoracic esophagus putting the patient at risk for aspiration. 4. Trace aspiration or mild atelectasis in the left lung base. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:21 am, immediately after discovery of the findings. Findings subsequently discussed with the surgical team in person, who plan on taking the patient to the operating room ABDOMEN (SUPINE ONLY) showed Intraoperative images were obtained during retrograde stenting of a proximal SMA stenosis. Please refer to the operative note for details of the procedure. CHEST (PORTABLE AP) showed Endotracheal tube terminates in the proximal right mainstem bronchus. Recommend retracting. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:47 pm, 1 minutes after discovery of the findings. CHEST (PORTABLE AP) showed The endotracheal tube terminate 5.4 cm above the carina. Advancement by 2 cm is recommended. There has been interval placement of an enteric tube which terminates in the body of the stomach. A left internal jugular Swan-Ganz catheter terminates in the distal left brachiocephalic vein. There are small bilateral pleural effusions with bibasilar atelectasis. There is mild pulmonary edema. There is no focal consolidation or pneumothorax. The cardiomediastinal silhouette is stable in appearance. There are no acute osseous abnormalities. CHEST (PORTABLE AP) showed The endotracheal tube terminates 5.1 cm above the carina. A an enteric tube crosses the diaphragm and terminates outside of the field of view. Hazy bibasilar opacities are unchanged from prior study most likely represent trace pleural effusions. There is no focal consolidation, pulmonary edema or pneumothorax. The cardiomediastinal silhouette is normal in appearance. There is central pulmonary vascular congestion without overt pulmonary edema. No acute osseous abnormalities are identified. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are stable, as is the cardiomediastinal silhouette. Mild elevation of pulmonary venous pressure with bilateral layering pleural effusions and compressive atelectasis at the bases. DX CHEST PORTABLE PICC LINE PLACEMENT showed Right PICC line tip is at the cavoatrial junction. NG tube tip is in the stomach. Left internal jugular line tip is at the left brachycephalic vein and does not reach SVC. It Bilateral pleural effusions are small on the right and moderate on the left. No appreciable pneumothorax. No pulmonary edema. Single-contrast upper GI showed 1. The anastomotic site was not visualized due to poor transit of the injected contrast into the duodenum with resultant back up and gastroesophageal reflux and patient aspiration, which required suction and induction of oxygen therapy. 2. A ___ feeding tube was placed within the stomach as it could not be advanced past the pylorus. CHEST (PORTABLE AP) showed Aspirated Optiray is seen within the lower lungs bilaterally. Radiology showed No evidence of a small bowel obstruction. Oral contrast material is seen within the distal small bowel and proximal colon. CHEST (PORTABLE AP) showed Comparison to ___. The lung volumes are normal. Moderate cardiomegaly without evidence of pulmonary edema. Retrocardiac atelectasis, right basilar atelectasis, likely presence of a small left pleural effusion. The course of the feeding tubes and the position of the right PICC line are stable. CHEST (PORTABLE AP) showed Comparison to ___. No relevant change is noted. 1 of the feeding tubes was removed. The second feeding tube is in stable position. Stable position of the right PICC line. Minimal decrease in severity of the bilateral parenchymal atelectasis, the extent of the mild to moderate pleural effusions is unchanged. No evidence of pulmonary edema. Borderline size of the cardiac silhouette. Radiology showed No evidence of obstruction with passage of oral contrast completely into the colon. CT ABD AND PELVIS W/O CONTRAST showed 1. Patient is status post surgery for mesenteric ischemia, with an anastomosis of the distal duodenum to the distal jejunum. There is a large nonspecific loculation of fluid located in the anterior aspect of the abdominal cavity with an air-fluid level. No evidence of extraluminal contrast. 2. Newly developed fractures including a wedge fracture of T12 and a fracture of the posterior element of T11. 3. Dense material located in the hilum of the liver, likely reflux of oral contrast into the biliary system. Correlate clinically. 4. Small bilateral pleural effusions. Radiology showed 1. Nasogastric tube overlies the stomach. 2. Improved mild bibasilar atelectasis. Ultrasound-guided drainage. showed Successful US-guided drainage of serosanguineous abdominal collection. Sample was sent for microbiology evaluation. Radiology showed Successful placement of a 18 ___ MIC gastrojejunostomy tube with its tip in the proximal jejunum past the anastamosis. The gastric port should not be used for 24 hours. CHEST (PORTABLE AP) showed Right-sided PICC line projects to the cavoatrial junction. The NG tube has been removed. Lungs are low volume with bibasilar atelectasis. Bilateral effusions have resolved. Cardiomediastinal silhouette is stable. No pneumothorax is seen CHEST (PORTABLE AP) showed In comparison with the study of ___, there is engorgement of ill defined pulmonary vessels consistent with worsening pulmonary edema in this patient with left lower lobe collapse and left pleural effusion. Area of increased opacification in the left upper zone was shown to represent a more prominent area of consolidation than expected merely from the plain radiograph. CT ABD AND PELVIS WITH CONTRAST showed 1. Contrast administered through the gastrojejunostomy tube passes into the colon with no evidence of leak. 2. Interval decrease in size of a thin rim enhancing loculated fluid collection in the anterior abdomen as well as a small amount of free air, consistent with resolving postsurgical collections. This collection is more organized compared to the prior exam. 3. Small left pleural effusion is not significantly changed, right pleural effusion is decreased in size. 4. Small consolidation at the right lung base is likely due to aspiration. CT CHEST W/CONTRAST showed Widespread broncho pneumonia, right lower and left upper lobes. Collapsed left lower lobe. Severe compression fracture, T12 vertebral body. If there is concern about neurologic compromise, MRI should be obtained. UNILAT UP EXT VEINS US showed No evidence of deep vein thrombosis in the right upper extremity. Left hip radiographs, two views, and pelvis radiograph, single AP view, portable. showed Status post open reduction internal fixation of the left femur. CHEST (PORTABLE AP) showed In comparison with the study of ___, the cardiomediastinal silhouette is stable, as is the degree of pulmonary edema. Opacification at the left base is consistent with volume loss in left lower lobe and pleural effusion. Radiology showed Successful US-guided placement of ___ pigtail catheter into the collection. Samples was sent for microbiology evaluation. CHEST (PORTABLE AP) showed Diffuse left lung opacities are not significantly changed. Interval improvement of pulmonary congestion. G/GJ/GI TUBE CHECK showed No evidence of leak identified after the administration of water-soluble contrast through the gastrojejunostomy tube. Radiology showed Gastrostomy tube is again seen, unchanged. Pigtail catheter extending to the midline abdomen is again seen, similar orientation as the prior. Enteric contrast is now within the colon. Bowel gas pattern is unremarkable. No significant bowel distention. Consolidative opacities seen in the lungs, left greater than right. CHEST (PORTABLE AP) showed New right lower and mid lobe opacities may represent aspiration or pulmonary edema CHEST (PORTABLE AP) ___ showed Compared to chest radiographs, ___ through ___ at 05:30. Upper lobe pulmonary vascular congestion has improved, while bilateral perihilar opacification has improved on the right, not on the left. This could be edema, changing in distribution depending on patient positioning, but the lower lobes are still densely consolidated. Moderate bilateral pleural effusions are unchanged. No pneumothorax. Heart size is stable, not appreciably enlarged and mediastinal veins are not engorged. Right PIC line ends in the mid to low SVC. CHEST (PORTABLE AP) showed In comparison with the study of ___, there are improved lung volumes. Cardiomediastinal silhouette is stable. There has been some improvement in the substantial pulmonary edema, much of which could merely reflect the improved lung volumes. In asymmetric opacification in the left mid to lower lung is again seen. In the appropriate clinical setting, this would raise the possibility of aspiration/pneumonia. Obscuration of the left hemidiaphragm with retrocardiac opacification is consistent with pleural fluid and volume loss in left lower lobe. The patient was diagnosed with Other specified diseases of intestine, Unspecified abdominal pain. The patient was treated with ___ washout, 10cm SBR, re-anastamosis D4-distal jejunum ___ Washout, resection 40cm proximal jejunum ___ Ex-lap, SMA stent, SBR resection. At the time of discharge, the patient had small bowel necrosis. 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 an ___ year-old male with a history of pancreatitis c/b pseudocyst and multiple debridements, insulin-dependent DM, CAD s/p RCA stent, carotid artery stenosis s/p CEA, PAD s/p stent, HTN, prior alcohol use, recurrent C diff, and lymphocytic colitis who was admitted to the hospital with vomiting and abdominal pain. Upon admission, the patient was made NPO, given intravenous fluids and underwent imaging. A cat scan of the abdomen/pelvis was obtained which showed portal venous gas and pneumatosis in the duodenum and jejunum concerning for bowel necrosis. Based on these findings, he was taken to the operating room where he underwent an ex-lap, small bowel resection, and SMA stenting on ___. After the surgery he was admitted to the intensive care unit for monitoring. During his stay, he received blood products (RBCs and FFP) and returned to the operating room on ___ for primary re-anastomosis and closure of fascia. He was extubated on ___. On ___, the patient had a sodium of 151, and was started on D5W and TPN without sodium. He was transferred to the surgical floor on ___. However, he returned to the ICU soon after when he was reported to have a sodium of 158. He continued on D5W and started on an insulin drip for an elevated blood sugar. Once his hypernatremia improved, he was transferred back to the surgical floor. Neurosurgery was consulted for management of his T12 wedge fracture and recommended a TLSO brace on side of bed for use when he is out of bed to chair. ___ was consulted for enteral access and a GJ tube was placed. The G tube was kept to gravity, and tube feeds were initiated via the J tube. Plavix was started on ___ for mesenteric stent patency once enteral access was established. The patient again returned to the intensive care unit on ___ after he had an acute desaturation event with hematemesis, concerning for aspiration and possible upper GI bleed. He was started on broad spectrum antibiotics for presumed aspiration pneumonia based on his respiratory status, chest xray, and significant leukocytosis to 30. He initially required non-rebreather but was weaned to high flow nasal cannula and eventually to regular nasal cannula. He underwent a CT torso to evaluate for other infectious sources, which revealed an anterior abdominal wall collection concerning for abscess. A drain was placed into the collection by ___ on ___. While in the ICU, he developed dark red stools and similar output from his G tube. His hematocrit slowly dropped and he required transfusions. GI was consulted and recommended a BID IV PPI and upper endoscopy. Endoscopy was referred, as his hematocrit eventually stabilized. During his ICU stay, code status was discussed with the patient's wife, and he was transitioned to DNR/DNI. The patient was deemed stable for transfer to the surgical floor on ___. While on the surgical floor, the patient experienced episodes of emesis and there was concern for aspiration. Tube feeds were held and a bowel regimen was given which resulted in a large bowel movement. He received Lasix for diuresis. His wound vac was changed and the wound continued to heal well. A family meeting was held with the surgical team and palliative care and the decision was made to make the patient's care comfort measures only. Vitals signs were stopped, diet as tolerated, and medications provided for pain relief, agitation, and nausea. He was discharged to ___ to continue providing comfort care </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: FOOT AP,LAT AND OBL BILATERAL showed No evidence of subcutaneous gas of the right or left feet. No bony erosive changes. No acute fracture or dislocation. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. The patient was diagnosed with Rash and other nonspecific skin eruption. At the time of discharge, the patient had #Contact dermatitis with superimposed infection #Thyrotoxicosis. 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>SUMMARY: ___ yo F PMHx ___, stage IA serous endometrial adenocarcinoma s/p abdominal hysterectomy, b/l salpingoopherectomy, adjuvant chemo and brachytherapy (completed ___, DM2, HTN and eczema who presents with b/l ___ rash, most likely caused by exuberant contact dermatitis with MSSA superinfection and subsequent skin breakdown with associated id reaction on the body ___ the setting of diffuse xerosis. Hospital course complicated by symptomatic hyperthyroidism, started on beta blockade with improvement.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ without ___ medical history who presented to the ED today complaining of headache. The patient reports that she previously presented to the ED on ___ complaining of three days of sore throat, migraine-like headache, nausea, subjective fevers and chills, and body aches. She did have some C7 point tenderness at the time, but did not have photophobia or meningeal signs. She was thought to have a viral syndrome and was discharged after fluid resuscitation. She represented to the ED today with continuing headache. The patient notes that her viral symptoms have largely resolved. She describes a right temporal to frontal headache, ___ at worst, but currently ___. She notes that it is worse when she is lying flat than sitting upright. She previously had minimal photophobia, but is currently without symptoms. The patient reports that she has had chronic headache similar in quality to her present headache. She gets these every one to two weeks, generally aborts with ibuprofen. The difference between this headache and her usual headaches is the duration (now multiple days) and the fact that it prevents her from falling asleep. Her usual headaches are usual accompanied by mild photophobia and some nausea. She denies vomiting, diplopia, or visual phenomena. . In the ED, initial vital signs were 99.2 82 127/76 18 100%. A CT head was performed which did not demonstrated intracranial bleed. A lumbar puncture was performed in the ED with a WBC count of 16 (N6, L90) and RBC 715 which improved to 36 over subsequent vials. Protein and glucose were normal at 21 and 54, respectively. Radiology showed Normal radiograph of the chest. Radiology showed No acute intracranial injury. The patient was diagnosed with HEADACHE, UNSPEC VIRAL INFECTION. The patient was treated with Lumbar puncture. At the time of discharge, the patient had Primary diagnosis: Migraine headache . Secondary diagnosis: Viral syndrome. 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 is a ___ without significant past medical history who presented to the ED with viral symptoms and headache, s/p LP with no striking findings on CSF, admitted for symptom control and concern for aseptic meningitis. . #Headache Patient with headache for past 5 days with viral symptoms including sore throat, nausea, subjective fever and chills, and body aches. Viral symptoms largely resolved. Patient reported that headache was similar in quality to usual headaches (same location, nausea, mild photophobia), with the only difference being persistent pain and difficulty falling asleep because of the pain. In ED, patient afebrile, without meningeal signs, no bleed on CTH, and CSF with minimal WBC count (possibly accounted for by RBC ___ traumatic tap), normal protein and glucose. CBC without leukocytosis. Neuro exam completely non-focal. Current symptoms seemed most consistent with patient's usual chronic headache vs. headache ___ viral syndrome vs. rebound headache from analgesic use. Bacterial meningitis was unlikely given lack of white cells in CSF. Headaches could still be result of viral meningitis, though still would expect a larger presence of white cells. Aseptic meningitis from NSAIDS was possible. History did not support venous thrombosis given lack of family or personal history of clot, no OCP use, and no history of smoking. Positional exacerbation of symptoms could be consistent with ICP, possibly idiopathic intracranial hypertension given obesity/overweight, but no concurrent use of tetracyclines, vitamin A, or OCPs, and no visual symptoms. Unfortunately, opening pressure of LP not recorded by ED. By the time the patient reached the floor, her headache was a ___. She was given some fiorcet for pain relief and offered ondansetron for nausea. On hospital day #2, the headache had completely resolved. The patient was encouraged to seek follow-up with her PCP and request ___ referral to the ___ Headache Center. Final CSF cultures are negative. . TRANSITIONAL ISSUES #Patient sexually active, and given vague viral symptoms (sore throat, myalgias, fever, headache), acute HIV syndrome could not be ruled-out. Patient should obtain HIV testing as an outpatient in ___ weeks. #Patient should consider further evaluation of chronic headaches as a component of her symptoms might be rebound headaches in the setting of frequent analgesic use.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___, RHD, transferred from OSH s/p puncture wound to left third finger with concern for flexor tenosynovitis. The patient was doing landscaping 3 days ago, when he must have gotten some sort of puncture wound to his left third finger, although he does not remember the exact trauma. He noticed that the distal finger tip got swollen that evening and has become progressively swollen, red, and painful, tracking down his finger, over the past 2 days. The patient has baseline depression. He states he has been lying in bed at home because the finger pain has been so bad. Denies fevers or chills. Radiology showed 1. Satisfactory position of right PICC 2. Multifocal right sided pneumonia. Consider 4 week radiograph to document resolution. Preliminary Findings were discussed with ___ by Dr. ___ at 13:25 on ___. The patient was diagnosed with TENOSYNOV HAND/WRIST NEC. The patient was treated with Incision and drainage, flexor sheath, left long finger.. At the time of discharge, the patient had Left third finger infection Right upper/middle lobe 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>The patient was initially evaluated at ___ where blood cx were obtained and he was given IV Unasyn. An xray of the hand was negative for foreign bodies and the pt was transferred to ___ for further evaluation. The patient was admitted to the plastic surgery service on ___ with a diagnosis of Suppurative tenosynovitis of flexor sheath, left long finger. Patient was taken to the operating room and underwent Incision and drainage, flexor sheath, left long finger, where immediate expression of pus was observed. The area was irrigated and a second incision was made at the volar surface. Patient tolerated the procedure without difficulty and was transferred to the PACU, then the floor in stable condition. Please see operative report for full details. Pt was subsequently put on Vancomycin and Unasyn. Cultures are growing mixed flora but predominantly with S. aureus. A blood cx from the OSH is noted to be positive for a Streptococcus spp per report. Infectious disease was consulted to assist in determining the antibiotic regimen necessary and appropriate to treat his infection. A TTE was also done to r/o endocarditis and was found to be negative. They recommended treatment for the flexor tenosynovitis, bacteremia as well as a newly diagnosed RUL pneumonia. He was sent home on a 2 week regimen of nafcillin as well as a 5 day course of levaqin to treat the pneumonia. Neuro: The patient received po dilaudid with good effect and adequate pain control. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: A po diet was tolerated well. Patient was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. ID: The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on ___, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. All questions were answered, and patient has appropriate follow-up care.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ yo right-handed man with PMH significant for atrial fibrillation, pancreatic cancer (stage IV with known hepatic metastases) and a left sided stroke in ___ (with fluent aphasia) who presents now as a transfer for incidental finding of a very small amount of hemorrhagic conversion of his prior stroke. The patient was DCed from the stroke service to rehab (___) on therapeutic lovenox for his afib and cancer related hypercoagulable state. Mr ___ only recently returned home from rehab and has been living with his sister who is very involved in his care. She reported to me (via phone) that the patient has been getting very upset and frustrated with her. He does not want her to prepare any of his medications (of which there are ~25) without him. He becomes somewhat paranoid that some of the pills will kill him. He will refuse to eat at times as well. CT HEAD W/O CONTRAST showed 1. Redemonstrated infarct in the left posterior temporal lobe, with known intraparenchymal hemorrhage, and small amount of regional subarachnoid hemorrhage and left tentorial subdural blood. There is no midline shift or mass effect. 2. No fractures are identified. CT ABDOMEN AND PELVIS WITH CONTRAST. showed 1. Interval enlargement of the segment VIII hepatic metastatic lesion. The remaining liver lesions have not significantly changed from ___. Mild interval increase in a hypodense mass in the pancreatic body (now measuring 14 x 14 mm) with upstream pancreatic duct dilation and atrophy of the pancreatic tail. 3. Please see separate dictations for details on intrathoracic findings. CT HEAD W/O CONTRAST showed Stable appearance of late subacute infarction involving the left parietal and posterior temporal lobes compared to 1 day earlier, with small amount of gyriform hyperdensity, compatible with a combination of hemorrhage in pseudolaminar necrosis. Thin adjacent subdural hematoma, which extends along the left posterior falx and left tentorium, is also stable. CT CHEST W/CONTRAST showed 1. Short term interval development of predominately upper lobe peribronchial and centrilobular opacities suggests an infectious etiology, A rapidly developing malignancy cannot be excluded, but substantially less likely. 2. Findings compatible with progression of disease, such as slight interval increase in lymphadenopathy as described. See same day CT abdomen/pelvis for details regarding infra-diaphragmatic structures. 3. Interstitial finding compatible with volume overload. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ ___ service) on the telephone on ___ at 5:08 ___, 5 minutes after discovery of the findings. