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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with h/o GERD, a fib, HTN, HLD who
presents for chest pain. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with Hyperosmolality and hypernatremia. 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 a ___ with h/o GERD, a fib on rivaroxaban, HTN,
HLD who presents for atypical chest pain and found to have
hyponatremia.
=============</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ presents s/p fall with left tib/fib fracture. Patient
reports on the day of presentation she was walking over a
slippery area near the beach and slipped and fell. She noted
immediate onset of pain in her left lower extremity. She was
taken to an outside hospital where she underwent plain films
which demonstrated a middle third tib-fib fracture of the left
lower extremity. She additionally obtain some abrasions of the
bilateral lower extremities. She has no focal numbness or
weakness distal to her injury. She is otherwise well. Open reduction internal fixation of the tibial
fracture.
Total fluoroscopy time of 115.2 seconds was recorded. The 10 spot images
obtained during fluoroscopy were brought to our review. Note is made that the
radiologist was not attending the procedure. The findings demonstrated the
process of open reduction internal fixation of the tibia. Note is made of the
presence of comminuted fracture of the fibula as well. was done. The patient was diagnosed with FX TIBIA W FIBULA NOS-CL, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, TETANUS-DIPHT. TD DT. The patient was treated with L tibia IMN. At the time of discharge, the patient had Left tib/fib 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 left tib/fib fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation of
left tib/fib 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 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
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Radiology showed 1. No evidence for fracture or dislocation. Slight subluxations can probably
be explained by substantial facet joint degenerative changes.
2. Rightward shift of the mid brain associated with uncal herniation and mass
effect from a large left-sided subdural hematoma, difficult to precisely
compare for change compared to the prior CT.
This was discussed at 9:10 p.m. with Dr. ___ immediately after
discovery time by telephone. Radiology showed Post-surgical changes involving the left frontal, temporal, and
parietal regions with small amount of hemorrhage, pneumocephalus, catheter in
place, and effacement of the adjacent sulci. There is a decreased rightward
shift of normally midline structures to 8 mm compared to 10 mm previously.
Continued followup is recommended. Radiology showed Postsurgical changes along the left convexity with small amounts
of blood products and pneumocephalus, similar in extent to prior study;
followup imaging as clinically indicated. Radiology showed Post-surgical changes along the left convexity with small amount
of blood products and pneumocephalus, similar to prior study. Radiology showed Status post left frontoparietal craniotomy, in comparison with
the prior head CT, there is a persistent subdural collection, causing mild
effacement of the sulci and midline shifting towards the right as described
above, followup with head CT is recommended. Small locules of intracranial
gas are redemonstrated. No diffusion abnormalities are detected to suggest
acute or subacute ischemic changes. There is mild dural enhancement, likely
consistent with the surgical approach. Radiology showed No acute chest abnormality. Radiology showed Unchanged appearance of left subdural hematoma and its associated mass effect,
s/p drain removal. The patient was diagnosed with SUBDURAL HEM W/O COMA, FALL ON STAIR/STEP NEC, DIABETES UNCOMPL ADULT, HYPERCHOLESTEROLEMIA. The patient was treated with ___ Left craniotomy for ___ Dr. ___. At the time of discharge, the patient had Subdural hemorrhage
Cerebral edema
Altered mental status
Dysphagia
Aphasia
Metabolic Acidosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to ___ under the care of Dr.
___ and On ___ she was taken emergently to the OR for a
craniotomy. She was trasnferred to the TSICU post-op erativeyl,
CT imaging showed expected post-op changes.
On ___: Repeat Head CT was done earlier due to concern for
increased confusion in TICU; There was slight improvement.
Sutures placed around JP drain site due to bleeding. She was
transferred to the SDU in stable condition on ___. MRI done on
___ was negative for acute or subacute stroke. On ___, her
HCO3 was low at 13, an ABG was ordered which then showed she was
metabolic acidotic. Renal was consulted for further management.
She remained aphasic, following commands, and noded her head
appropriately intermittently. EEG monitoring was started on ___
to further evaluate her aphasia as her MRI head was negative for
stroke. on ___ her NG tube was replaced and tubefeeds were
started. Medicine was consulted for further management of her
DKA. They recommended changing her insulin to regular and when
TF to goal can d/c IVF. Repeat head CT was performed for R
pronator drift which was stable. EEG showed no seizure activity.
NG tube was pulled out by patient overnight.
On ___, her exam improved, she was able to say her name and
hospital. She continued to follow commands. She was able to take
her pills craushed with ice cream, a formal speech and swallow
evaluation was ordered. Her HA1C was 7.8. EEG showed no seziure
activity for 48 hrs and was discontinued.
Patient's examination continued to improve on ___ with her
aphasia demonstrating signs of resolving by her ability to say
her name and current location.
On ___, her staples were removed. Her exam continues to
improve. She received a bed at ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of bladder cancer since ___, prostate cancer,
TCC,left nephroureterectomy with PERC nephrostomy, right renal
pelvic tumor presents from clinic for hyperkalemia and frequent
PVCs on EGK. Radiology showed 1. 3.7 x 4.1 cm soft tissue mass likely arising from the prostate, and
obliterating the right seminal vesicles, with possible early invasion into the
adjacent rectum, concerning for progression of prostate carcinoma in the
setting of markedly elevated PSA.
2. New osseous metastases within L2, L4, L5, left ilium, sacrum, and right
aspect of the pubic symphysis.
3. New bilateral external iliac and right obturator lymphadenopathy.
4. New prominent para-aortic and paracaval nodes do not meet strict criteria
for adenopathy, but are also concerning for metastatic involvement.
5. Mild right hydronephrosis. Percutaneous nephrostomy tube and
nephroureteral stent in situ. Right peripelvic stranding may reflect
underlying pyelitis.
6. Post left nephroureterectomy. No recurrent mass at the nephrectomy bed.
7. Please refer to the separate chest CT dictation regarding intrathoracic
findings.
NOTIFICATION: The impression and recommendation above was entered by Dr. ___
___ on ___ at 17:53 into the Department of Radiology critical
communications system for direct communication to the referring provider. CT CHEST W/O CONTRAST showed 1. Foci of sclerosis involving the left lateral sixth rib and T7 vertebral
body are new from ___, concerning for osseous metastatic disease.
2. Unchanged bilateral pulmonary nodules measuring up to 4 mm.
3. Moderate to severe centrilobular emphysema.
4. Please refer to separate report for same day CT abdomen pelvis study for
discussion of findings below the diaphragm. The patient was diagnosed with Acute kidney failure, unspecified, Urinary tract infection, site not specified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>======================
BRIEF SUMMARY
======================
___ man with history of bladder cancer, prostate cancer,
TCC, left nephroureterectomy with percutaneous nephrostomy,
right renal pelvic tumor who presented from clinic with initial
concern for hyperkalemia and PVCs on ECG.
Initial presenting hyperkalemia was determined to be falsely
elevated from a hemolyzed sample, and repeat potassium was
within normal range.
He was monitored overnight on telemetry, which revealed
occasional PVCs, from which he was asymptomatic. Urine analysis
was possibly suggestion of a UTI, though difficult to interpret
in the setting of his complicated history with percutaneous
nephrostomy tube. Though he was asymptomatic, he did have mild
leukocytosis, so he was treated for UTI with ceftriaxone, then
transitioned to amoxicillin (history of enterococcus UTI in the
past, urine culture is pending), to complete a 7-day course of
antibiotics for complicated UTI.
CT chest/A/P revealed findings concerning for a recurrence of
his prostate cancer (PSA markedly elevated and imaging showing
numerous bone mets and a large mass arising from the prostate).
==========================
PROBLEM-BASED SUMMARY
==========================
ACUTE PROBLEMS:
#Hyperkalemia:
He was found to have K 6.3 at his outpatient urology visit, but
from a hemolyzed specimen. EKG at outpatient visit showed PVCs,
so he was referred to the ED. This admission, he was found to
have potassium levels within the normal range (ranging from 4.4
to 5.2 on nonhemolyzed samples). EKG and telemetry revealed
moderate PVC burden from which was asymptomatic, no other
changes. No intervention was required for pseudohyperkalemia. At
the time of discharge he did have a mild true hyperkalemia which
we did not treat as this is likely chronic and well tolerated in
the setting of his known CKD.
#Premature ventricular contractions:
Occasional PVCs were noted on EKG and telemetry, moderate
burden. Given that his potassium level was within the normal
range, and he was asymptomatic, he did not require further work
up.
#UTI:
He had a UA significant for large leukocytes and large blood, in
the setting of leukocytosis 12.5 on admission. He was
asymptomatic, but in the setting of his complicated medical
history, s/p L nephrectomy and now with R percutaneous
nephrostomy tube and ureter stent, as well as his leukocytosis,
he was treated for possible UTI. He received ceftriaxone
(___), then was transitioned to amoxicillin (as he grew
enterococcus in the past) to complete a total 7-day course of
antibiotics (last day on ___. Urine culture was pending at
discharge. Please follow up urine culture to guide treatment.
#R Nephrostomy tube, ureter stent
#R Hydronephrosis:
He was evaluated by urology who thought his nephrostomy tube to
be draining well, no concern for obstruction despite mild
hydronephrosis noted on CT, without indication for intervention.
He does have hydronephrosis seen at OSH abdominal ultrasound
with right indwelling ureteral stent. He should follow up with
urology regarding scheduled ureteroscopy and laser ablation with
Dr. ___ on ___.
#CKD vs ___:
Creatinine was elevated at 2.4 from prior baseline of around
1.8. Elevated creatinine at this admission likely represents new
baseline creatinine due to progression of his renal disease.
Less likely obstructive ___ from prostate mass. Low concern for
obstruction from nephrostomy tube given urology evaluation with
good urine output.
#Malignancy
#Suspicion for recurrent prostate cancer w/ bone metastasis
He has a history of prostate cancer previously treated in
___, with likely prostatectomy or partial prostatectomy
followed by radiotherapy in ___. PSA had resolved to ___ in
___. Recently, a PSA surveillance at PCP was elevated at 241.
Repeat PSA performed day prior to admission was elevated at 388.
CT torso showed a prostate mass and bony lesions concerning for
metastatic prostate cancer. Patient and his family were made
aware of the imaging findings, and the high suspicion for
recurrence of prostate cancer with metastases. Patient generally
defers medical decision making to his family, but he did ask
questions about the work up his cancer and appears to understand
the situation. Patient and family were informed of the necessity
of oncology follow-up as an outpatient. He has an appointment
scheduled with Dr. ___. He does complain of bony
sacral pain, controlled with Tylenol, possibly related to
malignancy.
CHRONIC PROBLEMS:
#HTN: He was normotensive and was continued on home amlodipine
5mg.
#Constipation: He was continued on home colace PRN.
#Depression: He was continued on home duloxetine.
==========================
TRANSITIONAL ISSUES
==========================
- He will finish total 7-day course of antibiotics, last day of
amoxicillin is on ___.
- Please follow up results of urine culture to guide treatment.
- He has CT findings suspicions for recurrent prostate cancer
with bony metastases, in the setting of elevated PSA. Patient
and family are aware.
New medications: amoxicillin
Changed medications: none
Stopped medications: none
#CODE: Full (presumed)
___
Relationship: wife
Phone number: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ PMHx of HTN, HLD, cholecystectomy who was transferred
from OSH for concern for ischemic colitis.
Pt was well until ___ afternoon when she developed sudden
onset of sharp, cramping, severe lower abdominal pain. Pain was
so severe that pt collapsed and briefly lost consciousness. She
then presented to OSH ED where CT scan showed collpase and
thickening of the colon c/w ischemic colitis. Pt was then
transferred to ___ for possible surgical management.
In ED initial vitals were 98.6 66 113/64 20 98%RA. Lactate was
1.0 and WBC was normal. Surgery was consulted and recommended
medical management. Pt given morphine for pain control,
cipro/flagyl for empiric coverage, 2L NS, and was transfered to
floor.
On floor, repeat lactate was 2.1. VS remained stable. This
morning, pt says that her pain was greatly improved and is ___
at rest. She reports three large bowel movements yesterday that
were blood streaked, but not bowel movements since. Denies
nausea, emesis, back pain, CP, SOB, fevers, chills, HA. Radiology showed 1. Large bowel wall-thickening and submucosal edema in the vascular
distribution of the ___. While there is no apparent stenosis or thrombosis of
the ___, proximally, a more distal arterial occlusion cannot be excluded;
however, this overall appearance of bowel may also be seen with "low-flow"
venous ischemia. Inflammatory and infectious processes also remain
differential diagnostic considerations, that might be assessed by colonoscopy.
2. Periportal edema and small ascites, particularly perihepatic. This may
relate to the process, #1, above and/or to volume overload with
"third-spacing."
3. Bilateral simple-appearing renal cysts.
COMMENT: A "wet read" was entered into RIS-web by Dr. ___ discussed with
Dr. ___, ___ at 9:40 p.m. on ___. His preliminary findings
are concordant with the final interpretation. The patient was diagnosed with NONINF GASTROENTERIT NEC, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had Colitis. 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># Colitis - There was initial concern for ischemic colitis that
would require surgical intervention. Lactate was 1.0 on arrival,
increased to 2.0 several hours later, but repeat lactate was
1.3. Patient clinically improved quickly, and surgery was not
necessary. Presentation and CTA findings were consistent with
ischemic colitis in ___ distribution, but
infectious/inflammatory colitis could not be excluded as no
occlusion was seen in ___. Ciprofloxacin and flagyl were
continued throughout admission and stool studies were sent and
pending upon discharge. Patient was without abdominal pain and
was tolerating PO.
# Hypotension: Pt was borderline hypotensive with complains of
intermittent lightheadedness. Lisinopril was held and IVF @
125cc/hr given. When patient was able to take PO, fluid and salt
intake encouraged. BPs returned to normal when patient returned
to normal diet and she was no longer lightheadeded.
# Anemia: Patient reported bloody bowel movements, but they
ceased after admission. Hemoglobin decreased with hydration from
12.4 on admission to a low of 9.5. It rose to 10.0 on day of
admission. Transfusion was not required.
# Hypokalemia: Was likely due to GI losses. Resolved with
repletion.
# HTN: Lisinopril was held due to borderline hypotension. Pt
instructed not to restart his medication until she followed-up
with her PCP.
# Hyperlipidemia: Stable. Continued simvastatin, aspirin 81mg.
# GERD: Stable. Continued omeprazole. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ s/p C6/C7 anterior discectomy/fusion on ___
for syrinx and C6/7 disc herniation who was recently discharged
on ___ and now presents with return of neck pain which she
describes as pulsatile and worse than any pain she had after the
surgery. She was actually off of pain medication from ___ -
___, however the pain returned yesterday and has gotten
progressively worse since. She was taking PO dilaudid w/o
relief. Had nausea w/3 episodes nbnb vomiting. No fevers/chills.
Feels fatigued from not eating/drinking, but no focal weakness.
No UE numbness or tingling.
Of note, she was admitted from ___ for her elective
surgery, as she wished to have decompression to avoid further
injury in the future. She also needed neurosurgery clearance for
her police academy given her cervical syrinx found on prior
imaging. Post-operatively, her pain had been controlled with
oxycodone and IV dilaudid that was switched to po dilaudid. She
also complained of numbness on the R side of her body. Her
symptoms improved by the time of discharge and she was
discharged on po dilaudid ___ mg q4hr:prn as well as bisacodyl.
She was scheduled to f/u with Dr. ___ on ___.
In the ED, initial vitals were: 99.6 78 128/83 18 100%. Labs
significant for a Hct 34.9 (was 38 on ___. Was given IV
zofran and dilaudid 1mg which improved pain temporarily. She
later received po dilaudid 4 mg and tizanidine with litting
improvement in her pain. On exam, she had neck pain and back
pain radiating down the R leg. Neurosurgery was consulted, and
after review of her C-spine imaging, did not feel that surgical
intervention was necessary. She was therefore admitted to
medicine for pain control. VS upon transfer: 98.0 71 101/69 18. Radiology showed Status post C6/7 anterior fusion without evidence of hardware complications or
change in alignment. The patient was diagnosed with CERVICALGIA, ABN REACT-PROCEDURE NOS. At the time of discharge, the patient had Primary:
Radiculopathy/Muscle Spasm
Nausea
Headache
Secondary:
C6/7 disc herniation and syrinx s/p C6/7 anterior cerivcal
discectomy/fusion on ___.
Secondary:. 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 a23F s/p C6/C7 anterior discectomy/fusion on ___
for syrinx and C67 disc herniation, discharged on ___ who
initially presented with acute neck pain. While in the hospital
she developed thoraco/lumbar/sacral musculoskeletal pain with
radation down the right posterior thigh concerning for muscle
spasm and radiculopathy.
#Radiculopathy
While the patient was in the ED and turning to her side she
noted sudden onset lower back pain with radiation down her right
posterior thigh. Her symptoms were thought to be consistent with
a radiculopathy and muscle spasm as she had tenderness to
palpation over the paraspinal muscles and positive straight leg
raise. Neurologically the patient's exam remained normal with
the exception of strength in the right lower extremity initially
that was limited by pain though improved prior to discharge.
Imaging of the region was not felt to be warranted given lack of
true focal neuro deficits on exam, patient's age, and no
previous history of malignancy, fevers or IVDU. She was
initially given dilaudid with minimal relief of her symptoms and
profuse itching secondarily. Dilaudid was subsequently
discontinued. She was then started on muscle relaxant, IV
toradol, ultram, and gabapentin with improvement of her pain.
She was discharged with a 10 day course of gabapentin, tramadol,
ibuprofen, flexeril for pain managment and plan for physical
therapy. She was also provided with omeprazole to take in the
setting of her high dose NSAID use. Prior to discharge she was
ambulating the floors without significant pain.
# Cervical syrinx s/p C6/C7 anterior discectomy/fusion with
anterior neck pain.
Ms. ___ was admitted to the hospital for neck pain and nausea.
She was assessed by the neurosurgery team and had imaging of her
C-spine that did not show any complications or change in
alignment from her recent surgery. In addition Ms. ___
incision site was without evidence of skin or soft tissue
infection with well-healing scar in the post-surgical period. It
was thought that her worsening neck pain that brought her into
the hospital was secondary to overuse/strain in the setting of
recently walking 6 miles after being relatively inactive.
#Headache
#Nausea
She was also noted to have a headache, nausea/dry heaving, and
dizziness. It was thought very unlikely that her symptoms were
due to meningitis because she was without elevated white count
or fever throughout the course of her hospitalization, no
meningismus or other infectious signs. It was thought that her
symptoms were most likely due to a viral syndrome and improved
prior to discharge. Her nausea was treated with zofran and
compazine with QTc monitoring.
#Normocytic Anemia Hg/Hct 12.3/ 34.9 MCV 91
Patient with anemia noted on CBC to somewhat be expected in the
setting of her age and menstruation with some drop likely
diluational in nature in setting of IVF. Iron studies including
ferritin and serum iron were obtained and normal. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ otherwise healthy woman who presents
with 2 days of severe abdominal pain. She reports that the pain
started about 2 days ago and was mostly in her left lower
quadrant, radiates to the back. It became more severe over the
next few days she also had intermittent diarrhea. Her last
bowel movement was yesterday evening, described as nonbloody.
She has been able to tolerate p.o., and denies nausea or
vomiting. She does endorse subjective fevers and chills at
home. She has not had any urinary symptoms. Of note, she states
that
she had similar pain about 6 weeks ago that improved without any
intervention over the course of the week. She has not had any
prior episodes other than these 2. Radiology showed Diverticulitis with phlegmon and mild scattered pneumoperitoneum, but no fluid
collection. The patient was diagnosed with Dvtrcli of lg int w/o perforation or abscess w/o 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>The patient presented to Emergency Department on ___. She
was diagnosed to have acute uncomplicated diverticulitis and was
admitted to Acute Care Surgery unit for appropriate management.
She was made NPO, put on antibiotics (IV ciproflagyl and PO
metronidazole) and IV fluids.
During the entire hospital course review of systems had as
follow:
Neuro: The patient was alert and oriented throughout
hospitalization and pain was well managed.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. She was
therefore, the diet was advanced sequentially to a Regular diet,
which was well tolerated. Patient's intake and output were
closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. Her white cell count
trended from 19.7 to 9.6 on discharge.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a 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: ___ yo M h/o NSCLC with mets to brain p/w one week of dyspnea. Pt
reports one week of dyspnea with cough productive of blood
clots. Denies CP/abd pain. +mild nausea without vomiting.
.
Pt dx'd with lung CA in ___. He has declined chemotherapy
in the past due to negative experiences when wife had
chemotherapy for lung CA. Pt is now s/p whole brain XRT for
mets.
.
In the ED: T 98.4, 90/52, hr 80, 24, 89% ra. cxr showed large r
opacity and large pleural effusion. cta showed numerous large
segmental and lobar PEs with R-sided necrotic mass. LENIs showed
L DVT and R superficial clot. CT head showed multiple mets with
? internal hemorrhage. Pt given asa 325 mg po, levofloxacin 750
mg iv, morphine 15 mg po. Dr. ___ with oncology service had GOC
discussion with patient in the ED: Pt is now DNR/DNI and given
the risks for bleeding has declined heparin treatment of
DVT/PEs. Pt was amenable to IVC filter placement, which occured
via ___ prior to transfer to the floor.
.
ROS: as above. o/w complete ROS negative. Radiology showed 1. Large opacity within the right lower lobe representing known mass.
Superinfection cannot be excluded with subtle suggestio of associated air
bronchograms.
2. Increasing right pleural effusion. Radiology showed 1. Numerous lobar and segmental PEs bilaterally as detailed above. Subtle
flattening of the interventricular septum of the heart may suggest early heart
failure. This can be further evaluated for on echocardiogram. There is no
evidence of parenchymal infarct.
2. Growing mass in the right lower lobe with liquefaction and locules of gas.
Opacities adjacent to the large mass may represent infection versus spread of
malignancy.
3. Severe background of centrilobular emphysema. Radiology showed 1. Deep venous thrombosis involving the distal left popliteal vein with
extension into at least one of the left posterior tibial veins.
2. Thrombus in the lesser saphenous vein, which is a superficial vein,
however, comes in close proximity to the popliteal vein, approximately within
1 cm. Radiology showed Multiple metastatic lesions, as above, most of which are better
assessed on MRI. Right temporal lobe lesion has increased region of
hyperdensity on the current study, which may be due to increase in size of the
lesion/increase in cell content, however, hemorrhagic component is not
entirely excluded and could be excluded on MRI susceptibility sequence. Radiology showed Successful deployment of permanent Venatech IVC filter. The patient was diagnosed with PULM EMBOLISM/INFARCT. The patient was treated with placement of IVC filter ___. At the time of discharge, the patient had Primary:
___
Secondary:
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>___ yo male with metastatic NSCLC now here with dyspnea, found to
have DVT and PE. CT head showed multiple metastatic lesions,
and
a hemorrhagic component could not be entirely excluded. Thus,
pt
was not started on anticoagulation. He did have an IVC filter
placed on ___.
# Metastatic NSCLC: discussed with Dr. ___ contacted Dr
___. Radiation oncology determinted that XRT to tumor
would not be beneficial from a palliative perspective for his
hemoptysis. Patient and family met with palliative care on ___
and elected for ___. I discussed his plan with his
daughter ___ on ___ and they would prefer to avoid outpatient
appointments for now. They know that they can call us in the
clinic at any point for assistance. He will be continued on
oxygen and morphine for pain and dyspnea control.
# DVT/PEs: Due to brain mets and intermittent hemoptysis as well
as pt's preference, pt was not started on anticoagulation. IVC
filter was placed. No concern for pneumonia.
# COPD: Continued Albuterol, Tiotropium, Symbicort for
symptomatic
relief.
# DVT ppx: Pneumoboots
# Code status: DNR/DNI</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Radiology showed Right middle lobe consolidation worrisome for pneumonia. Radiology showed Status post posterior metallic fusion of L5 and S1 in anatomic
alignment without evidence of acute fracture or dislocation. Please note that
CT may be more sensitive in evaluating for infection. Radiology showed 1. There are four lumbar-type vertebrae, labeled L2 through L5, congruent
with the numbering on prior imaging studies and the ___ operative note.
2. The intervertebral device at L5-S1 is located to the right of midline,
extending to the ventral margin of the right neural foramen. There is no other
post-operative CT for comparison.
3. Erosion of the right inferior endplate of L5 overlying the interbody
device, suggesting loosening and the possibility of infection, given the
history of fever. MRI would be more sensitive for evaluating extend of
infection, as well as detecting an epidural collection or paravertebral
collection, if clinically warranted.
4. Posterior fusion hardware at L5 and S1 appears unremarkable without
evidence for complications.
Findings were discussed by Dr. ___ with Dr. ___ over the
telephone on ___ at 4:30 pm. The patient was diagnosed with FEVER, UNSPECIFIED. The patient was treated with N. At the time of discharge, the patient had Postoperative fever. 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.
Intravenous antibiotics were not given. His inflammatory
markers were trended and improved through his hospital admission
as did his pain. 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: HPI: The patient is an ___ year old right handed woman who
presents with about 18 hours of headache, lightheadedness,
intermittent dysarthria, left lower face weakness, and
difficulty
using the left side. She only has a known history of
hypertension
(on two medications and aspirin) and possibly hyperlipidemia
(not
on medications). She has been feeling well recently with no
recent injury or illness. She was doing ___ cleaning in her
house yesterday but did not think she overexerted herself. She
has been eating and drinking okay. Last evening around 19:30 ___,
she developed a right temporal pulsatile headache; she has no
history of migraines and does not usually have unilateral or
pounding headaches. She typically has bifrontal dull achy
headaches once or twice per month that resolve with
acetaminophen. She took two acetaminophen and felt somewhat
better. She went to bed at 21:30 ___. She awoke at 06:30 AM and
felt lightheaded. There was no vertigo or gait imbalance. Her
husband (who has hearing loss) thought she may or may not have
been harder to understand in terms of her enunciation. She
reports feeling "odd" but denied any other symptoms including
neck pain, palpitations, chest pain, nausea, dyspnea on
exertion,
vision changes, or difficulty moving her arms and legs.
Nonetheless, she and her husband went to ___ in the
morning where some basic studies were performed, and she was
sent
back home. When her son took her home, he noticed as she was
getting out of the car that her left arm and leg didn't seem to
be moving in a coordinated fashion, and when she gave her
something to drink some of it spilled out of the left side of
her
mouth. He thought that she seemed "not herself" and had
asymmetry
of her face on the left. This prompted him to bring her to our
Emergency Department. Here, due to an unknown time of onset of
symptoms, a Code Stroke was not called, but Neurology was
consulted after it was discovered on examination that she had a
left-sided visual field cut. MR HEAD W/O CONTRAST showed Restricted diffusion in the right basal ganglia, right insula and throughout
the right parietal and temporal lobes consistent with acute ischemia in the
territory of the M1 segment of the right middle cerebral artery.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 3:13 ___, minutes after discovery of the
findings. CTA HEAD WANDW/O C AND RECONS showed 1. No evidence of acute hemorrhage or infarct.
2. Interval placement of right internal carotid artery metallic stent with
complete occlusion of the entire internal carotid artery. Minimal collateral
retrograde flow is seen at the most distal aspect of the supra clinoid
segment. The right MCA demonstrates markedly decreased flow. The left-sided
vasculature for is well patent with adequate arterial flow.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 8:35 ___, 5 minutes after discovery of the
findings. Radiology showed 1. No retroperitoneal hematoma. Mild stranding in the right inguinal region
and pelvis with a local rectus sheeth expansion, compatible with a small
amount hematoma in this area.
2. 1.3 cm heavily calcified splenic artery aneurysm, located at the hilum.
3. 2 hypodense lesions within the pancreas, likely representing cystic
lesions. Further evaluation with MRI is recommended non emergently if
clinically indicated.
4. Indeterminate left renal hypodensity measuring 2.8 cm, which may represent
a cyst. This can be further evaluated at the time of pancreatic MRI. Radiology showed AP chest compared to ___:
New nasogastric drainage tube ends low in nondistended stomach.
Lungs are fully expanded and clear. Pleural effusion is small, if any. ET
tube in standard placement. Heart size normal. Radiology showed AP chest compared to ___ and ___:
Mild pulmonary edema developed between ___ and ___. Subsequently,
the edema has improved somewhat, but there is more consolidation at the right
lung base that could be due either to atelectasis or new pneumonia. The heart
size is top normal. Nasogastric tube passes into the stomach and out of view.
Pleural effusions are small. No pneumothorax. Dr. ___ was paged at 12:30
as soon as the study was reviewed. Video oropharyngeal swallowing examination showed Gross aspiration of nectar thickened barium and inability to form bolus with
pureed barium.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations. Radiology showed 1. Small right pelvic hematoma, likely related to prior arterial puncture for
cerebral angiography.
2. Right colic venous gas as well as venous gas in the left hepatic lobe,
without associated pneumatosis, likely benign in nature. Correlation with
serum lactate and serial physical exam is recommended.
3. New moderate right and small left nonhemorrhagic pleural effusions.
4. 1.8 cm pancreatic cystic lesion. If serial CT imaging is planned for this
patient, this lesion could be followed up on these studies. Otherwise, the
standard recommendation for followup would be an MRCP in 6 months.
5. Unchanged benign appearing left renal cysts.
6. Extensive diverticulosis, without evidence of diverticulitis. Rectal fecal
loading.
NOTIFICATION: Findings were discussed with Dr. ___ by Dr. ___ at
15:55 via telephone on the day of the study, 5 minutes after discovery. Radiology showed 1. No evidence of acute cardiopulmonary process.
2. Moderately severe compression fracture at thoracolumbar junction of
uncertain chronicity. Correlate clinically for acuity. CTA HEAD AND CTA NECK showed High-grade stenosis (70-80%) at the bifurcation the right internal carotid
artery that extends approximately 1 cm into the internal carotid artery. The
3D reformations are pending. Once the 3D reformations are obtained an addendum
will be issued if any changes are identified. Radiology showed 1. No evidence of acute intracranial process.
2. Rotatory orientation of C1 and C2 is most likely positional, however,
clinical correlation is recommended to exclude underlying ligamentous injury. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT. The patient was treated with ___ angiogram with R ICA stenting
___ angiogram with clot aspiriation. At the time of discharge, the patient had Right MCA infarct resulting from Right Carotid 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>___ is an ___ year old woman who presented in the
evening of ___ complaning of progressive right temporal
pulsatile headache and acute onset left hemiparesis, facial
droop and vision loss. When she initially presented to the ED,
CT showed no clear infarct or hemorrhage but CTA reveled
high-grade stenosis of the right ICA. In the scanner in the ED
she became unresponse with right gaze deviation and less
movement in her left arm. SBP was in the 140s (down from 200s)
and the initial thought was that there may have been a brief
seizure or possible flow-related symptoms in the setting of BP
drop. Repeat CT showed developing right cerebral watershed
distribution infarcts. Neurosrugery was consulted urgently who
made a decision to take the patient to angio for R ICA stenting.
Post-angio scans showed improved flow and she was awake, alert,
with mild dysarthria, following commands antigravity in her LUE.
Per Nsurg ASA 325, plavix 75 was started. By 7:45 ___, however,
she was no longer following comands on the left, only
withdrawing to pain and triple flexing the left leg. Repeat CTA
showed restenosis of the R carotid, and M1 distribution
infarction on the R. Neurosurgery had a discussion with the
family about the risks and benefits integrelin and repeat angio
for aspiration of the clot, which they agreed to. She recieved
15mg integrelin and post-angio again had improved flow in the R
MCA territory. She has had improved spontaneous movement on the
left side and is following simple commands off sedation. MRI
showed patchy ischemia in the right MCA territory.
She was transferred to floor after extubation. She became
febrile and had a worsening leukocytosis. She underwent a fever
workup, which included blood cultures, urine cultures, and a
chest x-ray. Chest x-ray showed that she had a new right lower
lobe opacity concerning for pneumonia. She was given Vancomycin
and Zosyn for empiric treatment for pneumonia, for a planned 14
day course to finish on ___. A PICC line was placed
after antibiotics were started. Upon transferring to the floor
she was found to be in atrial fibrillation with rapid
ventricular response. She was given IV metoprolol and her oral
metoprolol dose was increased to 50mg BID. She spontaneously
converted to normal sinus rhythm and her rate has been while
controlled since. She was not started on warfarin because she
was already on Aspirin and Plavix for her carotid stent (which
she will continue for three months). Starting a third
anticoagulation agent would greatly increase her risk of
hemmorhage.
Her blood cultures grew out gram positive cocci in clusters
which speciated to staph epidermidis. Her urine culture grew out
yeast and she was started on fluconazole on ___, for a
planned 7 day course to be completed on ___.
Her physical exam improved and she had increased stregth in both
the left upper and left lower extermity. She became more
interactive and her mental status also improved. A repeat
bedside swallow evaluation found that she was still at increased
risk of aspiration. Her hematocrit continued to drop and a CT
abdomen/pelvis showed show a right groin hematoma that was
stable. An incidental finding of portal venous gas was noted as
well as a 1.8 cm pancreatic cystic lesion. Her lactate was
normal and the suspicion of bowel perforation was low.
Acute care surgery placed a PEG tube on ___, after her repeat
blood cultures were negative. Her blood pressure continued to be
difficult to controll and amlodipine 5mg was added. She resumed
tube feeds on ___ without incidence.
During the admission, her blood pressures have been mildly
difficult to control. She was put back on her home medications
and amlodipine was also started. If her blood pressures
continue to be above a systolic of 180, would uptitrate her oral
antihypertensives.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with h/o HTN, COPD, and PAD, presenting with
question of new seizure. Per husband, pt was feeling fine and
mentating at baseline yesterday afternoon. Husband noted
yesterday 5:30pm that the patient had gentle constant shaking of
her upper and lower extremities lasting approximately ___
with dry heaving for ___. During that time the patient had a
decreased level of responsiveness, did not recognize her
husband, and would not answer the husband's questions, speaking
"gibberish." No bleeding from tongue. Husband noticed diaper was
soaked with urine after shaking was over (has fecal and urinary
incontinence at baseline). Afterwards she seemed very sleepy and
slept for approximately 3 hours. Pt's husband and son woke pt up
and she had difficulty expressing that her chronic leg pain was
bothering her and spoke in broken sentences; also c/o HA. Pt was
given home Dilaudid and went to sleep. This am, pt still not
oriented and didn't recognize husband and had trouble finding
words. Pt received another dose of Dilaudid and husband called
PCP who recommended transfer to ___. She was complaining of some
lower abdominal pain. No shortness breath, cough, chest pain. No
weakness in her upper or lower extremities, headache.
L midline in for IVF ___ due to poor PO intake for past 2
months. 15# weight loss in past 2 months.
Last BM yesterday. Radiology showed 1. No acute intracranial process. However, if there is clinical concern for
acute infarction, MRI is more sensitive.
2. Multiple areas of old infarction.
3. Chronic small vessel ischemic disease and atrophy.
These findings were discussed with Dr. ___ by Dr. ___
telephone at 3:10 p.m, ___. Radiology showed 1. Increased streaky opacity within the right lung base which could reflect
atelectasis but infection cannot be excluded.
2. Emphysema.
3. Unchanged 15 mm nodule within the lingula. As noted on the prior PET CT
from ___, continued imaging followup of this lesion is
recommended, and a chest CT should be obtained at this time.
4. Aortic arch aneurysm, unchanged. Radiology showed No acute infarct. Extensive small vessel ischemic changes with lacunar
infarcts and two larger infarcts in the left occipital and left cerebellum as
described. No abnormal enhancement. The patient was diagnosed with OTHER CONVULSIONS, FEVER, UNSPECIFIED, OTHER MALAISE AND FATIGUE, HX VENOUS THROMBOSIS/EMBOLISM, LONG TERM USE ANTIGOAGULANT. The patient was treated with Lumbar puncture ___. 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 presenting with question of new seizure day
prior to admission, presenting with lower abdominal pain and
found to have complicated UTI.
#Possible seizure, AMS: According to pt's husband, episode day
prior to admission was most likely consistent with a seizure of
unknown etiology. As pt has had poor PO intake and malnutrition,
pt may have had hypoglycemia or electrolyte imbalance triggering
seizure. Acute stroke was considered especially with pt's
history of HTN and vasculopathy and husband endorsing pt having
aphasia, and imaging ruled out intracranial hemorrhage, acute
ischemic infarct and mass. Infectious process was considered and
LP was not consistent with bacterial meningitis or viral
encephalitis; HSV PCR of CSF negative. Pt was initially
empirically treated with IV acyclovir until PCR came back
negative on ___. CSF and blood cultures did not have
microbial growth. Neurology was consulted and recommended EEG.
Per neurology, L temporal sharps were seen on 24hr continuous
EEG which were indicative of being at risk for future seizures.
This L temporal activity would explain pt's seizure episode and
accompanying aphasia. Keppra seizure prophylaxis was held at
this time due to fact that this has sedating effects and pt was
already having waxing and waning delirium throughout hospital
course. Moreover, pt expressed wish to have her treatment
comfort-focused. It was recommended that the pt follow-up in
neurology clinic and if pt has future episodes of seizures,
Keppra will be re-considered. Pt was discharged alert and
oriented x2, and was given a prescription for Ativan 0.5-1mg PRN
agitation.
#UTI, complicated: Pt had leukocytosis initially which resolved
on hospital Day 2 and pt with lower abdominal pain after having
seizure day prior to admission, and this may have been related
to UTI. Urine culture grew out enterococcus and pt was treated
with ampicillin PO, and Foley catheter was discontinued. UCx
sensitivities returned on ___ which showed sensitivity to
ampicillin. Pt remained hemodynamically stable and did not
fulfill SIRS criteria. HD stable, no criteria for SIRS except
for fever. U/A rechecked as initial ua was not fully consistent
with infection- repeat clean but repeat UCx growing
enterococcus. Pt was discharged with Ampicillin 500mg q6H and
instructed to complete 10-day course for complicated UTI.
#Labile BP: Pt's BP initially 180s on ___. Pt was not on
antihypertensives as outpt but pt's chronic hypertension is most
likely reason for pt's past infarcts that were seen on imaging.
Pt was given a day of lisinopril 2.5 daily which brought
pressures were 140-150s but as pt had poor PO intake, she
triggered on ___ for SBP at 78. BP responded well to bolus
and was put on maintenance IVF to maintain BP for one night, and
lisinopril was discontinued. FeNa calculated to be 0.1% and thus
most likely hypovolemic ___ poor PO intake. Thereafter, BP
elevated to 170s and remained stable in 150-170s upon discharge.
As pt was asymptomatic with elevated BP, and pt wished to have
comfort-focused care, we deferred starting antihypertensive
although could be reconsidered if was symptomatic.
#Peripheral arterial disease: Pt was on coumadin and Plavix as
outpt. She had multiple vascular surgeries in past, most recent
surgeries in ___ on lower extremities. After intracranial
hemorrhage was ruled out with imaging, pt was cleared by
neurology to continue Plavix and coumadin throughout
hospitalization. INR remained therapeutic and no changes were
made to coumadin dose. Pt has a follow-up appt with vascular
surgery on ___.
#Chronic pain: Pt has chronic pain in lower extremities, mainly
in L leg. Per pt, there has been no acute worsening of chronic
pain and this was managed with
continued home medications: standing gabapentin, Dilaudid PRN,
Tylenol PRN.
#Palliative care: Upon admission, pt's husband (HCP) reversed
pt's DNR/DNI status to full code as he believed that pt agreed
to that code status without fully understanding the meaning of
DNR. As we have ruled out many acute processes which could have
caused pt's acute change in mental status besides UTI, and main
issues at time of discharge appeared to be chronic in nature
including pain control and poor PO intake/weight loss.
Palliative care was consulted and spoke to pt on goals of care-
pt expressed wish to have comfort focused care at home. A formal
meeting was done with ___ (pt's husband and proxy) on
___ and he was emotionally overwhelmed by pt's
hospitalization and was educated on pt's needs. He is amenable
to discussing goals of care at home with palliative care team
and is onboard in terms of being comfort-focused. Pt's husband
recommended that ___ work with pt in order to assist her out of
bed to wheelchair so that she can enjoy the outdoors. Social
work was also consulted and upon discharge, pt was set up with
___ services along with palliative care and social work
follow-up to visit home in order to further discuss goals of
care, code status and possible transition to hospice care. Pt is
to continue to have infusion therapy through midline three times
a week as before admission as pt continues to have poor PO
intake.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with a history significant for CF with MAC,
temporal lobe epilepsy, stable carotid stenosis, depression, and
anxiety disorder, who was referred in from PCP after patient
reports 2 week history of increased falls and lower extremity
weakness. PCP is requesting coordination of care through
psychiatry and neurology.
He presented today reporting falling 5 times PTA with report
that legs feel weak and will not support him. The patient stated
that this has been going on for about 3 months. He also reports
that he has ongoing vertigo but this symptom does not always
precede weakness in his legs. He denies any vision changes,
headaches, N/V, paresthesias/decreased sensation,
myalgias/arthralgias, and endorses normal appetite recently. He
has not had loss of consciousness, or had any focal neurological
deficits. He does not feel lightheaded, and denies chest pain,
worsening shortness of breath, dyspnea on exertion or worsening
cough. Denies any shaking movements or stiffening. He notes that
he has become less active within the last year, but cannot
contribute his lack of activity to anything specifically. Radiology showed No acute cardiopulmonary process. CT HEAD W/O CONTRAST showed No acute intracranial process. The patient was diagnosed with Major depressive disorder, single episode, unspecified, Low self-esteem. At the time of discharge, the patient had PRIMARY DIAGNOSIS
=================
Weakness
Cystic Fibrosis
Depression
Acute Kidney Injury
SECONDARY DIAGNOSIS
===================
Gastroesophageal Reflux Disease
Temporal lobe epilepsy
Primary nocturnal enuresis. 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>Information for Outpatient Providers: Mr. ___ is a ___ with
a history significant for CF and anxiety disorder, as well as
depression, was referred in from PCP for further evaluation by
PCP after presenting today with falls and lower extremity
weakness.
ACTIVE ISSUES
# FALLS/WEAKNESS: patient reporting falls at home because felt
that "legs cannot support him." Not likely neurological in
nature. On neurological exam, patient exhibits ___ strength.
Gait WNL, but endorsed subjective weakness. He demonstrated heel
and toe walking, and was able to stand up from squatting
position without assistance. Further, MRA/V of head, noncon CT
were negative. Cardiogenic etiology not likely either as EKG
WNL, and no SOB/chest pain/ palpitations endorsed. ___ be due to
dehydration/possible malnutrition however patient states that
eating/drinking habits and bowel habits remain unchanged. Most
likely not related to chronic peripheral vertigo as dizziness
episodes did not always coincide with weakness. Physical therapy
cleared him as safe to go home, and psychiatry evaluated him and
was in agreement with primary team, that he does not currently
endorse any SI and is safe to discharge home.
# PASSIVE SUICIDAL IDEATION: patient with no prior history of
suicide attempts but active ideation in ___ and passive
suicidality currently. ED staff overheard what is to be though
of as active ideation. Psychiatry evaluated him and was in
agreement with primary team: that he does not currently endorse
any SI and is safe to discharge home. He will follow up with Dr.
___ as an ___.
# ACUTE KIDNEY INJURY: unclear precipitant but likely prerenal
in nature. After 1L NS and maintenance fluids, Cr normalized.
CHRONIC ISSUES
# MYCOBACTERIUM AVIUM INTRACELLULARE INFECTION: followed by ID.
Not currently in treatment, per last note, given stable symptoms
and difficulty with regimen.
# CYSTIC FIBROSIS: continued, levalbuterol,
fluticasone-salmeterol. Dornase was held ___ being non
formulary.
# GERD: Continued home pantoprazole, ranitidine.
# TEMPORAL LOBE EPILEPSY: continued home clonazepam. Not on
keppra.
# PRIMARY NOCTURNAL ENURESIS: home desmopressin.
# HYPERTENSION: home valsartan.
Transitional Issues
====================
[]Consider repeat UA for microscopic hematuria seen during this
admission
[]Patient hesitant to go to therapist in ___. ___ benefit
from referral to more local therapist. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ with past medical history of hypertension, chronic
back pain attributed to lumbar disc disease, Diabetes type 2
complicated by Diabetic neuropathy, chronic opiates for above
issues complicated by constipation requiring movantik, GERD with
chronic reflux, COPD, ongoing tobacco abuse, schizoaffective
disorder with a prior suicide attempt, who presents with
progressive cough and dyspnea x 10 days. Patient reports that
10
days prior to presentation, she noticed symptoms of cough
productive of green sputum. Denies chest pain, palpitations,
lower extremity edema. CHEST (PA AND LAT) showed 1. No acute cardiopulmonary abnormality.
2. Prominent hila bilaterally may reflect dilated pulmonary arteries and be
suggestive of pulmonary arterial hypertension.
3. Hyperinflated lungs compatible with history of COPD. CHEST (PORTABLE AP) showed Comparison to ___. There is an interval increase in interstitial
and vascular markings, suggesting the presence of mild pulmonary edema.
Borderline size of the cardiac silhouette persists. No larger pleural
effusions. No pneumonia. Chest x-ray showed Hyperaeration. Mild pulmonary edema, similar to previous. CHEST (PORTABLE AP) showed ET tube tip is 7.5 cm above the carinal. Heart size and mediastinum are
stable. There is interval enlargement of the hila and development of bibasal
opacities potentially aspirations or progression of infectious process. It
might be in part exaggerated by low lung volumes compared to previous
examination but true progression of bibasal abnormality CIS breast an. No
definitive pleural effusion is seen. No pneumothorax is present. No
definitive evidence of pulmonary edema is noted. Radiology showed Lungs are low volume with bibasilar atelectasis. A NG tube has been placed in
the interim with its tip projecting below the diaphragm over the stomach. The
ET tube is unchanged. Cardiomediastinal silhouette is stable. No
pneumothorax is seen. Radiology showed Lungs are low volume with mild interstitial edema the ET tube, NG tube are
unchanged. There is bibasilar atelectasis. Cardiomediastinal silhouette is
stable. No pneumothorax is seen Chest portable radiograph showed Stable mild interstitial edema.
Unchanged position of supportive and monitoring devices. The patient was diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation, Dyspnea, unspecified. The patient was treated with Intubation ___
Extubation ___. At the time of discharge, the patient had COPD Exacerbation
Toxic metabolic encephalopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of COPD, HTN, DM2, chronic opioid use,
schizoaffective disorder who presented ___ to ___
with dyspnea x 10 days. Had concerning respiratory status with
tachypnea so transferred to ___ ED for further care. At ___
patient required intubation ___ for hypercarbia and altered
mental status. Extubated ___, now transferred to ___ per
patient and family request.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ year-old lady with a history of MCTD
complicated by ILD, esophageal dysmotility, atypical chest pain,
asthma presenting with chest pain. Chest radiograph showed Bibasilar interstitial lung disease has been more fully characterized by a
recent CT. No definite superimposed secondary process such as pneumonia,
although subtle new abnormalities may be difficult to detect in the setting of
chronic lung disease. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had 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>Mrs. ___ is a ___ y/o F with a history of mixed connective
tissue disease complicated by ILD, esophageal dysmotility,
atypical chest pain and asthma who presented with atypical chest
pain.
#Chest Pain:
She has had a history of atypical chest pain but this time she
noted that it lasted for much longer than it usually does. The
differential is broad including angina, pericarditis, esophageal
dysmotility, and MSK (myositis). In the context of having mixed
connective tissue disorder, she was considered to be at higher
risk for cardiovascular disease (Ungprasert ___, I___).
A pharmacologic stress test showed no abnormalities
(communicated to her cardiologist). A1c at 5.5. LDL at 173. The
results were inconclusive, but this was thought to be either due
to esophageal spasm/dysmotility or GERD. She was treated with
Maalox and lidocaine and she was discharged on omeprazole twice
a day. She was also discharged on atorvastatin 40 mg.
#Cramping
Has had leg cramps for many years. Electrolytes normal, CK
normal. Thought due to CellCept and Prednisone combination, but
etiology unknown. At discharge, cramps at baseline. Discharged
on Vitamin B6.
#Mixed Connective Tissue Disorder c/b ILD
Being managed by Pulmonology at ___ and Rheumatology at ___.
Pulmonology consulted in patient. Continued on prednisone 10 mg
daily, myocphenolate mofetil 1000mg BID. Bactrim for PCP
prophylaxis decreased to 3x/week.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Ms. ___ is a ___ RH woman with a history of
significant psychiatric illness, hypothyroidism and right
retinal
microaneurysm who presents with monocular left visual changes.
The patient was doing eye exercises with a chart yesterday when
she suddenly noticed that the vision in her left eye "blacked
out" suddenly and completely, lasting several seconds. The
vision then returned to normal and she denied blurriness,
changes
in color saturation, diplopia or eye pain. She again had a
similar episode at 10am this morning, afterward she did feel
faint and light-headed so laid down. Her vision then returned
to
normal, though while we were testing her vision today, she noted
she had a circumferential "tire like ring of black" around her
vision in her left eye. She otherwise denies vertigo, changes in
strength, changes in hearing, trouble swallowing, headaches,
numbness/tingling and has otherwise been feeling normal. She
does
endorse a significant increase in personal stress, including her
mother being in the hospital in the last few days and her
husband
recently stopping his job. Radiology showed No acute intracranial process. Radiology showed 1. Non-opacification of the left sigmoid sinus, new, with apparent collateral
vessels in this venous drainage pathway. When correlated with the concurrent
cranial MRI/MRV, the constellation of findings most likely represents partial
thrombosis of the left sigmoid sinus.
