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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F PMH significant for severe atopic disease with prior episodes of MSSA bacteremia related to likely skin source, elevated IgE levels, and eosinophiila who presents with ongoing fevers, abdominal pain, and cough after recent hospitalization for likely viral gastroenteritis. Radiology showed Partial resolution of the previously seen right middle lobe pneumonia with some persistent opacity. Continued followup until resolution is suggested. No new consolidation. The patient was diagnosed with CHEST PAIN NEC, PNEUMONIA,ORGANISM UNSPECIFIED, LEUKOCYTOSIS, UNSPECIFIED , FEVER, UNSPECIFIED. At the time of discharge, the patient had Primary diagnosis: Viral syndrome NOS Secondary diagnosis: Atopic dermatitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F with PMH of severe atopic dermatitis complicated by MSSA bacteremia, eosinophilia, elevated IgE, osteopenia, and depression/anxiety who presents with likely viral illness. ACTIVE ISSUES # Fevers: Most likely continuation of viral illness. Attributed last week to a brief viral gastroenteritis. Resolved rapidly with IV fluids after which patient was discharged. On follow-up with ID on ___ patient was feeling better with the exception of fatigue. Labs drawn at that time remarkable for leukocytosis to 14.8. The patient subsequently developed fever to 101.4, sore throat, and burning epigastric pain. On the recommendation of ID, she presented to the ED. CXR with interval improvement in RML opacity. UA negative. Rapid respiratory viral screen sent but specimen was inadequate. Patient was treated with 1 day of aztreonam and clindamycin IV for possible pneumonia. She was never febrile in the hospital and reported that her symptoms improved overnight. Given resolution of the opacity on CXR and resolution in symptoms with the exception of sore throat and nasal congestion, antibiotics discontinued on HD#2. Per ID, patient was discharged on 6 days of clindamycin 300 mg PO Q6H to cover for possible bacterial infection. Follow-up with Dr. ___ was scheduled. # Sore throat: Likely viral syndrome. Treated as above. # GERD: Epigastric pain on admission most likely due to GERD vs. mild gastritis. Symptoms resolved spontaneously. CHRONIC ISSUES # Severe atopic dermatitis: Extensive confluent maculopapular rash. Continued home skin regimen. # Osteopenia: Continued home calcium and vitamin D. # Multiple allergies: Continued home hydroxyzine. TRANSITIONAL ISSUES - Discharged on clindamycin 300 mg PO Q8H for 6 days - Consider PPI if patient has further issues with abdominal pain - Follow-up with ID scheduled - Follow-up with PCP scheduled</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 unclear history of Crohns disease and previous partial SBOs managed conservatively. He presents today with 3 days of abdominal pain, nausea, and low-grade fevers to 100.4F. Yesterday evening he had a syncopal episode, which he says happens whenever he has an obstruction. He presented to ___ following his syncopal episode. A CT A/P was performed, which showed dilated small bowel and stomach with a decompressed colon and mild ascites. There is no evidence of perforation or pneumatosis. He had on ___ surgery was consulted for management of partial SBO. Radiology showed Small-bowel obstruction with transition point in the right lower quadrant and associated small amount of ascites and mesenteric edema. No free air. Chest radiograph. showed Enteric tube terminates overlying the expected location of stomach. MR ___ showed 1. Resolving partial small bowel obstruction. Edematous segment of ileum just proximal to the transition in the right lower quadrant is likely related to obstruction. No specific or convincing MR evidence of inflammatory bowel disease. 2. Persistent but decreased interloop fluid and mesenteric edema. 3. Distended stomach without mechanical obstruction. Notably stomach was also distended on prior CT. When small-bowel obstruction resolves consider gastric emptying study to evaluate for underlying gastroparesis. 4. Small bilateral pleural effusions. The patient was diagnosed with Unspecified intestinal obstruction. At the time of discharge, the patient had Partial small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the Emergency Department on ___. Neuro: The patient was alert and oriented throughout hospitalization; pain was managed with either intravenous morphine or hydromorphone. The patient's pain resolved entirely prior to discharge. 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 and ambulation were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially placed on bowel rest with a ___ tube in place for decompression. On HD 3, given evidence of resolving obstruction, the NGT was removed. On HD 4, he underwent MR ___ to evaluate for evidence of crohn's disease. The MR was suggestive of resolving partial bowel obstruction without definitive evidence of active inflammation, but did not possible delayed gastric emptying. Additionally, per the radiology fellow, there was no evidence of stricture suggesting chronic inflammation. Following the MR, the patient's diet was resumed and advanced to low residue per gastroenterology, which he tolerated without pain, nausea or vomiting. Given po tolerance, he was discharged to home and will follow-up with his gastroenterologist and surgeon as an output for further work-up of possible crohn's disease. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile 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: ___ year old male with no significant medical hx presents with headache, right sided weakness. Patient reports that he has been "feeling off " and persistent headache for the past 5 weeks. He states that today he developed right arm weakness and having difficulty using his right hand. He reports falling on ___ without head strike. On that day was helping his son build a shed, he tripped and fell onto his right leg. He was evaluated at OSH where CT head revealed large left SDH with apprx 11mm MLS. He was medflighted to ___ for further evaluation. Neurosurgery was consulted. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. The patient is status post left-sided craniotomy for drainage of chronic subdural. Improvement in subfalcine herniation. 2. There postoperative changes, including pneumocephalus, and blood products of variable age in the area of the evacuated subdural. The patient was diagnosed with Nontraumatic acute subdural hemorrhage, Altered mental status, unspecified. The patient was treated with ___ L craniotomy for ___ evacuation. At the time of discharge, the patient had Left 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># L ___ Mr. ___ is a ___ male on ASA 81mg with history of fall, no headstrike, with presented to OSH with 5 weeks of headache and feeling off. OSH CT head showed large L acute on chronic SDH. He was transferred to ___ for neurosurgical evaluation. He was admitted to the neuro step down unit and consented for surgery. He went to the OR on ___ for left craniotomy for ___ evacuation. A subdural drain was placed. patient tolerated the procedure well. He was extubated in the OR and transferred to the PACU for recovery. He was alert and joking with family on post-op check with improvement in right sided weakness. He was straight cathed x1 for urinary retention. He remained neurologically and hemodynamically stable and transferred to ___ for further monitoring. Post-op ___ showed pneumocephalus, but with improvement in midline shift. He was started on a nonrebreather mask for 24hrs. Subdural drain was removed on POD#2. He remained neurologically and hemodynamically stable. He was evaluated by physical therapy who recommended discharge home. He was discharged home in stable condition on POD#4.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx ___ Disease and a recent admission for LLL PNA/Empyema s/p decortication, recent discharge ___ for acute renal failure felt to be AIN in combination w DRESS from zosyn, who presents with altered mental status and fall. Patient was brought in by his home health aide who reports that over the past week he has had a change from his baseline mental status with episodes of confusion. She reports today he was not using his walker instead picked up multiple items from his bedroom and brought him into the kitchen for no apparent reason. He then fell to the ground as he was not using his walker. He has additionally noted some cough but no fevers or chest pain. No fevers, chills, n/v/d, abd pain, sputum production, dysuria. He is not quite sure why he is here, denies any knowledge of confusion at home, does endorse falls ___ mechanical reasons. In the ED initial vitals were: 97.5 80 156/79 100% ra - Labs were significant for HCT 31 at baseline. No fevers, no leukocytosis or left shift. CXR w possible LLL consolidation, ED gave ctx/azithro. No UA was sent. Radiology showed Continued interval improvement of the bilateral parenchymal opacities and essentially resolved bilateral pleural effusions. More conspicuous opacity projecting over the heart on the lateral view potentially within the right middle lobe may be atelectasis although infection is not excluded. Radiology showed No acute intracranial abnormality identified. Radiology showed 1. No acute cervical spine fractures identified. 2. Left 5-mm apical lung nodule, overall unchanged compared to the prior exam. A CT in six months is recommended for further evaluation. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. At the time of discharge, the patient had PRIMARY DIAGNOSIS 1. Fall SECONDARY DIAGNOSIS 1. ___ Disease 2. Orthostatic Hypotension 3. Hypothyroidism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ w/ ___ dz, hypothyroidism, multiple recent admissions for PNA/empyema s/p decortication and acute renal failure (AIN) likely from DRESS syndrome ___ zosyn, who presents from home with possible confusion and falls. ACUTE ISSUES #History of Fall/Pre-syncope: From the patient's history, his fall was secondary to not using his walker at home which he uses at baseline due to ___ disease and bradykinesia. He reports no trauma, and his CT head, and CT C spine were negative. He was evaluated by physical therapy, and discharged home with recommendations for discharge home with 24 hour assistance. #Encephalopathy: On arrival to the general medicine floor, the patient had no signs of reduced attention; there was concern for infection in the ED due to a possible LLL infiltrate on CXR, however the pt did not meet SIRS criteria, and had a normal CBC and differential and normal lung exam. All of his electrolytes were normal, in addition to renal and liver functions testing. Thus antibiotics were held on admission. A TSH on admission was low at 0.095. After speaking to his nurse, his medications were reconciled, and he has been taking Levothyroxine 100mcg QD. Given his reduced TSH, his Levothyroxine dose was decreased to 88 mcg QD, which was verbally communicated to his nurse, and he should have repeat TSH testing with his PCP. #Lung nodule: Incidentally found on imaging. Discussed with patient. 6 month follow up recommended CHRONIC ISSUES #Parkinsons dz: The patient was continued on his home medications including Carbidopa-Levodopa and Pramiprexole. #Hypothyroidism: The patient's home Levothyroxine dose was decreased to 88 mcg as described above. #Orthostatic Hypotension: The patient was discharged to continue his home Fludrocortisone. TRANSITIONAL ISSUES -please check repeat TSH as levothyroxine dose was decreased to 88 mcg given low TSH of 0.095 on admission. Prior dose was 100mcg -pls consider bed alarm at night to avoid future falls. -pls institute fall precautions and monitor pt at all times during the day to avoid falls. Pls ensure pt uses walker or wheel chair at all times -Pt was found to have a Left 5-mm apical lung nodule, overall unchanged compared to the prior exam. A CT in six months is recommended for further evaluation. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old gentleman s/p fall on ___ while vacationing in ___. Per report, he was getting ready to leave his friend's house and while putting on his shoes fell forward. Immediately after the fall was unable to move his extremities. When the patient arrived to the ___, he was able to move arms (proximally) but was unable to move hands. MRI C-spine revealed severe degenerative changes with severe cord compression at C3-7 with T2 signal changes. The patient was inpatient for approx. 8 days and received physical therapy/occupational therapy. Per the patient, insurance would no longer cover therapies and was transported back to the ___ for further treatment. He subsequently presented to ___ ___ and then transferred to ___ for spine evaluation. MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE showed 1. Mild prevertebral soft tissue edema in the C4 through C5 levels with minimal heterogeneity of the anterior longitudinal ligament, may be degenerative in nature, though given the history of trauma, ligamentous injury cannot be excluded, though no frank tear is seen. 2. Heterogeneous bone marrow signal and edema spanning the C3 through the C6 levels is likely degenerative, though fracture is difficult to assess given the background signal abnormality. 3. Severe spinal cord impingement with cord signal abnormality spanning the C3-C4 through C5-C6 levels compatible with edema or myelomalacia. 4. Severe multilevel cervical spondylosis, as described, with severe spinal canal narrowing and cord compression at multiple levels and severe neural foraminal narrowing at multiple levels. 5. Millimetric bilateral thyroid nodules measure up to 3 mm. No further evaluation is necessary. RECOMMENDATION(S): 1. If there is continued concern for fracture, consider further evaluation with CT or comparison to priors, if available. 2. 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. CHEST (SINGLE VIEW) showed Mild left infrahilar opacity, likely atelectasis. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. Suggestion of hairline nondisplaced fracture right C1 transverse process. 2. There is severe degenerative arthritis of the cervical spine with severe central canal narrowing, cord flattening at C3-C4, C4-C5, C5-C6 levels. CERVICAL SINGLE VIEW IN OR showed Images obtained for surgical purposes C-SPINE SGL 1 VIEW showed No previous images or image of the type of catheter involved. No evidence of abnormal opaque catheter on the single frontal view presented. MRI THORACIC AND LUMBAR PT6 MR SPINE showed 1. Relatively low bone marrow signal suggests some degree of red marrow reconversion, which may be secondary to anemia, smoking, or chronic systemic illness, including chronic cardiac, liver, or renal disease. An infiltrative process is less likely. Please correlate with clinical history and laboratory data. 2. Incompletely evaluated postsurgical changes in the cervical spine. Myelomalacia at C4 is again noted. 3. Normal appearance of the thoracic spinal cord. No significant thoracic spinal canal narrowing. 4. Partially sacralized L5. 5. Thoracolumbar scoliosis. 6. Multilevel degenerative disease and prominent posterior epidural fat and lumbar spine, as detailed above, with moderate to severe thecal sac narrowing at L2-L3, moderate thecal sac narrowing at L3-L4, and mild to moderate thecal sac narrowing at L4-L5, and with mass effect on multiple traversing and exiting nerve roots in the lumbar spine, as detailed above. The patient was diagnosed with Unspecified cord compression. The patient was treated with ___: Posterior bilateral laminectomy C3-C4, C5-C6, and superior C7; also, proximal foraminotomies C3-4 on the left, C5-6 on the right, and C6-7 on the left.. At the time of discharge, the patient had C3-C6 spinal cord compression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a pleasant ___ year old gentleman who was transferred to ___ from ___ on ___ for evaluation of cervical spinal cord compression after a fall sustained on ___. #Cervical Spine Compression: He was admitted to the Neurosurgery service for preoperative assessment. His cervical spine was immobilized in an Aspen collar. He underwent a posterior bilateral laminectomy C3-C4, C5-C6, and superior C7 with proximal foraminotomies left C3-4, right C5-6, and left C6-7 on ___. Please see separately dictated operative report by Dr. ___ for full detail. Hemovac drain was left in place following surgery. The patient was instructed to continue Aspen cervical collar at all times when out of bed for 10 days following surgery. His neurologic examination was stable postoperatively and remained notable for four-extremity paresthesias as well as decreased grip strength. The patient was evaluated by physical and occupational therapy who recommended acute rehabilitation following discharge. #Urinary Tract Infection: Preoperative urinalysis was consistent with urinary tract infection. The patient was initiated on 7-day course of ciprofloxacin, which he will plan to complete following discharge. #Urinary Retention The patient was admitted with foley catheter in place given urinary retention. He underwent repeat voiding trial on ___ and was unable to void. The foley was replaced with plans for follow-up with Urology in one week. An MRI of the thoracis and Lumbar spine was performed to rule out neurologic cause for urinary retention. It showed diffuse disc bulge at L2-L3 flattens the anterior thecal sac with crowding of the nerve roots. No severe spinal canal narrowing at any level. No abnormal signal abnormalities in the thoracic spinal cord. MRI reviewed with Neurosurgeon on-call, consistent with epidermal lipomatosis. At the time of discharge, the patient's vital signs were within normal limits and neurologic examination remained stable. He stated that his pain was adequately controlled. He was able to tolerate oral intake without nausea and vomiting. The patient was ambulating with supervision. Foley catheter was in place. Patient feels when his foley catheter is tugged, and also felt the insertion of catheter. He is able to feel normally when he wipes his anus. He is able to feel the urge to urinate, just unable to initiate stream. He will plan to follow up with Dr. ___ Urology following discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yoF with h/o ischemic CVA not on AC, COPD, lung cancer s/p lobectomy, and ___ transferred from ___ for evaluation of T4 compression fracture s/p mechanical fall. She lost her balance while trying to get into car and fell. She struck the back of head. She denies LOC but daughter notes she was somewhat dazed and confused after fall. She denies chest pain, palpitations, lightheadedness/dizziness, sweating, numbness/tingling or any unusual symptoms prior to the fall. Her laceration was stapled at ___. She normally uses a walker, lives with her family at home. In the ED, initial vital signs were: 97.6 79 164/74 16 94%RA - She was noted to be dizzy with low blood pressure upon standing - Labs were notable for: CBC and chem-7 nl, trop neg x2, UA neg - CXR showed small region of possible PNA or bronchiolitis of RLL - OSH Imaging: CT torso: smooth indentation in superior endpoint of T4, patchy tree in ___ nodules in RLL, no dominant mass. Head CT: negative CT c spine: called ___- negative - Patient was given: 2L NS, ASA 162, levofloxacin 750 IV - NSGY was consulted and recommended f/u in 2 weeks with Dr. ___ On Transfer ___ were: 97.2 75 161/54 14 98%RA Chest radiograph. showed 1. SMALL REGION OF POSSIBLE PNEUMONIA OR BRONCHIOLITIS, RIGHT LOWER LOBE, BEST APPRECIATED ON OUTSIDE CT PERFORMED ___. 2. SEVERE EMPHYSEMA, PULMONARY FIBROSIS, AND BRONCHIECTASIS. UNILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right lower extremity veins. The patient was diagnosed with Oth fracture of fourth thoracic vertebra, init for clos fx, Unspecified fall, initial encounter. At the time of discharge, the patient had PRIMARY: Mechanical fall with T4 compression fracture SECONDARY: CVA ___ with residual right lower extremity weakness COPD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yoF with h/o ischemic CVA not on anticoagulation, COPD, lung cancer s/p lobectomy, and ___ transferred from ___ for evaluation of T4 compression fracture s/p mechanical fall, admitted for presumed pneumonia based on chest x-ray findings and reported cough and shortness of breath. Patient's fall was thought to be secondary to progressive weakness of her right lower extremity, which she has had since CVA in ___. She appears to have had multiple falls over the past month due to buckling sensation of her right leg upon walking. Other etiologies to fall, including orthostatic hypotension, cardiac event, and infection, were ruled out. Neurosurgery evaluated her in the ED and recommended outpatient follow-up in 2 weeks. Physical therapy evaluated her and recommended discharge to rehab to increase strength and mobility. However the patient declined and would prefer home ___. Patient was also evaluated by speech and swallow and found to be aspirating on thin liquids. The patient was given information on thickening liquids. Patient was admitted for pneumonia given report of cough and shortness of breath, as well as CXR and CT torso showing signs suggestive of pneumonia. However, she clinically did not appear to have pneumonia given lack of fever, hypoxia, leukocytosis, or new shortness of breath or cough. She stated that her current cough and dyspnea were chronic from her COPD. Of note, she was admitted at OSH from ___ for pneumonia and treated with levofloxacin. It was therefore thought that radiographic findings were residual from her recent pneumonia and not indicative of an active infection. Given her COPD patient was started on tiotropium and advair. She should follow up further titration.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ gentleman with history of alcohol abuse who presents after a fall down 15 stairs while intoxicated. He was assessed by the trauma service yesterday evening and his collar was cleared. This morning, after regaining sobriety, he complained of severe hand weakness as well as lower extremity weakness limiting his ability to ambulate. He has since ambulated with physical therapists, however, he continues to have subjective leg weakness as well as numbness and tingling on the soles of his feet. He denies any incontinence of bowel or bladder or saddle anesthesia. He has severe weakness in his hands and states that he is unable to cross his fingers, his hand grip is weak and his finger extension is also weak. He has numbness and tingling which is worse on his bilateral middle, ring, and small fingers. He denies significant neck pain. He does endorse a history of mild, chronic neck pain for the past ___ years which has been diagnosed as degenerative disc disease. He denies pain other problems or joints. Radiology showed No acute findings. CT HEAD W/O CONTRAST showed No acute intracranial process. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST showed 1. No acute fracture. 2. Relative lucency surrounding the right maxillary canine which should be correlated for possible loosening. CT C-SPINE W/O CONTRAST showed No acute fracture or traumatic malalignment. CT torso showed No acute sequelae of trauma. MR ___ WAND W/O CONTRAST ___ MR ___ SPINE showed 1. Prevertebral edema extending from C2 through at least T3, most pronounced from C3 through C5, with suggestion of anterior longitudinal ligament strain, without clear disruption. 2. Disc herniation at ___ be traumatic in etiology contributing to severe spinal canal stenosis at this level. There is edema of the spinal cord at this level secondary to trauma. 3. T2 hyperintensity along the posterior paraspinal muscles from C2 through C6 is suggestive of interspinous ligament strain. 4. Multilevel degenerative changes as described above. Possible ___ changes at C6-C7 versus bony contusion in the setting of trauma. Radiology showed No acute fracture or dislocation. Degenerative changes, as above. Radiology showed No acute fracture or dislocation of the bilateral hands. Degenerative changes, as above. CR - CHEST PORTABLE AP showed No pneumonia or acute cardiopulmonary process. The patient was diagnosed with Laceration without foreign body of nose, initial encounter, Fall (on) (from) unspecified stairs and steps, init encntr, Syncope and collapse, Alcohol abuse with intoxication, unspecified. At the time of discharge, the patient had Central Cord. The patient was given written instructions concerning 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 for observation to ensure that he recovered from his injury. pnemoboots were used for DVT prophylaxis. Pain was controlled with IV and PO pain medications. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Physical therapy was consulted for mobilization OOB to ambulate. 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: ___ is a ___ year-old woman with an inflammatory bowel disease felt to be Crohn's who had an abdominal colectomy with end ileostomy in ___ at an OSH, s/p ileostomy revision due to prolapse in ___ and now ___ s/p lap proctectomy who presents with pain and swelling at her perineal incision. She was evaluated by her PCP 1 day prior and started on Keflex and cipro for concern of cellulitis. On exam, she reports feeling generally unwell for the past few days and a new pressure sensation near her incision. She notes her drain has ~80 cc of serosanguinous output each day. She denies fevers, chills, chest pain, shortness of breath, nausea, vomiting, changes in ileostomy output, or difficulty voiding. CT ABD AND PELVIS WITH CONTRAST showed 1. Postoperative changes in the presacral space with soft tissue stranding and heterogeneous hypodense non organized fluid measuring up to 2.0 cm in the postsurgical bed, likely a seroma. No organizing or rim enhancing fluid collections. 2. Of note, physiologic bilateral adnexal cysts are noted superior to the presacral postoperative changes, and should not be mistaken for fluid collections. 3. No bowel obstruction. 4. Nonobstructing right renal stone measuring 3 mm. The patient was diagnosed with Other specified diseases of anus and rectum. At the time of discharge, the patient had Crohn's disease with retained rectum. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented to ___ ED on ___ for pain and swelling along her incision s/p lap proctectomy. She was admitted for further workup. Neuro: Pain was well controlled on Tylenol and tramadol for breakthrough pain. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulm: The patient remained stable from a pulmonary standpoint; oxygen saturation was routinely monitored. He/She had good pulmonary toileting, as early ambulation and incentive spirometry were encouraged throughout hospitalization. GI: The patient was initially kept NPO. Patient's intake and output were closely monitored. GU: At time of discharge, the patient was voiding without difficulty. Urine output was monitored as indicated. ID: The patient was closely monitored for signs and symptoms of infection and fever. CT imaging did not reveal a drainable fluid collection. Examination of the incision site did not indicate active infection. She was initially started on Cipro and flagyl empirically which was discontinued. She had concern for a yeast infection predating the admission and exacerbated by the antibiotic infusion. Heme: The patient received subcutaneous heparin and ___ dyne boots during this stay. She was encouraged to get up and ambulate as early as possible. The patient is being discharged on prophylactic Lovenox. On ___, the patient was discharged to home. At discharge, She will follow-up in the clinic. This information was communicated to the patient directly prior to discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with h/o EtOh abuse brought in intoxicated complainting of chest pain radiating down L arm for the past several hours. He has had this kind of chestp ain before. Also feels short of ___. Admits to EoH use. Radiology showed No definite acute cardiopulmonary process. The patient was diagnosed with ALCOHOL ABUSE-UNSPEC, ATRIAL FIBRILLATION. At the time of discharge, the patient had Primary diagnosis: Alcohol intoxication Multifocal atrial tachycardia Secondary diagnosis: 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>Patient left against medical adivce. He was able to voice that he was leaving against medical advice and understood the risks of leaving against medical advice. He was advised that if his symptoms worsened, then he should return to the ED to be re-evaluated. #Atrial fibrillation/atrial multifocal tacyhcardia: Patient has a history of paroxysmal atrial fibrillation and has presented to ED in RVR previously. Converted to sinus after 2L NS. The patient reports that drinking can exacerbate his heart rhythm. It was planned for him to received metoprolol 12.5mg QID, but the patient left AMA. Of note, cardiac enzymes were negative. #History of alcohol abuse: Patient was placed on CIWA scale upon admission. He was given a banana bag as well. The patient also had LFTs that were elevated likely due to his recent alcohol ingestion. The patient's LFTs were noted to be downtrending.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with PMH significant for CAD, CHF with preserved ejection fraction, Gold Stage IV COPD on 2L O2 baseline, diabetes type 2 on insulin, morbid obesity, sleep apnea, h/o hypercarbic respiratory failure ___, recurrent b/l lower extremity ulcers, h/o cocaine use, ___ heavy alcohol use, who presented from clinic today for unilateral L leg swelling x 2 weeks. She reports gradual swelling, left greater than right. No fevers/chills, no significant burning or pain, just increased pressure. She reports a discomfort at the bottom of her feet, left greater than right. No trauma, no rash. She also reports a single episode of chest pressure in her left chest that came on at rest with no inciting features, lasted 5 seconds, and did not recur. She never has anginal symptoms while climbing stairs or otherwise exerting herself. At her PCP office, her left leg was noted to be enlarged compared to the right and she was referred to the ED for lower extrem doppler. In the ED initial vitals were: 97.5 70 121/80 18 98% 2LNC. Note was made of weeping RLE concerning for cellulitis. Chest: Frontal and lateral views showed Persistent prominence of the hila suggesting pulmonary vascular engorgement/enlargement of the central pulmonary arteries, similar to prior, with possible mild increase in vascular congestion as compared to prior study. BILAT LOWER EXT VEINS showed Less than optimal due to body habitus. The peroneal veins were not seen bilaterally. Otherwise, no evidence of deep venous thrombosis in the bilateral lower extremities. The patient was diagnosed with CELLULITIS OF LEG. At the time of discharge, the patient had Primary diagnoses: Chronic venous statis, venous stasis ulcer, cellulitis Secondary diagnoses: Paroxysmal a fib, copd, obesity, DM. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ AAF with diabetes, CHF, COPD, recurrent multi-drug resistant UTI and multiple comorbidities presents with lower exrem swelling, L>R, as well as dysuria with pyuria on U/A. ___ grossly negative for PE but not conclusive. CXR shows potentially mild increase in pulmonary vascular congestion but exam less concerning for fluid overload as cause and patient satting well on baseline oxygen. Exam showed chronic venous stasis changes with developing ulcer on left medial leg and some erythema concerning for possible overlying cellulitis. Pt overall afebrile, satting ___ home oxygen, vital signs stable, deemed safe for discharge home on antibiotics for cellulitis and to follow-up management of chronic venous insufficiency.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ PMH notable for HTN/HLD, IDDM, and RCC s/p nephrectomy (___) c/b CKD that presents w/ 5days of pain/swelling/erythema of R forearm/elbow. ___ Radiology showed Mild soft tissue swelling about the elbow without joint effusion. No acute fracture or dislocation. The patient was diagnosed with Cellulitis of right upper limb. At the time of discharge, the patient had Right forearm cellulitis and potential septic olecranon bursitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the hand surgery team. The patient was found to have a Right forearm cellulitis and potential septic olecranon bursitis and was admitted to the hand surgery service. The patient was started on IV ancef, which resulted in improvement in symptoms. The patient was given anticoagulation per routine, and the patient's home medications were continued throughout this hospitalization. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the Right upper extremity. He will take oral cefadroxil for 7 days for antibiotic therapy. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old gentleman with a PMH of non-ischemic dilated cardiomyopathy (EF 20%), COPD, previous PNAs, now admitted with dypsnea and chest pain. Of note, he was admitted to ___ for acute decompensation of CHF ___. Radiology showed Similar appearance of moderately increased interstitial lung markings suggestive of pulmonary fibrosis. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS. At the time of discharge, the patient had Acute on chronic systolic heart failure Acue on chronic kidney injury Restrictive lung disease Diabetes Mellitus 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>Mr. ___ is a ___ year-old gentleman with a PMH of non-ischemic dilated cardiomyopathy (EF 20%), COPD, previous PNAs, admitted with dypsnea and chest pain. ACTIVE ISSUES # Dyspnea: Dyspnea was thought to be multifactorial from acute on chronic systolic HF, cocaine induced pulmonary fibrosis, and COPD flare. He has a baseline LVEF of ___ from his previous echo. On physical exam, he demonstrates all the classic signs of heart failure (elevated JVP, crackles in the lungs, and lower extremity edema). Patient is not on a beta-blocker due to ongoing cocaine use, and not on spiranolactone due to non-compliance. He was diuresed with IV lasix and continued on home losartan, digoxin, atorva and aspirin. He required 3L nasal cannula, which was weaned off with diuresis. For his subjective SOB he was given nebs, which improved his symptoms. At discharge, his weight was 85.3 kg. # Chest Pain: His chest pain was unlikely to be ischemic in nature given that his troponin is around his baseline level of 0.04 to 0.10 and an ECG showing no signs of ischemia. It was described as chronic and intermittent. He was monitored on telemtry without any events. CHRONIC ISSUES # CKD: His baseline creatinine level is around 1.3 to 1.5 with elevations to 2 occasionally. Usually, he presents with an elevated creatinine from baseline on presentation and trend down during the course of hospitalization. He presented with Cr 1.7 which trended down to his baseline and was thought that in the setting of decompensated heart failure, he had poor forward flow to the kidneys. # COPD: Stable. Continued albuterol nebs at needed. # Diabetes: Stable. His last HbA1c was 7.9 on ___. Continued reduced regimen of insulin glargine 40 units at breakfast and bedtime and titrated up to home regimen with insulin sliding scale AC and HS # GERD: Stable. Continued home omeprazole. # Anxiety: Continued home lorazepam as needed. TRANSITIONAL ISSUES: - At discharge, patient was referred to ___ ___/ ___ Counseling as part of discharge plan. - At the time of discharge, blood cultures x2 from ___ had not finalized. As of ___, there was still no growth to date. - CODE: confirmed FULL - EMERGENCY CONTACT: ___ (sister), ___, alternatively, ___ (sister), ___, ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS: Radiology showed Right-sided vascular access catheter tip at the cavoatrial junction. Cardiomediastinal silhouette is at upper limits for normal for size. Small-to-moderate bilateral pleural effusions with compressive atelectatic changes. Bilateral atelectatic changes. There are no pneumothoraces. Mild degenerative changes the left shoulder joint. CT LOWER EXT W/C RIGHT showed 1. Soft tissue edema involving the entire calf and visualized knee, and skin thickening, predominantly posteriorly is most consistent with cellulitis. 2. No evidence for necrotizing fasciitis. 3. Trace knee joint effusion. UNILAT LOWER EXT VEINS RIGHT showed 1. Right calf veins were not evaluated due to patient pain. Otherwise, no deep venous thrombosis visualized in the right femoral and popliteal veins. 2. Significant soft tissue swelling in the right popliteal fossa. 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>TRANSITIONAL ISSUES =================== [] Patient was not able to attend IVIG appointment for NHL. Please ensure this is rescheduled (per oncologist, defer until infection has resolved). [] CXR demonstrated stable pleural effusions since CT chest from ___. Please f/u for symptoms and repeat CXR to assess for resolution. [] Patient and husband reported desire to re-establish care with a psychiatrist/therapist and may need assistance to accomplish this. [] Patient should re-establish care with cognitive neurology. [] Patient should be referred to ___ wound clinic # CODE: FULL # CONTACT/HCP: Husband (___) ___ (cell)</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of acute RLE ischemia due to popliteal occlusion, s/p most recently in ___, angiojet angioplasty and popliteal stent placement. He has been intermittently compliant with medications. His last episode of rest pain in ___ resulted after discontinuing his aspirin. After his ___ procedure, he was discharged on ASA81 and Plavix x1 month and lifelong xarelto. He stopped his aspirin "months ago" and stopped his xarelto on ___. On ___ he noted severe rest pain that woke him up from sleep, in the RLE calf. This resolved when he moved his extremity and bent his leg to the side. He resumed his xarelto the following day and his pain has since improved but has not resolved. He is now able to walk ___ yards, and was able to take the bus to the hospital without pain. He intermittently will have rest pain which will shortly resolve. Of note, ABI in the ED was 0.81. Radiology showed No acute cardiopulmonary process. ART DUP EXT LO UNI;F/U RIGHT showed Essentially occluded right popliteal artery stent with minimal flow in the calf vessels. NOTIFICATION: Findings were communicated via phone at 10:00 AM on the day of the study by the sonographer to the ordering physician. ART EXT (REST ONLY) showed On the right, outflow arterial disease at the level of the popliteal artery with severely decreased resting ABI. On the left, outflow arterial disease at the level of the popliteal artery with mildly decreased resting ABI. The patient was diagnosed with Other disorder of circulatory system, Pain in right ankle and joints of right foot. The patient was treated with ___ - R angiojet thrombolysis & popliteal stent placement. At the time of discharge, the patient had right limb ischemia. The patient was given written instructions concerning 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 ___ M w/ hx of PAD and right lower extremity limb ischemia who was admitted to the ___ ___ on ___. The patient was taken to the endovascular suite and underwent R angiojet thrombolysis & popliteal stent placement. For details of the procedure, please see the surgeon's operative note. The patient tolerated the procedure well without complications and was brought to the post-anesthesia care unit in stable condition. After a brief stay, the patient was transferred to the vascular surgery floor where he remained through the rest of the hospitalization. Post-operatively, he did well without any groin swelling. he was able to tolerate a regular diet, get out of bed and ambulate without assistance, void without issues, and pain was controlled on oral medications alone. He was deemed ready for discharge, and was given the appropriate discharge and follow-up instructions.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with history of insulin-dependent diabetes mellitus, cerebrovascular accident, dementia, diastolic heart failure, and recent admission for complete heart block with permanent pacemaker placement and possible seizure who was transported from her assisted living facility after she was noted to be confused and hypogylcemic to ___ despite oral glucose. In the ED, she was afebrile (98.8), normotensive, and mildly bradycardic (58) and received 25g of D50, with improvement in fingerstick blood glucose to 125. Rectal temperature less than 1 hour later was documented as 93, but she was otherwise hemodynamically stable. EKG at that time showed atrioventricular pacing at 59. Bair hugger was applied and warmed normal saline infused. Blood cultures were drawn, and she was started on vancomycin/levofloxacin for possible retrocardiac opacity. Noncontrast head CT was negative. Temperature and fingerstick blood glucose had normalized by the time of transfer to the floor. The patient was diagnosed with IDDM W SPEC MANIFESTATION, ALTERED MENTAL STATUS . At the time of discharge, the patient had Primary: Hypoglycemia Hypothermia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ with history of insulin-dependent diabetes mellitus, cerebrovascular accident, dementia, diastolic heart failure, and recent admission for complete heart block with permanent pacemaker placement and possible seizure who was transported from her assisted living facility after she was noted to be confused and hypogylcemic to ___ despite oral glucose. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ male with a PMHx AF on ASA, HTN, HL, systolic dysfunction, and lumbar stenosis s/p decompression/fusion L2/3 and L3/4 who presents with left face/arm/leg weakness. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. No acute intracranial abnormality. 2. Patent intracranial vasculature without significant stenosis, occlusion, or aneurysm. 3. Patent cervical vasculature without significant stenosis, occlusion, or dissection. 4. Minimal areas of white matter hypodensity likely reflecting chronic small vessel ischemic disease. 