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT, INTRACRANIAL HEMORR NOS. At the time of discharge, the patient had Primary diagnosis: Intraparenchymal and subarachnoid hemorrhage Left MCA stroke Secondary diagnosis: Acute kidney injury Depression 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. ___ was admitted to the neurology service on ___ as a transfer from an outside hospital ED for intraparenchymal hemorrhage as noted in the HPI. Lovenox was held initially. #NEUROLOGY Neurologically, his exam was noted to be unchanged from prior admission and remained stable. NCHCT was repeated and showed no changes, with known small SAH with small SDH extension. Given that hemorrhage was unchanged from prior, and he is at high risk for stroke ___ afib and/or hypercoagulability due to pancreatic cancer, lovenox was restarted. Repeat NCHCT 1 day later showed no changes in the size of hemorrhage. Upon speaking with the family, there had been plan of switching from lovenox to apixaban as outpatient, given high cost of lovenox. We discussed that there is no evidence for apixaban to treat hypercoagulability from pancreatic cancer, but given likely poor compliance with lovenox (patient resistant to two injections per day) in addition to high cost, after conversation with PCP and cardiologist, Mr. ___ was switched to apixaban 5mg BID (no need for renal dosing given normal renal function on discharge see below but surveillance of renal function and adjustment accordingly is necessary). #RENAL His creatinine was elevated on admission to 1.6 (confirmed poor PO intake in ___ days prior to admission), likely pre-renal and downtrended to 1.1 upon discharge with IVF and good PO intake. #PSYCH/SOCIAL As in HPI, sister had sent patient in for question of suicidal ideation. Patient was in good spirits here and denied suicidal ideation. He was seen by social work given concern for poor situation at home. Patient expressed that he felt safe going home with his sister, and his sister agreed to take him home. He was offered an alternative (rehab) but he declined. #HEME/ONC Patient was scheduled for a CT torso with contrast as outpatient, which was done as inpatient on the day of discharge per family request. Results to be followed up upon by Dr. ___ wanted these images, final read pending at time of discharge. #TRANSITIONAL ISSUES [ ] CT torso results</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with a recent diagnosis of small vessel vasculitis on 60 mg of prednisone daily, transferred from ___ for evaluation of incidental pneumoperitoneum on CXR. 2d ago, patient's ICD detected rapid runs of SVT. Since he had a routine follow up appointment in the ___ clinic at ___ today, his cardiologist ordered EKG and CXR for further evaluation. After he went home, he received a call that his CXR showed new pneumoperitoneum. He then presented to the ED at ___, where he had a CT scan that showed pneumoperitoneum and R colon pneumatosis. CHEST (PA AND LAT) showed New moderate pneumoperitoneum. Unless the patient has had an invasive procedure introducing air in to the abdomen, this is an indication of an intestinal perforation. Moderate cardiomegaly, unchanged since ___. Lungs well expanded and clear. There is no pleural effusion. Trans subclavian right ventricular pacer defibrillator lead unchanged in position since at least ___, continuous from the left pectoral PET generator. NOTIFICATION: Dr. ___ reported the findings to ___ by telephone on ___ at 3:25 ___, 0.5 minutes after discovery of the findings. Dr. ___ reported the findings to Dr ___ by telephone on ___ at 3:27 ___, 3 minutes after discovery of the findings. The patient was diagnosed with PERITONEAL DISORDER NEC. At the time of discharge, the patient had Pneumoperitoneum - unknown source. 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>___ M on 60 mg of prednisone daily presents with incidental free air seen on CXR. Subsequent CT scan w/ pneumoperitoneum, R colon pneumatosis. Patient is completely asymptomatic, hemodynamically stable, and non-tender on exam. The patient was admitted to the Acute Care Surgery service for observation. He was started on IV antibiotics, kept nothing by mouth, given IV fluids, and monitored closely with serial abdominal exams. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. 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. 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 had no pain. The patient was discharged home without services. The patient was discharged with a prescription to complete a 2-week course of antibiotics for a suspected GI source of the pneumoperitoneum. The patient had follow-up scheduled with his cardiologist, rheumatologiost, and in the ___ clinic. He was instructed on danger signs to watch for when home. 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: Ms. ___ is a ___ with a history of HIV on HAART (last CD4 ___ ___ that has been complicated by previous noncompliacne, PCP pneumonia, cryptococcal pneumonia, possible recurrent aseptic meningitis- also with ___ malformation abd migraine headaches who presents to the ED with headache, fevers, chills and malaiase. Radiology showed No acute intrathoracic process. Radiology showed No mass or acute intracranial process. The patient was diagnosed with TORTICOLLIS NOS. The patient was treated with lumbar puncture ___. At the time of discharge, the patient had Acute viral infection migraine 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 ___ with a history of HIV/AIDS and previous cryptococcal meningitis here with HA, fevrs, chills, myalgias and arthralgias that was probably due to acute viral syndrome with superimposed migraine.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMHx significant for severe vascular diseae & hypertension presents with 4 days of ___ and epigastric pain, inability to tolerate PO. CHEST (PA AND LAT) showed Pulmonary vascular congestion and mild to moderate pulmonary edema with small right pleural effusion. No signs of free air below the right hemidiaphragm. CT abdomen pelvis showed 1. Mild cardiomegaly with small bilateral pleural effusions. Lower lung ground-glass opacities may represent atypical edema, difficult to exclude an early pneumonia in the left lower lobe. 2. Extensive vascular disease with aortoiliac stent in place, appearing patent. 3. No findings the left lower quadrant to account for pain. Carotid Doppler Ultrasound showed Mild homogeneous atherosclerotic plaque in the left ICA and mild intimal thickening in the right ICA resulting in less than 40% stenosis bilaterally. ___ DUP EXTEXT BIL (MAP/DVT) showed Patent bilateral great and small saphenous veins. For detailed description of calibers please refer to sonographer report in PACs. The patient was diagnosed with Heart failure, unspecified. The patient was treated with Cardiac catherization. At the time of discharge, the patient had PRIMARY DIAGNOSIS ------------------ ACUTE SYSTOLIC HEART FAILURE CORONARY ARTERY DISEASE VIRAL GASTROENTERITIS SECONDARY DIAGNOSIS -------------------- DIABETES. 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 a PMHx significant for severe vascular diseae & hypertension presented with 4 days of ___ and epigastric pain, inability to tolerate PO. # Acute systolic heart failure. New diagnosis. Fluid resuscitated in ED with 1L NS and this caused acute onset of shortness of breath and pulmonary edema. CXR showed pulmonary vascular congestion, and BNP obtained was 7k. Admitted to heart failure service for new diagnosis of CHF. Echo on admission showed EF of 30% to 35%. Initially diuresed well with boluses of 20 IV Lasix, maintained euvolemia without maintenance diuretic. Work up revealed 3vessel coronary artery disease. Cardiac surgery evaluated and recommended CABG. Vascular surgery approved discontinuation of Plavix given recent stent. # ___ ABDOMINAL PAIN: History of renal infarct that presented similarly in ___. CT abdomen/pelvis unrevealing for etiology of abdominal pain. Etiology thought to be likely viral gastroenteritis. Improved considerably and was taking full POs by the time of discharge. # Proteinuria: patient has urine Pr/Cr ratio 5.4. Renal consulted and recommended etiology was likely diabetic nephropathy. Bp med changes included uptitration of ACE. No renal biopsy required. CHRONIC ISSUES # DIABTES MELLITUS: Hb A1c 8.6%. # PERIPHERAL ARTERIAL DISEASE: maintained on home dose Asa 325. Plavix stopped ahead of CABG. TRANSITIONAL ISSUES ------------------- WEIGHT ON ADMISSION : 71.6 kgs WEIGHT ON DISCHARGE: 70.9 kg DISCHARGE CR:0.8 # 3 VESSEL CORONARY ARTERY DISEASE: Patient scheduled for outpatient CABG on ___. Stop metformin on ___. Stop lisinopril on ___. # NEW DIAGNOSIS OF HEART FAILURE: Likely ischemic in nature, full evaluation otherwise negative. Patient NOT started on maintenance diuretic. Discharged with ACEi, carvedilol, ASA, high dose statin # MED CHANGES: Aspirin decreased from 325 to 81 Lisinopril increased to 40mg daily Clopidogrel discontinued Hydrochlorthiazide discontinued Labetolol discontinued # Consider Hep A/B vaccination</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ with history of asthma, depression/anxiety, active tobacco smoking who presents with acute onset chest pain with exertion. Patient describes nearly ten minutes of left sided chest pain, dull in quality and non-radiating while walking to work. There was some associated shortness of breath, though he is a smoker and also thought he was affected by the humid weather. No nausea, palpitations, or lightheadedness/dizziness. After the pain resolved spontaneously, patient experienced two subsequent short-lived episodes in quick succession. Throughout the day, he then noticed some left hand numbness, which he attributed to known carpal tunnel. Later on in the afternoon, patient presented for a previously scheduled dental procedure, which was deferred iso hypertension (163/109). Patient was instructed to undergo evaluation at an urgent ___, which he did. ECG showed a new RBBB compared to ___ and so patient was loaded with aspirin and told to present to the ___ ED. Upon initial evaluation in the ED, patient experienced another episode of the same chest discomfort, dull and left-sided, self-limited and without any significant associated symptoms. In the ED initial vitals were: 97.7 89 149/93 18 97% RA CHEST (PORTABLE AP) showed No acute intrathoracic process The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had coronary artery 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>Patient is leaving against medical advice. Risks of leaving the hospital prematurely, including severe disability and death, were discussed with the patient. Mr. ___ is a ___ year old man with history of asthma, depression/anxiety, active tobacco smoking who presents with acute onset chest pain with exertion. ============= ACTIVE ISSUES ============= # Unstable angina: Patient presents with new onset left-sided chest pain occurring with exertion. Presentation is concerning for evolving coronary artery disease, unstable angina given new onset chest pain. CAD risk factors: active tobacco smoking with longstanding history, hypertension. ECG notable for RBBB, inferior TWIs, and anterolateral STDs (all new since prior tracing ___. Troponins NEG x3. Exercise stress was transitioned to pharmacologic stress, perfusion study shows a mild perfusion defect involving the LAD territory. -not taking medications at home -started on: heparin gtt (d/c'd ___ aspirin 81 mg PO daily atorvastatin 80 mg PO daily metoprolol succinate XL 50 mg PO qHS -plan was for TTE, cardiac catheterization but patient not willing to stay over the weekend and therefore leaving AMA # Microscopic hematuria: Patient has a reported history of lithotripsy. Patient should have subsequent urine studies with possible CTU/urine cytology/cystoscopy as an outpatient given his significant history of smoking. # Elevated blood pressure: Currently normotensive, though with report of elevated BP at urgent care. - Consider initiation of ACE-I if persistently hypertensive =================== TRANSITIONAL ISSUES =================== [] continue aspirin 81 mg PO daily [] continue atorvastatin 80 mg PO qPM [] continue metoprolol succinate XL 50 mg PO daily [] monitor BP as an outpatient, if persistently hypertensive, consider starting ACEi [] consider TTE-- recommended while inpatient, however patient left AMA before this could be done. [] consider cardiac catheterization-- recommended while inpatient, however patient left AMA before this could be done. [] consider HgbA1c, lipid panel to assess for additional cardiac risk factors [] repeat urine studies. Consider CTU/urine cytology/cystoscopy if persistent microhematuria given smoking history</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with a PMH of chronic Hep B, H/ pylori s/p treatment with Prevpac, laparoscopic cholecystectomy for biliary colic in ___, who presents with abdominal pain. MRCP showed Mild dilation of the extrahepatic bile duct with focal caliber change in the distal CBD near the ampulla, without definite evidence of an obstructing stone or lesion. Further evaluation with EUS/ERCP is recommended. The patient was diagnosed with Epigastric pain. At the time of discharge, the patient had Biliary obstruction Possible Common bile duct abnormality. 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 F with PMHx of chronic Hep B, H pylori s/p treatment and s/p laparoscopic CCY in ___ who presents with abdominal pain with N/V, dilated biliary tree on imaging and elevated/obstructive LFTs. MRCP shows change in caliber of distal CBD though no obvious stones. Symptoms and lab abnormalities resolved without intervention and pt has close follow up planned with ERCP team for procedure.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y/o firefighter with Crohns disease managed with mesalamine and mercaptopurine, and multiple SBOS in the past year, who presents to the ED with ~20 hours of abdominal distension, nausea, and vomiting. He has had multiple episodes of brown-green emesis, decreased flatus, and no bowel movements since yesterday. He denies any fevers/chills. He has been found on colonoscopy and CT to have primary TI disease, and was scheduled for a right colectomy with Dr. ___ on ___. We are consulted to assist in the management of recurrent SBO. Radiology showed Findings consistent with small bowel obstruction. No definite free air. Findings discussed with Dr. ___ (ACS) by phone at 9:30pm on ___. The patient was diagnosed with INTESTINAL OBSTRUCT NOS. 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>Patient was admitted to ___ Department of Surgery from the Emergency Department. His brief hospital course is as listed. Neuro: Patient's mental status was monitored regularly per floor protocol. He received IV acetaminophen for pain relief. Once tolerating oral foods and medication, he was transitioned to oral acetaminophen. Cardio: Patient's heart rate and blood pressures were monitored routinely per floor protocol. He continued his home lisinopril, amlodipine, and HCTZ. No acute issues were addressed during this hospitalization. Pulmonary: Patient's respiratory rate and oxygen saturation were monitored regularly during his hospitalization. No acute issues were addressed during this hospitalization. GI/FEN/GU: Given patient's suspected SBO, patient received a NGT in the ED. He was given IV fluids for hydration. Patient's electrolytes were monitored routinely and repleted as appropriate. Once patient had return of bowel function and his NGT output decreased, his NGT was removed. Patient was started on regular diet without incident prior to discharge home. His urinary output was monitored to ensure adequate peripheral perfusion. Patient continued his home mesalamine and pantoprazole. Heme: Patient's hematocrit was monitored to rule out concern for bleeding. He continued his home aspirin. ID: Patient's fever curve and WBC count was trended. Patient was afebrile throughout hospitalization. Patient was given IV flagyl and cipro until he could tolerate oral medications. He was discharged home to continue a 7 day course of antibiotics. PPX: Patient was given subcutaneous heparin for DVT prophylaxis. Once patient was tolerating oral medication and nutrition, he was discharged home with appropriate prescriptions. He will return to service on ___ for surgery.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH afib on warfarin, CKD, DM, CHF presents after falling. Pt was at ___ yesterday when he went to the bathroom, missed a step, and fell on his side. He has severe pain in his L hip. He is unsure if he hit his head. Not clear if this was a syncopal episode as the patient has baseline cognitive impariment and is a poor historian. He recalls being confused during this event. Per note in OMR, he has been confused and lightheaded recently. Radiology showed Though there is no radiographic evidence for displaced fracture of the left hip, given the clinical history of inability to bear weight after sustaining a fall, an occult fracture cannot be completely excluded and further imaging is recommended if clinical suspicion for fracture exists. Radiology showed No definite acute cardiopulmonary process. Radiology showed 1. No acute intracranial process. 2. Persistent ventriculomegaly, reflecting either preferential central atrophy or communicating hydrocephalus, is unchanged in extent since ___. Radiology showed 1. No fracture or acute malalignment in the cervical spine. 2. Multilevel degenerative changes of the cervical spine, as described above resulting in at least moderate canal narrowing. Radiology showed 1. No evidence of fracture or abnormal alignment of the left hip. 2. Degenerative changes of the bilateral femoroacetabular joints, sacroiliac joints and lumbar spine, as described above. The patient was diagnosed with SYNCOPE AND COLLAPSE, HERPES ZOSTER NOS, HYPERTENSION NOS, CARDIAC PACEMAKER STATUS. At the time of discharge, the patient had Hypovolemia Orthostatis Shingles. 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: ___ with PMH DM, afib on coumadin, CKD presents after poor PO intake and sustaining fall at ___ with subsequent hip pain s/p negative CT head / neck / pelvis but failed to ambulate safely so admitted for placement. # Hypovolemia: Pt presented orthostatic and was bolused one time each day of admission. Pt's wife reports that he is no longer drinking fluids, only drinking tea. "He dislikes the taste of water". Furosemide was held during hospitalization and will be held on discharge due to poor PO intake and admission with orthostasis. # Left leg weakness / pain: Pt presented with profound left leg weakness, and while he never c/o pain, he actually would jolt upright when his left hip was externally rotated. He was given standing PO tylenol, and encouraged to work daily with ___, during which he improved on his weight bearing and ambulation. Initially team considered obtained MRI left hip to assess for muscle transection or nerve damage from fall, however, since pt was spontaneously improving with ___, determined that pt was actually not weak but limited by pain. no e/o of left pelvis fx, no paresthesias or pain currently, weak mostly in hip adn knee. Weakness worse after fall. Dorsal column neuropathy may be related to unsteadiness. currently unsteady but able to bare weight - check B12, CK - ___ c/s # Mechanical fall: Pt reports walking through a door and there not being a step, so he fell. He denies LOC. He fell on his left side, and extensive CT imaging of left hip / pelvis/ head / neck are not concerning for fracture. Pt also has h/o of carotid hypersensitivity, but based on hx this is unlikely as pt reports losing balance after stepping through a door. # Shingles: Pt presents with paninful lesions behind left leg without e/o vescicles. Since the time course of shingles is unknown, team did not feel that acyclovir or other antiviral would change duration of lesions or alter likelihood of postherpetic neuralgia. # DOE: Pt initially complained of dyspnea on exertion, which was thought to be ___ to pulm htn possibly with a component of COPD given smoking hx. Pt was never wheezing or poorly moving air or clinically with rales on exam. He was also never hypoxic or SOB when working with ___. # Afib on coumadin: CHADS 3. Pt was continued on atenolol 25mg PO qd and was continued on warfarin 4mg PO qd. # CKD: (baseline 1.7-1.9) Pt was given IVF for orthostasis on admission and Cr downtrended to 1.5 # DM: not on insulin at home, but has been on humalog ISS during hospitalizations # Anemia: baseline hct 32. Stable # BPH: Pt was continued on home doxazosin 4 mg tablet. # CHF EF 54%: Held furosemide for poor PO intake, and will hold on discharge pending clinical improvement and PO intake. Was taking furosemide 20 mg tablet. # B12 Def ___ gastrectomy: B12 was > ___. # Code: Full (discussed with patient) # Communication: Patient # Emergency Contact: Ms. ___ ___ TRANSITION ISSUES # consider resuming furosemide as was stopped on admission ___ orthostasis # Pt does not c/o pain, so do not rely on his hx to tell ___ msk pain</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old Male who presents with 8 days of fevers to 102, nausea/vomitting, hemolysis and transaminitis. The patient is at baseline healthy, when 8 days prior to admission he notes lethargy, nasuea and vomitting. He was at college, and went to the ___ health ___, who performed a liver scan which was reportedly normal. He continued with his symptoms, after returning home for ___. He denies knowing others with the same symptoms. He also describes headaches, palpitations and sore throat along with the other symptoms. He notes that several days prior to admission his urine became darkly colored. The patient was diagnosed with FEVER, UNSPECIFIED, HEADACHE. At the time of discharge, the patient had primary: EBV mono, low grade DIC, hepatitis, flu. 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 M w/ no significant PMH who presents with fevers, n/v, splenomegaly, transaminitis, elev direct bili and is EBV IgM pos and influenza A positive. #EBV Mononucleosis, Transaminitis: He initially presented with GI symotoms (nausea and vomitting) most likely related to hepatitis but over hosp course dev pharyngitisn exam with enlarged tonsils. EBV IgM positive with ___, smear with atypical lymphs. CMV Ab neg. Pt had transaminitis (AST ALT 300s), elev bili (up to 3), splenomegaly and also had low grade DIC (slightly elevated INR and PTT) all related to EBV. Initial concern for autoimmune hemoltic anemia in setting of low hapto and elev LDH and elev bili (though direct higher than indirect) and coombs and agglutinin were somewhat inconclusive and most likely there was a low grade hemolytic anemia. EBV can cause an autoimmune hemolytic anemia (anti-i). Ferritin in the 2000s making HLH (EBV can cause HLH) unlikely. Heme/onc and ID involved in his care. He was given zofran, IVF as supportive measures. He was told to avoid contact sports bc of splenomegaly and risk of splenic rupture. #Influenza A: He was started on tamiflu day ___ w/ plan to treat for 5 d #Coagulopathy, Diseminated Intravascular Coagulation, Hemolysis: slightly elev INR and PTT but stable, this was likely a low grade DIC (elev D dimer, FDP, though fibrinogen normal) combined w/ acute hepatitis. Hematology was consulted. He never required transfusions</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ F w PMHx of HLD, depression, and rheumatoid arthritis who presents to ___ ED after sudden onset of difficulty writing and visual disturbance - her symptoms resolved within ~1 hour. A code stroke was called upon arrival. Ms. ___ has significant difficulty in recalling the events prior to her admission, so much of the history is supplied by her partner, ___. They both agree that Ms. ___ was "exhausted" today, more so than normal. They were at a camera shop around 3:30PM when Ms. ___ tried to write a check to pay for their items. She found she had great difficulty writing and her handwriting was extremely messy. She was able to grip the pen and did not feel weak, persay, though her hand "wasn't doing what I wanted it to." With some effort, she was able to write the check and the clerk was able to read it. She and ___ got in the car to drive to Ms. ___ previously scheduled doctor's appointment. ___ was driving. About 5 minutes after leaving the store, Ms. ___ began to complain of a mild left sided headache and associated blurry vision on her right side. She did not cover one eye to see if the blurry vision was monocular or binocular. At her doctor's appointment today, Ms. ___ recounted the story to the physician who did ___ screening examination for stroke. Ms. ___ deficits had apparently resolved, but the physician referred Ms. ___ to ___ "to get an MRI." Currently, Ms. ___ states that her headache and blurry vision have resolved - she estimates that they lasted ~1 hour. Her handwriting is also back to her baseline and she does not endorse any difficulty controlling the right hand. She denies any associated weakness, numbness, difficulty speaking or comprehending speech. Notably, Ms. ___ has been suffering from "severe exhaustion" for at least the past week. Her partner and her friends having been concerned about her and urged her to make the above doctor's appointment. Ms. ___ partner also states that Ms. ___ memory has been quite poor for sometime - though she believes it was worse today. ED CODE STROKE ONLY CT Q13 CT HEAD showed 1. No acute intracranial process. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Normal head and neck CTA. 2. No acute intracranial abnormality. 3. Interval increase in the size of bilateral thyroid nodules. Further evaluation with ultrasound of the thyroid can be performed. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. No evidence of infarction. 2. Similar appearance of non-specific periventricular and subcortical white matter T2/FLAIR hyperintensities, suggestive of chronic small vessel ischemic changes. 