2. No evidence of intra-orbital sequelae of cerebral venous disease.
3. No intracranial hemorrhage, edema or mass effect.
4. No hemodynamically significant stenosis of the cervical carotid arteries,
by NASCET criteria.
COMMENT: Discussed with Dr. ___ (Neurology service) by Dr. ___
___ at 11:30 hours on ___, at the time of discovery. Radiology showed 1. Hypoplastic left venous sinus system with diminished flow-related
enhancement.
However, when correlated with the concurrent CTA, there is non-opacification
of the left sigmoid sinus and venous collaterals are present along this venous
drainage pathway. The constellation of findings is most consistent with
partial thrombosis of the left sigmoid sinus, new since ___.
2. No acute infarct, edema or intracranial hemorrhage.
COMMENT: Discussed with Dr. ___ (Neurology service) by Dr. ___
___ at 1130H on ___, at the time of discovery. The patient was diagnosed with CHEST PAIN NOS, VISUAL DISTURBANCES NEC. At the time of discharge, the patient had Primary diagnosis
1. left eye monocular vision changes
2. hypoplastic left sigmoid and transverse venous sinuses,
possible partially occlusive thrombus
Secondary diagnosis
1. Schizoaffective disorder/Bipolar disorder
2. Right retinal microaneursym. 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># Transient visual loss: Pt initially presented with 2 episodes
of transient monocular vision loss, and had other instances of
visual abnormalities during daily examinations by the neurology
team in the ED and each morning. In the ED, pt reported seeing a
ring of black, while during subsequent exams, pt reported
blacking out of central vision and "cracked" appearance of her
visual field in the left eye. She was worked up for multiple
etiologies. No apparent neurologic pathology on CT, MRI, MRA/MRV
scans. Scans were normal, with the exception of a hypoplastic L
sigmoid sinus and partial thrombus of unclear chronicity and
likely unrelated to current presentation. Ocular etiologies were
investigated with ophthalmology slit lamp exam, which showed no
abnormalities. Of note, visual fields were not completed (to be
completed in Neuro-ophthalmology visit). CTA showed normal
vasculature/no significant atherosclerosis in the aortic arch
and TTE showed a PFO but no thrombus. Hematologic causes (i.e.,
hypercoagulable diseases) were not investigated due to low risk
factor profile; pt is a non-smoker, has never been on estrogen,
has no h/o prior clots, and has no significant FH. Thus, the
etiology of her symptoms is unclear. She was started on ASA 81mg
during this admission. She will be followed in ___
clinic with VF testing, and will also follow up with her regular
ophthalmologist. She was instructed to make an appt for MRI of
orbits prior to her neuro-ophtho appt.
# L sigmoid sinus partial thrombosis: seen on MRV. This was felt
to be an incidental finding unrelated to the patients
presentation. She was started on ASA 81. She will need a repeat
MRV and follow up with Stroke neurology. She was given the
number to schedule her outpt MRV.
#Chronic kidney disease: pt was noted to have an elevated Cr of
1.3-1.4 during admission. Her baseline is 1.3-1.5 for the past
several years due to prior ___ nephrotoxicity. Her Cr
levels remained stable during admission (based on baseline
levels.) Pt is being followed by PCP and nephrology for this
issue.
#Hypernatremia: pt was noted to have slightly elevated Na at 146
on day of admission. Etiology was unclear, and her level was
tracked during admission. Her baseline Na has previously been in
high 130s-140s, and she has had previous issues with
hypernatremia. Her Na level came WNL at 143 at the time of
discharge. Pt is being followed carefully by her PCP and
nephrologist. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female who is s/p an MVC this morning with + LOC and
+SB. There was no air bag deployment. She was driving in a
parking lot at low speed when another vehicle struck her car at
approximately 30mph. She was initially transported to ___
___ for evalaution and workup revealed a small right parietal
SDH. She was neurologically intact and trasnferred to ___ for
further management and care. She reports of a mild ___
headache. She denies nasuea, vomiting, dizziness, difficulty
ambulating, changes in vision, hearing, or speech. CHEST (PORTABLE AP) showed No acute intrathoracic process CT HEAD W/O CONTRAST showed Right cerebral subdural hematoma, increased in size, now 10mm. No significant
mass effect or midline shift. CT HEAD W/O CONTRAST showed Stable right subdural hematoma compared to 1 day earlier, without sulcal
effacement. The patient was diagnosed with SUBARACHNOID HEM-NO COMA, MV COLLISION NOS-DRIVER. At the time of discharge, the patient had Right parietal 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>The patient was transferred from ___ for small R
parietal SDH and admitted to the Neurosurgery Service on ___.
Her initial head CT showed expansion of right parietal SDH. She
was started on levitiracetam for seizure prophylaxis and
monitored with serial neurologic checks per routine.
On ___, the patient remained neurologically stable. Repeat
head CT on ___ showed stable right parietal SDH. She was
deemed ready for discharge home. A thorough discussion was had
regarding post-discharge instructions. She was provided with a
prescription for levitiracetam to continue until follow up and
she was instructed to follow up with Dr. ___ in ___ weeks
with repeat head CT at that time.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ G3P3 with a PMH significant for AML s/p treatment, now in
remission, presents to the ED with 1 day of bilateral lower
abdominal pain. Pain started last night (___) around 2200. Is
constant and aching, rated initially ___, throughout the lower
abdomen but slightly more right than left-sided. She tried OTC
meds at home with little relief. She was seen in ___ clinic
this morning for routine follow-up and was sent to the ED given
her significant pain.
She denies any fevers, chills, vomiting, dysuria, vaginal
discharge or bleeding, diarrhea, constipation. She has nausea
with the pain. She did have intercourse on ___ with her
partner (of one week), and the condom did break. The intercourse
was only uncomfortable in that it was with a relatively new
partner but described as non-painful. She does not believe her
partner has had any sexually transmitted infections. Radiology showed 1. Bilateral fluid-filled tubular structures within the pelvis most likely
represent bilateral hydrosalpinges including suggestion of bilateral
inflammatory changes. Although an inflamed appendix intermingled with the
right adnexa is hard to exclude, a small inflammed tube seems much more
likely. Active pelvic inflammatory disease is a likely etiology and further
evaluation with ultrasound is suggested.
2. Cholelithiasis without evidence of cholecystitis. Radiology showed 1. C-section scar with possible small fibroid at the C-section scar.
2. Fluid within the cervix.
3. Left hydrosalpinx.
Addendum: This study was discussed with Dr. ___ at 845 AM on ___ by Dr.
___. The ultrasound shows a dilated tube on the left with a slightly thick
wall and debris. The ovary is seen adjacent to this. This is not a classic
___ since the ovary is seen separate from the tube, and but the amount of
debris in the tube is compatible with a pyosalpinx. This tube measures 5.2 x
2.3 cm on the images where it appears the largest. This change in diagnosis
from hydrosalpinx to pyosalpinx is compatible with the patient's clinical
history of PID. Radiology showed 1. Fluid-filled rim-enhancing tubular structures in both adnexa are most
consistent with pyosalpinx as noted on the recent ultrasound.
2. 9 mm fluid filled appendix without ___ stranding to suggest
appendicitis. The patient was diagnosed with ABDOMINAL PAIN RLQ, ACUTE MYELOID LEUK-IN REMISS. At the time of discharge, the patient had bilateral pyosalpinx. 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 made NPO and admitted from the
emergency department for serial abdominal exams and IV
gentamicin and clindamycin for presumed pelvic inflammatory
disease in the setting of leukocytosis to 19.7 with left shift,
elevated ESR and CRP, and a final pelvic ultrasound consistent
with 5.2cm left pyosalpinx that was not amenable to ___ guided
drainage. General surgery was consulted as appendicitis could
not be ruled out and recommended the addition of IV flagyl.
Since she had significant RLQ tenderness and the initial CT scan
was not able to visualize the appendix, a repeat CT with IV and
oral contrast was ordered to rule-out appendicitis. She refused
to drink oral contrast throughout the day, saying that she would
have emesis with it although she continued to ask for coffee and
food. Her abdominal exam throughout hospital day 1 was unchanged
with significant RLQ tenderness and some voluntary guarding but
no rebound tenderness. She was afebrile and her vital signs were
stable.
On hospital day 2, Ms. ___ continued to refused to drink the
oral contrast through the day, ultimately throwing the oral
contrast on the floor. In the afternoon, she was unable to void
despite several attempts, and a foley was placed for urine
output monitoring. She had two brief episodes of anxiety marked
by crying, hyperventilation, tachycardia to 120 and elevated
blood pressure (140/70). The first was related to her aversion
to drinking oral contrast, and the second was related to placing
the foley catheter. She continued to report no change in her
abdominal pain, and her abdominal exams during both episodes was
unchanged with continued tenderness on the right side but no
rebound. Both episodes resolved with IV ativan. Social work was
consulted for support as the patient repeatedly threatened to go
home during these episodes. In the afternoon, she spiked her
first fever to 102.7 at 5pm. She initially refused to have labs
drawn but eventually consented to labs. Her WBC remained
elevated. As she had not received a full 24 hours of intravenous
antibiotics and her exam continued to have no evidence of
peritoneal signs, she was monitored with serial exams overnight.
Early in the morning on hospital day 3, Ms. ___ had increased
abdominal pain, continued fever to 101.5 at 3am and new
development of rebound tenderness on exam. She was again
counseled on the importance of a repeat CT scan with oral
contrast. She then agreed to drink some oral contrast in order
to proceed with a repeat CT scan, which revealed bilateral
pyosalpinx and normal appendix. Infectious disease was consulted
for persistent fever despite IV antibiotics, and they
recommended intravenous levofloxacin and flagyl for 24 hours
afebrile, which could then be transitioned to a 7 days oral
outpatient antibioitic course. At this point, she had been
afebrile since 7am, her WBC count was trending down, and her
abdominal pain was improved with less tenderness on exam and no
peritoneal signs. Throughout the day she continued to express
her desire to stop intravenous antibiotics, to eat, and to go
home. Multiple efforts were made to explain the importance of
continued inpatient hospitalization for intravenous antibiotics,
labs, and monitoring for her pelvic infection. Later in the
evening, Ms. ___ ultimately signed out against medical advice
with the knowledge that improper treatment of her infection
could result in her death. Her foley catheter and IVs were
removed prior to her departure. She was counseled on the
importance of continuing outpatient antibiotics and to return to
the emergency room if she had any change in symptoms including
continued fever, worsened abdominal pain, nausea/vomiting, or
any other concerns.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a PMH of non-ischemic cardiomyopathy with EF 35-40% p/w
several weeks of DOE which worsened yesterday. He states his
symptoms started around 2 weeks ago while he was in ___ and
were stable to mildly worsening until yesterday he had
significant worsening of his SOB. He notes the SOB is present
mainly with exertion and has been limiting his activity but
resolves with rest. He has no accompanied wheezing. He has not
any symptoms like this before. He denies any chest pain or
pressure, PND, and orthopnea. He notes intermittent ankle
swelling which he attributed to gout and which has currently
resolved. He flew in to ___ where he recieves his medical
care on ___ and underwent prostate biopsy on ___ which was
uncomplicated. He has noted no changes in his urination since
the biopsy including hematuria, dysuria, frequency, or changes
in his stream. He had an associated occasionally productive
cough but denies fevers and chills. CHEST (PA AND LAT) showed No radiographic evidence for pneumonia. CHEST (PA AND LAT) showed In comparison with the study of ___, there is little interval change.
The cardiac silhouette is at the upper limits of normal in size and there is
no evidence of acute pneumonia, vascular congestion, or pleural effusion.
Streak of atelectasis is seen at the left base. Radiology showed 1. No specific evidence of malignancy on this non contrast CT
2. FINDINGS CONSISTENT WITH SICKLE CELL DISEASE INCLUDING AUTO INFARCTION OF
THE SPLEEN, VERTEBRAL ENDPLATE INFARCTION.
3. CHRONIC FINDINGS INCLUDING A FULLNESS OF THE LEFT ADRENAL GLAND, SIMPLE
CHOLELITHIASIS. Radiology showed No evidence of malignancy on the current examination. The patient was diagnosed with RESPIRATORY ABNORM NEC. The patient was treated with Upper and lower endoscopy, ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Unprovoked, pulmonary embolism. Duodenitis,
hematuria
SECONDARY DIAGNOSIS: Sickle Cell. Hypertension, Diabetes,
Systolic 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>___ with a PMH of non-ischemic cardiomyopathy with last EF 35%
p/w several weeks of DOE with significant worsening over the
past day.
# Pulmonary embolism: Dyspnea, likely secondary to PE. His
presentation was initially concerning for a systolic CHF
exacerbation given the gradual onset and known cardiomyopathy.
However, he has not had prior CHF episodes in the past but he
only has mild bibasilar crackles, no ___ edema, no history of
PND/orthopnea. No evidence of acute ischemia with negative
biomarkers in ED. Alternatively, give his acute worsening on the
day PTA and presentation with tachycardia/hypoxia in the setting
of potential malignancy and recent plane flight a PE could be
considered. Wells score indicates moderate probability and
D-dimer was elevated. Cr too elevated for CTA so patient
recieved a VQ scan was ordered which shoed In terms of other
potential diagnoses, no evidence of pneumonia or infection.
Patient has sickle cell but does not appear to be in a crisis
and is without significant anemia.
- Was up to date on age appropriate cancer screening. However
early satiety prompted up to rule out a GI maligancy, discussed
below.
- Rivaroxaban 15mg BID for 21 days then 20mg daily for at least
6 months of anti-coagulation.
# EARLY SATIETY: Weight stable since ___ but reports subacute
onset of poor appetite and early satiety. No night sweats. Hct
is slightly down. Given recent possibly unprovoked PE, occult
malignancy should be excluded. CT Torso and ___ without
concerning findings for malignancy.
# ACUTE KIDNEY INJURY: Presented with Cr of 1.9. Patient with
diabetic nephropathy based on past labs but no evidence of CKD
and recent Cr measurement of 1.0 within 1 week. Suspect a
pre-renal etiology potentially related to decreased cardiac
output related to his above dyspnea. No evidence of poor PO or
increased volume losses. Could consider a post-renal etiology
given his suspected prostate cancer and recent urologic
procedure although he does not endorse any obstructive symptoms.
Urine lytes with FeUrea of 47%. Creatinine was 1.2 by time of
discharge.
# HEMATURIA: Likely ___ recent prostate biopsy procedure +
heparin gtt. However does have history of bladder cancer, but
most recent cystoscopy was normal. Unlikely from renal course
given presence of small clots.
# LACTIC ACIDOSIS: Most likely reflects a type B lactic acidosis
related to metformin use in the setting of renal failure. Could
consider a type A acidosis although his vitals and exam are not
c/w shock. LFTs within normal limits.
# DM2: Held home metformin given lactic acidosis above. Please
restart as an outpatient.
# HTN: Cont metoprolol, HCTZ, simvastatin
# Code: FULL (confirmed)
# Emergency Contact: ___ (daughter) ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old M with newly diagnosed HFrEF (EF 28%
___, persistent Afib, HTN, HLD, recently admitted for CHF
exacerbation and rapid AF, now re-presenting with one day of
profound fatigue as well as transient disequilibrium and garbled
speech. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Noncalcified plaque at the origin of the right internal carotid artery with
no evidence of stenosis.
2. The remainder of the vessels appear normal
3. Possible subcentimeter right thyroid lobe nodules, however not definitive
and may be artifactual.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. No acute infarction.
2. Small chronic infarcts involving the left occipital lobe, right posterior
parietal lobe and right posterior cerebellar hemisphere.
3. Moderately extensive supratentorial white matter signal abnormality
nonspecific, but likely sequela of chronic small vessel ischemic disease. Radiology showed Lungs are clear. Heart size is normal. There is no pleural effusion. No
pneumothorax is seen The patient was diagnosed with Dizziness and giddiness, Other fatigue, Altered mental status, unspecified, Unspecified atrial fibrillation. The patient was treated with DC Cardioversion ___. At the time of discharge, the patient had PRIMARY:
========
Atrial fibrillation
Hypertension
CHF exacerbation
Subacute/Chronic CVAs
SECONDARY:
==========
Hyperlipidemia
Transaminitis. 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:
====================
___ with HFrEF, persistent AF despite multiple cardioversions,
recently admitted at ___ from ___ for CHF exacerbation
in the setting of AF with RVR s/p successful cardioversion, now
readmitted with profound fatigue and transient neurologic
symptoms, found to have recurrent atrial tachycardia and
subacute/chronic CVAs with no residual deficits.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with h/o dementia, bipolar
disorder,
T2DM, hypothyroidism, CVA, recurrent UTIs, and recent admission
from ___ for confusion and worsening tardive dyskinesia
attributed to E coli UTI, who re-presents to the ED with
worsening mental status, agitation, and tardive dyskinesia. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Findings compatible with late acute to subacute left cerebellar infarct.
2. No large hemorrhage or midline shift. Examination is significantly limited
by patient positioning, motion and beam hardening artifact.
3. Additional findings described above.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:06 am, 5 minutes after
discovery of the findings. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Please note the study is suboptimal due to extensive motion artifact which
limits evaluation of intracranial structures.
2. Within these limitations, several areas of high signal on the diffusion
weighted images are seen in the left cerebral hemisphere are seen without
definite correlate on the ADC sequences. While these lesions could represent
subacute infarcts, other lesions are not excluded given degree of motion and a
repeat study may be helpful for further characterization.
RECOMMENDATION(S): A repeat study when patient is more cooperative would be
helpful to better characterize the left cerebellar lesions.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:21 pm, 1 minutes after discovery
of the findings. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had PRIMARY:
==================
Subacute encephalopathy in the setting of dementia
Cerebral vascular accident
Failure to thrive
Severe malnutrition
SECONDARY:
==================
Tardive dyskinesia
Schizophrenia vs bipolar disorder
Hypernatremia
Recurrent urinary tract infection, ___
Oropharyngeal dysphagia
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>PATIENT SUMMARY FOR ADMISSION:
================================
___ with h/o dementia, bipolar disorder, T2DM, hypothyroidism,
CVA, recurrent UTIs, and recent admission from ___
forconfusion and worsening tardive dyskinesia attributed to E
coli UTI, who represents to the ED with worsening mental status,
agitation, and tardive dyskinesia found to have
subacutecerebellar stroke.
Ultimately, due to a persistent decline in mental status and
failure to thrive, especially with regard to severe malnutrition
and cachexia, the medical team, psychiatry team, and geriatric
service met with the family and it was determined that the
patient would benefit most from home hospice. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ yo man w PMHx significant for DMII, HTN, HLD, GERD
presents with 5 weeks of watery diarrhea (24x/day) associated
with abdominal cramps. Patient reports significant decreased
appetite, with 25lb weight loss in the past two weeks. The
patient had planned a 2 week trip to ___, and
prior to leaving had started experiencing symptoms of bloating,
loose stools, and abdominal pain. While on vacation, the
diarrhea worsened, increasing in frequency and becoming watery.
Patient visited PCP ___ ___ (one day after returning from ___
when her returned from the ___ ___ stool analysis and lab
tests that were unremarkable. Patient presented to the ED (___
___ on ___ where he had a an abdominal CT that
showed pancolitis, but both stool and blood samples were
unrevealing. Patient was discharged on ciprofloxacin. Patient
was then seen by outpatient GI on ___ who ordered a new stool
analysis, added flagyl to his treatment, and scheduled him for a
colonoscopy. Once the stool came back positive for C. diff
(___), the patient was started on PO vancomycin. His GI
physician suggested the patient should visit the ED given his
dehydration and weight loss. Patient denies recent antibiotic
use or hospitalization. Radiology showed Normal bowel gas pattern without evidence for obstruction or free
intraperitoneal air. The patient was diagnosed with Enterocolitis due to Clostridium difficile. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo man w PMHx significant for DMII, HTN,
HLD, GERD
presents with 5 weeks of watery diarrhea (24x/day) associated
with abdominal cramps and 25lb weight loss. Prior to admission,
he was found to have a stool sample positive for C. difficile
and an abdominal CT that showed pancolitis.
# C.Difficile Colitis: Prior to admission, the patient was
started on PO vancomycin 24h per GI recommendation. Because the
patient he was reporting >24 BMs per day, he was instructed to
go to the ED, given concern for dehydration and electrolyte
abnormalities. On admission, the patient was HD stable, afebrile
with WBC 9.3. Exam notable for generalized weakness and dry
mucous membranes. Labs were notable for Na of 132, glucose of
302. KUB showed normal bowel gas pattern without evidence of
obstruction or free intraperitoneal air. He received a bolus of
2L NS and was continued on his vancomycin 125 mg PO Q6h. Over
the course of his hospital stay, the patient's symptoms improved
with decreased frequency of BMs to approximately 10/day,
improved appetite, and significant improvement in his abdominal
pain. He was discharged with instructions to complete a 14-day
regimen of vancomycin (First day: ___ - Last day: ___.
# Anemia/BRBPR: Patient's HgB dropped from 13.8 on admission to
11.9 on ___ but did not continue to downtrend. Likely
multifactorial including initial hemoconcentration with dilution
following IVF as well as GI losses as patient reported
occasional blood on the toilet paper that started in the setting
of his very frequent BMs. On discharge, his Hgb was 11.8.
Requires outpatient follow with GI after resolution of colitis
for colonoscopy.
# DM2: Patient with known DM2, recent HbA1C=10.1. On admission,
blood sugar >300. Despite standard HISS, an diabetic diet
in-hospital, blood sugar remained high. Requires follow-up and
adjustment of oral antidiabetics with possible addition of
insulin.
#Hyponatremia: Likely hypovolemic hyponatremia in the setting
above c. diff infection.
***TRANSITIONAL ISSUES***
# Continue Vancomycin 125 mg PO QID for a total of 14 days (Last
day: ___.
# To follow-up with PCP, ___ (___) within
___ days of discharge.
# To follow-up with GI specialist, Dr. ___
(___) as an out-patient within 2 weeks of discharge.
# Patient had reported a little bright red blood per rectum
without hematochezia, likely from hemorrhoids. Will require
follow-up.
# Patient is diabetic with last HbA1c of 10.1. Blood sugar in
the hospital >300. Patient may require increasing oral
antidiabetics or adding on insulin. Will require follow-up with
PCP for proper management of diabetes.
#CODE: Full
#Contact: Girlfriend (___) - ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of HTN and high cholesterol who is presenting as a
transfer from ___ with NSTEMI on heparin and nitro. Radiology showed Fluoroscopic images demonstrate placement of a Swan-Ganz catheter. Please
note that the superior portion of the catheter tip is not included on the
field of view. Please refer to the operative note for additional
details.There is gaseous distention of the stomach. Radiology showed There is a Swan-Ganz catheter with the distal tip projecting over the main
pulmonary artery in good position. Impella catheter is seen within the aorta.
Heart size is within normal limits. There is no focal consolidation, large
pleural effusions, pulmonary edema, or pneumothoraces. Radiology showed Fluoroscopic images demonstrate placement of a Swan-Ganz catheter. On the
last image, the distal tip appears to terminate within a distal right main
pulmonary arterial branch. This could be pulled back 4-5 cm for more optimal
placement. Please refer to the procedure note for additional details. Radiology showed The Impella device has been removed. There is a Swan-Ganz catheter,
endotracheal tube, feeding tube, and chest tubes which are in standard
position. Heart size is upper limits of normal. There remains some
prominence of the upper left mediastinum, unchanged. There is minimal
blunting of the right CP angle. Lungs are relatively clear. There is no
pneumothoraces. Lower extremity arterial duplex US. was done. Radiology showed Evidence of severe right lower extremity ischemia. No evidence ischemia on
the left. KNEE (AP, LAT AND OBLIQUE) RIGHT showed Moderate joint effusion. Right TKR without fracture or dislocation. Portable chest showed There is a new large right-sided pneumothorax and right-sided pleural
effusion. New area of focal opacification in the left midlung which may be
due to pulmonary vascular congestion or aspiration/pneumonia in the
appropriate clinical setting.
NOTIFICATION: The findings were discussed with Dr. ___. by
___, M.D. on the telephone on ___ at 5:10 pm, 5
minutes after discovery of the findings. Chest radiograph showed Compared to the examination from 2 hours prior, a right upper pleural pigtail
catheter has been placed, with decrease of the right apical lateral
pneumothorax, though with small residual apical component and residual partial
collapse of the right upper lobe. No other interval changes seen. CHEST (PORTABLE AP) showed Comparison to ___. The right internal jugular vein catheter and
the right chest tube are in stable position. On the current radiograph, there
is no evidence of pneumothorax. Moderate cardiomegaly. Mild retrocardiac
atelectasis. No larger pleural effusions. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, with the right chest tube
on water seal, there is no evidence of appreciable pneumothorax.
Otherwise no change. Chest radiograph showed Compared to the earlier same day examination, there has been exchange of the
right internal jugular central venous catheter with the tip now terminating at
the cavoatrial junction, satisfactory. There is no associated pneumothorax.
There is otherwise no significant change compared to the earlier same day
examination. The right pigtail pleural catheter remains in place and there is
no gross pneumothorax. There are likely small bilateral pleural effusions
with bibasilar atelectasis and linear lingular atelectasis. There is no
worsening or new consolidation. Chest AP view. showed Chest AP view is compared to a prior done ___. Right-sided pigtail
catheter and right IJ line are unchanged in position. Small bilateral
effusions right greater than left have slightly increased in volume.
Cardiomediastinal silhouette is stable. No pneumothorax is seen. Lungs are
low volume. CHEST (PORTABLE AP) showed Compared to chest radiographs ___, through 11:33.
Small right pleural effusion stable, no detectable right pneumothorax,
following removal of the right pigtail pleural drainage catheter. Previous
mild cardiomegaly has resolved and small pleural effusions are smaller.
Moderate left lower lobe atelectasis unchanged. No pulmonary edema.
Right jugular line ends in the low SVC. Chest radiograph PA and lateral showed No definite evidence of pneumothorax. Stable small pleural effusions. The patient was diagnosed with ST elevation (STEMI) myocardial infarction of unsp site. The patient was treated with ___ Cardiac cath with Impella insertion and 2 DES
___ Impella repositioning, unsuccessful impella removal
___ 1. Coronary artery bypass grafting x1 with left internal
mammary artery to the left anterior descending artery. 2.
Removal of Impella device with aortotomy.. At the time of discharge, the patient had Myocardial infarction, coronary artery disease s/p Coronary
artery bypass graft x 1, drug-eluting stent placement x 2
Past medical history:
Hypertension
LBBB
Osteoporosis
Hyperlipidemia
Basal cell carcinoma of skin
b/l total knee replacement
Cataract extraction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of HTN and high cholesterol who is presenting
as a transfer from ___ with NSTEMI on heparin and
nitro found to have inferior STEMI successfully
revascularization of RCA, remaining 90% LAD occlusion
complicated by reperfusion VT and cardiogenic shock requiring
mechanical support with Impella.
In CCU, ___ catheter placed. Attempted echo verification
of placement of impella, however this appeared somewhat shallow
so bedside advancement was attempted. This was complicated by
coiling of impella in LV. Attempted to withdraw the impella
unsuccessfully, and so CSurg was consulted. Patient was taken to
the the OR on ___ for impella removal and concomitant coronary
artery bypass graft x 1. Please see operative note for surgical
details. Following surgery she was transferred to the CVICU for
invasive monitoring. Arrived from OR intubated and sedated on on
Epi infusion for hramodynamic support. On POD#1 was noted to
have a cold right foot and loss of pedal pulses. Vascular
surgery was consulted and the patient was taken tot he operating
room for a Right femoral exploration and thrombectomy. She
underwent a thrombectomy on ___ and pedal pulses returned and
systemic anticoagulation with heparin was maintained for
profusion. The patient will not require anticoagulation and will
be discharged on Plavix and aspirin. She will follow up with the
vascular surgery team as an outpatient. She has groin staples in
place which should be removed 2 weeks after placement (___).
Her perfusion returned after surgery, however she has moderate
right foot sensation loss. She will be discharged with a
multi-podus boot and will need follow up with physical therapy.
CT's were removed and patient developed a right PTX-a pigtail as
placed with lung re-expansion. Water seal trial was successful
and Pigtail was removed without incident on ___. Her discharge
CXR shows no residual PTX. She was started on Lopressor prior to
discharge but was not started on a statin due to allergy. A
foley was replaced on ___ due to acute urinary retention. She
was started on Flomax and will be discharged with a foley
catheter in place. A UA was obtained and was negative. A voiding
trial should be attempted at rehab. The patient was evaluated by
physical therapy and was deemed appropriate for rehab. The
patient should have aggressive physical and occupational therapy
at rehab to help facilitate recovery of strength in her right
foot. She will be discharged to ___ at
___ on ___ on POD 5.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with a history of A. fib on
apixaban, type 2 diabetes, MVR, mental disability with
developmental delay who presented after an unwitnessed fall. CHEST (PORTABLE AP) showed No acute intrathoracic process. CT HEAD W/O CONTRAST showed 1. No intracranial hemorrhage or calvarial fracture.
2. Global age-related involutional changes.
3. Mild paranasal sinus disease. CT C-SPINE W/O CONTRAST showed Acute avulsion fracture of the anteroinferior corner of the C3 vertebra,
likely due to hyperextension.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:08 pm, 5 minutes after
discovery of the findings. C-SPINE NON-TRAUMA ___ VIEWS showed Unchanged appearances of the known C3 fracture. The patient was diagnosed with Type 2 diabetes mellitus with hypoglycemia without coma, Long term (current) use of insulin. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>HOSPITAL COURSE
===============
Mr. ___ is a ___ man with a history of A. fib on
apixaban, type 2 diabetes, MVR, mental disability with
developmental delay who presented after an unwitnessed fall,
found to be severely hypoglycemic likely in the setting of
medication errors and had C3 fracture with plan for non-surgical
management.
ACTIVE ISSUES
=============
# Hypoglcyemia
# DMII: Likely ___ to missed meal and incorrect medication
administration. Per most recent PCP ___ (in external reports),
on glimepiride 2mg daily and 34 u lantus. Per ___ is on 40 U
lantus, 4mg BID glimepiride, and metformin 500mg BID. Based on
his pill bottles from home, it appeared he was taking
glimepiride 4mg BID and lantus without any metformin. ___
consulted and decreased his Lantus significantly with good
results.
# A-fib: Failed cardioversion ___. Initial heart rates are
not well
controlled in the 120's, started metop tatrate 12.5mg q6h,
titrated to 25mg q6 for goal HR < 110. Continued apixiban 5mg
BID.
# Fall
# C3 spine fracture: C3 avulsion fracture: Non-operative per
orthopedics. Cervical collar in place at all times. Activity as
tolerated. Follow-up in spine clinic in 2 weeks.
# Home safety
# Medication errors: Multiple falls recently. Likely both
hypoglycemia and excess amlodipine dosing could be contributing.
___ recommended acute rehab, and on discharge will need higher
level of care to assist with medication and insulin
administration.
CHRONC ISSUES
=============
# Prostatomegaly
# Hematuria
# Flexible cystoscopy: Follows with urology. No current change
in
management, follow up in 6 months for possible procedure. Stable
inpatient.
# PE: Subsegmental, found in syncopal work up last admission. On
apixiban for afib. Unclear if significant or incidental finding.
Continued apixiban.
TRANSITIONAL ISSUES
===================
[] Medication changes
- Reduced dose of insulin Lantus to 18U QHS
- Increased Metoprolol Succinate XL from 50mg to 100 mg PO DAILY
- Stopped amLODIPine 10 mg PO BID (normal blood pressure)
- Stopped glimepiride 4 mg oral BID
[] Check morning blood sugars, if < 120 would decreased his
Lantus by at least 2 units
[] Follow up scheduled with ___ Diabetes and Spine Clinic
# CONTACT: ___
___: sister
Phone number: ___
Cell phone: ___
>30 minutes spent on complex discharge.</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 a PMH of atrial
fibrillation on warfarin, CAD s/p CABGx2, systolic heart failure
with an LVEF of 25%, carotid stenosis s/p CEA, and recent
admission for mechanical fall c/b multiple bruises and liver
laceration (___), now being readmitted with increased
dyspnea on exertion, a few episodes of acute SOB and continued
right-sided abomdinal pain. Patient is being admitted for
observation, pain control and serial hematocrit monitoring.
Patient notes that he felt fine when he left the hospital on
___. The next day, "things went South," and the following day
"things went farther South." The patient developed increasing
dyspnea on exertion, just after walking 2 steps up the stairs,
so that he had to go up the stairs on his bottom one step at a
time. Additionally, he had 9 episodes of right-sided, lower
chest pain over the past three days; these episodes responded to
nitroglycerin. These episodes were accompanied by shortness of
breath. He has a dry cough at baseline, as this cough increased
in frequency, but is not productive. He denies any orthopnea,
PND, weight gain, central chest pain or peripheral edema. He
also notes more anxiety than usual.
.
In the ED, initial vs were: T 98.4 BP 133/76 HR 108 RR 16 SaO2
98%RA. Physical exam with ecchmosis around R eye stable; AOx3,
although slightly more confused; lungs CTAB no crackles; heart
irregular no S3, no elevation of JVD, abd firm, slightly
distended and tympanitic, no chest wall tenderness, no ___ edema.
Labs were remarkable for BNP 2485, differential with
neutrophilic predominance of 77.8%, INR 2.7. Troponin <0.01. CT
abdomen and pelvis with contrast showed no evidence of liver
laceration or evolution of ascites, with a decrease in the
amount of ascites since imaging on ___. Vitals on Transfer:
Temp: 97.8 °F (36.6 °C), Pulse: 82, RR: 24, BP: 152/68, O2Sat:
96 on RA.
.
On arrival to the floor, the patient developed an acute episode
of chest pain and shortness of breath on transfer from the
stretcher to his bed. His vitals on arrival were 97.3 184/109 58
98%RA. He received one nitroglycerin 0.4 mg SL, which resulted
in decrease in BP to 140/80.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Radiology showed Mild interstitial edema with bilateral small pleural effusions. Radiology showed 1. No evidence of acute intra-abdominal pathology.
2. Amount of ascites since the examination of ___ has decreased. Radiology showed No CT evidence for acute intracranial hemorrhage. Bifrontal areas
of encephalomalacia unchanged from ___. The patient was diagnosed with SHORTNESS OF BREATH, ATRIAL FIBRILLATION. The patient was treated with ___ - Cardiac catheterization with right coronary artery
stenting. At the time of discharge, the patient had Primary diagnosis-
# CHF exacerbation
# Right PDA stenting with bare metal stent
# Acute delerium. 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>IMPRESSION: ___ M with a PMH significant for A.fib (on
Coumadin), carotid stenosis, presumed ILD, severe coronary
artery disease (s/p 4V CABG), ischemic cardiomyopathy with an
LVEF of 25% with recent admission for mechanical fall and
conservatively managed liver laceration, who presented with
refractory shortness of breath now with hospital course
complicated by delirium now status-post cardiac catheterization
(___) with right coronary artery stenting.
# ACUTE ON CHRONIC DYSPNEA - Patient presented with increasing
dyspnea since discharge and evidence of persistent mild
pulmonary edema on CXR. Thought to be acute on chronic CHF
exacberation (LVEF 28%) but not much improvement with diuresis.
No evidence of consolidation or obvious infection on admission.
His BNP was mildly elevated. Cardiac enzymes on admission were
negative and his EKGs were reassuring. Received Lasix 40 mg IV x
1 on ___. Pulmonary embolism seemed less likely given his
anticoagulation needs. Given these findings, a chronic etiology
was considered most likely (deconditioning, pulmonary disease or
natural evolution of CHF). Cardiology was consulted and decided
a cardiac catheterization was necessary given his long-term
ischemic cardiomyopathy and concern for a reversible lesion. He
underwent cardiac catheteriztion on ___ with stenting of the
right coronary artery. Following the procedure, he was
maintained on Aspirin and started on Plavix 75 mg PO daily. He
was diuresed following catheterization, and was euvolemic for
several days prior to discharge. He was discharged on home dose
of lasix 40mg po daily.
# ACUTE DELIRIUM - Concern for delirium following admission with
inattentiveness and combativeness. Sleep patterns had been
erratic. Has occurred with prior hospitalizations. No infectious
cause was identified. Cardiac etiologies were treated as above,
but did not appear to be acute in nature, so unlikely to
precipitate acute change in mental status. Hematocrit was
stable, as was CT abd/pelvis, so unlikely to be related to
recent fall and liver laceration. in addition, CT head was
unchanged. Patient has underlying dementia predisposing him to
delerium.
Geripsych was consulted and followed patient closely. Optimal
regimen for controlled agitation was seroquel 25mg qHS with prn
dose. Patient was still confused at the time of discharge, and
___, primary team and geripsych recommended ___
___ facility to family. Family refused rehab, and
insisted on taking patient home. Family was encouraged to avoid
alprazolam and trazodone, and to continue seroquel as dosed
in-house.
# ACUTE DIARRHEA - Overnight on ___ developed episodic, watery
diarrhea that remained non-bloody. No abdominal pain or
cramping. Afebrile and without leukocytosis. C.diff toxin was
negative. Patient had been receiving large amount of
medications to prevent constipation which likely precipitated
diarrhea. It resolved spontaneously and did not return.
Abdominal exam was reassuring. Patient had stable hematocrit.
# CORONARY ARTERY DISEASE - Patient presented with strong
history of CAD and known 4-vessel disease with two prior CABG
surgeries. EKG reassuring on admission and cardiac enzymes flat
despite subjective dyspnea complaints. BNP slightly elevated on
admission. No history of chronic stable angina symptoms
recently. P-MIBI in ___ showing fixed RCA and LAD lesions.
Despite these findings, cardiology opted for cardiac
catheterization on ___ and stented his right coronary artery.
He was continued on Aspirin 325 mg PO daily, Simvastatin 20 mg
PO QHS, Imdur 90 mg PO daily and his Ranolazine. Plavix 75 mg PO
daily was added given his stent placement.
# CHRONIC SYSTOLIC HEART FAILURE WITH PRESUMED ACUTE
EXACERBATION - Presented with chronic systolic failure and LVEF
of 25% (since ___. Secondary to chronic graft occlusions with
WMA and fixed deficits in RCA, LAD remaining (ischemic
cardiomyopathy). Admitted with concern for volume overload,
requiring IV Lasix. His supplemental oxygen was weaned. His ACEI
was held on admission given concern for renal insufficiency, but
was restarted prior to discharge given improving renal function.
Metoprolol was increased to 100mg po BID and home sasix dosing
was continued. His aldosterone antagonist was held throughout
admission and at discharge. His daily weight was monitored and
he was maintained on strict I/O monitoring with a goal fluid
balance of even to 0.5L negative daily.
# ATRIAL FIBRILLATION - CHADs-2 score of 5 (CHF, HTN, DMII, h/o
TIA). Increased metoprolol to 100mg BID for improved rate
control. Coumadin was held on the two days prior to discharge
and patient was instructed to have INR checked by ___ on ___
with results sent to cardiologist Dr. ___ further
instructions on dosing.
# OSA/RLD - Likely contributing to chronic dyspnea complaints.
Patient has underlying ILD per report, without CT imaging
suggestive of interstitial process. FEV1 is 60% of predicted
value. No prior smoking history. CT chest showing pleural
plaques only with possible prior asbestos exposure. Consider
repeat PFTs and possible thin-cut CT scan of chest to evaluate
chronic dyspnea.
# ACUTE ON CHRONIC RENAL INSUFFICIENCY - Baseline CR 1.2-1.7,
elevated on admission. Attributed to systolic failure
exacerbation vs. worsening baseline renal insufficiency. This
improved with improvement in his cardiac function and decreased
diuresis.
# TRANSITIONAL ISSUES -
- INR to be checked on ___ and sent to Dr. ___,
___ warfarin on discharge until further instructions
- electrolytes to be checked on ___ and sent to Dr.
___
- spironolactone held on discharge
- for delerium, trazodone, alprazolam, and donepezil were
discontinued. Patient should be given 25mg seroquel qHS with
additional 25mg as needed for agitation. Follow-up scheduled
with cognitive neurologist Dr. ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ mechanical fall down three stairs, landed on her left
side. Did not hit her head, denies LOC. No preceding light
headedness, SOB, CXP, dizziness. C/O left shoulder and left
knee/calf pain. Specifically denies left hip or groin pain.
Denies numbness or tingling. No neck or back pain. Fall occured
at 18:00. NPO since ___. Radiology showed No acute intracranial process. Radiology showed No acute fracture or traumatic malalignment. Radiology showed 1. Split and depressed-type fracture of the lateral tibial plateau, Schatzker
type 2, with 1.1 cm depression of the articular surface. A spiral component
to the fracture extends down to the mid tibial diaphysis.
2. Moderate lipohemarthrosis.
3. Status post fasciotomy. The patient was diagnosed with FX UPPER END TIBIA-CLOSE, TRAUMATIC COMPARTMENT SYNDROME OF LOWER EXTREMITY, FALL ON STAIR/STEP NEC. The patient was treated with ___ - Left calf fasciotomies and tibial plateau ex-fix. At the time of discharge, the patient had Tibial plateau fracture and compartment 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 presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left calf compartment syndrome and tibial plateau
fracture and was taken emergently to the operating room on
___ for left calf fasciotomy and external fixation of tibial
plateau fracture. Postoperatively she was admitted to the
orthopedic surgery service. She subsequently underwent several
operations including repeat I&D and vac change on ___,
ex-fix removal, ORIF left tibial plateau fracture, and vac
placement on ___, and left lower extremity lateral wound
split thickness skin graft and medial primary closure with vav
placement over skin graft and incisional vac placement over
medial primary closure.
The patient tolerated the procedure 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. She was transfused
2 units of pRBCs for a HCT of 20.3 on POD2. The patients home
medications were continued throughout this hospitalization. She
was evaluated by psychiatry for medication management with mild
agitation while an inpatient. They recommended limiting
benzodiazepine use in addition to continuing her home
medications. Her platelet count increased to greater than ___ on
___ and hematology was consulted for further evaluation.
Given her lack of signs of an infection this was thought to be
reactive in nature and they recommended following her CBC and
monitoring her clinical status. Her platelets began to trend
down on ___ and she remained afebrile with stable vital
signs and no signs of an infectious process. 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 touch down weight bearing in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ year female with history significant for
hemorrhoids, diverticulitis, and polyps who presents with 2 day
history of colicky abdominal pain, constipation, followed by 2
loose stools with "mucousy" blood in the toilet.
In the ED, initial vitals were:
Temp. 97.9, HR 66, BP 136/93, RR 18, 100% RA
Labs in the ED were notable for elevated lactate 2.5, Hg/Hct
15.8/45.4, and WBC of 11.7. UA negative for nitrites and
leukocytes.
CTA was significant for no evidence of mesenteric ischemia,
hyperenhancing 5mm focus along the wall of the jejunum that may
represent polyp or extravasation and hiatal hernia. The patient
was given 1L NS. She was noted to be anxious in the ED and
received her AM dose of ativan at that time. CTA ABD AND PELVIS showed 1. No evidence of mesenteric ischemia.
2. Hyperenhancing 5 mm focus along the wall of the jejunum seen only on portal
venous phase may represent a polyp or venous extravasation. No arterial
extravasation identified.
3. Hiatal hernia.
4. Trace pleural effusions. The patient was diagnosed with RECTAL & ANAL HEMORRHAGE. The patient was treated with Flexible Sigmoidoscopy ___
Endoscopy ___. At the time of discharge, the patient had Primary:
Gastrointestinal bleeding
Colitis
Hiatal Hernia
Secondary:
Anxiety
Skin cancer s/p Mohs
Cataracts
Constipation
GERD
Migraine headaches
GERD
Hypercholesterolemia
Hypertension
Hypothyroidism
Neck pain
Osteopenia
Recurrent urinary tract infections
Pedal Edema
Hemorrhoids. 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 ___ year female with history significant for
hemorrhoids, diverticulitis, and polyps who presents with 2 day
history of colicky abdominal pain, constipation, followed by 2
loose stools with "mucousy" blood in the toilet noted to be
guiac positive in the ED with signs/symptoms concerning for
possible lower GI bleed.
# Bright red blood per rectum:
Ms. ___ was admitted to the hospital because she noted
bright red blood per rectum. She was noted to be guiac positive
in the Emergency room. She was admitted and evaluated with
sigmoidoscopy and endoscopy. She remained hemodynamically stable
throughout the course of her hospital stay. Her sigmoidoscopy
showed colitis that was thought to be most likely due to
constipation or ischemia though CTA was without evidence of
mesenteric ischemia. Endoscopy was also done that showed known
hiatal hernia but no active evidence of bleeding. A biopsy was
taken at time of sigmoidoscopy and the results will be mailed to
the patient. It was recommended that Ms. ___ continue
taking daily prilosec and also take daily colace and miralax for
constipation.
#Colicky abdominal pain
Ms. ___ endorsed symptoms of colicky abdominal pain prior
to admission in the setting of constipation. Given her history
of constipation, straining with stooling, and hard stools her
symptoms were thought to be most likely due to constipation.
Infection less likely given absence of fever and exam that was
non-focal, with no evidence of rebound or guarding. She was
discharged with stool regimen including colace and miralax.
# Hypertension
-continued atenolol 25 mg daily
# Hypercholesterolemia
-continued lovastatin
-Aspirin held intially in setting of possible GI bleed but
restarted prior to discharge
# GERD with large hiatal hernia also seen on EGD
It was recommended by gastroenterology that patient continue
prilosec daily.
#Hypothyroidism
-continued levothyroxine
#Depression/Anxiety
-continued mirtazapine
-continued AM and ___ lorazepam</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Neurology at bedside for evaluation after code stroke activation
within: 5 minutes
Time (and date) the patient was last known well: 0500 on
___ clock)
___ Stroke Scale Score: 2
t-PA given: Radiology showed 1. No acute intracranial hemorrhage or mass effect. Please see MRI of the
head performed subsequently regarding multiple small acute infarcts in the
left cerebral hemisphere.
2. Patent major intra and extracranial arteries as described above.
Extensive atherosclerotic disease with calcified and noncalcified plaques in
the aortic arch, arch vessels, common carotid arteries and the bifurcations
and cervical internal carotid arteries as described above.
Approximately 50% stenosis in the right common carotid artery, less than 20%
in the left common carotid artery and approximately 55% stenosis at the left
common carotid bifurcation.
Left Cervical ICA: Prominent calcified and noncalcified plaques in the left
proximal cervical internal carotid artery extending from the common carotid
bifurcation, causing approximately 60-65% luminal narrowing, based on European
criteria, though 30% based on NASCET criteria, over a length of approximately
2.1cm; the difference can be attributed to tortuous course and expanded vessel
contour. Tiny hypodense focus within-? thrombus or volume averaging.
Right cervical ICA: Less than 20% stenosis
Intracranial ICA: Mild-moderate narrowing of the cavernous carotid segments
on both sides.
3. Multilevel, multifactorial degenerative changes are noted, with mild canal
moderate to severe foraminal narrowing with deformity on the nerves from C3-C7
levels.
A small sclerotic focus in the T4 vertebral body question bone island or a
sclerotic neoplastic lesion. Correlate clinically to decide on the need for
further workup or followup.
4. Periapical lucencies noted around the left mandibular third molar-
correlate with dental examination. Radiology showed Heart size is within normal limits. There is mild tortuosity of the thoracic
aorta. There are no focal consolidations, pleural effusion, or pulmonary
edema. There are no pneumothoraces. MR HEAD W/O CONTRAST showed 1. Several foci of acute-subacute infarction in primarily the left MCA
territory as detailed above, likely embolic; no evidence of hemorrhagic
transformation, significant edema or mass effect.
2. T2/FLAIR signal hyperintensity in the periventricular, subcortical, and
deep white matter which is nonspecific but likely on the basis of chronic
small vessel ischemic disease. CT HEAD W/O CONTRAST showed 1. No evidence of acute hemorrhage.
2. Unchanged appearance of left frontal lobe subcortical hypodensity.
3. Age-related involutional changes and likely sequela of chronic small vessel
ischemic disease. CAROTID DOPPLER ULTRASOUND showed Less than 40% stenosis of the bilateral internal carotid arteries. Doppler
suggests that the left ICA stenosis is less severe than suggested by CTA ___. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT, HYPERTENSION NOS. The patient was treated with tPA at ___ on ___. At the time of discharge, the patient had Left MCA 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>___ presenting with stroke causing sensorimotor deficits of RUE
s/p tPA at 7:06am ___ (___ and some subjective
improvement in signs and symptoms. Etiology likely large vessel
to vessel embolus. His HA1c=5.6, and LDL=78.