5. Minimal paranasal sinus disease, as described. MR HEAD W/O CONTRAST T9113 MR HEAD showed 1. White matter hyperintensities suggesting chronic small vessel ischemia. Otherwise normal study. CHEST (PORTABLE AP) showed Comparison to ___. Mild elevation of the left hemidiaphragm with subsequent left basilar atelectasis. Mild elongation of the descending aorta. No pneumonia, no pulmonary edema. Borderline size of the cardiac silhouette. LEFT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the left lower extremity veins. The patient was diagnosed with Cerebral infarction, unspecified. The patient was treated with tPA at ___ on ___. At the time of discharge, the patient had TIA, chronic left-sided 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>___ is a ___ year old man with hypertension, hyperlipidemia, atrial fibrillation L (on ASA), and chronic spine disease with resultant baseline left-sided weakness. He presented to an OSH on ___ with acute worsening of his baseline left arm and leg weakness. There, he was found to also have left-sided facial weakness and his initial ___ stroke scale was 5. He was given tPA and then transferred to the ___ neurology stroke service. His MRI brain did not show evidence of an acute stroke. His left facial weakness resolved but his left arm and leg weakness persisted. Altogether, we were suspicious of a TIA as the cause of his worsening symptoms, but an acute worsening of his chronic left limb weakness secondary to pain was also considered. He has several factors that puts him at risk for having strokes in the future, including: - Atrial fibrillation - Hypertension - Hyperlipidemia, although this has been well controlled with Atorvastatin (LDL 66) Because of his atrial fibrillation, we discontinued his home aspirin and started apixaban (5 mg BID). He was in atrial fibrillation throughout his admission, occasionally in RVR. His PO metoprolol was increased and then converted to Toprol XL. He required one dose of IV diltiazem for RVR. He had an echocardiogram as a part of his stroke work-up which showed a severely decreased LVEF of 23%. He developed severe left neck and shoulder pain while in the hospital which seemed to be musculoskeletal in nature, as he had spasms of his cervical paraspinal and trapezius muscles. He was continued on his home pain medications as well as lidocaine patches and Flexiril. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with a PMH significant for tardive dyskinesia (? secondary to prolonged Clozapine exposure), bipolar disorder, multiple abdominal surgeries (Roux-en-Y gastric bybass, distal pancreatectomy, splenectomy, revision of gastrectomy/choledochojejunostomy), Vit D/Vit B12/testosterone deficiency, and anemia of chronic disease who presents as unrestrained driver in ___. Per report he was unrestrained driver who struck the highway barrier whereafter his car spun around 180 degrees. The patient was found on the passenger side of the car. EMS found the patient confused and unable to answer questions. They could not obtain IV access and found the patient to be hypotensive with a systolic pressure blood pressure of 80. For this an interosseous access was established. Upon arival he was initially noted to have GCS of 14 with slow speech and was somnolent. Patient was initially found to not be responsive to commands, and he did not remember the event. He complained of left forearm pain, nose pain (fracture nose last week with planned surgical repain in ___ in ___ weeks), and headache. Radiology showed Bilateral upper lobe right greater than left opacities, similar compared to prior study. Radiology showed No acute intracranial process. Buckled right nasal bone fracture. These findings were discussed with the surgical team at 12:45 p.m. on ___ in person. Radiology showed No acute fracture or malalignment. These findings were discussed with surgical team at 12:45 p.m. on ___ in person. Radiology showed 1. No acute intrathoracic injury. No acute intra-abdominal injury. 2. Bilateral upper lung opacities with nodularity, likely represent scarring from prior infection; however, acute infection in this area cannot be ruled out. This is similar in appearance compared to CT chest on ___. 3. Segmental fracture of the radius and fracture of the ulna better described on concurrent radiographs of the forearm. 4. Incidental note is made of 6-mm calcified right thyroid nodule. 5. Bilateral renal cysts. Radiology showed Dispalced segmental fracture of the radius and fracture of the mid-to-distal ulna as described above. Evaluation of the wrist is limited due to overlying cast or splint material. Radiology showed Intraoperative images from ORIF of a comminuted radius and ulna fracture. Radiology showed Nondisplaced fracture of the base of the right long finger proximal phalanx. Radiology showed Nondisplaced fracture of the base of the right long finger proximal phalanx. Radiology showed 1. Small non-occlusive right upper lobe subsegmental acute pulmonary embolus. 2. Substantially increased bilateral lower lobe consolidations, which likely include a large component of atelectasis, but superiorly are concerning for pneumonia or aspiration. 3. Right thyroid calcification. These findings were reported to Dr. ___ by Dr. ___ by telephone at 10:36 a.m. on ___ at the time of discovery of these findings. Radiology showed No bilateral lower extremity DVT. The patient was diagnosed with FX FOREARM NOS-CLOSED, MV COLLISION NOS-DRIVER, TETANUS-DIPHT. TD DT, BARIATRIC SURGERY STATUS . The patient was treated with 1. Irrigation and debridement down to and inclusive of bone of open ulna and radius fracture. 2. Open reduction internal fixation both-bones forearm fracture including segmental radius and ulnar shaft. 3. Examination under anesthesia distal radioulnar joint for joint stability.. At the time of discharge, the patient had s/p Motor vehicle crash Injuries: Nasal bone fracture Left ulnar & radius fractures Right ___ phalanx fracture 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>He was admitted to the Acute Care Surgery team. Orthopedics consulted for the fractures in his left forearm and he was taken to the operating room for repair of these injures. Postoperatively he was noted to have significant swelling and was monitored closely for compartment syndrome. His compartments on exam did remain soft and the swelling decreased significantly with elevation using a stockinette attached to IV pole. His right middle finger fracture was evaluated by Hand Surgery. His finger remained splinted while discussions for operative repair were underway. Occupational therapy was consulted for splinting of his extremities. He was taken to the operating room again on ___ for repair of his finger fractures and nasal fracture (of note, was an exacerbation of an old nasal fracture and elective repair had been scheduled prior to this injury). Following the procedure, he desaturated in the PACU requiring re-intubation. This is believed to be from residual anesthetic. He was admitted to the SICU. Over the next ___ hours, he was weaned from the ventilator and extubated without incident. He was bronched prior to extubation and purulent secretions were found. His chest x-ray at that time showed bilateral atelectasis with mild hilar congestion. He was started on Cipro which will continue through ___. He was transferred to the floor the following day hemodynamically stable. He did require intermittent nasal oxygen once transferred form the ICU and was continued on nebulizer treatments. He was noted with pain control issues postoperatively and was initially started on MS ___ with oral ___ for breakthrough pain. Because of some mental status changes felt likely from the narcotics these were stopped and he was started on around the clock Tylenol and standing Ultram. He was also seen by Physical therapy given his history of frequent falls. It is being recommneded that he go to rehab after his acute hospital stay.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old male who complains of MVC, EJECTION. ___ yo male transferred from outside hospital where he presente after rollover MVC with ejection fom vehicle. Was ambulaory at scene. Found to have SDH, orbital and pelvic fractures. Multiple abrasions. Patient denies LOC. No abdominal pain. Negative C spine CT prior to transfer. +ETOH. Radiology showed No acute intrathoracic abnormality. CT HEAD W/O CONTRAST showed 1. No evidence of intracranial hemorrhage or infarction. 2. Extensive ethmoidal air cell opacification suggestive of hemorrhage in the setting of a facial bone fracture, not well visualized on this non-dedicated examination. NOTIFICATION: Findings were conveyed by Dr. ___ to Dr. ___ telephone at 13:22 on ___, 1 min after interpretation. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST showed Left orbital floor blow-out fracture with resultant it opacification of the bilateral ethmoidal air cells and air-fluid level within the left maxillary sinus. No evidence of ocular muscle entrapment. NOTIFICATION: Findings were conveyed by Dr. ___ to Dr. ___ at 13:29 on ___, 1 min after discovery. Radiology showed No obvious fracture or dislocation. If symptoms persist, consider followup radiographs for further assessment with MRI. The patient was diagnosed with SUBDURAL HEMORR-COMA NOS, FX SACRUM/COCCYX-CLOSED, FX ORBITAL FLOOR-CLOSED, LAC EYELID SKN/PERIOCULR, OPEN WOUND OF LIP, MV TRAFF ACC NEC-DRIVER. At the time of discharge, the patient had Trauma: motor vehicle accident left orbital floor blowout fracture sacral fracture bifrontal subdural hematoma subarachnoid 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 admitted from an outside hospital after being involved in a motor vehicle accident. He reportedly sustained a loss of consciousness. On imaging studies, he was reported to have sustained a left orbital floor blowout fracture, a sacral fracture, a bi-frontal subdural hematoma and a subarachnoid hematoma. He also sustained a laceration to his eye lid and lip. Because of the head injuries, he was evaluated by the Neurosurgery service. The patient was placed on neuro checks and was started on a course of keppra for seizure prophalaxis. During his hospital course, the patient remained neurologically intact. He was evaluated by occupational therapy and no out-patient cognitive evaluation was warrented. Additional injuries to the face included a left orbital floor blowout fracture. The patient was evaluated by the Plastic surgery service who determined that there was no facial instability and no need for surgical intervention at this time. The patient was placed on sinus precautions and the laceration to his upper eyelid and lip were sutured. Upon admission, the patient reported low back pain. Cat scan imaging was done and showed an oblique fracture of the left sacrum. For this, the patient was evaluated by the Orthopedic service. Serial hematocrits remained stable. To further evaluate this, the patient underwent pelvic films which showed a pelvic fracture with a sacral component but no anterior ring injury. This was treated in a closed manner without manipulation. The patient was instructed in TDWB by the physical therapist and was cleared for discharge home. Prior to discharge, the patient met with the social worker who offered referrals for substance abuse resources. On HD #4, the patient was discharged home in stable condition. His vital signs were stable and he was afebrile. He was tolerating a regular diet and his pain was controlled with oral analgesia. He was instructed to follow-up with his primary care provider if he continued to have left knee swelling. Appointments for follow-up were made with the Orthopedic, Neurosurgery, and Plastic Surgery service. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p fall from 12 foot ladder while attempting to cut tree branches at his house. He landed on his right leg and noted immediate pain and inability to weight bear. No headstrike or LOC. He was taken to ___ where xrays demonstrated multiple RLE fractures for which he was transferred to ___. There was also a question of a possible open fracture due to a small plantar poke hole at his foot in close proximity to a ___ digit fracture. He was given ancef and tetanus at the OSH. The patient was diagnosed with FX SHAFT FIB W TIB-CLOS, FX PHALANX, FOOT-OPEN, FALL-1 LEVEL TO OTH NEC, FX METATARSAL-CLOSED. The patient was treated with 1. Operative treatment right tibia fracture with intramedullary nail. 2. Closed treatment right fibula fracture without manipulation. 3. Washout and debridement open fracture, right ___ toe. 4. Closed treatment right metatarsophalangeal dislocation right great toe. 5. Closed treatment ___ and ___ metatarsal fractures with manipulation. 6. Closed treatment right ___ toe with metatarsophalangeal dislocation with manipulation.. At the time of discharge, the patient had 1. Right tibia/fibular fracture. 2. Open right ___ metatarsophalangeal dislocation, great toe. 3. ___ and ___ proximal phalanx fractures, right foot. 4. ___ interphalangeal toe dislocation.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have R tibial shaft fracture and multiple R foot fractures and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for IM nail of the R tibia and closed reduction and washouts of the R foot fractures, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with services 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 heel weightbearing as tolerated in the right lower extremity in a short aircast boot, and will be discharged on Lovenox for DVT prophylaxis. He will be discharged on a 10 day course of Keflex for his open fracture. 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 a ___ y/o female RHD who was cutting an avacado on ___ and sustained a laceration for the volar surface of her left index just distal to the PIP joint. She states she went to ___ where she recieved a tetanus shot, had her hand washed-out and sutured. She states within the first 24 hours she developed spreading erythema and swelling which was significantly worsened over the last 12 hours and thus she presented to the ED. We are consulted by the ED for possible tenosynovitis of the left hand. Radiology showed No fracture, dislocation or evidence of radiopaque foreign body with diffuse swelling of the index finger. The patient was diagnosed with SYNOVITIS NOS. The patient was treated with ___: 1. Irrigation and debridement of flexor tendon sheath. 2. Repair of the flexor digitorum profundus tendon in zone 2. 3. Repair of the radial digital nerve to the index using the operating room microscope.. At the time of discharge, the patient had Left index finger laceration with flexor tendon and digital nerve injury complicated by 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>Ms. ___ was admitted to the Orthopaedic Hand Surgery service following I&D of her left ___ digit with repair of FDP tendon and radial digital nerve on ___. She tolerated the procedure well and was taken to the PACU in stable condition. Intra-operative cultures were taken, which ultimately grew H. influenza and Coag + S. aureus. While in-house, she was given IV Unasyn for empiric antimicrobial coverage. She was given an orthoplast radial gutter splint POD #2. She remained afebrile during her stay. At time of discharge, she was tolerating a regular diet, her pain was well-controlled with oral medications and her clinical exam continued to show improvement. She was discharged home on POD #1 with plan to continue on PO Augmentin for another 12 days. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with PMH significant for cryptogenic cirrhosis c/b variceal bleeding s/p TIPS (___), ascites, hepatic encephalopathy requiring high doses of lactulose, and recurrent right hepatic hydrothorax (used to have to get weekly thoracentesis) on diuretic presenting with confusion and lethargy. Per patient's wife, he has had increasing encephalopathy symptoms (confusion, poor sleep, tremors) despite lactulose Q2h and frequent bowel movements. Has also had worsening pain in his back from a recent fall in the bathroom and has increased fluid retention. In the ED, initial vitals were: 97.4 97 115/68 16 99% RA Labs were notable for: WBC 7.7, H/H 7.3/23.3, plt 82, INR 1.5, normal chemistries with Cr 0.9, lactate 1.7, AST/ALT 67/65 with tbili 1.1, alb 2.5. Serum tylenol level 15, urine tox and rest of serum tox negative. UA unremarkable. Consults: Hepatology was consulted and agreed with infectious work-up and increase in lactulose to treat HE. Admission to liver. Vitals prior to transfer: 97.9 89 129/75 16 98% RA Currently, vitals 97.9 131/54 86 20 100%. Patient floridly delirious, repeating his own name over and over again. ROS: per HPI. Unable to assess further due to HE. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Severely technically limited evaluation of the abdomen. 1. Patent TIPS of wall-to-wall color flow with increased velocities compared to the prior study of ___, however this may be secondary to suboptimal velocity measurement conditions. 2. Patent hepatopetal flow in the main portal vein. 3. Cirrhotic liver with small amount of perihepatic ascites and a right pleural effusion. L-SPINE (AP AND LAT) showed Mild compression deformity at T12 appears to be new when compared to the prior study and acute fracture cannot be excluded. Recommend correlation with clinical examination findings a tenderness in this area to exclude an acute fracture. NOTIFICATION: Findings were discussed with Dr. ___ by telephone at 4.05pm on ___ at the time of discovery. The patient was diagnosed with ALTERED MENTAL STATUS . The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with PMH significant for cryptogenic cirrhosis c/b variceal bleeding s/p TIPS (___), ascites, hepatic encephalopathy requiring high doses of lactulose, and recurrent right hepatic hydrothorax (used to have to get weekly thoracentesis) on diuretic presenting with confusion and back pain. # HEPATIC ENCEPHALOPATHY: On arrival to ED, pt AOx0. No signs of infections (bl cx NGTD, Urine cx NGTD, no ascites), no portal vein thrombosis seen on US. Started on 60mL lactulose Q2H, with resolution of encephalopathy in 24 hours. Transitioned to 30mL Lactulose QID with ___ daily and no signs of encephalopathy. Some concern that patient was not taking lactulose at home as directed. Wife and pt adamant about compliance with medications. Discharged on lactulose 30mL QID with close updates to the liver center. Dr. ___ was contacted and suggested possibly reducing size of TIPS in the future if hepatic encephalopathy continued to be a problem. # ANEMIA: Pt noted to have worsening anemia of Hgb 6.8 from baseline ~8. Given 2U rbc with appropriate bump. No melena, BRBPR. Vit B12, folate, iron, ferritin wnl. Needs outpatient followup. Endoscopy in ___ with grade 2 varices and portal gastropathy, no evidence of bleeding. Colonoscopy in ___ without polyps or evidence of bleeding. # T12 COMPRESSION DEFORMITY: Pt had ongoing back pain from previous hospitalization when he fell off the toilet. XRAY showed T12 anterior compression. No neurologic symptoms. Likely ___ osteoperosis from chronic steroids used to treat adrenal insufficiency. Instructed to take acetaminophen 650mg TID prn, hot packs, ___. Can consider MRI in the future. Pt already set up with outpaitent ___. # Variceal bleed s/p TIPS: Last EGD in ___ with GEJ varices which did not require intervention. # Ascites: h/o TIPS in ___. Recent diagnostic paracentesis on ___ was without evidence of SBP or malignancy. No history of SBP. Lasix and spironolcatone discontinued on recent admission due to hyponatremia. RUQ US without significant ascites in ED. # Cirrhosis: Cryptogenic. MELD 11 on admission, trended up to 16. Patient is on transplant list. # COAGULOPATHY: INR up to 1.9 on ___. Likely from decreased PO intake and frequent bowel movements. Given Vitamin K 5mg once on ___. Received heparin SC as platelets were over 50. # Adrenal insufficiency: Continued home hydrocortisone 15mg TID. No stress dose steroids were given since no signs of infection or hemodynamic instability. Spoke to outpatient endocrinologist, Dr. ___ suggested close followup to reassess steroids. # GERD: Continued home pantoprazole q12h and calcium carbonate. ========================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of COPD, on 4L home O2, presents with dyspnea over the past ___ days. Increased dyspnea is associated with worsening cough and subjective fevers and chills at home. She reports that she can barely ambulate from DOE. She had to sit down when trying to move from her kitchen to her bathroom which is only a shoert distance away. Reports she was hospitalized for pneumonia two weeks ago and is continuing to take a low dose of azithromycin at home as per her pulmonologist's recommendation. Reports a chronic cough but no change in sputum characteristics. Denies chest pain. CHEST (PA AND LAT) TECHNIQUE: Chest radiograph, AP and lateral views COMPARISON: Chest radiograph ___ FINDINGS: There is no pleural effusion, or pneumothorax. Mild bibasilar atelectasis is similar compared to ___. Emphysematous changes are noted in bilateral lungs. Cardiomediastinal and hilar silhouettes are normal size. IMPRESSION: No radiographic evidence of pneumonia. showed No radiographic evidence of pneumonia. The patient was diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION. At the time of discharge, the patient had PRIMARY DIAGNOSIS: ------------------ - COPD exacerbation - Emphysema/COPD - GOLD stage 4 - Chronic hypoxemic-hypercarbic respiratory failure SECONDARY DIAGNOSIS: -------------------- - Hypertension, essential - Essential tremor - Periocular dermatitis - anxiety. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with medical history of COPD, on home Oxygen 4L, presenting with acute on chronic shortness of breath. Active Issues: -------------- # EMPHYSEMA/COPD: GOLD STAGE 4. COPD exacerbation given increased SOB, increased cough and sputum production over the last several days. Trigger for exacerbation unclear, though she does endorse subjective fevers and chills recently, which may be suggestive of a URI; of note, her CXR is without evidence of consolidation. Her D-dimer was negative so imaging for PE was not pursued. Will plan to treat for other causes of chronic cough, including GERD and allergic rhinitis. Continued her home O2 requirement of 4L; she was started on a levofloxacin course for 7 days, end date ___ in the setting of a COPD exacerbation. Levofloxacin was chosen because she had chronically been on azithromycin. She should restart azithromycin 250mg daily as chronic prophylaxis on ___. Continued home long-acting inhalers: Dulera and aclidinium and started standing albuterol and ipratropium nebs. She was also started on prednisone 40mg x7 days, followed by prolonged taper 30mg x1 week, 20mg x1 week, 10mg x1 week- pulmonologist Dr. ___ was made aware. She was also given a proton pump inhibitor to treat for GERD and loratidine and fluticasone proprionate for allergic rhinitis. ___ consult recommended acute ___ rehab vs LTAC. # Periorbital dermatitis: Improved and resolving. History of eczema. Most likely in the setting of seasonal allergies vs. other allergic exposure such as contact. Dermatomyositis felt unlikely given no proximal muscle weakness or evidence of myopathy on exam. Improved with supportive management. Recommend hydrocortisone cream x1 wk if patient is willing Chronic Issues: ---------------- # HTN: held home meds for now, with plan to restart at time of discharge # Anxiety: continued home medications ***TRANSITIONAL ISSUES*** - will need prolonged steroid taper: Prednisone 40mg x1 week, 30mg x1 week, 20mg x1 week, 10mg x1week, and possibly indefinite steroids. - treated with Levoquin in setting of COPD exacerbation, end date ___ - restart azithromycin 250mg daily on ___ - goal O2 sats on 4L NC should be 90-95% - consider outpatient palliative care given her end stage lung disease to discuss future goals of care with regards to hospitalization, potential for repeat tracheostomy, etc. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old gentleman with history of aortic stenosis currently undergoing TAVR workup, CAD s/p DES to the left main, left circumflex, LAD, type II DM, who presented to clinic due to concern for low H/H and guaiac positive stools. Patient notes having worsening shortness of breath with exertion as well as dark/tarry stools today. He has felt tired and fatigued over the past several days but only had dark/tarry stools for one day. He denied any fevers, chills, night sweats, diarrhea, chest pain, chest pressure, cough. He does note having episodes of dry heaving but no vomit or blood noted. Also acknowledged having lightheadedness over the past two days. Denies any epigastric pain. Does acknowledge taking "a couple" ibuprofen for back pain, although he states he has not taken them everyday. Given presentation and concern for GI bleed, referred to ___. In the ED, initial vitals were: 97.1, 128/56, 18, 100% on RA. Labs were notable for INR 1.3 (not on Coumadin), WBC 11.8, H/H 6.___.5. LFT's normal except for AST 43. Chemistry panel unremarkable. Troponin x 1 negative. Rectal exam notable for melena. Lactate 1.6 UA 16 RBC, no bacteria. CXR: no acute cardiopulmonary process. Streaky bibasilar opacities likely reflect atelectasis. In the ED, patient received pantoprazole 40 mg IV x 1, 500 cc normal saline. Received 1 unit PRBC in the ED. On the floor, patient continues to feel fatigued. Denies chest pain, chest pressure, shortness of breath. Chest radiograph showed No acute cardiopulmonary process. Streaky bibasilar opacities likely reflect atelectasis. UNILAT LOWER EXT VEINS showed 1. No evidence of deep venous thrombosis in the left lower extremity veins. 2. Moderate superficial soft tissue edema within the left lower extremity. TEETH (PANOREX FOR DENTAL) showed No comparison. Several missing teeth. No evidence of focal osteolytic changes. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with EGD (___). At the time of discharge, the patient had Duodenal ulcer Melena GI-Bleed. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Key Information for Outpatient ___ year old gentleman with history of aortic stenosis currently undergoing TAVR workup, CAD s/p DES to the left main, left circumflex, LAD, type II DM, who was admitted to ___ with a low H/H and melena. # Acute blood loss secondary to GI bleed: On admission the patient was hemodynamically stable. His Hgb was 6.8 from a baseline of 9. He was given 2 units of PRBCs and responded appropriately. He was started on Pantoprazole 40mg IV BID, given fluids. His aspirin and Plavix were continued in the setting of his recent DES placed in ___. GI evaluated the patient and performed an EGD on ___. They found multiple duodenal ulcers and cauterized a visible vessel within one of the ulcers. He was observed overnight and did not have signs of a rebleed. His diet was advanced to a regular diet and the patient did well. His Hgb remained stable at > 8.0. Patient was discharged home on a PO PPI and with instructions not to take NSAIDs. He should be on high dose PPI for at least 8 weeks followed by daily after that. He will need repeat outpatient endoscopy. # CAD: Patient is s/p catheterizaiton in ___ with DES to left main, left circumflex, LAD. - continued aspirin and clopidogrel as above. - continued atorvastatin 80 mg PO QPM. - Metoprolol was initially held in the setting of GI bleed. After he remained stable he was restarted on metoprolol prior to discharge. # Left Lower Extremity Swelling: Patient had 2+ pitting edema in his LLE. ___ was performed and showed no evidence of deep venous thrombosis. # Hypertension: - Initially held valsartan given GI bleed, and re-started upon stabilization. - Initially held metoprolol succinate and re-started prior to d/c. # Type II DM: - Held glipizide while in house. - Started Humalog insulin sliding scale. # BPH: - Held tamsulosin initially give GI bleed. Re-started prior to discharge. *****TRANSITIONAL ISSUES***** #CODE: DNR/DNI #HCP/CONTACT Next of Kin: ___ Relationship: DAUGHTER Phone: ___ - NEW MEDICATION: Omeprazole 40mg PO Twice a day for the next 8 weeks followed by daily there after - FOLLOW-UP: Patient needs a repeat EGD in 8 - 10 weeks. - INR elevated to 1.4. Not on warfarin. Likely secondary to poor nutrition status over past month. Please re-draw INR at next visit and consider vitamin K supplementation. - continued work up for TAVR - follow up panorex taken on ___ for TAVR</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ man with PMH significant for intractable epilepsy ___ childhood meningitis who presents after a prolonged seizure. Per ___ providers, his last seizure was 3 months ago. He had a seizure this morning and EMS was called. He received 4 mg Ativan from EMS for continued seizure during transport and additional 2 mg in ___ for continued seizure, after which the patient stopped seizing. The patient continued to be altered. He was transferred to ___ for EEG. Chest: Frontal and lateral views showed Possible minimal pulmonary vascular congestion. No focal consolidation. The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ man with PMH significant for intractable epilepsy ___ childhood meningitis on ZON/PHT who presented after a prolonged GTC treated at an OSH with LZP. His mental status was initially concerning for a a prolonged post-ictal state. His Dilantin level was in the middle of his baseline range. The precipitant for prolonged seizure was unknown, but infection (none identified on UA or CXR) and non-compliance were initially considered. Initial EEG showed L hemispheric slowing with occasional sharp and slow-wave discharges, and he had one subclinical L temporal seizure on morning the morning of ___ on EEG. His work-up, which included LFTs, CXR, lactate, CBC, chem 10, UA, and urine culture were unremarkable. He was monitored on telemetry without any events noted. He was started on clobazam 5mg BID in consultation with his outpatient epileptologist Dr. ___. His mental status improved to baseline. Also, we switched his omeprazole to famotidine to minimize interactions with clobazam. Subsequent EEG over last 24 hours improved significantly as well with only occasional L temporal discharges. Overall, it is possible that a URI may have lowered his seizure threshold, but there were no other clear triggers. He was discharged home with resumption of prior home ___ services. He will 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 ___ year-old woman with history of ___ Disease, cognitive impairment, schizoaffective disorder who presents from nursing home with diaphoresis and confusion. HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ year-old woman with history of ___ Disease, cognitive impairment, schizoaffective disorder who presents from nursing home with diaphoresis and confusion. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD. showed Motion artifact degrades the diagnostic quality of the imaging 10 x 8 mm hyperdense lesion in the right frontal lobe. No underlying vascular malformation or associated arterial enhancement of this lesion. MRI should be considered for better characterisation. No intracranial aneurysms, arterial occlusion or significant stenosis. Moderate calcific atherosclerotic disease of the carotid siphons bilateral, but no significant stenosis. Subacute to chronic infarct in the left basal ganglia. Periventricular hypodense changes suggesting microvascular disease. Dilatation of the lateral ventricles which is slightly disproportionate to sulcal size. CT HEAD W/ CONTRAST Q1211 CT HEAD showed 1.0 cm round hyperenhancing lesion in the right frontal lobe, which appeared hyperdense on the noncontrast exam, with possible evidence of prominent draining lesion coursing nearby. The finding is nonspecific and may represent cavernous malformation or other vascular malformation rather than metastatic disease or primary mass given no associated edema. Consider MRI for further evaluation plan clinically amenable. The patient was diagnosed with Altered mental status, unspecified, Parkinson's disease. At the time of discharge, the patient had Primary diagnoses ========================== # Urinary Tract Infection # Right Frontal lobe mass #Acute encephalopathy likely secondary to UTI induced delirium, on top of underlying cognitive impairment Secondary Diagnoses: ___ # Schizoaffective/Bipolar # Hyperlipidemia # Anxiety # Hypothyroidism # Pseudobulbar affect. The patient was given written instructions concerning 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 Ms. ___ is a ___ year-old woman with history of ___ Disease, cognitive impairment, schizoaffective disorder who presented from nursing home with tachycardia, diaphoresis and confusion and was found to have UTI (ucx grew GAS)treated with 5 day course of ceftriaxone last day ___ and new frontal lobe lesion on CT Head. ================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo male w/ h/o diabetes (recently sarted on glyburide and metformin one week prior to admission), who presented as a transfer from ___ for hypertriglyceridemia-induced pancreatitis. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. Splenomegaly. 3. Trace perihepatic ascites. The patient was diagnosed with Unspecified abdominal pain. At the time of discharge, the patient had Pancreatitis Hypertriglyceridemia Type 2 Diabetes. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo M h/o hypertriglyceridemia, HTN, DM, who presents with acute pancreatitis in the setting of hypertriglyceridemia, admitted to the ICU for persistent tachycardia and initiation on insulin gtt for treatment of hypertriglyceridemia in setting of pancreatitis. #Acute pancreatitis ___ hypertriglyceridemia: No complicating features on CT scan with lipase elevated to 588 on admission. Pain was controlled successfully with morphine and tylenol. A RUQ ultrasound was performed that showed steatosis and no gallstones. GI was consulted and recommended initiation of insulin gtt with D5 containing IV fluids. The patient was kept NPO, insulin gtt and IVF fluids were initiated. His ___ level dropped from 3013 on admission ___ to 580s with insulin gtt. Triglycerides were trended twice daily along with LFT to monitor for complication of pancreatitis which remained within normal limits. Gemfibrozil was continued. His diet was started after triglycerides stabilized in the high 500 range. Insulin lantus 10U given and insulin gtt stopped two hours later. He tolerated diet and was transferred to the floor. On the floor he continued to do well with pain resolved on regular diet on day of discharge. Discharge ___ was stable in the 500's. #Diabetes mellitus: The patient presented with recently diagnosed diabetes mellitus, started on metformin and glyburide less than one week prior to presentation. HbA1C measured at 12%. He was started on insulin gtt for treatment of hypertrigylceridemia as above. ___ diabetes consult was placed. He was given Lantus 10U to overlap with completion of gtt and placed on humalog sliding scale. He will be discharged with 10U Lantus, 1:25 ISS for BG>170 and metformin for diabetes control. He will discuss with his PCP ___ referral to local endocrinologist. #Hypertriglyceridemia: As discussed above. Additionally, patient continued on gemfibrozil and endocrinology recommended starting Lovaza 4g. He will be discharged with prescription for this medication. #OSA: The patient was trialed on CPAP at night. #Constipation: He was given bowel regimen including senna, colace, bisacodyl, and miralax. #Sinus tachycardia: likely in the setting of ongoing inflammatory response to acute pancreatitis, along with volume depletion in the setting of pancreatitis as well. He was volume resuscitated.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH Roux-En-Y gastric bypass and metastatic gastric cancer diagnosed ___ on FOLFOX (___) with multiple recent admissions in the last month for self-resolving gastric outlet obstruction, hematochezia ___ presumed anal fissure, abd pain ___ constipation, headache/chills, now returns with Fever, nausea/vomiting CHEST (PA AND LAT) showed No acute intrathoracic process. CT ABD AND PELVIS WITH CONTRAST showed 1. No acute intra-abdominal or intrapelvic process to account for the patient's abdominal pain. 2. Persistent gastric antral thickening compatible with known malignancy without evidence of obstruction, unchanged from prior study. 3. Large, heterogeneous cystic and solid right adnexal mass, presumed to be a Krukenberg tumor and unchanged from prior study. The patient was diagnosed with Unspecified abdominal pain, Fever, unspecified, Nausea with vomiting, unspecified, Dehydration. At the time of discharge, the patient had PRIMARY DIAGNOSIS. abdominal pain secondary to metastatic gastric cancer SECONDARY DIAGNOSES. anal fissure 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>TRANSITIONAL ISSUES ================= [] Please follow up with palliative care regarding initiation of duloxetine and further management of pain symptoms [] Please follow up with oncology, especially in regards to having missed chemotherapy originally planned for ___ [] Please follow up with oncology regarding stable normocytic anemia as well as blood cultures drawn on ___ (currently NGTD) BRIEF HOSPITAL SUMMARY ===================== ___ PMH Roux-En-Y gastric bypass and metastatic gastric cancer diagnosed ___ on FOLFOX (___) with multiple recent admissions in the last month for self-resolving gastric outlet obstruction, hematochezia ___ presumed anal fissure, as well as abdominal pain, N/V, body aches believed to be due to neulasta reaction who presented for this hospitalization with fever at home up to 102, N/V, and crampy abdominal pain. She was treated symptomatically with oxycodone, ibuprofen, and dicyclomine for pain as well as Compazine for nausea with improvement in her symptoms. ACUTE ISSUES =========== #Fever/Chills Patient presented with 2 day history of chills and reported temperature measured at home up to 102. Of note, she had a similar presentation the week prior that was believed to be due to a reaction to Neulasta that improved with Tylenol, diphenhydramine, and cetirizine; however, she has not had Neulasta again between that last admission and this current one. Patient was afebrile upon admission and remained as such throughout admission. Her WBC count was 11.4 and trended down to 8.4 during her stay. CXR, CT A/P, and UA were not concerning for any source of infection. Blood cultures on day 2 showed NGTD. As she was not neutropenic on admission, she did not receive antibiotics. She was treated with Tylenol and ibuprofen PRN with resolution of her chills. #Abdominal Pain #Body Aches Patient presented with R crampy abdominal pain that was intermittent in nature and not associated with radiation in symptoms or changes with eating or stooling. She stated she had been having regular bowel movements prior to admission without any bright red blood per rectum or black stools. She stated the pain was partially relieved with dilaudid in the ED. In addition she also endorsed diffuse body aches that started the same time as fevers and chills on ___. She denied any recent sick contacts. LFTs and CK were within normal limits. CT A/P did not suggest obstruction or other identifiable causes of her abdominal pain aside from noting stable gastric changes associated with her known malignancy. She was treated symptomatically with dicyclomine (a new medication for her), Tylenol, ibuprofen. Palliative care was consulted and recommended switching dilaudid to oxycodone, which also helped her pain. We recommend she follows up with palliative care in the outpatient setting to consider starting duloxetine to help both with mood and body aches. #HA #Nausea/Vomiting Patient reported feeling nauseous and experiencing 1 episode of non-bloody, nonbilious emesis on ___. On admission she denied further emesis and was able to tolerate PO without issue. Also reported persistent HA that was worse in morning and associated with blurry vision and sensitivity to light and sound. Of note, she endorsed a similar HA on prior admission for which a brain MRI was done and revealed no metastatic disease or intracranial pathology. Her nausea was treated with Compazine and her headaches were treated with the pain medications discussed above. #Metastatic Gastric Cancer On FOLFOX (last ___ with chemotherapy originally planned for ___. This dose of FOLFOX was missed given her hospitalization and symptoms described above. Dr. ___ primary oncologist, was the attending on service and aware of this. Plan to continue chemotherapy when outpatient. Appointment scheduled for day after discharge. This patient was prescribed, or continued on, an opioid pain medication at the time of discharge (please see the attached medication list for details). As part of our safe opioid prescribing process, all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with Type I diabetes diagnosed ___ years ago, last HbA1c per his mother ~13%, presented to ___ with acute onset generalized weakness, shaking, nausea, emesis and hyperventilation, transferred to ___ for management of diabetic ketoacidosis. Radiology showed AP chest reviewed in the absence of prior chest radiographs: Very low lung volumes make it difficult to exclude small areas of subtle pulmonary abnormality, but I see no regions of the lung abnormal enough to consider pneumonia. Heart size is normal. No pleural abnormality. Radiology showed Interval placement of a right PICC, with the tip in the upper right atrium. The catheter can be pulled back 2 cm to place the tip in the low SVC. The patient was diagnosed with NIDDM UNCONTROLLED W/KETOACID, LONG-TERM (CURRENT) USE OF INSULIN. At the time of discharge, the patient had DKA uncontrolled Type I diabetes hypertriglyceridemia. The patient was given written instructions concerning 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: ___ with Type I DM with 1 prior episode of DKA presenting with weakness and hyperventilation found to have DKA thought to be secondary to medication noncompliance and likely dietary indiscretion. ACTIVE ISSUES ============= #Diabetic Ketoacidosis: Pt. found to have an anion gap metabolic acidosis, ketonuria, and hyperglycemia, consistent with DKA in the setting of insulin noncompliance and high sugar intake at work. Desite an elevated WBC, pt. without any clear infectious source on admission. His serum and urine tox returned negative. Pt. was admitted to the ICU, volume resuscitated with IVF, and placed on an insulin gtt. His anion gap gradually closed over the first 24 hours. He began tolerating POs and was placed on a subcutaneous regimen of insulin (36 units of Humalog ___ + ISS) per ___ Diabetes Consult recommendations. Given difficult vascular access, a PICC line was placed on ___. Pt. remained stable and was transferred to the floor. ___ was increased to 40 units BID, and humalog sliding scale increased. A1c 14.2, indicating long term poor control. Blood sugars improved to 200s for 24 hours prior to discharge. Patient was offered ___ follow up, but declined, easier for him to follow with his PCP for the time being. He has follow up the day after discharge to ensure adherence and establish close follow up with diabetic nurses for the next days to weeks. He was started on lisinopril for proteinuria. He was counseled on and reported good knowledge of a diabetic diet. #Hypertriglyceridemia- likely due to diabetes and insulin deficiency. Improved significantly, started on Lipitor (previously prescribed by PCP, patient was not taking prior to admission). His family visited during this admission and were supportive of the patient. He agreed to improve adherence and work closely with his outpatient providers to improve diabetic control. Full code. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with morbid obesity, chronic abdominal wounds from prior hernia repairs w/ multiple prior infections including MRSA & VRE, recurrent infections and sepsis from chronic foot wounds, HFpEF, CKD (likely ___ DM), IDDM (A1C 9.1 ___, restrictive lung disease, HTN, HLD, prior ETOH use disorder, history of PUD, anxiety & depression, chronic pain, chronic Foley, & recent calcaneal osteomyelitis who presents after a fall. CT HEAD W/O CONTRAST showed No acute intracranial process. Mild small vessel disease. CHEST (PORTABLE AP) showed Limited exam given rotation and suboptimal penetration. Mild edema not excluded. Right lung base poorly assessed. If needed, a repeat study with dedicated PA and lateral views would be helpful to better assess. CT chest abdomen and pelvis. showed 1. Extensive soft tissue stranding and edema within the partially imaged pannus without evidence of an organized fluid collection. 2. Mild right hydronephrosis without evidence of an obstructing stone or mass. 3. No definite pulmonary embolism or acute aortic injury on this suboptimal examination. 4. Increased consolidation at the right lung base is concerning for pneumonia. 5. Cholelithiasis. 6. Stable pelvic and inguinal lymphadenopathy. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 6:09 pm, 5 minutes after discovery of the findings. HEEL (AXIAL AND LATERAL) RIGHT showed Evidence for a soft tissue wound at the plantar aspect of the heel with concern for osteomyelitis at the underlying plantar aspect of the calcaneal body. NOTIFICATION: The impression above was entered by Dr. ___ on ___ at 17:05 into the Department of Radiology critical communications system for direct communication to the referring provider. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had Hypoglycemia Uncontrolled type 2 diabetes mellitus Hypoxic hypercapnic respiratory failure Obesity hypoventilation syndrome Suspected sleep apnea Congestive heart failure with hypervolemia Chronic foot wounds complicated by calcaneal 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>___ is a ___ year old man with a history of morbid obesity c/b obesity hypoventilation syndrome, OSA, HFpEF, hernia repairs c/b chronic abdominal wounds, IDDM, HTN, EtOH use disorder, anxiety/depression, chronic pain (methadone), chronic foley, and recent calcanel osteomyelitis (on levofloxacin/flagyl) who was admitted from rehab with hypoglycemia and initially required ICU stay for hypercarbic and hypoxemic respiratory failure and significant diuresis for volume overload. # Acute on chronic hypercapneic hypoxic resp failure: # Acute on chronic diastolic CHF # Obesity hypoventilation syndrome (OVHS) # Obstructive sleep apnea (OSA): Patient arrived at THE hospital lethargic and requiring 6L NC to 15L NRB a rebreather to maintain normal saturations, requiring admission to the medical ICU. However being more alert, he was quickly weaned to 2L NC with sats in ___, and safe for transfer to medicine. Soon he was weaned to RA. However he continued to desaturate to ___ when sleeping. Assessed by sleep medicine but adamantly refused BiPAP, CPAP, or a sleep study. Also refused tracheostomy with ventilator use. Daytime O2 sats improved modestly with IV diuresis although continued to drop his O2 when asleep. He used to be on 4L O2 at night but has not since at least ___ due to insurance issues. Patient likely has OHVS and OSA. Long smoking history so likely has COPD and pHTN as well. His (mild) response to diuresis suggests hypervolemia may play a role although no clear evidence of pulmonary edema on exam or imaging (both limited due to his habitus); no evidence of PNA or PE on imaging either. He was continually diuresed with Lasix 160 IV ___ until ___. He was then transitioned to oral torsemide. He will be discharged on 120 mg QAM and 80 mg QPM and will need ongoing monitoring of labs and volume status. (Unfortunately weights and intake/output data were inaccurate and/or challenging to interpret). # IDDM: Presented with hypoglycemia. The diabetes consult service followed during this admission and was noted to have extremely erratic sugars associated with erratic eating habits. Home metformin held and restarted at a reduced dose on discharge. He will be discharged on lantus 64 U BID, and a Humalog regimen incorporating meal-associated insulin and sliding scale together (see sliding scale for details). # Enterococcal bactiuria # Chronic Foley Ucx ___ sensitive only to linezolid. Likely colonizer given chronic foley. No fevers, WBC, urinary symptoms, and so not treated. # Chronic foot wounds c/b calcaneal osteomyelitis: Continued metronidazole and levofloxacin (per ID plan for at least 10 weeks of antibiotics). Continued wound care per podiatry's instructions. Follow-up in ___ clinic. (See wound care recommendations below) # Depression: Patient endorsed depressed mood and dissatisfaction with poor quality of life as well as hopelessness. SW consulted this admission. Patient denied any thoughts of hurting himself. Continued on buspirone, hydroxyzine PRN, trazodone, and ramelteon. # Chronic Abdominal Wound: # Abdominal pain Patient with chronic abdominal wound, which remained stable and did not appear infected during the admission. He experienced abdominal pain that was stable during the admission, without evidence of a new acute process. Continued dressing changes. He has outpatient plastics follow-up next week for pre-op for surgical intervention in ___. CHRONIC ISSUES # HTN: Continued amlodipine and lisinopril # HLD: Continued Atorvastatin # Chronic pain: Continued gabapentin, methadone, oxycodone # Smoker: Continued nicotine patch # Vitamin D deficiency: Continued cholecalciferol # GERD: restarted omeprazole at discharge ================================================== ================================================== POST-DISCHARGE PLANS/RECOMMENDATIONS AND TRANSITIONAL ISSUES</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w schizoaffective d/o, ? polysubstance abuse, ? RA on plaquenil, COPD, numerous ___ surgeries with hardware and resultant hardware and soft tissue infections p/w BLE pain and erythema. Pt was recently admitted to ___ at end of ___ for BLE cellulitis, seen by ID and started on a 2 week course of daptomycin (? AIN to vanco). She reports that in the last few weeks she has had worsening erythema/induration and pain in BLEs (L worse than R). She has also had fevers, chills, sweats, nausea and vomiting. She reports her chronic cough, without chest pain. She reports dysuria and chronic loose stools. Denies joint pains. Radiology showed 1. Findings as above notable for subcutaneous edema within bilateral lower legs without soft tissue gas or radiopaque foreign body. 2. Hardware within the right distal tibia and fibula with perihardware lucency along the syndesmotic screw raising concern for loosening. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the right PICC line has been removed. The lung volumes continue to be low. Moderate cardiomegaly without pulmonary edema persists. Old healed right-sided rib fracture. No pleural effusions. No pneumonia. ___ DUP EXTEXT BIL (MAP/DVT) showed No evidence of deep venous thrombosis in the right or left lower extremity veins. CT right lower extremity with contrast. showed 1. Bilateral subcutaneous edema most prominent over the distal lower extremity, left worse than right. No well defined drainable fluid collection. Findings may represent cellulitis in the appropriate clinical setting. 2. Chronic osseous changes related to prior trauma, surgery, and possibly infection are stable. No evidence of acute osteomyelitis. 3. No evidence of hardware failure in the right lower extremity. 4. Mildly impacted fracture at the base of the left first proximal phalanx. The patient was diagnosed with CELLULITIS OF LEG, HYPERTENSION NOS. At the time of discharge, the patient had Cellulitis Secondary: COPD Chronic pain Schizoaffective 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>___ w schizoaffective d/o, chronic cellulitis and previous hardware infections in LEs presents with recurrent cellulitis # BLE cellulitis: The patient has a history of complicated lower extremity infections with history of MRSA. Elevated CRP 35. Wound culture from ___ grew pan-sensitive enterobacte which is likely a contaminant. The patient had CT of her ___ which was consistent with cellulitis. There was no drainable fluid collection and no evidence of osteomyelitis. The patient was seen in consultation by ID who recommended starting IV daptomycin. The patient's exam improved and she will be discharged on oral clindamycin to complete an additional 7 days. She will need to follow up with ID after discharge. She was seen by orthopedics who felt that her hardware isn't currently causing a problem, but could be removed on patient request. The patient should follow up with Dr. ___ as an outpatient to discuss further. The patient was also seen by wound care nurses. # Chronic pain: The patient is on high doses of narcotics in additon to other sedaiting medications as an outpatient. She was contiued on her home regimen of MS contin, oxycodone, tizanidine, baclofen and gabapentin. She was also continued on bowel regimen. I discussed the risk of high dose narcotics with the patient and encouraged her to discuss tapering these medications with her PCP. She currently follows with PCP at the ___, Dr. ___ will continue care here at ___ following her discharge from her ___. #Schizoaffective disorder The patient was appropriate throughtou her hospitalization and was continued on seroquel. # COPD: no acute exacerbation Continued home inhalers (advair, spiriva) #?Rheumatoid arthritis COntinued on Plaquenil</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with PMHx HTN, diastolic HF (EF 55%), tachy-brady syndrome s/p pacemaker, atrial fibrillation on warfarin, obesity, and chronic pain tapered off of narcotics who presents with chest pain, DOE and weight gain. He had been feeling well until a few days prior to presentation to the ___ when he started to have pressure-like chest pain with DOE while walking around his house. He also noted increased fatigue. His chest pain was substernal with radiation to the back (not normal for him) that resolved when sitting down and recurred intermittently throughout the day. He has had symptoms like this with prior CHF exacerbations and says "this is not an MI." He reports moderate compliance with low-salt diet, fluid restriction, and taking all of his medications. He increased his PO Lasix from 20mg to 40mg without any improvement in his symptoms. No recent fevers, chills. He was seen in Dr. ___ office with his concerns and was then referred to the ___. He has had multiple hospitalizations in the past year for CHF exacerbations. He was recently admitted ___ for similar symptoms and received IV diuresis and readjustment of antihypertensives. Radiology showed No acute cardiopulmonary abnormality. Radiology showed 1. No evidence of pulmonary embolism or aortic dissection. 2. Heterogeneous thyroid with a right thyroid nodule which has been previously seen on ___ ultrasound. 3. Simple hepatic cyst in segment 5. The patient was diagnosed with CHEST PAIN NOS, RESPIRATORY ABNORM NEC, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had acute on chronic diastolic heart failure 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>___ with PMHx HTN, diastolic HF (EF 55%), tachy-brady syndrome s/p pacemaker, atrial fibrillation CHADS2 of 2 on warfarin, obesity, and chronic pain recently tapered off of narcotics presenting with chest pain, DOE and weight gain consistent with heart failure exacerbation. # Acute on chronic dCHF exacerbation: Has history of HFPEF, last echo in ___ with LVEF > 55% and mild symmetric LVH with normal biventricular cavity size and global systolic function. He was last hospitalized with exacerbation in ___ and was discharged with 20mg PO lasix daily. Last seen in ___ clinic on ___ and appeared relatively euvolemic, so no changes to medications or management were made. He reported complaince with medications but BP was elevated on admission. He also reported not "being perfect" with his diet. He had no evidence of ischemic etiologies for worsening heart failure with negative trops and normal EKG. The most likely cause for worsening heart failure could be related to his recent exacerbation of his Afib with rapid ventricular response despite successful cardioversion in ___. He briefly had an IV Lasix gtt that was changed to bolus dosing with moderate repsonse. He appeared euvolemic and he was continued on Lasix 40mg PO daily. His heart rate was controlled by increasing his diltiazem to 240 BID with good response and ventricular rate in the 60-80s. His lisinopril was held initially given Cr bump, but was restarted prior to discharge with stable kidney function. # Hypertension: Patient reported compliance with all mediations, but BP elevated on admission to floor of 140/103. Goal SBP < 130. His diltiazem was uptitrated and he was continued on hydralazine, labetalol and lisinopril while also being diuresed. Patient's blood pressure were more controlled on discharge with SBP 120-130s. # AoCRF: Serum creatinine levels have been elevated since ___, which coincided with his treatment for CHF with diuretics. Patient with baseline Cr of 1.8. Elevated on admission to 2.2, likely ___ poor forward flow and renal vasculature congestion with aggressive diuresis. He was discharged with stable renal function on lasix 40mg daily and lisinopril 40. # Atrial Fibrillation: First noted in ___. CHADS2 = 2 for CHF and age. S/p ablation in ___ that was successful for approx 1 month per patient. Since that time he has noted more frequent palpitations and worsening heart failure symptoms. He was continued on warfarin for goal INR ___, which was increased to coumadin to 7.5 for persistent low INR. His diltiazem was increased to 240 BID, and continued on labetalol with ventricular rate <90. # Tachy/Brady Syndrome: S/P biventricular pacemaker. Not pacing on recent ECG or tele during admission. # Chronic Pain: Tapered off of his narcotics as of ___. Avoided NSAIDs in setting of CKD and hypertension. Tylenol PRN for pain. #Depression/Anxiety: Chronic. Stable. Continue home fluoxetine and lorazepam</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ F with a complicated past medical history, including Type I DM c/b ESRD s/p renal transplant ___, CAD s/p MI ___, antiphospholipid Ab syndrome with remote h/o PE on coumadin, and scleroderma, who presents with two days of nausea, vomiting, confusion, and lethargy. Radiology showed No evidence of acute cardiopulmonary process. The patient was diagnosed with URIN TRACT INFECTION NOS, END STAGE RENAL DISEASE, VERTIGO/DIZZINESS, KIDNEY TRANSPLANT STATUS. At the time of discharge, the patient had Primary diagnoses: -Diabetic ketoacidosis -Urinary tract infection -Acute renal insufficiency Secondary diagnoses: -Type I diabetes mellitus. The patient was given written instructions concerning 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 ___ F with complex past medical history, most notable for poorly controlled Type I DM c/b ESRD s/p renal transplant ___, CAD s/p MI ___, antiphospholipid Ab syndrome with remote h/o PE on coumadin, and scleroderma, who presented with DKA, ___, and enterococcal UTI. Active issues: #DIABETIC KETOACIDOSIS: The patient initially presented to ___ ___ with glucose >600, Anion gap 30. This rapidly improved with administration of IV fluids and insulin gtt. On transfer to ___ ED, her glucose was 297, and anion gap had almost closed at 14. She was transition to subcutaneous insulin with one hour overlap with gtt and maintained on IV fluids until ___, at which point her creatinine returned to baseline and she was taking adequate PO fluids. Her nausea and vomiting had resolved prior to admission to the floor. She was restarted on her home insulin regimen and her FSBGs remained mostly stable in the ___. The trigger for this episode of DKA was most likely the patient's UTI, treatment for this was begun immediately upon admission as below. #ENTEROCOCCAL URINARY TRACT INFECTION: UA on admission showed trace leukocytes, 5WBC, few bacteria. The patient has a history of frequent UTI (likely ___ self-catheterization), although the patient denied dysuria. She was begun immediately on antibiotic treatment with vancomycin and ciprofloxacin. Urine culture grew out >100,000 Enterococcus sensitive to vancomycin, after which the ciprofloxacin was discontinued and the patient was maintained on vancomycin until blood cultures from ___ showed no growth by ___. Prior to discharge, the patient was transitioned from vancomycin to PO nitrofurantoin, on which she is discharged and will finish the remainder of a 10-day course at home. The patient remained afebrile and asymptomatic throughout her admission. #ACUTE RENAL INSUFFICIENCY: The patient presented with Crt 2.0 (baseline 1.0), most likely secondary to dehydration, with possible contribution from post-renal obstruction (patient had no urine output the day prior to admission). Acute rejection in the setting of missing 3 doses of immunosuppressants is possible, but unlikely in this case with rapid response to intravenous fluid repletion. The patient was maintained on intravenous fluids until her creatinine returned to near baseline (1.2) and remained stable, and she was taking adequate PO fluids. Her creatinine remained at baseline throughout the remainder of her admission. #ESRD S/P RENAL TRANSPLANT: The patient missed 3 doses of her home tacrolimus and Cellcept due to nausea and vomiting. She was restarted on her immunosuppresant medications upon admission to the hospital and her tacrolimus levels were trended and followed by the renal transplant team. Her renal function quickly returned to baseline with IV fluid repletion. Acute rejection in the setting of missed immunosuppressants was thought unlikely. A renal transplant ultrasound on ___ showed no evidence of obstruction in the graft kidney. The patient's home vitamin D and calcitriol were continued throughout her admission. She will need to have her tacrolimus level checked one week after discharge (___). #SUPRATHERAPEUTIC INR: On coumadin for antiphospholipid syndrome. She had an elevated INR of 6.5 (goal 2.5-3.5) on admission likely due to drug-drug interaction between warfarin and ciprofloxacin. Her warfarin was held and INR was trended until it returned to her goal range. It was restarted at 3mg daily on ___ following an INR of 3.5 the previous day. Her INR was 1.1 on discharge, and she was instructed to measure her INR at home daily for the next several days and to communicate the results to her ___ clinic for further titration of coumadin. Lovenox bridge was considered, but the patient reports having been subtherapeutic in the past without any need for bridge. #TYPE I DIABETES MELLITUS: The patient was maintained on her home dose of insulin Glargine (40U QAM and 30U QHS) as well as her home Humalog sliding scale, with stable daytime FSBGs. Chronic issues: #ANTIPHOSPHOLIPID AB SYNDROME with H/O PE: The patient's warfarin was held due to a supratherapeutic INR as above and restarted on ___. She will check her INR at home and communicate results with her ___ clinic as she has been doing. #CAD s/p MI: Due to an episode of chest pain during vomiting before admission, she was ruled out for MI, with EKG only significant for right axis deviation that was resolving on follow-up EKG. Her troponin was mildly elevated, peaking at 0.07 in the setting of demand ischemia due to tachycardia on admission. She remained asymptomatic and was continued on her home regimen of atorvastatin, metoprolol, and aspirin. #SCLERODERMA: The patient was maintained on her home dose of 7.5mg prednisone daily with good symptom control. #HYPERTENSION: The patient remained normotensive to slightly hypertensive during admission, with systolic blood pressures ranging 120s - 160, with a one-time asymptomatic SBP of 188,. She was continued on her home regimen of amlodidpine and metoprolol. Her home valsartan was held until her Creatinine returned near baseline and was restarted on ___. # GOUT: The patient was continued on her home allopurinol. # PAD: The patient was continued on her home cilostazol 100 mg every other day. # DEPRESSION/ANXIETY: The patient was continued on her home duloxetine and despiramine for depression and Ativan for anxiety. She was continued on her home trazodone and zolpidem QHS for sleep. # HYPOTHYROIDISM: The patient was continued on her home levothyroxine dose. # GERD: The patient was continued on her home ranitidine and Nexium. Transitional issues: # FOLLOW-UP: -Primary care: the patient will be contacted by Dr. ___ office to schedule a follow-up appointment -Nephrology: the patient will be contacted by Dr. ___ office to schedule a follow-up renal appointment within the next two weeks -Endocrinology/diabetes: the patient will follow up with Dr. ___ at the ___ on ___ at 3:30pm -___: the patient was scheduled to have an appointment with Dr. ___ the ___ on ___ to plan for a breast biopsy. The patient's admission was communicated to Dr. ___ the ___ will contact the patient within a few days of discharge to schedule a new appointment. -Blood cultures from admission were pending on discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with h/o B cell lymphoma s/p EPOCH and CHOP in remission, cirrhosis of unknown etiology with multiple complications, HTN, T2DM, CKD not on HD, seizure d/o, who presents as transfer from OSH with abd pain, AMS, UTI. LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT showed 1. Nonocclusive thrombosis of the main portal vein, extending to left portal vein, unchanged from ___. Right portal vein was not well visualized. 2. Cirrhotic liver with evidence of portal hypertension. Moderate volume ascites. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___ through ___. Atelectasis at the right lung base is mild. Right pleural effusions small if any, both unchanged. Upper lungs clear. Heart size normal. Left PIC line ends in the low SVC. The patient was diagnosed with Unspecified abdominal pain. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Hepatic encephalopathy SECONDARY DIAGNOSIS: 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>___ with h/o B cell lymphoma s/p EPOCH and CHOP in remission, cirrhosis of unknown etiology c/b ascites s/p peritoneal drain, SBP, esophageal varices, hepatic hydrothorax, non occlusive portal vein thrombus, HTN, T2DM, CKD not on HD, seizure d/o, who presented as transfer from OSH with abdominal pain and AMS. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old right handed male with past medical history notable for thyroid cancer s/p resection, Tourette syndrome and macular degeneration who presented with acute onset of right upper extremity weakness. MR HEAD W/O CONTRAST showed Punctate foci of acute infarct in the left parietal cortical and subcortical regions. No MRI signs of hemorrhage CHEST (PORTABLE AP) showed Bibasilar focal linear atelectasis or scar with otherwise clear lungs. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. No evidence acute intracranial abnormalities. 2. Approximately ___ stenosis of the proximal to mid left internal carotid artery by NASCET criteria. Mild right proximal internal carotid artery atherosclerosis without stenosis by NASCET criteria. 3. The left vertebral artery arises directly from the aortic arch, a normal variant. 4. Small caliber of the P1 segment of the right posterior communicating artery is most likely related to fetal type configuration with greater supply from the right posterior communicating artery, but its irregular appearance is suggestive of superimposed atherosclerosis. No evidence for flow-limiting stenosis elsewhere in the major intracranial arteries. 5. Status post thyroidectomy with unchanged abnormal appearance of the right laryngeal cartilages. RECOMMENDATION(S): MRI would be more sensitive for an acute infarction, if clinically warranted. The patient was diagnosed with Cerebral infarction, unspecified, S/p admn tPA in diff fac w/n last 24 hr bef adm to crnt fac. The patient was treated with TPA at OSH.. At the time of discharge, the patient had L MCA territory Stroke likely Cardioembolic in nature. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ man with a PMH of HLD, thyroid cancer s/p resection, Tourette syndrome and macular degeneration, who initially presented to an outside hospital with the acute onset of RUE weakness and facial droop. On initial assessment at OSH, exam notable for SBP 200s-220s, NIHSS 4 with right facial and upper extremity weakness. Was given tPA approximately 1:45 hrs from onset with improvement in proximal right upper extremity strength by the time of transfer to ___ for post-tPA care. Pt has risk factors given hyperlipidemia and prior history of malignancy. No known hx of HTN, although presented with SBP>200. No hx of atrial#Fo fibrillation in the past. The patient was admitted to the Neurology Stroke Service for post-TPA management and further care. The following issues were managed: #Neuro: Multiple punctate foci of ischemia -Given the abrupt onset and multiple areas of ischemia in the left cortex, the patient was started on eliquis. -Telemetry monitoring did not show atrial fibrillation, however likely the patient could have paroxysmal afib and will require further long-term monitoring. -Other stroke risk factors were also assessed, LDL was within normal limits . HbA1C was also 5.4. No significant atherosclerosis was noted, however patient was found to have a left fetal PCA on imaging. -Patient recovered well s/p TPA and was cleared by ___ to return home with outpatient ___ services. #Neuro: Focal Motor Status Epilepticus -During the patient's hospitalization, the patient was noted to have developed sudden onset right facial and arm twitching that lasted 12 minutes consistent with focal motor status epilepticus likely due to cortical irritation in the area where patient had ischemic injury. -The patient was loaded with IV keppra and put on a maintenance dose of this medication of PO 750mg BID. Since this episode, the patient did not have any further events. -The patient also had a routine EEG obtained to have for baseline purposes s/p his ischemic injury. #Pulmonary: -Patient noted to at times desaturated overnight during deep sleep with spontaneous recovery. The patient could also have an underlying sleep apnea or sleep disorder which can be evaluated in the outpatient with a sleep study. #ID: Urinary Tract Infection: -On Urinalysis testing, patient noted to have leukocyturia and hematuria. He was placed on IV Ceftriaxone with a goal of treatment for UTI with antibiotics for 7 days total (until ___. -The patient remained aefebrile during the hospitalization. 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? () Yes - () No 4. LDL documented? (X) Yes (LDL = 73) - () 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 - (X)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 (verbally or written)? (X) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (X) Yes - () No 9. Discharged on statin therapy? () Yes - (X) No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (X Yes [Type: () Antiplatelet - (X Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (X Yes - () No - () N/A Transitions of Care Issues: 1. Stroke follow-up appointment is scheduled for this patient. 2. In addition, patient will be sent home with ___ monitor to look for evidence of afib. 3. Patient was started on eliquis 4. Patient's TSH was measured to be high and the T3 was noted to be low. Patient should have repeat testing to elucidate the interpretation of thyroid function tests. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with history of breast cancer s/p right mastectomy (___), hypothyroidism on Synthroid, osteoporosis and Vit B12 deficiency who presents with intermittent unsteadiness x5d. As per the patient, she awoke on ___ morning (___) and when she went to get out of bed she felt unsteady on her feet, so she spoke with her family who thought that she may be dehydrated and encouraged her to drink water. By lunchtime she was feeling much better and did not experience any further dizziness or strange sensations for the next two days. On ___, she awoke and again felt dizzy, however this time she rehydrated, but the dizziness did not resolve until ___. Finally on ___, she awoke in the morning, experienced the dizziness, but this time it was persistent and was not abating, thus she called her PMD who was out of town, so she was referred to ___ Urgent Care. MRI AND MRA BRAIN AND MRA NECK showed 1.5 cm left medial occipital meningioma without surrounding brain edema. No other enhancing brain lesions. Small vessel disease and brain atrophy. No significant abnormalities are seen on MRA of the head and neck. The patient was diagnosed with Dizziness and giddiness. At the time of discharge, the patient had Benign Paroxysmal Positional Vertigo Meningioma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ right handed female with h/o breast cancer s/p right mastectomy (___), hypothyroidism, with incidental mass on CT who presents with intermittent unsteadiness x5d. CT mass suspicious for meningioma given that it is well circumscribed and there is no visible edema on CT. MRI was ordered which confirm this as well as no evidence of infarct. After admission to the neurology service, ___ Hall Pike Maneuver was performed and was positive to the right consistent with a diagnosis of benign paroxysmal positional vertigo. Physical therapy was consulted and performed vestibular physical therapy with relief some of her symptoms. They recommended discharge home with home physical therapy services. She was instructed to call her PCP to schedule ___ follow up appointment in ___ weeks. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with PMH of HFpEF, CAD s/p PCI ×3 with multiple stents placed, peripheral vascular disease, DMII, COPD, HTN, h/o CVA, and HLD who presents with left sided substernal chest pain radiating to the left arm and back x1 day. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___ most recently ___. Moderate to severe cardiomegaly is chronic. Pleural effusions small if any. No pneumothorax. No pulmonary edema. No pneumonia or is substantial atelectasis. Vascular pattern in the lungs suggests chronic lung disease, perhaps emphysema though conceivably interstitial fibrosis. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Unstable angina, acute on chronic heart failure with preserved ejection fraction SECONDARY DIAGNOSES: Hypertension, Atrial fibrillation, Chronic kidney disease, Peripheral vascular disease, history of CVA, Hyperlipidemia, Type 2 diabetes mellitus, Chronic obstructive pulmonary disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female with history of CAD s/p multiple stents, HFpEF, PVD, CKD, DMII, HTN, and HLD who presents with substernal chest pressure found to have mild troponin elevation without EKG changes iso CKD concerning for unstable angina vs. NSTEMI. Patient remained chest pain free while in house. She was diuresed due to volume overload and had uptitration of coreg and losartan due to hypertension. She was discharged on a diuretic regimen of furosemide 40mg daily. ACUTE ISSUES: ============== # ?Unstable Angina # Known Coronary Artery Disease # Chest pain Patient presents with substernal chest pressure radiating to her left arm and back that occurred while ambulating to her house. Pain resolved after 3 doses of NG with symptoms concerning for angina. Troponin on admission mildly elevated to 0.02 in the setting of CKD, but EKG reassuringly without STE or depressions and patient was without chest pain on arrival to ER. She has a known history of significant coronary artery disease with multiple stents. Recent dobutamine stress in ___ without evidence of inducible ischemia. Suspect pain was secondary to volume overload and hypertension. Per patient, she would not like to undergo cath due to risk of kidney injury in the setting of contrast. She was monitored on telemetry and continued on home Aspirin 81mg daily and pravastatin 80mg daily. Her carvedilol was increased to 25mg BID for antianginal effects and blood pressure control. Her home losartan was increased to 50mg BID for blood pressure control. She also continued on her home ranexa. #HFpEF: #LVOT obstruction LVEF >55% on last TTE. Appeareded volume overloaded with elevated JVP and 2+ pedal edema to knees on admission. Not on daily diurectics at home due to worsening renal function. Due to an inducible LVOT gradient on her ___ stress test, careful diuresis was done to avoid detrimental preload reduction. She was diuresed with lasix 20mg IV daily or BID. When euvolemic, she was switched to 40mg daily. She was continued on home losartan. Her coreg was increased as above. Her losartan was also increased. #HTN: Patient continued to have elevated SBPs while in house with SBP values of 150-180s. Her coreg was increased and her home losartan was increased. Her home amlodipine 10mg was continued. #Normocytic Anemia: Likely anemia of chronic disease. No current signs or symptoms of bleeding. Will require further follow-up with out-patient provider</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with hypertension, diabetes mellitus, rheumatoid arthritis, remote H/O atrial fibrillation in ___, presenting with palpitations and lightheadedness. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality The patient was diagnosed with Unspecified atrial fibrillation, Diarrhea, unspecified. At the time of discharge, the patient had -Atrial fibrillation with rapid ventricular response -Prior gastrointestinal bleeding -Diarrhea -Hypertension -Hyperlipidemia -Type 2 diabetes mellitus -Rheumatoid arthritis -Gastroesophageal reflux disease -Vocal hoarseness -Weight loss -Anorexia -Benign prostatic hypertrophy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with hypertension, diabetes mellitus, rheumatoid arthritis, remote H/O documented atrial fibrillation in ___, presented with palpitations and was found to be in atrial fibrillation with a rapid ventricular rate that converted after initial attempts at rate control with diltiazem. # Atrial fibrillation: Per ED report, ventricular rate to 170s on presentation. He received diltiazem 10 mg IV x3 and diltiazem 30 mg po x 2 and 3 L IVF in ED. Upon transfer to floor, he was in NSR at ___ with stable BP and no longer feeling palpitations. TSH normal. Possible triggers included hypovolemia and electrolyte shifts from diarrhea, decreased appetite and PO intake (discussed below). ___ seemed unlikely (afebrile, no leukocytosis). CHADS2 = 2. CHADS2VASC = 3. Patient has history of GI bleed as well as H/O syncope/falls and subarachnoid hemorrhage. ___ = 3. Given this, anticoagulation was deferred. He was started on metoprolol 25 mg q6 hours and transitioned to metoprolol succinate. Lisinopril was decreased (after initial discontinuation) to allow for BP toleration of metoprolol. TTE revealed normal EF. # Diarrhea: Possibly causing hypovolemia and electrolyte shifts, triggering his episode of atrial fibrillation. Stool O+P and stool culture were negative. # Weight loss and decreased appetite: Given smoking history, his recent voice change, 8 lb weight loss in the past few months, decreased appetite and PO intake were concerning for malignancy. CXR without any nodules. Patient has declined colonoscopy several times due to not having a ride. This could be contributing to hypovolemia and AF discussed above. # Hypertension: Hypotensive in setting of metoprolol and lisinopril. Discontinued home lisinopril initially and resumed at lower dose as above. # Type 2 Diabetes mellitus: Last HbA1c in ___ was 5.8%. Not currently on any agents per patient. He did not require insulin during this admission. # RA: Continued Leflunomide 20 mg and acetaminophen prn. # BPH: Continued home Doxazosin 4 mg QHS TRANSITIONAL ISSUES: [ ] New medication: Metoprolol 50 mg extended release daily. [ ] Continue to encourage colonoscopy. [ ] Consider further workup as outpatient, e.g., lung CT. [ ] Consider ENT referral as outpatient. [ ] Patient reports that he would like to be DNR/DNI, however has not discussed this in the past with any providers. Exploration of patient's values/goals should be continued with ___ provider as outpatient, especially if malignancy workup is pursued. [ ] Monitor for diarrheal symptoms. [ ] Will require BP check and assessment of renal function and electrolytes at ___ Episodic Visit given that lisinopril was started at half of home dose (5 mg instead of 10 mg). Will also require PCP follow up for similar issues in ___ weeks. # CODE: Do not resuscitate (DNR/DNI). Patient says he would not want measures to "bring him back." This includes intubation and resuscitation, even if felt to be temporary. # CONTACT/HCP: ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with hx acute liver failure ___ acetaminophen overdose s/p DDLT (___) c/b delayed abdominal closure, sigmoid ulceration, renal failure requiring RRT, recently admitted for GI bleed, who presents with fever and headache. CHEST (PORTABLE AP) showed Interval decrease in now small to moderate right pleural effusion. DUPLEX DOPP ABD/PEL showed 1. Patent hepatic vasculature. 2. Stable fluid collections in the region of the ligamentum teres and main portal vein. 3. Small right pleural effusion. CT abdomen pelvis without intravenous contrast. showed 1. Acute colitis of the cecum, ascending and proximal transverse colon which is likely due to infectious or inflammatory etiology. 2. Status post liver transplant with no interval change evident, however, given the lack of intravenous contrast the portal vein and hepatic venous anastomosis cannot be well assessed on current examination. 3. No evidence of appendicitis or fluid collections in the abdomen and pelvis. Radiology showed No radiographic evidence of free intraperitoneal air, although evaluation is limited by portable supine technique. CT of the abdomen/pelvis without contrast showed 1. Persistent pancolitis. Wall thickening of the ascending and transverse colon appears improved compared to the earlier CT. Wall thickening of the descending colon and rectum is better appreciated on the current study secondary to interval progression of oral contrast to the rectum, and is likely unchanged compared to earlier CT. No pneumatosis or pneumoperitoneum. 2. No interval change in the appearance of the liver transplant. Radiology showed 1. No evidence of bowel obstruction or free intraperitoneal air. 2. No significant stool burden. Radiology showed 1. Several air-filled loops of colon, grossly unchanged from prior film with no evidence of bowel obstruction. 2. No significant stool burden. Radiology showed 1. No displaced rib fracture. 2. Moderate sized right-sided pleural effusion with compressive atelectasis in the right lower lung. 3. Mild cardiomegaly. 4. Minimal atelectasis in the left lower lung. DUPLEX DOPP ABD/PEL showed 1. Elevated velocity in the proximal main hepatic artery up to 275 cm/sec which is concerning for possible stenosis. CT angiogram of the abdomen is recommended for further evaluation of the hepatic artery. The transplant hepatic vasculature is otherwise patent. 2. Trace fluid again seen adjacent to the ligamentum teres, unchanged from prior imaging. 3. Stable right pleural effusion. RECOMMENDATION(S): CT angiogram recommended look for hepatic artery stenosis. NOTIFICATION: The findings were discussed via telephone by ___ with ___ on ___ at 2:15 pm, 20 minutes after discovery of the findings. Abdominal CTA showed 1. There is a small 5 mm pseudoaneurysm of the right hepatic artery branch with significant narrowing proximal to the pseudoaneurysm which may account for the previously seen elevated velocity on the ultrasound examination. The left hepatic artery arises directly from the aorta and is patent. 2. Stable left hepatic lobe pneumobilia and mild periportal edema. 3. Slight interval increase in the right-sided pleural effusion. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 6:00 pm. The patient was diagnosed with Fever, 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>PATIENT SUMMARY ============== Ms. ___ is a ___ woman with hx acute liver failure ___ acetaminophen overdose s/p DDLT (___) c/b delayed abdominal closure, sigmoid ulceration, renal failure requiring RRT, recently admitted for GI bleed, who presented with fever, headache, diarrhea, neutropenia, and metabolic acidosis and was found to have C diff colitis. She is s/p 10 days of inpatient treatment, with improvement of symptoms. Immunosuppressive meds were also adjusted during her stay. ACUTE ISSUES: ============= # Neutropenic fever # Diarrhea # C. difficile colitis C. diff PCR and toxin assay positive on admission. CT showed pancolitis. Absolute neutrophil count ~1000. Course also complicated by BRBPR which likely reflected irritation of known sigmoid ulcer in setting of c. diff colitis and known hemorrhoids. CRP elevated 167, which downtrended to 30 after treatment with IV Flagyl and PO/PR Vancomycin. Blood and urine cultures, UA without growth. #RUQ vs. Right chest wall pain Patient with ongoing pain ill-described of R chest wall/ RUQ. Elevated alk phos but otherwise LFTs wnl. Hx of PE and on apixiban. Sometimes described reproducible pain with palpation of chest wall. CXR without evidence fracture. RUQUS without PVT. Initially concerning for hepatic artery stenosis, but CTA abdomen was not concerning. Increased hepatic artery velocities likely ___ R hepatic pseudoaneurysm vs aberrant L hepatic anatomy, but thought to be clinically insignificant per radiology. Suspect diaphragmatic irritation secondary to colitis, improved with treatment of c diff. #Non-anion gap metabolic acidosis Most likely secondary to bicarbonate losses in the setting of severe diarrhea from C. difficile colitis. Improved with treatment of c. diff. ___ on CKD Post transplant course c/b ___, renal failure with brief HD requirement. Cr 2.5 on admission, up from 1.9 on recent discharge now down to 1.8. Most likely pre-renal in setting of diarrhea/decreased PO intake and now improving. #R foot pain Currently being worked up as outpatient, had EMG ___. Decreased gabapentin dosing for renal function. CHRONIC ISSUES: =============== #H/o fulminant liver failure ___ APAP OD s/p DDLT ___ CMV negative donor/recipient. Course c/b sigmoid ulceration and renal failure. Azathioprine was recently discontinued during last admission due to leukopenia. Decreased tacrolimus to 4 mg Q12H, then to 3.5 mg Q12H on discharge. Continue Bactrim SS daily, valganciclovir 450 q48h. #Hx of PE: Continued apixaban 5mg BID. #HTN: Stopped home carvedilol while infected, then restarted at a lower dose. #GERD: Continued home pantoprazole. #MDD/Anxiety s/p multiple suicide attempts, most recently ___. Continued home mirtazapine, hydroxyzine, venlafaxine. Decreased gabapentin per renal dosing. TRANSITIONAL ISSUES: ==================== #Immunosuppresion #S/p DDLT ___ [] Monitor tacro level (decreased to 3.5 at discharge) [] Monitor neutropenia with weekly CBC. [] Increased valgancyclovir to 450mg daily per creatinine clearance. #C difficile colitis [] Consider probiotics to prevent recurrence #Known sigmoid ulcer [] Plan for repeat colonoscopy after stable resolution of c. diff colitis #Stable right pleural effusion: [] Noted on imaging since ___. TTE with normal cardiac function. Did not pursue thoracentesis this admission as effusion stable, patient was asymptomatic and would require stopping anticoagulation with apixaban. #HTN: [] Restarted carvedilol at a lower dose s/p resolution of infection. Uptitrate prn. # CODE: FULL confirmed # CONTACT: ___ son ___ ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx of etoh cirrhosis, roux-en-y bypass Ulcer at the GJ anastomosis here c/o fevers and chills since day prior. Pt reports feeling generalized malaise yesterday and subsequently developed fevers to 101, arthrlagias/myalgias as well. Denies abd pain, n/v/d, HA, cough, sore throat, rhinorrhea, blood in stool, dysuria, flank pain, sob, chest pain. In the ED, initial vitals were T101.6 116 113/64 18 100% RA. Labs notable for WBC 8.9, HCT 26.3, ALT 34 AST 53 AP 125 Tbili 2.2, lactate 2.9. UA clean, CXR was unremarkable. She was given vanc and cefepime and transferred to the floor. CHEST (PA AND LAT) showed No acute intrathoracic process. Dobbhoff tube tip in the GE junction. Advancement recommended. Radiology showed Successful uncomplicated ultrasound guided diagnostic paracentesis yielding 15 mL of clear yellow fluid from right lower quadrant. The fluid was sent to the lab as requested. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed No focal liver abnormality and normal liver Doppler. Small right effusion and ascites again noted as well as splenomegaly. . The patient was diagnosed with FEVER, UNSPECIFIED. The patient was treated with Paracentesis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT AND PLAN ___ yo F w/PMH significant for alcoholic cirrhosis and previous Roux-en-Y gastric bypass presents with fever. # Fever: Most likely infectious source is upper respiratory tract infection vs. SBP secondary to paracentesis. Received vanc/cef in ED, narrowed to ceftriaxone overnight on night of admission. Viral panel was negative. We started ceftriaxone at 2g daily. ___ guided diagnostic para on ___ showed 525 WBC, 9 Polys, at which point we decided to treat for SBP for 5 days with oral Ciprofloxacin. Her dobbhoff became clogged. We were unsuccessful at unclogging. Pt needs placed under MAC. Pt made follow up for replacement. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/PMH HTN p/w sob + weakness x 4d, found to be hypotensive/tachycardic and admitted to ___ for c/f occult infection/septic picture. Pt states that he recently returned from ___, had a mild cough x 4d. Reports mild dyspnea, worse on exertion. Patient reports that he did not get up at all during the plane flight. Denies hemoptysis. Patient reports no fever/chills/nausea/vomiting/diarrhea/dysuria. He did present to his PCP yesterday morning and was tested with rapid strep screen, results pending. . In the ED, initial vitals: 97.2 74 105/50 16 96% 2L Nasal Cannula Labs significant for: WBC 6.6, Hct 35.6 Plts 192. PMN 82% BUN 45, Cr 1.1, Gluc 258, P 0.9, ALT 41, AST 22, AP 28, u/a +ketones 40, proBNP 171 Ca: 8.1 Mg: 1.6 P: 0.9 . EKG: 1mm st depressions in anterior septal leads. tachycardia to 120s. CTPA: showed no PE or aortic pathology. Bedside ultrasound did not demonstrate any significant effusion or major wall . After CT the patient became tachycardic once again to the mid ___. Received 2L NS. At this time he was febrile to 102 received Tylenol, vancomycin, levofloxacin and metronidazole. Admitted for c/f occult infection . On arrival to the ICU, the pt was tachycardic to 130s-140. He had an episode almost immediately of what was thought to be seizure-like activity; He flailed himself across the bed with jerking extremity movements. After this he appeared to be very confused. Was given 1mg IV ativan. He was noted to have melena and vomited coffee-ground appearing material. NG lavage was performed, which showed coffee-grounds and did not clear even after 400 ccs. GI was consulted. HCT was rechecked on arrival to the unit and was now at 22 from 35 earlier. ABG performed which did confirm this lab result. 3u pRBCs were ordered with plan to give all. Also ABG showed that he had a primary respiratory alkalosis. Pt was hypomagnesemic, hypophosphatemic, and electrolytes were repleted. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria. Denies arthralgias or myalgias. Denies rashes or skin changes. Radiology showed Minimal atelectasis. No focal infiltrate identified. Radiology showed 1. No PE or acute aortic syndrome. 2. Enlarged subcarinal lymph node. 3. Fatty liver. Radiology showed Patchy infrahilar opacities, particularly about the left hilum, which are new compared with ___. They were not apparent on a ___ CT scan, so, in the absence of intervening pathology, may very well represent atelectasis related to low lung volumes. In the appropriate clinical setting, the ddx would include aspiration or infectious infiltrate. Fever, gastrointestinal bleeding, intubated. Portable AP chest radiograph was reviewed in comparison to ___. Meanwhile, the patient was extubated. Heart size and mediastinal silhouettes are stable. Left lower lobe opacity appears to be increased in the interim and might reflect atelectasis, although aspiration or progression of pneumonia cannot be excluded in this location. No appreciable pleural effusion is seen. No pneumothorax is demonstrated. was done. The patient was diagnosed with TACHYCARDIA NOS, HYPOTENSION NOS. The patient was treated with Intubation and mechanical sedation. At the time of discharge, the patient had GI bleed gastric ulcer acute blood loss anemia duodenitis Probable Aspiration Pneumonia Mechanical Ventillation for respiratory distress. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o M history of HTN, HLD presents with hypotension and shortness of breath, with initial concern for PE given recent travel. However d-dimer and CTA were negative. Patient ultimately found to have anemia and UGI bleed and transferred to ___. . # GIB: Pt presented with tachycardia, lethargy, found to have melena on rectal exam and coffee grounds on NG lavage (not clearing with 400cc). Denies n/v/epigastric pain. Denies significant NSAID use or hx of ulcers, gastritis. Endorses some EtOH use s/p trip to ___ but no h/o ETOH abuse. HCT 35 on admission, down from ___ HCT of 49.5. Repeat HCT was 22.2. got 5uprbc. No known cirrhosis or varices. Imaging here documented fatty liver but no cirrhosis. [patient was electively intubated for egd due to episodes of apnea. intubated ___, extubated ___ w/o events] Patient undewent EGD on endoscopy showed dried blood mixed with food in stomach, couldn't visualize well. on ___ underwent repeat EGD which showed stomach ulcer with "cherry red spot" that was clipped x2, likely source of bleeding, also had some smaller erosions. Patient will need f/u with GI as well as repeat EGD in ___ weeks. Patient HCT were trended and remained stable. On day of transfer out of ICU HCT was 31. Patient's diet was advanced to clears on ___ and tolerated well. His H pylori serology was POSITIVE. Since is currently on levofloxacin for possible pneumonia, he can start a course of triple therapy for H. Pylori once he is done with a course of levofloxacin. He remained on a protonix drip for 72h to end on ___ and then transition to high dose oral BID PPI. It will be important to document a treatment cure for h. pylori during his future endoscopy because of the presence of significant PUD. He will be discharged on a prevpac (lansoprazole/clarithromycin/amoxicillin) to take for 14d and then take a BID PPI after completion. # FEVER/Respiratory Distress requiring intubation and mechanical ventillation after first EGD Patient with fever to 102.9 on day of admission with non-specific respiratory symptoms. His initial CXR not suggestive of PNA. Patient at the time was hypotensive with concern for sepsis so he was started on vanc/levoflox/flagyl. Antibiotics were then narrowed to levofloxacin for ?CAP. Following procedure patient developed productive cough and nasal congestion with cxr note of bibasilar opacities suggesive of ?aspiration event given recent intubation. Upon arriving to the medical floor he had a lower grade fever to 100.2, but no signs of ongoing sepsis. The GI team reported copious purulent nasal secretions at the time of his second endoscopy raising the possibility of sinusitis. His fever curve continued to decline. He will be discharged on clarithromycin/amoxicillin to treat his H.Pylori and these antibiotics also have good coverage for community acquired pneumonia organisms. # Hyperglycemia: Patient was hyperglycemic on presentation, possibly due to stress response. A1C of 6.2 # Seizure/Loss of Consciousness - on arrival to FICU pt experienced a short episode of seizure activity, followed by confusion. Denies history of seizure disorder. Received 1mg ativan. No further episodes since. ___ have been related to metabolic disturbances. Unlikely withdrawal seizure, as patient has not been scoring on CIWA. No further seizure activity. # ?Alcohol Abuse: Pt endorses ___ glasses of wine a night, though this value changes with different encounters with various medical providers. Recent trip to ___ but denies drinking to excess at that time. Pt with documented hx of alcohol use on Atrius records but no clear documentation of abuse. # ___: Cr 1.1 at presentation (baseline 0.8). Improved to baseline with fluid resuscitation. . # Fatty liver - seen on CT. c/f diabetes or could be ___ alcohol use vs metabolic syndrome given A1c 6.2. Does not appear to have progressed to cirrhosis. ALT mildly elevated, AST wnl. Alk phos mildly elevated. No RUQ symptoms, no vomiting or pain. No abdominal pain or tenderness. Recommend outpatient followup. Plan At discharge --clarithromycin/amoxicillin for possible pneumonia --nasal saline rinse --clarithromycin/amoxicillin/omeprazole x2 weeks for h. pylori --arrange outpatient GI followup for repeat endoscopy</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female with a history of metastatic lung cancer s/p cycle 4 premetrexed/carboplatin who is admitted with bradycardia and hypotension. The patient states she has been feeling very tired and weak and has had dizziness and lightneadedness when she walks. She has fallen twice recently. She has found by a home health nurse to have a heart rate as low as the ___ and a blood pressure as low as the ___ systolic. She went to her local ED and recieved a dose of atropine and antibiotics and was transferred to the ED here. The patient states that about a week ago she started having some dysuria. In the last couple of days she has had urinary frequency as well. She reports having a UTI a month ago and her symptoms did get better before these started again last week. She denies any fevers, cough, shortness of breath, nausea, or change in ostomy output. CHEST (PORTABLE AP) showed Persistent left upper lobe collapse without evidence of pneumonia. Decreasing mass, left hilus and left upper lobe. Possible pulmonary metastasis, right lower lobe. This examination neither suggests nor excludes the diagnosis of pulmonary embolism. The patient was diagnosed with Urinary tract infection, site not specified. At the time of discharge, the patient had C. difficile infection Adrenal insufficiency. The patient was given written instructions concerning 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 a history of metastatic lung cancer s/p cycle 4 premetrexed/carboplatin who is admitted with bradycardia and hypotension. Concern for UTI: U/A at ___ concerning for UTI with ___ WBC, ___ RBC, 0 Epis, 2 + bacteria, moderate ___, - nitrites but culture growing mixed bacteria consistent with contamination. U/a and culture here negative. She was initially put on ceftriaxone which was discontinued. C. Diff: C. diff positive with some increased watery ostomy output. Started on PO vancomycin for 14 day course. Hypotension: possibly due to infection, adrenal insufficiency or dehydration. Her baseline systolic blood pressures in clinic appears to be 100-120. She did not appear significantly hypovolemic on examination and infection overall did not appear severe enough to be causing this degree of hypotension. She was placed on stress dose steroids with hydrocortisone with improvement in her blood pressure. She was transitioned back to her home dose of decadron prior to discharge. BP's on day of discharge 120's systolic. Bradycardia: she has chronic sinus bradycardia for years, no changes on ECG, no evidence of conduction disease on telemetry or ECG. She does report increased falls and ? syncopal episode at home. Her bradycardia may be contributing but she is not interested in an intervention such as a pacemaker. TSH normal. Chest pressure: Atypical chest pressure since she fell, likely musculoskeletal (reproducible on exam), no ischemic ECG changes, troponin negative and resolved. Could also be due to lung mets. Thrush Continued home clotrimazole. Metastatic Lung Cancer S/p cycle 4 premetrexed/carboplatin ___. She is finished with carboplatin, per oncology plan to continue with maintenance premetrexed. Continued home atovaquone, dronabinol, folic acid, keppra, ativan, omeprazole, pampazine, and trazadone. FEN: Regular diet PAIN: Continued home oxycontin at night and PRN ultram.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with history of CAD s/p MI and s/p CABG ___ years ago, HTN, HLD, DM, and CHF presenting with shortness of breath waking her up from sleep at 0300 this morning. She also reports five pound weight gain over the past 2 days from dry weight 160-161 lbs to 167 lbs. She notes that she ate a lot of salty food at a family party 2 days ago. Otherwise denies any recent symptoms of illness prior to this episode. Only recent stressor is that brother in law passed away unexpectedly 1 month ago. Patient has had multiple admissions for similar presentations including here in ___ and ___ in ___. En route she was given SLNG x3 and Lasix 20 mg IV. CHEST (PORTABLE AP) showed 1. Mild pulmonary edema. 2. Cardiomegaly. CHEST (PORTABLE AP) showed Previous mild pulmonary edema has resolved. Pulmonary vasculature is still engorged. Severe cardiomegaly is chronic. No pleural abnormality. Vascular clips denote prior coronary bypass grafting. The patient was diagnosed with Heart failure, unspecified. The patient was treated with RHC ___. At the time of discharge, the patient had Primary Diagnosis: - Acute on Chronic Diastolic Heart Failure - Complicated UTI Secondary Diagnosis: - Hypertension - Hyperlipidemia - CAD s/p MI and CABG - Diabetes Mellitus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o F w/hx CAD s/p MI and s/p CABG ___ ago, HTN, HLD, DM, and CHF with preserved EF presenting with CHF exacerbation in setting of hypertension and diet indiscretion. # Acute on Chronic Diastolic Heart Failure: Previous TTE in ___ with EF > 75%. proBNP elevated to 1610 on admission. Potential triggers include patient's reported dietary indiscretion, hypertension to 180s on arrival, and UTI (see below). No known history of CAD and CMs negative. She was diuresed with Lasix drip and boluses. When euvolemic she underwent R heart cath which showed moderate pulmonary hypertension and mildly elevated right/left sided filling pressures with preserved cardiac output. She was continued on imdur and amlodipine as below. Carvedilol was decreased to 12.5 mg bid. # Hypertension: Continued home imdur and amlodipine. Carvedilol was decreased to 12.5 mg bid from 25 mg bid given heart failure. As patient remained hypertensive in house hydralazine was added and dose uptitrated. # Complicated urinary tract infection: Urine culture on admission grew E. coli and Klebsiella. She denied symptoms. Given DM2 she was treated for complicated UTI with ceftriaxone and transitioned to ciprofloxacin to complete ___AD s/p MI and CABG: Patient had ___ persantine stress which showed no large WMAs. Patient has had no recent chest pain and troponins negative. She was continued on home ASA, imdur, and carvedilol. Simvastatin was changed to atorvastatin given that simvastatin is contraindicated with amlodipine. # CKD: Cr 1.8 on admission (baseline Cr 1.7-2.0). No further action was required. # Diabetes Type II: Contineud on glargine and Humalog sliding scale. Doses adjusted as needed. # Hyperlipidemia: Home simvastatin was changed to atorvastatin given concern for contraindication of simvastatin with amlodipine. # Gout: Continued home allopurinol #GERD: Continued home omeprazole 40mg # Glaucoma: Continued home eye drops # CODE: Full Code # CONTACT: ___ (brother) ___ (home), ___ (cell)</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old woman with history of ETOH cirrhosis who presented to the hospital on ___ for weight loss and failure to thrive over the past several weeks. She has had ___ weight loss and decrease appetite. Also had a waxing and waning cough with sputum production. CHEST (AP upright AND LAT) showed No acute intrathoracic process. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Patent portal vein with hepatofugal flow, new since ___. 2. Cirrhotic liver with macronodular contour as recently characterized on MRI ___. CHEST (PA AND LAT) showed Interval increase in right pleural effusion is substantial the fusion is currently large. There is small left pleural effusion. There are bibasal opacities highly concerning for developing infection. There is vascular congestion but no overt pulmonary edema. No pneumothorax. Old rib fractures on the right. CT ANGIOGRAM OF THE CHEST showed Motion limited examination demonstrates: 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Large right and small left effusions, worse when compared to prior MR. 3. Advanced cirrhosis with splenomegaly and gastroesophageal varices, consistent with portal hypertension. 4. Collapse of the right lower lobe due to compressive atelectasis from the large right pleural effusion. 5. Atelectasis or early airspace disease left lung base. Radiology showed Right pigtail catheter with a portions of the curled component both overlying and external to the thoracic cavity. No pneumothorax. CHEST (PORTABLE AP) showed Small right pleural effusion has decreased. Right pleural catheter is in place. There are low lung volumes. Cardiomegaly is stable. Mild vascular congestion has improved. Bibasilar opacities have improved. There is probably small left effusion. There is no evident pneumothorax. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is increased haziness at the right base with poor definition of the hemidiaphragm, consistent with reaccumulation of layering pleural effusion. Some of this could merely represent a more upright position of the patient. The cardiomediastinal silhouette is stable. Mild indistinctness of pulmonary vessels is consistent with mild elevation of pulmonary venous pressure. Radiology showed No significant interval change since the prior chest radiograph. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. Radiology showed Increasing right pleural effusion with underlying atelectasis/consolidation. Chest Radiograph showed Grossly unchanged large right pleural effusion. CHEST (PORTABLE AP) showed Comparison to ___. Mild increase in extent of the pre-existing right pleural effusion and of the resulting atelectasis of the right lower lungs. Stable appearance of the heart and of the left lung. Stable course of the feeding tube. CHEST PORT. LINE PLACEMENT showed Comparison to ___. The patient has been intubated. The tip of the endotracheal tube projects 1 cm above the carinal. The device should be pulled back by approximately 1-2 cm, to avoid intubation of the right main bronchus. The patient has also received a right internal jugular vein catheter. The course of the catheter is unremarkable, the tip projects over the cavoatrial junction. No complications, notably no pneumothorax. The previously placed feeding tube is in stable correct position. Increasing extent of the pre-existing right pleural effusion, with compressive atelectasis of the right lung basis. The left lung and the left heart border appear stable. Radiology showed Findings of gastric obstruction despite the presence of an enteric tube. US ABD LIMIT, SINGLE ORGAN PORT showed Small amount of ascites, mostly seen in the right lower quadrant. Right pleural effusion. DX CHEST PORT LINE/TUBE PLCMT 4 EXAMS showed Feeding tube tip is in the distal stomach. Distended stomach, multiple bowel loops in the upper abdomen. Radiology showed Successful right internal jugular access with transjugular intrahepatic portosystemic shunt placement with decrease in porto-systemic pressure gradient. RECOMMENDATION(S): 1. Given the patient's acute hepatic decompensation, the TIPS was under dilated to 6 mm in order to maximize hepatic parenchymal perfusion while still decreasing the portosystemic gradient enough to decrease variceal bleeding. However, the patient continues to be at high risk for rebleed if she does not return for full dilation of the TIPS. We will continue to monitor the patient's LFTs, and when they began to decrease/normalize and her acute hepatic decompensation begins to resolve, we can discuss timing to bring the patient back for TIPS stent dilation. 2. Suggest continued NG tube decompression, given patient's abdominal distention. CHEST (PORTABLE AP) showed Large right pleural effusion with adjacent atelectasis is likely unchanged allowing the difference in positioning of the patient. Small left effusion with adjacent atelectasis is stable. Right IJ catheter tip is at the cavoatrial junction. NG tube tip is out of view below the diaphragm. ET tube is slightly low the tip only 1 cm from the carina, could be retracted 1-2 cm for more standard position. There is no evident pneumothorax. Cardiac size cannot be evaluated. Radiology showed ___ radiographic evidence of small-bowel obstruction. CHEST (PORTABLE AP) showed In comparison with the study of ___, the tip of the endotracheal tube now measures approximately 2.3 cm above the carina. The other monitoring and support devices appear stable. Increased haziness at the right base could reflect either some increase in right pleural effusion or a more supine position of the patient. The left effusion is much smaller and there are bilateral atelectatic changes at the bases. CHEST (PORTABLE AP) showed In comparison with the study of ___, the tip of the endotracheal tube lies approximately 2.2 again there are bilateral layering pleural effusions, more prominent on the right with underlying compressive atelectasis. Although the pulmonary vessels are not well seen, they do appear to be indistinct and engorged, consistent with some elevation of pulmonary venous pressure. In view of the extensive pulmonary changes, it would be extremely difficult to exclude superimposed pneumonia in the appropriate clinical setting, especially in the absence of a lateral view. Cm above the carina. Other monitoring and support devices are stable. Radiology showed Continued dilation of the cecum, with decreased gaseous distention of the other large bowel loops. Radiology showed No gastric distension. Dilatation of the cecum has minimally improved. Improved previously seen distended bowel loops in the pelvis. CHEST (PORTABLE AP) showed Allowing the difference in positioning of the patient large right pleural effusion with adjacent atelectasis is unchanged. There are lower lung volumes. Vascular congestion in the left lung has improved. Cardiac size cannot be evaluated. Left lower lobe opacities are stable. Lines and tubes in unchanged standard position. No other interval change from prior study. CHEST (PORTABLE AP) showed Comparison to ___. Increase in extent of the right pleural effusion. Stable monitoring and support devices. Mild increase in retrocardiac atelectasis. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, there is little overall change. Again there are low lung volumes with large right pleural effusion and underlying compressive atelectasis. Multiple mild atelectatic changes and small effusion on the left. The monitoring and support devices appear stable. CT of the chest abdomen and pelvis. showed 1. Status post esophageal varices embolization with a new outpouching seen about one of the varices medial to the gastric cardia, with focus of an extraluminal contrast measuring 2 cm, and, and surrounding 2.7 x 2.0 cm hyperdensity concerning for a hematoma. These findings are concerning for a variceal bleed. 2. New splenic infarct. 3. Fluid-filled ascending and descending colon, associated with bowel wall edema, may be reactive or from colitis. Please correlate clinically. 4. Cirrhotic liver with patent TIPS, with small volume ascites. 5. Interval increase in size in a large right-sided pleural effusion with a similar small left-sided pleural effusion. Extensive atelectasis and volume loss in the lower lungs, complete atelectasis of bilateral lower lobes, and secretions within bronchial tree of lower lobes. 6. No evidence of pulmonary embolism. 7. Mild gallbladder wall thickening, similar to ___, likely reactive or from underlying chronic hepatic disease. Clinically correlate to exclude cholecystitis. RECOMMENDATION(S): An ___ consultation is recommended. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 6:40 pm, 5 minutes after discovery of the findings. Radiology showed No significant interval change. CT HEAD W/O CONTRAST showed Atrophy. No evidence of mass, hemorrhage or infarction CHEST (PORTABLE AP) showed Allowing the difference in positioning of the patient there is no interval change in large right pleural effusion, small left pleural effusion with adjacent atelectasis. There is minimal vascular congestion. Lines and tubes in standard position Radiology showed Significant improvement in cecal dilation and no radiographic evidence of obstruction. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Patent TIPS. 2. Right pleural effusion. Small ascites. 3. Nondistended gallbladder containing sludge with thickened wall in keeping with underlying liver disease. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is even further opacification involving almost the entire right hemithorax, consistent with pleural effusion and some significant volume loss in the right lung. Small left effusion with atelectatic changes at the base. Monitoring and support devices are stable. CHEST (PORTABLE AP) showed Comparison to ___. The tip of the endotracheal tube projects approximately 25 mm above the carina. There is now complete opacification of the right hemithorax. Stable left retrocardiac atelectasis, stable appearance of the left heart border. UNILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right lower extremity veins. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___. Very large right pleural effusion completely collapsing right lung and severely shifting mediastinum leftward is unchanged since ___, worsened since ___. Progressive heterogeneous opacification in the left lung could be due to edema from redirected blood flow, but raises concern for widespread aspiration or multifocal pneumonia. Heart size is indeterminate, probably at least mildly enlarged. Indwelling esophageal drainage tube passes a probe ending just above the diaphragm, and is looped in the stomach passing out of view. ET tube in standard placement. Right jugular line ends in the low SVC. CHEST (PORTABLE AP) showed In comparison with the study of ___, the endotracheal tube is been removed. An there again is essentially complete opacification of the right hemithorax with some volume loss in the ipsilateral lung, but with shift of the mediastinal contents to the left. Otherwise little change. Again CHEST PORT. LINE PLACEMENT showed In comparison with the earlier study of this date, placement of a chest tube at the right base has has no appreciable affects on the continued complete opacification of the right hemithorax. Monitoring support devices unchanged. CHEST (PORTABLE AP) showed NG tube tip in the stomach. Right internal jugular line tip is at the level of lower SVC. Right PICC line tip is at the level of mid to lower SVC. Heart size and mediastinum are stable There is substantial interval decrease in right pleural effusion which is currently small to moderate, the position of the right pigtail catheter is unchanged. Apical pneumothorax cannot be excluded, minimal. CHEST PORT. LINE PLACEMENT showed In comparison with the study of earlier in this date, there is an placement right subclavian PICC line that extends to the mid to lower portion of the SVC. Otherwise, little change. Radiology showed Support lines and tubes are unchanged in position. Cardiomediastinal silhouette is within normal limits. There is a large right-sided pleural effusion and increased density at the right lung, worse since previous. Several old right upper posterior rib fractures are again seen. Left lung is relatively clear. UNILAT UP EXT VEINS US showed 1. Nonvisualization of the right cephalic vein. Otherwise, no evidence of deep vein thrombosis in the right upper extremity. 2. PICC line within the right basilic vein. CHEST (PORTABLE AP) showed Comparison to ___. There is now complete opacification of the right hemithorax. The right pleural drain is no longer visible. The right internal jugular vein catheter has been removed. The other monitoring and support devices are in unchanged position. Mediastinal shift to the left, with a decrease in volume of the left hemithorax. Mild retrocardiac atelectasis. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___. Since ___, large right pleural effusion has recurred, responsible for persistent leftward mediastinal shift, with no appreciable change since ___. Subsegmental atelectasis at the left base is mild to moderate. Heart size is indeterminate since the right heart border is obscured. No pneumothorax. Right PIC line ends in the right atrium. Nasogastric drainage tube passes into the stomach and out of view. Radiology showed Successful dilation of existing TIPS stent up to 12 mm with reduction of pressure gradient from 21 mmHg to 14 mmHg RECOMMENDATION(S): Monitor hepatic hydrothorax; the patient may benefit from a parallel TIPS if the ascites/hepatic hydrothorax is not improved. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___ one. Very large right pleural effusion has not improved, collapses the entire right lung, responsible for over circulation in the left lung and shifting the mediastinum to the left. No pneumothorax. Right PIC line ends close to the superior cavoatrial junction. Nasogastric feeding tube passes into the stomach and out of view. Radiology showed No significant interval change since the prior chest radiograph. Radiology showed Successful ultrasound-guided diagnostic and therapeutic right thoracentesis. Radiology showed No significant interval change since the prior radiograph. Near complete whiteout of the right lung and mediastinal shift towards the right, likely reflecting an increased atelectatic component and decreased pleural effusion. CHEST (PORTABLE AP) showed Right PICC line tip is at the level of cavoatrial junction. The up of tube tip is in the stomach. Heart size and mediastinum are stable. There is interval substantial decrease in right pleural effusion, potentially after thoracocentesis. There is no definitive pneumothorax demonstrated. DUPLEX DOPP ABD/PEL showed 1. Patent TIPS with expected reduction in peak systolic velocity after TIPS dilation on ___. 2. No focal liver lesions. 3. Stable splenomegaly. No ascites. 4. A right pleural effusion is noted. CHEST (PORTABLE AP) showed Increased consolidation in the right lower lobe may represent atelectasis, though pneumonia is not excluded in the proper clinical setting. Slight interval decrease in right pleural effusion. The patient was diagnosed with Weakness. The patient was treated with ___ - Thoracentesis ___ - TIPS ___ - EGD with banding of bleeding esophageal varices ___- thoracentesis ___- paracentesis ___ - TIPS upsize. At the time of discharge, the patient had Primary Diagnosis ================== Septic shock Alcoholic cirrhosis Hepatic hydrothorax Urinary tract infection Respiratory failure Renal failure Secondary Diagnosis ================ Hyponatremia 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>___ woman with decompensated EtOH cirrhosis who initially presented to ___ on ___ with fatigue, and was found to have new ascites/hydrothorax and a UTI. Patient has had a long complicated hospital course, has been transferred twice to the ICU for hypoxemic respiratory failure, most recently on ___ when she then developed hypotension in the setting of bleeding esophageal varices. She underwent TIPS w/banding on ___, without further episodes of GI bleeding. During this MICU stay, she also developed an enterococcus UTI which was treated with linezolid. She continued to be febrile and hypotensive even after a full treatment course, and in this setting received further broad spectrum antibiotics and antifungals. A family meeting was held, and the decision was made to focus on comfort measures only. Antibiotics were therefore stopped, and when this happened her fevers also stopped and her mental status improved. Infectious work-up, including pleural fluid and ascitic fluid, remains negative. She continued to have ongoing large hepatic hydrothorax, requiring frequent thoracentesis and at one point a chest tube was placed. However given the large volume output and subsequent fluid/hemodynamic shifts as well as the rapid reaccumulation of fluid, the chest tube was removed and she was aggressively diuresed with Lasix gtt, spironolactone, torsemide/metolazone with improvement. Given ongoing hypoxemia, repeat chest xray was done which showed improvement of hydrothorax but also revealed a consolidation consistent with HAP. Patient was treated with HAP coverage with resolution of oxygen requirement. After a palliative consult, patient made it clear she wanted everything to be done so she could go home healthy and see her family/new grandson. Patient was discharged to an LTAC. #CAP: presented with CAP on CXR, treated with CTX, azithro until ___. #Fever: Patient had temperature of 100.8 on ___. Urine thought to be most likely source given weakly positive UA and patient was empirically covered with linezolid given h/o VRE; when urine culture returns her LTAC will be contacted to narrow her antibiotics. #HAP #Respiratory Distress/Tachypnea/R Pleural Effusion/Pneumonia Patient initially transferred to the MICU for tachypnea and hypoxemia. Found to have an acute increase in R sided pleural effusion concerning for recurrent hepatic hydrothorax with evidence of acute pulmonary edema. She had negative CTA, and TTE was without intrapulmonary shunting. She was diuresed aggressively with and started on duonebs and albuterol along with levofloxacin with improvement in her oxygenation. On ___ - TIPS upsize was performed by ___ with further diuresis w/ Lasix and metolazone with further improvement in her respiratory status. She was subsequently transferred out of the ICU to the floor, where she continued to be hypoxemic. CXR showed worsening right hydrothorax so patient had several thoracentesis done to help alleviate this. Once improved, patient continued to be hypexoemic. Repeat CXR showed forming consolication consistent with HAP. Patient was treated with vanc and ceftax for 8 days. Oxygen requirement resolved. # E. Coli UTI: UCx grew E. Coli sensitive to CTX. She was treated with CTX from ___ to ___. #Alcoholic cirrhosis/hepatitis w/ grade 2 varices and encephalopathy: Continued home FoLIC Acid, rifaxamin, lactulose, spironolactone; held nadolol briefly while in the ICU. # Hyponatremia: Patient had an acute decrease in sodium with a nadir of 126. This was thought to be a combination of diuretic effect and SIADH in the setting of her lung disease. She was placed on a fluid restriction with some improvement in her sodium. She was discharged on a 1.2L fluid restriction with a sodium of 130. #Weight loss/poor nutrition/Refeeding: Started on tubefeeds with nutrition following. #Anemia Hb slightly down from baseline on admission, drop in H/H with hematemesis on ___ with multiple transfusions of PRBC, on endoscopy bleeding esophageal varices s/p TIPS and banding on ___. No further bleeding. Discharge H/H: 7.6/22.9 ___: Renal consulted, attributed to over diuresis. Patient was kept even and ___ resolved. On discharge, Cr: 0.7 CHRONIC: # History of alcohol abuse: Although patient denying alcohol use, family is concerned about her alcohol use. Her current presentation was consistent with alcohol use. She was counseled extensively about the importance of stopping alcohol use and enrolling in relapse prevention as outpatient. #Electrolyte abnormalities #Refeeding sydnrome: Hyponatremia, hypomagnesaemia, hypocalcemia, hypophosphatemia, and hypokalemia likely nutritional given poor PO intake. Consistent with starvation ketosis on admission, which is now improved although developed refeeding syndrome after starting tube feeds which required aggressive electrolyte repletion. #Anxiety/depression. The patient is followed by Dr. ___ ___. She was continued on home remeron and clonazepam. She also received lorazepam PRN. #History of asthma, chronic bronchitis: She received duoneb and albuterol treatments. She was also placed on advair for controller medication. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of HTN & Afib (s/p PPM placed in ___ with chest pain and negative ACS workup, negative radiologic trauma workup i/s/o a motor vehicle crash, being evaluated for ?syncope and pain. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial process. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed No acute fracture or traumatic malalignment. Radiology showed Moderate cardiomegaly, mild pulmonary edema and possible trace pleural effusions. Probable retrocardiac atelectasis. Radiology showed 1. No active bleeding or solid organ injuries. 2. No hemothorax, hemoperitoneum, or pneumoperitoneum. 3. Pulmonary edema and cardiomegaly. 4. Mediastinal lymphadenopathy may be reactive. 5. No displaced fractures identified. 6. Prostatomegaly. 7. Mid left renal likely hemorraghic or proteinaceous cyst. RECOMMENDATION(S): Nonurgent renal ultrasound is recommended. The patient was diagnosed with Chest pain, unspecified, Car driver injured in collision w car in traf, init. At the time of discharge, the patient had S/p motor vehicle accident Musculoskeletal pain 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>___ PMH of Afib (s/p PPM placed in ___, on coumadin), HTN, who presented s/p motor vehicle accident of unclear circumstances, had a negative trauma workup, but was admitted for observation and evaluation of chest pain, which was thought to be mostly musculoskeletal who was discharged with appropriate follow up #Motor Vehicle Accident Circumstances are unclear as patient is unable to provide clarity as to what led his car to flip over causing airbags to deploy. Denies mechanical dysfunction of car or hitting an object. Patient denied LOC and noted that he recalls entire incident. Patient was seen by trauma surgery in ED, and had CT C-Spine, Head, Torso which was negative for acute injury. However, had chest pain and was admitted to medicine service. Patient ambulated with nurse the night after the incident, and strength/balance was found to be normal. Pain on right chest wall was felt to be musculoskeletal. #Chest Pain Presented with two sources of mild chest pain: substernal and on lateral aspect of R ribcage. ACS workup negative as troponin were negative x3. EKG was difficult to interpret as was paced, and interrogation of pacer showed no abnormalities. TTE performed which showed mild AS/AR, moderate LVH, normal LV regional/global systolic function, mild RV dilation, mild global RV systolic hypokinesis, trivial pericardial effusion, no clear evidence of cardiac trauma. Fortunately, sub-sternal chest pain resolved with time, however, patient warrants consideration of outpatient stress test or repeat TTE to trend findings, as he noted that he had similar pain 2 months ago. As for right sided chest pain, it was reproducible with palpation, felt to be ___ airbag trauma, and was given a lidocaine patch for it. #HTN During hospitalization patient was noted to have HTN to 190 most likely ___ withholding medications in setting of trauma. Patient's BP improved with restarting home regimen. #AFib Coumadin was continued at home dose of 5mg daily during hospitalization. INR 1.9 on discharge, and patient needs repeat INR checked on ___ by ___ #Oral lesion Patient was found to have ~1.5 cm raised purple lesion on hard palate which he noticed after the accident. Was felt to be possibly ___ trauma from dentures being forced backward by airbag. Speech and swallow performed bedside exam and patient was able to swallow normally. He was rec'd to follow up with ENT in 2 weeks to ensure that it has resolved, or for further evaluation if it persists.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male history of intellectual disability, diabetes mellitus, urothelial cell cancer of the upper urinary tract status post partial nephrectomy (___), urothelial/transitional cell cancer of the bladder s/p trans-urethral bladder mass resection (___), ESRD on HD MWF who p/w ___ weeks of worsening back pain and difficulty ambulating with "buckling" of right leg and difficulty urinating. Patient denies any fevers. No recent trauma. Denies any numbness or weakness of the upper extremities and only endorses numbness of the left knee. MR ___ SPINE W/O CONTRAST ___ MR SPINE showed 1. No evidence of a lumbar spine mass. 2. Extensive edema involving the right greater than left lumbar paraspinal musculature is nonspecific with the differential including reactive edema from trauma and degenerative change as well as infection/inflammation. Neoplastic involvement is less likely but cannot be excluded given history of TCC/bladder cancer and thoracic mass. 3. Edema within the lower back subcutaneous at may represent extension from the above described paraspinal process, although may also represent normally found dependent changes. 