3. Unchanged appearance of punctate foci of GRE susceptibility in the right frontal white matter, which may represent vessels or a sequela or prior hemorrhage. Chest: Frontal and lateral views showed No acute cardiopulmonary process. No significant interval change. The patient was diagnosed with OTHER MALAISE AND FATIGUE, VISUAL DISTURBANCES NEC, HEADACHE. At the time of discharge, the patient had Primary diagnosis: Possible TIA Secondary diagnosis: Hyperlipidemia 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>Ms. ___ is a ___ y/o F with a PMHx of HLD, depression, and rheumatoid arthritis on Prednisone who presented to ___ ED after sudden onset of difficulty writing and visual disturbance which resolved after 1 hour concerning for possible TIA. # Possible TIA: Ms. ___ reported symptoms that her hand wasn't doing what she wanted it to do but no focal weakness or difficulty with anything else besides writing a check. She also had difficulty remembering the details surrounding the event. Given these symptoms and the pecuiliar story, she was worked up for a possible TIA. Stroke risk factors include: HbA1c 6.5 and cholesterol panel as follows: HDL 67, LDL 91 and triglycerides 132. She had CTA and MRI which showed patent vasculature and no evidence of stroke. She was started on aspirin 81mg. She had a TTE which did now show any thrombus. Tele showed NSR. She was discharged with plans to record her heart rhythm with ___ of Hearts monitor. It is not clear that this episode was a TIA but given her risk factors and possible prior TIA in the past, she should continue on aspirin and be followed closely for further symptoms. # Memory impairment: The only finding on exam was poor recall, specifically poor retrieval. She was able to register and store 3 objects. Vitamin B12 and folate were sent but were pending on discharge. TSH was normal. She will need ongoing neurology follow-up for this issue. # Depression: Patient was continuted on Escitalopram Oxalate 20 mg PO/NG DAILY # Hyperlipidemia: Patient was continued on Atorvastatin 10 mg PO/NG QPM # Rheumatoid arthritis: Patient was continued on PredniSONE 15 mg PO/NG DAILY Transitional issues: - endorsed memory problems and had difficulty with memory retrival on exam, not storage. Will need ongoing work-up - f/u ___ of hearts data - f/u vitamin b12, folate levels - will need diabetes treatment: HbA1c 6.5 - repeat UA, had trace protein and 3 rbcs - f/u final read of mRI - may need thyroid ultrasound, had bilateral thyroid nodules on CTA (TSH 0.67) - HCP: ___ (partner) ___ - Code: presumed FULL</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year-old right-handed woman with a past medical history of migraines, renal stones and possible POTS (postural orthostatic tachycardia syndrome) who was admitted for recurrent episodes of loss of consciousness. This history is obtained from discussion with the patient and data from ___. Other records are not available for review. Radiology showed No acute cardiopulmonary process. Radiology showed 1. There is no evidence of acute intraparenchymal pathology. 2. Incidentally noted is a T1 hypo-, T2 hyper-intense nonenhancing lesion arising from the dorsal clivus and extending exophytically into the prepontine cistern which may represent an ecchordosis physaliphora at the dorsal wall of the clivus. This may be further evaluated with a sagittal CISS sequence and thin axial pre and post gad images and a CT of the skull base. The patient was diagnosed with SYNCOPE AND COLLAPSE, CARDIAC DYSRHYTHMIAS NEC. At the time of discharge, the patient had inappropriate 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>NEURO: Ms. ___ was admitted to Neurology Service after having an event of unresponsiveness during tilt table testing that was concerning for seizure. She monitored on continuous video EEG for 48 hours. Several of her medications (amitriptyline, florinef, mestinon, metoprolol) were stopped in order to better evaluate her baseline function and capture events. She did have 3 typical events in the first 24 hours of admission. These occurred while on the commode, and began with the usual tachycardia and palpitations, followed by rising tingling sensation up the neck and shortness of breath, slowly losing the ability voice though at first able to understand, then no longer able to speak or understand, and finally LOC. She would remain unresponsive to sternal rub or nailbed pressure, despite normal blood pressure, after she had been laid supine, and this would persist for 5 minutes. After this she would awaken and appear back to baseline, no post-ictal period. EEG was normal during all of these events. However, EKG leads of the EEG did capture intermittently elevated heart rate to 140-160s alternating with normal rate during the episodes. Autonomics was consulted in order to rule out primary dysautonomia. The autonomics testing done just prior to admission had revealed only inappropriate tachycardia, with no other evidence of systemic primary dysautonomia and stable BP during her testing and event. THe autonomics team recommded MRI brain with thin cuts through brainstem, this showed They also recommended urine catecholamines and 5-HIAA which were pending at the time of discharge. She will follow up with autonomics division in 2 weeks. She does not need to restart mestinon/florinef/etc, because she does not have orthostatic hypotension (only tachycardia). Topamax was also stopped because of concern for worsening her symptoms, and also it was ineffective for migraine prophylaxis for her. SHe was started on nadolol as recommended by cardiology (see below) and we will also try this for migraine ppx. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F with a history of atrial fib on ___ with recent fall resulting in ___ in ___ complicated by rib fractures and right sided pleural effusion that required drainage presents with recurrent effusion and SOB. In terms of her pleural effusion, her daughter reports that it was first discovered by the patients cardiologist after Ms. ___ was complaining of shortness of breath. A CXR was done for further evaluation which revealed a pleural effusion. The pleural effusion, however, is noted on prior CXRs from ___ (unavaible in our system, only per reports in radiology reports). She was going to be evaluated by IP but then she suffered a ___ and her pleural effusion was managed as an inpatient (see below). She was last hospitalizated from ___ where she had a ___ and also underwent drainage of the known pleural effusion. She had an uncomplicated removal of 2.5 liters of exudative effusion (Tprot pleural fluid/Tprot serum >0.5). CT chest after drainage showed trapped lung with residual pneumothorax but no effusion. She was going to follow-up with IP as an outpatient for further management of her pleural effusion. The pleural effusion was thought to be secondary to trauma from rib fractures related to her fall. She presents from ___ today for increasing SOB. Her SOB was intermittent after her time post-discharge. She noted that it was worse when it was going to rain. She went her PCP on ___ for a follow-up visit where a CXR showed reaccumulation of right effusion. She became increasingly SOB with exertion the day prior to admission and SOB worse with lying flat so she went for evaluation at ___. She also described wheezing and cough. She was then transferred to ___ for further management. In the ED, initial vitals were: 97.8 85 170/111 18 98% Labs in the ED notable for WBC 4.9, Hg 12.1, Plts 106. Chem 7 with sodium 141, potassium 4.1, Cl 104, BUN 24, BUN 16, Cr 1.0, INR 1.3. On the floor, she reports feeling comfortable in bed in terms of her respiratory status. She does have a headache. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. 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 arthralgias or myalgias. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little change in the pleural effusion extending upward to the midportion of the right lung with associated volume loss in the right lower and possibly right middle lobe. The left lung is essentially clear and there is no evidence of vascular congestion. CHEST (PORTABLE AP) showed Moderate to large right pleural effusion is unchanged. No pneumothorax. Right lung base is obscured and substantially atelectatic. Apparent increase in cardiac silhouette size is due in part to adjacent pleural effusion. Left lung clear. Heart size normal. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormality. 2. No evidence of new hemorrhage. CHEST (PORTABLE AP) TECHNIQUE: Portable chest radiograph, frontal view COMPARISON: Chest radiograph ___ FINDINGS: Previously seen large right pleural effusion is now resolved. There is no consolidation or pneumothorax. Cardiomediastinal silhouette is normal size. Tortuous aortic contour is stable. IMPRESSION: Right pleural effusion is resolved. No pneumothorax. showed Right pleural effusion is resolved. No pneumothorax. The patient was diagnosed with PLEURAL EFFUSION NOS, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT. The patient was treated with ___ THORACENTESIS. At the time of discharge, the patient had PRIMARY DIAGNOSES: 1. Pleural effusion 2. Possible partial temporal lobe seizures. SECONDARY DIAGNOSES: 1. Hypertension 2. Atrial fibrillation 3. Arthritis 4. H/o ___. 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>In brief this is a ___ yr old female who has a hx of Afib on Apixaban, hypertension, recent admission for fall w/ traumatic SDH & SAH, recent admission for a ___ complicated by rib fractures and right sided hemorrhagic pleural effusion, now presenting with SOB and found to have recurrent right pleural effusion.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: FROM ADMISSION NOTE: Ms. ___ is an ___ y/o woman with type II diabetes, hypertension, hypercholestermia, and diabetic neuropathy and recurrent cellulitis with a past history of DVT and PE, presenting with right toe pain. FOOT AP,LAT AND OBL RIGHT showed 1. Osteolysis along the medial aspect of the distal portion of the proximal phalanx of the third toe with soft tissue swelling, concerning for osteomyelitis. 2. Dislocated third toe at the PIP joint. UNILAT LOWER EXT VEINS LEFT showed Limited study due to severe soft tissue swelling at the left calf, obscuring visualization of the posterior tibial and peroneal veins. No deep vein thrombosis is identified in the remaining deep venous system in the left lower extremity. FOOT AP,LAT AND OBL RIGHT showed Proximal phalanx of the right third toe has been partially resected,, at a level 12 mm from the proximal interphalangeal joint. There is no subcutaneous emphysema. No other changes since preoperative foot radiograph on ___. Chest radiograph. showed 1. Right PICC tip in right atrium. Considering withdrawing 1.5 cm for better positioning. 2. Right lower lobe atelectasis. 3. Trace left pleural effusion. NOTIFICATION: The findings were discussed with ___, IV nurse by ___ ___, M.D. on the telephone on ___ at 6:04 pm, 1 minutes after discovery of the findings. The patient was diagnosed with Type 2 diabetes mellitus with other specified complication, Other acute osteomyelitis, right ankle and foot. The patient was treated with Right third toe amputation (___). At the time of discharge, the patient had Osteomyelitis. 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 history of DM2, remote DVT/PE, on lifetime AC, admitted for subacute cellulitis/osteomyelitis of right third toe s/p uncomplicated amputation.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with advanced metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary presents with worsening of abdominal pain, nausea, vomiting. Radiology showed 1. Markedly increased primary and metastatic tumor burden. Metastatic deposits extend through the anterior wall defect into the "ostomy". 2. Distention of proximal loops of small bowel with relative decompression but node discrete transition point in the distal ileum, compatible with partial obstruction likely due to mass effect by the large intra-abdominal cystic mass. Radiology showed No intraperitoneal free air. Normal bowel gas pattern. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed In comparison with the study of ___, there are lower lung volumes. No evidence of vascular congestion or acute focal pneumonia. There has been placement of a nasogastric tube that extends to the lower body of the stomach. Residual contrast material is seen in the colon. The patient was diagnosed with Unspecified intestinal obstruction. The patient was treated with NGT. At the time of discharge, the patient had PRIMARY DIAGNOSES: Metastatic intraperitoneal mucinous adenocarcinoma Partial small bowel obstruction Hypotension Thrombocytosis. 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 metastatic intraperitoneal mucinous adenocarcinoma of presumed appendiceal primary not currently receiving treatment who presented with abdominal pain, abdominal distension, emesis found to have partial small bowel obstruction. Patient had CT scan upon admission that showed increased primary and metastatic tumor burden as well as a partial bowel obstruction. Surgery was consulted and recommended no surgical intervention. NGT was placed to intermittent suction with minimal output. NGT placed to gravity and pt had nausea and abdominal pain. NGT was then placed back on to suction with relief of symptoms. NGT was to gravity prior to discharge and patient's pain was stable. Imaging noteable for worsening of patient's malignancy. Pt has been out of the country (___) for nearly a year and has received some medical treatment there (antibiotics per her family). Patient reported that she would not want chemotherapy or surgery. Palliative care was consulted and met with the patient. After an extensive goals of care discussion, pt was made DNR/DNI and is going home with hospice services. TRANSITIONAL ISSUES -Patient was discharged with "Hospice comfort kit contents"- acetaminophen 650 suppository, atropine 1% oral drops, bisacodyl 10 mg suppository, haloperidol 5 mg/1 ml oral solution, lorazepam 5 mg/1ml oral solution, senna-s -Also wrote script for fentanyl patch if needed -Please maintain patient's comfort -MOLST form was signed on ___. DNR/DNI, do not hospitalize</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female with dementia who presents today after an unwitnessed fall in her assisted living facility ___.) The patient is unable to provide a history and does not participate completely with physical examination. CHEST (PA AND LAT) showed Partial limited examination with no evidence of pneumonia. DX ABDOMEN W CROSS TABLE LATERAL showed No fracture or dislocation of the right hip. The patient was diagnosed with FX DORSAL VERTEBRA-CLOSE, OPEN WND KNEE/LEG/ANKLE, OPEN WOUND OF ELBOW, UNSPECIFIED FALL, TETANUS-DIPHT. TD DT. At the time of discharge, the patient had #T12 compression fracture without spinal cord impingement #Dementia, mixed alzheimer's and vascular type #Chronic hepatitis C. 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: Ms. ___ is an ___ year old woman with mixed vascular-Alzheimer's dementia, chronic hepatitis C, and osteoporosis who presents today from her locked dementia unit for an unwitnessed fall and was found to have T12 compression fracture and minor leg laceration. #) FALL: Although unwitnessed, suspect mechanical fall given vision difficulties and history of distal sensory polyneuropathy. Lower suspicion for cardiac etiology. Her ECG showed no ischemic changes. Urinalysis and toxicology screen were unimpressive. She needs supervision when out of bed. She sustained a minor left tibial laceration that required sutures. These will either fall out spontaneously or can be removed in 1 week, whichever is sooner. #) T12 COMPRESSION FRACTURE: Unclear chronicity. Radiology thought "acute" but patient's daughter reports she has an old vertebral compression fracture (films from ___ ___ in ___. Per Spine surgery, activity is as tolerated since this is not an unstable fracture. She was fitted for ___ brace and should wear this when out of bed if tolerated. She needs to follow up in clinic with Dr. ___ in 2 weeks. #) OSTEOPOROSIS: Patient has a history of osteoporosis and hypovitaminosis D. She She is not on a bisphosphonate. Unclear of last DEXA. Consider starting calcium and vitamin D. Consider discontinuing PPI if possible since it impairs both vitamin D and calcium absorption (Am J Med. ___. #) ALZHEIMER'S & VASCULAR DEMENTIA: Continued memantine and galantamine. #) CHRONIC HEPATITIS C: Has chronically elevated transaminases. Untreated. No history of cirrhosis or evidence of synthetic dysfunction by coagulation studies. TRANSITIONAL ISSUES ------------------- []Sutures may be removed from left tibial laceration in ___ days []2mm left upper lobe nodule discovered incidentally on trauma CT T-spine. There was no specific follow up recommended for this nodule. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with chronic pancreatitis ___ gallstones previous h/o Puestow procedure (___) and h/o choledocholithiasis with recent ERCP, sphincterotomy, and multiple stone extraction presents to ___ for abdominal pain. Pain was similar to last time she was admitted (late ___ where they discovered she had choledocholithiasis. Radiology showed No evidence of acute cardiopulmonary process. NG tube in appropriate position. Radiology showed No evidence of deep vein thrombosis. The patient was diagnosed with INTESTINAL OBSTRUCT NOS. At the time of discharge, the patient had Partial 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 was admitted to the Acute Care Surgery Service on ___ with a partial small bowel obstruction. The patient was transferred to the hospital floor for further care. The hospital course was uneventful and the patient was discharged to home. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with PMH of seizure disorder s/p TBI, ETOH abuse and T2DM presents with abdominal pain. CHEST (PORTABLE AP) showed No prior chest radiographs available. Symmetric bibasilar opacification could be pneumonia, but atelectasis is more likely. Pleural effusions small if any. No pneumothorax. Upper lungs clear. Heart size normal. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic liver with evidence of portal hypertension including ascites and splenomegaly. No focal lesions. No specific sonographic findings to explain the patient's increasing transaminitis. 2. Cholelithiasis without evidence of cholecystitis. CTA ABD AND PELVIS showed 1. No evidence of active hemorrhage in the region of the ampulla, adjacent to metallic CBD stent, or elsewhere in the abdomen or pelvis. 2. Severe hepatic steatosis. Mild nonspecific contour nodularity of the liver. No focal hepatic lesion. 3. Trace ascites in the abdomen, most notable in the right lower quadrant. 4. Splenomegaly, measuring 13.9 cm in length. 5. 7.1 x 4.1 cm intraparenchymal fluid collection in the pancreatic tail. Additional intraparenchymal fluid collection in the pancreatic uncinate process measuring 3.1 x 2.1 cm. Findings likely represent necrotic fluid collections from recent acute pancreatitis. Peripancreatic stranding seen on outside CT from ___ has largely resolved. 6. Wall thickening of the second portion of the duodenum, likely postprocedural in nature. Stent extending from the proximal common hepatic duct to the second portion of the duodenum, containing air throughout. 7. Small bilateral pleural effusions, right greater than left, with adjacent, compressive atelectasis. Radiology showed Technically successful coil and Gel-Foam embolization of the gastroduodenal artery. RECOMMENDATION(S): Continue to monitor for evidence of further bleeding. Radiology showed 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral upper lobe predominant multifocal pneumonia. 3. Small to moderate right greater than left bilateral pleural effusions with compressive atelectasis of the bilateral dependent lung bases. 4. Hepatic steatosis. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 3:51 pm, 1 minutes after discovery of the findings. The patient was diagnosed with Cholangitis. The patient was treated with ERCP ___ GDA embolization. At the time of discharge, the patient had Acute necrotizing gallstone/alcohol pancreatitis Alcoholic hepatitis Bacterial pneumonia GI bleeding DM2. 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>___ history of TBI complicated by seizure disorder, psoriatic arthritis on humira, active EtOH abuse, history of EtOH pancreatitis and T2DM who has alcoholic hepatitis on suspected alcoholic cirrhosis and necrotizing pancreatitis(alcohol vs gallstone). Course complicated by ERCP with post sphincterotomy bleed requiring metal stent and ___ embolization. # Acute blood loss Anemia # UGIB - post-sphincterotomy bleed, s/p GDA embolization on ___, stabilized # Acute Necrotizing pancreatitis - initially thought to be gallstone pancreatitis for which he underwent ERCP with sphincterotomy on ___, but now appears to be most likely alcoholic pancreatitis. He is clinically improved and tolerating diet with supportive care -- outpatient ERCP/ACS followup, repeat ERCP in 4 weeks -- He can follow up with GI closer to home post PCP follow up # Decompensated alcoholic cirrhosis - new diagnosis, hepatology following, appreciate recs. After initial concern about EtOH hepatitis and rising ___ score he stabilized without need for steroids. --monitored nutrition, advanced diet to high-protein low-fat diet per liver recs may need NGT if not meeting caloric targets, but appears to be doing so now --For his cirrhosis he needs outpatient follow up. For pancreatitis ? CCY although alcohol favored over gallstone pancreatitis. #Sinus tachycardia #Fever #Hypoxia #Multifocal Pneumonia - Initially now concern for infection though given concurrent hypoxia and low grade fever, CTA chest performed showing PNA, no PE. Placed on Vanco/CTX, narrowed to ceftriaxone and he will be discharged on a 3d course of levofloxacin. #ETOH abuse/withdrawal Long history of ETOH abuse and recent admission for withdrawal with possible withdrawal seizure treated with CIWA protocol. s/p phenobarb loading and rescue dose in the ED. - completed phenobarb protocol/taper</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ yo M with aPMHx of colonic polyps (last c-scope was ___ years ago) and bacterial overgrowth s/p ___ year of antibiotics who p/f ___ for further work up of an abdominal mass. . The patient began to have body aches and upper abdominal pain about 7 days PTA. He tried multiple over the counter medications and they were ineffective. The patient went on vacation to ___ this weekend and on ___ the patient reports having one blood streaked, solid stool. Then around noon, the patient had ___ blood from his rectum. Denies frank pre-syncopal symptoms. He then drove to ___ were imaging revealed an ascending colonic mass with cecal dilation and mild stranding. He was then transfered to ___ for further work up. . Patient currently complain of mild stiffness in his upper abdomen (RUQ/LUQ). Denies n/v. Is passing gas but has not had a stool in 24 hours. His last stool was small and semiformed with some blood. The patient denies w/l, f/c. . 10 point ROS is otherwise negative, except per above The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, ABDOM/PELV SWELL/MASS UNSP SITE. The patient was treated with colonoscopy with biopsy. At the time of discharge, the patient had lower GI bleeding ___ to colon mass suspicion for colon ca and possible liver metastasis. 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 M with a PMHx colonic polyps s/p multiple removals all of which were benign in the past per report, gastric overgrowth c/b UGI ulcer s/p ___ year of antibiotics who p/w 1 week of abdominal pain progressive to bloody stools with a CT scan from OSH that showed a narrowing in the ascending colon with cecal dilation and mild stranding without free air on CXR, normal lactate. . # Ascending colonic adenocarcinoma with Hematochezia. Etiology suspected was colonic adenocarcinoma given radiographic appearance. Other considerations could include lymphoma vs. adenoma. Colonscopy was performed on ___ confirming suspicion of colonic adenocarcinoma. Biopsy was taken during admission and returned POSITIVE for adenocarcinoma just after pt discharge. Pt's laboratories remained normal and his diet was successfully advanced without complication. Pt reported normal BM prior to ___. There was no evidence of any GI bleeding during admission. CT scan at ___ raised concern for hepatic metastasis. See below. Pt and family wished to undergo colorectal surgical evaluation at ___. Pt's family arranged for this appointment which reportedly occurred ___ at 2Pm. In addition, pt's family wished to investigate which oncologist to follow up with, preferring to f/u at ___. Pt and family were provided with contact information to set up an appointment at ___ or ___ if desired. SOcial work was consulted during admission. -Attempting to call pt's 2 listed telephone numbers after discharge to relay the pathology results. Left message for the patient to return my call. In addition, called over to PCP's office but the office was closed for the day. . # hypodensities in liver-per family report this had been noticed in the past. This was noted on OSH CT imaging. Liver function, per laboratory testing appeared intact. DDx includes cysts vs. metastasis. Pt may require a liver biopsy in the outpatient setting to confirm metastatic disease. Pt wished to follow up at ___ and ___. Pt will f/u with PCP for ongoing care as well. CEA was elevated. AFP WNL. . # HTN-continued ACEI . # HLD-continued statin .</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with CABGx3 (___), anterior MI (___), ischemic CM s/p ICD (EF ___ was ___, DM2, DVT (off coumadin ___ noncompliance), chronic chest and R leg pain, and multiple prior ED visits and admissions for syncope and/or chest pain, now presenting with chest pain. Radiology showed No acute process. The patient was diagnosed with CHEST PAIN NOS, DIABETES UNCOMPL ADULT, AORTOCORONARY BYPASS. At the time of discharge, the patient had PRIMARY DIAGNOSIS: ================== # Musculoskeletal 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>Mr. ___ is a ___ with CABGx3 (___), anterior MI (___), ischemic CM s/p ICD (EF ___ was ___, DM2, DVT (off coumadin ___ noncompliance), chronic chest and R leg pain, and multiple prior ED visits and admissions for syncope and/or chest pain, now presenting with chest pain.