CTA Head/Neck no acute intracranial hemorrhage or mass effect
but did reveal extensive atherosclerotic disease with calcified
and noncalcified plaques in the aortic arch, arch vessels,
common carotid arteries and the bifurcations and cervical
internal carotid arteries. MRI Head w/o showed several foci of
acute-subacute infarction in primarily the left MCA territory as
well as chronic small vessel ischemic disease. ECHO (TTE) showed
LVEF>55% and a normal left atrium with no trombus/mass. Carotid
dopplers showed less than 40% stenosis of the bilateral internal
carotid arteries. The patient was started on aspirin 81 and
atorvastatin 80. He was also evaluated by occupational therapy
who recommended outpatient OT. He was provided a prescription
for these services. He was discharged in stable condition with
close neurology follow up.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 78) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? () Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year-old Female with PMH significant for
hypertension, atrial fibrillation (not on anticoagulation),
adjustment disorder, anxiety, prior left breast cancer (invasive
lobular adenocarcinoma, s/p XRT and tamoxifen), osteopenia,
presenting to the ED with a L wrist fracture (comminuted
displaced left distal radius fx with ulnar styloid fx). The
patient fractured her wrist on ___, when she was walking
into a casino and lost her footing on an uneven entryway. Denies
fever, chills, weight loss, nausea, vomiting, diarrhea, dysuria.
On ___ she went to a Dr ___, who wrapped her
hand and only let her leave when she promised to see her Dr ___
___ soon. On ___ she saw her PCP in ___, who "did not
like the color of the hand" and sent her to the ___ ED. Per
the patient the hand has felt numb and been dusky in color ever
since the fall. She is no able to move her ___ finger, she can
wiggle her other fingers. Radiology showed Comminuted distal radial fracture with intra-articular extension,
displacement, and slight impaction. Displaced ulnar styloid fracture,
unchanged. Radiology showed Slight interval improvement in alignment of the comminuted distal radial
fracture. Persistent mildly displaced ulnar styloid fracture. The patient was diagnosed with JOINT EFFUSION-L/LEG, POPLITEAL SYNOVIAL CYST. The patient was treated with external fixation and splinting of L wrist fracture. At the time of discharge, the patient had Primary Diagnosis
1. comminuted displaced left distal radius fx with ulnar styloid
fx
2. altered mental status from narcosis
Secondary Diagnosis
1. osteopenia. 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 significant for hypertension, atrial fibrillation
(not on anticoagulation), adjustment disorder, anxiety, prior
left breast cancer (invasive lobular adenocarcinoma, s/p XRT and
tamoxifen), osteopenia presenting to the ED with a comminuted
displaced left distal radius fx with ulnar styloid fx that
underwent closed reduction in the ED, admitted to medicine with
escalating pain requirements.
# COMMUNITED DISPLACED LEFT DISTAL RADIUS, ULNAR STYLOID
FRACTURE - Status post closed reduction by Hand surgery. Now in
a splint, the patinet continues to have severe pain. Is S/p a
large amount of pain medication in the ED for which she required
narcan. She was discharged on tylenol, naproxen, and oxycodone,
with some continued pain (she was counseled that she would
continue to have some pain until she had surgery). She will
follow up in hand clinic for surgery later this week. Pre-op
labs and EKG done.
# HYPERTENSION - BP well controlled in the 100-110 systolic
range. continued home ACEI and ___
# ATRIAL FIBRILLATION - CHADS-1. Currently in NSR on EKG with
adequate rate control on ___ and ___. cont beta blocker
and ___ 81
# OSTEOPENIA - started calcium and vitamin D supplementation.
# ANXIETY AND ADJUSTMENT DISORDERS - Stable mood. Continue
mirtazapine, paroxetine. Held alprazolam given concern for
sedation
# dizziness: cont meclizine
# CODE: FULL
# CONTACT: ___ (son) - ___
TRANSITIONAL ISSUES
- follow up outpatient with Hand Clinic for outpatient surgical
fixation</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y/o gentleman without any significant
medical history who presented to the ED from his PCP's office
for a Hgb of 6. Radiology showed 1. No imaging features to suggest small bowel lymphoma.
2. Multiple abnormal appearing segments of small bowel are identified, some
with apparent wall thickening and other with fecalization as described above
which may be related to processes such as Crohn disease. Assessment is limited
given the static nature of CT enterography, and as the majority of enteric
contrast was in the colon. MR-Enterography is recommended for further
evaluation.
The findings were discussed with the treating team at 6:15 p.m. on ___. The patient was diagnosed with GASTROINTEST HEMORR NOS. The patient was treated with EGD
Blood transfusion. At the time of discharge, the patient had ___ 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 ___ y/o gentleman with approximately one
month of melenic stools, excessive aspirin use and labs
suggestive of ___ deficiency anemia suggestive for upper
gastrointestinal bleeding.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old male who presented to the
Emergency Department on ___ as a transfer from an outside
facility status post fall off the back of a moving pick-up truck
with a severe traumatic brain injury. The patient was
transferred to ___ for
escalation of care. The Neurosurgery Service was consulted for
evaluation and management recommendations. CHEST (PORTABLE AP) showed 1. Endotracheal tube in standard position.
2. Low lung volumes with patchy ill-defined opacities in both upper lobes as
well as to a lesser extent in both lower lobes which could reflect atelectasis
and/or contusion.
3. Multiple left-sided rib fractures without large pneumothorax or pleural
effusion.
4. Marked gastric distension for which enteric tube placement is recommended. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Extensive traumatic right-sided subdural, bilateral subarachnoid, left
parietotemporal intraparenchymal, and left-sided epidural hematomas as
described above.
2. Right-sided mass effect with effacement of the right lateral ventricle and
5 mm of right to left midline shift. No hydrocephalus, or subfalcine or uncal
herniation.
3. Nondisplaced fractures of the left zygomatic, greater wing of the left
sphenoid, and squamous portion of the left temporal bones as described above. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No fracture or traumatic malalignment.
2. Mild degenerative change of the cervical spine. CT chest abdomen and pelvis showed 1. Acute bilateral rib fractures including the anterior left second through
seventh ribs, the posterior left fourth through seventh ribs, and the anterior
right first through eighth ribs. No pneumothorax.
2. Bilateral dependent atelectasis in the upper and lower lobes with trace
left-sided hemothorax.
3. No solid organ injury within the abdomen or pelvis. DX ELBOW AND FOREARM showed No acute osseous injury of the left elbow. CHEST (PORTABLE AP) showed In comparison with the study ___, the tip of the the subclavian base
central line of is about at the level of the cavoatrial junction.
Endotracheal tube has been somewhat withdrawn with the tip at the clavicular
level, approximately 6.5 cm above the carina.
Continued low lung volumes accentuates the enlargement of the cardiac
silhouette. Retrocardiac opacification has decreased and there is no evidence
of vascular congestion or acute focal pneumonia.
The left rib fractures are much better seen on the recent CT. CT HEAD W/O CONTRAST showed 1. Right-sided acute subdural hematoma is mildly increased in size from most
recent head CT, now measuring 1.0 cm across maximal with, previously measuring
up to 0.8 cm, and extending to the tentorium and falx.
2. There is a lenticular shaped hyperdense extra-axial collection abutting the
right temporal lobe measuring up to 1.3 cm, which is new or increased in size
from most recent head CT and given the shape likely represents an epidural
hematoma.
3. There has been interval placement of a right-sided intraparenchymal
drainage catheter which terminates in the deep white matter of the right
frontal lobe. The presence of placement of a intraparenchymal drainage
catheter was confirmed by conversation with Dr. ___.
4. Diffuse subarachnoid hemorrhage, left parieto-occipital intraparenchymal
hemorrhage, and left temporal epidural hemorrhage with mass effect and right
to leftward midline shift of 5 mm are all unchanged.
5. Nondisplaced calvarial fractures are better assessed on recent head CT with
bone algorithm. There is no evidence of a new or worsening fracture.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr ___,
___ on the telephone on ___ at 5:45 pm, 5 minutes after discovery
of the findings. DX CHEST PORTABLE PICC LINE PLACEMENT showed The tip of a left subclavian central line projects over the upper right
atrium, approximately 1 cm beyond the cavoatrial junction.
Opacities within the left hemithorax likely reflect atelectasis, better
evaluated on the CT chest from earlier today. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Interval right hemicraniectomy and evacuation of an acute right subdural
hematoma. Small residual right temporal extra-axial collection, either
epidural or subdural.
2. Unchanged large left parietal intraparenchymal, left temporal epidural, and
bilateral subarachnoid hemorrhage. Unchanged small subdural hemorrhage along
the tentorium and falx.
3. No evidence of new hemorrhage. Resolution of prior midline shift. The
basilar cisterns are patent. CHEST (PORTABLE AP) showed Retrocardiac opacity, which may reflect pneumonia, stable. Mild increased
left upper lobe hazy opacity could reflect developing pneumonia in this
region. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS showed 1. No evidence of a temporal bone fracture on the study. Please note that the
nondisplaced fracture involving the squamous portion of the left temporal
bone, characterized on CT head ___, is not included in the field
of view of this study (too cranial).
2. Partially visualized diffuse subarachnoid hemorrhage, intraventricular
hemorrhage, right temporal subdural hemorrhage, and left temporal epidural
hemorrhage are unchanged from CT head ___.
3. Postsurgical changes from right hemi-craniectomy with overlying swelling,
high-density fluid, likely representing blood products, and foci of air in the
scalp, all unchanged from ___. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No evidence of new hemorrhage.
2. Interval expansion of the right cerebral hemisphere into craniectomy site,
with approximately 4 mm rightward shift of normally midline structures.
3. Question interval increase in size of right lateral ventricle compared to ___ prior exam. Recommend attention on follow-up imaging.
4. Approximately 3 mm new interhemispheric hygroma.
5. Grossly stable right temporal extra-axial hemorrhage, along with left
parietal intraparenchymal, left temporal epidural, and bilateral subarachnoid
hemorrhage.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:35 pm, 5 minutes after
discovery of the findings. CHEST (PORTABLE AP) showed Left-sided PICC line, ET and NG tube are unchanged. Cardiomediastinal
silhouette is stable. There is subsegmental atelectasis in the left lung
base. No pneumothorax is seen there is no pleural effusion CT of the temporal bones. showed 1. Nondisplaced left parietal fracture extending into the left squamous
temporal bone. However, no evidence for fracture involving petrous temporal
bones on either side. No evidence for fracture small quantity of new fluid
within mastoid air cells bilaterally.
2. Unchanged findings associated with extensive intracranial hemorrhages. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Status post right hemi craniectomy with interval removal of surgical drain
with slightly increased expansion of the right cerebral hemisphere into the
craniotomy site and increased hemispheric hypodense subdural fluid collection
measuring up to 6 mm in thickness.
2. Interval evolution of left frontoparietal temporal intraparenchymal
hemorrhage, left frontal subarachnoid hemorrhage, left temporal epidural
hemorrhage, and right extra-axial hemorrhage. Re-demonstration of left and
right parafalcine subdural hematoma with right parafalcine subdural hygroma.
Right word 5 mm midline shift similar to prior. Increased effacement of the
left occipital horn.
3. Interval decrease in size of small left parietal scalp hematoma.
4. Increased opacification of the ethmoid sinuses, and bilateral maxillary
sinuses with complete opacification of the sphenoid sinus. Increased partial
opacification of bilateral mastoid air cells with new fluid in the bilateral
middle ear cavities. These findings do not necessarily imply an infectious
process in the setting of endotracheal intubation, however. CHEST (PORTABLE AP) showed Comparison to ___. The lung volumes have slightly decreased. As
a consequence, areas of basilar atelectasis are visualized. No pleural
effusions. No new focal parenchymal changes suggestive of pneumonia. No
pulmonary edema. The feeding tube and the endotracheal tube are in stable
correct position. DX CHEST PORTABLE PICC LINE PLACEMENT showed Comparison to ___. The patient has received a right-sided PICC
line. The course of the line is unremarkable, the tip projects over the lower
aspect of the right atrium, to be at the cavoatrial junction, the line needs
to be pulled back by approximately 9-10 cm. No complications, notably no
pneumothorax. Otherwise unchanged radiograph. DX CHEST PORTABLE PICC LINE PLACEMENT showed In comparison with the earlier study of this date, the right subclavian PICC
line is been pulled back so that the tip is in the mid to lower SVC.
Otherwise, little change. DX CHEST PORTABLE PICC LINE PLACEMENT showed Compared to chest radiographs ___ through ___.
New tracheostomy tube is midline. No appreciable mediastinal widening. No
pneumothorax. Mild cardiomegaly stable. Lungs clear. No pleural effusion.
Right PIC line has been partially withdrawn and now ends in the upper SVC, CT HEAD W/O CONTRAST Q111 CT HEAD. showed 1. Continued evolution of a large left frontal intraparenchymal hemorrhage and
bilateral extra-axial hemorrhages as detailed in the findings. No evidence of
a new intracranial hemorrhage.
2. Status-post right hemi craniectomy with a persistent subdural hygroma.
3. Improved, partially imaged paranasal sinus disease. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Pulmonary vasculature is more engorged and mediastinal veins are more
distended and moderate cardiomegaly has worsened, indicating interval
progression of cardiac decompensation.. Basal lung consolidation has
worsened, either atelectasis or pneumonia. No pneumothorax.
Right PIC line ends at the origin of the SVC. Tracheostomy tube midline. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. CT HEAD W/ CONTRAST Q1211 CT HEAD showed 1. No rim enhancement of the extra-axial fluid collection at the right
craniectomy site to suggest empyema. However, superimposed infection cannot
be definitively excluded on the basis of imaging.
2. Resolving left parietal parenchyma hematoma is stable compared to ___. Known subarachnoid hemorrhage is not adequately reassessed due
to the presence of intravascular contrast.
3. The ventricles are stable in size and configuration compared to ___, though slightly increased in size compared to ___.
4. Nondisplaced left squamous temporal bone fracture is again seen. CT CHEST W/O CONTRAST showed 1. Mild improvement in the atelectasis of the bilateral lower lobes with
component of aspiration changes not excluded. Superimposed infection is
difficult to exclude radiographically and clinical correlation is recommended.
2. Multiple bilateral segmental rib fractures are again noted. CHEST (PORTABLE AP) showed 1. Distal tip of the right PICC now terminates in the confluence of the right
subclavian and right brachiocephalic vein.
2. No pneumothorax.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:11 am, 1 minutes after
discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Status post right hemi craniectomy with evolution of a right subdural
hygroma. No acute intracranial hemorrhage.
2. Resolving left parietal parenchymal hematoma without acute component,
minimally decreased associated edema.
3. Stable size and configuration of the ventricles compared to ___.
4. Nondisplaced left squamous temporal bone fracture which is unchanged. CHEST (PORTABLE AP) showed Lungs are low volume. No new consolidations. Old healed posterior third rib
fracture on the right. There are no pleural effusions. No pneumothorax is
seen. Tracheostomy tube in place. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Interval right cranioplasty, no acute hemorrhage.
2. Left MCA distribution subacute infarct, stable.
3. Suggestion of trace extra-axial fluid collection overlying left temporal
lobe.
4. Right temporal lobe encephalomalacia, volume loss.
5. Remainder as above. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Interval development of right hemispheric extra-axial collection at the
cranioplasty level measuring up to 0.9 cm in maximal thickness. Differential
considerations include postoperative hygroma versus subacute/chronic subdural
blood products.
2. Grossly stable ventricle size as described.
3. Additional grossly stable findings as described. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Stable examination. No new acute infarction or new hemorrhage.
2. Unchanged 8 mm hypoattenuating right subdural collection.
3. Unchanged evolving left frontoparietal subacute infarction.
4. Unchanged ventriculomegaly.
5. Expected postoperative findings from large right craniotomy, unchanged.
6. Right mastoid effusion, unchanged. RF - GI TUBE CHECK showed The Foley tube is located within the body of the stomach. No definite
evidence of contrast leak. G tube placement check (optiray ordered) showed Gastrostomy tube appropriately positioned within the body of stomach. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Postsurgical changes seen following right frontotemporal craniotomy. There
are evolving infarcts in the right temporal lobe and left frontoparietal
regions. No evidence of hemorrhagic transformation or new major acute
infarct.
2. Persistent enlargement of the lateral ventricles, third ventricle, and
fourth ventricle, which appears increased in size since ___
although similar to ___. The patient was diagnosed with Multiple fractures of ribs, unsp side, init for clos fx, Prsn outsd pk-up/van inj in clsn w nonmtr veh in traf, init. The patient was treated with ___ - Right Neurovent placement
___ - Right decompressive hemicraniectomy, subdural
hematoma evacuation, removal of right Neurovent
___ - Trach and PEG
___ - Cranioplasty
___: Trach decannulated. At the time of discharge, the patient had Traumatic brain injury
Epidural hematom
Subdural hematoma
Traumatic subarachnoid hemorrhage
Intraparenchymal hemorrhage
Brain compression/Mass effect
Nondisplaced fractures of left zygomatic, left sphenoid, left
temporal bones
Multiple rib fractures
Seizures
Pneumonia
Dysphagia
Hypertension
Tachycardia
Oral thrush. 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 status post fall off the back of a moving
pick-up truck with a severe traumatic brain injury. CT of the
head in the Emergency Department revealed extensive traumatic
right sided subdural, bilateral subarachnoid, left sided
epidural, and left parietotemporal intraparenchymal hematomas
with mass effect and 5mm of leftward midline shift.
#Traumatic Brain Injury
The patient was admitted to the Neurosurgery Service for close
neurologic monitoring. He was started on Keppra for seizure
prophylaxis. He was started on 3% hypertonic saline. A right
Neurovent was placed for ICP monitoring. The procedure was
uncomplicated. Please see ___ Record for further
intraprocedural details. Repeat CT of the head showed proper
Neurovent placement, but worsening of the patient's multifocal
traumatic intracranial hemorrhage. Additionally, the patient's
ICPs were spiking to and sustaining in the ___. He was given a
bolus of mannitol, which brought his ICPs down to the ___,
however his ICPs remained consistently high despite medical
management. Given this, the patient was taken to the OR for a
right decompressive hemicraniectomy with subdural hematoma
evacuation and removal of right Neurovent. The operation was
uncomplicated. Please see ___ Record for further
intraoperative details. The patient was maintained on Keppra and
3% hypertonic saline postoperatively. His neurologic exam
remained stable. 3% was discontinued for hypernatremia. Patient
sodium was titrated to goal of >140. Overnight ___, the
patient had roving eyes on exam. STAT CT was stable. Patient was
placed on EEG, which was concerning for seizures. Keppra dose
was increased to 2g BID. He continued to have intermittent
seizures on EEG overnight and early morning on ___ and
Epilepsy recommended starting Vimpat 200mg BID as a second
agent. EEG remained negative for seizure thereafter and the EEG
was discontinued on ___. Repeat NCHCT on ___ showed expected
evolution of TBI but was otherwise stable. The patient's
neurological exam remained stable throughout the subsequent
period in the ___. He was then transferred to the floor ___.
On ___, he underwent cranioplasty with Dr. ___. Please see
operative report for further detail. Postoperatively, he was
closely monitored in the TSICU. VP shunt placement was offered
due to concern for hydrocephalus. This was discussed at length
with the patient's guardian (his brother) who ultimately decided
against pursuing a VP shunt or EVD placement. On ___ the
patient was made floor status. CT head on ___ demonstrated a
0.9cm extraaxial fluid collection on the right side, correlating
with mild swelling observed on exam. Cranioplasty staples were
removed on ___. Keppra was weaned off with last dose scheduled
___. Patient underwent a repeat CTH due to concerns for ongoing
right facial droop on ___. CTH with evolving infarcts in the
right temporal lobe and left frontoparietal regions, with no
evidence of hemorrhagic transformation or new major acute
infarct and persistent enlargement of the lateral ventricles,
third ventricle, and fourth ventricle.
#Agitation/Restlessness
Patient remained neurologically stable but with persistent
restlessness and agitation in bed requiring the use of
restraints to prevent patient injury to himself and pulling at
tubes/lines. Psych was consulted for medication recommendations.
Remelteon was added ___. Neurology was consulted to assist in
transitioning AEDs to include mood stabilization, and Lamictal
was added ___. They plan to uptitrate as outpatient prior to
weaning keppra. He was unable to wean from mitts and enclosure
bed, and buspirone was started on ___ per psych
recommendations for continuing agitation, and Trazodone was
increased. He was weaned from mitts on ___ and agitation
continued to improve. Lamictal was increased to 50mg BID on
___ per neurology recommendations. Buspirone was increased to
15mg TID and Seroquel PRN was added per psych recommendations on
___. Mitts were placed back on briefly on ___ due to
concern for pulling at PEG. Lamictal dose was slowly titrated up
to goal of 150mg BID on ___. He was starting on standing
Seroquel to help with agitation. Enclosure bed was discontinued
on ___ and patient was placed in a low bed with a 1:1 sitter.
#Left Temporal Bone Fracture
Otolaryngology was consulted for a left temporal bone fracture.
A dedicated CT of the temporal bones was obtained.
Otolaryngology recommended an outpatient audiogram and
outpatient follow-up.
#Concern For CSF Leak
Otolaryngology was consulted for concern for a CSF leak when the
patient began draining fluid from his nose. He was placed on CSF
leak precautions. The drainage self resolved.
#Respiratory Failure
The patient was intubated and was unable to wean from the
ventilator. Acute Care Surgery was consulted for a tracheostomy,
which was placed on ___. ACS removed the trach sutures ___.
First trach downsize was done by respiratory therapy on ___.
He was first seen by speech and swallow on ___ to assess PMV
use, they saw him again on ___ and noted that he could begin
to use PMV with supervision. On ___, a cap trial was started,
but the cap had to be discontinued after 1 hour following a
desaturation to 89% in the setting of agitation. Cap trials were
re-initiated on ___ with QID capping for ___ minutes. Trach
was changed to 6 CFS on ___. 24 hour cap trial started ___
was successful; the patient did not desaturate. His trach was
decannulated by respiratory therapy on ___. Patient was
without respiratory concerns throughout remainder of
hospitalization.
#Aspiration Pneumonia
The patient developed an aspiration pneumonia. He was initially
started on broad spectrum antibiotics, which were narrowed once
the cultures resulted. Patient developed leukocytosis and a low
grade fever ___, Tmax of 100.8. CXR was concerning for PNA.
Antibiotics were changed to Keflex based on the sensitivities.
On ___, he was noted to be febrile to 103, chest xray with
concern for worsening pneumonia. He was started on Nafcillin x 1
days. Infectious Disease weighed in, as patient was continually
febrile. He was changed to Vancomycin and Cefepime on ___.
He was given Tylenol Q6hr and started on a cooling blanket to
help with temperature control. A CT chest revealed improvement
in bilateral lower lobe atelectasis. Sputum culture was obtained
on ___ and grew out commensal respiratory flora. The patient
continued to experience low grade temperates and ID recommending
continuing vancomycin and cefepime, with the possibility of a
central component to these episodes. Vancomycin and cefepime
were discontinued on ___. Patient remained afebrile.
#Leukocytosis
In addition to a chest xray demonstrating pneumonia. On ___, a
urine culture was obtained which was negative. Bilateral ___
were negative. Blood cultures continued to be negative. CDiff
was sent on ___ and was negative. A head CT was obtained to
rule out intracranial infection, it was negative. WBC down
trended and was within normal range at time of discharge.
#Hypertension
Patient was started on labetalol for tachycardia/hypertension,
and it was titrated as tolerated.
#Dysphagia
Speech and Language Pathology was consulted and recommended the
patient be NPO. A NGT was placed. Nutrition was consulted for
tube feeding recommendations and adjusted tube feedings as
needed. Acute Care Surgery was consulted for a PEG, which was
placed on ___. Feeds were adjusted by nutrition, changed to
bolus feeds on ___. PEG was pulled out by patient on ___,
foley catheter placed in tract. ACS replaced PEG on ___ and
placement confirmed. Patient remained on bolus tube feeds.
#Family Coping
Social Work was consulted and followed for family coping. There
was a family meeting that took place on ___ with social work
to discuss steps for rehab once medically stable and prognosis.
Guardianship paperwork was obtained by his brother.
#Disposition
Physical Therapy and Occupational Therapy were both consulted
and recommended rehabilitation. Case management was contacted
and informed the team on ___ that the brother has outside
legal councel completing the guardianship. ___ legal is also
aware of the plan. CM looked for rehab facilities speciailizing
in TBI care at the request of the brother. ___ was
obtained. ___ guardianship was obtained. Patient was
discharged to rehab on ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of cholelithiasis & cholangitis ___ s/p
ERCP with stent placement and subsequent stent change x2 with
CBD
stricture thought to be inflammatory in nature. She had a CT
abdomen ___ which demonstrated a hypoenhancing area in the
head of the pancreas which was consistent with
pancreatitis/necrosis but could not rule out pancreatic head
mass. The plan was for her to f/u with West2a in clinic with a
repeat CT abdomen prior to operative intervention (likely
cholecystectomy with biliary bypass). She did not keep many
outpatient appointments and refused an outpatient CT scan
because
she had "personal issues" going on involving her apartment and
her kids. She presented to her PCP today complaining of
increasing right sided abdominal pain x 1 week. She reports
long
term poor appetite and nausea which has not changed recently.
She
reports that her eyes turned yellow 2 days ago and this is what
prompted her to go to her PCP. Also endorses darkened urine and
lighter color stools. No fevers, no emesis. Radiology showed 1. Intra- or extra-hepatic ductal dilatation with the common bile duct
measuring up to 3 cm. CBD stent appears to have migrated in a reverse
configuration.
2. Perfusional defects noted in segment V of the liver, but no focal lesions.
3. Stable hypodensity in the pancreatic head and stable pancreatic tail
pseudocyst. Stable portacaval lymph nodes. Radiology showed No acute chest abnormality. The patient was diagnosed with ABDOMINAL PAIN RUQ, JAUNDICE NOS. The patient was treated with ERCP and biliary stent placement ___
Cholecystectomy, choledochojejunostomy and intraoperative
ultrasound of the pancreas ___. At the time of discharge, the patient had Bile duct stricture in the setting of chronic pancreatitis. 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 with biliary obstruction. She underwent
ERCP on ___ with replacement of her common duct stent with
good drainage of bile. Her liver function tests improved
greatly, and she was tolerating a regular diet and passing
flatus and stool. Due to chronic cholecystitis and chronic
severe biliary stricture, she underwent cholecystectomy,
choledochojejunostomy and intraoperative ultrasound of the
pancreas on ___. She tolerated the procedure well. The rest
of her postoperative course was uncomplicated as follows:
Neuro: The patient had an epidural placed for pain control.
However it did not provide good pain relief. On POD #2 the
epidural dislodged inadvertently and was subsequently removed.
She was started on a PCA and was transitioned to oxycodone. She
was also given IV toradol on POD #4 as an adjunct and discharged
home with 3 days of PO toradol, and oxycodone prn.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: 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. She tolerated a
regular diet on POD #4 without nausea or vomiting. She also
received an aggressive bowel regimen which was successful in
producing multiple episodes of gas and a large stool.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. She received unasyn from
___ through the am of ___. She was switched to augmentin which
she tolerated. She will take augmentin through ___ for a total
of 14 days of antibiotics.
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.
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. She is passing gas and having bowel movements with
the help of a bowel regimen and is being encouraged to wean the
oxycodone and use toradol as a bridge for the next few days. 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 female with history of CAD, DVT s/p IVC filter, HTN,
HLD and who presented to the ED complaining of worsening
frequency of presyncopal symptoms and chest pain. Describes pain
as burning x7 days and unrelieved with Maalox. Associated with
nausea but no vomiting. Has woken up with diaphoresis at night.
No relieving symptoms. Presyncopal symptoms worse on sitting up.
Has fainted at table before, but has not struck head or lost
consciousness (of note, family denies that patient has lost
consciousness). Patient is largely wheelchair dependent but can
use walker with seat for up to 3 minutes, does not say she is
dizzy while standing.
In the ED, initial vital signs were T 97.6 P 68 BP 164/79 R 18
O2 sat 96%. EKG was performed for chest pain, but no change from
prior EKGs noted. Patient was given 1g ceftriaxone for suspected
UTI. Foley was inserted which put out 1L clear urine. Radiology showed No acute cardiopulmonary process. Radiology showed No evidence of hydronephrosis. Radiology showed No acute process of the chest including no evidence of acute
aortic syndrome or pulmonary embolism. The patient was diagnosed with SYNCOPE AND COLLAPSE, CHEST PAIN NOS, URIN TRACT INFECTION NOS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had Chronic atypical chest pain
Urinary retension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>HOSPITAL COURSE: ___ year old female with a PMH of CAD, DVT s/p
IVC filter, HTN, HLD, and presyncope who presents with worsening
presyncopal symptoms and chest pain. She had a cardiac workup
including CTA to rule out microdissection which was negative.
She was found to be retaining urine and failed a voiding trial
so a foley to gravity placed. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ previously healthy who presented with a 2 week history of
nausea, anorexia, 10lb weight loss, tea-colored urine, and
pruritus. Patient's family told him that he was jaundiced.
Today, the patient denied abdominal pain or discomfort but did
note that recently he has been gassy and taking pepto-bismuth
for his symptoms. He has had an almost constant, dull, and
diffuse discomfort of his abdomen.
He reported no fever, chills, UTI symptoms or abnormal stool. He
has no recent travel or food poisoning. He denies taking any
medications or acetaminophen. He has been consuming dry beef
that his mother brought from ___, but many other family
members have been eating the same food and are asymptomatic.
In the ED, initial vitals:
ED physical exam: -- 134/78 79 17 100%RA
Physical exam: alert, not in distress
HEENT: scleral icterus, PERLA, EOM intact
Lung: cta
___: rrr, normal s1,s2
Abdomen: soft, lax, non tender, no ascites or fluid thrill,
normal bowel sounds
Skin: slightly jaundice
LL: no ankle edema or calf pain
Labs were significant for ___ 13.3, INR 1.2, ALT 1868, AST 939,
TBili 7.9, Dbili 5.5, lipase 102, cholesterol 225
Imaging showed hepatic steatosis
Patient was given 2L NS bolus.
Patient was seen by Hepatology/
Decision made to admit for further workup.
Vitals prior to transfer: ___ 115/68 79 18 99%RA
On arrival to the floor, the patient stated he was hungry with
some mild epigastric discomfort he believed was related to
hunger.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Echogenic liver consistent with steatosis. Other forms of liver disease and
more advanced liver disease including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. Adenomyomatosis of the gallbladder.
3. No cholelithiasis or cholecystitis. Ultrasound-guided liver biopsy showed Uncomplicated non-targeted liver biopsy. The patient was diagnosed with Acute viral hepatitis, unspecified. The patient was treated with (___): Percutaneous liver biopsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male without significant medical
history who presented with a 2-week history of nausea, anorexia,
10lb weight loss, tea-colored urine, and pruritus found to have
transaminitis with AST/ALT ___, Tbili 7.3, Dbili 5.2, IBil
2.1. Ultrasound revealed only hepatic steatosis. Laboratory
workup was unrevealing. He subsequently underwent liver biopsy
on ___. Tolerated the procedure well. Discharged home on ___
with follow-up with Dr. ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ old woman with a history of
antiphospholipid antibody syndrome on warfarin, epilepsy on
Lamictal, migraine headaches and end-stage renal disease on
hemodialysis who presents with gait unsteadiness, vertigo,
oscillopsia and diplopia. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. No evidence for acute intracranial abnormalities.
2. Chronic bilateral sphenoid sinusitis and chronic small mucous retention
cyst in the right posterior ethmoid. Chronic near complete opacification of
the right mastoid air cells and partial opacification of the right middle ear
cavity. Please correlate with any associated active symptoms.
3. No evidence for flow-limiting stenosis in the cervical or major
intracranial arteries.
4. Partially visualized small bilateral pleural effusions with adjacent
atelectasis. Partially visualized ground-glass opacities with perihilar
predominance in the upper lobes are suggestive of pulmonary edema, but
infectious etiology is not excluded. Small peripheral ground-glass opacities
in the anterior right lower lobe are nonspecific. These abnormalities are new
compared to the ___ chest CT.
5. Extensive mediastinal and hilar lymphadenopathy is again partially
visualized. Prominent supraclavicular and bilateral cervical lymph nodes are
not significantly changed compared to the ___ neck CT. Etiology of
lymphadenopathy cannot be determined on this exam.
RECOMMENDATION(S):
1. MRI would be more sensitive for an acute infarction, if clinically
warranted.
2. Consider follow-up chest CT in 3 months, if clinically warranted.
NOTIFICATION: Impression items 1 and 3 were included in a wet read by a
radiology resident at the time of the exam. The entire impression and
recommendations above were entered by Dr. ___ on ___ at 15:04
into the Department of Radiology critical communications system for direct
communication to the referring provider. The patient was diagnosed with Dizziness and giddiness. At the time of discharge, the patient had Diplopia. 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 with dizziness, gait instability, and
double vision that were concerning for stroke. CTA was normal.
Her symptoms improved to baseline after dialysis. She was
cleared by ___. No changes were made. She has had similar
presentation and workup for it multiple times. She should
continue her outpatient regimen, including her warfarin
according to her treating physicians recommendations.
- CTA revealed mall apical bilateral pleural effusions with
adjacent
atelectasis and ground glass opacities. Recommended follow-up CT
in 3 months.
- Continue home medications. </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 history of gallstones
and DM type 2 who presents with right upper quadrant pain
radiating to her back. The pain began the evening of ___
___ an hour after eating a meal of rice and cheese cake. The
pain persisted through the night, preventing her from sleeping.
She vomited 6 times on ___ at which point the pain subsided,
and she was pain free until ___. She reported no blood in her
vomit. ___ evening she at a meal consisting of fish at 6 ___
and her RUQ abdominal pain started at 7 ___. She rated the pain
___ at that time and could not find any position that relieved
the pain. She took Motrin for the pain that mildly reduced the
pain, which was a ___ upon arrival to ED. She denies any
diarrhea, dizziness, fever or chills in the past 3 days. Radiology showed 1. Tensely distended gallbladder with two stones, one of which may be impacted
in the gallbladder neck. Findings are equivocal for cholecystitis and
correlation with lab evaluation and exam findings is recommended. If
clinically indicated, HIDA can be obtained for further assessment.
2. Echogenic liver compatible with fatty deposition. Other forms of liver
disease including advanced hepatic fibrosis/cirrhosis cannot be excluded on
this study. The patient was diagnosed with CHOLELITH W AC CHOLECYST, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. The patient was treated with ___: Laparascopic cholecystectomy. At the time of discharge, the patient had Acute cholecystitis. 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 Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound revealed a tensely distended
gallbladder with two stones, one of which may have impacted the
gallbladder neck, equivocal for cholecystitis. The patient was
subsequently placed on bowel rest, given intravenous fluids,
pain medication and Unasyn. The patient subsequently underwent
laparoscopic cholecystectomy, which went well without
complication; please see operative note for details. After a
brief, uneventful stay in the recovery room, the patient was
transferred to the general surgical ward for further
observation.
Post-operatively, pain was well controlled. Diet was
progressively advanced as tolerated to a regular diet and well
tolerated. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirrometry, 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 on POD1, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH of Metastatic colon cancer (s/p right colectomy, right
heparin lobectomy, chemoradiation, w/ recurrence, s/p LAR, loop
ileostomy, hysterectomy/BSO , on ___ until ___, Rectal
Wall dehiscence (c/b presacral abscess s/p ___ drain then
upsizing, on prolonged Abx), Right leg DVT (s/p IVC filter, on
lovenox), who presents with vomiting found to have SBO UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. CT abdomen pelvis showed 1. Small-bowel obstruction with transition point in ileal loops in the right
lower quadrant. No evidence of perforation or ischemia. Small amount of free
fluid.
2. Persistent dehiscence of the posterior rectal wall with slight interval
decrease in associated presacral air and fluid collection containing a
percutaneous drain.
3. Moderate to severe right-sided hydronephrosis and hydroureter which extends
the level of the presacral collection. Degree of hydroureter appears similar
compared to the previous exams.
4. Interval increase in size of pulmonary metastases. Change in the size of
hepatic metastases is difficult to assess.
5. Small right greater than left pleural effusions. CHEST (PORTABLE AP) showed Comparison to ___. The patient has received a feeding tube. The
course of the tube is unremarkable, the tip of the tube projects over the
central stomach. No complications, notably no pneumothorax. Stable position
of the right Port-A-Cath. Visualization of a vena cava filter. The patient was diagnosed with Other intestnl obst unsp as to partial versus complete obst, Other specified soft tissue disorders, Unspecified abdominal pain. At the time of discharge, the patient had Primary
Small bowel obstruction
Secondary
Metastatic colorectal cancer
DVT
rectal wall dehiscence. 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>___ PMH of Metastatic colon cancer (s/p right colectomy, right
heparin lobectomy, chemoradiation, w/ recurrence, s/p LAR, loop
ileostomy, hysterectomy/BSO , on ___ until ___, Rectal
Wall dehiscence (c/b presacral abscess s/p ___ drain then
upsizing, on prolonged Abx), Right leg DVT (s/p IVC filter, on
lovenox), who presents with vomiting found to have SBO, reoslved
with 24 hours bowel rest.
#SBO
Patient with vomiting and lack of ostomy output at home with
imaging on admission consistent with small bowel obstruction,
surgery consulted, without acute complication requiring surgical
intervention. Made NPO, NG placed. Ostomoy output resumed fairly
quickly, NG tube removed, advanced diet slowly which was
tolerated well. Patient had some episodes of hypoglycemia which
resolved after resuming full diet.
#Anemia
Hb downtrended from 9.5 on admission to 7.1 on ___ AM. There was
some cncern about blood clots from NGT. However, Hgb stabilized,
and patient did not require transfusion.
#Chronic Malignant Pain
Symptoms at baseline. Transitioned to IV morphine given NPO
status, but then resumed home dose. Also started standing bowel
regimen. Slightly down-titrated oxycodone dose given SBO/?ileus
at discharge.
#Metastatic colon cancer (s/p right colectomy, right heparin
lobectomy, chemoradiation, w/ recurrence, s/p LAR, loop
ileostomy, hysterectomy/BSO , on ___ until ___ As per
Dr ___ recent note, was to have restaging after Abx
complete, as she is considering restarting FOLFOX at that time.
However, now CT with increased pulm mets, which will need to be
communicated to her oncologist
#Rectal Wall dehiscence
CT A/P on admission revealed persistent dehiscence of the
posterior rectal wall with slight interval decrease in
associated
presacral air and fluid collection. Having 50cc daily output
from
JP. Continued daptomycin, cipro, flagyl through ___. Daptomycin
dose was adjusted from 600mg daily to 300mg daily per OPAT.
#Right leg DVT (s/p IVC filter, on lovenox)
-Continued once daily lovenox
#Hypothyroidism
-Continued synthroid
Transitional Issues
[] increased size of pulmonary mets seen on CT AP
[] Please continue on standing bowel regimen to prevent SBO in
the
setting of chronic opioid use.
[] oxycodone dose reduced from ___ to 2.5mg-5mg while patient
was in the hospital with good pain control. Please assess
whether increased dose is needed
[] Daptomycin dose reduced from 600mg to 300mg daily per OPAT.
Patient to continue antibiotics through ___.
[] Consider removal of JP drain if persistent low output
#HCP/Contact: Mother ___ ___
#Code: Full confirmed </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 h/o provoked
post-surgical PE in ___ (negative thrombophilia w/u,
anti-coagulated for 6 mo), presenting with 2 days of worsening
substernal chest pain. Radiology showed Partially occlusive RML and RLL lobar, segmental, and
subsegmental pulmonary emboli and partially occlusive LLL segmental and
subsegmental pulmonary emboli are demonstrated. No CT evidence of right heart
strain Radiology showed Large occlusive expansile thrombus in the left greater saphenous vein at its
confluence with the femoral vein. The patient was diagnosed with PULM EMBOLISM/INFARCT, ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
- acute Pulmonary embolus
SECONDARY DIAGNOSIS:
- acute lower extremity Deep venous thrombosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman with a h/o PE in ___ (negative
thrombophilia w/u), presenting with gradual onset CP ___
partially occlusive PEs.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ man with past medical history of idiopathic
pulmonary
fibrosis, hypertension, hyperlipidemia, depression, and
dysphagia
who presents with about 4 days of fever to a high of 102,
increased nonproductive cough, mild epigastric abdominal pain,
decreased appetite, and general weakness. Starting on ___
he found he was unable to get himself out of bed due to
weakness,
and states he has been very shaky. He denies dysuria or
hematuria
but states that his urine has been darker than usual. At
baseline
he ambulates unassisted. He and his son also note that around
the
time of onset of his symptoms, he had a fall at home, and his
wife was unable to get him up off the floor, so he was down for
about 1 hour. He denies head strike or loss of consciousness at
that time. Denies headaches, neck stiffness or vision changes.
Denies vomiting or diarrhea. Denies blood in his stool. His son
believes his mental status is at his baseline. HE ___ any sick
contacts, chest pain, dyspnea. Radiology showed Diffuse abnormalities in the lungs compatible with underlying interstitial
lung disease. No definite superimposed acute process given stability compared
to prior. CT HEAD W/O CONTRAST showed No acute intracranial process. No evidence of intracranial hemorrhage or
fracture. CT C-SPINE W/O CONTRAST showed No evidence of acute fracture or traumatic malalignment. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Slight interval increase in size of right complex right hepatic lobe cystic
lesion with internal avascular echogenic contents. Nonurgent, multiphasic
liver MR is recommended for further evaluation. If contraindication to MR, CT
could be considered.
2. Stable left hepatic lobe simple appearing cyst.
3. No evidence of cholelithiasis or acute cholecystitis.
RECOMMENDATION(S): Nonurgent, multiphasic liver MR is recommended for further
evaluation. If contraindication to MR, CT could be considered. CT CHEST W/O CONTRAST showed No evidence of pneumonia.
Stable interstitial abnormality which most likely represents age related
fibrosis.
Decrease in size of the left axillary lymph nodes which are most likely
reactive. The patient was diagnosed with Fever, unspecified, Weakness. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ man with past medical history of idiopathic
pulmonary fibrosis, hypertension, hyperlipidemia, depression,
and dysphagia who presents with about 4 days of fever to a high
of 102, increased nonproductive cough, mild epigastric abdominal
pain, decreased appetite, and general weakness, likely a viral
infection.
#Weakness, poor po intake
#SHortness of breath
#Viral Syndrome
Patient presents with 4 days of high fevers, non productive
cough, sore throat, mild epigastric pain, poor po intake,
increased home O2 use, and weakness. Patient has diffuse
crackles on exam but consistent with his known IPF. CXR reading
is confounded by his concomitant ILD, could not rule out
underlying infection. Started on CAP therapy with azithromyicn
and ceftriaxone. CT scan done which did not show any evidence of
a PNA or aspiration (h/o aspiration PNA with normal video
swallow study), so abx were stopped. WBC remained wnl. Urine Cx
negative, blood cxs NGTD. He was saturating well on RA at rest,
but did become more visibly dyspneic with minimal exertion (such
as holding conversation), so patient was placed 1L NC for
comfort (uses O2 most of the time at home). Patient afebrile for
>24 hours prior to discharge. He reports feeling weak but much
better than when he came in to the hospital. ___ evaluated and
recommended rehab.
#Fall:
Patient had a fall at home in the setting of weakness. CT head
and CT neck were normal. He is normally independent at home but
was more deconditioned than baseline. Will be discharged to
rehab per ___ recs.
# ___ (Baseline Cr ___:
Patient had elevation in creatinine to 1.5, likely due to
hypovolemia in the setting of illness. Received 2L IVF
throughout his admission and Cr at time of discharge was 1.5.
# Liver lesion:
RUQUS showed slight interval increase in size of right complex
right hepatic lobe cystic lesion with internal avascular
echogenic contents. He will need nonurgent, multiphasic liver MR
for further evaluation.
CHRONIC ISSUES
--------------
# BPH
# Bladder thickening:
Continued on finasteride and tamsulosin.
# HLD:
He was continued on rosuvastatin
# Primary prevention:
He was continued on aspirin and home Vitamin D
# Rhinitis:
He was continued on loratadine. He should resume ipratrop nasal
spray after discharge as this was not on formulary.
# Depression:
Continued citalopram
# HTN:
Continued on home chlorthalidone
TRANSITIONAL ISSUES
=================
[ ] Please check Chem 7 in ___ days to check kidney function, as
patient's discharge Cr 1.5, which was stable throughout
admission but above recent baseline of ___.
[ ] Please encourage good PO fluid intake given patient's ___
and viral illness
[ ] Patient should be scheduled for follow up with his
Pulmonologist for follow up of his IPF.
[ ] Patient will need a ___, multiphasic liver MR for
further evaluation of interval increase in size of complex right
hepatic lobe cystic lesion with interval avascular echogenic
contents, which was identified on ultrasound during this
admission.
[ ] Patient saturates well and appears comfortable on RA at
rest, but does become more visibly dyspnic after minimal
exertion such as holding a long conversation. Please provide NC
O2 for patient as needed for exertion and as needed for patient
comfort.
[] Patient has history of aspiration but normal video swallow
study, showed no evidence of aspiration during admission and was
eating and drinking well, but would continue to monitor closely
#CONTACT: Name of health care proxy: ___
Relationship: wife
Phone number: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ year old male with minimal PMH besides known
T7-8 osteomyelitis, discitis, and epidural abcess s/p prior
laminectomy who presented with worsening back pain. His MRI
showed worsening anterior T7-8 collapse with increased
prevertebral soft tissue edema and new paravertebral fluid
collections concerning for discitis and osteomyelitis with
prevertebral spread. MRI also noted new adjacent right lower
lobe consolidations. He was treated for pneumonia in the ED
with Levofloxacin and admitted to the Neurosurgery service. He
underwent ___ guided bone biopsy of back ___, with gram stain
showing GPCs in pairs and clusters. Of note, he had prior
cultures with MSSA. He was transferred to Medicine for further
medical management of his infection. Radiology showed 1. New opacification in the right lower lobe, with left lesser opacities
elsewhere, suggesting pneumonia.
2. Endplate destruction of a mid thoracic interspace, consistent with sequela
of spinal infection, including increasing loss in height of adjoining
vertebral bodies since the prior MR, but better assessed on the accompanying
dedicated thoracic spine MR performed on the prior day. Radiology showed Successful 11g core needle biopsy of the T8 superior endplate (x
3) and T7-8 disc aspirate. Specimens were sent to pathology/microbiology for
the requested laboratory analysis. Results are pending. Radiology showed 1. Redemonstration of osteomyelitis-discitis at T7-T8 with slight increase in
the previously seen paravertebral fluid collections and a new small
paravertebral collection as described above.
2. ___ opacities in the right middle and lower lobes, consistent with
infection. Stable bilateral pleural effusions. Radiology showed 1. Minimal improvement in right lower lobe pneumonia with persistent effusion
tracking along the major fissure.
2. Endplate destruction of the T7/T8 interspace compatible with given
diagnosis of osteomyelitis/discitis. Radiology showed 1. Allowing for the difference in technique between non-contrast and
contrast-enhanced MR studies, there has been no significant short-interval
change in the degree of osseous destruction at the T7-8 level since ___, but there is progressive osseous destruction since an earlier study of
___.
2. The current contrast-enhanced study better characterized\s the T7-8
spondylodiscitis and vertebral osteomyelitis, demonstrating an intervertebral
rim-enhancing collection in direct communication with the large right-sided
paraspinal/pleural collection, likely empyema.
3. Multiple additional smaller loculated pleural-based collections in the
lung bases, compatible with additional empyemas. Extensive adjacent airspace
consolidations in the lung bases representing with ongoing pneumonia.
Clinical concern is raised for the proximity of the collections to the
descending aorta, with potential for infectious aortitis. Radiology showed Re-demonstration of osteomyelitis-discitis at T7-T8. Bilateral paravertebral
fluid collections, greatest on the right, are unchanged since MRI ___. Radiology showed Re- demonstration of osteomyelitis-discitis at T7 -T8 surrounded by bilateral
paravertebral and pleural collections. There is no change since MRI of ___ and CT yesterday, ___. The patient was diagnosed with BACKACHE NOS, PNEUMONIA,ORGANISM UNSPECIFIED. The patient was treated with T7-8 laminectomy
thoracotomy with drainage. At the time of discharge, the patient had T7-8 paraspinous abscesses
pleural effusions. 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 minimal PMH besides known MSSA
osteomyelitis, discitis, and epidural abcess at ___ s/p prior
laminectomy (___) and Nafcillin course who presented with
worsening back pain from continued infection and cough from CAP.
# MSSA T7-8 Osteomyelitis/Discitis: MRI spine ___ showed
interval anterior collapse of T7/T8 since ___, with
increased prevertebral soft tissue edema and new paravertebral
fluid collections, and new adjacent RLL consolidations,
concerning for discitis and osteomyelitis with prevertebral
spread. Patient was initially admitted to Neurosurgery service.
Underwent ___ guided deep bone biopsy of this area on ___,
with gram stain showing GPCs in pairs and clusters and cultures
growing MSSA. Antibiotics were held prior to the biopsy.