4. Multilevel degenerative changes of the lumbar spine most significant at L4-L5 and L5-S1 where there is mild-to-moderate spinal canal narrowing. 5. Mild amount of nonspecific presacral edema likely correlates with the patient's recently described bladder cancer. 6. Findings compatible with renal osteodystrophy correlating with the patient's history of end-stage renal disease. MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE showed 1. Expansile osseous lesion in the posterior aspect of T7 vertebral body with erosion of the posterior cortex, partially seen on the ___ abdominal/pelvic CT. Associated epidural mass centered in the right lateral spinal canal from mid T6 through mid T8 levels, with spinal cord compression at T7 and associated spinal cord edema from T6 through T8. This was previously seen on the ___ thoracic spine MRI without contrast. 2. No evidence for osseous, epidural, or leptomeningeal metastatic disease in the cervical or lumbar spine. 3. Multilevel cervical degenerative disease on with mild-to-moderate spinal canal narrowing and partial spinal cord compression at C3-C4, associated with focal myelomalacia, as seen on the ___ cervical spine MRI without contrast. 4. Several disc herniations without spinal cord compression are again seen in the thoracic spine. 5. Congenital lumbar spinal stenosis with superimposed degenerative changes, as described in detail in the preceding ___ noncontrast lumbar spine MRI report. 6. The partially visualized left kidney again demonstrates hydronephrosis, mild cortical thinning, and multiple cystic lesions which are not characterized on this exam. 7. Multi circumscribed T2 hyperintense, nonenhancing subcentimeter right posterior subpleural lesions along the right posterior sixth, seventh, eighth ribs, and a similar circumscribed oval 18 mm left posterior subpleural lesion along the left posterior eighth rib, are suggestive of paraspinal ganglia; there is no evidence for a mass or rib erosion on the ___ abdominal CT. 8. Circumscribed oval T2 hyperintense, peripherally enhancing structure medial to the left internal carotid artery at the level of C6, 10 x 11 x 20 mm, may represent a lymphatic structure, a ganglion, a nerve sheath tumor, or a necrotic lymph node. NOTIFICATION: Electronic wet reading to the emergency department was provided when this report was signed at 14:19 on ___. The emergency department and the consulting spine service were already aware of the thoracic spine mass compressing the spinal cord and degenerative disease compressing the cervical spinal cord from prior noncontrast MRIs. CT-guided spine biopsy showed Technically successful biopsy of T7 vertebral body lesion. A single 13 gauge 30 mm core was submitted for pathology. No immediate postprocedure complication. CT CHEST W/O CONTRAST showed No definitive evidence of intrathoracic metastatic disease. Other than the known T7 metastatic focus. CT abdomen and pelvis showed No evidence of metastatic disease in the abdomen and pelvis MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Study is mildly degraded by motion. 2. No acute intracranial abnormality. 3. 7 mm left occipital dural based enhancing mass with minimal mass effect on adjacent occipital lobe. While finding may represent a meningioma, metastatic disease is not excluded on the basis of this examination. Recommendation attention on follow-up imaging. 4. Paranasal sinus disease , as described. RECOMMENDATION(S): 7 mm left occipital dural based enhancing mass with minimal mass effect on adjacent occipital lobe. While finding may represent a meningioma, metastatic disease is not excluded on the basis of this examination. Recommendation attention on follow-up imaging. T7 through T9 spinal angiogram and embolization of bilateral T7 radicular arteries feeding bony tumor During the procedure the following vessels were selectively catheterized angiograms were performed: Left T9 radicular artery Right T9 radicular artery Right T8 radicular artery Right T7 radicular artery Left T8 radicular artery Left T7 radicular artery Right common femoral artery showed Tumor blush appreciated on injection of both right and left T7 radicular arteries. Successful embolization of right and left T7 radicular arteries. RECOMMENDATION(S): Plan per orthopedic THORACIC SINGLE VIEW IN OR showed Assessment is severely limited by underpenetration and overlying artifact the thoracic vertebral bodies and their levels cannot be well delineated. Alignment is grossly maintained. Please refer to operative note for details. T-SPINE showed Postoperative changes of the thoracic spine with no acute abnormality identified. The patient was diagnosed with Other specified diseases of spinal cord. The patient was treated with ___ guided biopsy of T7 vertebral lesion (___) Spinal angiogram for embolization of bilateral T7 feeders (___) Bilateral T6, T7, T8 laminectomy with medial facetectomy and foraminotomy with excision of extradural mass/epidural mass at ___. At the time of discharge, the patient had Primary diagnoses: Cord compression Spinal mass Secondary diagnoses: End stage renal disease Anemia Seizure disorder Developmental delay Urothelial renal cancer Urothelial bladder 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>SUMMARY STATEMENT ================= ___ male history of intellectual disability, diabetes mellitus, papillary urothelial renal cancer status post partial nephrectomy, transitional cell carcinoma s/p resection of bladder tumor, ESRD on ___ who presented with days ___ weeks of worsening back pain and difficulty w/ambulation found to have osseous lesion in the posterior aspect of the T7 vertebral body with associated epidural mass from mid T6 through mid T8 levels, with spinal cord compression at T7 and associated spinal cord edema from T6 through T8. Underwent ___ guided biopsy on ___ which was non-revealing. He underwent embolization of the mass followed by T6-T8 laminectomy w/ tumor resection on ___. Pathology of the mass returned shortly before discharge as papillary hemangioma. The final report is still pending. ACUTE ISSUES ============ #T7 vertebral body mass #Spinal cord compression Patient presented with symptoms of cord compression with nearly 1 month of lower extremity weakness (R>L) and urinary retention with evidence T7 bony lesion and new extra medullary extradural mass extending from T6-T8 on MRI w/ evidence of cord compression. Given the patient's history of malignancy, we were concerned that this mass may represent metastatic transitional cell carcinoma. Ortho spine and radiation oncology were consulted. Before treatment, it was decided that pt have biopsy to determine etiology. He underwent ___ biopsy on ___ w/o evidence of tumor on path (nondiagnostic). Patient underwent embolization of the mass prior to resection with neurosurgery. He then underwent T6-T8 laminectomy w/ tumor resection on ___ (ortho spine). Tumor was noted to be very vascular. Imaging studies conducted included (1) CT chest/abd/pelvis w/o evidence of metastatic disease, (2) MRI brain w/ 7mm dural based L occipital mass, c/f meningioma but cannot r/o metastatic disease. After surgical resection of the mass, pt had improved ___ weakness on exam ___ bilaterally on exam). He received dexamethasone while waiting surgical resection and several days days post-op (___). No evidence of urinary retention after surgery. ___ post op plain films were without acute change. Neuro oncology/neurology was also consulted given MRI findings and have recommended follow up as an outpatient with repeat imaging. Radiation oncology is planning for potential radiation therapy ___ weeks after surgery. Weakness significantly improved at discharge. Pathology of the mass returned shortly before discharge as papillary hemangioma. The final report is still pending. #Post op pain Pt had back pain in the setting of known vertebral lesion and and T6-T8 laminectomy ___. Pain is worse when dependent on incision site. Incision site looks c/d/i, though he is quite tender under dressing on exam. He has been receiving Tylenol 1g TID with good effect. Post-op he has been receiving OxyCODONE 5mg PO PRN (asking for ___ doses per day). He also has a lidocaine 5% Patch. #Sacral wound Was being followed outpatient in group home. Has two stage 3 pressure ulcers. Wound care team has been following patient with recommendations of: -Commercial wound cleanser or normal saline to cleanse wounds. -Pat the tissue dry with dry gauze. -Apply protective barrier wipe to periwound tissue and air dry. -Apply Duoderm gel to yellow wound bed -Apply Sacral Mepilex to cover both sites -Change dressing q 3 days CHRONIC ISSUES ================= #ESRD HD MWF. HD MWF. Patient initially underwent extra sessions of dialysis given need for MRI with contrast. Access: RUE AVF. His sevelamer was increased from 800 mg TID to ___ mg TID w/meals given persistently elevated phos. Due to hypercalcemia, his vitamin D and calcitriol were held. He was continued on cinacalcet and nephrocaps. Diet was renal. EPO was held as we were concerned for malignancy. #Hypercalcemia Elevated PTH, calcium and phos consistent with tertiary hyperparathyroidism given ESRD. VItamin D supplementation and calcitriol were stopped during this hospitalization. #Anemia: Likely secondary to ESRD. Hgb very slowly down-trending. We held EPO given concern for malignancy. ___ be able to resume EPO pending final path. Received mircera 150 mcg on ___. #Urothelial cell (transitional cell) carcinoma of the bladder s/p TURBT #Urothelial cell (transitional cell) carcinoma s/p R nephroureterectomy: Followed by urology as outpatient with recent hospitalization in ___ for urinary retention and failed voiding trials. Continued on tamsulosin. #Developmental delay #Intermittent explosive disorder Continued risperidone 3 mg QPM and 1mg daily Lorazepamd 0.5 mg PO BID:PRN anxiety #Seizure disorder Continued CarBAMazepine 300 mg PO TID #HTN: Continued amlodipine 5 mg daily #HLD Continued rosuvastatin 40 mg qpm Continued ezetimibe 10 mg daily Continued aspirin 81 mg daily #DM Held home linaGLIPtin 5 mg oral DAILY in house and pt was on ISS. He required very little insulin. #BPH: Continued home tamsulosin #GERD: Continued famotidine 20 daily #Rhinitis Continued fluticasone propionate nasal 2 spray daily **TRANSITIONAL ISSUES**</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: PCP: ___ . CC: fever, vomiting, elevated LFTs. . HPI/EVENTS: ___ h/o HTN/HLD, CKD Stage II, s/p L hip fx ___ admitted for elevated LFTs. Mr. ___ is at baseline usually quite independent, able to ambulate with a walker - but with an unstable gait requiring assistance at all times (fall risk). Mentally intact however occasional episodes of sundowning, with good appetite. Has 24 hr assistance at home. He was in his USOH until 1d PTA when developed decreased appetite. No abd pain. Last night at 2AM vomiting and noted to be mildly rhonchorous thereafter. Assessed by daughter (former ICU RN found pt to be febrile 100.4, vitals however stable). Presented to ___. There vitals stable. Labs notable for WBC 4, ALT/AST 417/669, t bili 2.8, alp 208. Found to have RLL PNA on CXR. Abd CT, RUQ prelim c/w acute cholecystitis. No CBD dilation. Also w/ 7 cm AAA. Given ctx/azithro and zosyn. Surgery consult there recommended ERCP and thus, pt transferred to ___. In ED here, vitals 99.1 60 104/46 22 94% 4L nc. EKG: NSR, normal intervals, no STE elevation or depression. Admitted for further eval. ERCP aware. . MRCP showed Very limited MRI due to patient's inability to cooperate. Cholelithiasis with extensive gallbladder wall edema, with an appearance more classic for third-spacing than acute cholecystitis. No choledocholithiasis. 7.6 cm infrarenal abdominal aortic aneurysm for which surgical consultation is recommended. Right upper and lower lobe pneumonia. NOTIFICATION: The findings and recommendations were communicated by Dr ___ to Dr ___ at 930AM on ___ by phone, approximately 45 minutes after initial interpretation. CHEST (PORTABLE AP)CHEST (PORTABLE AP)i showed Extensive consolidation has worsened in most of the right lung and base of the left lung. The sparing of the mid and upper regions of the left lung makes it less likely that this is pulmonary edema. Instead pulmonary hemorrhage or widespread aspiration pneumonia should be considered. Heart size is normal. Pleural effusions are presumed, but not substantial. No pneumothorax. Thoracic aorta is generally large and tortuous The patient was diagnosed with RESPIRATORY ABNORM NEC. At the time of discharge, the patient had Cholangitis/cholecystitis RLL pneumonia Delirium Abdominal aortic aneurysm. The patient was given written instructions concerning 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: ___ h/o HTN/HLD, CKD Stage II, s/p L hip fx ___ admitted for elevated LFTs. # GI: Mr. ___ was admitted from ___ with elevated LFTs and RUQ U/S, abd CT w/ signs of acute cholecystitis which included GB distention, perichole fluid, wall thickening, and GB stones. There was however no CBD dilation. He also presented with elevated LFT which were concerning for cholangitis. He, however, did not have any leukocytosis or ___ sign on presentation or throughout the hospitalization. He was initially placed on unasyn IV and then later levo/flagyl which was transitioned to oral form on HD3. He was evaluated by ERCP who recommended MRCP. The MRCP did not reveal any new findings (cholecystitis, no CBD) and was largely limited by motion artifact (as he was delirious during the study). Ultimately, his LFTs downtrended and the OSH blood cxs returned positive for Citrobacter (pansens). These were consistent with cholangitis/transitioned bacteremia with passage of a stone. Mr. ___ was able to tolerate a regular diet and had no N/V, abd pain on the day of discharge. He will complete a 2 week course of abx for presumed cholecystitis and cholangitis. He still has GB stones, but is not a likely candidate for elective cholecystectomy given his age. # RLL PNA: Mr. ___ also was noted to be hypoxic requiring initially 4L NC O2. CXR showed RLL infiltrate and was likely ___ aspiration in setting of N/V. It is likely that the cholangitis/cholecystitis led to N/V and then to the aspiration PNA. He was able to wean off the oxygen and the levoflox was continued to help cover the aspiration pneumonia too. # Delirium: Mr. ___ had episodes of sundowning. He was initially delirious, but became increasingly cognitively intact as the cholangitis/cholecystitis and pneumonia was treated. He is exceptionally hard of hearing and had a hearing aid in place. We aimed to optimize his nutrition, hydration, sleep. His daughter ___ also came daily to help provide frequent reorientation. # AAA - Mr ___ was found to have an incidental infrarenal 7 cm AAA on U/S and Abd CT. There was some evidence of intramural thrombus. This was treated conservatively given his age. His daughter (HCP) was made aware of this diagnosis and agreed with conservative approach. # HTN/HLD: on zebeta, norvasc. On statin, ASA. # Glaucoma: on latanoprost and alphagan gtt # OTHER ISSUES AS OUTLINED. #FEN: [X] IVF [X] Oral [] NPO [] Tube Feeds [] Parenteral #DVT PROPHYLAXIS: [X]heparin sc []SCDs #LINES/DRAINS: [X] Peripheral [] PICC [] CVL [X] Foley #PRECAUTIONS: [X] Fall [] Aspiration [] MRSA/VRE/CDiff/ESBL/Droplet /Neutropenic #COMMUNICATION: daughter ___ (HCP) at ___ #CONSULTS: ERCP, ___ #CODE STATUS: DNR/DNI. Confirmed w/ daughter ___ (HCP) after extensive discussions. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ hx HTN, COPD, OSA on CPAP, h/o PE ___ years ago on warfarin, s/p Spine surgery (L1 kyphoplasty d/t L1 compression) ___ (d/c'd to rehab day prior to arrival) who now presents from rehab d/t right thigh pain. Morning on day of arrival patient noted new right anterior thigh pain that occurred during an abrupt hip flexion. Pain started distally close to patella and radiated proximally to inguinal area. Pain was tingling and burning, worse with movement of leg and better without movement. No associated swelling or redness of skin. Not associated with chest discomfort, no change in his breathing, no new dyspnea. Pain improved with oxycodone, which he takes for post surgical pain. Denies trauma to that area. At rehab SaO2 noted to be 87% (baseline 85-93% per patient d/t COPD) and so transferred to ___ ED for further eval. In the ED initial vitals were: 98.0 hr 90 123/55 16 93% 3l - Labs were significant for INR 1.1, Hct 28.7 (d/c was 28.4), E 5.1, Cr 1.7 (baseline 1.4-1.7) TnT <.01, BNP 112 -- CT Abd/Pelvis w/out contrast with no evid of RP bleed -- Right Leg doppler without evid of DVT -- CXR without focal findings -- EKG without evid of right heart strain -- ED had clinical suspicion of PE and was started on Heparin gtt, no CTA done Vitals prior to transfer were: 98.0 88 128/66 16 90% RA On the floor, patient denies right thigh pain. Endorses mild low back post surgical pain which is not new. Denies bladder retention, bowel incontinence, saddle anesthesia. Denies weakness in Right or Left leg. Does not endorse pleuritic chest pain, does not endorse any new dyspnea and has baseline "shortness of breath" due to COPD. Denies any new skin changes, denies any new swelling of any leg. Re COPD - patient notes SaO2 reading on home O2 monitor when sleeping anywhere between 86-93%. Notes b/l lower legs with chronic edema that is not acutely worse. Of note, at last admission INR was reversed with VitaminK pre op and on discharge INR was 1.1, was restarted on PO Warfarin 5mg/day with plan for close INR checks and to increase dose as needed. He was not bridged. CHEST (PORTABLE AP) showed Left basilar atelectasis. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity to the level of the popliteal vein. Evaluation of the calf veins is somewhat limited due to body habitus. CT ABD AND PELVIS W/O CONTRAST showed 1. No evidence of retroperitoneal hematoma. 2. No acute intra-abdominal process. 3. Status post kyphoplasty at L1, with otherwise similar appearance of the spine compared to the to reference MRI L-spine dated ___ allowing for differences in technique. 4. Hepatic steatosis. 5. Dilated fluid-filled distal esophagus may be related to reflux. The patient was diagnosed with SKIN SENSATION DISTURB, HYPOXEMIA, RESPIRATORY ABNORM NEC. At the time of discharge, the patient had Primary Diagnosis: ================== Lumbar radiculopathy Secondary Diagnoses: ==================== History of DVT/PE COPD Obstructive Sleep Apnea. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ s/p spine surgery on ___ who presents from Rehab d/t Right anterior thigh pain #Lumbar radiculopathy Leg pain was initially though to be DVT with possible PE as patient was thought to be dyspneic with low SpO2 and therapy initiated for presumed PE. However, on further discussion with patient, his respiratory symptoms are chronic without any acute change. He has long standing COPD/hypoventilation from habitus and home SaO2 range high ___ to low ___ not on O2 at home. (Per patient, wears night time O2 monitor). Right thigh pain not consistent with DVT and has no exam or U/S findings to suggest DVT. Pain was transient and patient reports having similar episodes in the past. Seems more likely radiculopathic (L3) or perhaps superfical femoral nerve impingement. Patient's post surgical back pain is more symptomatic at this time. -- pain control with home oxycodone -- continue ___ at rehab facility # History of Pulmonary Embolus - Patient did have moderate probability on Wells ___ = 3 (Surgery < 4 wks, previous DVT), Simp ___ = 4 (Age, Surgery < 1mo, Unilateral limb pain, HR > 75). His h/o provoked PE is about ___ years ago, in the setting of cellulitis and surgery, and on warfarin since with no subsequent events. Of note patient's INR subtherapeutic since ___ in setting of reversal with Vitamin K d/t surgery. -- Bridge with lovenox at discharge -- Continue Warfarin and trend INR at rehab facility CHRONIC ISSUES: =============== # CKD: Cr 1.7 on arrival. Recent baseline 1.5-1.7. -- Avoided nephrotoxic medications during admission # COPD - not on O2 at home, per patient O2 at home 86- low ___. Longtime former smoker. -- continued home Tiotropium -- titrated O2 to 88-93% # OSA on CPAP: -- Continued home CPAP settings # Hypertension -- Continued nifedipine # Iron deficiency anemia - pt reporting recent normal endoscopy at the ___. He does not take his iron pills because they cause him constipation. Consider further work-up on follow up with PCP</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ with history of recently diagnosed (___) invasive carcinoma of the R breast with ductal/lobular features on letrozole (ER+/PR+/HER2- Gr2 R, no surgical intervention planned), EtOH use disorder (prior), known gait imbalance (evaluated by neurology in ___, possible myelopathic process in the setting of cervical spondylosis), HTN, and dyslipidemia who presents after a fall. Patient was using her walker while out and about yesterday, it Radiology showed Cardiac monitoring device appears to be in appropriate positioning. The patient was diagnosed with Encounter for examination and observation for unsp reason. The patient was treated with Linq recorder placement ___. At the time of discharge, the patient had Primary: Mechanical fall Fractured humerus Secondary: Supraventricular tachycardia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY STATEMENT Ms. ___ is a ___ year-old woman with a history of recently diagnosed (___) invasive carcinoma of the R breast with ductal/lobular features on letrozole (ER+/PR+/HER2- Gr2 R, no surgical intervention planned), EtOH use disorder (prior), known gait imbalance (evaluated by neurology in ___, possible myelopathic process in the setting of cervical spondylosis), HTN, and dyslipidemia, who presented after a fall, and was found to have arrhythmias on telemetry. ACUTE ISSUES #Fall #Fractured humerus: The patient initially presented in the setting of a mechanical fall, though she may have had prodromal symptoms of dizziness. XR of the R arm ultimately showed a proximal humeral fracture. Orthopedics determined that there was no indication for operative management and recommended pain control with physical therapy. She was made non-weight bearing with the RUE. The patient was seen by physical and occupational therapy and felt that the patient should undergo a period of acute rehab. However, the patient preferred to go home with additional services given poor experiences at rehab in the past. #Supraventricular tachycardia: In-house, the patient was noted to have intermittent increases in her heart rate to the 140s that were intermittently symptomatic with lightheadedness and palpitations. Electrophysiology was consulted and recommended Linq recorder placement and addition of diltiazem for rate control. The patient ultimately achieved excellent rate control and her Linq recorder placed on ___ without incident. CHRONIC ISSUES # R breast with ductal/lobular features on letrozole (ER+/PR+/HER2- Gr2 R, no surgical intervention planned): Patient follows with Dr. ___ (hematology/oncology) and Dr. ___ ___ (breast surgery). Letrozole was continued in-house. # HTN: Home ACE-i was held given normotension. # Dyslipidemia: Continued home pravastatin. # Insomnia: Continued home amitriptyline, though patient did note dry mouth. (NB patient does complain of dry mouth, should make this a transitional issue for her PCP) # GERD: Continued home omeprazole # Anxiety: Continued home lorazepam # Urinary issues: Given immediate release oxybutynin while inpatient. TRANSITIONAL ISSUES []consider alternate sleep medication to amitryptiline given patient reports dry mouth []consider home safety evaluation as an outpatient given history of falls []patient is non-weight bearing on the R upper extremity # CODE: Full with Limited trial of life-sustaining treatments # CONTACT: ___, ___ (friend) </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ (EU Critical ___ is a ___ M with a history of drug abuse (per wife, intranasal heroin and cocaine) who presents after being found down and altered. Per the EMS reports and OSH notes, Mr. ___ was found at a ___ clinic where he had an intake appointment. He went into the bathroom and, afterwards, was found slumped over and unresponsive. Per EMS, he was found down with 2-3mm pupils, an intact gag, and a RR of 8. He received Narcan 2mg IV with slight improvement in RR to teens but he remained unresponsive. He was taken to ___ due to concern for drug overdose. At ___, he was unresponsive, with initial VS BP 80/60, HR 72, RR 8, 91% RA. He got 1L NS bolus and was sent for CT scan, where he began having jerking of his upper extremities. He was treated with Ativan 2mg x2 and phenytoin 1360mg. His labs were unremarkable except a Cr of 2.2. He was transferred to ___ for concerns of status epilepticus and on the route over had lower BPs and again was less responsive. He was reportedly given another dose of Narcan. Radiology showed Low-lying endotracheal tube for which retraction by 1 to 2 cm is advised. NG tube should be advanced for more optimal positioning. Perihilar opacity which could reflect mild edema or aspiration in the right clinical setting. Radiology showed No acute intracranial abnormality. CTA HEAD AND CTA NECK showed Study slightly sub optimal due to poor opacification of the vessels, however there is no evidence of significant stenosis, aneurysm, dissection or other vascular abnormality. There is a focal area of consolidation within the superior segment of the left upper lobe, incompletely imaged. The patient was diagnosed with SEMICOMA/STUPOR, MYOCLONUS. At the time of discharge, the patient had PRIMARY DIAGNOSES: Heroin and cocaine intoxication and withdrawal, acute kidney injury 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>This is a ___ yo M with PMH of substance abuse who presents with altered mental status in the setting of opioid and cocaine abuse, intubated for airway protection and admitted to the ICU. # Altered mental status: A thorough workup performed prior to the patients arrival in the ICU included a tox screen that was positive for cocaine and opioids, a negative non-contrast head CT, a negative CTA head and neck, and an LP that had normal WBC and RBCs that cleared. This information all points towards acute drug intoxication as the most likely cause of his initial presentation (described as stupor, miosis, bradypnea which improved with narcan). Patient admitted to snorting a bag of heroin and taking cocaine 2 days prior to presentation once extubated. He was initially evaluated by toxicology. Evaluation by neurology given possible seziures and patient received EEG and started on phenytoin 100mg BID. EEG returned negative and phenytoin was stopped on ___. Spoke to PCP who corroborated no history of seizure disorder (except in the presence of drug intoxication). No history of EtOH withdrawal. Asterixis thought to be due to phenytoin, no evidence of liver disease. Patient was successfully extubated and mental status cleared after extubation. #Narcotic withdrawal: Patient began experiencing heroin withdrawal morning of ___ and was scoring on ___. He was placed on clonidine, dicyclomine, hydroxyzine, kaopectate, triaminic, and methocarbamol per ___ ___ protocol. Spoke to staff at ___ (below) who put us in contact with his ___ (had not yet actually seen MD) Dr. ___ ___ (cell), who felt it was okay and even preferable to initiate methadone while hospitalized since this would mean being in a monitored setting. He was started on methadone 20 mg daily on ___. Dr. ___ that Mr. ___ come to the clinic following discharge to continue his methadone titration - no appointment necessary. Patient received 25 mg methadone on ___ and 25 mg methadone on ___ prior to discharge. He was not scoring on ___ prior to discharge and his symptoms of anxiety and HTN were likely related to craving. Dr. ___ was contacted on ___ (the AM of patient's discharge) and he advised that patient should follow up in the ___ clinic tomorrow morning (___) between 6am and 11am (address as written below). This was communicated to the patient and he understood and expressed that he would likely have a ride to the ___ clinic tomorrow around 9am. Dicyclomine, hydroxyzine, kaopectate, triaminic, and methocarbamol were discontinued prior to discharge as patient was not requiring these medications and his symptoms were likely related to craving rather than withdrawal. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ year old female with hx of pancreatic cancer diagnosed ___ ___ s/p chemo and gamma knife radiation,type 2 diabetes, HLD, and recent history of GI bleed (admitted ___ ___ presents with increased fatigue, headache, and poor oral intake. She initially presented ___ to ___ urgent care with chills, fever to 100.4 and generalized weakness. She felt too weak to walk, and noticed very dark urine ___ the past few days, very poor PO intake and was transferred to ___ ED. Ultrasound done drainage. showed Successful US-guided placement of an ___ pigtail catheter into the left hepatic abscess. The patient was diagnosed with OTHER MALAISE AND FATIGUE, LEUKOCYTOSIS, UNSPECIFIED , ABDOMINAL PAIN GENERALIZED, MALIG NEO PANCREAS NOS. The patient was treated with ___ placement of catheter into hepatic abscess ERCP with stent removal and replacement. At the time of discharge, the patient had Primary: - Hepatic abscess - Biliary obstruction - Hyponatermia Secondary: - Headache - Anemia - GERD - OSA - Depression - Anxiety - T2DM. The patient was given written instructions concerning 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 ___ female with hx of pancreatic cancer (dx ___ s/p tx), T2DM, and recent history of GI bleed admitted with fever, fatigue, headache, and anorexia; found to have a large hepatic abscesses and biliary stent obstruction. ACTIVE ISSUES ============== # Hepatic Abscess: Patient was admitted from urgent care with increased fatigue, fevers, headaches, and poor PO tolerance. CT abdomen/pelvis with contrast revealed a new "large septated hypodense lesion within the left lobe of the liver" and "innumerable hypodense lesions" scattered ___ the liver. labs were also notable for an isolated alk phos elevation and normal T. Bili, concerning for early obstruction. The patient remained hemodynamically stable, but was started on Ampicillin/Sulbactam for coverage gram negative and anaerobic bacteria. After spiking fever she was transitioned to zosyn and a biliary percutaneous catheter was placed, draining 50cc from the largest abscess. Initial gram stain revealed gram negative and gram positive bacteria, so Vancomycin was added. An ERCP investigation of a previous biliary stent revealed migration and obstruction. It was removed and successfully replaced with a full metal stent. Cultures from the catheter placement revealed moderately resistant E. Coli and gram positive cocci. The patient was transitioned to meropenem and vancomycin with plan for ertopenem antibioisis ___ the outpatient setting. The patient remained afebrile and hemodynamically stable on following start of meropenem. She was discharged with plans for close follow up with infectious disease. # Headache: Patient presented with persistent bilateral headaches over the past month, bilateral ___ front and back. she also reported occasional vision blurriness, right temporal tenderness. She denied lightheadedness/dizziness, significant change ___ vision, and any tongue/jaw claudication with chewing. Given previous history of temporal arteritis, rheumatology and ophthalmology was consulted, but not found to have ocular involvement, and symptoms of headaache and temporal tenderness self resolved. Given low pretest probability, temporal biospy was deferred. # Hyponatremia: Na+ 126 on admission, with frank glycosuria on UA and Fingerstick glucose ___ 400s. With tighter glucose control and IVF hyponatremia self corrected without incident. Na+ on discharge: 140 CHRONIC ISSUES =============== # Type II Diabetes: At home NPH 45 units breakfast and dinner. Her home regimen was too aggressive, with some episodes of hyperglycemia, so she was de-escalated to 35 units of NPH at breakfast and dinner, and a less aggressive sliding scale. # Anemia: Patient was anemic on admission likely secondary to known bleeding from hemorrhoids. Admitted ___ and underwent Flex sig and colonoscopy which showed external hemorrhoids and diverticulosis, but no active bleeding. Hemoglobin/HCT were trended on this admission and remained stable. # GERD: Stable during this hospital stay. Continued home omeprazole. # Hypertension: Patient was hemodynamically stable ___ setting of infection. She had multiple episodes of hypertension, requiring 1x dosing of home labetolol. However, BP medications were generally ___ setting of infection, with normotensive vital signs. Will plan to restartlosartan 25mg PO Qday, labetalol 200mg po BID, amlodipine 10mg PO Qday on discharge # DVT: Patient had history of previous DVT, and was maintained on weight dosed enoxparin 120mg daily (increased from home dose of 90 mg SubQ per pharmacy). # OSA: Patient has history of OSA, and used nightly CPAP without event. # Anxiety: This issue was stable during this hospital stay. Patient continued continued home medication lorazepam. # Depression: This issue was stable during this hospital stay. Patient continued will continue home medication of citalopram. #DNR/DNI HCP: ___ (daughter) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ + for ETOH was walking down street looking at phone, saw a car coming down street and was startled, took a step back and fell striking head. She attempted to get up and had fallen back down. Reports having a bottle of wine per day. She was taken to ___ ___ and workup revealed a Right sided traumatic subarachnoid hemorrhage and a question of a small left sided SDH. Cervical collar was cleared at the OSH. She was subsequently transferred to ___ for further management and care. CT HEAD W/O CONTRAST showed Stable appearance of known small right temporal subarachnoid hemorrhage and right parafalcine and right tentorial subdural hematoma. No new focus of intracranial hemorrhage. The patient was diagnosed with SUBDURAL HEM W/O COMA, SUBARACHNOID HEM-NO COMA, 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>Mrs. ___ was directly transferred from ___ for traumatic subarachnoid hemorrhage and subdural hematoma. She was admitted to the Neurosurgery service with Keppra 1000mg initial load and Keppra 500mg BID. She was placed on a ___ protocol given her history of EtOH abuse. Her neurovascular exam was intact on admission. ___: She tolerated a regular diet. She was making adequate urine output. Pain was well-controlled on PO pain meds. Her neural exam remained to be intact. She was safe to be discharged to home.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is unable to provide history, so this has been obtained from review of documentation and discussion with nursing home and guardian ___, ___ CHEST (PORTABLE AP) showed 1. Mild pulmonary vascular congestion without frank pulmonary edema. 2. An oval air-filled structure projects over the left heart and may represent a large hiatal hernia or partial herniation of the stomach through the left hemidiaphragm. Comparison with priors, or the addition of a lateral view chest radiograph, would be helpful. 3. Small left pleural effusion. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Moderate intrahepatic biliary dilation and CBD dilation up to 11 mm in combination with a 2.2 cm hypoechoic lesion in the region of the pancreatic head is concerning for a pancreatic head neoplasm causing obstruction. Recommend pancreas CTA of the abdomen and pelvis for further evaluation. 2. 11.4 x 8.6 cm mixed solid cystic mass left adnexal mass is concerning for malignancy/metastatic disease. This can be also be evaluated on CTA of the abdomen pelvis. 3. Cholelithiasis without evidence of cholecystitis. RECOMMENDATION(S): CT of the abdomen and pelvis for further characterization of findings described in impression 1. and 2. CHEST (PA AND LAT) showed Heart size is enlarged. Mediastinum is stable. There is lateral views that represents elevation of left hemidiaphragm that might potentially represent rupture and herniation and bowel/stomach loops projecting in this location. Lungs are clear. There is no appreciable pleural effusion. There is no pneumothorax. The patient was diagnosed with Unspecified jaundice. At the time of discharge, the patient had # Biliary obstruction secondary to pancreatic Head Mass # Hyperbilirubinemia # Ovarian Mass # Abnormal EKG # Hydroureter # Hyponatremia # Hypomagnesemia # Abnormal CXR # Coagulopathy. The patient was given written instructions concerning 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 female nursing home resident with past medical history of dementia, cerebral palsy, hyperparathyroidism, hypertension, CAD, seizures, recent onset of painless jaundice, referred for admission and found to have evidence of pancreatic head mass and ovarian mass concerning for metastatic abdominal malignancy, subsequently discussed with patient's guardian who supported previous documentation that patient was DNR/DNI/do-not-hospitalize, discharged back to nursing home with plan to establish with hospice care # Goals of Care # Biliary obstruction secondary to pancreatic Head Mass # Ovarian Mass Patient referred for admission with painless jaundice, with imaging at ___ concerning for ovarian mass, and imaging at ___ concerning for pancreatic mass. Reviewed patient's chart, which included a MOLST form indicating do not attempt resuscitation, do not intubate, do not transfer to hospitalize. Situation was discussed with patient's guardian ___, ___ who agreed that initial MOLST form should be upheld, and patient's wishes respected. Discussed with guardian that imaging was concerning for metastatic abdominal malignancy, but that diagnosis would require biopsy--per guardian, patient's goals were palliative and comfort-oriented, and invasive biopsy and other diagnostic procedures would not be consistent with those goals. Reviewed patient's medications and modified her regimen to reflect her comfort-oriented goals. Started prn Zofran and oxycodone for symptoms. # Abnormal EKG Noted to have abnormal EKG with poor baseline, felt to represent likely sinus with PACs; initial plan had been to repeat EKG, but in setting of above described goals, further workup was not indicated # Hydroureter On OSH CT scan, hydroureter was seen, felt to be secondary to adjacent ovarian mass. In setting of above described goals, further workup was not indicated # Hyponatremia # Hypomagnesemia On labs noted to have electrolyte deficiencies. In setting of above described goals, further workup and treatment was not indicated # Abnormal CXR Noted to have elevation of left hemidiaphragm of unclear etiology. In setting of above described goals, further workup and treatment was not indicated # Coagulopathy Found to have INR 2 on admission. Unclear if nutritional versus synthetic. In setting of above described goals, further workup and treatment was not indicated Transitional Issues - Discharged to nursing home with plan to establish with hospice services - Per discussion with guardian, patient would only want to focus on treatments that provided her with comfort; patient's medication list was adjusted accordingly to only include medications that might bring symptomatic benefit to patient; added prn anti-emetic and pain medications (although patient did not require any during her hospital stay here) - Guardian is ___, ___ - Prior to discharge, provided warm hand-off to ___ provider NP ___ (___) > 30 minutes spent on this discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old woman with a past medical history of HLD, hypothyroidism, and TIA in ___ with transient "word salad" + R facial droop, who presents today with progressive sleepiness and was found to have a large R frontal IPH. CT HEAD W/O CONTRAST showed Minimal increase in size and related mass-effect of a large right frontal parenchymal hemorrhage. Leftward midline shift measures 9 mm without downward herniation. The patient was diagnosed with Nontraumatic intracranial hemorrhage, unspecified. At the time of discharge, the patient had Intraparenchymal Hemorrhage. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>After discussion with the patient's family at the time of presentation, the decision was made to pursue comfort measures only and planning for discharge to hospice with palliative care was initiated. On the morning following admission, the patient was noted to be more awake than at the time of presentation, likely due to clearing of lorazepam that was given at the OSH. Symptomatic treatment of pain, nausea, distress, etc. were continued and extraneous medications were stopped. Ms. ___ was discharged to inpatient hospice. AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? () Yes - (x) No - Not consistent with GOC 2. DVT Prophylaxis administered? () Yes - (x) No - Not consistent with GOC 3. Smoking cessation counseling given? () Yes - () No [reason () non-smoker - (x) unable to participate] 4. 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 5. Assessment for rehabilitation and/or rehab services considered? () Yes - (x) Not consistent with ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman presents to ___, transferred to ___ after developing 3 days of left-sided chest pain that was radiating to her neck and left shoulder. Underwent evaluation at ___ where she was found to have an increase in her chronic pneumomediastinum, therefore she was transferred. Does endorse some intermittent palpitations as well. Other than her pain and palpitations, patient denies any acute symptoms. Does endorse chronic shortness of breath with exertion, however does not report any acute changes in her breathing. Has a history notable for spontaneous pneumothorax ___ status post multiple video-assisted thoracoscopic surgeries with multiple pleurodeses, most recently over ___ years ago. Denies any fevers or chills. Followed by pulmonologist at ___, most recently seen here several years ago. In no acute distress, appears comfortable during interview. Thoracic surgery is consulted due to question of increasing size of pneumothorax seen on CT scan and based on the size a pigtail catheter was placed. he had an air leak, had symptomatic relief and her chest xray was a bit better Radiology showed Interval placement of a right-sided pigtail catheter with decrease in size of the right-sided pneumothorax. Previously seen intraperitoneal air is less clearly delineated but faintly visualized below the left hemidiaphragm. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little change in the substantial right pneumothorax despite the presence of a pigtail catheter. Indistinctness of the right hemidiaphragm with filling of the costophrenic angle is consistent with pleural effusion and basilar atelectatic changes. The left lung is clear and there is no evidence of pulmonary edema or cardiomegaly. CT CHEST W/O CONTRAST showed Smaller right chronic pneumothorax since ___. New right anterior chest tube is in place in the right hemithorax. New ground-glass opacities through right upper in lower lobes can represent expansion edema or, less likely, pneumonia. CHEST (PA AND LAT) showed In comparison with the study of ___, there is still a substantial chronic right pneumothorax despite the presence of the pigtail catheter. Continued filling of the costophrenic angle with basilar opacification consistent with pleural fluid and atelectatic changes. Left lung remains essentially clear and the cardiac silhouette is stable. The patient was diagnosed with Other pneumothorax, Chest pain, unspecified, Dyspnea, unspecified. The patient was treated with ___ Right pleural pigtail catheter placement. At the time of discharge, the patient had Right pneumothorax. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to the hospital for further management of her right pneumothorax. Her chest tube was on suction and an air leak was present. Her chest xray showed an apical , partially lateral pneumothorax but subjectively she felt better and was able to walk without getting dyspneic. Her chest xray remained the same on a waterseal trial and she subsequently had a chest CT done to evaluate bullous disease along with the extent of the pneumothorax. He chest CT on ___ showed a smaller "chronic" right pneumothorax compared to her CT scan in ___. Following 24 hours on waterseal her air leak was less but present therefore a pneumostat was placed so that she could be more ambulatory and return home while the leak resolved. Her chest xray with the pneumostat in place showed the same stable right apical/lateral pneumothorax. Her room air saturations were 97%. She was instructed how to drain the device and ___ was set up for home services. She was discharged home on ___ and will follow up with Dr. ___ in one week to assess the leak/tube and hopefully remove the pneumostat.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ Hx of CHF, CVA, Dementia AOx4, on ASA, multiple UTIs with hx frequent falls requiring walker presents s/p fall, + head trauma, unsure of LOC, unsure of events of fall, denies preceding Sx, no chest pain/headache/SOB, reports being on the floor for 30 minutes prior to being seen. In the ED, she complained of R scalp pain, R hip pain with palpation only and R distal posterior thigh pain with palpation only. Denies CP, SOB, Headache, vision change, hearing change, weakness, numbness, abdominal pain, nausea. Recently, she has had increased urinary frequency and when she got up today to go to the bathroom, that is when she fell. She denies lower abdominal pain, burning on urination, or flank pain. In the ED, initial VS 98.0 72 155/90 18 98% RA. Labs significant for pyuria with stable anemia and CKD. CT head showed no evidence of acute process and C-spine showed possible widening of OA joint with spine recommended soft collar and 1-week follow up with Dr. ___. Xray of Pelvis and R femur showed no evidence of injury. Given multiple falls, patient was given Nitrofurantoin for her UTI and admitted to medicine. On the floor, patient reports residual pain on right scalp, hip, and arm. Review of Systems: (+) per HPI (-) 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 No evidence of injury. Radiology showed No evidence of acute process. Stable intracranial findings. Small right parietal subgaleal hematoma with overlying soft tissue swelling. Findings suggesting inflammatory disease of paranasal sinuses. Radiology showed 1. No fracture identified. 2. Apparent increase in atlantodens separation, which is borderline. Although this may be due to underlying laxity at the joint which could be due to senescence or inflammatory arthropathy, ligamentous injury is not excluded by this examination. Correlation with physical findings and clinical presentation is recommended. If C1-C2 ligamentous injury is a possible clinical concern, MR may be of potential value. 3. Mild spondylolisthesis of C7 on T1, but probably explained by substantial facet degenerative changes. Moderate-to-severe cervical spondylosis affecting the whole cervical spine to varying degrees. 4. Bony demineralization. The patient was diagnosed with HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL, MULTIPLE CONTUSIONS NEC, SEMICOMA/STUPOR. At the time of discharge, the patient had Primary: #Complicated cystitis (urinary tract infection) #Ground level fall, multifactorial etiology Secondary: #Mild new widening of the atlantodens interval #Chronic congestive heart failure, compensated #Chronic kidney disease #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>In brief, this patient is an ___ year old woman with a history of CHF, stroke, dementia, diabetes mellitus type 2, multiple UTIs, and a history of frequent falls who presents with a ground level multifactorial fall and minor trauma. #Ground level fall: Presented to the ED after sustaining a fall at her assisted living facility. Fall reportedly occurred after she attempted to use the washroom at night, without assistance, in the dark, and without her walker. She sustained head trauma and she denied preceding symptoms and is unsure if she lost consciousness. In the Emergency Department she was worked up to assess for injury after the fall. CT head, pelvis film, and right femur film did not show any significant findings. However, a CT of the spine showed new apparent borderline widening of atlantodens interval to 3 mm since ___. Gerontology evaluated her on HD#1 and, after discussion, it was felt that the etiology of her fall was multifactorial though likely involved a mechanical component as she tried to walk without her walker or shoes in the setting of long-standing residual right sided weakness after her previous stroke. The fall was considered unlikely to be due to syncopal episode (she is on a number of antihypertensives though her blood pressure has been 130s-170s systolic while she has been on the floor) and given her lack of urinary symptoms (aside from increased frequency over weeks to months in the setting of furosemide)it was also considered unlikely to be related to complicated cystitis. She is being discharged with a soft neck collar which she is to wear for 1 week until she follows up with her orthopedist Dr. ___ she ___ also get follow up flexion-extension films). #Complicated cystitis: In addition, a urinalysis was performed in the ED which showed signs of urinary tract infection. It was thought that urinary tract infection may be a possible cause of fall and therefore she was admitted for further work-up. While in the ED she received one dose of nitrofurantoin and upon admission to the floor she was given 1g IV ceftriaxone. Labs were drawn again on the morning of ___ and she was found to have a new leukocytosis (to 14.7) with left shift. Initially, there was reservation to treat her for an infection given unreliable symptoms, however, the leukocytosis made the case more compelling so she was given a 10 day course of cefpodoxime. Her allergy history is questionable and she tolerated this last admission. Please monitor for signs of allergic reaction. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with PMH of afib on coumadin, CAD s/p PCI with LAD stent ___, presents with severeal months of dizziness and dyspnea, worsening in the past few days. The patient was diagnosed with VERTIGO/DIZZINESS. At the time of discharge, the patient had Primary: Heart Failure with Preserved Ejection Fraction Paroxysmal atrial fibrillation Secondary: Coronary Artery Disease Mild Aortic 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>___ year old female with PMH of afib on coumadin, CAD s/p PCI with LAD stent ___, presents with severeal months of dizziness and dyspnea, likely due to CHF exacerbation and atrial arrhythmia.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F with ileocolonic Crohn's disease s/p colectomy and end ileostomy in ___ on tofacitinib who presents with abdominal pain, nausea, increased stool output, and decreased PO intake after recent discharge from hospitalization for the same symptoms. ABDOMEN US (COMPLETE STUDY) showed Limited ultrasound of the abdomen demonstrates no sonographic abnormality. ABDOMEN (SUPINE ONLY) showed Non-specific, non-obstructive bowel gas pattern. The patient was diagnosed with ABDOMINAL PAIN UNSPEC SITE, NAUSEA WITH VOMITING, DEHYDRATION. At the time of discharge, the patient had Primary: Abdominal pain, nausea, vomiting Secondary: Ileocolonic Crohn's disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PATIENT: Mrs ___ is a ___ year old female with ileocolonic Crohn's disease with many recent admissions for concern of partial SBO who presents to the ___ ED with abdominal pain, nausea, vomitting, intermittent liquidy ostomy output, decreased PO, and lightheadedness. ACUTE ISSUES # Abdominal pain/N/V: Mrs ___ was admitted for recurrent abdominal pain, nausea, vomitting, increased liquidy stool output, and decreased PO intake. She had sharp pain at her old ostomy site about ___ min after meals. KUB did not show concern for obstruction, and abdominal U/S did not show any abnormalities. She was given dilaudid for the pain. She was also started on Hyoscyamine for abdominal pain and local lidocaine patches for pain at her old ostomy site. Abdominal ultrasound performed to evaluate for fistulous disease but was unable to identify any developing pathology. She remained afebrile with stable vital signs throughout and infectious work-ups were negative. As she was able to eat and tolerate an oral pain regimen she was discharged home with intent for outpatient follow-up. # Myalgias: Patient reported aches in her hips and legs at night and is also tender to palpation in neck, sternocleidomastoid, and right posterior hip. Treated symptomatically with her above pain regimen. # Pyuria: Patient's urinalysis had 100+ WBCs and bacturia on admission although patient did not endorse urinary symptoms. She was thought to have sterile pyuria and the medical team elected not to treat with antibiotics. Her urine culture eventually grew mixed flora consistent with contamination.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of 2 failed renal transplants status post IgA nephropathy who presents with dyspnea and upper body swelling. The patient states that ~1 week prior, he noted increasing swelling in his face, upper extremities, and chest, which had worsened until presentation. No associated skin lesion, chest pain. He then notes increasing shortness of breath, primarily with exertion, not exacerbated by lying supine, not associated with a cough, fevers, chills, or recent travel. Patient reports feeling weak as well (fatigued, no specific muscle weakness). Denies recent travel, sick contacts. UNILAT UP EXT VEINS US RIGHT showed No evidence of deep vein thrombosis in the right upper extremity. VENOUS MAPPING FOR DIALYSIS ACCESS showed 1. Occluded left cephalic vein in the mid forearm at the site of the previous failed left radial to cephalic AV fistula. 2. Patent right cephalic vein and bilateral basilic veins, radial artery, and brachial arteries, with specific measurements as detailed above. Radiology showed Successful placement of a 19cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Radiology showed The right pleural effusion has slightly increased in volume. A right-sided hickman catheter has been placed in the interim with its tip projecting over the distal SVC, the part which projects at the level of the clavicle appears to have a kink within it which could be positional. Small left pleural effusion is also stable. Cardiomediastinal silhouette is unchanged. No pneumothorax is seen. Radiology showed Technically successful conversion of an 8 ___ left transplant percutaneous nephrostomy tube to an 8 ___ nephroureteral stent. ?occlusion/worsening stenosis of SVC? showed 1. Widely patent SVC, without evidence of stenosis or thrombus. 2. Moderate bilateral pleural effusions, right larger than left. CT venogram of the thorax and upper extremities showed 1. Moderate narrowing of the proximal and marked narrowing of the distal SVC. 2. Eccentric nonocclusive thrombus within the mid to distal SVC, along the right lateral aspect of the tunneled dialysis catheter. 3. Several areas of apparent kinking of the dialysis catheter in the subcutaneous tissues. Correlate clinically. 4. Occluded left radiobasilic fistula. 5. Bilateral upper lobe centrilobular nodules may be infectious/inflammatory or could be in keeping with aspiration in the appropriate clinical setting. 6. Moderate right and small left pleural effusion. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 6:32 pm, 5 minutes after discovery of the findings. Radiology showed Technically successful balloon angioplasty of the SVC with good technical result RECOMMENDATION(S): Long-term dialysis access planning is necessary. SVC stenosis will likely reoccur quickly while a tunneled dialysis catheter remains cross the SVC. Radiology showed Moderate right and small to moderate left pleural effusions. Superimposed consolidation cannot be excluded. US NECK, SOFT TISSUE showed 1. 3.4 cm avascular right neck complex fluid collection within the subcutaneous fat of the right supraclavicular region demonstrating layering fluid-fluid level as described above likely represents an evolving hematoma. If there is continued increase in size of this lesion a contrast enhanced CT of the neck can be performed for better evaluation. 2. No communication with the adjacent jugular vein or common carotid artery. 3. The adjacent vessels are patent. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:48 am, 1 minutes after discovery of the findings. The findings and additional recommendations were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 1:05 pm, 1 minutes after discovery of the findings. BILAT LOWER EXT VEINS showed No evidence of acutedeep venous thrombosis in the right or left lower extremity veins. RENAL TRANSPLANT U.S. showed 1. Left iliac fossa transplant kidney demonstrating moderate hydronephrosis. 2. Doppler evaluation of the renal arteries is technically limited and the resistive indices may not reflect the true resistance of the renal parenchyma as they are measured at the level of the segmental arteries. If there is persistent clinical concern, may repeat study at no additional cost. BILAT UP EXT VEINS US showed 1. No evidence of deep vein thrombosis in the bilateral upper extremity veins. 2. Bilateral superficial edema noted. Radiology showed Successful placement of 8 ___ nephrostomy within the left lower quadrant transplant kidney. RECOMMENDATION(S): Keep PCN attached to bag. US ABD LIMIT, SINGLE ORGAN showed No focal fluid or collections. RENAL TRANSPLANT U.S. LEFT showed 1. Persistent moderate hydronephrosis of the left iliac fossa transplant kidney, minimally improved compared to prior study. 2. Doppler evaluation of the intrarenal arteries demonstrating appropriate resistive indices within the normal range. ABDOMEN US (COMPLETE STUDY) showed 1. Patent hepatic vasculature. No evidence of biliary dilatation. 2. No concerning hepatic lesions identified. 3. Moderate bilateral pleural effusions and small amount of perihepatic ascites. The patient was diagnosed with Disorder of kidney and ureter, unspecified, Dyspnea, unspecified, Essential (primary) hypertension, Anemia, unspecified. The patient was treated with Percutaneous nephrostomy tube placement (___) HD line placement (___). At the time of discharge, the patient had PRIMARY: ========================= End stage renal disease secondary to IgA nephropathy Chronic rejection with allograft renal failure SECONDARY: ========================= Immunosuppression Anasarca Hypertensive urgency vs emergency Pancytopenia Abnormal liver function tests. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ man s/p 2 renal transplants c/b acute graft rejection and recurrent IgA nephropathy, on chronic immunosuppression, initially presenting with volume overload and hypertensive emergency, found to have hydronephrosis, consistent with acute on chronic renal failure, now s/p PCN placement ___, converted to PCNU on ___, and initiated on HD on ___. Course complicated by SVC syndrome s/p angioplasty as well as tunneled HD line associated clot.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with hx HIV/AIDS (most recent CD4 count in 140s) and COPD presenting with palpitations, dyspnea on exertion, generalized weakness (worse over past 3 days). Denies fevers, sweats. Reports chronic cough with some increased sputum production and DOE. Reports that he has had chronic N/V/D since stomach flu approximately 1 months ago which lasted for 3 weeks, and has had subsequent poor PO intake. Also reports that he had been having a lot of back pain (chronic) over past 4 mo and he thinks that this has "worn him out". Patient is vague about symptoms, and admits to drinking etoh today. In the ED intial vitals were: 8 98.1 68 161/97 16 100% - Labs were significant for - EtOH 312, trop neg, K 3.1, lactate 1.7, AST 572 ALT 244. AP 201. wbc 5.5 w/ lymphocyte predominace Radiology showed No acute cardiopulmonary abnormality. COPD. Radiology showed 1. Echogenic liver which may be due to fatty infiltration however other more severe forms of liver disease including cirrhosis are not excluded. 2. Normal liver Doppler exam. The patient was diagnosed with ACUTE & SUBACUTE NECROSIS OF LIVER. At the time of discharge, the patient had Transaminitis Chronic back pain Alcohol intoxication. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ hx of HIV, EtOH dependence and mild COPD, presents to ED with 1 month hx of abdominal discomfort, nausea and recent hx of DOE and cough w/o increased sputum production. Pt found to have transaminitis. Pt has multiple complaints with no clear unifying diagnosis. # Transaminitis - Directly hepatocellular pattern w/ only cholestatic evidence being mildly elevated alk phos. AST: ALT elevated in 2:1 ratio c/w etoh toxicity. In OMR, has not had this degree of transaminitis in past however. The RUQ US showed cirrhotic liver without any acute finding. Pt's abdominal pain, malaise and myalgias could be indicative of infectious hepatitis, hepatitis panel and EBV/CMV was pending at discharge. Tylenol level was negative. In conjunction with recent increase in alcohol abuse, drug effect hepatotoxicity could be compounded. LFTs currently downtrending. GGT was elevated to 703. # Cough/DOE - No evidence of pneumonia/pulm edema on CXR, EKG was unremarkable and first set of trops neg. In an immunocompromised pt could consider atypical infection like PCP but no radiological evidence and pt would likely be in more acute respiratory distress. COPD exacerbation is possible given increased cough, some mild expiratory wheezing and SOB, however no increase in sputum. Shortly after admission did not complain of shortness of breath. Did not require supplemental O2. Spiriva and albuterol was continued. # Thrombocytopenia - Has not had this degree of abnormality in our OMR in the past. Could be evidence of ongoing alcoholism and worsening cirrhosis over the years. Could also be from acute infectious viral etiology. EBV/CMV and hepatitis serologies pending. # EtOH intoxication. Patient denies having history of withdrawals. He also denies any regular drinking since he started his antiretroviral therapy regimen. He was placed on a CIWA scale, however did not exhibit any signs or symptoms of withdrawal. He was started on folate, thiamine and a MVI. # Hypokalemia- Likely nutritional as patient has had poor po intake for at least a week or two. Was repleted this AM. # Cirrhosis - Patient with evidence of cirrhosis on RUQ US. Bili/cr/inr not elevated. Patient was encouragted to stop dirnking alcohol, especially while he is on antiretroviral therapies. He will follow-up hepatitis serologies as an outpatient. # HIV - Last CD4 140, pt reports that he is due for viral load and CD4 check which are currently pending. Continued on home medication regimen and dapsone. # COPD - continud with home medications # back pain - continued with oxycodone and gabapentin </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ w/hx of HIV on HAART, asthma, COPD, not on home O2 with recent hospitalization for Influenza c/b intubation for hypercarbic respiratory failure who presents with shortness of breath. Radiology showed Vague increased left basilar opacification, concerning for developing pneumonia in the appropriate clinical setting. The patient was diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, ASYMPTOMATIC HIV INFECTION. At the time of discharge, the patient had COPD Exacerbation HIV. The patient was given written instructions concerning 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 ___ w/hx of HIV on HAART, asthma, COPD (not on home O2) with recent hospitalization for Influenza c/b intubation for hypercarbic respiratory failure who presents with shortness of breath due to COPD exacerbation. . # COPD exacerbation: Patient presented with history of shortness of breath, cough with sputum production, and an increased oxygen requirement. CXR ruled out pneumonia as there was no sign of infiltrate. Patient showed rapid improvement with management of COPD exacerbation. He will complete a 5-day course of azithromycin (day ___ and prednisone 60mg PO X 5 days (day ___. The patient received education regarding COPD management. Spiriva was added to his home regimen of Symbicort daily and albuterol PRN. On discharge his ambulatory O2 sat was 89-90% on RA and 91-92% on room air at rest. . # HIV on HAART therapy: Last CD4 count 780, viral load undetectable in ___. We continued the patient's home regimen of Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY, Etravirine 200 mg PO BID, and Raltegravir 400 mg PO BID. . # HTN: Home regimen of labetalol 300 mg PO BID and lisinopril 5 mg PO DAILY was continued. The patient remained hypertensive throughout this admission with BPs as high as 170s/110s. The patient remained hemodynamically stable and asymptomatic. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ year-old with a h/o sarcoidosis, gastritis, HTN who presented as OSH transfer with right distal femur fracture. Patient was exercising per her usual routine when she bent over to pick up a weight, sustained a mechanical fall onto her right knee. She had immediate pain and inability to ambulate, was taken to OSH where x-rays revealed right distal femur fracture and she was transferred to ___. Radiology showed 1. Comminuted fracture through the distal right femur extending through the lateral femoral condyle, reaching the articular surface. No significant articular surface cortical step-off. 2. Moderate right knee joint effusion with lipohemarthrosis. Moderate ___ cyst. 3. Extensive tricompartmental degenerative changes throughout the right knee. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with FX NECK OF FEMUR NOS-CL, OTHER FALL. The patient was treated with ___: Right distal femur ORIF. At the time of discharge, the patient had Right distal femur fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ s/p fall with R distal femur fracture. Her imaging showed x-rays show comminuted Right distal femur fracture with likely intra-articular extension CT shows comminuted Right distal femur fracture with intra-articular fracture She underwent an open reduction and internal fixation on ___. The procedure was uncomplicated, her diet was advanced as tolerated and she was transitioned to PO pain medications. She will be touch down weight bearing, she has follow up in ___ days.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH multiple sclerosis, CKD, hx PE, osteoporosis, spinal stenosis, hx T12 compression fx, p/w severe low back pain x 10 days. Patient reports had severe low back pain on getting up from bed. She has difficulty walking due to the pain. She denies fever/chills, lower extremity numbness/weakness, and bowel/bladder incontinence. Radiology showed Chronic changes as described above. No findings concerning for an acute fracture. If clinical concern for fracture persists, MR is recommended for further evaluation. Radiology showed Loss of normal bone marrow signal with increased signal on the fluid sensitive sequence of the L1 vertebral body with associated mild enhancement concerning likely related to acute superior compression fracture. Follow up is recommended. Chronic T12 compression fracture with mild retropulsion of the supraposterior aspect of the T2 vertebral body effacing the ventral thecal sac and causing remodeling the ventral aspect of the cord without significant spinal canal narrowing. Multilevel spondylosis as above: -Moderate to severe right L2-L3 neural foraminal narrowing -Severe left L2-L3 neural foraminal narrowing -Severe L3-L4 and L4-5 spinal canal narrowing with crowding of nerve roots predominantly related to markedly thickened ligamentum flavum which may be ossified/calcified. Peripheral location of nerve roots in the inferior thecal sac possibly related to arachnoiditis. Findings discussed by Dr. ___ telephone with ___ and Dr. ___ at 4:45 p.m. on ___. Radiology showed No change on standing in alignment or degree of compression of the lumbar spine since ___. The patient was diagnosed with BACKACHE NOS. At the time of discharge, the patient had Primary Diagnosis: Acute T1 Vertebral Compression Fracture Secondary Diagnosis: CKD, MS, 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>___ y/o female with a past medical history of MS, CKD stage II, PE, osteoporosis, T12 compression fracture who presents to the ED with severe low back pain. # L1 Compression Fracture Patient reports continued lower spinal pain with negative plain film imaging at OSH. Repeat lumbar plain films negative for acute fracture however patient with poorly controlled pain. No concerning symptoms or exam findings for spinal compression. Patient had an MRI ___ which showed a new acute L1 compression fracture. She was seen by Orthopedics who recommended that she wear a TLSO brace. Her pain was controlled with Tylenol and Oxycodone. She was evaluated by ___ and discharged home in stable condition. She was continued on calcium and Vitamin D. # Hypertension She was continued on HCTZ and Metoprolol. Her blood pressure was well-controlled. # Hypothyroidism She was continued on home levothyroxine. # Chronic Diastolic Heart Failure She was continued on metoprolol and torsemide. # GERD She was continued on home omeprazole.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male with a history of tobacco abuse, major depressive d/o with psychosis, left MCA stroke in ___ with expressive aphasia who presents from his group home via EMS for complains of face pain and chest pain. Per group home staff, patient has been in "a bad mood" but otherwise at his baseline and they were unaware that he was having difficulties until the ambulance came to the house. In the ER he was unable to give a good history, whether due to psychiatric disease or his aphasia. In the ER he was expressing suicidality, but indicated to the psychiatric consultants that he had had SI for months and had a plan he would not disclose. Per ED staff he denied hallucinations and said he had been given his psych meds by group home staff. CHEST (PA AND LAT) showed Normal radiographs of the chest. CT HEAD W/O CONTRAST showed No acute intracranial abnormality. Moderate mucosal thickening with in the right maxillary sinus without air-fluid levels or aerosolized secretions to suggest an acute process. Mild to moderate soft tissue stranding and prominence anterior to the right maxilla is noted suggestive of cellulitis in the correct clinical setting. The lower limit is not completely included is not targeted. Periapical lucency noted around the right canine and premolar teeth of the maxilla. Correlate clinically with dental examination. Consider dedicated CT imaging of the face and neck as needed for better assessment. These are not adequately assessed on the present CT head study as not targeted. Mildly prominent adenoids. The patient was diagnosed with TOXIC EFFECT OF CARBON MONOXIDE, ACC POIS-CARBN MONOX NOS, ACUTE SINUSITIS NOS, SUICIDAL IDEATION. At the time of discharge, the patient had #Major depressive disorder, recurrent, severe with psychotic symptoms with psychotic features #Expressive aphasia #History of left ischemic stroke with residual deficits #Encephalomalacia #Dental caries. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>===================================================== ___ case manager: ___ ___ ___ Nurse coordinator: ___ ___ ___ including ___ ___ ===================================================== ASSESSMENT AND PLAN: ___ year old Ethipian male with past history of left MCA stroke in ___ with lasting expressive aphasia as well as severe major depression with psychotic features requiring ___ guardianship who presents from his group home with complaints of facial swelling & dental pain. In the ER he complained of suicidalilty so ___ initiated. Because of carboxyhemoglobinemia and mild leukocytosis was admitted to medicine for workup. #Leukocytosis: White blood cell count was 12 in the ER. He received cefazolin and azithromycin. There was concern for acute bacterial rhinosinusitus or pneumonia. He was afebrile with normal vital signs. He did not have bacterial sinusitis or pneumonia clinically or radiographically. He did not have a clear skin or soft-tissue infection of the face or neck to warrant antibiotics. He most likely has an odontogenic infection that lead to his leukocytosis, however, he had no pain or purulence on exam and interval exam showed improvement of mild facial asymmetry. Therefore, antibiotics were not continued and when his WBC count was then normal the day after admission he was felt to be medically cleared for discharge. A panorex dental series was done for dental consultants to evaluate for any teeth that would require extraction if he goes to an inpatient psychiatric facility. The dental consultant said that he would place a note in OMR based on the Panorex dental imaging and could do inpatient extractions, but not more complicated treatment planning such as fillings. However, the patient refused to get dental X-rays. Dental consult can see patient while on ___ 4 if necessary for dental pain. They would be more insightful as to how necessary the Panorex images are in the short term, rather than deferring any tooth extraction to the outpatient setting. Encourage oral hygiene with chlorhexidine oral rinse if tolerated. #Major depressive disorder with psychotic features, recurrent: He has a history of complex psychiatric disease with psychotic features associated with his depression. He has a ___ guardianship with ___ (___). He has been hospitalized multiple times in the past and has had ECT in addition to multiple antidepressants and antipsychotics. He saw his psychiatrist (Dr. ___ last on ___ at which time haloperidol PO was stopped in favor of higher dose ziprasidone. Since then he may have had changing behavior and worsening auditory hallucinations. He was seen by psychiatry in the ER and ___ was initiated prior to admission. Upon obtaining collateral from community based flexible support (___) team and outpatient psychiatrist, the psychiatry consult service concluded that Mr. ___ was off of his baseline because of recent refusal of care and behavior changes. It was therefore recommended that he have inpatient psychiatric admission for stabilization of his psychiatric disease for fear of further decompensation if he were to return home. He otherwise appeared cognitively at baseline in terms of answering questions with ___ word answers compared to his ___ neurology discharge exam in our documentation. He had no findings of serotonin syndrome, neuroleptic malignant syndrome, nor tardive dyskinesia. He was continued on his home medications of venalafaxine XR 150 mg po qam, benztropine 1 mg po qhs, ziprasidone 80 mg po BID, trazodone 50 mg po qhs. #History of left ___ territory ischemic stroke: He had an ischemic stroke in ___ with subsequent expressive aphasia, encephalomalacia, gait instability, and right hand weakness. He is able to speak in short answers, but responds appropriately to questions. His speech is laconic, but without dysarthria or paraphasic errors. He was continued on aspirin 81 mg daily. #Carboxyhemoglobinemia: Presented with COHb ___. He is a smoker and the most likely contributor is tobacco smoke inhalation. He was treated with oxygen in the ER, which was discontinued when he was admitted because the carbon monoxide source had been removed. #Tobacco abuse: Long-standing tobacco use. He was given a nicotine patch 14 mg daily #Hyperlipidemia: On simvastatin 20mg daily at home. This was continued. #GERD: On a proton-pump inhibitor at home. This was continued. #CODE STATUS: FULL TRANSITIONAL ISSUES ------------------- -please contact the patient's guardian with any medication changes as these must conform to a treatment plan -if he does not have inpatient tooth extraction by BID dental consultants, he requires close follow up with a dentist after discharge from inpatient psychiatry for tooth extraction </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an otherwise healthy ___ yo F visiting from ___, who tripped over 1 step while doing laundry and sustained a Left acetabular fracture. Immediate onset of pain and inability to bear weight. She was initially taken to ___, then transferred here. No HS or LOC. Denies pain elsewhere. No numbness or pareshesias. Active, independent community ambulator at baseline. Minimal pain in left hip previously. Radiology showed Acute fractures involving the left acetabulum, left superior and inferior pubic rami. PELVIS (AP ONLY) was done. The patient was diagnosed with Disp fx of anterior column of left acetabulum, init, Fall on same level, unspecified, initial encounter. The patient was treated with ___: L acetabulum ORIF. At the time of discharge, the patient had L acetabulum 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 L acetabulum fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for a L acetabulum orif, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient began experiencing continued bleeding from the incisional site during POD#1 for which her lovenox was put on hold from POD1-3. The bleeding stopped and the patient was restarted on anticoagulation. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touch down weight bearing in the left extremity, and will be discharged on 5000 units subcutaneous heparin for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o female with a history of COPD, PE on lovenox, and metastatic SCLC with prior hospitalization for pericardial effusion who now presents for weakness, dyspnea, and poor appetite. Chest: Frontal and lateral views showed New elevation of left hemidiaphragm with stomach seen beneath and with rightward shift of the mediastinum, new since PET-CT from ___ and chest radiograph from ___. Correlate with any interval procedure or injury versus other region for left diaphragmatic hernia or diaphragmatic paralysis. Left pleural thickening better assessed on preceding CT. Possible small left pleural effusion. The patient was diagnosed with Other fatigue, Adult failure to thrive. At the time of discharge, the patient had Primary: #metastatic SCLC # Failure to thrive # Weakness # Malnutrition Secondary: # Oral candidiasis: # Atrial fibrillation: # History of pulmonary embolism # COPD:. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ y/o female with a history of COPD, PE on lovenox, and metastatic SCLC with prior hospitalization for pericardial effusion who now presents for weakness, dyspnea, and poor appetite. # Failure to thrive # Weakness # Malnutrition Pt presents with subacute failure to thrive characterized by weakness, exhaustion, poor appetite, and dyspnea. She had few lab abnormalities on admission except for hypokalemia and hypoalbuminemia. She met with her outpatient oncology team while inpatient who felt that these symptoms were due mostly to progression of her cancer, and recommended hospice. The patient agreed, and decision was made to go to a hospice house. # Hypoxia # Dyspnea Her worsening dyspnea and hypoxia are likely secondary to progression of her SCLC. PET/CT in ___ demonstrated new subpleural mass along anterolateral chest wall, new nodules in lingual, and worsening mediastinal and left hilar lymphadenopathy. No wheezing or evidence to suggest active COPD exacerbation. No CXR evidence of infection. She was given supplemental O2 to maintain oxygen saturation > 92% which will continue at hospice and her home inhalers were continued. There is no indication to start antibiotics. # Extensive stage SCLC: Pt with diagnosis of SCLC in ___, now s/p 4 cycles of carboplatin/etoposide. Pt excluded from SRS/CK due to enlarging brain metastases and patient declined WBRT. PET/CT scan in ___ showed overall disease progression. Pt was initiated on nivolumab in ___ and received her ___ cycle on ___ and second cycle on ___. No further treatments are planned and the patient is transitioned to hospice hospice. For nausea, she was given Zofran prn and prochlorperazine prn For pain, she was given Acetaminophen prn # Oral candidiasis: stopped nystatin since going to hospice # Atrial fibrillation: holding rate control with metoprolol given hospice. Continuing lovenox but if patient decides she doesn't want to take it she can refuse. # History of pulmonary embolism: continuing lovenox. # COPD: Continue home albuterol and tiotropium More than 30 minutes were spent preparing this discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ F w recent admission to neurosurgery service for traumatic SDH and SAH from ___ (no operative management required) and PMHx of Afib (off coumadin since fall and bleeds), HTN, and HLD who presents to ___ ED as a transfer from ___ after she was noted to have word finding difficulty and difficulty ambulating at around 14:00 on ___. Deficits noted to be resolved within 5 minutes. She was transferred to ___ ED at the request of her family members for further evaluation. Ms. ___ reports that on the afternoon of ___, she was helping prepare dinner and clean the house up for her daughter's birthday. She admits "I may have overdid it." Dinner was served around 1PM(?) and she ate and conversed at the dinner table without any difficulty. At about 2PM, after she had finished her meal, she got up to go "sit in a soft chair" because she was feeling tired. As she got up, she felt as if she was having trouble standing and "felt funny." Her daughter reports, "it looked like she had forgotten how to put one foot in front of the other." She told her family "I don't think I can walk" and her son-in-law brought her a chair to sit down in. While she was sitting in the chair, she tried to talk to her family but felt like she was having difficulty getting her words out. She states that she had no difficulty in comprehending what was being said to her, she knew what she wanted to say, but "it was taking longer" to get the right words out. Her family was unable to appreciate a specific speech disturbance, but they did note that Ms. ___ was not acting like herself. Her daughter called ___ and EMS arrived shortly. Ms. ___ believes that her deficits resolved completely within ___ minutes and states that by the time EMS arrived, she was back to her baseline. Ms. ___ states that on the morning of her presentation, she had a very mild headache but that it had resolved by the time of her deficits. She reports that both of her legs felt "weak" but denies any focal motor or sensory deficits. She denies visual changes, difficulty swallowing, or problems with her bowel or bladder. MRI AND MRA BRAIN AND MRA NECK showed 1. No evidence of infarction or hemorrhage. 2. Moderate periventricular, subcortical, and deep white matter T2/FLAIR signal hyperintensity which is nonspecific but likely on the basis of chronic small vessel ischemic disease. 3. Unremarkable MRA of the head and neck. RECOMMENDATION Multiple bilateral thyroid nodules. Further evaluation with ultrasound could be performed on a non urgent basis. CHEST (PORTABLE AP) showed In comparison with the study of ___ from an outside facility, there is again extensive opacification involving the lower half of the right hemithorax, consistent with pleural effusion and substantial volume loss in the right middle and lower lobes. In the appropriate clinical setting, superimposed pneumonia would be impossible to exclude. No evidence of abnormality involving the left hemithorax or pulmonary vascular congestion. CT CHEST W/CONTRAST showed Large, layering, nonhemorrhagic right pleural effusion responsible for right lower lobe collapse. Multiple nondisplaced right upper rib fractures. No associated bleeding. Borderline enlarged lymph node at the thoracic outlet raises concern if the patient has a history of head and neck malignancy. 14 mm left thyroid lesion should be evaluated with ultrasound. RECOMMENDATION(S): Borderline enlarged lymph node at the thoracic outlet raises concern if the patient has a history of head and neck malignancy. 14 mm left thyroid lesion should be evaluated with ultrasound. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the patient has received a right-sided chest tube. The tube is in correct position. Almost all the right pleural effusion was drained. The might be a minimal pneumothorax at the site of tube insertion, at the medial bases of the right lung. No apical pneumothorax. Normal appearance of the heart and of the left lung. CHEST (PA AND LAT) showed 1. Heterogeneous parenchymal opacity in the right lower lobe has increased in density since the prior study, concerning for pulmonary hemorrhage or increasing pneumonia. 