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ w/ Afib, CAD s/p 4x CABG, HLD, HTN who was taken of warfarin 3 weeks ago in setting of normal Holter and two days ago presented with Afib w/ RVR in setting of pneumonia and restarted on warfarin, who presents with 10 minutes of right finger numbness and right facial weakness. The patient was in his usual state of health when two days ago (___), he presented to the BI ED for tachycardia and fever, and found to have a right lower lobe pneumonia and Afib w/ RVR. He was discharged yesterday on levofloxacin and has been afebrile since. Chest: Frontal and lateral views showed Trace right pleural effusion again seen. No definite focal consolidation. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. No acute intracranial abnormalities identified. 2. Unremarkable CTA of the head, with a patent circle of ___. 3. Unremarkable CTA of the neck, without evidence of internal carotid artery stenosis by NASCET criteria. MR HEAD W/O CONTRAST T9113 MR HEAD showed 1. Left parietal acute to subacute infarct without definite hemorrhagic transformation, as described. 2. Right frontal nonspecific white matter changes, which may represent microangiopathic changes are sequela of prior trauma or infarct. 3. Minimal paranasal sinus disease as described. NOTIFICATION: The impression and recommendation above was entered by Dr. ___ on ___ at 13:39 into the Department of Radiology critical communications system for direct communication to the referring provider. The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 1:41 ___, 10 minutes after discovery of the findings. The patient was diagnosed with Transient cerebral ischemic attack, 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>___ w/ Afib, CAD s/p 4x CABG, HLD, HTN, and previous stroke in ___ and TIA in ___ who presented with 10 minutes of right face and arm numbness and weakness, found to have a small ischemic stroke. He was just restarted on Coumadin 2 days ago and his INR was subtherapeutic. He will be bridged with lovenox until his INR is ___. While taking lovenox, his aspirin is being held, but can be restarted once the lovenox is stopped. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old male brought in by medics light from the scene after a reported 30 foot fall through skyline all performing snow maintenance building roof. Extrication time was approximately 40 minutes from the building. The patient was brought in with concern for pelvis injury. He is wearing a cervical collar, awake, alert, and oriented x3. Positive LOC according to bystanders. Patient is ___ only. He complains of abdominal pain and mild shortness of breath. Vital signs are normal on arrival. Has received 100 mcg of fentanyl prior to arrival. He denies significant headache, vision changes, nausea, vomiting. He states he has no medical history, allergies, medications, or surgical history. PELVIS (AP, INLET AND OUTLET) IN O.R. showed Open reduction internal fixation of a fracture through the left superior pubic ramus and left sacroiliac joint diastasis. Please see the operative report for further details. CHEST (PA AND LAT) showed AS COMPARED TO THE PREVIOUS RADIOGRAPH FROM EARLIER THE SAME DATE, A SMALL RIGHT APICAL PNEUMOTHORAX IS SIMILAR TO THE PRIOR STUDY. RIGHT LOWER LOBE OPACITY HAS PARTIALLY RESOLVED, AND REMAINDER OF THE LUNGS AND PLEURA ARE UNCHANGED. CHEST (PA AND LAT) showed As compared to the previous image, there is no substantial change in dimension of the right apical pneumothorax. The patient shows no evidence of tension. The pre described subtle right lower lung parenchymal opacity has completely resolved, a small atelectasis in the infra hilar right lung regions persists. Unremarkable left lung. Normal size of the cardiac silhouette. No pneumonia or pleural effusions. Radiology showed No fracture or dislocation of the wrist. CT HEAD W/O CONTRAST showed Minimal paranasal sinus inflammatory changes. Otherwise normal study. CT C-SPINE W/O CONTRAST showed 1. No evidence of fracture or dislocation. Right apical pneumothorax partially imaged. 2. Enlarged palatine tonsils with several tonsilliths. 3. Prominent cervical all lymph nodes likely within normal limits for patient's age. Radiology showed 1. Fractures of the left inferior pubic ramus, left iliac bone, and superior pubic ramus. 2. No acute cardiopulmonary process. Radiology showed 1. Moderate right pneumothorax and pneumomediastinum. Multiple right lung contusions. Nondisplaced right seventh rib fracture. 2. Grade two liver injury as detailed above. Small amount of perihepatic hemorrhage tracking inferiorly into the pelvis. 3. Possible tiny contusion in the superior aspect of the spleen. 4. Fractures of the superior and inferior left pubic rami. Fractures of the left sacral ale and left ischial tuberosity. Small anterior fractures of the right and left pubic bones at the pubic symphysis NOTIFICATION: Fracture of the pubic symphysis. CHEST (PORTABLE AP) showed Heterogeneous consolidation in the right lower lobe, new since earlier in the day is local bleeding due to contusion and small laceration seen on the chest CT scan. Followup advised. Small right pneumothorax, confirmed by the chest CT scan, is most readily seen along the right lower costal surface and is no larger now than it was earlier in the day. Small pneumomediastinum is unchanged. In the setting of closed chest trauma this need not indicate disruption of the esophagus or tracheal bronchial tree, either of which would probably produce more air in the mediastinum and conceivably hemo mediastinal hematoma. Otherwise the cardiomediastinal silhouette has a normal appearance. Left lung is clear and there is no left pleural abnormality. Detection of chest wall trauma is more reliable with torso CT. CHEST (PORTABLE AP) showed The expiration view was obtained on the instructions of the requesting physician. This may account for the apparent increase in size of the small right pneumothorax which, in reality, may be unchanged. It may also exaggerate the confluence of the previous consolidation in the right lower lobe due to local bleeding. I have discussed the advisability of retaining of obtaining full inspiratory chest radiographs hereafter. Interval increase in heart size and mediastinal venous caliber is due in part to lower lung volumes, but most likely increased intravascular volume as well. Left lung is clear and there is no left pleural abnormality. NOTIFICATION: Dr. ___ reported the findings to Dr ___ by telephone on ___ at 10:44 AM, 5 minutes after discovery of the findings. The explained that the patient has no findings to suggest continued bleeding in the lung or pneumonia. The patient was diagnosed with LIVER INJURY NOS, PELVIC FRACTURE NOS-CLOS, UNSPECIFIED FALL. The patient was treated with ___: Open reduction, internal fixation anterior pelvic ring and posterior pelvic ring injury with 7.3 mm screws. At the time of discharge, the patient had 1: Fall from 30 feet 2: Grade 2 liver laceration, small splenic injury 3: Anterior and posterior pelvic ring fracture, left-sided 4: moderate left-sided pneumothorax with pulmonary contusion 5: Right 7th rib 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 is a healthy ___ male who by report fell 30 feet through a sky light with GCS 15. He was brought to the emergency department by med flight was concern for pelvic or hip fracture. He complains of abdominal pain. Fast exam is negative. CT demonstrates pneumothorax and right 7th rib fracture, lung contusions. Imaging also reveal the patient has a left compression pelvic fracture, and Orthopedic Surgery was consulted. The patient was currently stable with a patent airway and pain well controlled. Head CT and cervical spine CT negative. CT abdomen demonstrates grade 2 liver laceration and small splenic injury. Patient was admitted to ___ for further management of injuries and serial hematocrits. HD2 the patient was taken to the operating room with Orthopedics for open reduction, internal fixation anterior pelvic ring and posterior pelvic ring injury with 7.3 mm screws. The patient tolerated the procedure well and remained hemodynamically stable. On POD1 the patient was transferred to the floor. Hematocrits remained stable. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient worked with Physical Therapy and 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. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with crutches, voiding without assistance, and pain was well controlled. He was cleared by Physical Therapy for home with outpatient ___. The patient was discharged home without services. The patient and his family received discharge teaching, including lovenox teaching with the use of an interpreter, and follow-up instructions with understanding verbalized and agreement with the discharge plan. He had follow-up scheduled with the ___ clinic and with Orthopedics. ..</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH HTN, COPD, and DMII p/w SOB. Pt woke up at 3am gasping for breath and that is why she came in. She has had DOE for many years now but this SOB was much worse and she "didn't feel good." No CP but admits to a "tightening" sensation in the ___ her chest, which she can point to. Also admits to lightheadedness with the SOB and also with the DOE that is chronic. Cough has been worse recently and productive of more sputum. No f/c/s, N/V/D, no dysuria. No blood in stool but stool is "dark" after starting iron supplements. Denies ___ edema. Denies orthopnea. Denies palpitations or syncope. Called EMS and O2 sat was 92% so she was placed on O2 NC by EMT. Radiology showed Moderate cardiomegaly, mild pulmonary edema and small bilateral pleural effusions consistent with CHF. The patient was diagnosed with ATRIAL FLUTTER, CHRONIC AIRWAY OBSTRUCTION, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with s/p ablation of atrial flutter ___. At the time of discharge, the patient had Primary: atrial flutter s/p ablation, decompensated diastolic heart failure Secondary: COPD, diabetes, hypertension, hyperlipidemia, history of gastrointestinal bleeding. 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 PMH HTN, COPD, and DMII p/w DOE of one day's duration found to have new diagnosis of atrial flutter with e/o pulm edema on CXR, now s/p ablation and diuresis. ACTIVE DIAGNOSES # Atrial flutter: Pt has severe COPD as well as diastolic heart failure and UTI on admission, so these may be contributors to atrial flutter. Hyperthyroidism was ruled out with normal TSH. TTE showed new right ventricular cavity dilation, free wall hypokinesis and pulmonary artery hypertension which were concerning for acute PE, but V/Q scan showed low probability of PE. She was initially rate controlled with diltiazem and metoprolol. Spontaneously converted to sinus rhythm just prior to TEE, so TEE was cancelled prior to flutter ablation ___. Metoprolol was continued post-procedure and diltiazem was stopped. Management of diastolic heart failure exacerbation and UTI as described below. Anticoagulation was initially held given patient's history of GI bleeding, but with a CHADS score of 4 she was started on warfarin, bridging initially with heparin IV (TTE results were concerning for possible PE, but V/Q scan was low probability for PE so heparin gtt was changed to a-fib protocol). Heparin gtt was replaced by Lovenox upon discharge. Anticoagulation should be continued for at least one month post-ablation. # Diastolic heart failure exacerbation: LVEF >/= 65% on TTE this admission, consistent with diastolic dysfunction. Patient was treated with IV furosemide with good response. Weight on discharge was 100.2kg, with no crackles on exam. She was returned to her home dose of torsemide 5mg daily upon discharge. Check chemistry panel ___ for monitoring s/p treatment for diastolic heart failure exacerbation. # UTI: s/p three-day course of ciprofloxacin for Klebsiella UTI. # Anemia: Pt has h/o iron deficiency anemia and GI bleeding (see below). Hct was 34.3 on admission. Hct reached a minimum of 28.8 but was 30.5 on repeat check the same afternoon. Hct was 30.4 on day of discharge. Rectal exam produced no gross blood and no gross stool (see below). # Right groin irritation: skin of right inguinal region had initially erythematous patch with gray film after ablation procedure, which improved on post-procedure day 2. There was no hematoma or bruit. Topical nystatin or Lotrimin was recommended as necessary. CHRONIC DIAGNOSES # h/o GI bleeding: She had no evidence of active bleeding, including no bowel movements for several days. Rectal exam ___ produced no gross stool or gross blood; guaiac was difficult to interpret in the absence of a true sample but the glove was guaiac negative. Attempted to advance bowel regimen on day of discharge as pt had not produced any stool for sampling and rectal exam had produced no significant sample, but pt declined aggressive bowel regimen. Hct was stable this hospitalization as described above. Continued omeprazole. Outpatient colonoscopy ___. # HTN: continued metoprolol as above. # DM2: held metformin in house and replaced with sliding scale insulin. Resumed home diabetes regimen upon discharge. # Hypercholesterolemia: continued simvastatin. # COPD: FEV1 of 42% of predicted in ___ (most recent spirometry), reduced DLCO on outpatient testing with evidence of emphysematous disease, outpt spirometry also shows restrictive features thought secondary to obesity. Continued spiriva, albuterol. Added ipratropium while hospitalized. Goal O2 sat upper ___ - low ___. On day of discharge, O2 saturation went down to 87-88% with ambulation while working with ___. Pt was asymptomatic. Further monitoring/management as outpatient is advised. TRANSITIONAL ISSUES Check INR on ___ and titrate warfarin accordingly. Stop Lovenox once INR >2.0. Warfarin can be stopped 1 month after ablation. Check chemistry panel ___ for monitoring s/p treatment for diastolic heart failure exacerbation. O2 saturation went down to 87-88% with ambulation while working with ___. Pt was asymptomatic. She has h/o COPD so slight desaturation might be reasonable in her case. Further monitoring/management as outpatient is advised. Colonoscopy on ___</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ right hand-dominant male, previously healthy who presents w/ trimalleolar fracture s/p fall. Patient's mechanism of injury was a fall down 25 feet from room while at work, onto grass surface. Reports that he landed on right ankle and fell onto right side w/ headstrike. Denies loss of conscioussness. Was unable to ambulate due to pain. External fixation of the right ankle in the OR. Sixteen spot fluoroscopic views demonstrate the process of open reduction internal fixation of complicated ankle fracture. Note is made that the radiologist was not attending the procedure. For precise details, please review procedure report. was done. The patient was diagnosed with FX TRIMALLEOLAR-CLOSED, FALL FROM BUILDING. The patient was treated with right pilon fracture ORIF ___. At the time of discharge, the patient had right pilon 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 right pilon fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for application of external fixator for R pilon fracture, 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 on ___ to Dr. ___ with anticipated ORIF following. 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: Ms. ___ is a ___ woman with history of BMI> 40, remote provoked DVT/PE in ___ s/p 6mo warfarin, multiple sclerosis, bilateral total knee arthroplasties and recent T2-T4 laminectomy for spinal stenosis (___) who presents with progressive dyspnea on exertion. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. The patient was diagnosed with Other pulmonary embolism without acute cor pulmonale, Dyspnea, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS: ==================== Submassive pulmonary embolism Acute hypoxic respiratory failure SECONDARY DIAGNOSIS: ======================= Obesity History of DVT/PE Spinal stenosis. 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 of obesity, provoked DVT/PE in ___ and recent T2-T4 laminectomy for spinal stenosis (___) who initially prsented with dyspnea, found to have submassive PE, s/p heparin gtt, then transitioned to warfarin (on ___ bridge), with subtherapeutic INR on discharge. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ year-old gentleman with history of HFrEF(iCMP, EF 31%), MDS and relapsed high-grade ___ lymphoma with Burkitt-like features, last treated with R-EPOCH (___) presenting following a fall with headstrike found to be neutropenic with low grade temperatures. CT HEAD W/O CONTRAST showed No acute intracranial process. CT C-SPINE W/O CONTRAST showed No fracture is identified. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormality on noncontrast head CT. Specifically no evidence of intracranial hemorrhage or acute large territory infarct. 2. Additional findings described above. CHEST (PORTABLE AP) showed Heart size is enlarged. Hiatal hernia is large. There is mild vascular congestion. There is no appreciable pleural effusion. There is no pneumothorax. Radiology showed There is a new right-sided PICC line with distal tip at the cavoatrial junction. Heart size is prominent but stable. Opacity along the right heart border is due to a very large hiatal hernia. There are no pneumothoraces. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___. Right PIC line ends in the right atriumd approximately 3 cm below the estimated location of the superior cavoatrial junction. Small to moderate right pleural effusion and large gastrointestinal hiatus hernia projecting to the right of midline, are long-standing. The hernia exaggerates the size of mildly to moderately enlarged heart. Upper lungs are clear. There is pulmonary edema and no pneumothorax. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___. Bilateral lower lobe collapse unchanged. Small right pleural effusion decreased. No pneumothorax. Mild cardiomegaly stable. No pulmonary edema or mediastinal widening. Right PIC line ends in the upper right atrium as before. CT HEAD W/O CONTRAST Q111 CT HEAD showed Atrophy. No significant changes since ___. No evidence of hemorrhage. RENAL U.S. showed No hydronephrosis. CT CHEST W/O CONTRAST showed -Bilateral small layering pleural effusions are larger since prior, right greater the left. Adjacent consolidations, left greater than right are likely due to aspirations, particularly in the presence of large hiatal hernia. -Increased fat stranding surrounding the partially imaged left kidney could represent infection, for clinical correlation. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed Multiple (approximately 7) bilateral punctate supra and infra tentorial acute infarct. These are most likely embolic in nature. No hemorrhagic transformation. No intracranial hemorrhage or mass. Generalized cerebral atrophy with white matter microangiopathic changes. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:25 pm, 5 minutes after discovery of the findings. Chest x-ray showed As above. CHEST (PORTABLE AP) showed 1. Interval increase in bilateral interstitial opacities, consistent with worsening pulmonary edema. 2. Focal increase in opacification at the right lower lobe, which may represent superimposed infection, aspiration, or asymmetric edema. 3. Small bilateral pleural effusions, right greater than left. CT abdomen and pelvis showed 1. Stable mild stranding involving the omentum on the right complete similar to the CT findings from ___. Mild increased perinephric stranding on the left, no evidence of hydronephrosis. Recommend clinical correlation to exclude underlying infection. 3. No other interval change. Noncontrast CT chest showed Compared to 3 days prior: 1. No evidence of lymphadenopathy. 2. Stable airspace opacification in the left lower lobe suggestive of consolidation. New small scattered areas of ground-glass opacities in the right upper and middle ___ represent infectious etiology. Clinical correlation recommended. 3. Mild interval increase in bilateral pleural effusions which are moderate. Stable bibasilar passive atelectasis. Radiology showed A new right PICC line projects over the mid SVC. Bilateral pleural effusions with subjacent atelectasis/consolidation. CTA HEAD AND CTA NECK Q16 CT NECK showed The study is degraded by incorrect bolus timing and motion artifact. No acute hemorrhage or large territorial infarct. Known bilateral punctate supra and infratentorial acute infarctions are better appreciated on prior MRI head done ___. These infarcts are most likely embolic in nature. Within the limits of the study there is no intracranial arterial aneurysm or occlusion. No ICA occlusion. No obvious ICA stenosis by NASCET criteria. Increased soft tissues surrounding the junction of V3 and V4 segment of the right vertebral artery may be secondary to accompanying veins or may represent dissection, these cannot be differentiated due to poor contrast bolus timing and repeat CTA is advised. RECOMMENDATION(S): Increased soft tissues surrounding the junction of V3 and V4 segment of the right vertebral artery may be secondary to accompanying veins or may represent dissection, these cannot be differentiated due to poor contrast bolus timing and repeat CTA or MR is advised if clinically indicated. CHEST (PORTABLE AP) showed Comparison to ___. Stable low lung volumes. Stable bilateral pleural effusions of moderate extent. Stable subsequent bilateral areas of atelectasis. Today's radiograph shows signs of mild pulmonary edema. Unchanged alignment of the sternal wires. Unchanged right PICC line. The patient was diagnosed with Laceration without foreign body of nose, initial encounter, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had PRIMARY: ------------------- ___ lymphoma with Burkitt's features Sepsis Neutropenic Fever Embolic cerebral vascular accidents Acute on chronic systolic heart failure Ischemic cardiomyopathy Coronary artery disease status post coronary artery bypass graft Atrial fibrillation, new SECONDARY: ------------------- Type II NSTEMI Toxic metabolic encephalopathy Normocytic anemia Acute kidney injury Acute urinary retention Benign prostatic hypertrophy Ureteral stricture Mechanical fall Diarrhea Oropharyngeal candidiasis Celiac disease Type II Diabetes Gastroesophageal reflux disease Anxiety. 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>SUMMARY: ___ man with PMHx notable for myelodysplastic syndrome and relapsed high-grade ___ lymphoma with Burkitt-like features, most recently on R-EPOCH (___), as well as HFrEF (LVEF 31%) and ischemic cardiomyopathy, and recent admission for MSSA bacteremia now re-admitted for mechanical fall with course complicated by neutropenic fever / sepsis, rapid a-fib, acute in-hospital delirium, and acute cardioembolic CVAs. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ morbidly obese female with recent diagnosis of substernal multinodular goiter, right > left, with tracheal compression status post open thyroid biopsy and tracheostomy (___), also found to have concurrent DVT/PE in the setting of aforementioned compression in R IJ and subclavian vein as well as significant R-sided PE burden (right main, lobar, segmental and subsegmental), currently subtherapeutic on Coumadin on arrival to ___ ED, who presented from ___ with persistent, severe anemia over the past 3 days. Per report, the patient had a negative guaiac, negative C. difficile and was subsequently transferred to ___ for further evaluation of persistent anemia. No known trauma history. Supposedly, the patient had been less responsive over the past few days, only opening her eyes and looking around which is worse than her baseline (per last ___ admission, responds to some questions, mouths some words). No vomiting, diarrhea. No fevers or chills. In the ED, the patient was placed on mechanical ventilation (CMV Vt:380 RR:14 FiO2:0.4) for tachypnea and high minute volume needs. In the ED, initial vitals: 99.0, 120, 129/69, 22, 96% trach mask Exam notable for: Morbidly obese, opens her eyes and looks around, otherwise unresponsive. Bilateral upper extremity swelling with intact pulses Lungs diminished RRR +S1S2 tachycardic No spinal tenderness, no CVAT Abd with diffuse mild tenderness without clear focality BLE with 1+ edema to the mid-shin with ___ intact Rectal tube with brown stool, Guaiac negative Labs notable for: WBC: 23.2 (90% neuts) Hgb:5.6 Plt:257 138 / 93 /27 / AGap=13 ------------- 200 3.5 / 32 /0.7\ ___: 19.7 PTT: 150 INR: 1.8 Lactate 2.1 -> 1.7 Trop <0.01 Alb:23, AST:49, ALT:61, Alk Phos:103, TBili:0.6 Lipase: 55 Flu Negative UA: Mod Blood, Large Leuks, Few Bacs, Many Yeast Urine and Blood Cultures: Pending Imaging: CTA Abd Pelvis ___ 1. Large right iliacus and right iliopsoas hematomas without active extravasation. 2. On postcontrast imaging, which scanned slightly more inferiorly than the precontrast series, there are additional smaller hematomas in the proximal right thigh without active extravasation. 3. Bibasilar airspace opacities, similar on the right and decreased on the left. Recommend clinical correlation to assess for the possibility of pneumonia. 4. Decreased size of a moderate pericardial effusion. No evidence of mass effect. CT Head w/o Contrast ___ 1. No evidence of intracranial hemorrhage or large territorial infarction. 2. Increased bilateral mastoid effusions with extension into the left middle ear cavity raising the possibility of otomastoiditis. No evidence of osseous erosion. 