Following the biopsy, he was started on Vancomycin, and switched
to Nafcillin once MSSA confirmed. He was transferred to
Medicine service for further management of his infection, with
ID and Neurosurgery following. His pain was controlled with
oxycontin, gabapentin, with oxycodone and hydromorphone as
needed for breakthrough pain. The pain service was also
consulted for assistance with pain management. On medicine, he
remained afebrile and leukocytosis resolved. He was
neurologically intact, but given significant bony destruction
and instability in his spine, decision was made to operate. Due
to the prevertebral extension of his infection and fluid
collections in the thorax, he need a combined surgery with both
Thoracics and Neurosurgery, via an anterior approach. Went to
the OR on ___.
# RLL Pneumonia: His CXR on admission showed significant
consolidations concerning for pneumonia. He received
Levofloxacin 750 mg IV once in the ED on ___, but no other
antibiotics prior to his bone biopsy. His MRI showed increased
prevertebral soft tissue edema and new paravertebral fluid
collections with adjacent right lower lobe consolidations,
suggesting that his pneumonia may actually be prevertebral
spread from his spine infection rather than a typical CAP. He
was nevertheless treated for CAP with Levofloxacin 750 mg PO
daily for 5 days given evidence of possible aspiration and
___ opacities on CT torso. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with diastolic dysfunction and COPD
presenting with 1 week of dyspnea that acutely worsened today
with associated mild swelling in the legs and generalized
fatigue. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality. CHEST (PORTABLE AP) showed As above. BILAT HIPS (AP,LAT AND AP PELVIS) showed Severe right and mild to moderate left hip osteoarthritis. No definite
fracture detected involving either hip. If there is ongoing clinical
suspicion for fracture, then CT or MRI could help further assessment.
No displaced fracture detected about the pelvis. KNEE (2 VIEWS) BILATERAL showed Osteopenia. Status post right TKR. Severe left knee osteoarthritis. No
fracture or dislocation detected in either knee on the available views. No
right knee hardware loosening or failure detected. CHEST (PA AND LAT) showed Mild interstitial edema has developed since ___. Mild cardiomegaly is
long-standing. Pleural effusions are small if any. No pneumothorax. Band of
atelectasis at the base of the right lung is the only focal pulmonary
abnormality. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION. At the time of discharge, the patient had Primary:
Acute respiratory failure
Secondary:
___ exacerbation
Opioid overdose
COPD exacerbation
UTI
Type II NSTEMI. 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
==========================
___ year old female with history of COPD not compliant with home
O2, HFpEF, spinal stenosis, severe OA, and neuropathy secondary
to chemotherapy who presented with respiratory failure requiring
BIPAP. She was found to have overdosed on tramadol along with
COPD and CHF exacerbations. She was treated with naloxone,
prednisone, antibiotics and lasix diuresis and improved. She was
transferred to acute rehab in good condition.
Acute Issues
==================
# Hypercapneic respiratory failure ___ opioid overdose, COPD and
CHF exacerbations
This was felt to be secondary to tramadol overdose with COPD and
CHF exacerbations. She was initially given naloxone and
improved. She was subsequently stabilized with 5 days of
levoquin and 5 days 40mg po prednisone for COPD exacerbation and
IV lasix diuresis for CHF exacerbation. She was subsequently
transitioned to home torsemide regimen. ___ evaluated patient
and recommended discharge to rehab. She was at her baseline
status with clear mentation and no daytime O2 requirement at
time of discharge.
#Toxic Encephalopathy. Patient with encephalopathy likely
secondary to some metabolic component of hypercarbia, as well as
supratherapeutic doses of tramadol. Improved with naloxine and
improved respiratory status. At baseline upon discharge.
# Acute Kidney Injury (baseline 1.1). Patient with ___ in
setting of likely hypovolemia and poor PO intake. Improved with
some IVF and improved PO intake.
# NSTEMI, type II. Patient with T wave inversions and mildly
elevated trops already downtrending suggestive of demand
ischemia in setting of COPD exarbation. Patient with known
history of demand NSTEMI in setting of COPD exacerbations.
Troponin peaked at 0.12. Aspirin continued. No chest pain
throughout admission.
# UTI
Urine culture grew >100,00 K. pneumonia with levoquin coverage
as above.
Chronic issues
============================
# Atrial fibrillation. Remained in normal sinus rhythm.
Continued metoprolol for rate control and aspirin.
# Neuropathic Pain
Patient trialed on Duloxetine 20mg and pain was well controlled
throughout admission.
Transitional Issues
==============================
- Patient was evaluated by ___ and requires acute rehab.
- She should follow up with her PCP following rehab stay.
- Tramadol was discontinued as it may have contributed to her
presentation of respiratory failure.
- She was started on duloxetine and tylenol with good pain
control.
- She was mildly hypernatremic during admission, Na 149 on
discharge. Please recheck Na on ___ and consider free water if
uptrending or not improved.
- Discharge weight: 83.7 kg
# CODE: Full (confirmed)
# CONTACT: ___ (___) ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ with a h/o HTN and DM2 who presented with
a fall. History obtained from medical record as patient is not
reliable. Per ED and SW notes: According to his wife, the
patient fell last night while walking to the door when he
tripped and fell to the right. He was on the floor for 13 hours
before EMS was called; per wife he is stubborn and she thought
he could get up. SW was involved in the ED and called Elder
Protective services as his wife appeared confused. Daughter also
lives at home. In the ED pt deined LOC, cp/sob, f/c/s,
presyncope, but was feeling weak prior to fall. When EMS arrived
he was prone in the bedroom, cool, confused, slow to answer
questions, FSG was 467. Per wife has had multiple falls recently
but usually gets up.
In the ED, initial VS were T: 97.9, HR: 100, BP: 116/79, RR: 14,
O2%: 94%, FSBG: 402.
Exam was notable for abrasions on the bilateral knees and R
elbow. He also had a normal rectal tone initially with guaiac
negative stools. Had maroon colored emesis in the ED and guaiac
positive one hour after arrival, NG tube placed. KUB shot, read
pending, per report not c/w obstruction. Labs: BUN 88 and
creatinine of 3.0 (unknown baseline), CK of 1808, Trop-T of
0.04, WBC of 18.4 (86%N), and lactate of 3.2. Glu 513. Ca ___
alb 3.8. Repeat lactate 2.4. Urine >186 Wbc's, mod bacteria, no
epis.
CXR without acute cardiopulmonary processes or signs of
infection. C-spine showed no evidence of acute fracture or
prevertebral soft tissue abnormality. CT head showed no acute
hemorrhage or fracture.
GI was consulted in the ED for occult positive gastric contents
on NG lavage and maroon vomitus, they recommended 40mg bid po
ppi.
Patient received 3L of NS, 40 mg of IV pantoprazole, 8 units of
insulin (regular), ceftriaxone
Transfer VS were Today 19:27 0 98.2 104 135/83 23 95% RA FSBG:
499.
On arrival to the floor, patient says he feels well in spite of
everything that's happened.
After arrival to floor, ED resident paged that NG tube needed to
be advanced. Tip was not clearly visible on CXR but it was at
60cm with some dark material present in tube. Given no recent
vomiting and likelihood that it was coiled, it was removed. CT HEAD W/O CONTRAST showed No acute hemorrhage or fracture identified. CT C-SPINE W/O CONTRAST showed 1. No acute fracture or prevertebral soft tissue abnormality of the cervical
spine.
2. Mild anterolisthesis of the C3 on C4 vertebral bodies is likely
degenerative. Radiology showed The lung volumes without acute cardiopulmonary process. CHEST (AP AND LATERAL) showed Nasogastric tube tip can only be traced to the proximal esophagus on the
frontal view. Recommend advancement. Radiology showed 1. No enteric tube identified.
2. Nonobstructive bowel gas pattern without evidence of free intraperitoneal
air. The patient was diagnosed with OTHER MALAISE AND FATIGUE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN. The patient was treated with N/A. At the time of discharge, the patient had Enterococcus UTI, hyperglycemia due to poorly controlled T2DM,
___ and hypernatremia caused by hyperglycemia.
Code status: Full
Discharge follow-up with Dr. ___ (PCP) (___). 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 male with PMH of DM2, HTN, CKD
stage 3 who presents to the hospital after a fall. Because his
wife ___ certain that the fall was serious enough to call
EMS, he was on the ground for 13 hours. In the ED, found to have
hyperGlc (400s) and UA c/w UTI, thought to have been the cause
of the fall. Due to dehydration, pt had hypernatremia and mild
___. In the ED, he had a single episode of maroon-colored emesis
(guaiac+) for which NGT was placed; stools were guaiac negative
and rectal exam revealed brown stool. H/H were stable through
his admission, and NGT was discontinued. The derangements above
were treated as described below:
Problem List
# Falls
# UTI
# Hyperglycemia/DM2
# Hypernatremia
# ___
# Maroon-colored emesis/?GIB
# Disorientation
# Troponinemia
# HTN
# Falls: Pt with reported history of several falls at home. This
fall was most likely precipitated by UTI, hyperglycemia,
?delirium. Due to being on the ground for 13h, patient had
hypernatremia (see below), mild ___ (see below), and CK
elevation to 1800. No reported hx of seizure-like activity or
sxs of syncope; additionally, other causes better explain the
fall. Given murmur heard on exam, echo was obtained showing LVH,
LVEF 70%, moderate aortic valve stenosis (valve area = 1.1cm2).
Patient discharged to rehab for further evaluation and
treatment.
# UTI: Patient's UA c/w UTI and urine cx growing Enterococcus.
Sensitive to ampicillin, nitrofurantoin (contraindicated due to
___, and vancomycin. Given sensitive to ampicillin, patient
was started on amoxicillin-clavulanic acid ___ PO q12h for a 10d
course for complicated UTI. This should be continued at rehab to
completion.
# Hyperglycemia/DM2: Patient presented with hyperglycemia to
400s, most likely due to infection and missed insulin doses. He
is on a glargine (50u breakfast, 42u dinner) and humalog (15u
breakfast, 50 units lunch) at home. Follows with an
endocrinologist at ___. Needs to f/u with Endocrinology
on discharge from rehab.
# Hypernatremia: As high as Na 150. Most likely ___ dehydration
due to being on the ground without free water access for 13h.
Initially we corrected with D5W based on free water deficit; Na
remained normal once patient taking PO as usual.
# ___ / CKD: Has history of stage 3 CKD (Cr baseline 2.5); Cr
3.0 on arrival. ___ most likely multifactorial due to (1)
relative hypotension in setting of UTI and (2) dehydration from
osmotic diuresis/hyperglycemia + free water restriction while he
was stuck on the floor. Re: (1), the patient had relatively low
systolic pressures (120s) during ___ 48 hours of admission; with
appropriate antibiosis, systolic pressures rebounded to
170s-200s (see HTN below). Cr improving (3.0 -> 2.8 -> 2.6).
Almost at baseline on discharge. Follow up with ___
nephrology.
# Maroon-colored emesis/?GIB: Single episode guaiac pos emesis
with guaiac neg brown stools. Hgb stable in ___. NGT placed in
ED but removed due to malposition on KUB and clinical stability.
# Disorientation: Patient with 24h of waxing-waning mental
status in hospital in setting of hyperglycemia, hyperNa, UTI as
above. Resolved with tx of illnesses as described above and
appropriate delirium precautions.
# Troponinemia: Patient with very mild Tn-emia on presentation
(0.13->0.14) and ECG at baseline, no chest discomfort. Most
likely represents a minimal elevation in setting of relative
hypotension, multiple illnesses as above, and ___ preventing
clearance of Tn.
# HTN: Patient was normotensive off home BP meds on arrival to
the floor. Initially held BP meds due to ___. However, once UTI
was txed, SBPs 170s-200s. Losartan 100/day restarted the day of
discharge; HCTZ continues to be held. Can be restarted at
discretion of rehab physician or PCP.
# Social: Initially thought that wife ___ filed with ___ at the
Elder Abuse Hotline and faxed written report to Ethos given
patient was down for 13 hours before EMS was called. Discussed
further with wife who noted that she didn't realize a fall was
"serious enough" to call EMS but would do so in the future if
something similar happened.
TRANSITIONAL
-Home Eval for fall prevention measures
-UTI: needs Augmentin 10d course for complicated UTI
-Hyperglycemia/DM2: needs f/u with ___ endocrinology
-___: f/u with ___ nephrology
-HTN: restart HCTZ or add additional antihypertensives as
appropriate</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo RHW with h/o chronic LBP s/p L4-5 fusion,
fibromyalgia, anxiety, depression, who presents with progressive
distal lower extremity numbness and weakness for the past 3
months.
The patient initially presented on ___ ___.
She had awoken that morning with severe numbness below the knees
bilaterally. Her legs were weak and she collapsed on attempting
to stand. She had a recent stomach flu a few days prior.
Examination demonstrated distal lower extremity weakness and
decreased sensation to pin and vibration, with diminished lower
extremity reflexes. There was concern for GBS. CSF was normal (0
cells, glucose 59, protein 24, neg CSF Lyme, neg bands). However
it was thought there was still benefit to treating empirically,
so patient received 3 doses IVIG. She developed fever to ___ F
after 3rd dose so no more were given. She also underwent MRI C,
T
and L spine, and MRI/A brain which were all unrevealing. Labs
were initially notable for CK almost 20K, attributed to fall,
but
this was mild and there was not prolonged down time. CRP 50, ESR
16, WBC 18.3. CK trended down with IVF and has been normal on
repeat checks since.
The pt was discharged to rehab and was then discharged home with
___. Neurologic work-up continued as an outpatient under care
of Dr. ___. EMG ___ showed acute length dependent
polyneuropathy with mixed axonal and demyelinating features.
Motor neuropathy and paraneoplastic Abs sent to ___ were
negative (GM1, GD1b, MAG, ___, CV2, amiphiphysin). Autoimmune
labs
neg ___, ANCA, SSa/b). On ___, CRP was down to 25, ESR 12.
The patient complains of severe pain, that was not part of the
initial presentation but began after returning home from rehab
and doing ___. It has become more severe and refractory to
medications in the past month. Pain includes R foot cramps,
sharp
pains at L posterior calf and feet, burning pain on soles of
feet, hypersensitivity to touch that is painful on L foot. Pain
is worse when putting pressure on the legs to stand, and on
touching the L foot. There are no paresthesias. She will
sometimes feel extreme cold but then legs are not cold to the
touch.
Pt also c/o losing muscle mass and bulk all over, including
upper
extremities, though there are no other symptoms in the upper
extremities (no weakness, numbness, tingling in hands/fingers).
She feels her health going downhill in general and is very
discouraged. She reports her L leg bends backwards on walking.
She had been using cane, but is now using a wheelchair.
Of note, the patient reports that her pain medications were
stolen from her 5 days ago. Since then she experienced severe
withdrawal symptoms (N/V/D and extreme pain). She had not slept
or ate well in days. She presented to ___ ED today, and her
neurologist felt she warranted additional workup since diagnosis
is unclear, and sent her to ___ ED. The patient reports she
was
supposed to have nerve and muscle biopsy tomorrow at ___. ___. Radiology showed No acute cardiopulmonary process. Radiology showed 1. Innumerable bilateral sub-2mm pulmonary nodules some of which are calcified
and shotty mediastinal lymphadenopathy. Differential includes
tuberculosis/fungal infection/sarcoidosis or less likely hematogenous mets
with calcification, ie osteogenic, mucinous, thyroid, breast origin.
Calcification suggests a chronic granulomatous infection (TB) should be
considered. Comparison with any old CT imaging is recommended.
2. Dilated CBD measuring up to 11-mm which abruptly terminates at the
pancreatic head with no stone seen. Possible thickening of the duodenum at the
ampulla is suspicious for malignancy. Followup ERCP/MRCP is strongly
recommended.
3. 5mm indeterminate hepatic hypodensity. Radiology showed Unremarkable MRI of the head with and without contrast. Radiology showed Mild degenerative changes of the cervical, thoracic, and lumbar
spine as described above. Post-surgical changes, status post disc spacers at
L4-5 and L5-S1 levels. No evidence of abnormal enhancement or abnormal signal
in the spinal cord. The patient was diagnosed with MUSCSKEL SYMPT LIMB NEC, LEUKOCYTOSIS, UNSPECIFIED , MYALGIA AND MYOSITIS NOS. At the time of discharge, the patient had 1. Compression polyneuropathy, 2. Fibromyalgia. 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 RHW with h/o chronic LBP s/p L4-5 fusion, fibromyalgia,
anxiety, depression, who presents with progressive distal lower
extremity numbness and weakness for the past 3 months. Neuro
exam is signficant for weakness that is asymmetric L>R and
more prominent distally than proximally in the lower
extremities, though there is question of giveway/effort in
judging the true degree of the weakness. This also makes it
difficult to distinguish an upper vs lower motor neuron pattern.
There is
decreased pinprick mostly in L4 distribution up to the knee,
with hyperasthesia in L5. Vibration sense is also diminished L>R
great toe, and DTRs are diminished in lower extremities.
Etiology of this presentation is unclear despite extensive
outpatient workup including MRI brain and spine, EMG, LP, and
several lab studies.
The patient had vague, non-specific positive findings, including
elevated CRP which has trended down, and elevated CK at initial
presentation, as well as leukocytosis intermittently seen. The
patient was admitted and monitored. A CT of the abdomen was done
that showed a duodenal wall thickening. She received a EGD and
biopsy that revealed only a cyst and no signs of neoplasm. the
CT of chest showed multiple small pum nodules/calcifications
with mediatinal LAD, however these were thought for the most
part to be chronic (based on previous radiology reports from
___ and ___ faxed from PCP ___.
Over her week of hospitalization the patient gained weight and
her objective signs of weakness (left foot drop) improved. Prior
to hospitalization the patient was eating only one meal a day.
She was also treated with B12 for a low normal B12, that may
have also contributed to her improvement. The patient was very
uncomfortable and frustrated with a diagnosis of compression
neuropathy secondary to malnutrition.
The patient's chronic pain was treated while she was here on her
home regimen on ___ and gabapentin. Of note, when her
medications were at her home dosing the patient was very
somnolent, difficult to arouse and O2 sat to the low ___. This
may have contributed to the patient's decreased PO.
The patient received physical therapy during her time and was
much improved on discharge. She was able to ambulate with a cane
and was deamed ready for d/c home with ___ services. Her hospital
course was discussed with her primary neurologist who
coordinated a follow-up for her. She was discharged on the pain
regiment she was on inpatient as detailed below. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male with no significant pmh
who presents with left sided chest pain, found to have left
upper
lobe anterolateral lung abscess and pneumomediastinum. BILATERAL UP EXT VEINS US showed No evidence of deep vein thrombosis in the bilateral internal and external
jugular veins. DX CHEST PORTABLE PICC LINE PLACEMENT showed 1. Right-sided PICC line ends at the cavoatrial junction. No evidence of
pneumothorax.
2. Focal opacification located laterally within the left hemithorax likely
represents infarct, secondary to adjacent pulmonary embolus as seen on CT from
___. However in a patient of this age, vasculitis cannot be
entirely excluded.
3. Persistent pneumomediastinum. The patient was diagnosed with Abscess of lung without pneumonia. At the time of discharge, the patient had Left upper lobe mass, presumed abscess
Pneumomediastinum
Reduced ejection fraction
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>___ man with no chronic medical problems who presented with left
sided chest pain and cough, with outpatient imaging showing left
upper lobe mass felt to be an abscess. He was treated with
vancomycin/zosyn and transitioned to ertapenem at discharge.
# Lung Abscess with Pneumomediastinum:
Patient presented with lung mass on CT scan, felt most likely an
abscess possibly precipitated by aspiration event in the setting
of alcohol/drug use v. small nodular bacterial pneumonia that
coalesced into abscess given inadequate treatment with 4 days of
PO levoquin as outpatient. Differential diagnosis also included
atypical infection (e.g. fungal) v. inflammatory process v.
malignant process, all felt much less likely. CT imaging ___
with progression of mass and concern for pneumomediastinum.
Infectious disease was consulted who recommended treatment for
pyogenic lung abscess with vancomycin/zosyn. Thoracic surgery
and interventional pulmonology were consulted for consideration
of biopsy v. abscess drainage. Both teams recommended
conservative medical management with close follow up, given low
concern for pleural involvement and very low concern for
mediastinitis given patient very well appearing and stable
throughout admission. Pneumomediastinum may have occurred
secondary to intranasal cocaine use v. coughing. HIV was
negative. ___ and ANCA negative. Blood cultures were no growth
to date. TTE without evidence of pericardial seeding. Jugular
vein ultrasound without thrombosis. On discharge, he was
transitioned to ertapenem with plan for at least 4 weeks of
antibiotics [Day 1 ___, with repeat CT chest in 4 weeks and
close PCP, ___, interventional pulmonology, and
thoracic surgery follow up. He will need further workup if mass
persists on repeat imaging status post antibiotics.
# Reduced ejection fraction:
Patient's TTE was notable for reduced ejection fraction of 45%
and mild global left ventricular hypokinesis. Most likely
secondary to alcohol and cocaine use. TSH was elevated at 5.3,
but T3 and free T4 were normal. He will need repeat TTE in 3
months and further outpatient work-up if persistent depression
of ejection fraction.
# Acute kidney injury:
Patient developed ___ from 0.9 on admission to 1.3. This
remained stable the next day, without improvement with IV
fluids. ___ was felt secondary to zosyn he received in house.
Vancomycin level was 19, so vancomycin felt less likely to be
culprit. Urine sediment without concerning findings. Patient was
encouraged to continue good PO intake on discharge. He will need
a repeat creatinine in 1 week to ensure normalization. </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 signficant PMH ESRD and
Afib on coumadin with history of CVA in ___ who presents
to the ED after being found unresponsive at her ECF. Per report,
patient was seen normal eating breakfast at 8am. She was then
found by staff unresponsive by staff sometime later, between 9am
and noon, although reports are conflicting. EMS was activated
and per report FSBG was normal. Her finger stick blood glucose
was normal per report and without complaint. Radiology showed 1. No acute cardiopulmonary process.
2. Chronic left lower lobe opacitiy may be due to aspiration, atelectasis or
scarring. Radiology showed 1. No acute intracranial process.
2. Chronic small vessel ischemic disease and age-related volume loss. The patient was diagnosed with SEMICOMA/STUPOR, END STAGE RENAL DISEASE. At the time of discharge, the patient had 1. Medication side effect
2. End stage renal disease
3. 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>ASSESSMENT & PLAN:
Ms ___ is a ___ year old with a history of ESRD, Afib on
coumadin, and history of CVA who presents from her ECF after
being found unresponsive this morning. She awoke spontaneously
in the ED during workup and is currently without significant
complaint.
# Unresponsive episode: Patient was last seen normal at 8am
morning of discharge. She was found unresponsive by staff at ECF
sometime between 9am and noon. She was brought to ED where she
was noted to be breathing comfortably with intact gag reflex.
She withdrew from pain in all four extremities. CT of head, CXR,
and initial lab work was unremarkable. During preparation for
intubation, patient apparently awoke spontaneously while staff
was out of the room. She was noted to be oriented and without
complaint. She was admitted to medicine for further workup and
observation. On arrival to the medicine floor she had no
significant complaint. Zyprexa was held. Troponins were negative
x2 and telemetry showed only occasional PVC's overnight. Given
concern for seizure, routine EEG was performed, which was
negative for epileptiform discharges per preliminary report.
Neurology was consulted who felt episode most likely due to
medication effect of zyprexa with poor baseline substrate given
recent hospitalziations and initation of HD. No further imaging
was felt to be indicated. Zyprexa should be discontinued on
discharge and any additional neuroleptic or sedating medications
should be used cautiously.
# Positive blood cultures: Patient noted to have GPC in clusters
growing from one culture set drawn in the ED. She was afebrile,
hemodynamically stable, and without complaint. She was
empirically started on daptomycin given recent VRE in urine
culture. Speciation of blood culture returned coagulase negative
staph, and antibiotics were discontinued as this was felt to be
contaminant
# VRE Bacteruria: Patient with VRE in urine culture on ___ prior
to previous discharge. She was not treated as she was
asymptomatic. Again had VRE in urine culture from ED on ___, and
again is asymptomatic. She did receive 1 dose of daptomycin
empirically for positive blood culture, as above. However,
antibiotics were discontinued with no current intention to treat
her VRE bacteruria.
# Afib: Continued rate controle with metoprolol tartrate 12.5mg
po bid. Discharged on home 25mg metoprolol succinate.
Additionally, patients CHADS-2 is at least 5 and she was
subtherapeutic on her INR on admission. However, given history
of GI bleed in past, she was not bridged with heparin drip.
Coumadin was increased to 2.5mg daily.
# ESRD. Due to PCKD. Initiated HD on ___. Continued HD on
TTS schedule. Continued home sevelemer.
# ?COPD: Patient recently treated for COPD exacerbation during
recent hospitalization. She was breathing comfortably now on
room air without signficant wheezes on exam. Continued home
albuterol and ipratroprium prn, which she did not require.
# Hx of CVA: Continued anticoagulation as above. Given embolic
nature of stroke, it was deemed reasonable for patient not to be
on statin.
# Hx of delerium/sundowning: Has occured with prior amissions.
Held zyprexa as above. Remained alert, oriented, and appropriate
during her stay.
# HTN: Continued metoprolol 12.5 bid as above. Discharged on
home 25mg metoprolol succinate.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ male w/ hx of DM, HTN, prostate CA
(currently opting for observation), colon CA s/p resection, CAD,
and prior traumatic SDH who presents as OSH transfer for R arm
weakness/sensory loss and aphasia. History obtained mostly from
wife and OSH records d/t patient aphasia. CT HEAD W/O CONTRAST Q111 CT HEAD showed No evidence of acute hemorrhage or acute large territory infarction. Please
note that MR would be more sensitive for evaluation of infarction. MR HEAD W/O CONTRAST ___ MR HEAD showed Multiple foci of restricted diffusion in the left cerebellar hemisphere and
adjacent to the trigone of the right lateral ventricle, in keeping with
multiple focal acute/subacute infarcts, which are likely embolic in nature.
Susceptibility within the left parietal lobe in a region of restricted
diffusion, suggestive of hemorrhagic products. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No evidence of hemorrhage.
2. Infarcts of the left frontal and parietal lobes, along with the bilateral
occipital lobes, are better assessed on prior MRI. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Redemonstration of left frontal and parietal infarcts as well as left
occipital infarct. No hemorrhage
2. Encephalomalacia in the lateral right temporal lobe is again seen likely
reflecting old infarct. Chronic bilateral basal ganglia lacunar infarcts and
right internal capsule lacunar infarct. Carotid Artery ultrasound showed Right ICA <40% stenosis.
Left ICA <40% stenosis. CHEST (PRE-OP PA AND LAT) showed In comparison with the outside study of ___, the cardiac silhouette is
within normal limits and there is no vascular congestion, pleural effusion, or
acute focal pneumonia. The patient was diagnosed with Weakness. The patient was treated with tPA. At the time of discharge, the patient had Acute ischemic stroke
Non-ST elevation myocardial infarction. 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
==========
___ is a ___ male w/ hx of DM, HTN, prostate CA
(currently opting for observation), colon CA s/p resection, CAD,
and prior traumatic SDH who presents as OSH transfer for R arm
weakness/sensory loss and aphasia, s/p TPA, course c/b NSTEMI.
TRANSITIONAL ISSUES
=====================
[ ] Follow-up w/ ___ expedited CABG, if patient were
to develop chest pain he would need to be urgently evaluated for
emergent PCI or CABG, please continue to monitor closely
[ ] Tentative plan to discharge on apixaban with Ziopatch, if
Ziopatch negative for occult arrhythmia will likely discontinue
apixaban and treat with Aspirin alone
[ ] Follow-up w/ interventional cardiology to discuss options
[ ] Continue optimization of diabetes given elevated A1c (8.3)
#Acute Ischemic Stroke
Pt presented w/ a mixed aphasia and RUE weakness concerning for
left MCA stroke. He received tPA on ___. CTA did not
demonstrate any large vessel occlusion or significant
atherosclerosis. MRI 24 hours s/p tPA demonstrated multifocal
acute infarcts in multiple vascular territories consistent w/ a
cardioembolic source, however TTE w/o an obvious source (EF
mildly reduced 50-55%). Per echocardiography fellow, windows
were appropriate and they didn't believe a TEE would offer
further advantage. Etiology of his stroke is believed to be
embolic stroke of undetermined source (ESUS), though given his
concurrent cardiac disease suspicion is highest for a transient
cardiac arrhythmia which led to cardiac thrombus formation. Pt
was transitioned to apixaban this admission (5mg BID), which we
will continue and consider stopping if his Ziopatch is negative.
Noted to have A1c of 8.2 and LDL of 109. Pt has an allergy to
statins and thus is on a PSCK9 inhibitor. He was seen by both
physical therapy, occupational therapy and speech therapy.
#NSTEMI
#CAD
Pt underwent recent LHC ___ (as an outpatient) and noted to
have 3V disease. Presented this admission w/ concern for chest
pain (was initially difficult to evaluate given aphasia) and
elevated troponin to 1.2. Cardiology was consulted and he was
started on a heparin gtt for an NSTEMI. Cardiac enzymes
downtrended. He was additionally evaluated by cardiothoracic
surgery who are pursuing an expedited workup for CABG. From a
stroke perspective he is okay for a heparin gtt as needed for
surgery. He additionally had a CXR, labs, and carotid dopplers
while inpatient. We also reached out to the structural heart
team for consideration of a complex PCI as an alternative to
surgery. Of note, the cardiology team did not believe there was
an acute indication for intervention during this
hospitalization. Pt was switched from atenolol to metoprolol
(consolidated at discharge to 50mg succinate). Also started on
ASA 81mg. He was discharged w/ a Ziopatch.
#DM
#HTN
Noted to have uncontrolled risk factors of DM and HTN. Increased
Valsartan this admission. Stopped atenolol and switched to
metoprolol as above.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL =109) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ X] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? () Yes - (X) No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[X ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (X)
Antiplatelet - (X) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (X) N/A -- high concern for atrial
fibrillation, so discharge on apixaban pending Ziopatch </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ woman with a deceased donor renal
transplant in ___ c/b stage IV chronic kidney disease in the
transplant ___ chronic allograft nephropathy, baseline Cr 3.7,
as well as secondary hyperparathyroidism, recurrent PEs
presenting with N/V/D and ___. RENAL TRANSPLANT U.S. showed Normal renal transplant ultrasound. CT HEAD W/O CONTRAST showed Mild paranasal sinus inflammatory changes. Otherwise normal study. VENOUS DUP UPPER EXT BILATERAL showed 1. The brachial and radial arteries on both sides appear widely patent. No
evidence of calcifications.
2. Right cephalic and basilic veins in as indicated above.
3. The the forearm loop graft is occluded and only the basilic vein is
visualized on the left side. Measurements as indicated above. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, KIDNEY TRANSPLANT STATUS. At the time of discharge, the patient had Primary diagnosis:
___
Infectious gastroenteritis
Secondary diagnoses:
S/p renal transplant
Hypertension
Hypercoaguability. 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 ___ woman with a deceased donor renal
transplant in ___ c/b stage IV chronic kidney disease in the
transplant ___ chronic allograft nephropathy, baseline Cr 3.7,
as well as secondary hyperparathyroidism, recurrent PEs who
presented with N/V/D and ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patietn seen and examined agree with house officer admission
note by Dr. ___ ___ with additions below Radiology showed 1. Post-surgical changes involving the left first metatarsal head. Although
post-operative radiographs since the last debridement are not available,
indistinct bony borders, fragmentation, and focal demineralization are
concerning for osteomyelitis. A large plantar soft tissue defect is depicted
on the lateral view.
2. Linear opacity overlying the third toe proximal phalanx, likely a foreign
body within the soft tissues, unchanged compared to the prior study from ___. Radiology showed Osteomyelitis of the first metatarsal as well as the base of the
first proximal phalanx. Inflammation of the soft tissues surrounding the
amputated metatarsal head as described above, with associated skin ulcer along
the plantar aspect- of the foot. No drainable fluid collections to suggest
abscess.
These critical findings were discussed with Dr. ___ at 12:01pm on
___ by Dr. ___ (fellow) Radiology showed 1. Postoperative changes status post resection of the first metatarsal head
as described above.
2. Linear (needle-like) foreign body seen along the soft tissues adjacent to
to the third metatarsophalangeal joint. These may represent the foreign body,
unchanged. The patient was diagnosed with OTHER POST-OP INFECTION, ABN REACT-SURG PROC NEC, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with Debridement of left foot first metatarsal and proximal phalanx. At the time of discharge, the patient had Primary: Osteomyelitis
Secondary: Diabetes mellitus, Congestive heart failure,
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>___ year old gentleman with h/o of type 2 diabetes complicated by
diabetic retinopathy, neuropathy, and persistent foot infections
presenting with acute worsening of an ulcer on his L foot, found
to have osteomyelitis of ___ metatarsal and ___ proximal
phalanx.
ACTIVE ISSUES
1. Osteomyelitis: The patient was started on empiric
antibiotics for cellulitis and suspected osteomyelitis upon
admission. He received 1 dose each of linezolid and cefepime,
and then was started on ampicillin-sulbactam on ___. The
foot ulcer was cultured and grew Group B streptococcus as well
as coagulase positive, methicillin-sensitive staphylcococcus
aureus. An MRI of the foot was performed which showed
osteomyelitis, and the patient was taken to the OR for
debridement and deep tissue culture by the Podiatry service on
___. Infectious diseases was consulted for antibiotic
management and agreed with coverage by ampicillin-sulbactam
pending final cultures. Deep tissue cultures revealed the same
organisms as above, and the patient was switched to nafcillin 2g
q4h per ID recommendations for a total course of 6 weeks. A
PICC line was placed, and the patient was discharged. He
remained afebrile and without signs of systemic infection
throughout the admission. Blood cultures remained negative.
Baseline ESR and CRP were drawn to be followed for improvement
as an outpatient. The patient will follow up with Podiatry in 1
week after admission and with ID in the ___ clinic in 2 weeks.
2. Type 2 Diabetes: The patient's diabetes is uncontrolled with
complications, including diabetic retinopathy and neuropathy.
He was initially started on his home regimen of Lantus 43 units
qhs and Humalog 8 units QAC, but due to uncontrolled blood
glucose levels (elevated to high 300s at times throughout
admission), his Lantus was titrated up to 50 units qhs and
Humalog was titrated to 20 units qac with SSI. The
hyperglycemia was likely caused, in part, by his acute
infection. He was discharged on this new insulin regimen and
will follow up with his primary physician for further
adjustments.
3. Rash: The patient was found to have multiple erthematous
papules covalesecing into plaques on the gluteal fold.
Differential diagnosis includes inverse psorias vs eczema. He
was empirically treated with topical Clobetasol Propionate 0.05%
Ointment. He was scheduled for a follow up appointment with
Dermatology as an outpatient.
CHRONIC ISSUES
1. Chronic Diastolic Congestive heart failure: the patient's
last echocardiogram ___ showed the left atrium was
moderately dilated, with mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). The patient was continued on his home carvedilol 25
mg BID and torsemide 20 mg BID. CHF was stable throughout the
admission.
2. Coronary artery disease: Stable during admission. Home
aspirin 81 mg and atorvastatin 80 mg were continued.
3. Hypertension: Stable during admission. Home torsemide 20 mg
BID was continued.
TRANSITIONAL ISSUES
1. The patient has a PICC line placed in his left arm and will
receive IV nafcillin q4h for 6 weeks. He received teaching from
___ prior to discharge. The PICC should be removed upon
completion of antibiotic course. He will follow up with ID in
the ___ clinic in 2 weeks for management.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ xfer from ___ hemodynamic instability
in setting of newly diagnosised ruptured AAA. Per OSH report, pt
presented to ___ of severe abdominal pain
radiating to back x ___ days. Has had associated anorexia w
reported 15# weight loss in last one week. Endorses substantial
increase in abdominal pain this ___ following episode of
coughing.
Reported to ___ for further evaluation. On arrival to
___ ED noted to have SBP ___ which improved w 1L resuscitation.
CT I- performed which showed contained rupture of 7cm juxtarenal
AAA. Arranged for emergent xfer to ___ for further
management. CTA CHEST AND CT ABDOMEN AND PELVIS showed 1. Acute rupture of large infrarenal aortobi-iliac abdominal aortic aneurysm
along its anterolateral left aortic wall with acute hemorrhage in the
retroperitoneum. No evidence of active arterial extravasation.
2. Sigmoid diverticulosis without evidence of acute diverticulitis.
3. Chronic emphysematous changes of the lungs with interstitial changes and
focal left lower lobe opacity suggesting superimposed atelectasis.
4. 0.8 and 0.7 cm pulmonary nodules. Followup CT in ___ months is recommended
for surveillance.
NOTIFICATION: The findings were discussed by Dr. ___ with vascular
surgery in person on ___ at time of discovery of findings. CHEST PORT. LINE PLACEMENT showed 1. Endotracheal tube tip ends 7.9 cm from the carina, and could be advanced 4
cm for optimal seating within the trachea.
2. New mild bibasilar atelectasis.
3. New small to moderate left-sided pleural effusion. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the patient has been extubated. And
the nasogastric tube was removed. The venous introduction sheet in the right
internal jugular vein remains in situ. Increasing left retrocardiac
atelectasis. Slightly increasing left pleural effusion. No pulmonary edema.
Unchanged appearance of the cardiac silhouette. The patient was diagnosed with ABDOM AORTIC ANEURYSM. The patient was treated with open infrarenal AAA repair. At the time of discharge, the patient had ruptured abdominal aortic aneursym. 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 transferred to ___ with a ruptured AAA on
___. He underwent emergent open repair. Despite the magnitude
of blood loss and surgery he tolearted the surgery well and his
post-operative course was uneventful. He was discharged home on
POD#6. His hospital course by system is summarized below.
Neuro: At the conclusion of the surgery an epidural was placed
for pain control. The patient suffered from some perioperative
delirium however this resolveed by POD#2. His epidural was
removed on POD#3 and he was transititoned to oral oxycodone and
tylenol which he required minimal amounts of up to the time of
discharge.
CV: The patient had a large amount of intra-op blood loss (7.2L)
requiring 9 units of PRBC as well as FFP and platelets
intraoperatively. He was hemodynamically post-operatively. On
POD#1 he was briefly on a nitroglycerin drip for pain control
which was weaned and he was started on home lisinopril as well
as metoprolol for blood pressure control. His blood pressure
remained in good control with the lisinopril and metoprolol
which he was discharged on.
Resp: The patient remained intubated following surgery. He was
weaned from the ventilator on POD#1. Due to the resuscitation
during the operation he was significantly fluid overloaded and
required lasix diuresis for seveal days. After diuresis his
oxygen was weaned and he was stable on room air by POD#3. There
were some incidental pulmonary nodules commented upon on his CT
scan that will require follow up scans in ___ months.
Renal: During the operation the aorta was clamped between above
the left renal artery. His creatinine peaked at 2.2 upon
admission and steadily improved post-operatively. He was
diuresed each day and his weight returned within 2 kgs of his
dry weight.
Endo: The patient initially was on an insulin sliding scale. His
blood sugar remained in good control and this was stopped. He
had no other endo issues.
Heme: Following the ___ transfusions the patient did
not require any further transfusions. His plavix and aspirin
were restarted following removal of the epidural. He was on subq
heparin for DVT prophylaxis.
ID: The patient was afebrile throughout the hospitalization. His
white count was initially elevated likely to a SIRS response to
the surgery but he never manifested any signs of infeciton and
was discharged without antibiotics.
Transitional issues:
1) Hypertension: The patient was started on metoprolol in
additon to his lisinopril for blood pressure control. He was
discharged on metoprolol and was instructed to follow up with
his PCP in the next week or two for a blood pressure check and
titration of his medication.
2) Pulmonary nodules that were incidentally found on his CTA
will need follow up in ___ months. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman with a history of renal transplant and prior
shoulder effusions who presented with 3 days of shoulder pain.
She reported "sleeping funny" on her shoulder and awaking with
severe pain on ___. She went to her PCP and orthopedic surgeon
on ___ who prescribed flexeril and suggested rest, ice, and
NSAIDs. The night of ___ the pain significantly increased with
swelling of the entire arm. She reported severe shooting pain
down her arm with any motion of the shoulder, elbow, or wrist.
No constitutional symptoms or other complaints elsewhere in her
body. CHEST (PA AND LAT) showed Comparison to ___. In the interval, the patient has developed
moderate pulmonary edema. The size of the cardiac silhouette is enlarged and
there are signs of basal apical blood flow redistribution. In addition, the
lateral radiograph shows signs of fissure oral fluid marking. Larger pleural
effusions are not present. No evidence of pneumonia. No suspicious nodules
or masses. UNILAT UP EXT VEINS US RIGHT showed No evidence of deep vein thrombosis in the right upper extremity. MR ELBOW ___ CONTRAST RIGHT showed Trace elbow joint effusion. Marked dense and extensive subcutaneous edema.
No bone marrow edema or bony erosion is detected.
Ligaments, tendons and muscles are grossly unremarkable.
Note made of prominent high-flow vessels in the subcutaneous soft tissues. MR SHOULDER ___ CONTRAST RIGHT showed 1. The study is significantly degraded by patient motion.
2. Large complex glenohumeral joint effusion with intermediate/low T2 signal
and subtle high T1 signal, significantly increased since ___,
increased laxity of the glenohumeral joint, increased bone marrow edema in the
proximal humerus, and new soft tissue edema about the shoulder. The
differential includes some degree of hemorrhagic and/or proteinaceous content
within the glenohumeral joint. Although the appearance is non-specific,
glenohumeral joint infection should be excluded. A severe noninfectious
inflammatory process of this extent would be unusual, but might also account
for this appearance.
3. The significance of subtle cortical effacement about the glenoid,
progressed slightly compared with ___, is dependent on the presence
or absence of infection within the joint. Otherwise, no bone erosion
detected.
4. Severe end-stage osteoarthritis of the glenohumeral joint with essentially
complete loss of hyaline cartilage and of the glenoid labrum, similar to ___.
5. Severe tendinosis of the supraspinatus and subscapularis tendons with
tendon attenuation and partial thickness tearing. The distal subscapularis
may be expanded by complex fluid within the tendon. Supraspinatus tendon is
probably fenestrated, with intrasubstance tearing. These changes have both
progressed considerably compared with ___. .
6. Severe tenosynovitis and tendinosis of the biceps tendon.
7. Moderate subacromial subdeltoid bursitis. Fluid in the SA/SD bursa is much
simpler than fluid seen within the joint.
NOTIFICATION: At the time of this dictation the primary team is aware of the
patient's joint effusion and concern for infection. Imaging guided
arthrocentesis is planned. INJ/ASP MAJOR JT W/FLUORO showed 1. Imaging Findings - nodular synovium in the secondary to synovitis.
2. Procedure - Technically successful aspiration of the right glenohumeral
joint. Requested laboratory examinations are pending. CHEST PORT. LINE PLACEMENT showed Comparison to ___. Newly inserted left internal jugular vein
catheter. The course of the catheter is unremarkable, the tip projects over
the upper to mid SVC. No complications, notably no pneumothorax. Decrease in
severity of the pre-existing pulmonary edema. Stable appearance of the
cardiac silhouette. CT CHEST W/O CONTRAST showed Diffuse ground-glass opacities, combined to small left pleural effusion,
likely reflect infection. The absence of an interstitial component. Is not
consistent with pulmonary edema. Small pleural effusion. Signs of pulmonary
hypertension. CHEST (PA AND LAT) showed In comparison with the study of ___, there has been a substantial increase
in asymmetric pulmonary edema, more prominent on the right. Blunting of the
costophrenic angles is consistent with developing effusions and bibasilar
atelectasis.
This in the appropriate clinical setting, given the extensive pulmonary
changes.
The left IJ catheter extends to the lower SVC. The patient was diagnosed with Other specified soft tissue disorders. The patient was treated with Placement of left IJ central line. At the time of discharge, the patient had PRIMARY DIAGNOSES
=================
SEPTIC ARTHRITIS
HYPONATREMIA
LOWER EXTREMITY EDEMA
GROUND GLASS OPACITIES, RADIOGRAPHICALLY CONSISTENT WITH
PNEUMONIA
ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE
HYPERKALEMIA
ANEMIA
SECONDARY DIAGNOSES
===================
END STAGE RENAL DISEASE STATUS-POST KIDNEY TRANSPLANT
CORONARY ARTERY DISEASE STATUS-POST DRUG ELUTING STENT ___
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>___ with a history of End Stage Renal Disease (secondary to
Focal segmental glomerulosclerosis, status post living-relative
renal transplant in ___, on Tacrolimus/Mycophenolic
acid/prednisone), now with chronic scarring and Chronic Kidney
Disease stage IV, coronary artery disease (status post
drug-eluting stent to left anterior descending artery), with
right shoulder presumed septic arthritis, right-upper extremity
swelling, found to have severe hyponatremia and hyperkalemia.
Patient was monitored in ICU, and course complicated by atrial
fibrillation with rapid ventricular response, which
spontaneously converted to normal sinus rhythm. She was given
antibiotics for presumed septic arthritis and found on CT to
have ground glass opacities consistent with pneumonia.
#PRESUMED SEPTIC ARTHRITIS: Sudden-onset pain, swelling, and
reduced range of motion, in setting of known shoulder/rotator
cuff injuries. Acute pain began on ___ and worsened over
subsequent days, not improved with pain medication. She
presented to the ED for evaluation but was admitted to the ICU
for hyponatremia and received a dose of ampicillin-sulbactam
prior to arthrocentesis by interventional radiology. In this
setting, white blood count on tap was well below threshold for
septic arthritis. MRI findings supported infectious process. She
had no leukocytosis or fever, but is chronically
immunosuppressed and thus unlikely to mount full response.
Notably, crystal stain negative for gout and lyme serology
negative. In terms of rheumatoid labs, none were conclusive.
C-reactive protein and erythrocyte sedimentation rate both
elevated at 198 and 38 respectively. Other labs included:
Rheumatoid Factor 15 (nml ___ C3-85 (nml 90-180); C4 31 (nml
___ anti-CCP negative. Consulted infectious disease, who
recommended ceftriaxone for lung as below while working up
shoulder. Progressed to cefpodoxime and had clinical improvement
on this regimen. Arthrocentesis culture data all negative though
acid fast culture is pending. Plan to continue cefpodoxime for a
total of 2.5 weeks.
#LOWER EXTREMITY EDEMA: Onset ___ afternoon. Recent
echocardiogram normal, no history of liver disease, bilateral
deep-vein thromboses unlikely on anticoagulation. Known historic
nephrotic syndrome though on admission urine protein was 1.1g,
elevated but not nephrotic range, increased to 2.2 on ___.
Concerning for worsening of underlying FSGS in setting of
reduced immunosuppression (discontinued mycophenylate,
prednisone switched to dexamethasone briefly for cortisol
stimulation test) vs. consequence of holding home lisinopril vs.
could be from fluid shifts in setting of repletion (though none
3 days prior to development). On 2-liter restriction. Given 60mg
IV furosemide on ___ with good urine output (1L),
-1650 on ___. Recommended to weigh self daily on discharge and
contact the renal transplant clinic if her weights are
increasing.
#GROUND GLASS OPACITIES, RADIOGRAPHICALLY CONSISTENT WITH
PNEUMONIA: CT chest was ordered to evaluate for etiology of RUE
edema (see below) but showed diffuse ground-glass opacities,
combined to small left pleural effusion, likely reflect
infection. Mild symptoms (intermittent nonproductive mild cough,
mild worsening of vitals though nothing severe). Treated with
cefpodoxime since ___, previously ceftriaxone/vancomycin
(started ___. Of note, ___ chest x-ray consistent with
worsening pulmonary edema, though patient remained without
dyspnea, tachypnea. Consider repeat imaging after antibiotic
therapy to ensure resolution and no underlying pulmonary
pathology.
RESOLVED HOSPITAL ISSUES
===========================
#HYPONATREMIA: Asymptomatic. Baseline 127-133. Admitted due to
hyponatremia to 117. This improved with normal saline in ICU and
3 amps bicarb in D5W on the floor. She required no repletion
after ___. Free T4 normal. Could have component of adrenal
insufficiency (see below) but difficult to assess given chronic
prednisone.
#CONCERN FOR ADRENAL INSUFFICIENCY (AI): Could fit clinical
picture on presentation (weight loss, hyponatremia,
hyperkalemia, acidosis, hypotension, anemia), though many of
these symptoms can be explained by chronic kidney disease, and
AI typically causes hypercalcemia. On cosyntropyn stimulation
test she technically met criteria for adrenal insufficiency
(prednisone replaced with dexamethasone for 2 days preceding).
However, patient chronically on prednisone ___ years) since
transplant. Patient is thus iatrogenically adrenally suppressed
for transplant, and we would expect insufficient physiologic
response to cosyntropin. Would consider stress dose steroids in
future times of acute illness, though she did not receive any
this hospitalization.
#RIGHT UPPER EXTREMITY EDEMA: Resolved over hospitalization.