2. Right pleural effusion has been drained and there is trace left pleural fluid. NOTIFICATION: Findings discussed with Dr. ___ by Dr. ___ at 1048AM. CT CHEST W/CONTRAST showed New airspace abnormality in the right middle and lower lobes has developed progressively following right pleural drainage. There is no evidence of lung trauma or cavitation to indicate a necrotizing infection. This still could be pneumonia, or nontraumatic hemorrhage, for example if the patient has dilutional thrombocytopenia from multiple transfusions. It could also be progressive re-expansion edema particularly if the chest is subjected to high negative pressure. Right basal pleural drainage catheter which drained nearly all of the previous right pleural effusion, is fissural which could lead to dysfunction, explaining moderate right anterior pneumothorax. CHEST (PA AND LAT) showed As compared to the previous radiograph: The consolidation at the right lung base is substantially smaller. There is an unchanged 2 cm right apical pneumothorax without evidence of tension. Normal appearance of the left lung. Unchanged shape and size of the cardiac silhouette. The patient was diagnosed with TRANS CEREB ISCHEMIA NOS, ATRIAL FIBRILLATION. At the time of discharge, the patient had transient ischemic attack exudative pleural effusion atrial fibrillation hypertension suspected cervical 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 ___ right-handed woman with atrial fibrillation off coumadin due to recent traumatic SDH and SAH, who presented to an OSH with a transient episode of word-finding difficulties and difficulty ambulating. She was transferred to ___ for further workup. On examination she had no aphasia or dysarthria as well as a symmetric pattern of lower extremity weakness most consistent with myelopathy. Her history is most concerning for TIA secondary to atrial fibrillation. MRI demonstrated no acute infarct, MRA showed patent vasculature. Neurosurgery cleared her to resume anticoagulation. She was started on apixaban 2.5 mg BID (given age and weight) and her aspirin was stopped. She was found to have a right pleural effusion in the context of multiple rib fractures as well as several borderline lymph nodes. A chest tube was placed with uncomplicated removal of 2.5 liters of exudative effusion. CT chest after drainage showed trapped lung with residual pneumothorax but no effusion. She will follow up in pulmonology clinic. Her lasix which was started for the effusion was discontinued. She was hypertensive to the 150-170s and her carvedilol dose was increased. ============================================ 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 = 73) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? () Yes - (x) No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: () Antiplatelet - (x) Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? (x) Yes - () No - () N/A </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p TLH, BS in ___ presenting with lower abdominal pain x 7 days. Patient reports that she was seen by her PCP over the weekend and was prescribed antibiotics for a UTI. Symptoms worsened and she went to her PCP again yesterday and was started on Cipro and Bactrim. The pain has progressed and moved into her left flank and LLQ. Describes her pain as constant, radiating to her back and has a pulling nature to it. Was initially having nausea but that has resolved. Endorses chills and some discomfort with urination and defecation, but no blood in her stool or urine, dysuria, urgency or other urinary symptoms. Denies CP/SOB, N/V, VB, abnormal vaginal discharge, weight changes. PELVIS, NON-OBSTETRIC showed In the pelvis, there is a complex structure without internal vascularity with both solid and fluid components measuring up to 12.4 cm across maximal diameter. There is no peripheral hyperemia. The differential for this structure could be large hematoma with a clot versus combination mass with superimposed hematoma or less likely an atypical peritoneal inclusion cyst or abscess. Given the lack of internal vascularity, this is less likely to be a mass. However, pelvic MRI can be considered for further characterization. MRI of the Pelvis showed 1. Enlarged right ovary which is encompassed by various stages of blood products, without discrete enhancing ovarian parenchyma. Differential diagnoses considerations include a torsed ovary with hemorrhage, a ruptured hemorrhagic cyst, or given various stages of blood product ruptured endometrioma, as there is no mass-like enhancement an ovarian neoplasm is felt to be less likely, although not completely excluded given that it could be complete by masked by overlying blood products. 2. Peritoneal inclusion cyst surrounding the left ovary with internal hemorrhage. 3. Abnormal T2 hypointense signal in the left ovary, raises the possibility of underlying endometriosis. 4. Subcentimeter pelvic sidewall lymph nodes are likely reactive. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:21 pm, 5 minutes after discovery of the findings. Radiology showed Intraoperative fluoroscopic images during insertion of a ureteral double-J stent. The patient was diagnosed with Unspecified abdominal pain. The patient was treated with LAPAROSCOPIC BILATERAL OOPHORECTOMY, RIGHT URETEROLYSIS, ENTEROLYSIS; PLACEMENT OF RIGHT DOUBLE-J STENT; RIGID PROCTOSCOPY/SIGMOIDOSCOPY & CYSTOSCOPY. At the time of discharge, the patient had RIGHT OVARIAN TORSON, ENCASED LEFT OVARY. The patient was given written instructions concerning 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 general surgery service for further workup of her pelvic fluid collection seen on CT and its associated abdominal pain. She was initially kept NPO on IV fluids in case of potential drainage or surgical procedure. She remained hemodynamically stable with stable hematocrits. Her pain was controlled with IV medications given her NPO status and she underwent serial abdominal exams, which revealed stable lower abdominal discomfort, but no peritoneal signs. Imaging was discussed with interventional radiology and it was felt that the mass appeared to be primarily clot and therefore would not be amenable or advisable for percutaneous drainage. Ms. ___ then underwent further imaging of the collection with pelvic sonogram and pelvic MRI (full radiology impressions are elsewhere in this document). On ___ her pelvic MRI was read and discussed with radiology. At this time it was felt that the mass likely originated from the patient's right ovary and was possibly a hemorrhagic ruptured cyst vs. endometrioma vs. torsed ovary vs. less likely ovarian mass. Given these imaging findings it was felt that she would be ___ served on the gynecology service and transfer was arranged. MRI revealed a right adnexal mass concerning for ovarian torsion versus ruptured endometrioma. She was transferred to the gynecology service and on ___, she underwent a laparoscopic bilateral oophorectomy, right ureteral lysis, anterior lysis, placement of right double-J stent, rigid proctoscopy and sigmoidoscopy, and cystoscopy. Please see operative report for full details. Immediately postoperatively, her pain was controlled with IV morphine. She was subsequently transitioned to oral oxycodone, Tylenol, and ibuprofen. The right ureteral stent placed intraoperatively remained in place for a planned 14 days. Her Foley catheter was removed on postoperative day 1 and she voided without difficulty. She was ambulating and tolerating a regular diet. For her hypertension, she was maintained on carvedilol and lisinopril. For her type 2 diabetes, she was maintained on an insulin sliding scale, metformin, and glipizide when she resumed her regular diet. On postoperative day 1, she was discharged home with close follow-up.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: The patient is a ___ old overweight man with a history of CAD, T2DM, HTN and dyslipidemia presenting from ___ Ophthalmology with a complaint of a dense right homonymous hemianopsia and flashing lights in his right eye for the past three days. Chest: Frontal and lateral views showed No acute cardiopulmonary process. CTA HEAD AND CTA NECK PQ147 CT HEADNECK. showed 1. Acute infarction of the medial left occipital lobe, with no evidence of hemorrhage. 2. Focal cut off of the the left P2 posterior cerebral artery, likely secondary to thrombus. 3. Focal narrowing of the left P1 posterior cerebral artery and high-grade narrowing of the mid basilar artery. 4. No evidence of aneurysm greater than 3 mm, dissection or vascular malformation. NOTIFICATION: The findings were discussed with Dr. ___, M.D. by ___, M.D. on the telephone on ___ at 11:26 AM, 5 minutes after discovery of the findings. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed 1. Subacute infarction involving the left occipital lobe with no hemorrhage and mild associated local mass effect with sulcal effacement but no midline shift. 2. Normal appearance of the hippocampal formations . The patient was diagnosed with Unspecified visual disturbance. At the time of discharge, the patient had Left occipital stroke. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old gentleman with DMII, history of CAD s/p stents in ___, HTN, dyslipidemia who presented from ___ Ophthalmology with complaint of three days of flashing lights in his right visual field and vision problems and was found to have a dense right homonymous hemianopsia. Upon admission, he had a CT/CTA of his head and neck which showed evidence of acute infarction of the medial left occipital lobe with a P2 cutoff of the left posterior cerebral artery felt secondary to a thrombus. Patient then had an MRI which showed the corresponding area FLAIR hypertensity within the medial L occipital lobe with associated restricted diffusion consistent with subacute left occipital infarct. This also showed right frontal gliosis presumably from a prior infarct as well as a chronic infarct in the right centrum semiovale. Possible etiologies of the stroke included cardioembolic (though no evidence of thrombus on echo)vs artery to artery/atheroembolic. Patient is not known to have atrial fibrillation and was monitored on telemetry throughout his stay. He will have ___ ___ Hearts monitor as an outpatient (arranged on day of discharge) to monitor for atrial fibrillation. Patient had a transthoracic echo which showed mild symmetric left ventricular hypertrophy with regional left ventricular systolic dysfunction c/w CAD, LVEF 45-50%, no evidence of intracardiac embolism or septal defect. On admission labs were notable for HbA1c 6.2, LDL 103 TSH 2.0, CRP 0.8. Patient was on aspirin 81 mg daily and atorvastatin 80mg daily at the time of admission. His aspirin was stopped, and he was started on clopidogrel, instead. He was continued on his atorvastatin. He should continue atorvastatin as an outpatient. Patient's blood pressure medications were reduced or held during hospitalization to allow him to autoregulate his blood pressures post-stroke. He was resumed on his home antihypertensives at their prior doses upon discharge. Patient was given acetaminophen given that he had a headache and with the thought that the strobing may represent stroke-induced migraine. Despite acetaminophen, the strobing/flashing continued. He had an EEG to evaluate whether the flashing might be due to seizure. EEG showed focal slowing over the area of infarct, did not show seizure but patient did not have flashing/"strobing" of his vision during the EEG. Patient was started on Keppra (levetiracetam) 750 mg BID for empiric treatment of possible seizure. After starting levetiracetam, patient had much less prominent flashing. Mr. ___ should have outpatient clinic followup with a Neurologist. Mr. ___ should continue his levetiracetam for several months, at least until he is seen in Neurology clinic. He should continue this until he is told to discontinue by a Neurologist. Mr. ___ should have outpatient followup in cardiology given his Echo findings as well as his history of intracardiac stents. Mr. ___ was evaluated by occupational therapy who felt he should have outpatient occupational therapy for vision services. He should also have follow up with an ophthalmologist as an outpatient. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with incomplete quadriplegia, frequent urinary tract infections with urosepsis, and recurrent nephrolithiasis who presents with fever and chills. Radiology showed Known atrophic right kidney with no evidence of hydronephrosis in either kidney. The bladder is decompressed, impairing evaluation. The patient was diagnosed with URIN TRACT INFECTION NOS. At the time of discharge, the patient had primary diagnosis: fever, hyponatremia secondary diagnosis: neurogenic bladder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with incomplete quadriplegia, frequent urinary tract infections with urosepsis, and recurrent nephrolithiasis who presents with fever and chills. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with history of IVDU in remission who presents following a seizure: MRA BRAIN W/O CONTRAST T___ MR HEAD showed 1. Study is mildly degraded by motion, with artifact limiting evaluation of right inferior M2 division. 2. Grossly patent intracranial vasculature without occlusion, stenosis, suggestion of dissection or aneurysm greater than 3 mm. 3. Paranasal sinus disease concerning for acute sinusitis, as described. CTA NECK WANDW/OC AND RECONS Q25 CT NECK showed 1. Patent cervical vasculature without stenosis, occlusion or dissection. 2. 12 x 8 mm right thyroid lobe nodule. The ___ College of Radiology guidelines suggest thyroid ultrasound for further evaluation. 3. Paranasal sinus disease as described. RECOMMENDATION(S): 12 x 8 mm right thyroid lobe nodule. The ___ College of Radiology guidelines suggest thyroid ultrasound for further evaluation. CHEST (PA AND LAT) showed Comparison to ___. All monitoring and support devices are removed. Normal size of the cardiac silhouette. Normal hilar and mediastinal contours. No pneumonia, no pulmonary edema, no pleural effusions. RENAL U.S. showed 1. Bilaterally the kidneys are mildly increased in echogenicity with reduced corticomedullary differentiation which can be seen in diffuse parenchymal disease. 2. No hydronephrosis. 3. No evidence of ascites. Radiology showed Appropriate position of the ET and enteric tubes. Hazy left mid lung opacity, likely consolidation and/or layering effusion CT HEAD W/O CONTRAST showed Probable small left parafalcine acute subdural hematoma. Recommend short interval follow-up head CT in ___ hours. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:31 ___, 1 minutes after discovery of the findings. CHEST (PORTABLE AP) showed Pulmonary edema likely with pleural effusions, overall demonstrating progression from prior. Lines and tubes positioned adequately. CHEST (PORTABLE AP) showed Comparison to ___. The bilateral pleural effusions have decreased in extent and severity. Borderline size of the cardiac silhouette persists. No pulmonary edema. No pneumonia. Stable mild retrocardiac atelectasis. The monitoring and support devices are in correct position. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Numerous scatter areas with slow diffusion suggestive of acute to subacute infarcts in the bilateral cerebral hemispheres and thalami, without evidence of mass effect or edema, as described above. The largest of these foci exists in the bilateral occipital lobes. Recommend evaluating for evidence of thromboembolic disease. 2. There is no evidence of intracranial hemorrhage or enhancing mass. 3. Paranasal sinus disease as described above. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:06 ___, 5 minutes after discovery of the findings. CHEST (PORTABLE AP) showed Improved bibasilar opacifications. This may be related to improved pleural effusion, but could be a manifestation of a more upright positioning of the patient. If the patient's clinical status permits, PA and lateral chest radiograph may be considered for accurate assessment of pleural effusion. RECOMMENDATION(S): PA and lateral chest radiograph for accurate assessment of pleural effusion. The patient was diagnosed with Unspecified convulsions. The patient was treated with LP ___ A-line ___ L subclavian CVL ___ TEE ___ Extubation ___. The patient was given written instructions concerning 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 ___ y/o F with history of IVDU in remission who presents following a seizure with severe lactic acidosis and acute hypoxic respiratory failure. No history of prior seizures, no FH epilepsy or hypercholesterolemia or early stroke/MI. CT and MRI and LP collectively form picture of acute, bilateral, posterior infarcts (septic emboli vs. cardioembolic vs. cocaine) without prior neurologic disease. EEG showed no seizure activity throughout MICU stay and was discontinued. She was maintained on Keppra, empirically treated with antibiotics and acyclovir. Negative TTE and TEE for valvular vegetation, with bubble studies showing no PFO. Daily blood cultures were sent, and antibiotics were discontinued with plan to send additional blood cultures if she became febrile. CTA/MRA head/neck were negative for bilateral vertebral dissection or vasospasm. She had repeated episodes of agitation on multiple sedation drips but was weaned and extubated without incident. On the medicine floor, she was stable with no seizure episodes, and telemetry did not reveal any arrhythmias. She developed ___ which may be attributed to acyclovir toxicity, hypovolemia, rhabdomyolysis, or CIN. Her ___ was resolving after discontinuing acyclovir and increasing fluid intake, with decreasing CK throughout her stay. She will have a repeat lab check after discharge and see nephrology in ___. For continued concern for cardiac source of embolic stroke, she was sent home with ___ of Hearts event monitor to detect any cardiac arrhythmias. The acyclovir was never restarted given pt had received 7 days at the time of discharge and given low suspicion for HSV infection. ======================== Active issues ======================== #Seizure: She had multiple seizures initially with no reported past history of seizures, etiology unclear. She was noted to have hyperreflexia and clonus on exam which raised the question of serotonergic excess, especially as a SSRI was recently added to her meds. LP excluded bacterial meningitis. HSV PCR sample was inadequate, but clinical suspicion was low. MRI showed bilateral nonenhancing posterior lesions, TEE showed no PFO (repeat TTE showed same result) or endocarditis, MRA/CTA showed no vertebral artery disease. ___ be related to the possibility of paroxysmal atrial fibrillation or other abnormal heart rhythm, although no arrhythmias have been noted on tele. Hypercoagulable state less likely given negative b2-glycoprotein and anti-cardiolipin. She was started on keppra and scheduled to follow up with the stroke service at the time of discharge. ___: Cr up to 2.2 on ___ from baseline 0.7. Possibly drug-induced from acyclovir vs CIN. Initial UA showed blood with minimal RBCs consistent with rhabdo. Repeat UA on ___ showed no blood. Renal US showed no hydronephrosis. An embolic etiology of the renal failure was considered as well, however, the rapid improvement in function made this less likely. Ultimately nephrology assisted with management, recommending IVF which led to improvement in patient's renal function. Pt is scheduled for repeat labs as an outpt and renal ___. #Elevated CK: elevated to 2439 and 270 on dc, indicating resolving rhabdomyolysis likely due to seizure. #Abnormal LFTs: ALT/AST peak at 136/164 on ___, downtrended during the hospitalization. ___ have been drug-induced, although Keppra and acyclovir are not common hepatotoxic agents vs ischemic vs rhabdo. Hepatitis panel was negative and RUQ US was WNL. #History of Opioid Abuse - Stable, ___ clinic confirmed dosage of 1.25 tabs. Pt was on 1 tab during the hospitalization and did well with this, could consider decreasing dose as an outpt. #Depression - Stable, has not been receiving home medications due to initial concern for serotonin syndrome in the ICU. Patient was feeling well without medications and so these were held at discharge. She should see her psychiatrist after discharge. # Shock, likely septic: She was febrile, tachycardic, with leukocytosis in ED. She was initially hemodynamically stable, then became hypotensive refractory to fluids after intubation, requiring levophed. This was subsequently discontinued as BPs improved. Most likely etiology of shock is sepsis given the fevers and leukocytosis. Possible sources include pulmonary in the setting of aspiration. UA was unremarkable and LP did not demonstrate meningitis. Medication effect is also possible given the temporal relationship with sedation and intubation. She was weaned from pressors and sedation and extubated. She was treated broadly on vancomycin/zosyn. #Acute hypercarbic/hypoxic respiratory failure / Mild ARDS: She was intubated due to inability to protect airway in setting of seizures. Chest x-ray showed rapidly worsening bilateral effusions and edema, which was concerning for ARDS vs. aggressive fluid resuscitation. P/F ratio was 264. She was maintained on low tidal volume ventilation, covered on antibiotics as above. She had improving chest x-rays and was extubated. #Anion gap metabolic acidosis due to lactic acidosis: Initial gas post intubation was 6.75/58. Gap rapidly closed and pH normalized as lactate cleared. Lactate was likely elevated due to seizure given the rapid clearance. She was initially treated with fomepizole for concern for ethylene glycol poisoning, but assay was negative. This resolved as she improved. # Leukocytosis: WBC was 16 on admission, without neutrophilic predominance. ___ be reactive in the setting of seizures or due to infection. She was covered on antibiotics as above. #Subdural hemorrhage: Initial CT imaging showed a 4mm hyperdense thickening of posterior falx concerning for subdural hemorrhage and neurosurgery was consulted. MRI showed no evidence of bleed and subsequent course did not suggest #Anemia: 14->9->9->10.4->12. Possibly dilutional i/s/o initially resuscitation. Trending upward prior to discharge (see lab section). ========================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS: ___ year old man with a history of Type 1 DM leading to L BKA, ESRD s/p LRD ___, CAD, PAD and osteoporosis who presents with 2 days of poor PO intake, vomiting, and difficult to control hyperglycemia. The vomiting has been all day including dry heaves NBNB. He noted blood sugars in the 600s yesterday. He believes this was either due to a malfunction of his insulin pump or a bad batch of insulin. He has been unable to take his PO medications for the past 2 days including his renal tx meds. He denies any fevers/ chills. No cp/abd pain/sob. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with RENAL & URETERAL DIS NOS, AORTOCORONARY BYPASS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, KIDNEY TRANSPLANT STATUS. At the time of discharge, the patient had Primary Hyperglycemic HyperOsmolar Nonketotic State Secondary Type I diabetes End Stage Renal Disease s/p transplant Chronic transplant rejection Left leg amputation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF HOSPITAL COURSE ___ year old man with a history of Type 1 DM leading to L BKA, ESRD s/p LRD ___, CAD, PAD and osteoporosis who presents with 2 days of poor PO intake, vomiting, and difficult to control hyperglycemia. Nausea/vomiting: Patient presented with 2 day hx of nausea, vomiting which was none bloody, non bilious, non projectile in setting of replacing pump insulin with ? expired batch of insulin. He was seen by ___ who evaluated the pump and confirmed its proper function and agreed that the most likely etiology of his nausea and vomiting was indeed refilling with a bad bunch of insulin, leading to HONK state with subsequenty osmotic diuresis and dehydration. He recieved IVF inhouse, was quickly able to tolerate a regular diet without nausea/vomiting, with the initial complaint that his stomach felt "raw" with p.o however this sensation resolved. He restarted his insulin pump with the correction factor changed to 1.55. He was discharged with a prescription for lantus 10Units to use in the event of pump failure for basal coverage. . ESRD s/p transplant: pt with hx of ESRD s/p transplant with chronic rejection. Cr elevated from recent baseline 1.3-1.4 to 2.0 on initial admission. Elevated Cr likely prerenal in setting of dehydration, and improved with initial IVF and oral hydration, 1.5 on discharge. Rejection was not suspected given that he only missed 2 doses of cellcept/tacrolimus when he was having nausea/vomiting. His tacrolimus level was 5.3 on discharge and he continued his home tacro 2mg q12 and cellcept 500mg BID. . Leukocytosis: pt with leukocytosis of unclear etiology. Exam non focal. DDx includes infection, gastroperesis flare. Infectious workup was negative and leukocytosis resolved. Blood cultures were pending at the time of discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ ___ man with a reported history of cardiomyopathy status post PPM who was BIBA after witnessed fall from standing earlier today. CTA HEAD AND CTA NECK Q16 CT NECK. showed 1. 12 mm mass within the suprasellar cistern, with areas of peripheral and internal calcification. The mass results in superior displacement of the optic chiasm and floor of hypothalamus. The differential includes craniopharyngioma, dermoid, and/or thrombosed aneurysm. 2. Moderate intracranial atherosclerosis moderate narrowing of the supraclinoid segment of the right internal carotid artery. 3. Moderate extracranial atherosclerosis, with 50-70% narrowing of the bilateral carotid arteries at the carotid bulbs by NASCET criteria. 4. Dental caries. Recommend nonemergent dental consultation. RECOMMENDATION(S): Recommend nonemergent dental consultation. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had Syncope - likely orthostatic hypotension. The patient was given written instructions concerning 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 advanced dementia, stage III CKD, sick sinus syndrome with PPM placement in ___, and a background history of colon cancer and DVT status post IVC filter placement, who was BIBA following an episode of syncope. ====================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F w/ h/o CAD s/p RES in RCA, DM2, COPD/Asthma, pulmonary HTN, fibromyalgia, who presented for back pain and lightheadedness. Pt has chronic lower back pain, however in the past two weeks, her pain has been more frequent. The pain located in the midline, lower back, sharp in quality, ranging from ___, and does wake her up at night. Pt complained of numbness, "pins and needles" sensation over her bilateral calf recently. She occasional experience stress incontinence and stool accidents, but those symptoms have not worsened. Pt reported lightheadedness, frequently associated with the onset of backpain. Her worst symptoms frequently occur in the morning when she woke up on the bed, with associated nausea and headache. She denies vision changes, focal weakness, or slurred speech. Of note, pt was recently started on Lyrica two weeks ago, and has stopped the medication three days ago because of these symptoms. Pt was also given 20 tablets of Meclizine two weeks ago for her "dizziness", which did not appear to have helped her symptoms. She occasionally takes oxycodone and ultram for pain, but did not report association to her symptoms. Pt recently were only on metformin for her diabetes, and her morning fasting ___ were 70-90s. Pt reported fever to 102 the day prior to admission. She also reported "coarse" throat, but no productive cough. There were also development of several tender nodes over her neck. Pt routinely experiences nonexertional chest pain that were felt to be ___ fibromyalgia as prior workup has always been negative. Pt denies significant weight changes, night sweats, joint pain, dysuria, diarrhea. In the ED, initial vitals 99.2 78 172/80 16 100% ra. As pt c/o short episode of chest pain after admission, cardiac enzymes were obtained with troponin 0.03. Pt was given 325 mg asa and 600 mg plavix. Cardiology consult initiated in the ED, who recommended d/c home if cardiac enzymes remain negative. Her ___ troponin downtrended to0 0.02 ___KMB. However, pt then complained of feeling weak with two weeks of vertigo symptoms. Rectal temperature was elevated at 100.6. Pt was subsequently admitted to medicine floor for further workup. . Pt was admitted to the medicine floor for fever of unknown origin and concerning UA. Her initial VS were 98.6, 118/58, 60, 16, 100% on 3L . ROS: per HPI Radiology showed No definite evidence of acute intrathoracic process. Unchanged compared with ___ allowing for difference in techniques. The patient was diagnosed with CHEST PAIN NOS, VERTIGO/DIZZINESS, BACKACHE NOS, CHRONIC AIRWAY OBSTRUCTION, CAD UNSPEC VESSEL, NATIVE OR GRAFT, DIABETES UNCOMPL ADULT. The patient was given written instructions concerning 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 w/ h/o CAD s/p RES in RCA, DM2, COPD/Asthma, pulmonary HTN, fibromyalgia, who presented for back pain and lightheadedness. . # Lightheadedness: Pt's light headedness is subacute, likely multifactorial. Temporally, it is associated with the initiation of Lyrica in the past two weeks. Other iatrogenic causes included meclizine. Hypotension from qhs use of imdur with higher dose carvedilol as well as hypoglycemia from qhs use of metformin can both cause morning lightheadedness. Other medications include meclizine, flexeril, Ultram, oxycodone, lasix. There is no evidence of orthostatic hypotension on the physical exam. URI and overall deconditioning could also be contributing factors. We continued her pain medication, including oxycodone and ultram, held her flexeril, meclizine, and decreased imdur from 60 mg qhs to 30 mg qAM, and decreased her carvedilol to 25 mg bid. We would recommend taking the medication in the morning rather than at night. . # Back pain: Pt has chronic lower back pain managed with epidural injection every three months and chronic pain medication. There were no red flag signs concerning for cord compression on the exam. She has known anterolisthesis of L4/L5, and prior diagnosis of spinal stenosis. Her chronic pancreatitis could potentially contribute to her pain. Depression is a potential cause/contributor to her symptoms. The resolution of her back pain is unlikely during his hospitalization. We continued her pain medication, and had social worker to help patient deal with the social stresses. . # Fever: She self reported fever at home to 102. She also had a documented rectal temperature of 100.6 in the ED. She had cervical tender lymphadenopathy, likely suggesting an URI. There were no evidence of pneumonia on CXR. There was a qusetion of pyuria, but urine culture showed skin flora . Pt remained afebrile with no leukocytosis during this admission. . # Coronary artery disease: Pt has DES in RCA. She had some chest pain in the ED with no EKG changes and her cardiac enzymes were negative. This has been consistent with her prior presentations, most likely secondary to fibromyalgia. We continued her home medication, with the exception of decreasing isosorbide mononitrate to 30 mg qd and carvedilol to 25 mg bid. . CHRONIC ISSUES # Diabetes mellitus: Pt has diagnosis of type II diabetes, currently only on metformin 1g per day. She was switched on sliding scale insulin during this hospitalization. . # Chronic diastolic CHF: likely secondary to hyertension. We held her furosemide for one day during this admission. . # COPD and asthma: Pt is obstructive airway disease likely ___ smoking. She uses 3L O2 at baseline. Her O2 sat drops to 91% on RA. We continued the equivalence of her inhalers. . # Chronic pancreatitis: Pt carries diagnosis of chronic pancreatitis. We continued her Creon with meal. . # GERD: Pt carries diagnosis of GERD and is on pantoprazole, ranitidine and sucralfate. We continued all three medication, however, given the dizziness, will consider discontinuing ranitidine. . TRANSITIONAL ISSUES # CODE STATUS: FULL # CONTACT: ___ (___) and ___ (___) # PENDING STUDIES AT DISCHARGE: none # MEDICATION CHANGES - STOPPED meclizine - STOPPED cyclobenzaprine - DECREASED Imdur dose to 30 mg in the AM from 60 mg qHS - DECREASED Carvediolol to 25 mg bid from 25 qAM & 50 qHS # FOLLOWUP PLAN - Pt will arrange followup with Dr. ___ - She has appointment on ___ at HCA with NP ___ - will recommend consolidate GERD medication, especially ranitidine - Sleep studies pending</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o woman with a PMH of alcoholic cirrhosis (c/b SBP, ascites, HE), non-variceal UGIB, s/p RNYGB, current G-tube for enteral feedings, recent admissions for abdominal wall abscess with EC fistula and recurrent ileus/SBO c/b ATN, encephalopathy, and recurrent clogging of G-tube, who now presents with diffuse abdominal pain and nausea. She described the pain as ___, constant, non-radiating, with no mitigating or aggravating factors. She has been having bowel movements. She has not been vomiting. She denied headache, fevers, chills, hematemesis, coffee-ground emesis, hematochezia, melena, diarrhea, or constipation. She was referred to the ___ ED. CT abdomen and pelvis showed 1. Enteric contrast reaches the mid-distal small bowel. The more distal small bowel is distended, perhaps slightly worse compared to prior and now contains more extensive fecalized material suggesting slow transit. No discrete transition point identified nor decompressed distal small bowel loops to further support an obstruction. Colon is also moderately distended with stool. Could consider repeat abdominal radiographs to confirm enteric contrast passage through the bowel as clinically warranted. 2. No evidence of abscess. Pigtail catheter seen along the left anterior abdominal wall without associated collection in this region. 3. Nodular liver with small volume ascites. 4. Persistent moderate right hydronephrosis with mild dilation of proximal right ureter, unchanged. 5. Cholelithiasis. 6. Persistent small left pleural effusion with some left lower lobe atelectasis. The patient was diagnosed with Unspecified abdominal pain, Nausea with vomiting, unspecified. At the time of discharge, the patient had Abdominal pain Constipation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ y/o woman with a PMH of alcoholic cirrhosis (c/b SBP, ascites, HE), non-variceal UGIB, s/p RNYGB, current G-tube for enteral feedings, recent admissions for abdominal wall abscess with EC fistula and recurrent ileus/SBO c/b ATN, encephalopathy, and recurrent clogging of G-tube, who now presents with diffuse abdominal pain and nausea. #Acute on chronic abdominal pain #Opioid induced constipation #Concern for ileus Recently admitted with abdominal pain, nausea, and emesis thought secondary to recurrent ileus or intermittent small bowel obstruction and now presents with similar symptoms; main presenting symptom right now is abdominal pain. CT abdomen and pelvis negative for acute obstruction but did demonstrate extensive fecalization and findings consistent with slow transit. Her symptoms are likely worsened by chronic opioid use, and on her prior admission, she was placed on simethicone and advised to limit her opioid use. Has not taken tramadol in 1 week due to her pharmacy not having it. Unlikely SBP, on ppx. Unlikely to represent complication of prior abdominal wall abscess given the reassuring CT findings. Med rx refill history shows that she was started on methylnaltrexone and Linzess, however patient is unsure if she has been getting these. These meds were not on her pre-admission or discharge medication lists on her last admission. After speaking with patient's boyfriend who manages her medications, it was determined that she does have a Linzess as well as methylnaltrexone at home, however was not being given these medications because he was following the last discharge paperwork medication list. Spoke with transplant surgery regarding her JP drain, they will not see her on this admission as her drain is functioning well and there is no purulent drainage or complications currently.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ year-old male with hx of OSA on CPAP who presents with 4 days of R temporal head pain, neck pain, and R eye visual changes; starting after he lifted weights 4 days ago. He reports that he hadn't lifted weights for around ___ years but was previously very active. He started lifting weights again 4 days ago and "over-did it". Since that time he has had neck pain over his right shoulder/neck pain on palpation and exacerbated by head turning to right, palpation. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Study is mildly degraded by motion. 2. Please note that patient refused further imaging after acquisition of the first set of upper axial T1 fat sat images and refused contrast due to apparent history of contrast dye allergy. 3. No acute intracranial abnormality including infarct, hemorrhage or suggestion of mass. 4. Patent intracranial vasculature without significant stenosis, occlusion or aneurysm. No evidence of carotid cavernous fistula. 5. Patent visualized portion of the cervical vasculature without evidence of significant stenosis, or occlusion. Note that the great vessel origins and proximal cervical arterial vasculature were not imaged. Within limits of study, there is no evidence of dissection in the visualized upper portion of the cervical vasculature, though the majority of the proximal vasculature was not imaged utilizing T1 fat saturation technique. 6. Grossly stable low lying cerebral tonsils again noted. The patient was diagnosed with Headache. At the time of discharge, the patient had musculoskeletal pain chronic right ptosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ presented with neck pain and intermittent blurry vision in the setting of recent weight lifting. On examination he had a right ptosis which was present prior to the weight lifting as well as tenderness over the right temple and neck. Given the concern for a potential carotid dissection, he was admitted to the Neurology service for vessel imaging. MRI showed not acute stroke. MRA was incomplete due difficulty completing the study and the origins of the vessels were not visualized. However, there was good flow within all of the cerebral vasculature which was imaged and there was no evidence of dissection. Given his reassuring examination, his MRA was not repeated and he was discharged home with supportive care. As there was no evidence of stroke, secondary stroke prevention was not necessary. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with h/u hypertension, narcolepsy presents with the above fracture s/p mechanical fall off of skateboard about one hour prior to arrival. Reports she fell off the board, hit her leg on the ground and had immediate severe pain in the left lower leg. Denies numbness/paresthesias. Denies other injuries. TIB/FIB (AP AND LAT) LEFT; ANKLE (AP, MORTISE AND LAT) LEFT showed 1. Mildly displaced oblique fracture of the distal tibial diaphysis. 2. No acute fracture or dislocation involving the ankle. TIB/FIB (AP AND LAT) LEFT; ANKLE (AP, MORTISE AND LAT) LEFT showed 1. Mildly displaced oblique fracture of the distal tibial diaphysis. 2. No acute fracture or dislocation involving the ankle. Intraoperative radiographs of the lower extremity. showed Intraoperative images were obtained during open reduction and internal fixation of the left tibia. Please refer to the operative note for details of the procedure. The patient was diagnosed with Oth fracture of lower end of left tibia, init for clos fx, Fall from skateboard, initial encounter. The patient was treated with left tibial IMN. At the time of discharge, the patient had left oblique tibial shaft 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 oblique tibial shaft fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left tibial IMN, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w h/o CAD, recent MI s/p PCI w stent failure and repeat PCI, ischemic cardiomyopathy w reported prior EF 25% following MI, recent course of treatment for pyelonephritis, DM2, HTN, tobacco use who presents w CAP and acute heart failure. CHEST (PA AND LAT) showed Dense right lower lobe posterior basal segment consolidation concerning for pneumonia, possibly aspiration pneumonia given its location. The patient was diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Hyperkalemia, Acute pulmonary edema, Pneumonitis due to inhalation of food and vomit, Dyspnea, unspecified. The patient was treated with N/A. At the time of discharge, the patient had - Fluid overload due to ischemic cardiomyopathy - 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>==========PATIENT SUMMARY========== Mr. ___ is a ___ year-old male with a history of coronary artery disease, recent MI s/p PCI w stent failure and repeat PCI, ischemic cardiomyopathy with reported prior EF 35% following MI, recent course of treatment for pyelonephritis, DM2, HTN, tobacco use who presented with shortness of breath and hypoxia and found to have CAP and acute heart failure, treated with a course of antibiotics and diuretics, now with improved shortness of breath and hypoxia. ==========ACUTE ISSUES ADDRESSED========== #Acute on chronic systolic heart failure (EF 25%): Presentation consistent with flash pulmonary edema in the setting of hypertension at rehab given ischemic cardiomyopathy. Initially required O2, but quickly weened to room air. Though overall improved, continues to have shortness of breath with ambulation, though sats consistently >90 during ambulation on room air. EF on TTE this admission at 25% severe regional left ventricular systolic dysfunction. Previous TTE ___ ___ with EF 35-40% with hypokinesis of anteroseptal and inferoseptal WMA. Given possible worsening, outpatient cardiologist spoken with; overall, reassured by clinical status and felt this change on echo EF prediction was likely just difference in estimation, and new area of reversible infarct was exceedingly unlikely, recommending swift outpatient follow up with Dr. ___ against possible recathetritization/viability studies (scheduled, see follow-up). Patient treated with IV Lasix to good effect, losartan, PO toresamide, and spironolactone started for heart failure management. Continued on metoprolol succ 50mg. Discharge weight 150 lbs. #CAP Dense consolidation in RLL w leukocytosis. Though patient denies cough, fevers upon admission or during hosptial stay, he did have episode of diaphoresis with shortness of breath; he was treated with CTX/azitho x5d (___), and upon discharge was without cough, sputum or fever. #CAD #NSTEMI ___ demand No chest pain at presentation, or during stay. No concerning ECG changes. Trop peaked at 0.11. Likely ___ increased demand in the setting of HF exacerbation and infection. The patient was continued on ASA, ticagrelor, metop. and lisinopril. ===============CHRONIC ISSUES===================== #DM2 Discharged on NPH 5 twice daily. #Tobacco Use Offered smoking cessation assistance, declined ===============TRANSITIONAL ISSUES================ 1. Appointment with Dr. ___ care) on ___. 