3. New partial opacification of the paranasal sinuses with aerosolized secretions raising the possibility of acute sinusitis. CXR ___ Bibasilar airspace opacities may reflect atelectasis though infection is difficult to exclude in the correct clinical setting. Persistent small bilateral pleural effusions with probable mild pulmonary vascular congestion. Superior mediastinal mass compatible with known thyroid goiter is better assessed on previous CT. CTA Chest ___ 1. Pulmonary embolism in the right lower lobe is not well seen and may be obscured due to artifact. Additional potential filling defects in the bifurcation of the right pulmonary artery may be artifactual or represent additional pulmonary emboli. 2. Re-demonstrated large retro sternal goiter that displaces and compresses the trachea. 3. Re-demonstrated attenuation of the bilateral internal jugular vein and right subclavian vein. The brachiocephalic and SVC are patent. 4. Mild pericardial effusion is unchanged. 5. Additional findings above. Patient received: IV CefePIME IVF NS (1000 mL ordered) IV CefePIME 2 g IV Heparin ___ units/hr IV Vancomycin 1500 mg Consults: ENT-Appears to be moving air though trach tube well (crusting on inner cannula cleaned by RT). Tracheoscopy clear to carina. Neck soft and without evidence of hematoma (no ecchymosis, no oozing from incision lines, no firmness aside from palpably enlarged thyroid). No evident source for hematocrit drop on H&N exam. Vitals on transfer: 98.0, 128, 96/44, 24, 100% vent Upon arrival to ___, the patient was unresponsive. ___ (RN from ___ reported that the patient had been unresponsive the entire time she was at the ___ and had intermittent perioral twitching. Per daughter ___, the patient had been mostly unresponsive since her thyroid biopsy but occasionally was able to mouth a few words. REVIEW OF SYSTEMS: (+) Per HPI (-) Otherwise CHEST (PORTABLE AP) showed Bibasilar airspace opacities may reflect atelectasis though infection is difficult to exclude in the correct clinical setting. Persistent small bilateral pleural effusions with probable mild pulmonary vascular congestion. Superior mediastinal mass compatible with known thyroid goiter is better assessed on previous CT. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No evidence of intracranial hemorrhage or large territorial infarction. 2. Increased bilateral mastoid effusions with extension into the left middle ear cavity raising the possibility of otomastoiditis. No evidence of osseous erosion. 3. New partial opacification of the paranasal sinuses with aerosolized secretions raising the possibility of acute sinusitis. CTA ABD AND PELVIS showed 1. Large right iliacus and right iliopsoas hematomas without active extravasation. 2. On postcontrast imaging, which scanned slightly more inferiorly than the precontrast series, there are additional smaller hematomas in the proximal right thigh without active extravasation. 3. Bibasilar airspace opacities, similar on the right and decreased on the left. Recommend clinical correlation to assess for the possibility of pneumonia. 4. Decreased size of a moderate pericardial effusion. No evidence of mass effect. Radiology showed Opacity of the left lung base appears similar may reflect left pleural effusion and atelectasis, however consolidative opacity cannot be excluded. Mild bilateral pulmonary edema similar to slightly increased from prior exam. Tracheostomy is partially visualized. NG tube is seen with tip projecting over left upper quadrant, side-hole may be near the GE junction, similar to prior exam. Left-sided PICC is seen with tip projecting over the right atrium, similar to prior exam. UNILAT UP EXT VEINS US LEFT showed No evidence of deep vein thrombosis in the left upper extremity. Unchanged superficial fluid collection in the left anterior upper arm. Radiology showed Left-sided PICC is seen with tip projecting at the cavoatrial junction/right atrium. NG tube is seen with tip projecting over left upper quadrant and side-hole likely at the GE junction. Tracheostomy catheter is again seen. Low lung volumes. Opacity at the left lung base appears similar and may reflect a combination of effusion and atelectasis. Consolidative opacity cannot be excluded. Mild bilateral pulmonary edema appears similar. Likely small right pleural effusion. The cardiac silhouette appears unchanged. Chest radiograph showed Compared to the earlier same day examination, upper enteric tube and tracheostomy tube as well as a left-sided PICC are unchanged. Lung volumes remain very low. Retrocardiac consolidation appears similar. There may be a tiny right-sided effusion, unchanged. There is no pneumothorax. The upper lung zones remain clear. CTA ABD AND PELVIS showed 1. Extensive intramuscular hematomas involving several right thigh compartments, with involvement of the entire thigh to the level of the knee as described above. Upper thigh involvement appears slightly more extensive compared to ___, but there is no active extravasation. 2. Minimal decrease in size of a now 11.1 x 8.1 x 4.7 cm right iliacus muscle hematoma. 3. Incidental 2.6 x 2.2 cm right adnexal lesion with a coarse calcification, for which the differential includes fibroma, cystadenofibroma ___ tumor. In the absence of prior imaging documenting stability, a pelvic ultrasound is recommended for further evaluation. 4. Similar right greater than left bibasilar consolidations, likely representing atelectasis. Pneumonia is unlikely in the absence of clinical symptoms. 5. Small pericardial effusion is likely similar accounting for redistribution. RECOMMENDATION(S): Nonurgent pelvic ultrasound is recommended if prior imaging is not available for comparison. NOTIFICATION: The findings and recommendation were discussed with ___ ___, M.D. by ___, M.D. on the telephone on ___ at 8:21 am, 2 minutes after discovery of the findings. Radiology showed Tracheostomy tube and NG tube are unchanged. There is subsegmental atelectasis in the right lung base. Cardiomediastinal silhouette is stable. Small bilateral effusions are stable. No pneumothorax is seen. Lungs are low volume. There is no evidence of pulmonary edema. Right upper lobe atelectasis has improved. CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS showed 1. Multiple, unchanged large intramuscular hematomas involving the iliacus and anterior and medial compartments of the right thigh. No new collection or evidence of active extravasation, allowing for limitations of assessment. There is extensive right lower extremity soft tissue edema. 2. Ventral abdominal wall hernia contains a loop of small bowel without complication. Chest radiograph showed Compared to the prior examination, lung volumes are lower, further accentuating the cardiac silhouette and pulmonary vasculature. Tracheostomy tube, left PICC, and upper enteric tube are unchanged. There is moderate cardiomegaly. No gross consolidation is seen. There are probable small persistent bilateral pleural effusions. There is no pneumothorax. Radiology showed The tip of the feeding tube projects over the stomach. Suspected malpositioned left PICC line with the tip appearing to project over the azygos vein. A repeat frontal radiograph without patient rotation is recommended. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 7:25 pm, 2 minutes after discovery of the findings. Radiology showed There are low bilateral lung volumes and the patient is again noted to be rotated. The left PICC line tip is now flipped downward and leftward, still appearing malpositioned. Unchanged cardiopulmonary findings. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___. Previous mild pulmonary edema has resolved, although vessels are crowded by chronically elevated right hemidiaphragm. Moderate cardiomegaly is chronic. Small pleural effusions are likely. No pneumothorax. Tracheostomy tube midline. Nasogastric drainage tube passes into the stomach and out of view. UNILAT UP EXT VEINS US LEFT showed 1. No evidence of deep vein thrombosis in the left upper extremity. 2. Nonocclusive superficial thrombosis of the proximal cephalic vein, extending to the junction of the subclavian vein. 3. Fluid collection within the left biceps measure up to 6 cm in long dimension; this would be amenable to ultrasound-guided aspiration if needed. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, RDMS on the telephone on ___ at 11:55 am, 15 minutes after discovery of the findings. Ultrasound-guided aspiration showed US-guided aspiration of a collection in the left upper arm, yielding 2 cc of sanguinous fluid. This most likely represents a hematoma. Aspirate was sent for microbiology evaluation. Radiology showed Lungs are low volume with bibasilar atelectasis. Tracheostomy tube remains in place. The NG tube is unchanged. Cardiomediastinal silhouette is stable. There are stable small bilateral pleural effusions no pneumothorax is seen CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed 1. Re-identified is a 5.7 cm heterogeneous ill-defined left thyroid mass demonstrating central cystic components and coarse scattered calcifications. Since the prior examination of ___, interval resolution of postoperative pneumocephalus and soft tissue inflammatory stranding. 2. There remains loss of defined fascial plane between the mass and the adjacent trachea, esophagus and thyroid cartilage. In addition, the lesion exerts right lateral mass effect on the right common carotid artery, with obscuration of intervening fascial plane, which appears progressed from prior examination. Although the mass does not appear significantly increased in size since examination of ___, the lack of improvement in stranding and obscuration of adjacent fascial planes raises concern for possible malignant process. 3. In addition, there is increased soft tissue prominence incompletely characterized at the visualized superior mediastinum posterior to the trachea as well as apparent increased size of a 1.6 cm paratracheal lymph node (series 304, image 147). 4. A spiculated left upper lobe lesion now measures 1 cm, previously measuring 5-6 mm. A 4 mm right upper lobe pulmonary nodule has also increased in size from prior examination. Recommend further evaluation with dedicated CT chest. 5. Additional findings described above. RECOMMENDATION(S): Recommend further evaluation of impression 4 with dedicated CT chest with without contrast. Radiology showed Successful placement of a ___ gastrostomy tube and triple-lumen catheter. Radiology showed Successful placement of a ___ gastrostomy tube and triple-lumen catheter. CT ABDOMEN AND PELVIS WITHOUT AND WITH INTRAVENOUS CONTRAST showed 1. Interval increase in bibasilar atelectasis. 2. No significant change to a moderate pericardial effusion. 3. Worsening intra- and extrahepatic biliary dilation with the common bile duct measuring up to 2.9 cm (previously 2.2 cm). 4. No findings to explain hematuria. Specifically, no urinary calculi, renal or urothelial lesion. 5. Stable right adnexal cyst with coarse calcification. 6. Evolving right iliopsoas and sartorius hematomas. The sartorious is slightly expanded from ___. 7. Incompletely assessed are severe degenerative changes of the left wrist with apparent osseous fusion of the carpal bones. RECOMMENDATION(S): MRCP for further evaluation of worsening biliary dilation. Pelvic ultrasound. Left wrist radiographs. CT CHEST W/CONTRAST showed 1. No change in size of the known large partially cystic right thyroid mass causing contralateral (left lower) displacement and compression of the adjacent trachea with obscuration of the fascial plane between the esophagus, trachea, thyroid cartilage, and right internal carotid artery. The trachea is patent via presence of a tracheostomy tube in appropriate position. 2. 1.0 cm left apical pulmonary nodule, given short interval increase in size, favors a benign process such as inflammation or infection, although short-term follow-up is recommend. 3. Right greater than left small pleural effusions with associated atelectasis. 4. Short-term stability of mildly enlarged mediastinal lymph nodes. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___ most recently ___. New left internal jugular line ends in the upper SVC. No attendant mediastinal widening. Lung volumes remain quite low. Small left pleural effusion is likely, unchanged. Moderate enlargement of cardiac silhouette is stable. Bibasilar atelectasis is mild to moderate. No pneumothorax. Nasogastric drainage tube ends in the stomach. Tracheostomy tube midline. Radiology showed Low lung volumes with atelectatic changes at the lung bases, and small left effusion. Findings are similar to the previous study from ___. CT-guided thyroid mass biopsy. showed Successful CT-guided thyroid mass biopsy as above. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little change. Monitoring support devices are stable. Continued low lung volumes with basilar atelectatic changes and small left effusion. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___ most recently ___. Lung volumes remain quite low. Atelectasis has worsened at the left lung base. Bilateral pleural effusions are likely, but not large. Moderate to severe cardiomegaly is chronic. Tracheostomy tip projects over the upper trachea. No pneumothorax or mediastinal widening. Left jugular line ends in the low SVC. CHEST (PORTABLE AP) showed Compared to chest radiographs ___: No pneumothorax. Small pleural effusions unchanged. Lung volumes remain quite low. Moderate to severe cardiomegaly is chronic. No pulmonary edema. Tracheostomy tube midline. Left central venous catheter ends in the low SVC. Radiology showed Patient rotation and low lung volumes limit evaluation. Tracheostomy is again noted. Left-sided central venous catheter terminates in the region of the distal SVC, unchanged. No evidence for pneumothorax. Unchanged mild blunting of bilateral costophrenic angles, compatible with small pleural effusions versus pleural thickening. Bibasilar atelectasis without evidence for new consolidation. Cardiomediastinal silhouette is not optimally assessed. Right upper mediastinal widening was shown to be secondary to right thyroid mass on prior chest CT. Internal fixation hardware is partially visualized in the proximal left humerus. The patient was diagnosed with Altered mental status, unspecified. The patient was treated with trach change on ___ ___ gastrostomy tube on ___ left triple-lumen IJ catheter with tip in the SVC on ___.. At the time of discharge, the patient had Anaplastic thyroid cancer Chronic respiratory failure secondary to obstruction from goiter Hemorrhagic shock from right ___ acquired pneumonia Pulmonary embolism Right internal jugular thrombus Pericardial effusion. 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 hypothyroidism, goiter since ___, sensorineural hearing loss, morbid obesity and recent admission ___ for tracheal obstruction and right vocal cord paralysis secondary to enlarged goiter requiring tracheostomy, with course complicated by diagnosis of PE/RIJ DVT/R subclavian DVT discharged on warfarin, who was admitted ___ from her LTACH with hemorrhagic shock from right iliopsoas/thigh hematoma and HCAP. Her course has been complicated by pericardial effusion, volume overload, various clots and bleeding episodes, and diagnosis of anaplastic thyroid cancer. Her intermittent desaturation, bloody secretions and air hunger reflect her thyroid cancer invasion into trachea. Although radiation therapy in combination with BRAF/MEK inhibitor has not been fully studied and patient may not be able to tolerate full course of radiation this would appear to be best trial of palliation. #Anaplastic thyroid cancer Patient has had a goiter for ___ years, and before ___ had no full workup per patient and daughter. She presented acutely ___ with compressive symptoms causing tracheal compression. At that time, biopsy showed fibrosis and was unrevealing for malignancy. However, during this hospitalization endocrinology was formally consulted and repeat biopsy was done; biopsy showed papillary carcinoma that degenerated into anaplastic cancer. Oncology was consulted and followed the patient. Radiation oncology was consulted and said that the risks of radiation outweighed the benefits. She was BRAF mutation positive and there was discussion regarding palliative Tafinlar and Mekinist for which insurance authorization is pending. Palliative care was also involved in her care and symptom management as below. Transfer to ___ for additional evaluation including the role of palliative radiation. #Acute on chronic respiratory failure secondary to tracheal obstruction secondary to goiter s/p trach #Anxiety #Subjective dyspnea #Tachypnea Patient expresses a significant amount of anxiety over trach and secretions, and often expresses discomfort. She was taken for two bronchoscopies with IP during this hospitalization, which showed mass and granulation tissue distal to the trach. Trach was extended past this on ___, but is temporary as mass is aggressive and will continue to grow. For symptom management palliative care was consulted. She was started on standing klonipin for anxiety control, with Ativan for breakthrough. She was given duonebs, mucomyst and saline nebulizers with some improvement in comfort. Morphine 1mg IV q8hrs was also started for refractory air hunger. #Hemorrhagic shock #Right iliopsoas hematoma #Left bicep hematoma #Hematuria #Bloody tracheal secretions Patient was admitted from her rehab with hemorrhagic shock from right iliopsoas/pelvic bleed in the setting of being discharged on warfarin for a RIJ thrombus and PE. She required two ICU transfers early in her hospital course, with CTAs that did not show active extravasation or anything intervenable. Heparin gtt and warfarin were held. She was supported with blood transfusions, and stabilized. However, throughout her course whenever challenged with heparin, she developed multiple bleeding issues: hematuria, left biceps hematoma, and bloody tracheal secretions from friable mass/granulation tissue. Decision was made to hold anticoagulation after discussion of risks/benefits with patient and family. #Right IJ thrombus #Left cephalic vein thrombus #PE Patient at risk for clots in the setting of malignancy and also in the setting of compression from goiter. As above, heparin was trialed multiple times, with bleeding each time. #HAP The patient had known tracheal compression s/p trach in setting of enlarged thyroid. On admission there was also concern for hospital acquired pneumonia, but breathing also worsened in setting of acute bleed. She was placed on mechanical ventilation in the ED for tachypnea, then weaned to pressure support in the ICU, then to trach mask with appropriate oxygenation. Her CXR was suggestive of PNA, so she was treated with Zosyn and vancomycin. Vancomycin was discontinued with MRSA negative swab and zosyn course completed. #Pericardial Effusion Likely malignant. Patient had a small pericardial effusion noted on ___ prior to this admission. She was found to have fluid around her pericardium on chest imaging, so TTE was obtained on ___. This showed a moderate pericardial effusion with RV collapse, consistent with hypovolemia vs tamponade physiology. Cardiology and cardiac surgery were consulted, who recommended a repeat TTE. On ___, this showed interval improvement in both the side of the effusion and lessened RV collapsed. CT surgery and cardiology recommended no further intervention at this time. Repeat ___ showed stable effusion. #Toxic Metabolic Encephalopathy The patient was supposedly unresponsive with intermittent twitching at ___ during her entire stay since her recent discharge ___. CT head with no evidence of intracranial bleed or abnormality. Neurology was consulted, who recommended an EEG, which was free from seizure activity and MRI was considered, however was unable to be performed due to plates in the patient's arms. Other differentials included thyroid dysfunction, hypercarbia, electrolyte derangements, and infection UTI vs PNA. Ultimately, she improved with Zosyn and vancomycin, while also correcting her anemia which suggested that her encephalopathy was likely due to infection and toxic metabolic encephalopathy. #Vitamin D deficiency #Hypocalcemia #Hypothyroidism Concern that compression from goiter causing hypoparathyroidism vs surgical disruption of parathyroid glands. Endocrinology followed her during her course, and she was vitamin D loaded and then resumed on 1000U daily. Calcium was repleted with feeds and IV. Levothyroxine was continued at home dosing. #severe protein calorie malnutrition Patient had an NGT for feeding at last discharge. She had a PEG placed during this hospitalization. #Sinus Tachycardia At last hospitalization ___ patient was started on metoprolol for sinus tachycardia. However, sinus tachycardia was likely compensatory in the setting of PE, malignancy, respiratory discomfort and anemia. Metoprolol was weaned off. #Goals of care The patient experienced a lot of emotional and physical discomfort during her hospitalization even prior to diagnosis of anaplastic thyroid cancer. At the time of diagnosis, the aggressiveness of this cancer was explained and patient and daughter were very clear that they wanted to seek treatment and be full code. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Extracted from Admission History and Physical ___ with PMH of HTN, severe AS, moderate MR, Afib on warfarin, chronic pleural effusion ___ valvular disease s/p L pleural catheter placement, CKD3/4, who is presenting with erythema and purulent drainage around pleural catheter site. CHEST (PORTABLE AP) showed 1. Small bilateral pleural effusions, decreased on the right status post thoracentesis. No pneumothorax. 2. Increased moderate pulmonary vascular congestion. 3. Decreased right basilar atelectasis. Unchanged left basilar atelectasis. CHEST (PORTABLE AP) showed 1. Unchanged small bilateral pleural effusions and pulmonary vascular congestion. 2. Unremarkable appearance of the left pleural catheter. No pneumothorax. AORTA AND BRANCHES showed Patent abdominal aorta and common iliac arteries with no evidence of stenosis. The abdominal aorta is very tortuous in the setting of severe atherosclerotic burden The patient was diagnosed with Pleural effusion, not elsewhere classified, Cellulitis of chest wall. The patient was treated with Left-sided intrapleural fibrinolysis (___) Right-sided thoracentesis (___). At the time of discharge, the patient had PRIMARY -Acute on chronic dyspnea on exertion. SECONDARY -Bilateral pleural effusions. -Tunneled pleural catheter site cellulitis. -Severe aortic stenosis/moderate mitral regurgitation. -Stage III/IV chronic kidney disease. -Paroxysmal 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>___ female with chronic bilateral pleural effusions due to severe aortic stenosis/moderate mitral regurgitation, has a left-sided tunneled pleural catheter in that regard, referred for (1) acute on chronic dyspnea on exertion and (2) recurrent tunneled pleural catheter site cellulitis. #Acute on chronic dyspnea on exertion due to chronic bilateral pleural effusions. She underwent thoracentesis for interval enlargement of the right-sided effusion. Simultaneously, the intrapleural fibrinolytics instilled via her left-sided tunneled pleural catheter on the morning she was referred had a delayed effect, finally draining well here. She was more comfortable and her ambulatory oxygen saturation was likewise high ninety-range without supplemental oxygen requirement thereafter. A bedside ultrasound on the day of discharge was also reassuring. Her TPC was capped in that regard. Her studies were still consistent with a transudate. We increased her torsemide to 40 mg daily to slow the rate of re-accumulation but this is not a long-term durable solution hence expedite TAVR assessment. Her weight and NT-pro-BNP at discharge are 125 pounds and 5831, respectively. #Severe aortic stenosis/moderate mitral regurgitation. She did not have decompensated heart failure but her valvular disease is decidedly the cause of her effusions. She was referred to our structural heart team for TAVR so hoped to expedite that process this hospitalization; however, renal insufficiency precluded an elective pre-TAVR coronary angiogram after all. She will have a low-contrast pre-TAVR CTA after discharge instead. Routine ultrasound of the aorta and branches was performed. She is robust for her age and high-risk for re-hospitalization until the cause of her effusions is addressed so remains a reasonable candidate for TAVR. She and her family are not opposed to it either. #Tunneled pleural catheter site cellulitis. The erythema receded, and her pleural studies were not consistent with a secondary infection of the pleural space, so converted vancomycin to doxycycline/cephalexin. It was once purulent, and she has been hospitalized for intravenous antibiotics in the past, so favor both MRSA and Streptococcus spp. coverage. CHRONIC/STABLE ISSUES #Paroxysmal atrial fibrillation. She is in normal sinus rhythm and rate controlled with diltiazem. There are no foreseeable interventions so resumed warfarin for a CHA2DS2-VASc of 4. #Stage III/IV chronic kidney disease. Attributed to hypertensive nephropathy and renovascular disease. Her creatinine of ___ is in keeping with her trend in the last year. ___ esophagus. Continued omeprazole. TRANSITIONAL ISSUES ================= []Drain left-sided tunnel pleural catheter three times weekly (i.e., ___. []Complete doxycycline/cephalexin for 10-day course of antibiotics in total. []Note torsemide was increased to 40 mg daily. Weight at discharge is 125 pounds. Adjust accordingly. []Repeat BMP within the next week. Consider magnesium supplement for cramps if hypomagnesemic. Do not administer with doxycycline. []Expedite outpatient TAVR assessment as planned. An appointment was not secured prior to discharge (___). []INR was not yet therapeutic by discharge. Next INR is due ___.