Likely reactive from presumed septic arthritis, though this is
not well described in literature. Imaging was negative for
right-upper extremity DVT; normal arterial duplex. Chest CT
could not evaluate vasculature without contrast. Not consistent
with thoracic outlet syndrome or SVC syndrome. Normal capillary
refill; no associated neurologic symptoms.
#NEW ATRIAL FIBRILLATION: Noted to have new onset atrial
fibrillation with raid ventricular response while in the ICU.
Converted spontaneously to normal sinus rhythm. Unclear
precipitant; probably presumed septic arthritis. Thyroid
stimulating hormone and free T4 normal. Started on empiric
antibiotics (as above) for concern that an infection may have
been the precipitating factor. Discontinued telemetry ___ due
to normal rate/rhythm.
#HYPERKALEMIA: K was elevated on admission (K peaked to 6.3),
treated with insulin, dextrose and kayexelate with improvement.
Likely secondary to renal failure although adrenal insufficiency
possible. No EKG changes during admission.
#END-STAGE RENAL DISEASE (ESRD) s/p LIVING RELATIVE RENAL
TRANSPLANT: Surgery in ___. Creatinine around baseline. UPEP
negative. SPEP with hypogammaglobulinemia (Immunoglobulin M 22,
normal is 40-230). Discontinued Mycophenylate on ___ per
transplant renal recommendations. Held home lisinopril on
admission but restarted on ___ in setting of increasing
proteinuria. Discharged on 1mg tacrolimus in the morning and
1.5mg at night due to subtherapeutic troughs on 1mg BID.
Continued on prednisone 4mg (though this was replaced with
dexamethasone preceding cosyntropin stimulation test).
#METABOLIC ACIDOSIS: Pt with chronic non-anion gap metabolic
acidosis. Was not tolerating oral sodium bicarb at home due to
abdominal pain. At baseline during admission. Possibly secondary
to ESRD, although concern adrenal insufficiency may be
contributing. Received 3 amps sodium bicarb as above.
#ANEMIA: History of anemia in setting of ESRD, on Darbepoetin
alfa injections. Baseline hemoglobin ___. Hemoglobin slightly
below baseline with no evidence of active bleeding currently.
Received 1u packed RBC each on ___ and ___, with appropriate
rise in hemoglobin. B12 250, Iron (on ___ was 59.
CHRONIC ISSUES:
======================
#HYPERTENSION: On amlodipine, carvedilol, and lisinopril at
home. These were initially held due to hypotension in the MICU.
They were all restarted prior to discharge.
#CORONARY ARTERY DISEASE: Patient with drug-eluting stent in
___. Last Echo in ___ was largely normal. Continued
Aspirin and Ticagrelor while in house. Reached out to
cardiologist Dr. ___ about stopping Ticagrelor >12
months out from Drug-eluting stent, but did not hear back prior
to discharge. Scheduled patient for follow up with Dr. ___ to
discuss. Additionally continued atorvastatin.
#h/o WEIGHT LOSS: Pt with recent weight loss. Fairly up to date
with cancer screenings. Needs outpatient follow up for repeat
colonoscopy.
#CODE: full code
#CONTACT: ___, husband, ___
TRANSITIONAL ISSUES
===================
[] MYCOPHENOLATE MOFETIL: discontinued on admission per Dr.
___
[] TACROLIMUS: reduced to 1.5 QAM and 1 mg QPM from 1.5 BID.
(Trough was elevated on admission, but low while inpatient on
1mg BID.)
[] ANTIBIOTICS: Patient should continue Cefpodoxime PO 400 mg
once per day until ___ for a 2.5 week course.
[] GROUND GLASS OPACITIES ON CT: Asymptomatic, though read as
most consistent with infection. Recommend repeat imaging in ___
weeks to evaluate for resolution.
[] LEG SWELLING: This developed on ___, 3+ edema, in setting of
worsening proteinuria. Her lisinopril was restarted. The
swelling was somewhat responsive to 60mg IV furosemide x3. Per
transplant nephrology team, she should weigh herself daily and
call if she is gaining weight. Otherwise she will have follow up
with Dr. ___ in 2 weeks.
[] CXR WITH PULMONARY EDEMA: Worsened on ___ compared to ___.
Described as "substantial increase in asymmetric pulmonary
edema, more prominent on the right. Blunting of the costophrenic
angles is consistent with developing effusions and bibasilar
atelectasis." Patient was asymptomatic with reassuring vitals
saturating well w/o dyspnea on room air. Correlate clinically on
follow up appointment.
[] ADRENAL INSUFFICIENCY: Technically, cosyntropin stimulation
test confirmed adrenal insufficiency, however, this is difficult
to interpret in setting of iatrogenic suppression of adrenals
with prednisone. It was ordered due to metabolic abnormalities
on admission and concern that the patient was not mounting a
systemic response to presumed infection. ___ consider stress
dose steroids for severe illnesses in the future.
[] WEIGHT LOSS: Recent history of weight loss. She is only 80lb
currently. She is fairly up to date on cancer screening. Further
workup should be discussed and considered in outpatient setting.
[] TICAGRILOR: In setting of ecchymoses, purpura, and ___ year
since stenting, would consider discontinuing ticagrilor pending
conversation with cardiology (Dr. ___.
[] PENDING RESULTS: Joint aspirate acid fast stain pending from
___, no growth as of ___. Low suspicion given improvement
without treatment for mycobacterium.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o COPD on home o2 p/w to OSH w dyspnea, CP, cyanosis.
pt, visiting ___, says that she woke up this AM with a 2
coughing spell followed by chest pain and dyspnea. pt's spouse
says she became cyanotic, which prompted them to OSH ED. Cardiac
enzymes and EKG at OSH was negative. CXR shows R ptx 50% w
slight
medastinal left shift. A chest tube was place. Serial CXR shows
resolution of ptx with mild R lung opacity. CT was done and
reveals spontaneous ptx, blebs, and lung nodules. pt was
transferred to ___ for further mgt. CHEST (PORTABLE AP) showed Right apical opacity may be due to prominent apical thickening/scarring,
correlate with more remote radiographs to ensure stability, if not, consider
followup chest CT. Bibasilar reticular opacities suggest chronic lung disease.
Relative lucency of the mid lungs likely relates to pulmonary emphysema.
Blunting of the right costophrenic angle suggesting a small right pleural
effusion. Right chest tube is seen. Subcutaneous emphysema along the right
chest wall. CHEST (PORTABLE AP) showed There is some overlying motion artifact which limits the examination. A right
basilar chest tube remains in place. There is air within the right lateral
chest wall and neck soft tissues consistent with subcutaneous emphysema.
Rounded lucency at the right apex likely represents a small pneumothorax.
There is bilateral parenchymal distortion with fibrotic changes at the bases
consistent with fibrotic lung disease. Multiple small nodular opacities with
associated right apical pleural thickening are again seen and may reflect
prior granulomatous infection. Clinical correlation is advised. Overall
cardiac and mediastinal contours are stable. CHEST (PORTABLE AP) showed Right chest tube is in place although more distally located than previously.
Apical opacity on the right is unchanged. No definitive pneumothorax is seen.
Interstitial changes and fibrosis in the lung bases is similar to previous
study CHEST (PA AND LAT) showed 1. Chest tube in appropriate positioning without evidence of pneumothorax.
2. Unchanged bilateral diffuse interstitial thickening representing chronic
interstitial lung disease. CHEST (PORTABLE AP) showed As compared to ___ radiograph from earlier the same date, a right
chest tube remains in place, with persistent loculated hydro pneumothorax at
right lung apex and small dependent pleural effusion at right lung base.
Overall, allowing for differences in technique and projection, there has not
been a substantial change in appearance of the chest since the recent study
from several hr earlier. The patient was diagnosed with OTHER AIR LEAK. At the time of discharge, the patient had Right spontaneous pneumothorax
Left lower lobe lung nodule. 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 evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for further
management of her chest tube. She was having some discomfort at
the tube insertion site which was relieved with Oxycodone. She
also had a one chamber air leak from her pleurovac.
Following admission to the Surgical floor her chest tube
remained on waterseal with the same air leak and her chest xray
showed almost full expansion of the right lung. Her oxygen
saturations were 99% on 2 LPM nasal cannula and attempts were
made to wean it off. She admits to being on oxygen at home but
states she uses it mainly with activity. She has been off of it
for 3 weeks during her stay in ___ as she couldn't fly with
an O2 tank.
After 48 hours on waterseal her air leak persisted and a
pneumostat was placed so that she could go home with her chest
tube while the lung healed and be followed in clinic. A
pneumostat was placed on ___ and 2 subsequent chest xrays
showed almost complete re expansion of the lung. Her oxygen
saturations were 95-99% on 2 LPM but attempts at weaning failed
with room air resting saturations of 85%. She had pleuritic
chest pain with deep breathing but was otherwise stable.
Arrangements were made for home oxygen therapy.
Of note, her Chest CT which was done at ___ on ___
showed a spiculated nodule in the left lower lobe and a PET CT
was recommended by Radiology after she is stable from this
pneumothorax. I explained the findings to the patient and her
husband and suggested that they stop at ___ Radiology
before they return to ___ so that they can get a hard
copy to give to her pulmonologist Dr. ___ ___
___. ___.
Ms. ___ was discharged to home on ___ with ___ services
for her pneumostat and home oxygen and will return to see Dr.
___ in the ___ Clinic on ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ recent sigmoid colectomy with diverting ileostomy on
___ with Dr. ___ divericulitis. Postop she recovered
well and was discharged home on ___. Was re-admitted
___ for leaking appliance and midline wound infection.
She was on vanco a few days, had her wound partially opened, and
was discharged home on Bactrim. She presents again tonight with
the same problem, that is, stool leaking out of the ostomy and
contaminating the laparotomy incision. There was increased
erythema around the incision today so she presented to an
outside
hospital and was subsequently transferred here for evaluation.
Ostomy output has been normal, no change. Radiology showed No evidence of leaks at the colorectal anastomosis. The patient was diagnosed with OTHER SPEC COMPL S/P SURGERY, ACCIDENT NOS. The patient was treated with Gastrograffin enema. 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>She was admitted to the Acute Care Surgery team for management
of her leaking ostomy appliance and treatment for fungal skin
infection. Due to the location of the stoma and patient's body
habitus the ostomy location was very close to her mid-line
incision. The wound itself was not infected. Wound ostomy
nursing was consulted and were able to make adjustments in her
appliances to new equipment which adhered over 24 hour period
without leakage. Miconazole powder was ordered for the fungal
irritation which showed signs of improvement during her stay.
She remained on her home medications during her stay and is
being discharged to home with services. She will follow up in
Acute Care Surgery clinic as instructed.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with a past medical history notable for
polycythemia ___, systolic heart failure s/p bioprosthetic
mitral valve replacement in ___, recent hospitalization
requiring ICU admission for GI bleed (___), who
presented with 1 week of weakness. The patient additionally
reports several episodes of dark stools over the past week. The
patient was seen by her PCP earlier on the day of admission and
found to be profoundly anemic and was sent to the ED for further
evaluation. The patient also reported significant dyspnea on
exertion, which had been steadily worsening. Despite her history
of CHF, she had not been taking her home lasix for some time.
She denied any fever/chills, chest pain, abdominal pain, and
dysuria. Rectal exam showed guaiac positive stools. CHEST (PA AND LAT) showed 1. Small bilateral pleural effusions with bibasilar atelectasis.
2. Mild interstitial pulmonary edema. CHEST (PORTABLE AP) showed Heart size and mediastinum are stable including cardiomegaly. Mild vascular
enlargement is demonstrated but no overt pulmonary edema is seen. Bilateral
pleural effusions are most likely present, small to moderate
Old first rib fracture is re- demonstrated on the left CHEST (PORTABLE AP) showed In comparison with the study of ___, there is continued enlargement of
the cardiac silhouette with only minimal elevation of pulmonary venous
pressure that is unchanged from previous studies. No acute focal pneumonia. The patient was diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS. The patient was treated with 1) EGD (___)
2) Colonoscopy (___)
3) Capsule endoscopy (___). At the time of discharge, the patient had PRIMARY:
----------------
# GI BLEED
# Acute anemia
# Acute on chronic systolic congestive heart failu. 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 polycythemia ___, systolic CHF
complicated by mitral regurgitation and mitral valve prolapse
now s/p recent mitral valve replacement in ___, as well as
recent admission & ICU stay for GI bleed presented with weakness
and dyspnea x1 week with dark, guaiac positive stools. Found to
be profoundly anemic in ED and tranfused 2U PRBC, then
transfused a third unit on ___. After transfusions, patient's
anemia was improved and she had no active bleeding during
hospitalization. She was also treated for volume overload in the
setting of acute on chronic congestive heart failure.
============================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female with PMH significant for DM, COPD chronically on 2L
home O2, developmental delay and numerous psychiatric diagnoses
who is sent in from her nursing home after she complained of
back pain and was found to have O2 sats in the ___ on her home
oxygen.
Per EMS report, nursing home called requesting transport to
hospital for evaluation of back pain this morning. EMS found
sats to be 97% on home O2 and lung exam was notable for rhonchi
on auscultation of all lung fields and productive cough. CHEST (AP AND LAT) showed Bibasilar opacities likely due to a combination of atelectasis, scarring,
difficult to exclude a component of aspiration/pneumonia. CHEST (PORTABLE AP) showed No change. CHEST (PORTABLE AP)
TECHNIQUE: Portable Chest radiograph, AP view
COMPARISON: Chest radiograph ___
FINDINGS:
There is right lower lobe consolidation, which could be pneumonia. Left lung
base atelectasis is similar to prior. There is small bilateral pleural
effusions. Cardiomediastinal silhouette is unchanged.
IMPRESSION:
No notable interval change. Possible pneumonia at right lower lobe. showed No notable interval change. Possible pneumonia at right lower lobe. VIDEO OROPHARYNGEAL SWALLOW showed Significant aspiration of honey NP ray consistencies, with penetration of
nectar-thick consistency.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations. PORTABLE ABDOMEN showed 1. Oral contrast and air seen in multiple loops of nondilated bowel, without
evidence of obstruction.
2. Lucency in the right lower quadrant is likely air in the ascending colon.
However, upright/lateral radiographs could be obtained to assess for free
intraperitoneal air. ABD SUPINE AND LAT DECUB showed No evidence of free intraperitoneal air or obstruction. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, HYPOXEMIA. At the time of discharge, the patient had Primary Diagnoses:
- Methicillin resistant Staph aureus pneumonia
- Urinary tract infection
- Aspiration
- COPD exacerbation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo female with PMH significant for DM, COPD chronically on 2L
home O2, developmental delay and numerous psychiatric diagnoses
who presents with hypoxia at her group home, found to have MRSA
PNA, UTI, meeting SIRS criteria on admission, found to be
grossly aspirating on video swallow.
ACTIVE ISSUES
=============
# Sepsis, MRSA PNA:
Patient initially with complaints of back pain at her group
home, noted to have an oxygen saturation in the ___. EMS arrived
and noted O2 sats 97% on patient's home O2, transported to our
ED where she was hypoxic requiring nonrebreather briefly,
tachycardic, tachypneic, with leukocytosis up to 19 this
admission, meeting sepsis criteria, with dirty UA and concerning
CXR for pulmonary source. Sputum cultures grew MRSA, and patient
was treated with an 8 day course of vancomycin to complete HCAP
course (lives in group home). Grossly dirty UA on admission (+
nitrite, large leuks, WBC 37 and 0 Epis), though with mixed
flora on urine culture, treated with 5 day course of cefepime,
transitioned to ceftriaxone once cultures resulted.
# COPD exacerbation:
Given history of COPD, with worsening productive cough, SOB,
consistent with COPD flare in the setting of above infection,
treated with 5 days total of steroids, standing duonebs, prn
albuterol neb, as well as home medications (guaifenesin and
advair). Additionally, given relative immobility, tachypnea, and
tachycardia, PE on the differential, however Ddimer is 548,
which is negative based on age-adjusted upper limit for Ddimer
(in her case, 500 + 270), making this less likely.
# Aspiration:
Given concern for aspiration during observed meals, speech and
swallow team consulted who on bedside evaluation cleared for
ground solids, nectar thickened liquids, meds whole in puree.
However, given continued concern with worsening lung exam and
repeat CXR with new R lower lobe opacity, video swallow obtained
which showed gross aspiration. Given patient with end-stage
dementia, and poor outcomes of gastric tubes in demented
patients (pressure ulcers, infections, delirium, and lack of
evidence for decreased aspiration events), continued patient on
ground solids, nectar thickened liquids, essential meds whole in
puree. Recommend mechanical soft diet, 1:1 feeding with frequent
encouragement to clear airways, oral care TID, standard
aspiration precautions (feeding when patient fully alert, seated
upright during PO intake and 30 minutes after, small bites/sips
at slow rate).
# ?UTI:
Grossly dirty UA on admission (+ nitrite, large leuks, WBC 37
and 0 Epis), though with mixed flora on urine culture. Given
mixed flora on initial culture despite floridly positive UA,
repeat UA and culture were done, however patient had been on
antibiotic coverage for 48 hours, and repeat UA/cultures were
negative. Patient incontinent and demented, unable to provide
reliable history regarding symptoms, thus given low risk for
antibiotics and high potential benefit if patient with true UTI,
treated with 5 day course of cefepime, transitioned to
ceftriaxone once cultures resulted with mixed flora.
# Abdominal pain:
Patient complained one evening of right sided abdominal pain,
exam unremarkable with stable vital signs, however given poor
historian abdominal films were obtained, which were negative for
obstruction or intraabdominal free air.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old lady with history of Mitral valve
prolapse ___ bioprosthetic MVR, atrial flutter (on coumadin)
morbid obesity, sleep apnea who presents with 2 days of
worsening dyspnea, orthopnea, peripheral edema. At baseline she
is able to walk ___ blocks before feeling short of breath.
Recently she was becoming short of breath with minimal exertion.
No shortness of breath at rest. Additionally she normally
sleeps on three pillows but recently was using four pillows. Per
records patient's dry weight is 180lbs however in the past 2
weeks patient reports ___ lb weight gain. She usually tries
to limit her salt intake but at times family makes food with
salt in it including canned soup. Her lasix dose was halved to
20mg daily in ___ by Dr. ___ increased back to 40mg
daily by PCP 2 weeks ago. She reports mild dry cough worse with
lying flat but denies any fevers, chills, night sweats, chest
pain, lightheadedness, palpitations. She was seen by PCP
yesterday who noted 15lb weight gain and asked patient to go to
ED for diuresis. Radiology showed Mild congestive heart failure. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSION NOS, MITRAL VALVE DISORDER, ATRIAL FIBRILLATION. At the time of discharge, the patient had Partial Dehiscence of Mitral valve replacement
RV dilation w/RV failure
CHF exacerbation. 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 lady with history of Mitral valve prolapse ___
bioprosthetic MVR, atrial flutter (on Coumadin) morbid obesity,
sleep apnea who presented with 2 days of worsening dyspnea,
orthopnea, peripheral edema, weight gain consistent with acute
on chronic CHF exacerbation.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ yo M with HFpEF, Afib on Apixaban, RCC with right
nephrectomy ___, and CKD stage III who was getting
outpatient labs in preparation for outpatient catheterization
when he was found to have Hct of 21, and he was told to go to
the emergency room, where his Hb was 5.7. He has had progressive
dyspnea and dizziness and difficulty walking longer distances
over the past few days and c/o lightheadedness worse with
exertion/standing up. He says this issue has gotten
progressively worse since he had his cardioversion in ___. He
reports multiple family members and his cardiologist told him
his color did not look good in the past month or so. Last known
value was Hgb 12 in ___, with Hb ___ of 15.7. He also
endorses increasing lower extremity and abdominal swelling of
the last month, with noticeable worsening also after his recent
cardio version. Notes pain in calves bilaterally which he has
never had before. Denies any chest pain, abdominal pain, nausea,
vomiting, diarrhea. No black or bloody stools, palpitations,
tachycardia, irregular heart beat, chest pain, exertional chest
pain or pressure. He has never had a colonoscopy, has a history
of IBS.
In the ED, initial VS were:
98.6
70
137/72
20
98% RA
Labs showed: Heme negative rectal exam. Hgb 5.7
Imaging showed:
Received: 1U PRBCs, 100 IV Lasix
Transfer VS were:
97.8
71
118/64
16
100% RA
On arrival to the floor, patient reports the findings noted in
HPI above. He feels MUCH better after the unit of blood. Has not
noticed any black or bloody stools. AP and lateral chest radiographs showed Mild pulmonary vascular congestion without pulmonary edema. CT abdomen and pelvis without contrast showed 1. Small to moderate volume simple density ascites and small right-sided
pleural effusion with mild diffuse superficial soft tissue stranding of
unclear source, is most likely secondary to volume overload. Though the
contour of the liver remains smooth, there is moderate splenomegaly.
Cirrhosis with portal hypertension is a possibility despite the relative
smooth contour of the liver and relative lack of volume redistribution.
Hematologic dyscrasias are also within the differential. Correlate with lab
values.
2. No retroperitoneal hemorrhage, or other definite source of hemorrhage.
3. 19 mm high density left renal lesion is likely a proteinaceous or
hemorrhagic cyst. Confirmation with renal ultrasound is recommended.
4. Post right nephrectomy. Otherwise no definite evidence of malignancy or
metastatic disease within the abdomen or pelvis given the confines of a
noncontrast examination.
5. Probable left adrenal myelolipoma.
6. Anemia.
7. Diffuse diverticulosis.
RECOMMENDATION(S):
1. Correlate with lab values and serology use for the possibility of cirrhosis
or hematologic dyscrasia.
2. Renal ultrasound. ABDOMEN US (COMPLETE STUDY) showed Moderate splenomegaly and small volume ascites. Limited views of the liver
show no focal lesions. Portal vein is patent with hepatopetal flow.
2 left kidney cysts are noted with no other concerning lesions. Status post
right nephrectomy. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. The patient was diagnosed with Anemia, unspecified. The patient was treated with Colonoscopy
EGD. At the time of discharge, the patient had Severe anemia secondary to chronic blood loss
Acute on Chronic diastolic CHF
CKD stage III
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>This is a ___ year old male with past medical history of
diastolic CHF, atrial fibrillation on apixaban, CKD stage III
admitted ___ with severe symptomatic anemia requiring
transfusion, suspected to be related to chronic GI blood loss,
workup without clear etiology, subsequently leaving the
hospital against medical advice.
Severe Anemia of Chronic Blood Loss secondary to occult GI
bleed
Patient presented with dizziness, found to have Hgb 5.7. He was
transfused 4 units of PRBCs with improvement in Hgb > 7, and
resolution of symptoms. Labs consistent with severe iron
deficiency. No signs of bleeding on cross-sectional imaging
,but did show splenomegaly, felt to relate to CHF below (and
not cirrhosis, per discussion with GI). Patient was seen by GI
and underwent ___ on ___, which showed no clear signs of
upper GI bleed, and was incomplete due to colonic redundancy
preventing visualization to the cecum on colonoscopy. Of note,
colonoscopy did show diverticulosis. Patient was seen by
Hematology who agreed with diagnosis of iron deficiency anemia
and recommended outpatient IV iron infusions. Given severity
of his initial anemia, and unknown cause, patient was
recommended for inpatient CT colonography and pill endoscopy,
however patient left against medical advice as below
# Discharge against medical advice
Team discussed recommendation for above workup with patient and
also the risks of not pursuing, including bleeding/hemorrhage,
cancer or death; patient was able to verbalize his
understanding of these risks and our recommendations; he
requested discharge home with outpatient GI, PCP and hematology
___. Team arranged for outpatient ___, discharged
against medical advice.
#Acute on Chronic Diastolic CHF
Patient with diastolic CHF who was admitted with 22lb weight
gain since last admission ___. Exam notable for JVD, lower
extremity edema. TTE without new wall motion abnormality.
Patient was IV diuresed from 322lbs to 308lb, but was not at
his dry weight at time of discharge against medical advice. Of
note, TTE did show elevated R sided filling pressures--would
consider repeat TTE when patient is euvolemic, and if still
present could consider additional workup. Discharged on home
Bumex 3mg BID.
#Splenomegaly
As above, attributed to CHF exacerbation. Could consider
repeat imaging when euvolemic, and if still present consider
additional workup
# Paroxysmal Atrial fibrillation
Initially held apixaban. Continued on amiodarone. Per
discussion with ___ cardiology, stopped patient's metoprolol
given good rate control with amiodarone and patient feeling
like metoprolol was causing side effects. Given that patient
had never had acute bleed (felt to be chronic and slow as
above), risk benefit was felt to favor restarting patient's
apixaban. Discussed with patient who agreed.
# ___ on CKD stage 4 - Cr 1.9 on admission, improved to
baseline 1.6 with diuresis.
#GERD: continued omeprazole 20mg daily
#BPH: Continued Flomax
# Lower Back pain: Tylenol PRN</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 PMHx notable for
DM2, HTN, HLD bipolar disorder, s/p CCY who presents with
abdominal pain and testicular pain. The patietn reports that he
had onset of epigastric and ___ pain at 1800 on the
day prior to admission. He reports that he had nausea and
diarrhea associated with it. He reports that the pain was
different than the pain that he was seen in the ___ ED for on
___. Work up at that time consisted of labs and CT scan which
did not show an acute process. Patient was discharged and was
doing well until the day of admission. He reports that he
developed the ___ abdominal pain at the ___ game.
Abdominal pain in the epigastric region, RUQ, RLQ. He reports
that he had intercourse for the first time yesterday but that he
used a condom. He denies dysuria or penile discharge. He also
denies fevers, chills, vomiting. SCROTAL U.S. showed Normal scrotal ultrasound. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Markedly limited right upper quadrant, the liver appears echogenic but
this may be exaggerated due to body habitus. Echogenic liver may be seen in
setting of hepatic steatosis.
2. Common bile duct not visualized. Radiology showed Normal appendix. The patient was diagnosed with ACUTE PANCREATITIS. At the time of discharge, the patient had PRIMARY DIAGNOSIS: 1. Abdominal Pain
SECONDARY DIAGNOSES: 2. Bipolar Disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old male with past medical history of type 2
diabetes, bipolar disorder, chronic abdominal pain of unclear
etiology admitted ___ with reports of abdominal pain,
workup notable for CT pelvis, scrotal ultrasound within
normal limits, lipase of 165, but clinical picture not
consistent with acute pancreatitis (symptomatically improved
with eating), with course notable for pain migrating throughout
abdomen depending on who asked him.
>> ACTIVE ISSUES:
# Abdominal Pain: Upon admission, patient was complaining of
abdominal pain with radiation to the groin. Patient underwent a
RUQ ultrasound which was negative for any abnormalities other
than mild hepatic steatosis, and patient also underwent a
scortal ultrasound for concerns for testicular pathology, which
was also negative. Patient then underwent a dedicated pelvic low
dose CT scan which did not reveal any appendicitis. Initial labs
were notable for a mild leukocytosis, thought to be stress
related and downtrended on HD#1. Other abnormalities including a
mildly elevated lipase, however not significant for
pancreatitis. Patient was treated conservatively with pain
regimen (oral no IV pain medications) and started to have
improvement in symptoms. Collateral information obtained from
family members reports that patient has had a history of
abdominal pain in the past with negative workup,
and per his mother, this may be a manifestation of personal
stress. He tolerated a normal diet, symptoms improved and he was
discharged home
# Concern for Steatosis - RUQ ultrasound showed possible
echogenic liver; this was communicated to patient's PCP; workup
deferred to outpatient
# Hypertension: Patient was restarted on home dose of atenolol
50 mg, however soon became hypotensive to the ___, asymptomatic.
It was considered that patient not compliant on this regimen,
and therefore was given low dose 12.5 mg daily. However because
of significant effect on blood pressure, this medication was
discontinued. This was relayed to patient's mother as well.
Patient to make appointment with PCP at which point can restart
this medication as an outpatient. No lightheadedness, dizziness,
syncopal episode or episodes of hypertension while inpatient.
.
# Diabetes Mellitus Type II: Patient on oral agents at home, and
was continued on insulin sliding scale while inpatient. Patient
did not have episodes of hyperglycemia or hypoglycemia while
inpatient.
.
# Hyperlipidemia: Patient was continued on home statin and
fenfibrate while inpatient.
.
# Bipolar Disease: Per patient, has not been on any psychiatric
type medication for several months. Patient previously was on
seroquel 600 mg PO QHS per his mother, and has an upcoming
intaking appointment at ___ (mental health ___ in ___
___. Patient appeared stable, and able to make informed
decisions, and therefore reinitiation of his therapy was not
indicated while inpatient. To be titrated by psychiatry as an
outpatient.
.
# Disposition: Patient was seen by social work prior to
discharge. Patient was given $15 for bus pass to return to ___
___, and was given a T-ticket for public transit. Patient
voiced understanding of plan to see a PCP upon discharge from
the ___ to ensure stability, and reinforced continuity of
care as paramount to patient's health. Communication with family
also through Mr. ___ mother.
.
>> TRANSITIONAL ISSUES:
# Steatosis: RUQ ultrasound showed possible echogenic liver, can
consider outpatient follow-up
# HTN: Patient's atenolol was held at discharge given normal
pressures without it and reported non-compliance at home
# Bipolar Disease: Patient to f/u with intake at ___ (___
Health Provider in ___, to consider re-initiation of
therapy. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male known to the Neurosurgery service following
recent admission and diagnosis of a ___ mass in the setting of
a lung mass, now s/p left occipital craniotomy for tumor
resection on ___ re-presents with fever and altered mental
status. He was recently discharged on ___. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. There is prominent diffusion-weighted hyperintense signal along the left
occipital resection margins with regions of confluent enhancement along the
lateral margins and regions of rim enhancement along the posterior inferior
margins demonstrating central hypoenhancement. The regions of rim enhancement
with central hypoenhancement appear to correspond to brain parenchyma on FLAIR
and T1 precontrast sequences and therefore is felt to be unlikely abscess, but
rather a combination of devitalized tissue, postsurgical ischemia/inflammatory
changes, residual hemorrhage product and possible residual lesion.
2. Soft tissue material in the occipital horn of the right lateral ventricle
demonstrates restricted diffusion and is without gradient echo susceptibility
blooming artifact. Lack of blooming artifact does raise possibility of
purulent material. However, there is no definitive associated enhancement.
The lesion does appear to demonstrate mild postcontrast enhancement on 1
motion degraded postcontrast sequence, but not on subsequent postcontrast
images and therefore hemorrhage product remains a differential consideration.
3. Interval increase in size of the ventricle suggest communicating
hydrocephalus.
4. Interval increase in size of the fluid/CSF signal intensity collection
overlying the left occipital parietal bone which appears to communicate with
the subarachnoid space most likely represents a pseudomeningocele. There does
appear to be a 1.1 cm peripherally enhancing fluid collection inferior to the
left mastoid tip, likely a seroma however close attention is recommended to
exclude infectious process.
5. Left frontal lesion demonstrating prominent gradient echo susceptibility
artifact is unchanged. The lesion does not demonstrate of T2 hypointensity
and central T2 hyperintensity and demonstrates avid postcontrast enhancement.
There is surrounding edema pattern. This is unchanged from outside hospital
MRI head of ___ and are not features typical for cavernoma, unless
there has been recent hemorrhage. This raises suspicion for additional site
of metastatic disease. Of note, no lesion was noted on outside hospital CT
head of ___.
NOTIFICATION: The findings were discussed by Dr. ___ with
Dr. ___ on the ___ ___ at 2:08 pm, 10 minutes after
discovery of the findings. CHEST PORT. LINE PLACEMENT showed Compared to chest radiographs ___.
Nasogastric drainage tube ends in the upper portion of a mildly distended
stomach.
Right apical lung lesion is presumably still present, but difficult to assess
on conventional radiographs. Heart size normal. Lungs elsewhere clear. No
pleural abnormality. Normal mediastinal and hilar contours. MR HEAD W AND W/O CONTRAST ___ MR HEAD showed 1. Subdural and subgaleal fluid collection surrounding the left craniotomy is
larger compared to ___. No restricted diffusion is seen within this
collection. However, possibility of superimposed infection cannot be excluded
on MRI appearances.
2. Enhancement at the resection margin and overlying dural enhancement appears
more conspicuous than before. Findings may reflect evolution of postoperative
changes or differences in study techniques/artifact.
3. Ischemic changes at the resection margin appears similar to before. No new
acute infarct is identified.
4. 9 mm left frontal lobe enhancing lesion is again demonstrated. Finding
remains suspicious for metastatic lesion.
5. 9 mm lesion in the right occipital horn is unchanged . CHEST (PORTABLE AP) showed In comparison with study of ___, the opacification in the right apical
region is again seen, though difficult to assess on plain radiographs. This
was well demonstrated on the CT study of ___.
The cardiomediastinal silhouette is stable and there is no evidence of
vascular congestion or pleural effusion. MR ___ SPINE W/O CONTRAST ___ MR SPINE showed 1. Study is severely degraded by motion.
2. Additionally, evaluation for metastatic disease is limited due to lack
administration of contrast, which was not administered due to patient
inability to tolerate examination. If clinically indicated, consider repeat
exam when patient can tolerate study.
3. Within limits of study, no definite evidence of lumbar spinal mass
identified.
4. Extremely atrophic a partially cystic left kidney again noted.
5. Nonspecific right perinephric fluid not definitely seen on prior abdomen
pelvis CT. If clinically indicated, consider renal ultrasound for further
evaluation.
6. Nonspecific lower lumbar dorsal soft tissue and psoas muscle probable edema
as described.
7. Approximately 30% L1 chronic anterior compression deformity.
8. Multilevel lumbar spondylosis as described, most pronounced at L3-4, where
there is mild vertebral canal and moderate bilateral neural foraminal
narrowing.
9. L4-5 moderate left neural foraminal narrowing. Radiology showed The tip of the Dobhoff projects over the stomach. Otherwise no significant
interval change. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had Metastatic neuroendocrine tumor to the ___
Lung lesion
Fever, resolved
Altered mental status
Aseptic meningitis
Toxic-metabolic encephalopathy
Bilateral lower extremity DVT. 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>#Altered mental status/Fever/aseptic meningitis/metabolic
encephalopathy/metastatic neuroendocrine tumor to the ___
On ___, Mr. ___ was admitted to the Neuro ICU with altered
mental status. LP in the ED had elevated protein, low glucose
and high opening pressure. Cultures were sent. He was noted to
have a mass on his neck on admission felt to be lymphadenopathy.
MRI was performed which did not show abscess. His wound was
noted to have purulent drainage and he was started on empiric
vancomycin, cefepime and ampicillin. Infectious disease was
consulted. Ampicillin was discontined on ___ per ID. He was
placed on EEG on ___ which was negative for seizure. He had
leukocytosis on admission which downtrended. He was transferred
to ___ on ___. Repeat MRI was stable and negative for clear
abscess but there was concern for ventriculitis ___ he had a
fever to 101.2 with WBC up trending, urine cultures and blood
cultures were sent and were all negative. Repeat CXR was done
and was negative. His family was consented for PICC line ___.
Placement of PICC was deferred in setting of elevated WBC with
unknown source. CSF culture was negative. Due to continued
fevers, worsening altered mental status, and continuing
elevation of WBC a family discussion was had regarding
additional surgical procedures verse CMO, after thorough
discussion, the patient was transitioned to CMO care with
Palliative care consult on ___. The patient's case was
re-discussed at ___ TUmor Conference on ___ and consensus
was that given the negative cultures, the profound
encephalopathy that the patient developed aseptic meningitis
with poor prognosis due to disease progression. All invasive
intervention were stopped per family's request as the patient
transitioned to CMO. Over ___ to ___ the patient
gradually improved, still confused, with expressive aphasia, non
lethargic anymore so the family asked for guidance in whether
the CMO status should be reversed or continue care. With the
involvement of Palliative Care, Hem/Onc, ID, nursing and
neurosurgery as discussed with Dr. ___ family
meeting took place on ___ where the family was presented
with the grim prognosis due to the pathology of the tumor
(neuroendocrine tumor, STAGE IV metastatic lesion possibly due
to lung). After hearing different opinions the family elected to
proceed with hospice care option and continue CMO status.
#Dysphagia
Due to altered mental status, the patient was made NPO on
admission. NGT was attempted to be placed on ___ for tube
feeding, but was unsuccessful as the patient non-compliant with
placement. SLP evaluated and recommended puree consistency with
thin liquids and 1:1 feeding. Family was consented ___ for PEG
placement for nutrition supplementation, however NGT was placed
over concern for patient self d/c'ing PEG. Tube feeds were
started ___. Given CMO status on ___ and repeat family meeting
on ___ to agree to hospice, the Dobhoff was removed and the
patient was allowed to eat to comfort.
#Bilateral lower extremity DVT's
On admission, the patient was found to have b/l DVT's and was
started on heparin drip with PTT goal of 50-70. Given CMO the
family elected to stop needle sticks with SQH and PTT checks,
and after discussion with Dr. ___ (patient's son)
elected to start Xarelto po for DVT and PE prophylaxis. ___
acknowledged the fact that there is a possibility for ___
hemorrhage while on anticoagulation. ___ discussed with his
mother ___ who also agreed on the patient being discharged
on Xarelto 20mg daily for patient compliance and minimal
medications since he is CMO status. It was also explained that
this medication provides prophylaxis protection but does not
guarantee that a PE or a DVT will not happen or expand.
Palliative care / hospice team to re-assess need for
anticoagulation. Per their request and after discussing with Dr
___ will discharge the patient on Xarelto and Hospice may
decide for continuation after discussion with the patient and
family and agree.
#Pain
Patient appeared to be in pain with movement on ___. MRI L
spine was ordered to evaluate for spinal metastasis. The patient
was moving to much in the scan so MRI was not obtained with
contrast, but non-enhanced scan was found to be negative for
metastasis. IV morphine and po oxycodone PRN were given
#Gout
On prior admission patient was found have gout flair in right
knee. Rheumatology had been consulted and colchicine started.
___ Rheumatology was consulted for updated recommendations for
persistent redness and swelling in right knee and new redness of
right ankle. Colchicine was titrated up per their
recommendation. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of atrial fibrillation on Coumadin, severe AS
s/p bioprosthetic AVR/CABG in ___, hypoparathyroidism, and
hypothyroidism, transferred from ___ with ICH. The patient
has dementia and is unable to provide much history. Per records
from the outside hospital, the nursing home and found that the
patient was increasingly bradycardic over the last 2 days. She
also has had multiple falls. CT scan of the head performed at
the outside hospital shows an intraparenchymal hemorrhage. The
patient is awake and alert and oriented x2 which is baseline per
the daughter's report. She denies any weakness, numbness,
tingling. She denies any chest or abdominal pain. She denies any
headache. She denies any vision changes. Her INR was 4.58 at the
outside hospital. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No intracranial hemorrhage or mass effect.
2. 6 mm linear calcification in the right posterior parietal lobe is likely
dystrophic in etiology and has been present since at least ___. This
may have been the finding thought to reflect intracranial hemorrhage on the
outside head CT. Radiology showed No acute fracture or dislocation. Moderate tricompartmental degenerative
changes of both knees. CT abdomen and pelvis without contrast. showed 1. No acute fracture.
2. 3.5 cm infrarenal abdominal aortic aneurysm.
3. Small amount of pericholecystic fluid is likely secondary to third spacing.
If there is clinical concern for acute cholecystitis, abdominal ultrasound
could be obtained for further evaluation. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___, most recently ___.
Moderate cardiomegaly has worsened. Lungs are grossly clear. No pleural
abnormality. PA and lateral chest radiographs showed New cardiac pacemaker lead terminates the right ventricle. No pneumothorax. The patient was diagnosed with Unspecified atrial fibrillation, Long term (current) use of anticoagulants. The patient was treated with Single Chamber PPM placed ___. At the time of discharge, the patient had Primary:
Toxic-Metabolic Encephalopathy
Hypercalcemia
Sick Sinus Syndrome
Hypoparathyroidism
Hypothyroidism
Afib
___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx of chronic A-Fib on coumadin, tachy-brady syndrome,
severe AS s/p bioprosthetic AVR/CABG in ___, CKD,
hypoparathyroidism, and hypothyroidism transferred for syncope,
bradycardia and suspected intracranial hemorrhage that was
revealed to be a calcification. She was admitted for
encephalopathy, ___, and PPM.
# Toxic Metabolic Encephalopathy: Patient with baseline dementia
but generally alert and confused. However, declining mental
status per HCP over past week; she presented agitated and
nonverbal. Patient noted to be obtunded and minimally arousable
on arrival to floor. Did follow commands and grossly appeared to
have cranial nerves intact. Suspicion was medication induced
given olanzapine IM 5mg x2 in ED with concurrent ___.
Additioanlly, patient with history of AMS with hypercalcemia.
She was found to be hypercalcemic to a corrected value >14. With
time and treatment of hypercalcemia, her mental status improved
to baseline.
#Hypercalcemia in setting of hypoparathyroidism: Pt with history
of hypercalcemia and AMS in past secondary to increased
exogenous calcium/vitD. Pt in ___ discharged on 0.25
calcitriol BID, appears to have been receiving 0.5mg BID at
nursing home. Her PTH was 5, suggesting again an exogenous
source of calcium. She was treated with IVFs, furosemide, and
48hrs of calcitonin. Her calcium supplementation was held as
calcium normalized. She was discharged on 0.25mg calcitriol once
daily and calcium carbonate 1250 mg BID.
Endocrinology follow up was scheduled. She will need to have her
calcium checked weekly. If corrected calcium falls below 8,
please increase calcitriol to 0.25 BID. Patient would benefit
from regular labs as below.
# Tachy-Brady syndrome and syncope: Patient with known
tachy-brady
syndrome. ECG with evidence of LBBB and LAFB in slow AF. Patient
was having symptomatic bradycardia with syncope. A
single-chamber PPM was placed ___ without complication.
Follow-up with ___ device clinic is scheduled.
# A-fib: patient with chronic A-fib on warfarin with goal INR
___. INR supratherapeutic on admission to 5.3. She was reversed
with Kcentra and Vitamin K given suspected ICH. No ICH on CT
Head re-read. Her CHADS-VASC2 is at least 6. She was restarted
on her home Coumadin.
___ on CKD: Patient presented with elevated Cr to 2.3, baseline
somewhere between 1.1 and 1.5. Urine lytes and hypercalcemia
consistent with intrinsic renal disease from hypercalcemia. Her
discharge creatinine was 1.7.
# HTN: Patient with known HTN presented with SBP to 200 treated
initially with hydralazine in ER. Patient apparently not on
antihypertensives although had prior discharge on amlodipine.
She was restarted on amlodipine 10mg daily.
# Hypothyroidism: Patient with known h/o hypothyroidism.
Continued on ___ synthroid per recent prescription refill.
# Microcytic hypochromic anemia: Consistent with baseline,
continue to monitor
# Chronic ischemic congestive heart failure (40-45%) with
history of aortic valve replacement and coronary artery bypass
graft ___: Patient with known h/o AVR and CABG (SVG to OM1)
both done at same
procedure in ___. She was maintained on aspirin and
atorvastatin. By discharge, she was restarted on home Lasix.
# Restless Leg Syndrome: Baclofen PRN </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M hx Afib known to Neurosurgery for bilat SDH Right > Left
and s/p right burr hole evacuation of ___ on ___ presented
with worsening unsteady gait over the past week and fall, no
headstrike, 4 days prior. Coumadin was stopped at his last
hospitalization. He complains also of general weakness. He
denies numbness, vision changes, nausea, vomiting. CT HEAD W/O CONTRAST showed 1. Status post placement of left frontal approach subdural drain with interval
decrease in size of subdural collection though high-density products are
visualized adjacent to drain terminus.
2. Grossly unchanged left convexity acute on chronic subdural hematoma.
NOTIFICATION: The findings were discussed with ___, N.P. by
___, M.D. on the telephone on ___ at 3:38 pm. CT HEAD W/O CONTRAST showed Expected evolution of postoperative changes status post left craniotomy and
multi compartment intracranial hemorrhages, without significant change. No
evidence of new hemorrhage or mass effect. The patient was diagnosed with Nontraumatic subdural hemorrhage, unspecified. The patient was treated with ___ - Left Craniotomy for Subdural hematoma evacuation. At the time of discharge, the patient had Bilateral subdural hematomas. 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 known to the
neurosurgery service s/p right burr hole evacuation on ___
for chronic bilateral subdural hematoma. Patient was readmitted
on ___ from OSH with worsening gait and confusion, found to
have worsening bilateral SDH Left > right.
#Chronic bilateral Subdural hematoma
Mr. ___ was admitted to neurosurgery service on ___
with worsening chronic bilateral SDH, Left>right. Consent was
obtained from health care proxy, and patient was taken to the OR
on ___ for Left burr holes for subdural hematoma evacuation
with placement of left subdural drain. The procedure went
accordingly with no intraoperative compilations. Please refer to
op note in OMR for further intraoperative details. Patient was
taken to Post operative area for further monitoring, where he
remained intact on exam, and was then transferred to the step
down unit for continued care. Post op head CT demonstrated a an
area of hyperdenisty at the drain terminus concerning for new
hemorrhage. The patient remained intact and a repeat CT on ___
remained stable. Subdural drain was pulled on ___. The patient
was evaluated by ___ and OT on ___ who recommended discharge
home with inhome ___ services. Patient remained stable and was
cleared to be discharged home on ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with history of Factor V Leiden, tobacco
abuse, and chronic LBP, known herniated discs at L4-L5 and
L5-S1, who was recently admitted to ___ for back pain, now
presents after multiple reported falls with diffuse pain. At
___, she was treated for acute gouty arthritis with
prednisone and colchicine, the latter of which she continued at
discharge. She was seen by neurosurgery and nuerology, who opted
for conservative management, ordered an outpatient EMG for a
___ sign, increased her gabapentin, and planned for her to
be seen in the pain clinic for outpatient steroid injections.
She reports a fall on ___ when she was walking in her yard
and then fell because her body gave out. It was reportedly
witnessed by her neighbor. She denies seizure like activity, CP,
SOB, dizziness or LH prior to the fall. She denies mechanical
fall. She then reports putting the dishes away ___ night
when she fell from standing into her wheelchair, again because
her body gave out on her. She then was going to bed and reports
falling on to her bed. Her nephew found her and she reports that
she looked unconscious. She notes that she couldn't see him
(because of her baseline blindness) but could hear what he was
saying. She reports being unable to move or keep her eyes open.
She woke up in bed, not remembering what happened after her
nephew found her. She was then sitting at her table outside with
her family when she couldn't move or talk. She denies urinary or
bowel incontinence or retention with last BM this morning. She
denies any fevers or chills at home. Her son called ___ who
brought her to ___, where she was transferred to ___ for
MRI evaluation of the lower ___.
In the ED, initial VS: 98.0 82 123/73 16 98% 2L pain 10.
-exam with diminished rectal tone, no saddle anesthesia
-given 15mg morphine, last 9pm
-INR >7, no signs of bleeding, had been escalating coumadin as
an outpt
-cord consult: Discussed with Dr. ___ resident.
Patient is a poor historian. Difficult to distinguish between
giveway weakness and true weakness on her, generally effort is
quite poor and pain limited examination. No sensory level with
intact reflexes. Proximal > distal weakness in lower extremities
as well as some weakness in upper extremities (full note to
follow). Given her coumadin use, prior history of inflammatory
disease (gout), degenerative joing disease of ___ (prior L5/S1
disc prolapse and S1 foraminal stenosis), I am concerned for
cord and root pathology. Please image with MRI: C/T and L ___,
with and without contrast MRI ___ imaging seems unremarkable
save some cervical discs not causing any cord immpingement.
Motion limited axials.
-MRI ___ done without acute pathology
-was asleep for the past two hours
Most Recent Vitals: 98.2 79 117/78 16 96% 2L.
Currently, the patient reports diffuse body pain and is thirsty.
ROS:
+Per HPI, occaisional chest heaviness that lasts for hours,
vomiting and dizziness with every vertigo spell, dysuria.
-fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, nausea, diarrhea, constipation, BRBPR, melena,
hematochezia, hematuria. Radiology showed 1. No acute intracranial abnormality.
2. Mild age-related atrophy and chronic small vessel ischemic disease.
Results were discussed with Dr. ___ at 9:50 a.m. on ___ via
telephone by Dr. ___. Radiology showed AP chest reviewed in the absence of prior chest radiographs:
Lung volumes are quite low with crowding of vessels. Nevertheless, there is
suggestion of several small nodules in the right mid and lower lung zone.
Patient is rotated to the right exaggerating the caliber of the mediastinum in
the region of the ascending aorta and obscuring the right hilus. Radiodensity
in that region could be due to large hilar lymph node calcifications or
additional nodules. In any case prior chest CT should be consulted, and if
unavailable, should be supplemented by a chest CT performed here. Heart is
normal size. Pleural effusion is small if any on the right. No pneumothorax.
Findings were posted to the online record of critical radiology findings, for
notification of the referring physician, at 12:23 p.m. Radiology showed 1. Resolving pulmonary edema.