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with a history of ESRD on Peritoneal Dialysis since ___ who presents as a direct admission from ___ for a recurrent episode of bacterial peritonitis. The patient reports that approximately 4 weeks ago he began to have symptoms of peritonitis including abdominal pain. He self treated with cipro for 2 weeks which initially helped with his symptoms. However his symptoms began to recur and he developed cloudy peritoneal fluid. He had no fevers or chills but he did endorse night sweats. No diarrhea, nausea or vomiting. Yesterday (___) the patient had fluid drained from his peritoneal catheter which reportedly showed over 600 WBCs. He was treated with 2 grams of Intraperitoneal vancomycin. Radiology showed PD catheter is curled within the pelvis. Mild ileus. The patient was diagnosed with END STAGE RENAL DISEASE. The patient was treated with Peritoneal dialysis catheter removal Peritoneal dialysis catheter replacement- ___ Tunnelled hemodialysis line placement- ___ Hemodialysis- ___. At the time of discharge, the patient had Primary- Peritonitis ESRD- initiated hemodialysis Secondary- History of hypertension prior to initiation of PD. 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: Mr. ___ is a ___ with a history of ESRD on Peritoneal Dialysis since ___ who presented as a direct admission from ___ for a recurrent episode of bacterial peritonitis.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with a history of CHF, CAD s/p DES in and RCA, and DMII presenting with low back pain. Per ED, patient states that he has had worsening low back pain over the past month but over the past few days has had multiple episodes of loss of bladder or bowel control. Associated with multiple falls he states the falls are secondary to his legs giving out from underneath him because of weakness. He does use a walker at home. He denies fevers chills chest pain shortness of breath or abdominal pain. He denies saddle anesthesia history of IV drug abuse. Upon arrival to the floor pt clarifies that about 1 month ago, he went to sit on the toilet seat, slipped, and fell to the floor. He experienced difficulty walking and R side low back pain after falling. For the past ___ weeks, he has experienced bowel and bladder incontinence and has noticed that his hands fall asleep at night. He has had 15 additional falls over the past month. He denies saddle anesthesia. Prior to fall, he was ambulating with a walker and could walk about 1 block with his walker before getting SOB. Recently, for the past month, he notes increased SOB while ambulating, can only walk from bed to hall before getting SOB. Associated cough with sputum production. Radiology showed Cardiomegaly without superimposed acute cardiopulmonary process. MR CODE CORD COMPRESSION PT27 MR SPINE. showed 1. Severe spondylotic changes of the lumbar spine most prominent from at L2-3 and L3-4 where there is severe spinal canal stenosis resulting redundancy of the cauda equina nerve roots superiorly. There is multilevel severe neural foraminal narrowing as detailed above. 2. Compression deformity of the T12 vertebral body with signal characteristics indicating possible acute to subacute stage. Consider further evaluation with a CT lumbar spine for better evaluation of bony detail. NOTIFICATION: The primary team was aware of these findings at the time of this interpretation. Additional the findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:18 am, 10 minutes after discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormalities. 2. Chronic microangiopathy and age related global atrophy. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. Mild anterolisthesis of the of C4 on C5 and C7 on T1 is likely degenerative in etiology. No acute fracture identified. 2. Extensive degenerative changes of the cervical spine with multilevel moderate vertebral canal and multilevel severe neural foraminal stenosis, as described above. 3. Mottled appearance of the bone may be related to osteoporosis. However, correlation with history of malignancy is recommended. If there is clinical concern, a nonemergent bone scan can be obtained for further evaluation. LUMBO-SACRAL SPINE (AP AND LAT) showed Degenerative changes. With intervertebral disc space narrowing at all lumbar levels. Intraoperative radiograph showed Intraoperative images were obtained during invasive procedure without a radiologist present. Please refer to the operative note for details of the procedure. Radiology showed Increased patchy opacities at both lung bases may reflect atelectasis or aspiration/pneumonia. The patient was diagnosed with Low back pain. The patient was treated with Spinal Decompression Surgery ___ - Laminectomy L1-L2, L2-L3, L3-L4 - Far-lateral decompression, L4-5 procedure - Laminectomy L5-S1 Coronary Cath ___. At the time of discharge, the patient had Primary Diagnosis: #Cauda Equina Syndrome/Cord Compression #Type I NSTEMI #CAP #Delirium #Urinary tract infection Secondary Diagnosis: #HFrEF #Acute Kidney Injury #Anion gap metabolic acidosis #Type 2 diabetes mellitus #Acute on chronic 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 an ___ man with a history of CHF, CAD, DMII, and a remote history of prostate cancer who presented after a fall one week PTA with new bowel incontinence, now s/p cardiac catheterization and spinal decompression ___. =============================== Acute medical issues addressed =============================== # Back pain ___ cord compression: Patient diagnosed with cord compression (cauda equina) on CT and MRI of the spine and had fecal incontinence and lower extremity weakness. Patient underwent L1-S1 laminectomy evening ___. His post-op pain was managed with scheduled Tylenol, prn Tramadol initially, and lidocaine patch. ___ worked with him during admission. Patient initially had a foley post-op and had issues with some urinary retention post-op despite an intact neurologic exam and had to be straight cathed. Due to ongoing urinary retention, a foley was placed on ___. On discharge, he had some weakness in his lower extremities still as described in his discharge physical exam. He will need to have a voiding trial at rehab but likely has permanent damage from his cauda equina. If there continue to be ongoing urinary retention issues, patient should have urology follow-up scheduled as an outpatient. #NSTEMI in setting of HFrEF (EF 45% in ___ and prior PCI in ___ of proximal LAD and distal RCA. Patient underwent cardiac catheterization on ___ prior to laminectomy with two stenotic coronary vessels. Given need for urgent spinal decompression, decision was made not to place bare metal stents due to concern for dual antiplatelet therapy during surgery. Patient did not undergo POBA. Patient was treated with atorvastatin 80 mg PO daily, ASA 81 mg PO daily, amlodipine 10 mg PO daily for BP control, metoprolol 6.25 mg PO q6h. His Bumex was initially held in setting of ___. He was given nitroglycerin available PRN chest pain. On ___, he was cleared for any future DAPT. Cardiology was reconsulted who recommended repeat EKG and trops. Trops were elevated (0.11), which they felt was from his catheterization. These were trended and they went down. Repeat EKG was unchanged and patient was asymptomatic. Pharmacologic stress testing was done on ___ which showed partially reversible, medium sized, severe perfusion defect involving the RCA territory. However, due to the fact that the patient was asymptomatic, the decision was made by Cardiology not to do an interventional procedures and instead treat the patient medically. Bumex 1 mg PO daily was restarted on ___ for crackles on exam and ___ edema. His losartan was held due to initial ___. #Concern for CAP. Patient with new productive cough and bilateral infiltrates on CXR concerning for PNA. However, patient afebrile and without leukocytosis. The decision was made to treat the patient for community acquired pneumonia as he was so stable. He was given azithromycin for 5 days and ceftriaxone, later transitioned to cefpodoxime for his outpatient treatment for a total of 7 days. He will require one day of cefpodoxime 200 mg PO q12h while at rehab (stop date ___. ___, likely prerenal in the setting of two interventional procedures and getting IV contrast. Cr peaked at 2.2. Spun urine showed sediment/casts which showed granular casts only. He was given prn IVF and his Bumex was held initially. His Cr improved and was 1.0 on discharge. His losartan was held due to initial ___. #Acute on chronic normocytic anemia: Patient's Hgb dropped to 6.9 ___ from 7.6 and 8.6, thought to be ___ intraoperative losses. He was given 1 unit PRBCs ___ with appropriate bump in his hemoglobin. His H&H stayed stable throughout his admission. He should have further outpatient workup of his anemia. #Elevated anion gap metabolic acidosis: Resolved. Patient acidemic on ABG found to be a primary metabolic acidosis with a slight superimposed respiratory acidosis, which resolved with IVF. However, he later developed a mild non-gap metabolic acidosis of unclear etiology. Would continue to trend electrolytes at rehab. #Delirium. Patient saying some non-sensical statements throughout hospital course and was not sleeping well at night. Likely multifactorial ___ PNA, spinal surgery, and urinary retention. Patient was never agitated and delirium has been improving, especially with treatment of PNA and after placement of foley. #UTI Patient with worsening delirium on ___. UA checked which was positive for 42 WBCs, few bacteria, and large leukocyte esterase. He was started on Bactrim DS 1 tab BID for a total of 7 days (stop date: ___. Urine culture was pending on discharge. #Thrombocytosis Plts increased >400k starting ___, most likely ___ UTI, 538k on day of discharge, may continue to trend. # DM II with recent hypoglycemic episode. Last HbA1c 6.3% on ___. Patient was given low dose sliding scale insulin. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Dr. ___ is a pleasant ___ gentleman with history of metastatic cholangiocarcinoma who recently underwent removal of a plastic stent with placement of a metal stent in the hepatic duct at ___ on ___, was discharged on ___ and returns today for vomiting and early satiety. He was initially seen by his PCP in ___, ___ was performed there showing duodenal wall thickening and he was transferred here for further evaluation. Pt states that his sxs have been gradually worsening over the last 3 wks, however he expected improvement with his recent procedure and has found that his symptoms are worsening. Radiology showed 1. Dilated stomach with marked wall thickening of the proximal duodenum as it passes near the porta hepatis at site of infiltrative tumor, consistent with duodenal outlet obstruction with possible infiltration of the duodenum. 2. Progressive irregular soft tissue density extending from the hepatic hilum inferiorly. Then nodular character of this density suggests progression of primary tumor and less likely non-specific inflammatory changes 3. Scalloping along the liver capsule concerning for metastases. 4. Common bile duct stent in expected position, though progression of intrahepatic biliary ductal dilatation. Radiology showed No acute cardiopulmonary process. No evidence of free air beneath the diaphragm. Radiology showed 1. New left lower lobe opacity. Rapid development and associated volume loss favor atelectasis over infectious pneumonia. 2. New poorly defined opacities in right upper lobe, which could represent developing bronchopneumonia or an acute aspiration event. 3. Moderate left pleural effusion with apparent subpulmonic component. Small right pleural effusion. The patient was diagnosed with VOMITING. The patient was treated with EGD with metal duodenal stent. At the time of discharge, the patient had 1. Small bowel obstruction 2. Pneumonia, aspiration 3. Metastatic Cholangiocarcinoma. 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 ___ yo gentleman with hx of cholangiocarcinoma, s/p biliary stenting on ___ now returning with vomiting and evidence of duodenal wall thickening on CT, concerning for partial SBO. # PARTIAL SBO: likely due to duodenal thickening, likely from spread of his cholangiocarcinoma. Patient underwent EGD with duodenal stenting with good results. He was able to slowly advance to a regular diet. He will avoid large food boluses, ruffage, or fiber, which could get stuck in the stent. He was seen by Nutrition to discuss appropriate food and nutritional supplement intake. # CHOLANGIOCARCINOMA: Patient is s/p ERCP on last admission. Although LFTs were elevated above baseline on this admission, they trended down without intervention. Patient will follow-up with his oncologist as an outpatient or seek cancer care closer to home in ___. # COUGH/ELEVATED WBC/?PNA: Patient with cough, elevated WBC and question of PNA on CXR. Patient likely aspirated during procedure in light of duodenal blockage. Levofloxacin 750mg QD was started for a total of 5 days. # ASTHMA: Advair was continued. Singulair was held in an effort to minimize medications patient needed to take orally. # HICCUPS: Patient with severe hiccups. Reglan was helpful at time. This medication can be continued as an outpatient. He also found that deep breathing and relaxation helped this. # GLAUCOMA: Latanoprost was continued.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ hx HTN, DMII, ___ (EF>55%), ESRD on ___ HD since ___, ex-smoker (quit 1970s), presumed myelodysplastic syndrome, p/w dyspnea and mild somnolence today preceded by ___ weeks nonproductive cough. HE was seen by ___ who found him to O2 82% on RA (normally runs 96-100%). He was sent to ___ by ___ MD. ___ triggered for hypoxia at triage for O2 sat 88%RA (not on home O2). Wife noted that ___ has had a dry cough for 1 week but unknown if he has had fevers. He remains at baseline with 2 pillow orthopnea and wheelchair bound. ___ did have scheduled HD yesterday and has not recently missed any sessions, though dialysis schedule this week was MTF because of the holidays. Review of systems negative for any fevers, chills, chest pain, nausea, vomiting, diarrhea. Of note, ___ is oliguric at baseline. Further history obtained from daughter was that ___ started getting URI symptoms on ___ with seemingly productive cough on ___ though he was unable to produce sputum. He did have a low grade temperature of 99.5 and was noted to be sluggish. His daughter noted that ___ started having what appeared to be a productive cough though he was never actually able to produce sputum. ___ has not had any sick contacts. He did not get the flu shot. ___ denies any myalgias. He has had multiple hospitalizations over the last ___ years for hyperkalemia in the setting of missed dialysis session (___), anemia with guaic positive stools and supratherapeutic INR (etiology not identified - ___, pneumonia (___), and CHF (___) at which time BNP was 3600. In the ED initial vitals were: 17:25- 0 99.1 66 157/38 22 88% ea - Labs were significant for lactate 2.4, VBG 7.42/50, trop 0.09, BNP 31074 (BNP 3600 in ___ at time of chf exacerbation), leukocytosis 35.7, h/h 12.5/38.1, thrombocytosis 838 (Noted 550 on ___ - Bedside u/s showed no pericardial effusion but with b/l pleural effusions - ___ was given 1g vanc, 4.5g IV pip-tazo empirically for possible HCAP Vitals prior to transfer were: 20:24- 0 82 24 96% Nasal Cannula CHEST (PORTABLE AP) showed Persistent small to moderate size right pleural effusion with right basilar opacity, likely compressive atelectasis. Minimal streaky left basilar atelectasis. Mild pulmonary vascular congestion. CHEST PA AND LATERAL showed 1. Largely unchanged chest radiograph since ___, with a similar appearing right pleural effusion. The patient was diagnosed with SEMICOMA/STUPOR. The patient was treated with Hemodialysis. At the time of discharge, the patient had PRIMARY: viral URI acute on chronic dCHF ESRD on Dialysis CHRONIC: HTN PVD DMII MDS AFib GOUT. 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/ hx dCHF (EF>55%), ESRD on MWF HD since ___, ex-smoker (quit ___) p/w dyspnea and mild somnolence today preceded by ___ weeks nonproductive cough with concern for hcap and acute on chronic dCHF. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with epilepsy who presents from clinic with seizures. PER ___ note: "She has suffered from complex partial epilepsy since the age of ___ CLINIC PROTOCOL W/O CONTRAST T7721 MR HEAD showed 1. Unremarkable contrast enhanced MRI brain. 2. No evidence of focal cortical dysplasia, focal lobar encephalomalacia, gray matter heterotopia or mesial temporal sclerosis. The patient was diagnosed with Epilepsy, unsp, not intractable, with status epilepticus. The patient was treated with Lumbar puncture ___. At the time of discharge, the patient had Breakthrough seizures complex partial epilepsy. 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 focal seizure with decreased awareness and secondary generalization admitted with breakthrough seizures. #Seizures: Seizures since the age of ___, unknown etiology. She presented with breakthrough seizures, thought to be from missing doses as well as irregular schedule and sleep deprivation. Also possibly some catamenial component as increased seizures with menstruation. She was intubated for airway protection in the ED. While in ICU she was quickly extubated. She had an event after extubation consisting of right arm triple flexion, rightward gaze preference but no EEG correlate. For workup of her epilepsy that has been difficult to control recently she had MRI that did not show any focal cortical dysplasia, focal lobar encephalomalacia, grey matter heterotopia, or mesial temporal sclerosis. LP was done as well without evidence of increased protein or infection. Encephalopathy panel was sent and pending at time of discharge. She was continued on lamictal 150/175mg, Keppra 1000mg BID. Level of lamictal was checked and pending at time of discharge. Overall feel that breakthrough seizures are iso non compliance as she has difficulty taking her morning medications due to her friends seeing her and not wanting them to know she takes medications. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ yo man with a PMHx of a L MCA stroke in ___ with resulting fluent-aphasia, pancreatic cancer with known liver mets, afib on Eliquis, HTN and HLD who presents to the ED with worsening slurred speech and word finding difficulties with MRI revealing subacute to late acute bilateral cerebellar hemispheres and left temporal lobe embolic infarcts. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed 1. Multiple new foci of slow diffusion involving the bilateral cerebellar hemispheres and left temporal lobe, demonstrating associated FLAIR hyperintense signal without definitive enhancement, compatible with a combination of late acute to subacute infarcts of varying chronicity. 2. Additional scattered foci of diffusion-weighted hyperintense signal without clear ADC hypointensity and equivocal FLAIR hyperintense signal of the bilateral frontal and right parietal lobes, concerning for subacute infarcts. 3. The above combination of findings would suggest a central/ embolic etiology. 4. Subacute left temporal lobe infarct, now demonstrating encephalomalacia and mildly enhancing gyriform diffusion-weighted cortical hyperintensity with pseudo normalization on ADC and associated pseudo laminar necrosis. There is gradient echo susceptibility blooming artifact within the subacute infarct compatible with hemorrhagic transformation, noted on prior CT examination. 5. Potentially, the gyriform diffusion-weighted hyperintense signal of the left temporal lobe could be seen in setting of seizure activity, however there is no cortical thickening to suggest edema. 6. Postcontrast examination is severely motion degraded. No clear enhancing mass lesions are identified. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephoneon ___ at 3:45 ___, at the time of discovery of the findings. Chest radiographs. showed Bibasilar atelectasis without lobar consolidation. Numerous pulmonary nodules are better visualized on prior CT chest examination. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. No evidence of acute intracranial hemorrhage. Evolving cerebellar and left temporal lobe infarctions. 2. No evidence of aneurysm greater than 3 mm, dissection or vascular malformation, or significant luminal narrowing. 3. Multiple enlarging lung nodules seen on CT chest from ___ which likely represents progressive metastatic disease. The patient was diagnosed with Cerebral infarction, 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># Neuro: Patient presented with worsening dysarthria and word finding difficult with MRI revealing late acute b/l cerebellar hemisphere and left temporal lobe infarcts, suggestive of cardioembolic etiology, also complicated by his underlying metastatic malignancy which may place him in a hypercoagulable state. Patient showed improvement in aphasia over course of admission, with improvement in naming objects and fewer phonemic and paraphasic errors. The patient was transitioned from apixaban to enoxaparin for therapeutic anticoagulation and medication was delivered to patient in the hospital. Blood pressures were initially allowed to auto regulate and then restarted on home antihypertensives upon discharge. -Risk factor labs: -HbA1c: 7.2 LDL: 149 TSH: 3.2 (CEA 218) -CTA H/N: unremarkable -MRI: Multiple new foci of slow diffusion involving the bilateral cerebellar hemispheres and left temporal lobe, demonstrating associated FLAIR hyperintense signal without definitive enhancement, compatible with a combination of late acute to subacute infarcts of varying chronicity. Additional scattered foci of diffusion-weighted hyperintense signal without clear ADC hypointensity and equivocal FLAIR hyperintense signal of the bilateral frontal and right parietal lobes, concerning for subacute infarcts. Subacute left temporal lobe infarct, now demonstrating encephalomalacia and mildly enhancing gyriform diffusion-weighted cortical hyper intensity with pseudo normalization on ADC and associated pseudo laminar necrosis. There is gradient echo susceptibility blooming artifact within the subacute infarct compatible with hemorrhagic transformation, noted on prior CT examination. -Echo: Apical hypokinesis, worse from ___. No discrete thrombus. Mild symmetric left ventricular hypertrophy. Increased left ventricular filling pressure. Mild mitral and tricuspid regurgitation # CV: Admitted in atrial fibrillation with RVR, improved after multiple IV doses of metoprolol and PO+IV Diltiazem, for which increased home metoprolol from 250mg daily to 300mg total daily dose. # HEME: Pancytopenia, especially thrombocytopenia during admission, likely secondary to recent chemotherapy administration on ___. Platelets downtrended to 27 on admission, without evidence of bleeding. After discussing case with Oncologist Dr. ___ 1u platelets with improvement in platelets to 57 upon discharge. # ENDO: DM, continued on insulin with SSI as needed. # ID: No evidence of infection on UA/UCx, CXR. # Global: - FEN: Maintained initially on cardiac heart healthy diet, transitioned to regular per patient preference. Releted electrolytes as needed - DVT PPx: Therapeutic Lovenox, pneumoboots - Bowel regimen - Precautions: fall and aspiration - Dispo: Floor bed with telemetry, ___ recommended outpatient ___, paperwork filed for home ___</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: In brief, this is a ___ female with PMHx significant for IDDM c/b neuropathy, severe gastroparesis with frequent flares, macular degeneration with legal blindness, and obesity, who is presenting with nausea, vomiting, and abdominal pain. She was admitted two weeks ago for a gastroparesis flare and had a temporary NJ tube placed for a tube feeding trial with a plan to have a follow up emptying study. Her feeding cycle was 16hr continuous/8hr off. 4 days prior to admission and about 9hrs into her feed, she felt her stomach becoming uncomfortably full, which triggered her to become nauseated and vomit (NB, bilious) and displaced her NJ tube. Following this episode, she reports severe (___) LLQ abdominal pain. She denies fevers, chills, chest pain, shortness of breath, dysuria, headache. Radiology showed Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in the proximal jejunum. The gastric port should not be used for 24 hours. The patient was diagnosed with Type 1 diabetes w diabetic autonomic (poly)neuropathy, Long term (current) use of insulin, Gastroparesis. The patient was treated with ___ Gastric Emptying Study Markedly abnormal gastric emptying with only trace activity leaving the stomach for the small bowel after 4 hours. ___ PERC G/G-J TUBE PLMT Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in the proximal jejunum. The gastric port should not be used for 24 hours.. At the time of discharge, the patient had PRIMARY DIAGNOSIS ====================== Gastroparesis flare, with nausea/vomiting/abdominal pain SECONDARY DIAGNOSES ====================== IDDM with Retinopathy, Neuropathy, Gastropathy Biliary ductal dilation Depression Chronic pain Primary 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>Summary ====================== ___ female with PMHx significant for IDDM c/b neuropathy, severe gastroparesis with frequent flares, macular degeneration with legal blindness, and obesity, who is presenting with nausea, vomiting, and abdominal pain, consistent with gastroparesis. She underwent GJ tube placement and was restarted on tube feeds. ACTIVE ISSUES ======================= # Nausea/vomiting/abdominal pain with gastroparesis: Patient presented with two days of symptoms consistent with prior gastroparesis flares. Patient was recently discharged with NJ trial (to see whether permanent g tube would be beneficial). Symptoms were improved with NJ, though temporary tube was dislodged and prompted nausea/vomiting/abdominal pain, for which pt was admitted this time. During this hospitalization, she underwent gastric emptying study which was grossly abnormal and then GJ tube placement on ___. Nausea, vomiting and abdominal pain largely resolved on post-op day 2, tolerating tube feeds and oral pain medication. She was discharged on pre-admission pain regimen. Nutrition and ___ Diabetes were consulted, and recommendations regarding tube feed regimen and diabetes management were made (discussed below).