2. Two subcentimeter lung nodules should be followed with repeat CT scanning
in six months. The patient was diagnosed with LUMBAGO, OTHER MALAISE AND FATIGUE, DIFFICULTY WALKING. At the time of discharge, the patient had Primary diagnosis: acute encephalopathy secondary to medication
side effect, chronic back pain, transaminitis, atypical 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>___ history of Factor V Leiden, tobacco abuse, chronic low back
pain, known herniated discs at L4-L5 and L5-S1 who presents
after multiple falls at home. There was concern for cord
compression based on ER exam with resultant MRI showed no acute
cord compression. Hospital course was significant for fall and
transient loss of consciousness work-up that revealed no serious
etiologies. Etiology of falls and transient loss of
consciousness was attributed to oversedation from gabapentin and
narcotics. Secondary issue was transaminitis of unknown
etiology.
# Recurrent falls secondary to acute toxic-metabolic
encephalopathy: Patient reported inability to move upper and
lower limbs after multiple falls. She is vague about the
descriptions of each fall but does not give a clear history of
syncope. Differential diagnosis includes primary neurological,
toxic-metabolic, medication side effect, orthostasis among other
considerations. On physical exam the patient was noted to be
very sedated but arousable. She also had small non-reactive
pupils. Her neurological exam was limited by effort, but
initially revealed decreased strength in the lower extremity
greater than upper extremity. Neurology was consulted and felt
that the patient had a functional problem. Serial exam showed
normalization of function after withholding sedating
medications. She had an MRI of the ___ done which showed no
cord compression with mild disc buldge at L4-L5 and L5-S1, no
spinal stenosis, and mild degenerative changes. The patient was
place on telemetry, no malignant arrhythmias were seen. A head
CT was done to look for an acute bleed given history of falls
and elevated INR but no evidence of SDH. The head CT showed no
acute process with mild age-related atrophy and chronic small
vessel ischemic disease. A tylenol level was performed, given
transaminiitis and percocet use, but was normal. An ESR was
done to evaluate for inflammatory myopathy, but was normal.
It was felt that her falls, difficulty moving her limbs and
sedation represented acute toxic-metabolic encephalopathy
secondary to percocet use and gabapentin. After holding
percocet and decreasing her gabapentin dose, the patient
improved remarkably. Her strength improved to ___ in upper
and lower limbs. ___ reevaluated patient and she was able to
resume her normal activity level. Her mental status improved and
she was alert and oriented x3 and talkative. It was decided to
discontinue her gabapentin and percocet and restart her on a
lower dose of oxycodone as needed for pain. Patient much more
alert today and strength is restored to normal after
discontinuing sedating medications.
The etiology of her likely recurrent falls is secondary to
medication side effect - specifically excessive sedation from
gapabentin and narcotics.
She was discharged home with ___ and services.
# Transient loss of consciousness- The patient reported a
possible loss of consciousness. It was unclear if this
represented syncope vs. transient loss of consciousness from
sedating medications as above. The patient did not describe any
syncopal prodrome nor did she describe a seizure like episode.
There was no evidence of malignant arryhthmia on telemetry and
an ECHO performed showed preserved EF without valvular lesions.
Neurology did not recommend any further imaging. Patient was
initially very sedated and mental status cleared after
decreasing sedating medications. Possible transient loss of
conscious was likely due to combination of gabapentin and
oxycodone causing sedation. No evidence of primary cardiac or
neurological process was observed.
# Transaminitis -
Patient noted to have elevated LFTs ___ 07:00AM
ALT(SGPT)-267* AST(SGOT)-249* LD(LDH)-307* CK(CPK)-33 ALK
PHOS-132* TOT BILI-0.4). Patient has history of elevated LFTs
(Atrius records show ALT/AST in low 40-50, negative recent
Hepatitis panels for A,B). She drinks only rarely. The patient
also complained of some nausea and vomiting. A RUQ ultrasound
with doppler was performed and showed status post
cholecystectomy with no biliary dilatation with fatty liver and
mild splenomegaly or vascular issues given history of Factor V
Leiden. Liver function tests have improved significantly.
Tylenol level was within normal limits. The patient had been
tested for hepatitis in the past. A hepatitis C test was done
and negative. Hepatotoxic medications were discontinued and the
patient was instructed not to take anymore tylenol and follow up
as an outpatient.
Patient should have further outpatient work-up.
# Elevated INR: INR was >7 on admission and trended down to ~4
and then ~ 2. The patient reports carefully following
outpatient provider ___. There was no evidence of
bleeding and a head CT was done to rule out intracranial bleed
after fall. The patient was restarted on 5 mg of warfarin per
day and will follow up with ___ clinic.
# Headache: Patient reported new onset frontal headache that
she describes as typtical migraine. Given fall and elevated
INR, concern for hematoma. No evidence of increaesed ICP or
bleed on CT. Headache resolved on own.
# Chest Pressure: The patient incidentally reporting vague chest
pain on morning of admission. MI has been ruled out, ECG without
ischemic changes, telemetry benign. CXR revealed incidental
nodules and ___ on CXR. ECHO showed normal LVEF without
valvular pathology. Her home omeprazole was continued.
Symptoms subsided.
# Back Pain: She does not describe any bowel or bladder
involvement with her back pain and MRI is also reassuring that
there is no evidence of cord compresson. Patient recently
evaluated at ___ by neurology and neurosurgery. Likely
chronic back pain. No evidence of cord compression, spinal
stenosis, or acute compression fracture. No spinal stenosis
seen. No abnormal signal within the
spinal cord. Multilevel mild degenerative changes without
spinal stenosis. Pain medication changed to oxycodone and
gabapentin discontinued. Patient may follow up as outpatient
with PCP.
# Depression and Anxiety: Patient reports anxiety at baseline.
She denied SI/HI. Is followed as outpatient by psychiatrist.
Outpatient meds including ___, wellbutrin were
continued.
# Hypertension: Stable. Continued doxepin, lasix, inderal.
# Gout: No evidence of acute gout flare. Colchicine was
continued.
# Incidental findings:
A. ___ CXR
Radiodensity in that region could be due to large hilar lymph
node calcifications or additional nodules. In any case prior
chest CT should be consulted, and if
unavailable, should be supplemented by a chest CT performed
here.
B. Chest CT performed on ___:
1. Resolving pulmonary edema.
2. Two subcentimeter lung nodules should be followed with
repeat CT scanning
in six months.
C. Fatty liver and mild splenomegaly. The possibility of more
significant
underlying liver disease, including fibrosis and cirrhosis,
should be
considered, particularly in view of the flattened portal venous
waveforms.
# Transitional Issues
- continue titration of pain regimen as outpatient, avoid
oversedation
- home with ___, continued assessment of fall risk
- follow-up LFTs on outpatient basis, consider work-up if still
elevated
- continuing management of anti-coagulation
- follow-up incidental findings as above related to lung nodule
and fatty liver</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Per Intitial ED Note:
This patient is a ___ year old female who BIBEMS complains of
fall. History is per EMS this patient is altered. She was found
at the bottom of her stairs with obvious facial
trauma. She has started to open her eyes spontaneously on
arrival. CT C-SPINE W/O CONTRAST showed Degenerative changes without fracture or malalignment. CTA HEAD AND CTA NECK showed 1. Unremarkable CTA of the head and neck. No evidence of vascular injury or
aneurysm.
2. The left lobe of the thyroid gland demonstrates a hypoattenuating 8 mm
nodule. This may be further evaluated with ultrasound if clinically indicated.
3. Unchanged appearance of a left zygomaticomaxillary complex fracture. FOREARM (AP AND LAT) LEFT showed 1. Comminuted distal radius fracture with mild impaction and intra-articular
extension.
2. Moderate soft tissue swelling. CT HEAD W/O CONTRAST showed 1. Stable intraventricular hemorrhage-slightly more and denser without
significant change in appearance compared to the initial CT on ___. No
new hemorrhage.
2. Multiple facial fractures as previously described on ___, incompletely
imaged as not targeted .
3. Bi-frontal extra-axial hypodensities may be related to atrophy or chronic
subdural hematomas. WRIST(3 + VIEWS) LEFT showed Increased dorsal angulation of intra-articular impacted comminuted distal
radial fracture. Radiology showed No acute cardiopulmonary process. No pelvic fracture. CT HEAD W/O CONTRAST showed 1. Minimal amount of hemorrhage in the lateral ventricles as detailed above.
2. Left facial and skullbase fractures better depicted on concurrent CT of the
face.
3. Prominent bifrontal extra-axial CSF potentially due to volume loss and
prominent subarachnoid space although low-density subdural fluid is also
possible. This can be further assessed at time of CTA. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST showed Left zygomaticomaxillary complex fracture. Left sphenoid sinus wall fracture
involving the left carotid canal should be further evaluated with CTA of the
head and neck to exclude vascular injury. Left zygomatic arch fracture
fragments seen approximately 3 mm from the coronoid process. The patient was diagnosed with CL SKUL BASE FX-COMA NOS, FX MALAR/MAXILLARY-CLOSE, FX ORBITAL FLOOR-CLOSED, OPEN WOUND OF FOREHEAD, OPEN WOUND OF AURICLE, ALCOHOL ABUSE-UNSPEC, FALL ON STAIR/STEP NEC. 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 pre-op/Emergency Department on ___.
Pt was evaluated by upon arrival to ED with X-ray (Chest, Wrist,
pelvis) and CAT scan (head, c-spine, Maxillofacial, CTA head &
neck) which were notable for Minimal amount of hemorrhage in the
lateral ventricles, Left zygomaticomaxillary complex fracture.
Left sphenoid sinus wall fracture, and comminuted distal radius
fracture with mild impaction and intra-articular extension.
Given findings, the patient was admitted to the Acute Care
Surgery/Trauma Surgery service for further evaluation and
management.
Neuro/Traumatic IVH: Given findings on CT, neurosurgery was
consulted upon arrival to the ED. Initial recommendations given
traumatic IVH were non surgical management with q1 neuro checks,
repeat head CT, seizure precautions with Keppra, blood pressure
control and CTA head and neck all of which were implemented.
Findings on repeat CT Head/CTA were reassuring and no further
neurosurgical management was indicated. Neurological status was
closed monitor and the patient was alert and oriented throughout
hospitalization
Facial Fractures: Given multiple facial fractures, plastic
surgery was consulted who recommended no acute surgical
intervention, a short course of augmenting, sinus precautions,
and soft diet, along with outpatient follow for consideration of
surgical intervention. All recommendations were implemented. An
ophthalmology consult given orbital fracture was also obtained.
Recommendations included conservative management with oral
antibiotics and sinus precautions as per Plastics and followup
as outpatient with ___ were implemented.
Radial Arm Fractures: Given with left distal radial fracture
Hand Surgery was consulted who attempted
bedside reduction and splint and recommended followup as an
outpatient in Hand Clinic.
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 were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was initially kept NPO for possible
operative intervention. The diet was advanced sequentially to a
soft diet, which was well tolerated. Patient's intake and output
were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a 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: ___ with PMHx of bipolar disorder, anxiety, IVDU, chronic HCV,
and seizure disorder presents to the ED with c/o increasing
frequency of seizures. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial abnormality. CHEST (PA AND LAT) showed Patchy opacification at the left lung base, concerning for infection. The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus. At the time of discharge, the patient had epilepsy
history of traumatic brain injury
homelessness
___ abuse
bipolar disorder
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>___ with PMHx of bipolar disorder, anxiety, IVDU, chronic HCV,
and seizure disorder presented with increasing seizure
frequency and witnessed GTC in the ED. She was monitored with
EEG off home keppra for spell capture and characterization who
course was complicated by symptoms of opioid withdrawal.
# Seizure Disorder
Patient reports epilepsy secondary to traumatic brain injury in
___, now with increasing frequency in setting of stopping her
keppra recently. She had witnessed GTC in the ED with high
lactate. Patient states she has not seen a neurologist in ___
years(last saw Dr. ___ @ ___) and is managed by PCP (Dr.
___ ___. Given her complex social history, she may have
both seizures and pseudoseizures, so home keppra was held for
EEG monitoring. Her EEG did not show any epileptiform discharges
or electrographic seizures even with sleep deprivation. She was
not comfortable with restarting keppra, because she thinks that
it doesn't work for her so she was discharged on zonisamide
400mg qhs. She will follow-up with epilepsy outpatient in one
month.
#Opioid withdrawal
The patient has a history of IVDA with last use of heroin 6 days
prior to admission. During this admission she experienced
withdrawal symptoms, which had improved significantly by the
time of discharge. She was given a prescription for a week of
dicyclomine and Simethicone.
#Right Hand Cellulitis
Gives history of significant swelling and pain, though currently
exam is not impressive. With history, and high risk nature of
site of injection, was treated with a 5 day course of
doxycycline
# ___ use including IV opiates
Last used IV heroin 6 days prior to admission. On chronic
methadone at ___ at ___
___ in ___, ___. Confirmed methadone dose 150mg daily, last
taken ___. During admission she was found to be using heroin.
She readily admitted to the incident and her needles were
confiscated. There were no other issues. She was seen by
addiction specialists and social work.
# Bipolar disorder
Reports mood is "okay" and denies SI/HI. Recent inpatient
psychiatric hospitalization in past ___. She was
continued on home Seroquel, sertraline, buspirone, prazosin,
mirtazapine, trazodone.
# Hx of endocarditis
History of endocarditis at ___ reportedly within past year.
No suspicion at this time for recurrent endocarditis, though is
at somewhat elevated risk due to active IVDU. Blood cultures
were negative.
# Chronic HCV
LFTs WNL. Plan to be treated at ___ (no need for GI
follow-up
at this time)
# IBS
Held home linaclotide since it was non-formulary, and patient
was exhibiting diarrhea from withdrawal.
# Fibromyalgia
Patient states she has a history of fibromyalgia and takes
Pregabalin and has been maintained on her home dose
TRANISTIONAL ISSUES
--------------------
AEDs on discharge:
Zonisamide 400mg qHS
[] follow up with neurologist
[] follow up chronic hepatitis C for treatment</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o F with history of duodenal ulcers and
dementia who presented as a transfer from ___ for
management of pulmonary embolism, arrived on heparin gtt. Per
reports, she is a resident of ___, and had a syncopal
episode lasting 30 seconds to 1 minute, prompting her to be
taken to the ED. At ___, she was found to have extensive
bilateral pulmonary emboli with right heart strain and elevated
troponins. She was transferred to ___ on heparin gtt which was
started around 1440 on ___. MASCOT was consulted and
recommended remaining on heparin gtt at this time, and
recommended further workup with lower extremity dopplers and
formal TTE. After discussion with the family and patient, they
clearly expressed not wanting to pursue aggressive measures at
this time, including IVC filter. However, should further
complications develop, they are willing to discuss more advanced
therapies at this time. Radiology showed Increased retrocardiac opacities may reflect atelectasis or consolidation. BILAT LOWER EXT VEINS showed 1. Deep venous thrombosis of the right femoral and popliteal veins.
2. Nonvisualization of posterior tibial and peroneal veins bilaterally. Within
these limits, no evidence of deep venous thrombosis in the leftlower extremity
veins. CHEST (PORTABLE AP) showed Cardiac size is top-normal. Patient has a large hiatal hernia. Enlargement
of the pulmonary arteries is again noted. There is no pneumonia, pulmonary
edema, evident pneumothorax or pleural effusions. Radiology showed Successful deployment of an infrarenal retrievable IVC filter.
RECOMMENDATION(S): Please contact the department of Interventional Radiology
with questions or concerns about the retrievable filter and for follow-up for
retrieval if clinically feasible. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed 1. The right IJ central venous catheter tip is in the right atrium,
approximately 1.5 cm below the estimated location of the superior cavoatrial
junction.
2. Enlargement of the pulmonary artery is stable. No evidence of pulmonary
vascular congestion or pulmonary edema.
3. Large hiatal hernia, unchanged. CHEST (PORTABLE AP) showed Right internal jugular line tip is in the proximal right atrium. Heart size
and mediastinum are unchanged including cardiac enlargement. Left
retrocardiac opacities concerning for infectious process. No appreciable
pleural effusion. Hiatal hernia is large, re-demonstrated. The patient was diagnosed with Other pulmonary embolism without acute cor pulmonale, Syncope and collapse. The patient was treated with ___: Placement of IVC filter. At the time of discharge, the patient had ===========================
Primary:
===========================
Syncope secondary to massive pulmonary embolism
Catheter-associated urinary tract infection
=============================
Secondary:
=============================
Anemia
Esophagitis
Peptic ulcer disease
Bullous pemphigoid
Alzheimer's dementia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>==========================
BRIEF SUMMARY
==========================
___ yo F with a history of bullous pemphigoid on steroids,
Alzheimer's dementia, who presented with syncope and found to
have extensive bilateral pulmonary emboli with right heart
strain. She received an IVC filter and was treated with a
heparin drip, transitioned to oral apixaban prior to discharge.
==========================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with bipolar disorder and
alcohol use disorder who presented to the ED with alcohol
intoxication and withdrawal. CHEST (PA AND LAT) showed No pneumonia or evidence of cardiac decompensation. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had # Alcohol Withdrawal
# Alcohol Use Disorder
# Clostridium difficile infection
# Bipolar Disorder with depressive symptoms. 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 bipolar disorder and
alcohol use disorder who presented to the ED with alcohol
intoxication and withdrawal with course complicated by severe
bipolar depression and Clostridium difficile infection.
# Alcohol use disorder
# Alcohol withdrawal, history of withdrawal seizures:
Patient has a long-standing history of heavy alcohol use
complicated by severe withdrawal with seizures. He received PO
phenobarbital (about 4mg/kg) in the ED after receiving a few
doses of PO and IV diazepam. The diazepam did not significantly
improve his withdrawal symptoms but the phenobarbital did help.
Upon arrival to the floor, his CIWA score was 12 so he was given
an additional ~4mg/kg dose of PO phenobarbital with improvement
in his symptoms. He had no further symptoms of withdrawal. He
was counseled on EtOH cessation.
# BPD
# Major depression:
No current signs of mania but rather severe depression. He did
not endorse any SI. He does have a complex psychiatric history
including multiple inpatient hospitalizations requiring ECT. Due
to concern for a manic episode prompting recent EtOH binge,
psychiatry was consulted and recommended inpatient psychiatric
admission for bipolar disorder with depressive symptoms. Due to
diagnosis of Cdiff as below, ECT was initiated while on the
medicine floor with treatments on ___ and ___ before completion
of cdiff treatment. He was transferred to an inpatient
psychiatry facility for ongoing management of bipolar disorder
on discharge.
# C. diff diarrhea:
Developed liquid stools, C.diff PCR positive, toxin positive
confirming active infection. Was started on PO vancomycin on
___. His mild diarrhea resolved rapidly, within 2 days of
starting PO vancomycin. Last dose on ___ for total course
of 10 days of PO vancomycin for a first episode of non-severe
CDI.
# Tremor:
In the setting of EtOH withdrawal. Persisted for a significant
time after all other withdrawal symptoms subsided. Based upon
subsequent history obtained from the patient, sounds chronic and
most likely essential tremor. He reports having been
treated with propranolol in the past with success (he was able
to tell me the typical doses or propranolol without any
prompting). He reported a good initial response to 20 mg
propranolol, but this eventually stopped being as effective, and
his treatment was apparently limited by lightheadedness
("wooziness") at a dose of 40 mg of propranolol. Given this
history and patient having some significant difficulty with
tremor during eating/drinking (e.g. trouble holding cup of water
to mouth), propranolol started at 20mg TID. Outpatient neurology
f/u scheduled for ongoing evaluation of tremor.
# Dyspepsia:
Suspect EtOH-induced gastritis. Improved w/ empiric PPI which he
should continue through ___.
# Thrombocytopenia: Suspect EtOH-related. Remained stable in
110s. Will need outpatient follow-up of thrombocytopenia after
discharge.
# Chronic back pain:
Treated conservatively with heat packs, tylenol, and lidocaine
ointment/patch.
# Housing instability
Currently living on the streets. SW consulted for resources. He
will benefit from ongoing SW involvement at the inpatient
psychiatric unit. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman with history of CAD (70% mid LAD, 80%
Diagonal,
100% occlusion of the LCx, mid RC 50-60%), PVD, T2DM, peripheral
neuropathy, CKD who presents with complaint of wheezing and
shortness of breath. CHEST (PORTABLE AP) showed No acute cardiopulmonary process, specifically no pulmonary edema. CHEST (PORTABLE AP) showed Lungs are low volume with subsegmental atelectasis in the right lung base.
The patient is rotated to the left. Cardiomediastinal silhouette is stable.
There is no pleural effusion. No pneumothorax is seen. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had Primary: Hypertensive Emergency
Secondary: CAD, DM2, CKD, PVD. 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 an ___ year old woman w/ ___ CAD (70% mid LAD,
80% Diagonal, 100% occlusion of the LCx, mid RC 50-60%), PVD,
DM2, CKD who presented with dyspnea and chest pain, found to be
in a hypertensive emergency with demand ischemia and flash
pulmonary edema.
TRANSITIONAL ISSUE:
=========================
[ ] Follow up blood pressure and basic metabolic panel at
post-hospitalization visit
ACTIVE ISSUES:
=========================
#HYPERTENSIVE EMERGENCY:
#ACUTE HYPOXEMIC RESPIRATORY FAILURE ___ FLASH PULMONARY EDEMA:
#NSTEMI, TYPE II:
#CORONARY ARTERY DISEASE:
Felt to be secondary to recently held losartan/hctz given
concern for progressive CKD outpatient. First felt dyspneic on
___ ___, worse on ___, and then presented to the ___ ED. Did
well in the ED on a nitro gtt and was diuresed, weaned from O2
to room air. Overnight, minimal events, until the first day of
her admission when she triggered for acute hypoxemic respiratory
failure and severe hypertension to 220s/120s. It appeared that
she still needed further diuresis and titration of her blood
pressure medications while on a nitro gtt. Nitro gtt was
re-started, and blood pressure medications rapidly titrated up
along with diuresis. The patient's blood pressure quickly
dropped to a much safer level within the hour, and was soon back
on room air, and was stable over the next two days. Please see
below for her final antihypertensive regimen at discharge.
Additionally, she had chest pain that resolved with her blood
pressure and diuresis. Trops were trended and did increase, but
not trended further despite further increase because she was
completely asymptomatic. All of this was felt to be demand
ischemia from her hypertensive emergency. Additionally, she did
not require any further diuresis once her blood pressure was
under better control.
CHRONIC/STABLE ISSUES:
=========================
#PVD:
- Continued home antiplatelets
#CKD:
- Monitored closely in the hospital. Did not restart hctz but
did restart losartan due to uncontrolled blood pressure.
#NEUROPATHY:
- Continued home pain medications
#DM2:
- Continued home insulin. No changes made.
#DEPRESSION:
- Continued home bupropion</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Chest: Frontal and lateral views showed Right-sided PICC terminates in the low SVC.
Redemonstrated right upper lung nodular opacity with fiducial marker, similar
to prior. No new focal consolidation. CT ABD AND PELVIS WITH CONTRAST showed 1. No acute intra-abdominal process. Diverticulosis without evidence of acute
diverticulitis.
2. Moderate hiatal hernia.
3. Severe T12 compression deformity appears increased when compared to the
study from ___, but similar compared to ___. There
is no significant change in alignment. UNILAT UP EXT VEINS US RIGHT showed Nonocclusive DVT in the right axillary vein and basilic vein.
NOTIFICATION: Findings were communicated via telephone with ___, MD
on ___ at 15:20, 15 minutes after discovery of findings. MRI THORACIC AND LUMBAR PT6 MR SPINE showed 1. Unchanged configuration of a T12 compression fracture, with persistent high
signal on water ideal images. Retropulsion results in mild canal narrowing,
but no cord compression or signal abnormality.
2. There is no evidence of vertebral discitis/osteomyelitis, or epidural
abscess.
PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal, height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
Jarvik, et all. Spine ___ 26(10):___
Lumbar spinal stenosis prevalence- present in approximately 20% of
asymptomatic adults over ___ years old
___, et al, Spine Journal ___ 9 (7):545-550
These findings are so common in asymptomatic persons that they must be
interpreted with caution and in context of the clinical situation. The patient was diagnosed with Vomiting, unspecified, Diarrhea, unspecified, Left upper quadrant pain, Tachycardia, unspecified. The patient was treated with PICC insertion, left upper extremity. At the time of discharge, the patient had Staph aureus (methicillin-susceptible) bacteremia
Acenitobacter bacteremia
Acute right upper extremity Deep vein thrombosis associated with
PICC line. 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:
PCP:
- please assess clinical resolution of bacteremia
- please discontinue PICC following full course of antibiotics
- Determine need for DEXA scan to evaluate for osteoporosis in
setting of T12 compression fracture in a male.
- CT chest ___ with bilateral pulmonary nodules, the majority
of which are stable however there is a slightly larger 4 mm
nodule which is seen along the course of prior biopsy tract.
Three to six-month follow-up chest CT is suggested.
- ___ year follow-up from ___ renal ultrasound to assess
interval change of the 3.6 cm right upper pole cyst
HOSPITAL COURSE:
#Staph bacteremia:
#Acenitobacter bacteremia:
#low back pain: MSSA bacteremia ___ bottles) + 1 Acenitobacter
___ bottles on initial set; of less clear clinical
significance), associated with PICC placed for daily hydration
at home. Working up any metastatic infection unrevealing. TTE
showing RA density, but nothing apparent on TEE. MRI not
suggesting osteo. Initially on Vanc/CTX. Cleared culture x72+
hours. Transitioned to Cefazolin 2g Q8 and Cipro 500 BID with
plans for 4 weeks (given the presence of a DVT) and 14 days,
respectively. In the meantime, while pt is to have his PICC in
place, continued the daily PRN saline boluses, though this plan
will be evaluated by PCP ___ 4 week treatment, given the
risk of complication long term.
#PEs:
#acute DVT: R First incident of clot per chart was ___.
Segmental and Subsegmental diagnosed in ___ and now confirmed
PICC-related DVT in right axillary vein as of pm of ___ pt
endorsing rivaroxaban adherence at home. Heme feeling that low
burden PE I/s/o PICC does not represent treatment failure and
may continue Rivaroxaban.
#niacin flushing reaction: Patient with an acute onset of upper
chest, bilateral UE flushing on day 6 of admission, with
pruritus, resolved in 2 hours without intervention. No evidence
of other drug rash. No recurrence. Most consistent with a niacin
reaction. Pt endorses generally not taking at home. He is on
Niacin per Dr. ___ oncologist, due to low niacin
levels, attributed to his ___
(which reportedly can cause pellagra). Unclear whether there was
some issue with his SR formulation releasing immediately; it was
restarted on a trial basis as of ___ with the plan to discontinue
if subsequent reaction occurred.
#RECURRENT ACUTE ON CHRONIC NAUSEA AND VOMITING, LACTIC ACIDOSIS
(RESOLVED): Multiple workups unrevealing. Patient reports
symptoms worsened following his chemotherapy, so GI thinks this
is possibly cisplatin-induced gastroparesis. He has previously
had an extensive work-up of his diarrhea during inpatient
hospitalizations, which has been notable for an elevated fecal
calprotectin, colonoscopy ___ without active mucosal
inflammation, normal MRE aside from known hepatic steatosis, and
stool cultures negative for c diff, campylobacter, salmonella or
shigella. Last hospitalization team attributed symptoms to
alcoholic hepatitis/gastritis in setting of AST>>ALT. This
dmission transaminases and lipase are normal, making alcoholic
hepatitis/gastritis less likely. During his stay, intermittently
with nausea Sx seemingly without specific prompt, but resolved
with PRN. Most effective agent appears to have been Compazine
IV. No nausea over the 2 days prior to ___. Returned on regular
home regimen.
#CHRONIC DIARRHEA: Has been worked up extensively both as
inpatient and outpatient in past and workup has been largely
negative. Per GI, they suspect diarrhea is related to past
radiation from anal cancer treatment as well as dysmotility from
his cisplatin treatment. Loperamide dose increased on last
discharge. Gets standing K supplementation. On the floor,
diarrhea is improved somewhat.
#CHRONIC ORTHOSTATIC HYPOTENSION: Likely ___ chronic diarrhea
and autonomic neuropathy, possibly from chronic alcohol, at home
on midodrine and fludrocortisone 0.2 and per pt gets 1L fluid
through PICC every day. BP generally stable this admission
though did have +orhtostatics responsive to NS bolusing
#ANEMIA: Stable, normocytic. No evidence of hemolysis on prior
admissions. Had normal B12, folate. Ferritin > 100, making iron
deficiency less likely, but with iron sat <20% need to consider
iron supplementation. Would repeat iron studies as outpatient.
# GERD, ___ ESOPHAGUS: Omeprazole increased to 40mg BID
last hospitalization. Will continue.
# THORACIC COMPRESSION FRACTURE: Severe T12 compression
deformity, new in ___. MRI was repeated given his staph
bacteremia without e/o diskitis but with disc retropulsion,
accounting for his pain. Partial response to Tylenol and lido;
but pt tolerating ambulation as of ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ gentleman with a history of IDDM,
HTN, and asthma but no known history of CAD or chest pain who
presented to ___ with L arm and chest pain and was
found to have lateral TWI and trop-I 0.33 concerning for NSTEMI.
He was transferred to ___ for further management.
Patient reports he was in his usual state of health until ~9pm
evening before presentation, when he noticed dull left arm pain.
He works as a ___, often lifting, and didn't think much of
the pain. He did check his blood pressure and noted it to be
220/100. His wife suggested he go to the ED but he declined.
Around ___ pain woke him up and he took an extra dose of
clonidine and returned to bed. He woke up again at 0500 with
dizziness. He called out of work. He was able to sleep until
0900 when he awoke with persistent L arm pain that now extended
into L lateral chest. Pain is dull, pressure like, and got worse
with exertion.
At ___, patient received SLNTG with improvement in pain. He
was started on a heparin gtt and received a full-strength ASA.
He was noted to be hyperglycemic, with f/s 400. Cr was 1.7
(denies known history of kidney disease, though has had
refractory HTN and baseline Cr 1.1-1.3).
He was transferred to our ED, where initial vitals were 6 98.4
85 141/95 18 98% . Trop-T was 0.08 --> 0.10 and Cr had improved
to 1.4. EKG showed LVH, TWI in V4-V6 and II, III, and aVF, and
J-point elevation in V1-V2. He was continued on a heparin gtt,
which was decreased from 1090 units/hr to 590 units/hr for
unknown reason (possibly high PTT at OSH? First PTT here 86). He
had returning CP and was put on NTG gtt starting at 0.14mcg;
this was briefly increased to 0.44 for ongoing CP. He was
admitted to the ___ service for medical management and
consideration of catheterization. Vitals prior to transfer were
5 98.7 70 158/93 18 99% RA. CT HEAD W/O CONTRAST showed No acute intracranial process. Radiology showed Normal bilateral renal ultrasound with appropriate arterial resistive indices. The patient was diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE. At the time of discharge, the patient had PRIMARY DIAGNOSES
====================
# Type II Non-ST Elevation Myocardial Infarction
# Hypertensive Emergency
# Acute Kidney Injury
CHRONIC ISSUES
===============
# Insulin Dependent Diabetes Mellitus
# Asthma
# Hyperlipidemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF SUMMARY STATEMENT: Mr. ___ is a ___ gentleman
with a history of difficult-to-manage HTN and IDDM who presented
with 1 day of L arm and chest pain and was found to have cardiac
enzyme elevation and EKG changes consistent with NSTEMI.
Initially, pt's NSTEMI managed for ACS with heparin gtt.
Following evaluation, pt's NSTEMI was thought to be type 2
demand ischemia in the setting of hypertensive emergency. As his
BP improved on a nitro gtt, pt's chest pain and arm pain
resolved. Exercise stress test was done and returned within
normal limits. He was started on a modified anti-hypertensive
regimen with success. BPs on day of discharge 130-150s/70-90s.
ACTIVE ISSUES
================
# NSTEMI: Pt. presented with left arm and chest pain. He was
found to have elevated cardiac enzymes and t-wave inversions in
inferior leads consistent with NSTEMI. Pt was found to be in
hypertensive emergency which was thought to be the likely cause
of his symptoms resulting in demand ischemia and a type II
NSTEMI. Pt. was initially medically managed with heparin gtt
which was later discontinued following improvement of his
symptoms with improvement of his blood pressures (arguing
against a coronary event). Pt. was maintained on heparin gtt
for 24 hours and d/c'ed when coronary event was thought to be
unlikely. Given significant risk factors of age, HTN, DM and
NSTEMI, pt. had a stress TTE which was without wall motion
abnormalities at rest and without ischemic changes with exercise
supporting more of a demand ischemia event. He was discharged
on ASA 81mg, atorvastatin 80mg, beta blockade, and ace
inhibitor.
# Hypertensive emergency: Per PCP, ___. has had difficult to
treat hypertension most likely ___ non-compliance. Pt. was
noted to be with SBP at home in 220s and on admission in 180s.
He was initially managed with nitro gtt and later transitioned
to a 4 drug oral regimen including amlodipine, chlorthalidone,
carvedilol, and lisinopril which he tolerated well. Pt. had a
significant headache, following admission in addition to blurry
vision in the setting of anti-plt therapy. For concern of an
intracranial bleed, pt. had a NCHCT which was negative for an
acute intracranial process. His neuro exam remained non-focal
and his vision returned to baseline shortly following improved
blood pressure control. We had extensive discussion with pt.
regarding the long-term effects of hypertension. It seems that
pt. has been non-compliant because he sometimes feels that his
BP meds make him lightheaded especially when he is at work (his
job is strenuous as he is a ___).
# ___: Pt. with ___ above his known baseline creatinine of
1.1-1.3 (in ___ records, verified by PCP). His creatinine
was elevated on admission consistent with ___. His urine lytes
return with evidence of intrinsic injury with FeNa 2.8%, FeUrea
55.8% consistent with ___ ___ hypertensive emergency. His
creatinine remained stable. He was instructed to have repeat
chemistry in approximately 7 days as an outpatient.
CHRONIC ISSUES
=================
# IDDM: Stable. Continued on home regimen of glargine 34 units
qAM and Humalog ISS
# Asthma: Continued Albuterol nebs prn
# Hyperlipidemia. Continued Atorvastatin 80mg daily
TRANSITIONAL ISSUES
===================
# Type 2 NSTEMI: Pt. continued on atorvastatin 80, asa 81,
carvedilol, and lisinopril at discharge.
# Hypertensive emergency: Pt. managed initially on nitro gtt
transitioned to PO regimen consisting of lisinopril,
chlorthalidone, carvedilol, and amlodipine.
# Outpatient Labs: Pt. should have repeat chemistries drawn one
week after discharge (sometime after ___.
# Code: Full Code
# Emergency Contact: Wife ___ </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
lymphoblastic blast crisis of CML day ___ after a double cord
transplant who presented to the ED with productive cough,
headache, sinus and ear congestion. Patient reports acute onset
of symptoms x4 d ago, since then little relief with flonase,
sudafed 30mg bid, allegra. Patient has a history of sinus
infections in the past, previously seen by ENT, intermittently
treated with Augmentin. Pt went to ENT today for appt, but was
told that her insurance expired, and was referred here to the ER
for eval.
In the ED, initial vitals were: 96.5 118 115/68 20 95%. Labs
were significant for WBC 17, Cr 1.7 (baseline 1.3-1.5), lactate
2.1. CXR was concerning for multifocal PNA. Patient was given
750mg po levoflox, Zofran, 650mg acetaminophen, an albuterol
neb, and Tesselon pearles as well as 1L NS. Case was discussed
with Dr. ___ recommended admission. Vitals prior to
transfer were 98.1 104 134/69 18 97%
Review of Systems:
(+) Endorses congestion, nose bleeds, nausea, and vomiting
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies dysuria, stool or urine incontinence.
Denies arthralgias or myalgias. Denies rashes or skin
breakdown. No numbness/tingling in extremities. All other
systems negative. Radiology showed Patchy bilateral lower lobe opacities worrisome for multifocal pneumonia. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. At the time of discharge, the patient had Community Acquired 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>Ms. ___ is a ___ with Hx of Lymphoblastic blast crisis of
CML day ___ after a double cord transplant who presented to the
ED with productive cough, headache, sinus and ear congestion,
found to have possible multifocal PNA on CXR.
# PNA: Patient with multifocal pneumonia, leukocytosis, though
no documented fevers. She endorses a history of congestion and
cough prior to this episode as well as nausea/vomiting;
possible that she had a viral URI and now has a super-imposed
PNA. Although do not need to treat with Tamiflu (as has had
symptoms for more than 48 hours), a nasal swab was performed but
did not have adequate cells for evaluation. She was discharged
on levofloxacin to finish a ___nd a 5 day course of
tamiflu.
# CML: In remission. Continue follow-up with outpatient
providers.
# TACHYCARDIA: likely secondary to acute inflammatory response
to pneumonia. Resolved with fluid resuscitation.
# ACUTE ON CHRONIC KIDNEY INJURY: Basline 1.1-1.3, Unclear
etiology of CKD. Patient has been encouraged to see nephrology
in the past, but is does not appear as if she has gone. Her
medications were renally dosed and her ___ improved back to its
baseline with fluids.
# INURANCE: Patient lost her insurance prior to this visit and
was notified in ___ clinic. Case management and social work
consults performed, and she obtained her insurance again.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is an ___ gentleman with a pmhx. significant for DM
II, HTN, AAA repair, and ?TIAs who is admitted from ___
___ with elevated LFTs, jaundice, and change in mental
status. Radiology showed Intra- and extra-hepatic biliary dilatation. Status post
cholecystectomy without prior imaging since the cholecystectomy prior to
today. Query echogenic lesion in the region of the pancreatic head.
Recommend further evaluation with CTA pancreas, MRCP, and/or ERCP. Radiology showed 1. Metastatic pancreatic neoplasm: Hypo attenuating 2.9 cm mass in the head
of the pancreas at the level of abrupt cutoff of the dilated pancreatic duct
concerning for primary pancreatic neoplasm with hypoattenuating lesions in the
right posterior segment of the liver concerning for hepatic metastases.
Prominent peripancreatic lymph nodes and multiple hypoattenuating, likely
cystic lesions throughout the body and tail of the pancreas.
2. Biliary: Moderate intrahepatic biliary dilation in the right posterior
segment may be related to local obstruction from hepatic metastases. Mild
centralized intrahepatic biliary dilation status post ERCP with biliary stent
in appropriate position.
3. Patent vasculature with conventional anatomy.
4. Exophytic gastric mass: Enhancing 2.5 cm mass from the gastric fundus
concerning for gastrointestinal stromal tumor. Endoscopic ultrasound could be
considered for further evaluation.
5. Circumferential thickening of the distal esophageal wall may represent
esophagitis in the appropriate clinical setting.
6. Large infrarenal abdominal aortic aneurysm status post endovascular aortic
repair. The patient was diagnosed with OBSTRUCTION OF BILE DUCT, JAUNDICE NOS, HYPERTENSION NOS. The patient was treated with ERCP. At the time of discharge, the patient had Metastatic Pancreatic Neoplasm
Stomach Mass. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is an ___ gentleman with a PMHx significant for
HTN, TIA, and AAA repair who is admitted with jaundice, elevated
LFTs, and RUQ concerning for mass.
# BILIARY OBSTRUCTION, ELEVATED LFTS, JAUNDICE: RUQ performed
on admission revealing echogenic lesion in the region of the
pancreatic head. Given concern for mass obstructing CBD, the
patient underwent ERCP with stent placement. With this therapy,
bilirubin and LFT's trended down. Biopsies were taken during
ERCP and were pending at the time of discharge. After ERCP, the
patient underwent CTA abdomen, which confirmed a pancreatic
lesion concerning for malignancy with evidence of likely liver
metastases. Given these findings, oncology f/u was recommended.
After discussion with the patient's PCP's office, it was decided
to refer the patient to Dr. ___. Unfortunately,
appointment was not able to be scheduled prior to discharge
because pathology had not yet returned. Dr. ___ office will
be in contact to arrange a follow-up appointment with the
patient after pathology has returned. Pt will need repeat ERCP
in approximately 6 weeks. ERCP office will contact him to
arrange this appointment.
# Stomach Lesion: Seen on CTA abdomen, concerning for potential
GIST. Given slow growth of GIST tumors and relatively rapid
growth of patient's pancreatic malignancy, further evaluation of
this stomach lesion was deferred to patient's PCP and
oncologist.
# Delirium: Likely toxic-metabolic encephalopathy in the setting
of biliary obstruction. Patient's mental status improved to
baseline after biliary stent was placed.
# Hypokalemia: Pt noted to have low potassium on the day of
discharge (3.0). Was repleted with 60 meq. Potassium will be
closely monitored at his rehab.
# HTN, BENIGN: Continued atenolol and lisinopril
# DMII WITHOUT COMPLICATIONS: Continued lantus. Held metformin
during admission, restarted on discharge.
# HISTORY OF TIA: Aspirin and aggrenox held for 5 days after
ERCP with sphincterotomy, can be restarted on ___.
# B12 DEFICIENCY: Continued B12 supplementation</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 F w/o significant PMH who
presents with L sided weakness and numbness. Hx obtained from pt
and family at bedside. CHEST (upright AP AND LAT) showed No acute intrathoracic process. MR HEAD W AND W/O CONTRAST T9112 MR HEAD. showed 1. No evidence of acute territorial infarction, intracranial hemorrhage, mass,
or abnormal enhancement. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. The patient was diagnosed with Weakness. At the time of discharge, the patient had Transient headache, confusion, LT sided weakness, and chest
tightness in the setting of severe anxiety after cocaine use.. 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 woman with no significant medical history presenting with
an episode of headache, confusion, LT sided weakness, and chest
tightness in the setting of severe anxiety after cocaine use.
Imaging with brain MRI and CTA head/neck unremarkable (without
vessel reformats to rule out small vasospasm read as normal by
both outside hospital radiologists and ___ radiologists). Lyme
serum sent and is pending. Orthostatics negative. Cardiac
enzymes normal. She was monitored on telemetry, given IVF
repletion, evaluated by ___. Symptoms improved spontaneously.
Gabapentin was trialed, however it made patient sleepy so this
medication was discontinued. Likely this could have represented
a transient vasospasm from cocaine that has resolved, as well as
a functional disorder given her significant anxiety.
Transitional Issues
- Follow serum Lyme
- Close PCP follow up
-___ with neurology x1 in ___ ___ at 3:30 ___
-outpatient echocardiogram to complete the stroke work up. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y/o man with a
history of rheumatoid arthiritis (previously on anti-TNF;
stopped
___, prior alcohol abuse complicated by chronic portal vein
thrombosis in the setting of pancreatitis, portal hypertension
with varices s/p band ligation presenting for evaluation of rash
and abnormal labs. CHEST (SINGLE VIEW) showed No previous images. The cardiac silhouette is at the upper limits of normal.
Indistinctness of pulmonary vessels suggests some elevated pulmonary venous
pressure. Opacification at the left base silhouetting hemidiaphragm most
likely represents a combination of atelectasis and pleural fluid. However,
there is suggestion of mild coalescence of opacification just above and
lateral to the lower cardiac border. In the appropriate clinical setting,
this would be worrisome for superimposed aspiration/pneumonia. ABDOMEN US (COMPLETE STUDY) showed 1. Cavernous transformation of the main portal vein consistent with chronic
portal vein thrombosis. A small amount of hepatopetal flow was identified
within the right portal vein.
2. No hydronephrosis identified. The patient was diagnosed with Encntr for obs for oth suspected diseases and cond ruled out. At the time of discharge, the patient had Leukocytoclastic Vasculitis. 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 ___ y/o man with a history of rheumatoid
arthiritis (previously on anti-TNF; stopped ___,
prior alcohol abuse complicated by chronic portal vein
thrombosis in the setting of pancreatitis, portal hypertension
with varices s/p band ligation who presented with worsening rash
and ___.
ACUTE ISSUES
============
# Rash
# Leukocytoclastic Vasculitis:
Patient with several month history of rash, with biopsy in ___
consistent with LCV vs hypersensitivity (eosinophils). ___ be
secondary to Influenza/pneumonia in ___, although this does
not explain progression of rash recently. ___ be related to
antibiotic use. Felt unrelated to rheumatoid arthritis by
rheumatology despite patient being off Humira. Autoimmune panel
was sent with most studies negative except for positive RF and
HBcAb. Hepatitis B viral load not detected. Resent HBcAb for
possible false positive, but results still pending at discharge.
Patient also had elevated IgA, concerning for IgA
nephropathy/henoch-schonlein purpura, though patient denied
abdominal pain and arthralgias. Per dermatology, patient did not
need treatment for rash itself as it was asymptomatic. Patient
also evaluated by wound nurse for blisters on feet and heels.
# Acute kidney injury:
Baseline creatinine 1.0, elevated to 1.7 on admission. Concern
for possible glomerulonephritis in setting of
LCV as above. Renal US showed no hydronephrosis. Patient had low
protein/Cr ratio and sediment showed few RBC casts. His Cr
remained stable, discharge Cr 1.7. Per renal, given patient's
recent NSAID use, his ___ could be NSAID induced ATN. Discharged
with close follow-up with nephrology for outpatient renal biopsy
if Cr remains elevated.
# Acute on chronic anemia:
No evidence of bleeding. Iron studies suggest anemia of chronic
disease. Haptoglobin, t. bili, fibrinogen argue against
hemolysis. Patient has a history of esophageal varices, but he
did not have changes in his bowel movements. The patient
received one unit RBC, and hemoglobin remained stable. Patient
had been taking OTC iron supplement which was held for concern
that it was related to rash. Evaluated by hematology who
reviewed his smear and did not see evidence of MDS. ___
consider outpatient hematology work-up if anemia persistent.
# History of portal vein thrombosis:
RUQ US showed stable chronic portal vein thrombosis.
# Right humeral fracture:
Patient with traumatic right humeral fracture on ___ of this
year, awaiting arthroplasty in ___. Patient had ongoing shoulder
pain not well controlled on home oxycodone regimen, so frequency
was increased to oxycodone 5 mg q4h PRN.
CHRONIC ISSUES
==============
# Rheumatoid Arthritis:
Diagnosed about ___ years ago. Previously on methotrexate, and
then started on Humira about ___ years ago.
Humira has been on hold since ___ and he has not had any flares
since then.
# Portal hypertension
# Esophageal varices s/p banding:
Held nadolol in setting of renal failure
# BPH:
Continued home tamsulosin
# Hypothyroidism:
Continued home levothyroxine
# Anxiety:
Continued home lorazapam as needed
# Insomnia:
Held zolpidem during this admission
TI:
[ ] Patient needs close follow-up with nephrology for possible
renal biopsy
[ ] Patient should have his Cr drawn on ___ with results
sent to PCP
[ ] Held home nadolol in setting ___
[ ] Patient found to be HBcAb positive, hepatitis B viral load
negative. Repeat HBV serology pending, to be followed up by
hepatologist, Dr. ___
[ ] Patient's anemia should be monitored. Consider outpatient
hematology work-up if does not improve with
[ ] Started on folic acid and thiamine for history of alcohol
use
[ ] Oxycodone increased for severe shoulder pain to 5 mg q6h PRN
on discharge</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman w/hx AS s/p TAVR (___), afib on coumadin,
HFpEF (EF 60-65%), BiV ICD (___), TIA presenting with
subacute dyspnea on exertion and chest pain. Chest: Frontal and lateral views showed No acute cardiopulmonary process. CTA CORONARY ARTERIES W/3D W/FUNCTION was done. CT CHEST WITHOUT CONTRAST showed No evidence of pulmonary edema or pneumonia. ANKLE (AP, MORTISE AND LAT) LEFT showed Mild periosteal reaction about the medial aspect of the ankle with
questionable small osseous erosion of the distal tip of the medial malleolus,
may represent early osteomyelitis in the correct clinical context, with other
etiologies including inflammatory arthropathy not excluded. Note that MRI is
more sensitive for detection of osteomyelitis.
Moderate soft tissue edema about the ankle, most pronounced medially.
NOTIFICATION: The impression above was entered by Dr. ___ on ___
at 11:48 into the Department of Radiology critical communications system for
direct communication to the referring provider. MR ANKLE ___ LEFT showed 1. No bone marrow signal abnormality to suggest osteomyelitis.
2. Diffuse subcutaneous edema of the left ankle without rim enhancing fluid
collection.
3. Mid substance Achilles tendinopathy with edema in ___ fat pad. No
Achilles tendon tear. The patient was diagnosed with Dyspnea, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS
======================
COPD
Cellulitis of Left Lower Extremity
Varicella Zoster
SECONDARY DIAGNOSIS
========================
ATRIAL FIBRILLATION
HEART FAILURE WITH PRESERVED 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>SUMMARY
===================
___ is a ___ year old woman w/hx AS s/p TAVR
(___), afib, HFpEF (EF 60-65%), BiV ICD (___), TIA
presenting with subacute dyspnea on exertion and chest pain.
Patient underwent a battery of tests and it was thought her
symptoms were likely due to COPD and deconditioning and
therefore she was started on a prednisone taper. Her hospital
course was complicated by both shingles outbreak and cellulitis
for which she was treated.
TRANSITIONAL ISSUES
=======================
[] Patient provided with albuterol, Spiriva and advair at
discharge
[] Should have cardiology follow up for HFpEF.
[] Should have pulmonary follow up for COPD as well as sleep
medicine for OSA.
[] increased Lisinopril to 10 mg qd for BP control. consider
further uptitration
[] if suspicion for angina, consider amlodipine 5 mg qd vs Imdur
30 mg qd for microvascular angina
[] Patient developed cellulitis of the left lower extremity
while inpatient and was instructed to complete a 10 day course
of Keflex. Patient should be evaluated for resolution of
cellulitis after completing the antibiotic course.
[] Next INR should be checked on ___.
Discharge Weight: 365 lbs
Discharge Cr: 0.8
ACUTE ISSUES
===================
# Subacute Dyspnea on Exertion:
Ongoing dyspnea on exertion in pre and post TAVR with similar
symptoms noted at last Cardiology visit in ___. Given the
large differential, patient underwent a battery of tests. Her
PFTs showed mild to moderate obstructive pattern with normal
DLCO. Pulmonary was consulted and thought that her symptoms were
unlikely due to pHTN despite her prior TTE (___) showing
elevated pressures because it was thought these pressures were
reflective of her pre-TAVR stenotic valve. Unfortunately, her
body habitus precluded nuclear imaging and TTEs have suboptimal
quality which precluded dobutamine/pacemaker-mediated stress
testing. However she did have a CTA Coronary which showed a
total Ca score of 1476. Given the elevated calcium score her
atorvastatin was increased. After reviewing her cath from
___, it was thought her symptoms were unlikely cardiac. She
was treated for a COPD exacerbation for 5 days which improved
her dyspnea.
#Cellulitis of the L ankle
Patient noted to have significant erythema and warmth of the L
ankle on ___. Denies fevers or chills. Per patient, she has
frequent episodes of cellulitis. Significant pain of palpation
of the ankle. Xray showing concern for erosive changes and
unable to rule out osteomyelitis. MRI was ordered and showed no
evidence of osteomyelitis. ID was consulted and recommended
treating for cellulitis. Patient was discharged to complete a 10
day course of Keflex.
# Atypical angina:
Symptoms occurring at rest without correlation to activity.
Troponin negative x2, no ischemic EKG changes. Given duration of
symptoms, and relatively clear cath in ___, low suspicion for
active ACS. Patient was trialed on amlodipine 2.5mg for
antinginal effects without relief in symptoms so this was
discontinued.
#VZV
Patient evaluated by dermatology on ___ for new rash consistent
with shingles. Treated with Valcyclovir 1g TID x7 days (start
___, end ___.
# AS s/p TAVR
TTE from ___ showing peak gradient 14mmHg, mean gradient 7mmHg,
valve area 2.8cm, EKG without ischemic changes. TTE on ___
showed valve was well seated.
# Afib
# Coagulopathy
On warfarin as had TIA/amaurosis fugax while on xarelto INR
supratherapeutic on admission. Rate control with metop succinate
100mg daily.
# HFpEF (EF 60-65%)
No evidence of volume overload on exam. BNP low though ___ be
falsely low iso obesity. Continued ___,
atorvastatin, and increased lisinopril.
#Asymptomatic pyuria
No symptoms of UTI. UA with 10 epis and likely contamination. No
indication for treatment of asymptomatic UTI and as such will
not repeat UA.
# IDDM
- decreased home Insulin U-500 160mg qAM and 120mg qdinner while
in house given change in eating habits while inpatient (carb
consistent, low fat diet).
#Coping
Patient taking care of two sons at home as well as herself.
Recently lost husband ___ years ago). SW consulted for coping.
================
CHRONIC ISSUES:
================
#Back/knee pain
Significant back and knee pain with activity and only on Tylenol
at home
- Tylenol PRN
# CAD
- Continued ___ 81mg
- Continued Atorvastatin 80mg
- Continued metoprolol XL 50mg daily
# HTN
- Continued lisinopril 10mg daily and metoprolol as above
# Depression
- Continued home Venlafaxine XR 225mg DAILY
- Continued home ClonazePAM 2mg QHS:PRN sleep
# OSA
- Continued CPAP
# Vitamin D deficiency
- Continued home vitamin D
=====================================
# CODE STATUS: Full confirmed
# CONTACT: ___ ___
Greater than 30 minutes spent on discharge planning.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old man with stage IIB Hodgkin lymphoma s/p 2 cycles of
ABVD c/b pneumonitis with subsequent PET-CT ___ showing
progression of disease who is now C3D6 ICE chemotherapy and
recently D/C on ___ (stayed for 3 days) who developed fever to
102.2 at home, with fatigue and new cough. Pt received his first
dose of neuopogen ___ morning prior to presentation to ED
but pt denies previous febrile reaction. Pt states that he
usually feels the peak effects of ICE chemo on day 5. He has
been laying in bed since his discharge, recovering from the
chemo. He states that on ___ ___, he began to experience
fevers/chills (denies rigors) and his T was checked which was
102.2. He states that he has developed a mild cough, productive
but unable to describe color, that started that day as well. No
SOB, CP, palpitations. He denies other infectious ROS including
HA, neck pain, nasal congestion, sore throat, odynophagia, ear
pain, n/v, abd pain, d/c, dysuria, rashes, or any other pains.
.
In the ED, initial VS were 98.2 104 107/65 16 99%. Labs notable
for WBC of 33 (up from 8; neupogen x1). UA unrevealing. Lactate
1.7. CXR did not show PNA. No antibiotics given. At time of
transfer to the ___ floors, VS were 97.9 91 109/65 16 97%. No
fever while in the ED.
.
Review of Systems:
Per HPI Refractory Hodgkin's lymphoma and ongoing fever.
COMPARISON: ___.
Mediastinal bulky mass is unchanged, bilateral. Lungs are clear. There is no
pleural effusion or pneumothorax. The Port-A-Cath catheter tip terminates at
the level of low SVC. was done. The patient was diagnosed with FEVER, UNSPECIFIED, HODGKINS DIS NOS UNSPEC. At the time of discharge, the patient had Primary: Fever
Secondary: Hodgkin's Lymphoma. 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 stage IIB Hodgkin lymphoma s/p 2 cycles of
ABVD c/b pneumonitis with subsequent PET-CT ___ showing
progression of disease who is currently receiving ICE
chemotherapy, p/w fever. Likely non-infectious but continued on
flagyl/cipro at time of dc. Cultures pending at dc but ngtd.
# Fever: T 102 at home with main localizing sign being a mild
productive cough. CXR in the ED showed no evidence of an
infiltrate or PNA. No antibiotics were started in ED. Exam on
admission did not suggest PNA. As a result, fever was thought to
be 2/t Neupogen and/or recent chemo. Pt was monitored while on
the ___ floor while not on antibiotics and Tmax was 101 after
the first day of admission. Neupogen was held on admission and
given the following day, at a lower dose of 300mcg QD, after he
did not have evidence of a fever. Cultures showed no growth to
date at time of dc. Was low grade in ___ at time of dc so
cipro/flagyl was continued. patient had close followup with
outpatient hem onc attending.
# Stage IIB Hodgkins Lymphoma: S/p 3 cycles of ABVD c/b
decreased DLCO that resolved with prednisone. Currently on ICE
(ifosfamide, carboplatin, etoposide) salvage chemotherapy since
___ after PET scan on ___ showed disease progression.
Repeat PET-CT ___ after cycle 2 ICE showed decreased LN size
and decreased FDG avidity. Recieved cycle 3 without incident
(c3d1 ___. Continued ppx with Acyclovir/Bactrim.
Transfusion scales in place for hct <21, plts <10.
# Depression/Anxiety: Continued Citaloparm, Zolpidem.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH of systolic CHF, etoh abuse, b/l ___ edema,
personality disorder, HL, and history of TBI who presents with
shortness of breath and lower extremity pain and swelling. Says
that he has been at rehab for the past four weeks and that he's
being "neglected and abused" by staff. He has multiple rambling
complaints and is at times difficult to redirect. His biggest
complaint is his leg, his right leg has a new ulcer and he
believes the legs are not being dressed properly. His shortness
of breath feels worse. He refused in the ED to take Lasix, and
also refuses on the floor. He states that Lasix cause his body
to shut down. On previous admissions he has been found cutting
the IV on a Lasix drip. He has vague complaints of chest pain,
and is unable, or unwilling, to describe his symptoms, but does
not have chest pain currently. Of note he is poorly compliant
with diuretics and diet.
In the ED initial vitals were: 98.1 ___ 18 96% RA
EKG: sinus rate of 98, prolonged QTC, otherwise normal
intervals, poor R wave progression with q-waves in V1-V3,
diffuse ST flattening
Labs/studies notable for: WBC 8.1 with 79% PMNs, H/H 9.8/32.2,
normal Chem7, BNP 2796, troponin < 0.01. UA with large leuks,
many WBCs, moderate bacteria, 19 RBCs. Chest xray showed stable
cardiomegaly and mild hilar congestion.
Patient was given: PO cipro
Vitals on transfer: 98.1 95 104/60 18 99% RA
On the floor, patient refused Lasix, he states he will improve
his volume overload by taking "his own nutrients". He was
screaming at staff. He was demanding pain medications.
ROS: On review of systems, denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies recent fevers, chills or rigors.
Denies exertional buttock or calf pain. All of the other review
of systems were negative. Cardiac review of systems is notable
for absence of chest pain, dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope. CHEST (AP AND LAT) showed Stable mild cardiomegaly with mild hilar congestion. CT HEAD W/O CONTRAST showed Chronic findings as discussed above. No evidence of fracture, hemorrhage or
infarction. CT C-SPINE W/O CONTRAST showed No evidence of fracture. Minimal anterior subluxation of C7 on T1 due to
degenerative disease.
Anterior fusion of C3 through C7 appears intact with no evidence of hardware
failure.
Degenerative disc disease with canal and foraminal narrowing at multiple
levels. The patient was diagnosed with Heart failure, unspecified. At the time of discharge, the patient had Primary diagnosis:
acute on chronic systolic heart failure
Urinary tract infection
Secondary diagnoses:
Leg ulcers
Mood disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>****LEFT AMA******
Mr. ___ was admitted ___ with acute systolic heart failure
exacerbation in setting of refusing diuresis at rehab. He was
treated with Lasix gtt at 20/hr with intermittent boluses of
80mg IV. He diuresed well but was refusing dietary restrictions.
He was maintained on a regular diet but was successfully losing
___ kgs per day. On the morning of ___, he became upset with
the ongoing diuresis and leg wounds in the middle of the night
and he left AMA. He was encouraged to stay but refused because
he didn't like the treatment which he felt was "experimental."
He understood the risks of leaving without adequate diuresis
including worsening heart failure and even sudden death. He
planned to seek care at a different hospital. He was also
treated for a UTI while admitted and finished his antibiotic
course while at ___.
#Acute on chronic systolic CHF exacerbation: EF 20% per ECHO
from ___. Patient presenting in setting of significant
systolic CHF but personality limits adherence to medications.
Currently refuses Lasix and torsemide as outpatient. Eventually
agreed to 60-80mg IV Lasix doses on condition of staying in the
hospital. Also continued on metoprolol. Did not obtain TTE as
exacerbation clearly related to non-compliance with medications.
He was attempted to be diuresed ultimately with a Lasix drip at
20mg/hr with some good effect (losing ___ per day) but this
was limited by his behavioral issues as mentioned above. He also
refused a fluid restriction.
#UTI: Found to have VRE UTI for which he was treated with
Fosfomycin.
#Leg ulcers: Do not look actively infected. Likely secondary to
venous stasis, seen by wound care and clean dressings were
maintained.
#Personality or mood disorder: very combative at baseline. On
Seroquel 50qAM and 100qPM Psychiatry consulted and recommended
behavioral interventions consistent with a prior social work
note. See recommendations:
For staff
Behavioral plan for ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx cirrhosis (NASH + ETOH), IDDM, COPD, CVA (L
hemiplegia), and schizophrenia, now presenting with altered
mental status.
He was noted by ___ to have confusion and disorientation, which
appeared to be new as of ___. He was unable to provide further
history given altered mental status. Per outpatient notes, he
has been gaining weight due to dietary indiscretion.
In the ED, initial VS notable for
97.8 88 136/51 18 100% RA
Exam was notable for soft abdomen, 2+ bilateral pitting edema,
guaiac positive stool, mild asterixis, no accessible ascites
seen on ultrasound.
He was given:
___ 18:44 IV Dextrose 50% 12.5 gm
___ 19:01 IVF 1000 mL NS 1000 mL
___ 21:55 PO/NG Lactulose 30 mL
___ 00:09 PO/NG Lactulose 30 mL
He was admitted to medicine for further management.
On arrival he had large bowel movement. Denies pain or
discomfort. CHEST (AP AND LAT) showed Mild pulmonary vascular congestion. No focal consolidation to suggest
pneumonia. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic liver with no focal hepatic lesions identified in this limited
examination.
2. Patent main portal vein.
3. Splenomegaly. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial process CT C-SPINE W/O CONTRAST Q311 CT SPINE showed No evidence of fracture or traumatic malalignment. The patient was diagnosed with Altered mental status, 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>___ with hx cirrhosis (NASH + ETOH), IDDM, COPD, CVA (L
hemiplegia), and schizophrenia, now presenting with altered
mental status.
# HEPATIC ENCEPHALOPATHY:
History of encephalopathy on lactulose maintenance, now with
acute encephalopathy and asterixis. Infectious workup negative
including bland UA, urine culture NGTD, blood culture NGTD,
negative CXR. No ascites. No portal vein thrombosis on RUQUS.
Patients home lactulose increased to 30mL po/pr q2h until he
cleared, then discharged on 30mL four times daily. Please
titrate to 3BM-5BM daily. Rifaximin 550 BID was started given
decompensated encephalopathy. Lactulose also written PRN for
additional orders if he becomes encephalopathic. If this is used
as a PRN order, please notify the staff MD.
# NASH / ETOH Cirrhosis: MELD 11 on admission, stable from
prior. Decompensated by encephalopathy as above. Last EGD in
___. History of variceal banding, but did not tolerate beta
blockers. No ascites currently. He was continued on his home
medications: pantoprazole, spironolactone, and furosemide.
# COAGULOPATHY: No evidence of active bleeding
CHRONIC ISSUES:
# Type 2 Diabetes: Continued insulin.
# Hypertension: Continued Lisinopril 10 mg daily.
# Schizophrenia: Continued Topiramate 100 mg PO BID, risperidone
briefly held but then restarted.
# COPD: Continued Fluticasone-Salmeterol Diskus (250/50) BID.
# Chronic pain: Held HYDROcodone-Acetaminophen while acutely
encephalopathic.
# Eye drops: Continued Latanoprost 0.005% Ophth. Soln. QHS.
# Hypothyroidism: Continued Levothyroxine Sodium 200 mcg daily. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ y.o. female known to service with chronic R SDH
after a syncopal fall. She was followed by Dr. ___ in the
___ clinic. She reports that for the past ___ days she
has had increasing headaches and gait instability. She has
tried OTC without much relief. She went to the ED and after
evaluation surgical planning was initiated. Radiology showed 1. Interval increase in size of right hemispheric convexity subdural hematoma
with associated increase in leftward shift of the normally midline structures.
2. No acute large vascular territorial infarction. Radiology showed No acute cardiopulmonary process. Radiology showed Interval right craniotomy and placement of a right subdural drain
with decrease in size of the right subdural fluid collection, which now
measures 14-mm, but persistent right sulcal and lateral ventricle effacement
and 8 mm leftward shift of normally midline structures. Large right subdural
air, likely post-procedural. Radiology showed Expected post-surgical changes in right subdural hematoma drain
with decrease in pneumocephalus. Stable 8 mm leftward shift of midline
structures. Radiology showed Since the previous CT examination, the subdural drain has been
removed. The size of the residual subdural has not significantly changed. No
definite new hemorrhage seen. Radiology showed No evidence of deep vein thrombosis in either leg. The patient was diagnosed with INTRACEREBRAL HEMORRHAGE. The patient was treated with ___: Right craniotomy and evacuation of subdural hematoma. At the time of discharge, the patient had Right 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>Ms. ___ was admitted to the Neurosurgery service. Pre-op
work up was initiated for plans for surgery on ___. Aspirin was
held and platelets were ordered on call to the OR. SBP was
controlled for a goal of less than 140. Consent was obtained for
the OR.
On ___ she was neurologically unchanged, (left drift, and LLE
weakness). She was taken to the OR in the afternoon, she
underwent a right frontal temporal craniotomy for ___
evacuation. A subdural drain was left in. She was extubated and
transferred to the ICU where she stayed over night.
On ___, the patients subdural drain was electively discontinued
and the insertion site was closed with staples. A physical
therapy consult was placed and the patient was mobilized out of
bed to the chair with assistance. The patient tolerated a
regular diet well. In the morning the patient went into atrial
fibrillation and had low urine output. The patient was given a
250cc bolus and the patient converted back into normal sinus
rhythm spontaneously. The urine output increased to over 30 cc
an hour. Given the patient low urine output and atrial
fibrillation the patient was kept in the intensive care unit for
one more day. In the evening the Foley catheter was
discontinued. On exam, the patient was alert and oriented to
person, place and time. Strength was full. There was no
pronator drift. The patient's incision was well approximated
and clean without drainage.
On ___ she was seen and evaluated and felt to be appropriate
for transfer to the floor with telemetry. She awaited a floor
bed, however none became available. On ___ she was stable and
underwent a head CT prior to discharge. There was no increase in
hemorrhage. She was on the floor on ___ and was stable. ___ was
following. Screening LENS were ordered and there was no blood
clot in either leg. She was transferred to rehab on ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo. w/history of severe migraines, now here with 2 weeks
of headache and 1 week of low back pain. First symptom was
headache similar to previous migraines but unrelenting for the
last couple of weeks, which she has not had since high school.
It
is left-sided, frontal, throbbing, associated with phonophobia,
nausea, and extreme light sensitivity: she wears her sunglasses
at night.
Also has sensation of floaters or tracers in eyes, and pain on
eye movements when looking to the side of the headache. She
thinks these visual symptoms may be related to her extreme
photophobia as they are improved with the sunglasses.
She has been taking ibuprofen 600 ___ x daily as well as
Fioricet, without relief, and just got prescriptions for
tramadol
and sumatriptan as well but was unable to tolerate these as they
made her feel trippy and woozy.
Over the last week, she also developed low back pain that
radiates down her entire right leg. The last couple of days has
had neck stiffness on the left side. No history of neck trauma
At the time of evaluation, pt had received morphine 5 mg IV
twice
and ondansetron, without relief. Radiology showed No evidence of an acute intracranial process. The patient was diagnosed with HEADACHE, LUMBAGO. The patient was treated with Lumbar Puncture ___. At the time of discharge, the patient had Migraine Headaches. 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: ___ h/o migraines p/w severe headache with bland LP and
unremarkable NCHCT. Her headaches improved with toradol and
sleep and were ascribed to migraine.
.
ACTIVE ISSUES
# Headache: The patient had a normal non-contrast head CT and
lumbar puncture. Her symptoms were likely migraine- related. She
responded well to Zofran and Toradol; she was discharged the day
after admission with unchanged exam.
.
INACTIVE ISSUES
# ruptured ovarian cyst
# lactose intolerance
.
TRANSITIONAL ISSUES
# MIGRAINE: Follow for prophylaxis needs</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: History is somewhat hampered by the patient's inability to
relate a coherent history. CT CHEST W/CONTRAST showed New 2.5 cm paramediastinal mass, adjacent to the aortic arch. Recurrence of
disease is likely. Severe pulmonary emphysema with multiple small areas of
nodularity and scarring, with a morphology unlikely to reflect metastatic
disease. Ultrasound sniff test showed No paradoxical diaphragmatic motion with rapid nasal inspiration. The patient was diagnosed with Adult failure to thrive, Weakness. At the time of discharge, the patient had Arthritis pain
Likely recurrence of Thymic cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ with Hodgkin lymphoma s/p chemo and mantle-XRT
___, thymic carcinoma s/p resection ___ with recurrence ___,
stable until ___ when lost to followup in our center, CAD s/p
IPMI and PCI with "3 stents", HTN, HL, COPD, active smoking,
BPH, GERD, depression/anxiety, chronic left shoulder pain, who
presents with fairly nebulous complaints.
# Multiple longstanding complaints in setting of known diagnosis
of recurrent thymic carcinoma: He has multiple complaints that
sound very chronic in nature. It is not entirely clear the
extent of his workup, also not unclear how closely he has been
followed for his thymic carcinoma. He has not been seen since
___ when the plan was for yearly CT scan and follow up with
Thoracic Surgery and Oncology. At the time he was lost to f/u
here he had fairly stable imaging. It is not clear if he has had
imaging in the last ___ years. CT imaging done at ___ here shows
a new 2-3cm lesion in the anterior medistiumum that is
concerning for recurrence. The case was discussed with thoracic
surgery who recommended ___ guided biopsy (if possible). The
patient declined this biopsy and requested outpatient evaluation
including a PET CT prior to discussion with Dr. ___. He
declined the inpatient ___ guided biopsy. He will have na
outpatient PET-CT and PFTs prior to his appointment with Dr.
___. Onc follow up as an outpatient. PCP has ___ to
Dr ___ (___)
# Acute on chronic pain,
# Shoulder and arm pain: Given longstanding history, report of
MRI shoulder, this sounds most likely due to
arthritis/capsulitis/tendinitis. Could have neuropathic/cervical
radiculopathy component (cervical arthritis, less likely
metastatic disease). Brachial plexopathy in context of expanding
intrathoracic mass is possible but not seen on imaging. Pain
better controlled in the hospital. Discussed with Patient and
family that will need long term follow up as appears arthritis
and that narcotics have no role in long term therapy for
arthritis pain. He will follow up with his PCP.
# HTN: Report of labile and elevated BPs PTA, but currently BPs
are reasonable here in spite of pain SBP 100-130 on home
medication while pain was well controlled. Continued home
regimen with pain control.
# HL
# CAD s/p MI
# Chest "clicking": Unlikely to be cardiac/ischemic etiology of
his symptoms given his ability to walk on level ground upwards
of ___ mile and his report of stable dyspnea when taking stairs.
Chest clicking is not an anginal type of pain. He is clear that
he does not have any chest pain. Troponin x1 here on admission,
many many hours (days per patient) out from onset of his
arm/shoulder pain. BNP negative. Pain improved with therapy for
MSK pain. Follow up with PCP as an outpatient.
# COPD: Stable. He says he takes Advair, Spiriva, and albuterol
- Continued inhalers
# GERD: Stable
- Continued omeprazole
# Depression/anxiety: Stable
- Continued citalopram
# BPH: Stable
- Continued Flomax </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ year old male patient with uncontrolled DM
type 2 who is status post right below knee amputation with c/b
surgical site infection and bone cyst, who presets to the ED
after having discharge from surgical site associated with
subjective fever and chills. condition started approximately
last
___ after visiting Dr. ___ in the clinic and sutures
were removed at that time. over the week, he experienced mild
shooting pain that comes and goes associated with some
malodorous
discharge. He states that these are similar symptoms as when he
had wound infection. He endorsed chills and subjective fever,
but
no anorexia, nausea/vomiting, chest pain, shortness of breath or
any other complaints. KNEE (AP, LAT AND OBLIQUE) RIGHT showed 1. Status post below right knee amputation. Of note distal most aspect of
tibia and fibula WAS EVALUATED ON A SUBSEQUENT STUDY.
2. Subtle rounded lucency along the distal tibia may represent a locule of
gas projecting over the mid tibia/ fibula, suspicious for infectious
subcutaneous emphysema.
RECOMMENDATION(S): Clinical correlation recommended to assess for infection
and necrotizing fasciitis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 1:32 AM, 5 minutes after discovery of
the findings. Chest radiograph. showed No acute cardiopulmonary process. Specifically, no pneumonia. TIB/FIB (AP AND LAT) RIGHT showed 1. Subtle rounded radiolucencies along distal lateral posterior stump may be
subcutaneous emphysema.
2. No radiographic evidence of osteomyelitis.
3. Status post right below-knee amputation with associated postsurgical
changes.
RECOMMENDATION(S): If persistent concern for osteomyelitis consider MR for
further evaluation. CHEST (PORTABLE AP) showed COMPARED TO CHEST RADIOGRAPHS SINCE ___, MOST RECENTLY ___ AND
___ AT 00:44.
LUNGS CLEAR. HEART SIZE NORMAL. NO PLEURAL ABNORMALITY. CONFIGURATION TO
THE UPPER MEDIASTINUM, WIDENED TO THE LEFT, COULD BE DUE TO FAT DEPOSITION OR
THE CONGENITAL ANATOMIC ANOMALY, PERSISTENT LEFT SUPERIOR VENA CAVA. Radiology showed No evidence of bowel obstruction. CT LOWER EXT W/C RIGHT showed 1. Soft tissue swelling and edema involving the right below-the-knee
amputation distal tissues, extending up to the level of the tibial tuberosity.
Multiple enlarged, reactive right inguinal lymph nodes.
2. There is a 2.7 x 1.6 x 0.9 cm peripherally enhancing fluid collection in
the soft tissues at the stump, concerning for a small abscess.
3. No evidence of underlying tibial or fibular cortical irregularity or
periosteal reaction. However, as noted on the prior radiograph, MRI is more
sensitive for evaluation of osteomyelitis.
4. There is no subcutaneous emphysema.
This preliminary report was reviewed with Dr. ___
radiologist.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 17:15 on ___, 5 min after discovery. The patient was diagnosed with Infection of amputation stump, right lower extremity, Amputation of limb(s) cause abn react/compl, w/o misadvnt. At the time of discharge, the patient had Rt Bellow Knee stump 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>Mr ___ is a ___ year old male with poorly controlled DM2,
who had BKA c/b surgical site infection who necessitated
revision and cyst excision one month prior to his current
admission, . The patient presented with wound discharge and
chills concerning for another episodes of right stump infection.
The patient presented with fever to 102.3 shacking chills with
no apparent source of infection other the Hx of mild discharge
from a tiny wound in the stump which on physical examination was
not apparent. Blood and urine culture were taken and the
patient was put on vanco cypro flagyl IV. He underwent CT of his
lower extremities which revealed a small fluid collection at the
tip of the stump ant. and distal to the tibia. a conservative
treatment was decided upon.
The patient presented with high levels of blood glucose that
were first hard to manage but as his infection was controlled so
as his glucose levels.
3 days before discharge the tiny crack in the stump was open and
an offensive smell purulent material was discharged with an
immediate relief. The fever did nor reoccurred. He was put back
on his home meds and tolerated diet well. Of note that the
patient suffers from CRF with Cr in the range of 1.7-3.3. His Cr
level during admission was 1.9 which went up as high as 2.8 and
now trending down to 2.3 on the day of his discharge. He has an
appointment with his nephrologist on the ___ and will be
trend his Cr level for this encounter on the beginning of the
week.
Mr ___ wound culture grew mixed bacteria, blood culture
had no growth. He was switched to Bactrim and was discharged
home with dry dressing and Po Abx. He was instructed not to wear
his prosthesis until he will be followed by Dr ___ in his
office within 10 days.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with PMHx significant for CMT, COPD, HTN. He
underwent a reconstruction of the R foot ___. He has
had a lateral foot ulcer on the right foot since surgery. The
size of the ulcer improved after the surgery. He also has a L
___ toe amputation at ___ last month and is
still healing from that. He reports over the last 5 days he was
having fevers / chills and also decreased appetite. He then
noticed increased redness and swelling to the Right Foot with
increased bloody and clear drainage from the lateral foot ulcer.
He has been doing daily dressing changes. Per the patient Dr.
___ has been treating him, mentioned that he might need
to go back to the OR to take some bone out around the ulcer
which could be causing the wound to remain open. He then decided
to present to the ED for further evaluation. He denies any
recent chest pain, shortness of breath, nausea, diarrhea,
constipation. He has not noticed any purulent drainage coming
from the R foot wound. He does not have sensation to the ___ and
does not report any pain ___ either foot. FOOT AP,LAT AND OBL RIGHT showed 1. Foci of subcutaneous emphysema along the lateral soft tissues adjacent to
the fifth metatarsal base which are concerning for infection and/or
ulceration. No definite underlying osteolysis to suggest acute osteomyelitis
radiographically.
2. Stable post operative changes.
3. Possible plantar foreign body. FOOT AP,LAT AND OBL RIGHT showed Interval postoperative changes, more prominent plantar surface soft tissue
swelling. Residual soft tissue air the surgical bed, may be postoperative or
from infection.. Otherwise as above DX CHEST PORTABLE PICC LINE PLACEMENT showed Right PICC line The patient was diagnosed with Cellulitis of left lower limb. The patient was treated with 1. Excisional debridement of bone, ___ metatarsal, right
foot.
2. Ulcer excision with primary closure, right foot.. At the time of discharge, the patient had Right Foot Infection with 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>The patient was admitted to the podiatric surgery service from
the emergency room on ___ for a R foot infection. On
admission, he was
started on broad spectrum antibiotics. He was taking to the OR
for Right foot debridement. Pt was evaluated by anesthesia and
taken
to the operating room on ___ for bone debridement and
primary closure. There were no adverse events ___ the operating
room; specimens were sent for micro and patholgy. please see the
operative note for details. Afterwards, pt was taken to the PACU
___ stable condition, then transferred to the ward for
observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on
vancomycin, ciprofloxacin, and flagyl while hospitalized. The
infectious disease team consulted post operatively for
antibiotic recommendation for possible osteomyelitis. Per ___
Infectious Disease, Patient was discharged with IV cefazolin, PO
flagyl and PO Cipro based on sensitivities for 6 weeks. His
intake and output were closely monitored and noted to be
adequtae. The patient received subcutaneous heparin throughout
admission; early and frequent ambulation were strongly
encouraged.
The patient was subsequently discharged to home on ___ with
antibiotics x 6 weeks and follow up with OSH infectious disease
___ ___. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with
the discharge plan. Patient is to be NON-WEIGHTBEARING to R
foot.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o demented F presenting from nursing home where she had is
thought to have had a mechanical fall. Fall was unwitnessed, was
found down in bathroom. Sent to ___ for
initial evaluation with subsequent transfer to ___. Head CT
and CT cervical spine at ___ negative. No PNA was seen there.
although rib fracture noted. ___.
.
In the ED, initial VS: Tc: 98.2 HR: 106 BP: 122/80 02 sat 99%
RA. In the ED she became hypotensive to 74/50 with altered
mental status, had elevated white count, thus she received
empiric antibiotic coverage with IV ceftriaxone and vancomycin.
No clear source was noted. An XR and CT showed fracture right
femur. She was found to be hypokalemic.
.
She received morphine 4mg IV, zofran 2mg, ceftriaxone 1g,
vancomycin 1g, potassium IV.
.
REVIEW OF SYSTEMS:
Denies fever, 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 Very limited study due to patient rotation without evidence for
large pneumothorax. Open reduction and internal fixation of the femur.
Note is made that the radiologist was not attending the procedure.
Total fluoroscopy time of 169.4 seconds was documented. The eleven
fluoroscopic spot images were brought to our review and demonstrate the
process of open reduction and internal fixation.
For precise details, please review procedure report. was done. Evaluation of the patient after femur fracture, with
pulmonary edema.
AP radiograph of the chest was compared to ___.
Bilateral consolidations appear to be increased as well as there is increase
in bilateral pleural effusion. On the other hand, there is no evidence of
pulmonary edema on the current examination. Enlarged aorta is consistent with
thoracic ascending aortic aneurysm, better appreciated on the CT chest from
___. No pneumothorax is seen. The right upper lobe nodule is
better appreciated on the CT torso not well seen on the chest radiograph. was done. Radiology showed 1. Unchanged appearance of the mediastinum.
2. Bilateral moderate pleural effusions.
3. Bibasilar atelectasis. The patient was diagnosed with FX FEMUR SHAFT-CLOSED, UNSPECIFIED FALL, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE. The patient was treated with - Orthopedic surgery to repair R femur fracture on ___. At the time of discharge, the patient had PRIMARY DIAGNOSES:
- R Distal Femur fracture s/p fall
- Delirium
SECONDARY DIAGNOSES:
- Dementia. 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:
___ F w dementia presents s/p fall presumed to be mechanical,
found to have R femur fracture. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old year old male with no significant PMHx, p/w RLQ pain
starting ___ after lunch, associated w/ mild nausea, no
emesis. Patient reports anorexia but otherwise denies
fevers/chills. Patient denies migration or radiation of pain
anywhere. Upon evaluation in ED, patient appeared comfortable.
Abdomen significant for focal RLQ TTP, no rebound/guarding. CT ABD AND PELVIS WITH CONTRAST showed Early aacute uncomplicated appendicitis. The patient was diagnosed with Unspecified acute appendicitis. The patient was treated with Laparoscopic appendectomy. At the time of discharge, the patient had Acute appendicitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male, admitted for RLQ abdominal pain,
abdomen/pelvis CT showed acute uncomplicated appendicitis. The
patient was made NPO and given intravenous fluids. Subsequently
went to the OR on ___ for a laparoscopic appendectomy. No
complications. He has been tolerating a regular diet and has no
issues voiding. His pain has been well controlled on
analgesics. He has been ambulatory. Follow up appointment was
made with Dr. ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman with a history of HTN who presented to the ED with
LLE swelling and pain for a few weeks. She reports that about 3
weeks prior to admission she was at her daughter's house when
she tripped over the threshold entering her house and she fell
to the ground landing on both her knees. She developed a
laceration and presented to ___ for evaluation. Per ___ records
x-rays were negative and no evidence of infection so she was
discharged home. Approximately one week prior to admit, two
weeks after initial fall, she was walking off the T in the ___
station when her foot caught a "spike" sticking up out of the
bricks, she tripped and landed on her left knee. The wound
reopened and it started bleeding a lot. She again presented to
___ where x-rays were negative and she was discharged without
antibiotics given no concern for infection. Over the next week,
several days prior to presentation to the ED she reports
increased redness, swelling and pain of LLE. She reports ongoing
bleeding from wound with severe pain, she has been applying
bacitracin to the wound and she has not seen any purulence or
other drainage from the wound. More recently she developed
tingling sensation in 3 of her toes. She saw her PCP for
evaluation this morning who referred her to the ED for work up.
In the ED, initial vitals were: ___ pain 97.8 87 136/88 18 100%
RA. Labs were notable for leukocytosis. Because extent of
swelling, pain and new paresthesias ortho was consulted for
potential compartment syndrome. Ortho was less concerned for
compartment syndrome or necrotizing fasciitis after evaluation,
they recommend plain films and ultrasound. ___ was negative for
DVT, x-ray negative for fracture and soft tissue US showing
edema consistent with cellulitis without abscess. Ortho final
evaluation was consistent with severe cellulitis and recommended
conservative therapy and strict LLE elevation at all times. She
was started on IV Vancomycin and admitted to medicine.
On the floor, she appears well and is in no acute distress. Her
pain is well controlled, currently ___ in severity and she
denies fevers. She reports subjective chills but otherwise feels
well.
Incidentally, her daughter presented to ___ ED at the same time
as her index ED visit and remains hospitalized for "kidney
problems"
Review of systems:
(+) Per HPI
(-) Denies fever, 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. Otherwise ROS is negative.
I reviewed records from ___ which arrived with the patient UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. US LOWER EXTREMITY, SOFT TISSUE LEFT showed Edema and complex fluid collection fluid is seen in the subcutaneous tissues
of the left shin, with some extension into the adjacent musculature.
Infection could certainly be possible in the proper clinical setting.
NOTIFICATION: Updated wording of wet read was discussed by ___ with Dr.
___. MRI of the left calf. showed 8.5 x 1.8 x 7 collection within the subcutaneous tissue of the anterior aspect
of the left leg could represent an organized hematoma, however superimposed
infection cannot be excluded. No evidence of muscle or bony involvement. Radiology showed No fracture. No focal erosion. The patient was diagnosed with Cellulitis of left lower limb. At the time of discharge, the patient had Hematoma with concern for infection
Cellulitis. 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 history of hypertension who presented to
the ED with left leg pain, swelling and redness for the past 3
weeks since two falls with an open pretibial wound.
# Cellulitis
# Left Leg hematoma
The patient presented with extensive edema of LLE with open
pre-tibial wound. She was seen by orthopedics given concern for
compartment syndrome which was felt to be unlikely. She had a
___ which ruled out DVT and an ultrasound which showed a fluid
collection. She was started on IV vancomycin and subsequently
underwent an MRI of her calf which confirmed a hematoma,
infection can not be ruled out. She was seen by plastic surgery
who performed a bedside I and D and hematoma evacuation. They
also made a second incision to drain the hematoma. The patient
remained afebrile without systemic signs of infection. She was
transitioned to oral Bactrim/Keflex to complete a 7 day course.
She will continue daily dressing changes with packing and kerlix
and follow up with plastic surgery next week. She was advised
to keep her leg elevated and to discuss returning to work at her
PCP follow up.
# Hypertension
Chronic, stable continued home medications: Lisinopril, HCTZ,
ASA
# HLD
- Continued statin
# Gout
Chronic, stable, no flares for "years" per patient
- Continued Allopurinol
# Glaucoma
Chronic, stable
- Continued Latanoprost eye drops</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y.o. M with myotonic dystrophy and mild mental ___
transferred from ___ s/p fall presents
with L lower extremity fracture. Radiology showed No acute intracranial process. Radiology showed No evidence of fracture or subluxation. The patient was diagnosed with FX ANKLE NOS-OPEN, UNSPECIFIED FALL, MYOTONIC MUSCULAR DYSTROPHY. The patient was treated with Left lower leg ORIF. At the time of discharge, the patient had L Comminuted Tib-Fib Fracture
Hypernatremia. 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 left open distal tibial shaft fracture and
hyponatremia and was initially admitted to the medicine service.
He was found to have hypovolemic hyponatremia, and when this was
corrected by oral intake, the patient was transferred to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left distal tibia I&D 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. 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 either 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 nonweightbearing in the left lower
extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ yo woman with history of metastatic bladder
cancer with no evidence of disease after 9 cycles of
pembrolizumab, pembro-induced COOP and atrial thrombus on
apixaban, who presents with increased fatigue and new PE +
port-associated right atrial clot noted on CT Torso. UNILAT UP EXT VEINS US RIGHT showed No evidence of deep vein thrombosis in the right upper extremity. The patient was diagnosed with Other pulmonary embolism without acute cor pulmonale, Intracardiac thrombosis, not elsewhere classified, Dyspnea, unspecified. At the time of discharge, the patient had Pulmonary embolism and port-associated RA thrombus
Constipation
Metastatic bladder cancer
Pembrolizumab associated COOP
Fatigue
Hypothyroidism
Normocytic anemia
L3 compression 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>___ with history of metastatic bladder cancer with no evidence
of disease after 9 cycles of pembrolizumab, pembro-induced COOP
and atrial thrombus on apixaban, who presents with increased
fatigue and new pulmonary embolism and port-associated right
atrial clot on CT Torso.
# Pulmonary embolism and port-associated RA thrombus. This may
be explained by apixaban failure as clot seemed to decrease
previously on enoxaparin. Workup included Trop/EKG/BNP that is
reassuring against heart strain. TTE suggests new atrial lead
thrombus, but poor quality. TEE was recommended for further
characterization, but this would not change management and was
not pursued as discussed with outpatient hematologist. Pacer
remains functional and treatment would be anticoagulation. Close
cardiology follow up would be valuable to monitor pacer
function. Interventional radiology was consulted for
consideration of port removal. Per ___, the removal of port would
only be performed after a minimum of ___ days of effective
anticoagulation with lovenox or coumadin (per protocol). Per ___,
the port only needs to be removed if malfunctioning. No need to
access port at this time. Patient was treated with heparin
infusion and transitioned to 1 mg/kg enoxaparin without
incident. RUE Doppler did not reveal RUE DVT.
# Fatigue. Hypothyroidism.
Fatigue is likely caused by hypothryroidism (related to steroid
use versus late pembrolizumab effects). Less likely due to clot
burden and inflammatory state.
Fatigue may also be due to steroid taper. TSH elevated and FT4
low. Initiating levothyroxine therapy as discussed with
outpatient provider who will monitor response.
# Constipation: Treated with bowel regimen.
# Metastatic bladder cancer, in remission. s/p radical
cystectomy and ileal conduit, ___. Solitary L parietal lobe
metastasis s/p resection ___ followed by CK to surgical bed
___. Received 9 cycles of Pembrolizumab (last ___ and
developed
COOP 6 months off pembrolizumab. Will update primary oncologist.
# Pembrolizumab associated COOP
Developed COOP 6 months off pembro. Treated with steroids; most
recently restarted on tmt dose steroid ___ for worsening
pneumonitis, but now tapered down to 5 mg daily. CT yesterday w/
stable 2mm nodules, no evidence of worsening pneumonitis.
Patient is continued on prednisone 5 mg daily.
# Normocytic anemia, stable. This is a combination of ACD and
iron deficiency. Continued on iron supplement.
#L3 Compression fracture: likely in setting of underlying
osteoporosis and prolonged steroid use. s/p denosumab on ___.
- Cont home Ca/vit D
Hospital course, assessments, and discharge plans discussed with
patient and family who express understanding and agree with
discharge. The above was discussed with outpatient oncologist
who also agreed with plan. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: History of Present Illness: ___ is a ___ year-old
woman with recent history of copious diarrhea presented to OSH
with right sided numbness and paresthesia, and is transferred
after syncope, bradycardia, hypotension for further evaluation
Patient endorses chronic diarrhea since ___ (constant since
___, notable for watery diarrhea ___. Outpatient workup
in
___ negative C diff, and upcoming colonoscopy scheduled
___. CHEST (PA AND LAT) showed No evidence of acute cardiopulmonary process. The patient was diagnosed with Syncope and collapse. At the time of discharge, the patient had Primary diagnosis
-Vasovagal syncope
Secondary diagnosis
-Diarrhea, unexplained etiology
-Unspecified disturbances of skin sensation. 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 a month-long
history of copious diarrhea presenting to ___ with
right-sided numbness and paresthesia, and was transferred to
___ after an episode of syncope, bradycardia, and
hypotension for further evaluation. Notably, the patient
recently underwent extensive workup for possible stroke/TIA and
infectious causes of diarrhea at BID-P, with no etiology found.
At ___ the patient's ED course was notable for negative
tropsx2 and non-specific t-wave inversions on several EKGs (no
baseline comparison available), AM cortisol 10.4 (nl). She was
monitored on telemetry overnight with no arrhythmias identified,
and had no further parasthesias or syncopal episodes, though she
had one short episode of dizziness. Low concern for cardiac
etiology, presumed vasovagal exacerbated by stress of recent
diarrhea, patient discharged to follow up with planned
outpatient colonoscopy on ___ in ___.
ACTIVE PROBLEMS
===============
# Syncope: Syncope in the setting of bradycardia and
hypotension, EKG with T-wave inversions of varying depths.
Differential diagnosis initially bradyarrhythmia vs. vasovagal
vs. hypocortisolism as primary causes. Ischemia seemed unlikely
in setting of negative trops and minimal chest discomfort in a
woman with high exercise tolerance. Seemed very likely vasovagal
and less likely cardiac, AM cortisol within normal limits. Safe
for discharge with outpatient follow-up
# Chest heaviness: Patient with chest heaviness and dyspnea
after crossfit workout on ___, resolved with rest, though
patient had repeat, milder chest heaviness and slight dyspnea on
___ while walking. Patient also with T-wave changes, DDx
vasospasm vs. MSK vs. anxiety. Determined low risk and possible
___ anxiety in setting of diarrhea, can ___ with PCP outpatient
for cardiology referral if deemed necessary
# Diarrhea: Voluminous, loose, non-bloody diarrhea ___ times
daily since ___. DDx infectious vs. autoimmune vs. IBS. Has had
extensive infectious workup at BID-P, all negative. Patient w/
colonoscopy schedule ___, should complete for most diagnostic
utility.
# Transient weakness/numbness extremities: Patient with
extensive workup at BID-P, no cause seen for stroke/TIA (MRI,
CTA/MRA, TTE w/ bubble), also no sign of MS on MRI. PCP should
___ hypercoag labs and Lyme studies from BID-P.
CHRONIC PROBLEMS
================
# Borderline B12 deficiency: Continue B12 PO as outpatient.
TRANSITIONAL ISSUES
===================
Transitional issues
[] Follow up with Dr. ___, ___
[] Complete scheduled colonoscopy on ___ with prep the night
before
[] Talk to your PCP about their perspective on starting a statin
and on the need for further cardiac workup of the T-wave changes
on your EKGs</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ long hx of spinal fractures and pelvic
instability/dislocations, who now p/w lower back/R hip pain w/
sudden onset 2 days ago. Crossed legs while sitting, then pain
began when she tried to stand. Since then has been unable to put
pressure on R side, has vomited once ___ pain. Denies
numbness/weakness/paresthesias. Called orthopedist/PCP who told
her to come to ED for evaluation.
In the ED, imaging was obtained:
- Pelvic/R hip x-ray: Degenerative disease at the hips is mild.
No acute fracture or dislocation.
- LS spine x-ray: No fracture or malalignment
- CT pelvis: No acute fracture or dislocation
- CT L spine: No acute fracture or spinal subluxation Radiology showed Degenerative disease at the hips is mild. No acute fracture or dislocation. Radiology showed No fracture or malalignment in the lumbar spine. Radiology showed No acute fracture or malalignment in the lumbar spine. Radiology showed 1. No acute fracture or dislocation.
2. Mild degenerative disease at both hips.
3. Trace amount of simple pelvic free fluid. The patient was diagnosed with LUMBAGO, FEM GENITAL SYMPTOMS NOS. At the time of discharge, the patient had Primary:
Acute Low Back Pain
Secondary:
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>___ yo F with long history of pelvic joint disease who is
admitted for pain control.
#Acute Pain: Patient has a long history of pelvic joint disease.
CT scan of the pelvis and lumbar spine showed no acute changes
in the applicable joints. She was seen in the ED by her
orthopedist Dr. ___ recommended an sacro-illiac joint
injection as an outpatient the following day. Physical Therapy
also saw the patient in the ED and cleared her to go home with
outpatient pain control and her walker at home. However, given
her reported pain in the ED in the setting of multiple drug
allergies she was admitted for pain control. She was given 10mg
oxycodone, 5mg valium, and standing Tylenol for pain relief. She
was also given Zofran for her nausea. The following morning, she
stated that she was ready for discharge and that her pain was
controlled for the time being and that she was planning on
attending her outpatient appointment for injection of the SI
joint. On day of discharge, she was able to walk to the bathroom
without difficulty, sit up unassisted, and shower unassisted.
#History of anaphylaxis: Multiple allergies (including
oxycodone) listed after anaphylactic reaction post surgery 2
weeks ago. Causative agent was not found. Oxycodone given in ED
without issue. An epipen was ordered for immediate use if she
began to have symptoms of
#HTN: continued enalapril and HCTZ
#Postmenopausal: continued estradiol
#Important Hospital Events:
1. Upon admission to medical floor, patient refused to transfer
to the hospital bed because she needed a harder mattress such as
the one on the stretcher. Fortunately, a compromise was found to
place the stretcher mattress on the hospital bed.
2. Her husband was seen taking pictures of Emergency room staff
citing litigous purposes and security was called to warn him
that he would be escorted off the premises if did so again.
3. Patient complained of a migrain headache the morning of
discharge and before the physician could respond to the
complaint and prescribe medication, the husband was seen by
patient sitter to provide the patient with outside pills after
very clear instructions that this was against hospital policy.
He refused inspection of the bottle
4. The patient insisted on ambulance transfer out of hospital,
and refused to pay for it out of pocket when informed that she
did not meet criteria for insurance coverage.
#Transitional Issues:
-Pt provided a Rx for home ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ woman with a pmhx. significant for
metastatic RCC with mets to skull on pazopanib, HTN,
hyperlipidemia and depression, who is admitted from the ED with
change in mental status and ___ activity. Radiology showed No infarct or hemorrhage. No evidence of abnormal enhancement or masses
within the confines of the study. Radiology showed Interval development of a small extra-axial hemorrhage at the cranioplasty
site, without mass effect on the adjacent brain.
NOTIFICATION: Findings were discussed with Dr. ___ by Dr. ___ at 15:50
on ___ via telephone, 5 minutes following discovery. The patient was diagnosed with SEC MAL NEO BRAIN/SPINE. At the time of discharge, the patient had seizure w/ fall, small head bleed
metastatic renal cell carcinoma
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>Pt is a ___ y.o female with h.o metastatic RCC to the skull s/p
cyberknife on chemo, HTN, HL, s/p ostomy for incontinence,
depression, COPD who was admitted with suspicion of new seizure,
c/b possible encephalopathy.
.
#Seizure, convulsive: No clear suggestion of infection or
metabolic cause. Pt was on tramadol as an outpatient which can
decrease the seizure threshold. This was discontinued. Primary
concern remained for metastasis. OSH CT was without acute
findings. However, CT at ___ concern for small hemorrhage near
craniotomy site. Unclear if this could precipitate seizure. The
patient was loaded on keppra and started on this medication.