</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ with history of depression with prior suicide attempt c/b exploratory laparotomy, anxiety, and dyslipidemia who presents with abdominal wall erythema and pain. Radiology showed 1. Fat stranding in the anterior abdominal wall inferior to the umbilicus consistent with reported history of cellulitis. No abscess or subcutaneous gas is identified. 2. No acute process within the abdomen or pelvis. 3. Cholelithiasis without cholecystitis. 4. Dilated common bile duct to 0.8 cm without visualized calcified stone or mass identified. Non urgent MRCP can provide further evaluation for underlying etiology if desired clinically. The patient was diagnosed with Cellulitis of abdominal wall. At the time of discharge, the patient had Primary Diagnosis ================= Abdominal wall cellulitis Secondary Diagnoses =================== Hyperlipidemia 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>Patient is a ___ with history of depression with prior suicide attempt complicated by exploratory laparotomy for acute abdomen and appendectomy, anxiety, and dyslipidemia who presented with abdominal wall erythema and pain, concerning for abdominal wall cellulitis.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH EtOH abuse, diverticuitis s/p ___ w/ reversal, c/b incisional hernia s/p laparoscopic mesh repair c/b recurrence, now w/ roughly 7 days of nausea, vomiting, and abdominal pain. He states that the pain is worst over his known, longstanding recurrent incisional hernia. He reports having generally been able to stay hydrated and denies drinking alcohol for ___ years. When his symptoms worsened, he decided to present to the ED for treatment of his hernia and requests that his hernia be repaired expeditiously. A CT A/P was performed in the ED which showed herniated bowel with some evidence of intermittent incarceration. though no current vascular compromise or obstruction. ___ surgery was consulted for further management CT abdomen pelvis showed 1. Single ventral hernia containing a loop of ___ bowel with hernia neck measuring approximately 3.0 cm. The loop of ___ bowel within the hernia is not dilated and has normal wall enhancement. However there is adjacent free fluid stranding lateral to the right aspect of that loop of bowel could be seen in the setting of intermittent incarceration. NOTIFICATION: The findings were discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 3:52 am, 5 minutes after discovery of the findings. CHEST (PRE-OP PA AND LAT) showed Compared to chest radiographs one ___. Patient has had median sternotomy. Heart size is normal. Lungs are clear. Mediastinal and hilar contours and pleural surfaces are normal. The patient was diagnosed with Other and unsp ventral hernia with obstruction, w/o gangrene. The patient was treated with ventral herniography w/ mesh. At the time of discharge, the patient had RECURRENT INCISIONAL HERNIA WITH 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 was admitted to the General Surgical Service for evaluation and treatment on ___. On (.___.), the patient underwent ventral hernia repair w/ mesh, 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, on IV fluids. The patient was hemodynamically stable. Neuro: The patient received IV morphine with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. 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 spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. on ___ and 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>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ ___ speaking man with a history of CAD (s/p DES to ___ at ___ ___ and DES to LCX and LMCA into bifurcation of LAD and LCX in ___ ___, severe AS, who presents with worsening chest pressure on exertion for the past few days. Carotid Doppler Ultrasound showed Mild bilateral heterogeneous plaque within the extracranial internal carotid arteries. No significant stenosis bilaterally (less than 40%). The patient was diagnosed with Chest pain, unspecified, Dyspnea, unspecified. At the time of discharge, the patient had Primary Diagnosis: - Severe Aortic Stenosis Secondary Diagnosis: - Coronary Artery Disease - Chronic Kidney Disease - Atrial Fibrillation - 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>This is a ___ ___ speaking with a history of CAD (s/p DES to ___ at ___ ___ and DES to LCX and ___ into bifurcation of LAD and LCX in ___ ___, severe AS, who presents with worsening chest pressure on exertion for the past few days. # Chest pressure: The patient presents with worsening chest pressure on exertion, concerning for unstable angina or symptoms from severe AS. Troponin negative x2. BNP is elevated to 2991 but we have no recent baseline. He was diuressed with 20mg IV lasix and then transitioned to his home dose. His symptoms were likely due to his severe aortic stenosis. Cardiac surgery was consulted for evaluation of aortic valve replacement. They recommended initial studies, including carotid artery ultrasound and several lab tests which are pending at time of discharge. He was doing well and discharged in stable condition. He was continued on aspirin, imdur, and statin. His plavix was held in anticipation of upcoming surgery. He will follow-up with Cardiac Surgery next week. # Lower Extremity Ddema: He has bilateral lower extremity edema, which per report is chronic. ___ negative for DVT. # Chronic Kidney Injury: Cr currently 1.6, from baseline per Atrius records 1.4-1.5 # Atrial fibrillation on Coumadin: Continued atenolol and coumadin. # Hypertension: Normotensive now. On atenolol and losartan at baseline. # BPH: Continued doxazosin. ====================</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with left spastic hemiparesis from a stroke in ___ who presented s/p mechanical fall this morning. Radiology showed No acute fracture. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the lung volumes have decreased. Areas of atelectasis are seen at the right lung basis. However, there is no evidence of pneumonia or pulmonary edema. No larger pleural effusions. Normal size of the cardiac silhouette. Normal hilar and mediastinal contours. MR ___ SPINE W/O CONTRAST showed Acute compression fracture of the L1 vertebral body with mild retropulsion of the dorsal cortex into the spinal canal causing mild to moderate narrowing of the thecal sac, but no compression of the conus medullaris. Radiology showed Mild pulmonary edema, increased from prior study. Radiology showed Chronic occlusion of the right proximal ICA with reconstitution in the distal ICA as well as the intracranial segment which is small and thread-like in caliber. No acute infarction. Radiology showed 1. No evidence of hemorrhage in the chest, abdomen, or pelvis. 2. Moderate emphysema. 3. Multiple pulmonary nodules, the largest which measures 6 mm. Recommend a repeat chest CT in 6 months. 4. L1 compression fracture, better evaluated on the recent MRI. 5. Probable median arcuate ligament syndrome. Recommend correlation with symptoms. MRI and MRA Head, MRA of the neck. showed 1. Chronic infarction, causing extensive area of encephalomalacia involving the right middle cerebral artery territory as described in detail above, causing encephalomalacia, ex vacuo dilatation of the lateral ventricle, and asymmetry of the right cerebral peduncle. 2. Occlusion of the right proximal internal carotid artery, with collateral flow via the external carotid artery and right posterior communicating artery. No aneurysms are identified. Radiology showed No evidence of DVT in the bilateral lower extremities. The patient was diagnosed with FX LUMBAR VERTEBRA-CLOSE, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT. At the time of discharge, the patient had L1 compression fracture Right temporal epileptiform discharges Multiple pulmonary nodules. 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 ___ y/o M s/p mechanical fall presents with L1 compression fracture. He was admitted to neurosurgery for further management. A TLSO brace was ordered and was measured for brace. On ___, TLSO arrived. He had low urine output and a 500cc bolus was given. ___ was consulted as well. On ___, patient was neurologically stable on examination in the AM. MRI L-spine was completed and showed PLL injury. TLSO brace was ordered to be worn when HOB>30 degrees and when OOB. He developed hypotension with a systolic of 88, 500cc bolus was given. He continued to be hypotensive with a systolic 69. He was placed in reverse Trendelenburg and began to desaturate. He also became dysarthric and lethargic. His O2 was increased to 5L. ABG was performed and was normal. Labs were sent and showed significant decrease in hct and plt count. Medicine was consulted. CXR was performed and showed some congestion. He was given an additional liter of fluid for continued hypotension. Neuro stroke was consulted for concern of stroke. Medicine recommendations were to transfer patient to the ICU and obtain CTA head, neck, chest, abdomen, and pelvis. Hematology was consulted for question of HIT. SQH and aspirin were held. He was transferred to the ICU after CTAs were preformed. Repeat labs showed improvement in hct and plt. He was restarted on SQH and aspirin given the erroneous labs and decreased risk of HIT. Neuro stroke recommended EEG, tegretol and lamictal levels, and discontinuing antihypertensives. On ___ Patient was normotensive and O2 sats were WNL. He was neurologically stable. Patient was transferred to the floor with telemetry. CXR revealed minimal pulmonary edema and some atelectasis at the lung bases. BLE dopplers revealed no evidence of DVT in the bilateral lower extremities. On ___ routine EEG shows L temporal periodic discharges. Patient was loaded with Keppra 1g then started on 750mg BID. On ___ EEG positive for epileptiform discharges, but no active seizures. Keppra was increase to 1000mg BID. EEG lead were removed. On ___, ___ evaluated the patient and was unable to work with him due to back pain. His pain regimen was increased. On ___, patient was unchanged. He had a positive U/A and was started on cipro. Mr. ___ was discharged to a rehabilitation facility on ___. As discussed in the discharge summary paperwork, the patient should follow up with Neurosurgery, Neurology and his PCP. Because of new-found pulmonary nodules on a chest CT, radiology recommended that he have follow-up screening by his PCP in approximately ___ months. At the time of discharge, Mr. ___ was afebrile, hemodynamically and neurologically stable.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old man with known peripheral arterial disease noticed an ulcer on his right second toe that progressively had became more painful, black and swollen. He presents to the ER for evaluation. Radiology showed No radiographic evidence of osteomyelitis. Radiology showed Evidence of right ileo-femoral and left femoral-popliteal occlusive disease with severe ischemia VENOUS MAPPING showed Patent cephalic and basilic veins bilaterally with small diameters. Please see the scanned vascular worksheet for a detailed diameters. VENOUS MAPPING showed The great and small saphenous veins are patent bilaterally. Please see digitized image on PACS for formal sequential measurements. CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS showed Diffuse atherosclerotic disease involving the abdominal aorta, iliac arteries and lower extremity runoff as described above. Heavy atherosclerotic calcifications cause stenosis and eventual occlusion of the superficial femoral arteries to the level of the popliteal arteries bilaterally. The popliteal arteries are difficult to identify due to bilateral total knee replacements.Though extensive atherosclerotic disease and multiple areas of stenoses, the three vessel runoff appears on the left, two vessel runoff on the right. The patient was diagnosed with CIRCULATORY DISEASE NEC. At the time of discharge, the patient had Peripheral Arterial Disease with ulceration. 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 man with known peripheral arterial disease noticed an ulcer on his right second toe that progressively had became more painful, black and swollen. He presents to the ER for evaluation. As right ___ pulses were not dopplerable, we obtained ABI/PVR which showed the femoral and popliteal waveforms are monophasic and the posterior tibial and dorsalis pedis Doppler waveforms are absent at the ankle. Metatarsal waveforms are flat. Further workup showed no evidence of osteo in the right second toe. He did not require pain medication and had no systemic infection with normal temp and wbc. Vein mapping showed excellent RLE conduit for bypass. Given these finding we will discharge him to home to return for angiogram within the next week secondary to no OR availability. He was discharged to home with family, ambulatory at baseline with a cane on all home medication. We will start him on bactrim prophalaxtically for the next week until angiogram scheduled for ___. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo ___ speaking female presents with lower back and neck pain with associated bilateral hand numbness. She is currently displaced from ___ due to the hurricane. She says that during the hurricane, she was using a bucket to try to get water out of her house when she strained her back and her lower back pain got much worse. Since that time she says she has had to sleep sitting up because of the pain. The pain does not radiate down from her back and she denies any radicular symptoms of the bilateral lower extremities. She is also having numbness of both hands, R > L but is currently denying neck pain. She says the neck pain has basically resolved. Her hand numbness is isolated to her hands and is generalized, without specific finger distribution. No bowel or bladder incontinence. Otherwise denies gait instability, loss of dexterity, change in handwriting, tripping, falling, dizziness, vision changes, chest pain, shortness of breath, nausea or vomiting. MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE. showed 1. Severe compression fracture of the T7 vertebral body, likely subacute and without significant retropulsion. 2. Acute appearing, severe compression fracture of L1 with mild bony retropulsion causing mild canal stenosis. No evidence for epidural collection, hematoma, or abnormal enhancement. 3. Posterior disc bulges at C5-6 and C6-7 resulting in moderate canal stenosis. 4. Multiple additional levels of background spondylosis throughout the cervical, thoracic, and lumbar spine, as detailed above. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:11 am, 20 minutes after discovery of the findings. Radiology showed 1. No findings of primary malignancy or metastatic disease in the abdomen or pelvis. 2. Incidental findings such as 5 cm simple appearing right adnexal cyst and endometrial thickening versus fluid in the endometrial cavity. Consider pelvic ultrasound. 3. Redemonstration of thoracolumbar compression fractures, better assessed on recent MRI of the spine. CT CHEST W/CONTRAST showed 9 mm right upper lobe nodule is suspicious for malignancy given the presence of right hilar and mediastinal lymphadenopathy. Options for follow-up include an FDG PET-CT now or repeat chest CT in 3 months. Attention should also be paid to a 6 mm left upper lobe nodule on follow-up imaging. Mild pulmonary edema. Compression fracture of the T7 vertebral body with 50% height loss is more completely assessed on thoracic spine MRI of ___. No additional fractures in the thoracic spine or rib cage. 10 mm left breast nodule is incompletely evaluated on this study. Recommend mammography if it has not been recently performed. Please see the separately dictated CT abdomen and pelvis report from the same date for description of subdiaphragmatic findings. RECOMMENDATION(S): FDG PET-CT now or chest CT in 3 months for continued assessment of 9 mm right upper lobe pulmonary nodule. Mammography if it has not been recently performed. PELVIS, NON-OBSTETRIC showed 1. Simple appearing fluid in the endometrium suggesting cervical stenosis. No endometrial thickening. 2. 5.4 cm simple appearing right adnexal cystic lesion. RECOMMENDATION(S): Follow-up pelvic ultrasound in ___ year to assess right adnexal cystic lesion. The patient was diagnosed with Low back pain. At the time of discharge, the patient had T7 and L1 Compression Fracture Lung nodule Breast nodule Vitamin D deficiency. 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 history of compression fracture in ___ presented with nontraumatic worsening lower back pain found to have compression fractures of L1 and T7, and possible malignant masses on CT torso. # L1 acute compression fracture: # T7 subacute compression fracture: Patient with known T7 compression fracture from earlier this year presenting with a nontraumatic L1 compression fracture. Given the lack of trauma there was concern for a pathologic fracture due to either malignancy or osteoporosis. CT torso was pursued which showed small nodules of the right upper lobe, left upper lobe and left breast along with mediastinal lymphadenopathy together concerning for malignancy. Interventional pulmonology was consulted who recommended PET CT first. Notably vitamin D levels were low, patient was possibly on vitamin D and calcium supplementation in ___ though she denies imaging/DEXA scans in the past. She was fitted with TLSO brace with marked improvement in pain after ___ evaluation and treatment. No focal neurologic deficits developed during the hospital course. Follow-up was arranged with PCP to organize PET/CT as well as DEXA scan for workup of possible pathologic fracture. # Concern for malignancy: As noted above hilar adenopathy, lung lesions and breast lesions were noted. Otherwise no endometrial thickening, labs were not suggestive of malignancy. Patient denied weight loss. Follow-up was arranged with PCP to continue the workup. # Hypertension: Patient is a history of hypertension and she was continued on her home medications without marked periods of hypertension or hypotension. ====================</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with Diabetes, CHF, COPD, CAD status post CABG (per the patient's daughter), GERD, gout, fibromyalgia, CKD who presents with right ankle fracture dislocation. There are 2 transverse lacerations approximately 5 cm above the medial malleolus. It is difficult on exam to tell if these probes deeply and communicate with the fracture. She was given Ancef in the ED and tetanus was confirmed. She underwent closed reduction with propofol sedation. this injury will require surgical fixation. Right ankle radiographs, three views. showed Status post reduction. Q61R showed 1. Trimalleolar ankle fracture, minimally displaced although imaging is performed in a cast. 2. Small bony fragments along the anterolateral aspect of the tibial plafond and highly suspicious for disruption of the anterior tibiofibular ligament. 3. Evidence of remote sprains of the posterior tibiofibular and deltoid ligaments. 4. Diffuse soft tissue swelling. 5. Extensive vascular calcification. ANKLE (AP, LAT AND OBLIQUE) IN O.R. RIGHT showed Intraoperative images were obtained during internal fixation of the tibial and fibular fractures. Please refer to the operative note for details of the procedure. CHEST (PORTABLE AP) showed No previous images. There are low lung volumes that accentuate the prominence of the transverse diameter of the heart. Relatively mild pulmonary vascular congestion. No evidence of acute focal consolidation. Intact midline sternal wires following apparent CABG procedure. CHEST (PORTABLE AP) showed In comparison with the study ___, there are slightly improved lung volumes. Continued substantial enlargement of the cardiac silhouette with some increase in engorgement of indistinct pulmonary vessels consistent with elevated pulmonary venous pressure. The left hemidiaphragmatic contour is no longer seen, suggesting a combination of pleural fluid and volume loss in the left lower. The patient was diagnosed with Oth fx upper and low end r fibula, init for opn fx type I/2, Fall same lev from slip/trip w/o strike against object, init. The patient was treated with Status post right ankle I&D/open reduction internal fixation ___, ___. At the time of discharge, the patient had Right open ankle 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 open ankle fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for I&D as well as open reduction internal fixation of right ankle, 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 ___ anticoagulation per routine. While inpatient, the patient was continued on IV Ancef for prophylaxis against surgical site infection. This was converted to p.o. Keflex at discharge. Pain control was somewhat of an issue during this hospitalization. The patient reported poor pain control and on ___ her narcotic pain regimen was increased slightly. At this time the patient had a spell where she stared blankly forward for roughly 1 minute as witnessed by her family members. Her family was concerned about a possible seizure and neurology was consulted. Neurology was not concerned for a seizure and recommended no further workup. They suggested the patient follow-up in neurology clinic as desired. The pain service also saw the patient after this event and suggested achieving pain control through gabapentin and Flexeril in addition to Tylenol and, if needed, oxycodone used sparingly. With this regimen, her pain was well controlled. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact. She did have some difficulty with urination postoperatively. She was straight cathed multiple times and ultimately a Foley was placed. A trial of removal of this Foley should occur in ___ days. The patient is NWB in the right extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ year old man with a PMHx s/f CAD, lung cancer, and prostate cancer who presented to his PCP's office with 2 months of worsening angina and shortness of breath. He states that for the last 2 months he has had worsening exertional non-pleuritic chest tightness. The pain worsens with activity, and improves with rest. It has been worsening in its duration, whereas previously the pain would improve in several minutes, over the last several days the pain has taken several hours to improve. He has not used nitroglycerin for the pain. . Mr. ___ also notes anorexia and dramatic weight loss of 60 lbs. over 60 days. Upon review of his flowsheets however, he has only lost 6 lbs over 60 days. He also espouses occassional "shaking in the face", as well as constipation. ROS is also positive for dysuria. . In the ED, initial VS were 96.7 47 142/67 16 99% RA. CXR was significant for left upper lung linear opacity and worsening of RLL opacity. Troponins were negative x 1. He was given levofloxacin, and 1L NS. . ROS: per HPI, denies fever, chills, night sweats, rhinorrhea, congestion, sore throat, cough, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena, hematochezia, hematuria. Radiology showed 1. Left upper lung linear opacity may represent lingering/residual pneumonia or an area of bronchiectatic inflammation - reimaging after treatment may be considered. 2. Increase in right lower lung nodule size; reimaging with nipple markers may be considered. Findings were posted to the Critical Results Dashboard at 15:11 on ___ by ___ The patient was diagnosed with CHEST PAIN NOS, WEIGHT LOSS, ABNORMAL, PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSION NOS, DIABETES UNCOMPL ADULT, CAD UNSPEC VESSEL, NATIVE OR GRAFT. The patient was treated with Catheterization with drug eluting stent placement. At the time of discharge, the patient had Coronary Artery Disease Depression Prior Lung Cancer, in remission Prior Prostate Cancer s/p prostectomy. 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 an ___ year old man with a past medical history significant for CAD, lung cancer, and prostate cancer who presented to his PCP's office with unstable angina. . ACTIVE ISSUES # Unstable Angina: Initially there was concern for unstable angina versus NSTEMI given 1 week of chest pain. There were no EKG changes concerning for STEMI, and no troponin elevations so unstable angina was diagnosed. Although levofloxacin was given in the ED, in the floor we doubted pneumonia given lack of clinical findings concerning for pneumonia (no cough, sputum production, fever, pleuritic chest pain) and CXR findings are not very impressive; LUL infiltrates may correspond to prior area of radiation. Positive stress test on ___ by EKG, but no areas of ischemia on nuclear imaging possibly consistent with balanced ischemia. Cardiac cath was performed on ___ which demonstrated restenosis in the BMS in the proximal LAD. A DES was placed in the mid LAD. The post-procedure course was notable for significant improvement of his chest pressure. He continued to complained of intermittent atypical chest pains not accompanied by EKG changes or cardiac enzyme elevations and relieved by maalox. Pt was seen by ___, who recommended rehab. . # Thrombocytopenia: Given quick onset < 48 hours after initiation of heparin, likely HIT type I (benign non-antibody mediated, self-resolving) vs. volume mediated. Upon discharge platelet count was 133. . CHRONIC ISSUES # Depression/Bipolar: Lithium was continued. . # Failure to thrive/Anorexia: Differential included worsening depression, malignancy, CAD, and indolent infection. Doubt malignancy given that Mr. ___ was recently deemed to be in total remission per Dr. ___. Pt was HIV negative. Nutrition consult recommended encouragement of Glucerna shakes. . TRANSITIONAL ISSUES # CODE STATUS: DNR/DNI # MEDICATION CHANGES: none # FOLLOW UP PLAN: - Gerontology appt on ___ - Cardiology appt with Dr. ___ on ___</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with a history of hypertension, paroxysmal atrial fibrillation (on home anticoagulation), pacemaker for tachybrady syndrome, and peripheral vascular disease, who is presenting with fever and sore throat for three days. Patient first noted an "ache" in her mouth and right side of her neck 3 days ago. She was also having subjective fevers and difficulty swallowing. No difficulty breathing. She first presented to her doctor yesterday, who prescribed her an unknown antibiotic. However, she developed increased neck swelling overnight, and so presented to the ED. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed 1. Sialadenitis involving the right ___ duct and submandibular gland with reactive lymphadenopathy and substantial adjacent inflammation extending into the right sublingual space, parapharyngeal space (including right infratemporal fossa), and carotid space without an organized fluid collection identified. Inflammatory change extending into the right sublingual space raises the possibility of Ludwig's angina. No definite involvement of the retropharyngeal space. 2. No definite enhancing confluent fluid collection. CHEST (PORTABLE AP) showed Right sided PICC tip in the mid SVC. No pneumothorax. The patient was diagnosed with Sialoadenitis, unspecified. The patient was treated with Bedside ENT scope ___. At the time of discharge, the patient had Primary Diagnosis: - Sialadenitis and sialolith Secondary Diagnosis: - Atrial Fibrillation - 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>SUMMARY: Ms. ___ is a ___ woman with a history of hypertension, paroxysmal atrial fibrillation (on home anticoagulation), pacemaker for tachybrady syndrome, and peripheral vascular disease, who is presenting with fever and sore throat for three days, now in the ICU for airway monitoring given concern for Ludwig's angina. # Submandibular swelling: Patient presented with right submandibular gland sialadenitis with 2 stones in Wharthin's duct. There was initial concern for Ludwig's Angina. ENT was consulted and evaluated the patient. Bedside scope was performed which showed airway edema. She was given dexamethasone 10mg, started on unasyn (d1 = ___. Per ENT recs she was given warm compresses, firm salivary gland massage, and sialogogues. Her swelling quickly improved. She improved and was discharged home with a 10-day course of augmentin. # Leukocytosis: Patient presented with a WBC of 16. Most likely related to siladenitis as above. Patient had no other localizing symptoms and other studies were not concerning for UTI or PNA. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ otherwise fairly healthy presenting after fall onto right side today. She was walking her dog when there was a sharp tug on the leash causing her to lose her balance and land on the right side. Immediate onset of pain and inability to bear weight. No numbness, tingling, no head strike. The patient denies LOC, premonitory symptoms and ROS is otherwise at baseline. HIP NAILING IN OR W/FILMS AND FLUORO RIGHT IN O.R. showed As above. The patient was diagnosed with INTERTROCHANTERIC FX-CL, OTHER FALL, ACTIVITIES INVOLVING WALKING AN ANIMAL, HYPERTENSION NOS. The patient was treated with Open reduction and internal fixation of right intertrochanteric femur fracture with TFN- ___. At the time of discharge, the patient had Right intertrochanteric 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>Ms. ___ presented to the ___ emergency department on ___ and was evaluated by the orthopedic surgery team. The patient was found to have right intertrochanteric femur fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF right hip fracture with TFN, 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 rehab 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 weight-bearing as tolerated in the right lower extremity, and will be discharged on subcutaneous heparin 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: ___ is a ___ F w/ hx of COPD, DM and hypothyroidism who presents with 1 day of dyspnea and hemoptysis. CHEST (PA AND LAT) showed Abnormal increased parenchymal opacification of the right upper and middle lobes. Main differential considerations include multifocal infection and/or hemorrhage. RECOMMENDATION(S): Follow-up imaging is appropriate depending on clinical circumstances to show resolution of opacities within about 8 weeks. Otherwise, chest CT should be considered. CT CHEST W/O CONTRAST showed 1. Extensive centrilobular ground-glass opacities and consolidations in both lungs, likely represent multifocal infection and/or alveolar hemorrhage. Lymphatic involvement of the lungs is considered less likely. 2. Extensive lymphadenopathy throughout the chest and imaged upper abdomen is consistent with history of B-cell lymphoma. 3. Mild fluid overload with small right pleural effusion and small pericardial effusion. 4. 1.7 x 2.2 cm right adrenal adenoma. 5. 1.4 cm right posterior hepatic lobe hypodensity, potentially a cyst or hemangioma, but incompletely characterized. Comparison with prior imaging is suggested, and if none available, an ultrasound can be obtained for further assessment. BILAT LOWER EXT VEINS showed 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. 2. Enlarged bilateral inguinal lymph nodes compatible with known history of lymphoma. RENAL U.S. showed 1. Normal renal ultrasound. No evidence of masses, renal calculi or hydronephrosis.. 2. Small bilateral pleural effusions, right greater than left. CHEST (PORTABLE AP) showed 1. Significant worsening of known pulmonary hemorrhage. Superimposed infection cannot be excluded on the basis of this examination. 2. Small left pleural effusion is likely. DX CHEST PORTABLE PICC LINE PLACEMENT showed 1. Tip of left PICC projects over the cavoatrial junction. 2. Similar radiation with redemonstration of bilateral airspace opacities, similar to the prior study. CHEST (PORTABLE AP) showed Improvement of bilateral diffuse opacities. Radiology showed Successful placement of a double lumen chest power Port-a-cath via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. The patient was diagnosed with Hemoptysis. At the time of discharge, the patient had PRIMARY DIAGNOSIS ================ ___ vasculitis Mantle cell lymphoma SECONDARY DIAGNOSIS =================== Acute hypoxic respiratory failure Paroxysmal atrial fibrillation ___ ventricular tachycardia Chronic obstructive pulmonary disease Type II Diabetes Mellitus, insulin dependent 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>SUMMARY ======= Ms. ___ is a ___ female with COPD, DMII, and hypothyroidism who presented with dyspnea and hemoptysis, diagnosed with ___ ANCA vasculitis (positive MPO antibody), diffuse alveolar hemorrhage, and mantle cell lymphoma. Her hospital course was complicated by acute hypoxic respiratory failure and ___ from vasulitis. She was started on high dose steroids and received Cytoxan/rituximab (___) for both her vasculitis and lymphoma, and was stable on room air by time of discharge. ACUTE ISSUES ============ # ___ Vasculitis # Hemoptysis Patient initially presented with one day of hemoptysis. Initial work up notable for CXR and CT chest showing diffuse alveolar hemorrhage vs multifocal infection. Given lack of systemic symptoms (including leukocytosis or fever) or concerning for infection, this was presumed to be alveolar hemorrhage, which also fit with her recent hemoptysis. Interventional pulm was consulted but pt was deemed a poor candidate for bronchoscopy d/t diffuse nature of pulmonary hemorrhages. Given concurrent ___ and recent epistaxis, vasculitis was considered as etiology of hemoptysis, and vasculitis labs were sent. Work up notable for CRP 170, ANCA positive, and myeloperoxidase Ab positive (>8) consistent with ___ vasculitis. Proteinase 3 Ab negative, C3/C4 normal, HIV negative, ___ negative, ___ negative, and ___ Abs negative. IgG and IgM returned at 1478 and 60 respectively. Rheumatology, nephrology and pulmonology were consulted and provided assistance with management. She was given 1000mg methylpred daily for 3 days followed by prednisone 80mg/kg. Given concurrent hematologic malignancy, pt was transferred to ___ service for further management. Her vasculitis was thought to be a paraneoplastic workup related to her mantle cell lymphoma, and she was started on cyclophosphamide, rituximab, and prednisone 100mg daily for treatment. Following her course of cyclophosphamide and rituximab, she was continued on 80mg prednisone daily with taper per rheumatology. Her symptoms, including hemoptysis and shortness of breath improved with treatment. Additionally, her kidney function improved and she was weaned to room air. She will follow up with heme/onc, rheumatology and nephrology for further management. #Mantle Cell Lymphoma Diffuse lymphadenopathy was initially discovered on CT chest at ___, and seen again on repeat CT at ___. A lymph node biopsy from ___ showed mantle cell lymphoma. Her G6PD was normal, and she had neg HIV/Hep on workup. On ___, a PICC was placed, and she was started on rituximab/cyclophosphamide, and given 100mg prednisone for 4 days (she received 80mg prednisone on D1). She was also started on atovaquone for PCP ppx, ___ 500mg q48h (renally dosed)(switched to azithromycin on ___, and allopurinol, renally dosed at 100 mg qd. Her PICC was replaced with a ___ port on ___. She will follow up in ___ clinic for further management. #Acute hypoxic respiratory distress iso DAH, vasculitis #COPD Hospitalization complicated by acute hypoxic respiratory failure requiring increasing doses of supplemental oxygen, up to 6L NC and shovel mask, with occasional desaturations into the ___. These episodes typically resolved with deep breathing. She was treated with steroids and chemotherapy as above. Additionally, she received IV Lasix, duonebs q6h and albuterol nebs prn. Pulmonary was consulted, recommended adding azithromycin 250mg MWF and acapella TID. Her O2 requirement decreased throughout her stay and she was on room air by discharge with stable saturations during ambulation. #New onset paroxysmal atrial fibrillation #NSVT On ___ AM, she noted heart palpitations and increased trouble breathing. She was found to be in atrial fibrillation on telemetry and EKG for about 15 minutes. She responded to IV 5mg bolus of metoprolol, and returned to ___ without symptoms. She was continued on telemetry for the next week without recurrent afib. Etiology felt to be ___ acute illness. Anticoagulation and nodal blockade were deferred given lone episode with obvious trigger and concern for developing thrombocytopenia. Additionally, on ___ AM, she had a 20 second run of NSVT with symptoms. Her electrolytes were repleted. EKG showed no acute ischemic process. She remained in NSR for the duration of her stay. #Anemia In ED, pt H/H 7.3/24.2, but on following H/H had dropped below 6, she received 2 units pRBCs with good response and H/H remained stable. Anemia was presumed ___ hemoptysis/diffuse alveolar hemorrhage, but given resolution of hemoptysis, H/H remained stable through stay on floor prior to transfer to ___ service. While with BMT, we administered blood products as needed. Her discharge Hgb was 7.4, and she was transfused 1u pRBC prior to discharge. ___ In ED, Cr 2 from a baseline of 0.8. Elevated Cr similar to presentation at ___ one week prior. No hx of kidney disease. Initial ___ included UA showing proteinuria, hematuria, 31 WBC, hyaline casts. Renal U/S normal. Initially presumed ___, given IVF, but pt had concurrent pulmonary symptoms and recent epistaxis. With concern for systemic vasculitis, rheumatology and nephrology consulted. Work up notable for vasculitis as described above. Renal biopsy was considered, but given tenuous clinical picture and positive diagnosis by ANCA, was deferred. Nephrology agreed with rheumatology and heme/onc plan to start high dose steroid course for 3 days. Medications were renally dosed and nephrotoxic medications, including NSAIDS, were held. She was also diuresised with furosemide prn as above. Her Cr continued to improve during her stay and was 1.6 at time of discharge. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ s/p mechanical fall, fell off of a 3 foot platform while painting in his house and struck his forehead. Occurred 2 days ago. Has had persistent neck pain since that time. Radiology showed 1. No acute intracranial process. 2. Non-displaced midline frontal bone fracture with blood in the frontal, maxillary and sphenoid sinuses. A maxillofacial CT has been suggested for further evaluation of these and any additional facial fractures. NOTE ADDED IN ATTENDING REVIEW: There is no intra- or extra-axial hemorrhage or evidence of cerebral edema. No pneumocephalus is seen. Radiology showed 1. Displaced type II fracture of the odontoid process, with 4 mm anterior displacement of the distal dens fragment, but no spinal canal compromise. 2. ___ burst fractures of the anterior and posterior neural arches of C1, again without canal compromise. 3. Multilevel degenerative disease with foraminal but no "critical" canal stenosis. Radiology showed Re-demonstration of non-displaced midline frontal bone fracture and C1 ___ burst fracture. No additional fractures. Extensive fluid and air in the maxillary and sphenoid sinuses may represent the sequela of acute sinusitis or additional blood. Radiology showed No acute intrathoracic process. The patient was diagnosed with FX C2 VERTEBRA-CLOSED, FALL-1 LEVEL TO OTH NEC, FX C1 VERTEBRA-CLOSED, CLOSED SKULL VAULT FX, HYPERTENSION NOS, DIABETES UNCOMPL JUVEN. The patient was treated with Anterior odontoid screw fixation. At the time of discharge, the patient had Type 2 Dens fracture. Undisplaced ___ fracture Frontal bone 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>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#1. Physical therapy was consulted for mobilization OOB to ambulate. Plastic surgery was consulted for frontal bone fractures. They did not recommend any further intervention or follow-up for your fractures. 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 F with DM, COPD, peripheral vascular disease with claudication and polymyalgia rheumatica presenting with right sided chest pain. CHEST (AP AND LAT) showed Emphysema, left mid lung atelectasis. Please refer to subsequent CTA chest for further details. Radiology showed Degenerative changes without acute fracture or dislocation. CT HEAD W/O CONTRAST showed No acute intracranial abnormalities. CT C-SPINE W/O CONTRAST showed 1. No acute cervical spine fractures identified. Moderate to severe degenerative changes seen throughout the cervical spine. 2. Partial atelectasis of the left upper lobe is better evaluated on the dedicated CT of the chest performed on the same day. CTA chest. showed 1. No evidence of a pulmonary embolism or aortic abnormality. 2. New partial atelectasis of the left upper lobe, is likely secondary to bronchial impaction. A superimposed infectious process cannot be excluded. 3. New 6 mm nodule in the left lower lobe (3;98). A six-month followup is recommended for further evaluation. The patient was diagnosed with CHEST PAIN NEC, RESPIRATORY ABNORM NEC. At the time of discharge, the patient had 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>___ yo F with DM, COPD, peripheral vascular disease with claudication and polymyalgia rheumatica presenting with right sided chest pain. # Right-sided Chest Pain: On exam, pain is reproducible with movement and palpation. Presentation likely due to costochondritis. No evidence of ACS or pericarditis given unremarkable EKG and cardiac biomarkers. CXR notable for L-sided atelectasis. CTA negative for PE. No dermatomal rash to suggest Zoster. She was managed with Tylenol, lidocaine patch, and continued on her hme oxycodone. NSAIDs were avoided given CKD. The patient had mild improvement in her symptoms at the time of discharge. She was discharged with Lidocaine patches for her pain. # Pneumonia: Exam most notable for inspiratory crackles at RLL, dyspnea, and increased sputum production concerning for pneumonia. Initial labs most notable for leukocytosis to 15. Patient recently hospitalized in ___, patient meets criteria for HCAP. Chest CT notable for pulmonary nodules with atelectasis concerning for possible post-obstructive pneumonia. The patient received IV Ceftriaxone in the ED. The patient was subsequently transitioned to Augmetin 875 mg PO BID x 10 days.</s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male has ETOH cirrhosis complicated by varices, ascites, SBP on cipro prophylaxis, listed for liver txp with MELD 30, GAD, OA of bilateral hips s/p right THR (___) presenting for hyponatremia iso recent decrease in diuretic dose. Multiple recent admissions for hyponatremia and volume overload, most recently last week. His labs from ___ came back with sodium 124 and we recommended he come into the ED but he declined, wanted to see his liver doctor ___ in clinic today. At clinic, repeat sodium was 123, so they sent him to the ED. In the ED, sodium worsened to 117, has been improving (now ___ with diuresis. Per renal team, volume overloaded, so now diuresing. No pocket of ascites to target on bedside U/S per ED. CHEST (PA AND LAT) showed 1. Possible right lower lobe pneumonia. 2. Mild enlargement of the cardiac silhouette and previously noted mild pulmonary edema are improved from ___. NOTIFICATION: The findings were discussed with ___ Resident ___, by ___, M.D. on the telephone at 08:00 immediately following discovery of the findings. IMPRESSION: 1. No pneumonia. 2. Mild enlargement of the cardiac silhouette and previously noted mild pulmonary edema are improved from ___. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic liver with splenomegaly. No ascites. 2. Patent portal veins, although there is slow flow in the right posterior portal vein and reversed direction flow in the left portal vein. CHEST (PORTABLE AP) showed In comparison with the study of ___, the questioned increased opacification at the right base is no longer seen. There is the vague suggestion of some increased opacification at the left base. This could merely represent atelectatic changes, though in the appropriate clinical setting a developing aspiration could be considered. Cardiomediastinal silhouette is stable. There is minimal indistinctness of pulmonary vessels that could represent mild elevation in pulmonary venous pressure. No evidence of pleural effusion. CT CHEST W/CONTRAST showed No evidence of metastasis to the chest. Moderate-sized hiatus hernia. Paraesophageal varices. Evidence of cirrhosis with portal hypertension. Multiple collaterals within the upper abdomen. Ill-defined hypodense lesion within the right lobe of liver has been better characterized by an MRI done on ___. CT HEAD W/O CONTRAST Q111 CT HEAD showed No evidence of acute intracranial abnormality identified on noncontrast head CT. The patient was diagnosed with Hypo-osmolality and hyponatremia. The patient was treated with Teeth extraction with OMFS. At the time of discharge, the patient had Primary Diagnosis ================= Hyponatremia Secondary Diagnosis =================== ETOH Cirrhosis c/n varices Tooth Infection Insomnia Chronic 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 SUMMARY =============== ___ year old male has ETOH cirrhosis complicated by varices, ascites, SBP on cipro prophylaxis, listed for liver txp with MELD 30, GAD, OA of bilateral hips s/p right THR (___) presenting for hyponatremia. His tolvaptan dose was uptitrated to 30mg daily with stabilization of serum Na. He maintained euvolemia on this dose of Tolvaptan without any other diuretics and thus his home diuretics were held on discharge. </s>
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ y/o male with htn, dementia, hypothyroidism, referred from admission after his NH found blood in toilet - ? if from stool or urine so they sent him to the emergency room. He was found to be retaining urine in ___ staff reported to RN that over past 3 weeks he has been much more confused, is eating less and has lost 25 lbs. CHEST (PA AND LAT) showed No previous images. There is hyperexpansion of the lungs suggesting underlying chronic pulmonary disease. Enlargement of the cardiac silhouette with left ventricular prominence and dense calcification in the descending thoracic aorta. No evidence of pulmonary vascular congestion, pleural effusion, or acute focal pneumonia. Surgical clips are seen in the region of the left breast. CT HEAD W/O CONTRAST Q111 CT HEAD showed There is no definite evidence of subacute infarcts, although, underlying moderate to severe chronic small vessel ischemic changes decreased sensitivity of this exam in detecting deep white matter subacute infarcts. There is generalized brain parenchymal atrophy. 2 subtle foci of abnormality in the anterior frontal lobes are likely an artifact. Paranasal sinus disease, as above. BILAT HIPS (AP, LAT, AND PELVIS) 5 OR MORE VIEWS showed No fractures. Degenerative changes bilateral hips. No worrisome osseous lesions. The patient was diagnosed with Hematuria, unspecified, Acute kidney failure, unspecified. The patient was treated with CBI in ED. At the time of discharge, the patient had Hematuria with 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>___ h/o hematuria & urinary retention h/o remote prostate cancer, dementia with significant decline 1 month ago, HTN, and hypothyroid was sent from ___ for hematuria noted to have poor PO appetite and 25 pound weight loss over the past month. 1. Hematuria with urinary retention h/o prostate cancer -Foley placed in ED for retention (?obstruction from mass/prostate vs blood clots) with mention of pyuria however urine culture without growth and antibiotics not continued. Attempted to remove foley ___ but patient developed bleeding and significant pain and it was left in. Foley was removed successfully ___, and patient able to void without retention noted on bladder scans. -Hematuria is concerning for malignancy especially in setting of h/o prostate cancer; sister notes prostate cancer about ___ years ago treated with radiation ?+/-surgery, but I do not have access to these records. He had seen a urologist before, but she does not believe he sees one anymore. At this point sister (HCP) with support from her daughter-in-law who is a hematologist they would like to see urology and likely pursue cystoscopy. This will be done as an outpatient. 2. ___ vs CKD Due to paucity of records unknown baseline Creatinine. Creatinine stable at 1.3. 3. Microcytic anemia -Due to paucity of records unknown baseline hemoglobin with differential of anemia including hematuria vs underlying malignancy. This can be followed outpatient. 4. Dementia ___ Alzheimer's with dementia workup unrevealing for alternative cause. Discussed progression of dementia with sister who is very familiar with this as their sister died with dementia. At this time will continue with supportive care, which includes 1:1 assistance with feeding. Continue donepezil. Patient's sister ___ ___ is HCP and I also spoke with her daughter-in-law ___ ___ (hematologist) to help make goals of care decision. Need to continue to address code status as patient currently full code. 5. Malnutrition, poor PO intake Appreciate recommendations from SLP and nutrition. Patient is having difficulty eating in setting of dementia essentially forgetting to chew & swallow. With prompting and 1:1 assistance he does fine with regular foods; in setting of absent back molars he can be changed to ground meat consistency if he has further difficulty. Continue ensure enlive TID with meals and magic cup BID. Chronic Medical Problems 1. HTN: continue amlodipine and metoprolol 2. HLD: holding simvastatin (due to interaction with amlodipine and risk>benefit given age and comorbidities) 3. Hypothyroid h/o Grave's: continue levothyroxine >30 minutes spent on discharge planning </s>