Given, no fever, leukocytosis, or signs of meningitis, there was
no current indication for LP. Given, pt's history of depression,
there was some consideration of changing keppra to an
alternative AED and it was decided on ___ to transition over to
depakote. Pt was given a final dose of keppra on ___ and a
depakote load of 1500mg. Depakote was started at 750mg BID on
___. Neurosurgical did not think there was anything to do
regarding the possible small intracranial hemorrhage. ___
recommended transitioning to depakote and checking a level on
___ AM, and the ___ will draw this and fax to Dr. ___
(___) and Dr. ___. She has follow up with oncology
at ___, ___ in 2 weeks. She is discharged home with a
walker.
.
#chronic headache/intracranial ___ has a h.o
headaches. She is s/p cyberknife therapy for frontal skull vs.
frontal lobe metastasis, details unclear. Headache and possible
small bleed were felt to be due to fall after seizure. As
above, initial OSH CT unrevealing for acute process. No fever or
leukocytosis or signs of meningitis. However, CT at ___
revealed small extraaxial hemorrhage which was very small and
possibly related to trauma from fall. The neurosurgical service
was consulted and did not have further recommendations. The
neurooncology service recommended transition to depakote for
seizure prophylaxis. Her tramadol was discontinued and she was
started on PO oxycodone and acetaminophen therapy.
-headache is semiacute, on chronic (was taking meds at home)
.
#Encephalopathy, NOS vs. mood ___ exhibited some frontal
disinhibition as well as mood lability during admission. Per her
home SW, and PCP she has exhibited lability in the past and has
had some cognitive impairments after her prior surgery. Seemed
as though disinhibition and emotional lability were increased
during this admission, though decreased prior to discharge. It
is theoretical that this could be atypical manifestation of
concussion, or from keppra (was discontinued), vs. acute
exacerbation of her depression/stress related to her current
medical and social condition (finances, divorce). Social work
was consulted as well as ___ and OT who recommended rehab, but
patient refused, so will go home with increased services. Pt was
given PO ativan with good effect. Pt has ___ TIWK, home health
aids who help her clean weekly and help with her finances, and
home Soc worker. She will get ___ services too.. She has a
friend who helps with her cat. Her husband according to SW,
appears agreeable by phone, but patient reports he's not that
helpful to the patient. Pt does have a therapist, but stated
that she has been unable to see her therapist due to financial
concerns (of note, it appears that her finances are helped by
social worker, but pt has some cognitive deficits and forgets
her PINs and then reports having difficulty with fiances. She
has insurance. She is discharged to home with increased
services and will follow up with neurooncology ___.
.
#metastatic ___ on pazopanib as outpt, held during admission.
OK to restart upon discharge. follow up with oncologist ___
.
#adrenal ___ hydrocortisone and
fludricortisone at home doses.
.
#HTN, ___ home meds
.
#depression- Continued outpt sertraline and remeron. Social work
was consulted. Pt expressed that she has a therapist in the
outpatient setting and that financial concerns have been a
barrier in the outpatient setting. She will benefit from
continued support by social work and therapist.
.
DVT PPx:hep SC TID
.
CODE: DNR/DNI
.
Transitional (external):
-continued SW and therapist support for ongoing depression and
social situation</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with extensive PMH, hospitalized ___ for sepsis and
RP hematoma after a fall, course complicated by acute
cholecystitis managed with percutaneous cholecystostomy, also
c/b acute-on-chronic renal failure and acute-on-chronic CHF. He
was discharged to an extended care facility, and was again
hospitalized ___ due to concern for stroke. He has been
recovering well at rehab, though his cholecystostomy tube did
fall out on ___, without recurrence of his RUQ pain. He
presented to the ED tonight after noticing foul-smelling brown
fluid coming from his umbilicus. He has not been having pain or
obstructive symptoms, and has no history of abdominal surgery.
He denies fever, chills, nausea, vomiting, diarrhea, or
constipation. Radiology showed No drainable collection seen. Mixed echogenic material subjacent
to the stoma bag may represent phlegmonous material; however, it is difficult
to distinguish this from neighboring omental fat from known paraumbilical
hernia. Infection cannot be excluded by US. This area is better visualized on
the reference CT examination from ___. The patient was diagnosed with INTESTINAL FISTULA. At the time of discharge, the patient had 1. colocutaneous fistula
2. cellulitis. 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 on ___ under the Acute Care Surgery
Service for management of his colocutaneous fistula. Given his
extensive past medical history, he was deemed not a surgical
candidate for repair of the fistula. The wound/ostomy nurse was
consulted who applied an appropriate pouching appliance to the
fistula. Errythema was noted near the site of the fistula, and
an ultrasound was obtained to rule out a drainable fluid
collection, which was negative. He was initially started on
empiric antibiotic treatment with
vancomycin/ciprofloxacin/flagyl on admission, however, after the
negative ultrasound, the errythema was attributed to cellulitis
and his antibiotics were changed to keflex for a total course of
2 weeks. His coumadin was held on admission given the initial
consideration of surgery as well as its possible interaction
with ciprofloxacin. The patient's INR remained therapeutic
during his hospitalization between 2.3 and 2.4. At discharge,
plan to restart coumadin at prior dose on ___.
.
His vital signs were monitored throughout his hospitalization
and he remained afebrile and hemodynamicaly stable. His home
cpap therapy was continued. He wasm encouraged to mobilize out
of bed as tolerated. He was initially kept NPO and given IV
fluids, but was restarted on a regular diet on ___, which he
tolerated without abdominal symptoms. His intake and output were
monitored. His blood glucose levels were monitored QID and
covered with an insulin sliding scale as needed. His home
medications were continued while in the hospital, with the
exception of the coumadin as noted above.
.
At discharge he is feeling well, afebrile and hemodynamically
stable, tolerating a regular diet and is at his baseline
functional status. His cellulitis is improving on exam and his
fistula is well contained in a colostomy pouch.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w HTN s/p TEVAR & L renal artery stent ___ for type B
aortic dissection, discharged 2 days prior to presentation,
returns w focal neck pain. Pt has focal, non-radiating, midline
lower neck pain that began 2
days ago on the morning of discharge. Was felt to be
musculoskeletal at that time due to the presence of tenderness
and improvement with tylenol and heat packs. Pt states that
after he went home it persisted. Last night it increased in
severity and kept him up most of the night. Early this AM it
became so
unbearable that he could not move his neck so he went to ___
___. Since receiving IV pain meds, pt's pain has improved. On
arrival to ___ pt has full range of motion of his neck and
___ pain. He is admitted for further evaluation given resent
TEVAR. CTA CHEST WANDW/O CANDRECONS, NON-CORONARY showed 1. Expected postoperative appearance following repair of type B aortic
dissection.
2. The proximal neck vessels appear normal without evidence of dissection.
The excluded left subclavian artery is occluded proximally but reconstitutes
after approximately 3 cm.
3. The main arterial structures of the abdomen and pelvis are patent.
Notably, the left renal stent is patent and both kidneys enhance
symmetrically.
4. Tiny amount of thrombus adherent to the wall of the right brachiocephalic
and jugular veins is noted (02:39) but does not extend to the SVC possibly
secondary to previous central venous catheter.
5. Stable enlargement of the main pulmonary artery suggesting component of
pulmonary hypertension.
6. 1.2 cm hypodense nodule in the right adrenal gland is incompletely
characterized but is statistically most likely an adrenal adenoma. Attention
can be paid on follow up imaging. MR CERVICAL SPINE W/O CONTRAST showed Limited examination. Multilevel degenerative changes most pronounced at C5-C6
and C6-C7. No abnormal cord signal detected. Increased signal between the
spinous processes of C1 and C2 on inversion recovery images is nonspecific and
may indicate mild ligamentous injury without disruption. Given the limited
nature of examination, this could not be fully evaluated. MR ___ WAND W/O CONTRAST showed 1. No evidence of epidural collection.
2. Multilevel degenerative changes as detailed above most pronounced at C5-C6
and C6-C7 where there is cord remodeling without abnormal cord signal. The patient was diagnosed with CERVICALGIA, POSTSURGICAL STATES NEC. At the time of discharge, the patient had Back/Neck 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. ___ was admitted to the hospital with severe upper
back/neck pain. Given his recent TEVAR he was admitted to the
hospital for full evaluation. THe pain team was consulted who
felt the pain was musculoskeletal and recommended muscle
relaxers and pain medications. The neurology team also
evaluated and did a MRI of the cervical spine which was
basically unremarkable. The pain improved with time and
medication. We have arranged for follow up with the PCP ___ 2
days to discuss ___ or other therapies for the discomfort. A
prescription for a muscle relaxer to take if needed was also
given.
During the hopitalization, BP was in excellent control,
130-110/80s. All BP medications were continued in the hospital.
He will follow up with his PCP further titration. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with history of CAD s/p attempted PCI of CTO of RCA
___ with plan for recanalization ___ who presented ___ with
CP this evening.
The patient reports central chest pressure last evening at 7pm
that occurred when he was watching TV. It was ___ non-radiating
sharp pain. It lasted 45 minutes; resolved 30 minutes after
taking nitroglycerin x2 by EMS. He was also given a full dose
aspirin. He denies nausea, vomiting, diaphoresis, ripping or
tearing pain. Prior episodes of chest pain occurred with
exertion.
He was brought to ___ troponin x1 was <0.015. EKG was unchanged
without any signs of ischemia. He was given 1 inch of
nitropaste. CHEST (PA AND LAT) showed No acute abnormality. The patient was diagnosed with Cardiomyopathy, unspecified. At the time of discharge, the patient had Primary:
Chest Pain
Secondary:
CAD s/p attempted PCI of RCA ___ with plan re-canalization on
___
Paroxysmal Atrial Fibrillation
Hypertension
Hyperlipidemia
PVD s/p ___ iliac and femoral stents.
Gout
BPH
HLD. 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 with history of CAD s/p attempted PCI of CTO of RCA
___ with plan for re-canalization ___ who presented to the
ED with CP concerning for ACS.
# Coronary artery disease:
Patient presented with chest pain at rest and given underlying
CAD, the pain was concerning for unstable angina. He had known
total occlusion of RCA s/p failed PCI in ___ with planned
recanalization procedure on ___. Initial chest pain was
sub-sternal and resolved about 40 minutes after taking
sublingual nitroglycerin.
Throughout hospital stay EKG's were normal and troponin x3 were
negative. He did not have any chest pain throughout this
hospital course. Dr. ___ was informed of the patient's
condition and hospitalization. In discussion with him and
cardiology team, it was determined that the patient could return
for planned RCA recanalization procedure on ___. Patient
was continued on his home dose of 325 mg Aspirin, Plavix,
metoprolol, and Pravastatin throughout his hospital stay.
# Paroxysmal Atrial fibrillation (___: 3):
Patient was in normal sinus rhythm throughout hospitalization.
Patient has never been on anticoagulation. He was previously
taking Flecainide, but this was recently stopped given abnormal
stress test and he was started on Metoprolol. Further discussion
regarding anticoagulation of atrial fibrillation at time of
follow up should be considered. He was continued on home dose of
Metoprolol and aspirin.
# PVD s/p stenting:
Patient was continued on high dose aspirin and Plavix. Aspirin
325 mg continued as patient on this previously per
recommendation for PVD.
# HTN: Patient was continued on home losartan and amlodipine. He
remained normotensive throughout hospital stay.
# HLD: Patient was continued on pravastatin, fish oil.
# BPH: Patient was continued on home doxazosin
# Gout: Patient was continued on home dose of allopurinol </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old man w/ PMH anemia, DVT/PE on
Coumadin, glaucoma, CKD, NSTEMI ___, depression,
thrombocytopenia who presented with confusion and left shoulder
pain s/p fall. Radiology showed No acute cardiopulmonary process. Radiology showed No fracture or dislocation. CT HEAD W/O CONTRAST showed The study is severely limited due to patient motion. Within the limitations,
there is no evidence of large intracranial hemorrhage, no evidence of midline
shift. There is no evidence of acute large territory infarction, however
detection is significantly limited due to motion.
RECOMMENDATION(S): If there is deterioration in exam or other concern, repeat
imaging may be obtained as clinically indicated.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:05 am, 5 minutes after
discovery of the findings. CT C-SPINE W/O CONTRAST showed Study is moderately limited due to motion.
No evidence of traumatic malalignment. No acute fracture. The patient was diagnosed with Altered mental status, unspecified, Weakness, Abnormal coagulation profile, Long QT syndrome. At the time of discharge, the patient had metabolic encephalopathy
fall
weakness
supratherapeutic INR. 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 w/ PMH anemia, DVT/PE on Coumadin,
glaucoma, CKD, NSTEMI ___, depression, thrombocytopenia who
presented with delirium and left shoulder pain s/p fall.
#Toxic metabolic encephalopathy: Per family, several days of
hallucinations and weakness prior to admission consistent with
delirium. Felt to be most likely related to recent URI with poor
sleep due to cough, ultimately leading to delirium. Initially on
azithromycin for ? bronchitis which was stopped due to lack of
evidence of bacterial infection. Treated with cough suppressant
and bowel regimen as well as delirium precautions with
improvement in delirium.
#Fall/Weakness: Trauma eval in ED negative. Seen by ___ with plan
for rehab.
#Supratherapeutic INR
#H/o DVT/PE: On warfarin at home with INR elevated on admission,
possibly related to azithromycin. Warfarin was held until ___,
on which his home dose of 7.5mg is resumed given INR of 2.5</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/Necrotizing gallstone pancreatitis requiring multiple
hospitalizations (most recently dc ___. Pt presents with
fever to 101.4. She denies localizing symptoms, specifically
denies abdominal pain, nausea, vomiting, shortness of breath,
chest pain, open wounds. Radiology showed 1. Moderate-sized left pleural effusion is relatively unchanged since
___.
2. Multiple multiloculated pseudocysts in the left upper quadrant with drains
in place are decreased in size since ___ however, a collection within
the head of the pancreas is not significantly changed and does not contain a
drainage catheter.
3. No free fluid or signs of pancreatitis or pancreatic necrosis. Radiology showed 1. No evidence of abnormal fluid collection or mass seen in the neck. The
mastoid air cells are clear.
2. Partially visualized large left-sided pleural effusion with compressive
atelectasis. Evaluation of the patient with pleural effusion after
chest tube placement.
AP radiograph of the chest was compared to ___.
The left pigtail catheter is in place. There is a substantial interval
decrease in pleural effusion. Heart size and mediastinum are stable. Upper
lungs are clear. Right lung is unremarkable. was done. Evaluation of the patient with left pleural effusion.
AP radiograph of the chest was reviewed in comparison to ___.
The Dobbhoff tube passes below the diaphragm with its tip not included in the
field of view. Left pigtail catheter is in place. There is interval decrease
in left pleural effusion. Still present right pleural effusion are most
likely small to moderate. There is no pneumothorax. No pulmonary edema
demonstrated. was done. Evaluation of the patient after chest tube removal.
AP radiograph of the chest was reviewed in comparison to ___
obtained at 09:37 a.m.
The left pigtail catheter has been removed. There is no interval development
of pneumothorax and there is no interval increase in pleural effusion. Basal
consolidation and atelectasis are noted. The heart size and mediastinum are
stable. Lungs are essentially clear with only mild vascular congestion. was done. Radiology showed 1. Roughly 20 cm stretch of transverse colon beginning at the hepatic flexure
with prominent wall thickening, edema and surrounding marked inflammatory
change. This degree of findings with phlegmonous change with decreased size
of an uncinate pancreatic pseudocyst is most suggestive of partial cyst
rupture with leak of pancreatic enzyme contents across the mesocolon causing
secondary inflammation. No frank abscess. Diverticulitis is hard to exclude
but seems much likely as the etiology to describe the overall findings.
2. Transgastric catheter continues to drain the pancreatic tail pseudocyst,
which is decreased in size compared to prior examination; a superior
subphrenic extension, including an air-fluid level, persists but has also
decreased. An uncinate process pseudocyst is also decreased in size; however,
the now largest pancreatic head pseudocyst has intervally increased in size,
and it may exert focal mass effect on the adjacent traversing duodenum.
3. Trace ascites likely secondary to inflammation.
4. Simple renal cyst.
Results were discussed over the telephone with Dr. ___ by Dr. ___
___ at 3:20 p.m. on ___, five minutes after discovery. Radiology showed 1. Left greater than right bibasilar consolidations are similar to prior
examination and could represent atelectasis; however, their pattern of
___ particularly at the left base is worrisome for pneumonia. A
small to moderate left sided simple density pleural effusion has decreased in
volume compared to prior study.
2. Abdomen and pelvis findings are included on a separate report.
Results were discussed over the telephone with Dr. ___ by Dr. ___
___ at 3:20 p.m. on ___, five minutes after discovery. Radiology showed New PICC line terminating in the superior vena cava. Radiology showed 1. Increased organization of a phlegmon surrounding the proximal tranverse
colon consistent with walled off fat necrosis. No discrete drainable abscess
in this region. Known transverse colitis within this fat necrosis is
unchanged. No free intraperitoneal air or pneumotosis.
2. Mild decrease in a subdiaphragmatic abcess. Drainage of this abscess would
be difficult given its location and risk of infecting overlying pleural
effusion.
3. Mild increase in a nonhemorragic left pleural effusion.
4. Mild decrease in size of the pancreatic head and uncinate pseudocysts.
Increase in pancreatic body pseudocyst and stable pancreatic tail pseudocyst
with a drainage catheter.
Results were conveyed via telephone by Dr. ___ to ___
at 16:00 on ___ within 10 minutes of observation of findings. The patient was diagnosed with FEVER, UNSPECIFIED, HYPERLIPIDEMIA NEC/NOS. The patient was treated with ___ placement. At the time of discharge, the patient had Primary:
Diverticulitis/Transverse Colitis
Pleural effusion
Secondary:
Pancreatitis with pseudocysts
Secondary 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>___ w/Necrotizing gallstone pancreatitis requiring multiple
hospitalizations presents with fever, found to have transverse
colitis, managed conservatively with antibiotics.
#Transverse colitis, diverticulitis
The patient presented with fevers and was initially started on
cipro and flagyl, suspecting a GI source. She continued to
have fever and rising WBC. A CT neck to eval for mastoiditis or
neck abscess was obtained as the pt had a dobhoff and mild neck
pain which did not show signs of infection. Antibiotics were
broadened to include vanc and aztreonam. Repeat CT abd then
revealed transcolonic inflammation and colitis/diverticulitis
with possible mircoperforation that may have been due to
longstanding inflammation from pancreatitis. The patient was
followed by infectious diseases who recommended continuing
Cipro/flagyl/aztreonam. The patient improved clinically but
platelets continued to rise despite dropping WBC count. The
patient therefore underwent repeat abdominal CT scan on ___
which showed an area of fat necrosis and a sub diaphragmatic
abscess. Radiology felt there was no approach to safely drain
this abscess via ___ guided drainage. The case was also discussed
with surgery who have been following the patient who felt
operative intervention was not indicated. The decision was made
with infectious disease to discharge the patient on a prolonged
course of PO flagy and IV aztreonam. She will follow up in the
___ clinic at which point a decision will be made regarding
repeat imaging and duration of antibiotic therapy.
#Pleural Effusion:
The patient has had a recurrent left pleural effusion. She
underwent thoracentesis to evaluate for infection. Studies were
not consistent with infection but cytology did show atypical
cells - favor reactive mesothelial cells; inflammatory cells and
histiocytes. The patient will need repeat imaging to asses for
underlying malignancy once her acute illness and pleural
effusion have resolved.
#Pancreatitis with pseudocyst
The patient remained on tube feeds and was tolerating clear
liquids. She is followed by the ___ team/Dr. ___
follow up at the beginning of ___ as scheduled.
#Diabetes: ___ pancreatic insufficiency
The patient's lantus was decreased to 12 units with good glucose
control. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant ___ w/ Stage IV adenocarcinoma of
the
appendix on cetuximab, s/p R hemicolectomy with diverting
ileostomy, complicated by chronic partial SBO on TPN, bilateral
hydronephrosis s/p b/l ureteral stents and percutaneous
nephrostomy tubes, recent polymicrobial bacteremia and liver
abscesses s/p 6 weeks of IV antibiotics, who presents with
fevers
of ___. DX CHEST PORTABLE PICC LINE PLACEMENT showed In comparison with the study of ___, the monitoring and support devices
are unchanged. There is increasing right pleural effusion with volume loss in
the right lower lobe. No evidence of vascular congestion or acute focal
pneumonia, though in the appropriate clinical setting it would be impossible
to exclude consolidation at the right base, especially in the absence of a
lateral view. Radiology showed Successful US-guided aspiration of a right hepatic lobe fluid collection.
Sample was sent for microbiology evaluation. Radiology showed Interval placement of a right chest tube which projects over the right mid to
lower hemithorax. No significant interval change in the moderate right
pleural effusion. CHEST (PORTABLE AP) showed Right base pigtail catheter is in place. There is no evident pneumothorax.
Now small right effusion has markedly decreased. No other interval change
from prior study. Radiology showed Mildly dilated air-filled small bowel loops in the mid-left lower quadrant,
similar to prior CT and radiograph could be early small bowel obstruction.
Close attention on follow-up. CT CHEST W/O CONTRAST showed PERSISTENT SMALL POSSIBLY LOCULATED RIGHT PLEURAL EFFUSION SMALL PNEUMOTHORAX,
FOLLOWING INSERTION OF RIGHT PLEURAL DRAINAGE CATHETER, LARGELY FISSURAL.
MODERATE VOLUME OF RIGHT LOWER LOBE ATELECTASIS IS NEW SINCE ___.
SEVERE DISTENTION AND RETENTION OF FLUID IN OF THE ESOPHAGUS PUTS THE PATIENT
AT RISK FOR ASPIRATION.
SMALL AREAS OF LIKELY NEW PNEUMONIA.
NEW MILD ANASARCA.
EMPHYSEMA.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:20 ___, 1 minutes after discovery
of the findings. Radiology showed Trace right pneumothorax ; however this was better evaluated on today's CT
scan of the chest. Otherwise there is no significant interval change since
the prior examination. . CT abdomen pelvis with contrast showed 1. Again seen are four common bile duct metal stents. Compared to ___, there is decreased intrahepatic biliary ductal dilatation in the portion
of the hepatic parenchyma drained by the left biliary stent. There is also
new pneumobilia in this region. Mild hyperenhancement of the hepatic
parenchymal in this region is favored to represent either cholestatic
hepatitis or cholangitis.
2. There is persistent intrahepatic biliary ductal dilatation in the segments
drained by the right anterior stent. Again seen in this region is a resolving
biloma/abscess which is similar in size compared to ___.
3. No significant intrahepatic biliary ductal dilatation is noted in the areas
drained by the other 2 right-sided biliary stents.
4. Similar to mildly decreased size of a segment 8 hypodensity, compatible
with resolving abscess. No new hepatic lesion is seen.
5. Mild persistent right hydronephrosis is slightly decreased compared to
prior studies. There is no left hydronephrosis. The bilateral percutaneous
nephrostomy tubes are in appropriate position.
6. Similar appearance of multiple splenic hypodensities, compatible with
infarcts.
7. Diffusely thickened bladder wall may be related to under distension and
tumor involvement, however clinical correlation to exclude cystitis is
recommended.
8. Similar appearance of persistent posterior bladder mass with loss of rectal
fat plane worrisome for metastatic involvement.
9. Similar appearance of retroperitoneal lymphadenopathy.
10. Bilateral pleural effusions and patchy nodular airspace opacity in the
lung bases, right middle lobe, and lingula were better evaluated on the
dedicated CT of the chest from ___. Please see that report for
further details. Radiology showed 1) Successful balloon sweeps of the right anterior metallic stent
2) Successful ___ PTBD placement through the right anterior stent
3) Successful balloon sweeps of the left biliary stent
4) Successful placement of a left 10 ___ internal external biliary drain
through the interstices of the existing left internal metal stent.
RECOMMENDATION(S): Patient can remain to bag while she defervesces. After
this, she should return for a repeat cholangiogram to evaluate the stent
patency and flow. The ___ team will follow the patient. CHEST (PORTABLE AP) showed In comparison with study of ___, there is little overall change.
Again there is a small apical pneumothorax. Little change in the atelectatic
streaks at the right base with residual effusion. Mild atelectatic changes
are seen at the left base and the central catheters are stable. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, the apical pneumothorax on
the right appears to have slightly decreased. Otherwise little change. The patient was diagnosed with Unspecified abdominal pain, Fever, unspecified. The patient was treated with Hepatic abscess aspiration
Bilateral percutaneous transhepatic biliary srain placement
R chest tube placement. At the time of discharge, the patient had Primary:
Cholangitis
Hepatic abscess
R pleural effusion
Secondary:
Metastatic appendiceal carcinoma. 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 ___ w/ Stage IV adenocarcinoma of the
appendix recently on cetuximab, s/p R hemicolectomy with
diverting ileostomy, complicated by chronic
partial SBO on TPN, b/l hydronephrosis s/p b/l ureteral stents
and PCNs, recent polymicrobial bacteremia and liver abscesses
s/p 6 weeks of IV antibiotics, who p/w chief complaint of fevers
and was found to have a hepatic abscess, cholangitis requiring 2
PTBDs, and progression of stage IV appendiceal cancer. The
hepatic abscess was aspirated by ___ and grew ___ and
klebsiella. She was also found to have cholangitis and had 2
PTBDs placed with ___. For the hepatic abscess and cholangitis
she was treated with ceftriaxone and fluconazole. Per ID recs
she will receive 4wks of antibiotics from PTBD placement (last
day ___ and will be followed by OPAT. PTBDs were capped prior
to discharge and further plan will be decided by ___ as an
outpatient.
She also had a CT placed for R pleural effusion which was
removed prior to discharge. Her pleural fluid analysis was
consistent with an exudate, but was negative for malignant cells
on cytology.
#Cholangitis.
She had an elevated bilirubin, fevers, and an elevated WBC
count, all consistent with cholangitis. The patient already has
4 biliary stents that were placed by ___. ERCP was attempted but
unable to be completed as there was external compression of the
pylorus, likely from progression of her malignancy, that made it
impossible to pass the scope. As a result she underwent
bilateral internal/external PTBD placement with ___ on ___ with
good drain output. There was a slight decrease in her bilirubin,
with marked improvement in her clinical status. With drain
placement and ceftriaxone her WBC went down, she was afebrile,
and her abdominal pain improved. Her bilirubin stabilized at
around 5.1 and is unlikely to drop much further given her
metastatic disease. Her PTBDs were capped, and her bilirubin
remained stable. ___ will see her as an outpatient to discuss
further management of the drains. Per ID she will continue
ceftriaxone for 4 weeks from drain placement (last day ___.
She will be followed by OPAT as an outpatient.
#Hepatic abscess
Cultures from hepatic abscess on most recent admission grew pan
sensitive Enterococcus and E.coli ___. She received Zosyn
for about 6 weeks and completed treatment ___ per chart. CT
abdomen from ___ showed a small hepatic abscess. Hepatic
abscess was aspirated ___ and grew ___ and klebsiella. She
was initially started on zosyn, but was transitioned to
ceftriaxone per ID recs with a plan to continue until ___ (per
above). She was also started on fluconazole to treat the
___. She will be followed by OPAT as an outpatient.
#R Pleural effusion.
The patient had reaccumulation of her R sided pleural effusion
so IP was consulted and placed a chest tube. The fluid analysis
was consistent with an exudate but cytology was negative for
malignancy. The chest tube was pulled a few days after
placement. She was monitored for signs of reaccumulation but did
not develop any.
#Goals of care.
There were many goals of care discussion had with the patient
and her family and friends. Before speaking with the family, the
inpatient team reached out to the patient's outpatient
oncologist, Dr. ___ her thoughts on the patients
prognosis. She informed the team that the patient had been
reluctant to have goals of care discussions in the past and
expressed that the patient may not benefit from further
therapies, may not even be able to receive them given her
current clinical condition, but that if she is able and wants
more treatment Dr. ___ will discuss options with her. She
also stated that if the patient wants hospice she feels that is
a good option today. Hospice was brought up with the patient and
her family. The family felt hospice would be a good option for
the patient, but the patient was still hesitant and was asking
about more treatment options. Ultimately the patient agreed to
go home on hospice, with the knowledge that if she does improve
clinically she has the option of coming off hospice and
receiving more treatment. Unfortunately the company that
provides her ___ services will not provide hospice services to
someone who is still receiving TPN and antibiotics. As a result
she went home resuming her prior ___ services with palliative
care with the option of readdressing hospice when she completes
her antibiotic course on ___.
#Erythema around colostomy site.
Patient states that she has had erythema and irritation around
the ostomy site for weeks. She says she was supposed to see
wound care as an outpatient but unfortunately it did not happen.
Wound care saw her here and gave her a new ostomy bag. She feels
the erythema and irritation is improving. A few days prior to
discharge she was noted to have some blood in her ostomy which
appeared to be coming from her stoma. She says this happens
intermittently at home. Her hgb was stable so there was low
concern for a GI bleed.
#Vomiting.
The patient had one day where she had dark brown emesis that was
gastroccult positive. There was a concern for a GI bleed so she
was started on a high dose pantoprazole IV BID and given a PRBC
transfusion. The next day she was still having some emesis
(which is baseline for her), but it was not dark and was
non-bloody. Her hgb was also stable, decreasing the concern for
a GI bleed. She continued to have intermittent nausea and so she
was continued on her home regimen of IV Zofran 8mg BID, with one
8mg PRN Zofran. Of note, she has a chronic malignant partial
SBO, but a CT abdomen on ___ was negative for obstruction. She
also had ostomy output throughout her admission.
#Pain.
On admission the patient was on a fentanyl patch 50mcg/hr with
oxycodone PRN. She was also given IV dilaudid while here for
breakthrough pain. Her fentanyl patch was also increased to 75
mcg/hr because of increased pain. Prior to discharge she needed
to be transitioned to PO medications so her pain medication
needs were calculated based on her PRNs. As a result her
fentanyl patch was increased to 100mcg/hr with oxycodone 15mg PO
Q4H:PRN with adequate pain control.
#Appendiceal cancer.
Followed by ___. Her chemo has been on hold given her
infection and overall clinical decline. The patient plans to see
her outpatient oncologist after discharge and wants to pursue
further treatment options.
#Severe Protein calorie malnutrition.
She was continued on her home TPN. Nutrition was consulted and
made adjustments as needed.
# Anemia
Likely secondary to antineoplastic therapy and inflammatory
blockade from
malignancy. She had a hgb drop at one point during the admission
when there was a concern for GI bleed. She was transfused at
that time, and her hgb remained stable but low after that.
#Hyperglycemia.
Had elevated glucoses during this admission. She was started on
a regular insulin sliding scale and had 10U insulin added to her
TPN. The hyperglycemia was most likely from her infection.
#Vaginal discharge.
Likely yeast infection. Patient has been on antibiotics, also
patient reports symptoms are similar to prior yeast infections.
She was being covered with the fluconazole she was getting for
the ___ that grew out of her hepatic abscess.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year-old gentleman with alcoholic cirrhosis decompensated by
refractory ascites and encephalopathy who has been referred in
for evaluation of worsening renal function. RENAL U.S. showed 1. No evidence of hydronephrosis.
2. Cirrhotic liver, with large volume ascites. The patient was diagnosed with Abdominal distension (gaseous)
Alcoholic cirrhosis of liver with ascites. The patient was treated with EGD with banding ___
Large volume paracentesis ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS
=================
Acute kidney injury
SECONDARY DIAGNOSES
===================
Decompensated alcoholic cirrhosis. 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 gentleman with alcoholic cirrhosis decompensated by
refractory ascites and encephalopathy who referred from liver
clinic for sub-acute worsening renal function in setting of
intermittent hematuria.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with localized unresectable neuroendocrine tumor encasing
the mesentery who developed nausea yesterday evening and was
transferred with a diagnosis of SBO from OSH. The patient has
had upset stomach off and on with gas sounds for the past few
weeks, but there was a change with nausea developing yesterday. Radiology showed Small-bowel obstruction, likely distal as dilated loops of bowel are seen to
the level of the pelvis. MR ___ showed 1. Evidence of unchanged distal small-bowel obstruction secondary to the
central mesenteric mass as described above.
2. Unchanged edema and mucosal hypoenhancement of the most distal dilated
small bowel loops proximal to the transition point concerning for vascular
compromise. Evidence of marked luminal narrowing of the SMV and SMA.
3. Moderate amount pleural effusions and large amount of intra-abdominal
ascites.
4. Unchanged central mesenteric mass biopsy-proven neuroendocrine tumor with
associated mesenteric adenopathy.
5. 8 mm hypoenhancing right hepatic lobe lesion, incompletely evaluated and
remains indeterminate. This can be followed on subsequent imaging. ULTRASOUND-GUIDED PARACENTESIS showed 1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 3.5 L of thin milky pink fluid were removed. Fluid samples were submitted
to the laboratory for cell count, differential, culture, and cytology. The patient was diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst. The patient was treated with Endoscopic retrograde cholangiopancreatography
Magnetic resonance elastography. At the time of discharge, the patient had Small bowel obstruction
Pancreatic neuroendocrine tumor
Ascites. 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>#Small bowel obstruction
#Pancreatic neuroendocrine tumor
The patient initially presented with nausea and was found to
have a small bowel obstruction secondary to his known pancreatic
neuroendocrine tumor. He was initially treated with an NG tube,
kept NPO, treated with fluids and Zofran for nausea. However, by
the second day of his admission, his symptoms were markedly
improved, his NGT was removed and his diet was advanced.
Endoscopy showed normal mucosa in esophagus, stomach and
duodenum. MRE showed evidence of unchanged distal small-bowel
obstruction secondary to the central mesenteric mass. Based on
these findings, the patient's clinical improvement, and his
ongoing ascites, surgery decided to hold off on a bypass at this
time and see him in follow up as an outpatient.
# Ascites
Per hepatology evaluation, ascites seems to be multifactorial
due to portal hypertension due to the obliteration of his portal
vein and encasement of his SMA/SMV by his tumor, as well as
obstruction of his lymph system contributing to chylous nature
of the ascites. The liver is unlikely cirrhotic given normal
LFTs,
synthetic function and non-cirrhotic appearance on OSH CT scan.
For the concern for chylous ascites (based on patient's
description) as well as overall malnutrition, he was seen by
nutrition, who recommended a low fat, sodium restricted diet
with ensure enlive supplements mixed with beneprotein and 15 mL
medium chain triglycerides oil. A triene/tetraene ratio was also
checked with results pending on discharge; if> 0.4 and s/sx of
deficiency consider parenteral fat emulsion. He had a
paracentesis on the day of discharge, both therapeutic on
schedule for his weekly tap and also diagnostic to evaluate for
chylous ascites. Also continued home Lasix 10 mg daily while
inpatient.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is an ___ female patient with history of
hypertension, diabetes, arthritis, on steroids, dementia
presenting with her son for evaluation of ongoing weakness. The
patient was seen in the ED on ___ for abdominal pain and
shortness of breath and had a negative CT scan at that time. She
was diagnosed with a UTI and discharged home. Today she returns
with worsening pain weakness and shortness of breath. The
shortness of breath is worse with exertion. She is now also
requiring oxygen as she desats to 88 or 89% on room air. Her son
is also noticed that she has had new bilateral lower extremity
swelling. She has no history of heart failure. Son denies any
nausea vomiting or diarrhea. No black or bloody stools. However
he does note that she has been having poor p.o. intake. Radiology showed No definite acute cardiopulmonary process. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Elevated right hemidiaphragm is similar to before.
3. Trace left pleural effusion. The patient was diagnosed with Dyspnea, unspecified. At the time of discharge, the patient had Urinary tract infection
Hypoxia. 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 history of hypertension, diabetes,
rheumatoid arthritis on steroids, dementia presented with UTI,
abdominal pain, and dyspnea/hypoxia. Treated with 5 days
ceftriaxone, etiology of hypoxia unclear but resolved
spontaneously.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with history of sarcoidosis presents with
worsening shortness of breath, back pain, and dehydration.
Patient is ___ days post left pharngoplasty, arytenoid adduction,
and medialization laryngoplasty and since then she reports she
has not fully recovered, with poor ability to tolerate p.o. and
worsening back pain, which is chronic for her. Denies any fever
or chills at home. Has a chronic cough, which is nonproductive.
She denies any N/V/D orthopnea, PND or sputum production. CHEST (PA AND LAT) showed No acute findings. Radiology showed Limited evaluation of the vertebral bodies at the upper thoracic spine. This
remains of clinical concern, CT is more sensitive and should be considered.
Query pulmonary nodule projecting over the right mid lung appear recommend
dedicated chest x-ray for further evaluation. VIDEO SWALLOW STUDY showed Penetration with thin liquids, but no aspiration.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations. The patient was diagnosed with SHORTNESS OF BREATH, HYPERCALCEMIA, DIABETES UNCOMPL JUVEN. At the time of discharge, the patient had Primary Diagnosis:
- Paradoxical vocal cord dysfunction
Secondary Diagnoses:
- Urinary tract 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>___ with h/o sarcoidosis, hypercalcemia and recent laryngeal
surgery for vocal cord paralysis admitted for progressive DOE
and coughing since her surgical procedure 1 month ago, as well
as expedited neurology consultation for new urinary incontinence
and gait instability.
# Dyspnea and cough without hypoxemia: Patient presented with
dyspnea and cough that had worsened since her ENT surgical
intervention 1 month ago. Appeared to be upper airway in nature.
No evidence of PNA on CXR, no elevated WBC count, EKG unchanged
from prior. Patient localized a sensation to her throat which is
worse with eating and results in coughing. Lungs were clear to
auscultation without wheezing but with occasional transmission
of upper airway sounds. ENT was consulted and declined to scope
the patient because she had been scoped the day prior to
admission without evidence of any pathology that could be
contributing to her presentation. They recommended video swallow
to rule out aspiration but otherwise no acute intervention.
Video swallow on ___ was w/o evidence of aspiration.
Differential includes paradoxical vocal cord dysfunction. Her
omeprazole was subsequently increased to 40mg BID. Despite the
patient's ongoing symptoms, there was no immediate need for
inpatient work up. She was therefore able to be discharged home
for ongoing workup as an outpatient. She will have close follow
up in pulmonary and neurology clinic. We have also recommended
referral to speech pathology for empiric treatment of
paradoxical vocal cord dysfunction.
# Hypercalcemia: Total serum calcium of 11.0 on admission which
resolved after receiving 2L IVF in the ED. Differential includes
sarcoidosis (1,25-OH-VitD pending), malignancy, and
calcium-alkali syndrome (serum bicarbonate elevated). Normal PTH
makes primary hyperparathyroidism highly unlikely. Low 25-Vit-D
(value of 21 this admission) could be consistent with
sarcoidosis or other granulomatous processes if the 1,25-Vit-D
comes back as high (currently pending). Patient's serum
phosphate was low on presentation but this is confounded by her
poor PO intake in the setting of her dysphagia. The patient is
scheduled to follow up with both pulmonology and neurology at
___, as well as her PCP, for ongoing evaluation of this issue.
1,25-OH-Vitamin D will be followed up by her pulmonologist.
# Back Pain, Urinary Incontinence, Lower Extremity Weakness /
Gait Instability: Per patient, her back pain has not changed in
years. However, her gait instability and urinary incontinence
are new/subacute in onset and raised concern for malignancy vs
neurosarcoidosis. Neurology was consulted on ___ for evaluation
of her lower extremity weakness, gait instability and urinary
incontinence. They felt that her presentation was not consistent
with neurosarcoidosis or normal pressure hydrocephalus and there
was no need for imaging studies. Their impression was that her
weakness was secondary to deconditioning and mild electrolyte
abnormalities (mild hypophosphatemia) and that they would
resolve with physical therapy and electrolyte repletion. At
discharge, the patient was prescribed potassium, phosphate and
magnesium supplements to aid in preventing electrolyte
imbalances.
# UTI: Urine culture from admission grew >100k E.coli resistant
to ampicillin, cefazolin, ceftriaxone, ciprofloxacin, tobramycin
and bactrim. It was sensitive to ampicillin/sulbactam,
ceftazidime, gentamicin, meropenam, nitrofurantoin, and zosyn.
Given the patient's allergy history and use of prednisone, she
was prescribed a 7 day course of Augmentin (___) to
complete as an outpatient.
# Diabetes: The patient's insulin sliding scale was increased at
discharge given hyperglycemia into 300s-400s during admission.
==== TRANSITIONAL ====
# 1,25-OH-Vit-D pending at discharge
- Patient has pulmonology follow up with her outpatient
provider. Please follow up the 1,25-OH-VitD sendout lab for
question of sarcoidosis as underlying cause of her hypercalcemia
# Urinary Incontinence
- 7 day Augmentin course for UTI
- Started oxybutynin 5mg PO TID
- Patient has an outpatient urologist with whom she will
schedule a follow up appointment
# Cough, SOB, possible paradoxical vocal cord dysfunction
- Pulmonary follow up appointment scheduled
- PCP follow up within 1 week: we highly recommend outpatient
speech pathology referral for empiric treatment of paradoxical
vocal cord dysfunction
# Back pain and lower extremity weakness / gait instability
- Patient will be called regarding scheduling follow up with
Neurology</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F with hx of ESRD on HD ___, HTN, moderate AS, and
bifasicular block who presents with a fall leading to R
intertrochanteric hip fracture and is transferred to the MICU
for respiratory status monitoring after general anesthesia. HIP UNILAT MIN 2 VIEWS RIGHT IN O.R. showed Intraoperative images from open reduction internal fixation of a right
proximal femur fracture Radiology showed Interval removal of endotracheal tube and placement of a right PICC with tip
likely in the lower SVC. No substantial change otherwise. The patient was diagnosed with INTERTROCHANTERIC FX-CL, UNSPECIFIED FALL. The patient was treated with ORIF of hip. At the time of discharge, the patient had Primary Diagnosis:
Right Hip fracture s/p ORIF
Secondary Diagnosis:
Heart failure with preserved EF
HTN
Gout
CKD stage V on Hemodyalisis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with h/o ESRD on HD ___, HTN,
and moderate AS who presents with a fall c/b L hip fracture and
s/p ORIF and transferred to MICU for continued intubation and
hypotension intra-operatively requiring phenylepherine.
# L Hip fracture: s/p successful ORIF by orthopedics.
Orthopedics continued to monitor patient's recovery daily during
her MICU and medicine floor stay and there were no
complications.
# Respiratory status: Pt intubated for general anesthesia
administration as patient did not tolerate spinal block. She
received 1 unit pRBC and 1.3L of fluid in the OR and remained
intubated in the event she developed flash pulmonary edema as
she does not make any urine and is on HD. Patient was
successfully extubated on ___. She had no further respitatory
distress during admission.
# Hypotension: Likely ___ multifactorial in setting of
intubation with positive pressure ventilation and likely volume
depletion given symptoms prior to fall (light-headedness ___
HD). Required phenylepherine in the OR and was then s/p 1 unit
pRBC and 1.3L as well. Patient did have a leukocytosis but no
fevers or chills and no report of any localizing source of
infection. She was weaned from phenylephrine and propofol and
pressures remained stable. Her blood pressure remained in the
85-100 Systolic range once transitioned to floor. She was
asymptomatic.
# Leukocytosis: Most likely reactive in nature, patient without
any localizing sources of infection and no fevers or chills on
presentation. Patient was given clindamycin perioperatively but
antibiotics were not continued. He leukocytosis is 12 and
downtrending at the time of discharge.
# ESRD: Anuric by report, has dialysis ___.
Patient missed HD on ___ and, on ___, patient was found to
have K 7.9 and decreased bicarb of 9. She had urgent bedside HD
and her lab abnormalities improved. Her last HD session was
___. She is scheduled for her next session on ___.
#Delirium: Pt had episodes of hypoactive delirium overnight
which improved with reorientation and during day light hours.
Attempt to minimize pain medications as possible.
# s/p fall
Per family, patient felt lightheaded as she usually does after
dialysis and unfortunately fell after standing. Family denies
patient was having any chest pain, shortness of breath. Denies
any recent cough as well.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old man with history of C4-C5 cervical fusion ___ years
ago), L2-L5 stenosis, DM2 and HTN, presents with left upper
extremity paresthesias and weakness. Symptoms began two months
ago. He has pain that starts in his left shoulder blade and
radiates down arm to level of elbow. From his elbow to his hand
he has paresthesias. He has lost his fine dexterity in his left
hand which feels weak. He has been using oxycodone for the pain
which helps, but recently needed to increase the dose because of
worsening symptoms. No aggravating factors. He has cervical
neck pain when flexing his chin to his chest, but not with head
rotation. He lost 20lb unintentionally over the past year.
Denies fever, chills, night sweats, blood in stool/urine. He
has recently developed a sore throat and cough, but no SOB. He
smokes ___ cig/day for the past ___ years. Radiology showed 1. Hardware overlies the lower cervical spine consistent with previous
cervical fusion. Lungs are relatively well inflated without evidence of focal
airspace consolidation, pleural effusions, or pneumothorax. The interstitium
is slightly prominent, but this may reflect small airways disease, age related
changes or smoking-related changes. Clinical correlation is advised. Overall
cardiac and mediastinal contours are within normal limits. No acute bony
abnormality is seen. Depending upon the etiology of the patient's cervical
mass, additional imaging with CT could be undertaken. Minimal degenerative
changes in the thoracic spine with no obvious vertebral compression fractures. Radiology showed 1. 5.6 x 6.2 cm enhancing mass arising from the upper pole of the right
kidney suspicious for renal cell carcinoma with large mass involving T1-T3
likely representing a metastatic focus as well as a concerning lesion in the
spleen.
2. Enlarged left subclavian lymph node may also represent metastatic
involvement.
3. Thicking of the bilateral adrenal glands without discrete nodule or mass
may represent hyperplasia, but metastases not excluded.
4. Cirrhosis with evidence of portal hypertension and esophageal varices.
5. Cholelithiasis. Radiology showed 1. Destructive soft tissue mass arising from the T2 left lamina extending to
the T1 through T3 posterior left paramedial vertebral bodies, with involvement
of the T1 through T3 costovertebral junction, towards segments of the left
first through third ribs, and left T1 through T3 neural foramen.
2. Encroachment of the mass into the spinal cord at the T2 and T3 levels,
with abutment against the cord.
3. No cervical lymphadenopathy.
4. Moderate maxillary sinusitis with acute features.
5. Post C5/6 anterior cervical fusion. Radiology showed Successful thoracic mass biopsy. Radiology showed 1. Large expansile mass lesion involving the posterior left paramedial
vertebral bodies from T1 through T3 levels as described in detail above,
causing left-sided neural foraminal narrowing at T1/T2, T2/T3 levels and also
left paracentral canal narrowing and impinging the thecal sac posteriorly, no
frank evidence of spinal cord edema is demonstrated.
2. The differential diagnosis for this lesion includes metastatic disease,
myeloma may have similar appearance.
2. Small cystic-appearing formation noted in the posterior lobe of the
thyroid gland on the right, there is also a small area of cystic signal on the
posterior aspect of the right parotid gland, possibly consistent with a small
intraparotid lymph node or cystic formation.
3. The patient is status post anterior fusion and discectomy at C5/C6 level. The patient was diagnosed with BONE & CARTILAGE DIS NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. The patient was treated with Core needle biopsy of the thoracic spinal mass ___. At the time of discharge, the patient had Metastatic malignancy, suspected renal origin with metastases to
thoracic spine, adrenal and spleen
Thrombocytopenia
Anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old man with history of C4-C5 cervical fusion ___ years
ago), L2-L5 stenosis, DM2 and HTN, who presented with left upper
extremity paresthesias and weakness. His PCP completed ___ spinal
MRI which showed a new T1-T3 mass without current cord
compression per our radiology second read. He was admitted for
expedited work up and biopsy. CT torso showed right renal mass
with likely metastases to adrenal gland and spleen. He received
a biopsy of the T1-T3 mass by interventional radiology on
___. Preliminary pathology on discharge showed likely
metastatic clear cell carcinoma, although final stains are
pending. He was seen by oncology who will continue to see the
patient upon discharge. He had significant left shoulder and
arm pain that improved with addition of oxycontin and oxycodone
for break through pain.
CT torso also showed cirrhosis suspected due to prior liver
injury from methotrexate treatment for his psoriasis. He will
be evaluated by hepatology as an outpatient prior to
chemotherapy initiation.
Work up for thrombocytopenia and anemia inclding normal iron
panel, normal B12, SPEP/UPEP negative, and reticulocyte count
low at 0.8. Poor production may be due to his malignancy or
other primary bone marrow process.
Patient's other health issues were managed during the hospital
stay per home regimens (hypertension, GERD, glaucoma).
Metformin was held during hospitalization and resumed on
discharge for diabetes mellitus.
Patient was FULL CODE throughout hospital stay. We conducted
several family meetings including the patient, his wife, and
their daughter, during his hospitalization to discuss the
medical plan and results as they were obtained. The patient was
aware of the malignant cells on his cytology, and the suspicion
for a renal origin as the primary, pending further pathologic
results. The patient also expressed understanding that further
diagnostic steps, discussion of the pathology results, and
eventually determination of a treatment plan and prognosis would
be forthcoming as he met with the oncology team as an
outpatient.</s> |