2. Please obtain electrolytes and renal function at follow up appointment. 3. Please monitor diuretic dosages and weights (patient plans to keep daily weight journal; dry weight of 150lbs). 4. Appointment with Dr. ___ on ___ for cardiac follow-up, changed from lisinopril to losartan per Dr. ___. Can consider initiation of Entresto given heart failure with reduced EF. 5. Please consider additional work up given EF reduction from 40% to 25% with outpatient cardiologist. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F on ASA 325mg hx kyphoplasty at L1 4 weeks ago who presents with numbness and weakness. ___ pt had L5-S1 steroid injection and subsequently felt an abnormal sensation in her rectum that developed in to numbness in her groin/labia. She had worsening back and leg pain ___ and ___ into the anterior thighs and lateral leg into lateral foot, worse on the right. The numbness in her groin is worse on the left. Yesterday she was dragging her right leg according to family due to pain. Today her right leg gave out from weakness. She had foley placed at OSH bc MRI showed distended bladder. Last urinated at 10:30am, MRI was performed at 22:30. Denies fecal incontinence. CHEST (PORTABLE AP) showed Heart size is enlarged. Mediastinum is stable. Lungs are clear. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial abnormality identified. Atrophy and probable chronic small vessel disease. CT L-SPINE W/O CONTRAST Q331 CT SPINE showed 1. Study is limited secondary to diffuse osteopenia. 2. Nondisplaced bilateral proximal T12 rib fractures as described. 3. Acute compression fracture of L1 with retropulsion of the posterior fracture fragments resulting in moderate to severe vertebral canal narrowing. 4. Redemonstration of known L2 vertebral body probable chronic compression deformity with superior endplate minimal bony retropulsion and at mild vertebral canal narrowing. 5. Mild-to-moderate bilateral L5-S1 bony neural foraminal narrowing. 6. Patient's known multilevel lumbar spondylosis better demonstrated on recent outside lumbar spine MRI. 7. High-density material within L1 and L2 vertebral bodies as described, question history of vertebroplasty. NOTIFICATION: Insert- LUMBAR SINGLE VIEW IN OR was done. LUMBO-SACRAL SPINE (AP AND LAT) showed Posterior fusion hardware between T11 through L4, without evidence of hardware complication. Chest x-ray showed Mild cardiomegaly. Postoperative changes. The patient was diagnosed with Unspecified cord compression. The patient was treated with ___: L1 laminectomy; T11-L4 fusion. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ y/o woman with history of dilated cardiomyopathy (LVEF ___, HTN, HLD, nonrheumatic MR, history of kyphoplasty at L1 4 weeks prior to presentation who presented with lower extremity numbness and weakness, found to have L1 compression fracture and severe lumbar spinal stenosis with compression of the thecal sac on MRI s/p urgent decompression with laminectomy, reduction, and fusion T11-L4 on ___, with post-operative course complicated by acute on chronic anemia, hypotension, ___, and toxic-metabolic encephalopathy. ============================ ACUTE ISSUES ============================ # L1 compression fracture: # Severe lumbar stenosis: # Cauda equina syndrome: On ___, Ms. ___ presented with back pain and lower extremity weakness after an outpatient epidural steroid injection. MRI at an outside hospital showed severe stenosis; Foley catheter was placed for urinary retention and the patient was transferred to ___ for further care. She was initially admitted to the neurosurgical service, and whe was taken urgently to the OR on ___ with Dr. ___ L1 laminectomy and T11-L4 fusion. Her operative course was uncomplicated; drain was placed in the OR. Postoperatively, she was extubated and monitored in PACU before transfer back to the floor. Post-op x-ray was performed on POD#1. Hemovac remained in place POD#1 due to high output and she was fit with a TLSO brace. On POD#3, ___, the Hemovac drain was removed. She mobilized with ___. The patient's Foley was removed and she was able to void spontaneously. The patient's pain was treated with scheduled Tylenol and Tramadol as needed. She should continue to wear TLSO brace when out of bed. She will need her staples removed and wound check in ___ days post-operatively, as well as spine follow up with AP/lateral spinal plain films in 4 weeks. # Toxic-metabolic encephalopathy: ___ hospital course was complicated by waxing and waning mental status consistent with delirium in setting of surgery and acute illness. NCHCT was obtained without acute intracranial abnormality. The patient's pain was treated as above. Her gabapentin dose was decreased. The patient was given Ramelteon to help promote a normal sleep-wake cycle. # Acute on chronic anemia: Patient with history of iron deficiency anemia, found to have worsened anemia on ___ and transfused 2 units PRBCs with appropriate increase in hemoglobin. Likely related to procedural blood losses. Hemoglobin subsequently remained stable and the patient did not require further transfusions. Hb 10 on day of discharge. Patient continued on home iron supplement. # Bacteriuria: Urinalysis from ___ notable for 4 WBC, small amount of bacteria, trace leukocytes, urine culture negative, without clear symptoms of urinary tract infection. She was initially started on ciprofloxacin, but this was stopped on ___ as culture was negative and patient was asymptomatic. The patient complained of urinary frequency after Foley was removed; multiple repeat urinalysis and cultures were negative for infection. # ___: Cr 1.1 initially from baseline of 0.6. Resolved with fluids. Cr 0.5 on day of discharge. # HTN: The patient had an episode of symptomatic orthostatic hypotension on post-operative day 1, likely secondary to hypovolemia and anemia. The patient's antihypertensives were initially held, and she was given intravenous fluids and blood transfusions as above with resolution of her hypotension. Her antihypertensives were slowly re-introduced, with stable blood pressures. Her home carvedilol was resumed, and half her home dose of valsartan. Please continue to monitor blood pressures and titrate medications as appropriate. # Chronic sCHF: LVEF ___. TTE from ___ unchanged from prior. Cardiology was consulted for assistance with management. Patient was initially hypovolemic and was given intravenous fluids to good effect. She was subsequently euvolemic throughout the rest of her course and did not require further fluids or diuresis. Her carvedilol and valsartan were resumed as above. Unable to obtain true discharge weight as patient unable to stand without TLSO brace. ============================= CHRONIC/STABLE ISSUES ============================= # HLD: Continued atorvastatin. Resumed aspirin (81 mg daily decreased from home 325 mg daily) in discussion with neurosurgery. # Depression: Patient no longer taking escitalopram >30 minutes spent on care/coordination on day of discharge. ============================= TRANSITIONAL ISSUES ============================= - Discharge weight: unable to obtain as patient in TLSO brace - Monitor volume status and consider diuresis if needed (LVEF 25%) - Patient should wear TLSO brace when out of bed - Patient will need an appointment for suture/staple removal and wound check in ___ days postoperatively (surgery on ___. Please call ___ to make this appointment. - Patient to follow up with Dr. ___ in 4 weeks, and will need AP/Lateral X-rays at the time of this appointment. Please call ___ to make this appointment. - Discharged on scheduled Tylenol and low-dose tramadol as needed for pain control. Please continue to assess pain and adjust regimen as appropriate. Patient has required very little tramadol while hospitalized. - Please check blood pressure and adjust antihypertensive regimen as appropriate. Discharged on half of home valsartan dose, uptitrate to home dose as appropriate. - Gabapentin dose decreased from 300 TID to ___ TID due to confusion; please continue to assess mental status and adjust dose as appropriate. - Started on Ramelteon at night for sleep; continue to assess need for this medication. - Continued home vitamin D and started on calcium supplementation for bone health. - Patient on ASA 325 as an outpatient; restarted on ASA 81 mg daily given no clear indication for full-dose aspirin - Communication: ___, daughter, ___ - Code: Full (confirmed)</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with HFrEF (EF 40%), CAD, bicuspid AV s/p AVR, AF on warfarin/digoxin, CAD s/p redo CABG/MV replacement/TV repair, COPD, and asthma presenting with 3 day history of dyspnea and productive cough. CHEST (PORTABLE AP) showed No focal consolidation to suggest pneumonia. The patient was diagnosed with Unspecified asthma with (acute) exacerbation. At the time of discharge, the patient had PRIMARY ======= Asthma exacerbation SECONDARY ========= Atrial Fibrillation Heart Failure with Reduced Ejection Fraction Coronary artery disease Hyperlipidemia Normocytic Normochromic Anemia Prostate Cancer Restless Leg 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>___ with extensive cardiac history, presenting for asthma exacerbation. His symptoms markedly improved with nebulizer treatments and steroids. ACUTE ISSUES ============ #Acute Asthma Exacerbation Patient's history and symptoms were concerning for asthma exacerbation. In the ED, patient was started on ipratriopium and albuterol, and given a dose of methylprednisolone. He was brought to ED obs for further monitoring, but had marked improvement after initial therapy. However, while boarding he was still symptomatic, and tachypnic while talking. There was initial concern for a possible PNA, and thus patient was started on Ceftriaxone and azithromycin, but this was discontinued given final read of his CXR. Though his sats continued to remain stable on RA, he continued to report subjective dyspnea, and had tachycardia to the 100s with ambulation. He was brought up to the floor were inhalers and steroids were continued, along with his home montelukast and advair. By the morning, the patient's symptoms had markedly improved, with ambulatory O2 sats ~94. There was low concern this was a HF exacerbation, as his CXR, BNP, and exam were not consistent with this. [] Patient should have close monitoring of his asthma, and discussion whether this is an appropriate regiment for him. CHRONIC ISSUES ============== #. Atrial Fibrillation INR goal 2.5-3.5 in setting of mechanical valve. INR 4.1 on morning of discharged. Was given 3mg, and instructed to follow-up closely for further monitoring of his INR. He was continued on metoprolol and digoxin. [] Patient will need close follow-up for monitoring of his INR, preferably ___ #. HFrEF Continued home Torsemide, Entresto, Spironolactone, and Digoxin. #. CAD/HLD Continued home atorvastatin #. Normocytic Normochormic Anemia Hemoglobin at baseline #. H/o Prostate CA Continued home tamsulosin 0.4mg PO QHS #RESTLESS LEG SYNDROME Continued ropinirole TRANSITIONAL ISSUES =================== [] Patient should have close monitoring of his asthma, and discussion whether this is an appropriate regimen for him. [] Patient had supratherapeutic INR at discharge in setting of receiving antibiotics for possible pneumonia. Consulted with pharmacy and decided to decrease warfarin from home 6.5mg to 3mg daily. He will need repeat INR drawn on ___, and adjustment to his warfarin dosing based on the result. #CODE: FULL #Health care proxy/emergency contact: ___ (wife): ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with PMH of CAD s/p CABG (___), CHF (EF 40%), DM2, HTN, CLL (stable), stroke x3 with residual hemiparesis and CKD (baseline Cr 2.0) who presents with productive cough and wheezing over the past 5 days associated with body weakness, rhinitis and n/v (non-bloody emesis x3 today). Diagnosed with bronchitis by PCP, and was started on levofloxacin. Came to hospital for increased wheezing and difficulties breathing. She reports very mild ___ swelling, not worse than normal. She does not weigh herself daily. Denies fevers or myalgias. Denies CP, abd pain, diarrhea or dysuria. States she has been compliant with her medications and follows a low salt diet. No recent travel or sick contacts. Of note, she was recently admitted in ___ with a fever, SOB and cough and was found to have E. coli bacteremia (likely ___ to urinary source) and a left lower lobe pneumonia. In the ED intial vitals were: 98.5 78 166/69 18 100%. Labs were notable for: proBNP: 5434, Trop-T: 0.20 (baseline), Cr 2.1, Hct 30.4. ECG showed SR at 88, LBBB, NA, non-specific ST TW changes. CXR: Increased left basilar opacity most likely represents combination of pleural effusion and atelectasis. Mild pulmonary edema. Patient was seen by cardiology who recommended ASA, beta blocker, statin and lasix to net goal neg ___ ___s admission to cardiology for CHF exacerbation in setting of viral URI. Patient was given: Albuterol 0.083% Neb Soln 1 NEB, Ipratropium Bromide Neb 1 NEB, PredniSONE 60 mg, Lasix ___ IV before transfer to the floor. Chest: Frontal and lateral views showed Increased left basilar opacity most likely represents combination of pleural effusion and atelectasis, although underlying consolidation not excluded. Mild pulmonary edema. CHEST (PORTABLE AP) showed Mild pulmonary edema and left basilar atelectasis and effusion are unchanged. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC. The patient was given written instructions concerning 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 of CAD s/p CABG (___), CHF (EF 40%), DM2, HTN, CLL (stable), strokex3 and CKD (baseline Cr 2.0) with residual hemiparesis who presented with productive cough and wheezing over the past 5 days and found to have the flu and CHF exacerbation. # Cough and wheezing: Positive for the flu. Given tamaflu and continued levofloxacin for possible superimposed bacterial infection. Treated symptomatically with oxygen, DuoNebs, Benzonatate, Guaifenesin, lozenges. # CHF exacerbation: BNP on admission 5434. Slightly volume up on exam and diuresed to dry weight on discharge. #Tropinemia: Likely in setting of demand from mild CHF exacerbation in setting of CKD. No chest pain or acute ST changes concerning for ACS. Held heparin drip. Continued home ASA. Not on ACE because of CKD. # Pancytopenia: Patient has history of CLL which can lead to pancytopenia since Autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), and pure red cell aplasia (PRCA) are well-described complications associated with chronic lymphocytic leukemia (CLL). Her hematocrit was around her baseline on this admission, and her admission leukopenia (___ 1798) and thrombocytopenia were likely exacerbated by infection; improved on discharge. CHRONIC MEDICAL ISSUES: # Type 2 diabetes: poorly controlled. Daughter states pt has very labile blood sugars at home. Continued home insulin regimen and ISS, held standing humalog with meals given episodes of hypoglycemia on recent hospital stay. # Chronic kidney disease: Patient's creatinine 1.9-2.1 throughout admission which is at her baseline. # Hypertension: Continued Metoprolol Tartrate 25 mg PO BID, changed to metoprolol succ 50 mg daily on discharge. # HL: Continued home statin.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male w/ a history of paraplegia (s/p work accident in his teens), recurrent UTIs, migraines, who presents with several days of lethargy and diaphoresis in the setting of recently treated UTI. Chest: Frontal and lateral views showed No focal consolidation to suggest pneumonia. Slight prominence of the superior mediastinum which may be due to AP technique and prominent vasculature. No prior for comparison to assess chronicity. If clinical concern for acute mediastinal or spinal process, CT is more sensitive and should be considered. Radiology showed 1. The striated nephrogram in the upper and lower pole of the right kidney and mild asymmetric right perinephric stranding in a patient with urosepsis is consistent with pyelonephritis. There is no evidence of renal abscess or perinephric collection. The kidneys are notable for multifocal bilateral cortical scarring from prior injury. Multiple nonobstructing renal stones are present bilaterally, largest in the right lower pole measures 1.0 x 1.2 cm. The remaining are punctate and scattered. No hydronephrosis. 2. Unusual lobulated morphology of the bladder is probably postsurgical. Multiple bladder stones are noted measuring up to 7 mm. Bladder wall thickening may relate to underdistention or represent cystitis. 3. Anastomotic sutures are noted in the region of the cecum. The appendix is not visualized and may be surgically absent. There are no inflammatory changes in the right lower quadrant. The patient was diagnosed with Acute pyelonephritis. At the time of discharge, the patient had Pyelonephritis Poison ___ - right hand. The patient was given written instructions concerning 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 w/ a history of paraplegia (s/p work accident in his teens), recurrent UTIs, migraines, who presents with several days of lethargy and diaphoresis in the setting of recently treated UTI, now w/ likely inadequately treated UTI leading to sepsis due to pyelonephritis. # Sepsis secondary to # Pyelonephritis: CTU shows R perinephric stranding c/w pyelo. Multiple stones, but non-obstructing. Urine cx shows GPC and GPR, likely not treated by ___ as prescribed last week. Started on Vanc/CTX here with marked improvement in symptoms, fever curve, and WBC (24->7). Urine cx at ___ from ___ with 3 different GPC isolate and one GPR isolate Urine culture here at ___ contaminated. Based on unrevealing culture data, ID was consulted to help provide guidance re: optimal oral abx treatment upon discharge. Based on prior culture data, Augmentin was recommended to complete 14-day total course of antibiotics Patient is strongly recommended to see Urology given h/o stones and prior urologic procedures with now frequent UTIs; he may also benefit from suppressive antibiotics in the future. # ___ - mild on the right hand after exposure prior to admission. Treated with triamcinolone cream x 7 days. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Mr. ___ is a ___ male with PMH most notable for morbid obesity s/p Roux en Y gastric bypass in ___ who presented to an OSH with severe LLQ abdominal pain which began approximately 12 hours prior. He also endorsed intermittent nausea, one episode of non-bilious emesis yesterday, and being febrile up to 101 at home. His last BM was on ___, and he reports no flatus since that time. He reports no CP/SOB, no dysphagia/BRBPR/melena. A CT scan done at the OSH was concerning for perforated colon, therefore he was transfered emergently to ___ for further evaluation. Radiology showed Right internal jugular central venous catheter in appropriate position. No pneumothorax or focal pneumonia. Left apical haziness could represent a component of non-cardiogenic edema, in addition to underlying fluid overload and right basilar atelectasis. The above findings were communicated to Dr. ___ by Dr. ___ telephone at 9:14 am, after attending review. Radiology showed Endotracheal tube may be advanced 2 cm for better positioning. Radiology showed Exact position of tip of nasogastric tube cannot be determined. The patient was diagnosed with PERFORATION OF INTESTINE, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, BARIATRIC SURGERY STATUS . The patient was treated with Subtotal colectomy End ileostomy. At the time of discharge, the patient had Small bowel perforation Colonic volvulus Incarcerated ventral hernia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to the General Surgery - Acute Care Service (ACS) at ___ on ___ for surgical management of colonic volvulus, an incarcerated ventral hernia and small bowel perforation in the setting of past Roux-en-Y gastric bypass. The patient was first evaluated at an outside hospital, but transferred to ___ emergently upon discovery of the small intestinal perforation. In the emergency department, the patient was noted to become hemodynamically unstable and required vasopressor support. He was taken urgently to the operating room at which point he underwent a subtotal colectomy with end-ileostomy. Two JP drains were placed, in the hernia sac and paracolic gutter, respectively. Please see the operative note for further details regarding this procedure. Post-operatively he remained intubated due to the complexity of the procedure and the patient's body habitus; he was transferred to the SICU for further care. While in the SICU, the patient's course was notable for a continued early vasopressor requirement including phenylephrine and norepinephrine. His lactate trended down appropriately. The patient remained intubated on HD#2 - HD#3 due to agitation with multiple attempts at weaning his sedation. He was extubated on HD#4 without difficulty. The hernia sac JP was removed and his NG tube was clamped with no residual. He was transferred to floor care on HD#6 once tolerating a full diet and off pressor requirement. The second JP drain was removed on HD#8. The patient remained on a regular diet which he tolerated well. He had adequate urine output via indwelling Foley catheter. Electrolytes were monitored due to high ostomy output; this trended down with addition of psyllium wafers to the patient's diet. He was evaluated by Physical Therapy and underwent multiple conditioning sessions with our ___ team. On day of discharge the patient was able to be transferred from bed to chair with assist and stand unsupported. He was discharged to a ___ rehabilitation facility in improved condition.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male with history of alcohol dependence/alcohol withdrawal seizures, hypertension, endocarditis treated medically at ___ about ___ years ago, and diabetes mellitus type 2 on insulin who was found unresponsive in bed and brought to ___ for hypoglycemia (BS 45) and hypoxemia (SpO2 ___ requiring intubation, with course complicated by seizures. He was transferred to ___ and admitted to the ___ for further management. He was treated for possible aspiration pneumonia and encephalomeningitis. ___ revealed severe mitral regurgitation secondary to an aneurysmal/perforated anterior mitral leaflet. Cardiac surgery consulted for mitral valve repair vs. replacement. CHEST (PORTABLE AP) showed Enteric tube courses below the diaphragm, out of the field of view. Endotracheal tube terminates approximately 5 cm above the carina. Extensive bilateral pulmonary opacities. Differential diagnosis includes massive aspiration, extensive multifocal pneumonia, severe pulmonary edema. Associated bilateral pleural effusions not excluded. No prior available for comparison. CHEST (PORTABLE AP) showed Pulmonary edema is unchanged. Support lines and tubes are also unchanged. Bilateral effusions are stable. Cardiomediastinal silhouette is unchanged. No pneumothorax. Chest radiograph, portable AP upright. showed Endotracheal tube terminating about 6 cm above the carina. Poor visualization of distal course of orogastric tube. Stable extensive pulmonary opacities most suggestive of severe multifocal pneumonia. Chest radiograph, portable AP semi-upright. showed Right internal jugular catheter is new, terminating in the upper superior vena cava. No other significant change. No pneumothorax. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are stable. The extensive opacification in the right hemithorax has decreased, with little overall change in the left hemithorax. In view of the enlargement of the cardiac silhouette, this change could represent decreasing pulmonary edema, with the remaining opacification reflecting bilateral areas of pneumonia. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are stable. Cardiomediastinal silhouette is unchanged and the diffuse bilateral pulmonary opacifications appear more prominent. Again, this most likely represents combination of substantial pulmonary edema and underlying areas of consolidation. Radiology showed Endotracheal tube tip projects 6.7 cm about the level of carina. Cardiac monitoring leads overlying the chest wall. An enteric tube is projecting over the distal esophagus. The heart size is unchanged. Right internal jugular catheter terminates within the proximal superior vena cava. Mildly prominent interstitial markings suggestive of pulmonary edema, unchanged from prior. Multifocal consolidative changes with mild interval improvement from prior. Mild interval improvement in aeration. CHEST (PORTABLE AP) showed It in comparison with the study of ___, the cardiac silhouette is less prominent and the pulmonary edema has essentially cleared. Hemidiaphragms are sharply seen consistent with resolved pleural effusion and basilar atelectasis, though some of this could merely reflect a more upright position of the patient. Endotracheal and nasogastric tubes have been removed. Right IJ catheter tip extends to the upper to mid SVC. CHEST (PRE-OP AP ONLY) showed Right internal jugular central line has been removed. Interval increase in left basilar atelectasis. CHEST (PRE-OP PA AND LAT) showed No acute cardiopulmonary abnormality. CHEST PORT. LINE PLACEMENT showed In comparison with the study of ___, there has been a mitral valve replacement performed with intact midline sternal wires. Endotracheal tube tip lies approximately 3 cm above the carina. Right IJ Swan-Ganz catheter tip is in the pulmonary outflow tract. Left chest tube is in place and there is no evidence of pneumothorax. CHEST (PORTABLE AP) showed Lungs are low volume with bibasilar atelectasis. The ET tube, NG tube and Swan-Ganz catheter has been removed. Left-sided chest tube is also been removed. Trace pneumomediastinum is seen. There is bibasilar atelectasis. Small bilateral effusions are stable. CHEST (PA AND LAT) showed 1. Bottom 3 sternal cerclage wires demonstrate leftward displacement, minimally more pronounced than prior study. If there is a clinical suspicion for dehiscence or infection, this should be correlated for clinically. 2. Small left pleural effusion, unchanged. The patient was diagnosed with Acute respiratory failure with hypoxia. The patient was treated with ___ 1. Mitral valve repair, radical reconstruction. 2. Autologous pericardial patch repair of perforation in the anterior mitral leaflet. 3. Commissuroplasty A3 P3 section. 4. Repair with 28 ___ annuloplasty band.. At the time of discharge, the patient had Primary: Multifocal pneumonia, likely due to aspiration Alcohol withdrawal Hypoglycemia Hypoxic respiratory failure Severe mitral regurgitation Secondary: Hypertension Diabetes mellitus type 2 ETOH dependence/Alcohol withdrawal seizures Hypomagnesemia Endocarditis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY: ========== ___ is a ___ y/o M w/ PMH of mitral valve endocarditis, alcohol use disorder with history of alcohol withdrawal seizures and IDDM2 that was found unresponsive in bed at his home on ___ and brought to ___ for hypoglycemia (BS 45) and hypoxemia (SpO2 ___, had seizures, required ___ transferred to ___ and admitted to the ___ where he was treated for septic shock and ARDS. He was extubated and transferred to medical floor on ___. ***</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of laparoscopic cholecystectomy ___ days (OSH) c/b cystic duct stump leak s/p interval ERCP with stent placement 4 days ago now presenting with RUQ pain. Patient reports he has had symptoms of 'reflux' with epigastric pain for several months and presented with acute on chronic epigastric/RUQ pain before his cholecystectomy ___ days ago. He was discharged in the interim but developed acute onset of RUQ pain, found to have a 'leak' and underwent ERCP/stenting 4 days ago. He recovered well from this procedure and remained afebrile without much pain until today when he developed return of his RUQ pain. He notes loss in appetite but denies vomiting; denies jaundice but has noted some pruritis of his right hemi-abdomen. Denies fevers or chills. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Persistent mild pneumobilia and fluid collection in gallbladder fossa, which could represent a biloma or seroma. Further evaluation with a HIDA scan is recommended. 2. CBD measures 3.6 mm. The patient was diagnosed with OTHER SPEC COMPL S/P SURGERY, ABN REACT-PROCEDURE NOS. At the time of discharge, the patient had Biliary leak. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ s/p open cholecystectmoy at ___ on ___ w/ subsequent obstruction s/p ERCP with stent placed on ___, admitted here with persistent biliary leak. Patient was admitted and had a HIDA scan, which was consistent with a small biliary stump leak. He was started on cipro/flagyl to complete 5 days of antibiotics. Fluid collection in gall bladder fossa was stable and did not require drainage. Patient's pain improved and diet was advanced as tolerated. Patient as ambulating prior to discharge. He will follow up with us in surgery clinic given his desire to transfer care away from ___ and should follow up with GI at ___ for stent removal.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y/o male with CAD s/p stents x2, thoracic aneurysm s/p grafting, HTN, bilateral RAS, MRSA UTI who presents with dyspnea. CHEST (PORTABLE AP) showed 1. Opacities at the medial lung bases are not able to be correlated given lack of lateral. In the correct clinical setting, these are concerning for underlying infection. Obscuration of the left costophrenic angle likely represents a small effusion. No pneumothorax. 2. Unchanged appearance of the cardiomediastinal silhouette and thoracic aortic stent. BILAT LOWER EXT VEINS showed 1. Deep vein thrombosis in the right common femoral vein. 2. No evidence of deep venous thrombosis in the leftlower extremity veins. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 1:33 am, within 30 minutes after discovery of the findings. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism. 2. Status post endovascular repair of a descending thoracic aortic aneurysm with thoracic stent graft seen in situ. However evaluation of the descending thoracic aorta and the abdominal aorta is severely limited as contrast has not reached these levels. Further imaging with dedicated CTA of the thoracic aorta can be performed if clinically indicated. 3. Small bilateral pleural effusions new since ___. There is mild bilateral pulmonary edema. 4. Mediastinal and hilar lymphadenopathy are likely reactive. CHEST (PORTABLE AP) showed Mild pulmonary edema as well as small bilateral pleural effusions. CHEST (PORTABLE AP) showed Compared to chest radiographs ___. No pulmonary edema. Small bilateral pleural effusions, right greater than left have increased since ___. No pneumothorax. Heart size normal. Thoracic aorta is extremely tortuous, somewhat dilated, containing a long Endograft, and all entirely unchanged since ___. The patient was diagnosed with Pneumonia, unspecified organism. The patient was treated with Cath on ___. At the time of discharge, the patient had Primary: # Acute-on-chronic Heart failure with preserved ejection fraction exacerbation # Unstable angina Secondary: # Thoracic aneurysm # Abdominal aortic aneurysm. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o male with CAD s/p DES x2 to RCA in ___ (___), thoracic aneurysm s/p grafting TEVAR, s/p infrarenal aorta repair with aorto right iliac graft, HTN, bilateral RAS, DVT s/p IVC filter, PVD, CKD, who presented with shortness of breath, transferred to Cardiology for management of unstable angina and HFpEF exacerbation. CORONARIES: 100% in-stent restenosis of RCA, R-L collaterals, 20% stenosis of pLM, dLM, 40% pLAD, 40% mLAD, 70% pDiag PUMP: EF 36% (___) RHYTHM: Sinus tachycardia. ====================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with history of afib on Coumadin, SSS s/p PPM, COPD/emphysema/interstitial pulmonary fibrosis on O2 at night, and HTN presents as transfer from ___ with LUQ and epigastric abdominal pain in the setting of known hepatic cysts. The patient has had LUQ abdominal pain for about 5 weeks now which has gotten worse over the past couple of days. She has a difficult time explaining her pain and when it began. She has been constipated recently and straining to have a BM. She felt that left sided abdominal pain worsened when she was straining to have a BM. She denies any vomiting, has +flatus, and last BM yesterday. She does have chronic nausea and was scheduled to have HIDA as an outpatient. She was also scheduled for rib films due to ongoing RUQ/flank pain. No recent trauma. She has known liver cysts and had one drained years ago. She does not recall the situation surrounding that cyst and whether or not she had any symptoms. In the ED, initial vitals were: 98.7 84 181/76 18 98% RA PE: bibasilar crackles, tender to palpation of the epigastrium and LUQ. otherwise normal except for chronic ___ venous stasis skin changes and dry MM. Hepatology was consulted and recommended: -have images uploaded and formally read by our radiologist to better characterize cysts and other potential etiologies for abdominal pain. -DO NOT ASPIRATE these hepatic cysts yet. Her case will need to be formally reviewed by hepatology, radiology, and liver surgery for diagnosis and intervention. -it is unlikely that she would be an appropriate surgical candidate given her comorbidities. -obtain outside medical records -can admit to medicine, hepatology consult if needed. Labs at OS___ were normal (Cr 1.0 and GFR 52, INR 2.6). She destatted and was placed on 2 NC. Labs were significant for trop <0.01. She received ___nd a ___ to he upper ebdeoment. At OSH, CT scan showed: 1. multiple hypodense liver lesions ranging from a few mm to the largest cyst 10x9x7 cm in the lateral segment of the left lobe previously measured at 10x8x6. It exerts mass effect in conjunction with an adjacent splenic cyst upon the stomach, somewhat increased from prior. 2. CBD distention to 8mm w/o etiology similar to prior 3. main pancreatic duct mildly prominent at 3-4mm in diameter with elongated tubular cysts in the head and uncitate process of the pancreas measuring up to 16mm in diameter, unchanged from prior. Possibly IPMN. 4mm cystic lesion in posterior tail of pancreas. 4. subtle induration of fat LUQ anterior to spleen, stomach and Left upper lobe of liver. Trace fluid is seen adjacent to the anterior periohery of LUL of liver not presents on earlier study, no surrounding inflammatory changes. 5.normal spleen and bowel with diverticulosis no diverticulitis. 6.hiatal hernia On the floor, patient is sleeping comfortably. When awake she complains of abdominal pain and slight nausea. Had normal BM yesterday. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Ultrasound-guided aspiration showed Successful ultrasound-guided aspiration of a 9.4 cm left hepatic cyst with collapse of the cavity on post aspiration imaging. 350 cc of dark non purulent fluid was aspirated with a sample sent for microbiology and cytology evaluation. The patient was diagnosed with Hepatomegaly, not elsewhere classified. The patient was treated with ___: Ultrasound guided drainage of a 9.4 cm left hepatic cyst. At the time of discharge, the patient had Primary diagnosis: Chronic, multi-organ polycystic process of unclear etiology. Secondary diagnosis: atrial fibrillation, fibrotic lung disease, psoriasis, cardiomyopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>***TRANSITIONAL ISSUES*** #Patient has a chronic, polycystic process affecting her liver, spleen, pancreas, and spleen of unclear etiology. ___ need further workup and drainage procedures depending on her pain level, goals of care. #Please assist for follow up with Dr. ___, her GI doctor in ___. Patient's nephew aware and will reach out for a follow up appointment. #CT A/P showing extensive bilateral fibrosis with honeycombing of the lung bases. Diagnosis may need clarification. #Patient noted to desat to 88% with ambulation, quickly recovered with rest, may need to wear oxygen more than just at night #Patient is troubled by her psoriasis, consider starting treatment #Warfarin follow by Dr. ___ ___, currently 2mg daily #Digoxin level 1.5, monitor closely as outpatient may need dose reduction #Discharge weight: 44.32kg (euvolemic exam) #CODE STATUS: DNR/DNI (confirmed ___ with patient) #CONTACT: ___, nephew ___, ___ ___ year old female with history of a chronic, polycystic process affecting her liver, spleen, pancreas, and spleen of unclear etiology, afib/SSS s/p PPM on warfarin, fibrosis/honeycombing of the lung bases on O2 at night who presents as transfer from ___ with chronic, worsening LUQ and epigastric abdominal pain. Abdominal imaging showed mass effect from these cysts, and our team believed this explained her chronic abdominal pain. On ___ she had an uncomplicated ultrasound-guided aspiration of a 9.4 cm left hepatic cyst with collapse of the cavity on post aspiration imaging. 350 cc of dark non purulent fluid. Cytologic evaluation was negative for malignant cells and no microorganisms were seen on gram stain or culture. After the procedure her pain had improved, though not completely. Our team believed this was most likely due to the multiple cysts that were not drained. We spoke extensively with the patient regarding the utility of further aspiration procedures. We noted that is very difficult to determine which cysts are generating her pain and that the cysts can re-accumulate fluid. Also explained the risk of infection and bleeding with each additional procedure. Given that her pain was "tolerable", she elected to defer any additional procedures at this time. We told her this can be readdressed as an outpatient if her pain level changes. Additionally, patient had diarrhea for ___ days after her procedure. This was likely related to an overly aggressive bowel regimen which was started given her presenting complaint of constipation. She was sent home with a bowel regimen to use as needed. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with HTN, GERD, who s/p L5-S1 hemilaminectomy, microdiscectomy in ___, who presents with low back pain x 1 day. Yesterday morning was saudering at work while on hands and knees and when he went to get on his feet, felt excruciating pain in his left lower back that radiated all the way down to his calf. Was barely able to continue working that day, as any movement and walking exacerbated the pain. Also noticed that his left foot was numb (since resolved) and that his left leg was weak and he was limping due to this. Took 15 200mg ibuprofen and 4 tylenol PMs over the course of the day. Eventually went to OSH ED and was transeferred here since his prior surgery had been done here. He sustained a work-related injury ___, with a L5-S1 disk rupture with central annular tear and protrusion of the nucleus pulposus. He underwent conservative therapy for a number of years with epidural steroid injections that temporarily relieved his pain. He underwent a L5-S1 hemilaminectomy, microdiscectomy by Dr. ___ on ___ without complications. His pain had completely resolved and was able to go back to work in ___ and had not been using any pain medication. In the ED, initial vitals were: 97 62 142/88 16 98% 2L na MRI spine showed status post left L5-S1 hemilaminectomy and microdiskectomy with small persistent disc bulge with associated left greater than right neural foraminal narrowing. No evidence of spinal canal stenosis or epidural collection. - The patient was given 1mg IV dilaudid x 3 and 5mg IV Morphine. Spine consulted in ED. Recommended admission to medicine for pain control and evaluation in AM by original surgeon Dr. ___. Vitals prior to transfer were: 8 98.5 86 141/79 18 93% RA Upon arrival to the floor, He states that the pain is tolerable when he does not move but any movement is excruciating. Felt that the morphine in the ED was more effective than the dilaudid. Also complains of a headache over the course of the day. Denies urinary or fecal incontinence. MR ___ AND W/O CONTRAST ___ MR SPINE showed 1. Postoperative changes related to interval left L5-S1 microdiscectomy and hemilaminectomy as described. Small fluid within surgical bed may be postoperative in nature. No definite enhancing collection identified. Recommend clinical correlation and attention on followup imaging. 2. Suggestion of small granulation tissue at L5-S1 discs midline dorsal margin, without spinal canal stenosis, and stable mild to moderate left neural foraminal stenosis. 3. No definite evidence of cord or cauda equina compression. 4. Stable degenerative changes at L5-S1 levels described. RECOMMENDATION(S): Postoperative changes related to interval left L5-S1 microdiscectomy and hemilaminectomy as described. Small fluid within surgical bed may be postoperative in nature. No definite enhancing collection identified. Recommend clinical correlation and attention on followup imaging. The patient was diagnosed with LUMBAGO, HYPERTENSION NOS. At the time of discharge, the patient had L5/S1 radiculopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ s/p L5-S1 hemilaminectomy, microdiscectomy in ___ presenting with acute back pain with positive straight leg raise with sciatica. #L5-S1 radiculopathy: Patient presented with lumbar back pain, radiating down the leg, MRI findings of herniated nucleus pulposus causing foraminal narrowing L>R, suggesting that his pain is most likely due to radiculopathy without evidence of cord compression. Also had paraspinal muscle tenderness which suggests presence of concommitant muscle spasm as well. Patient evaluated by spinal surgery team without recommendation for surgical intervention. Pain was controlled with IV/PO medication and transitioned primarily to PO ibuprofen with oxycodone for breakthrough pain. Valium also used for muscle spasm. Patient evaluated by ___ who recommended outpatient ___ and rolling walker that were provided. Patient was discharged with plan for close follow up with PCP and ___ to evaluate renal function in setting of hypertension and ibuprofen use. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ with hx of depression, PTSD with multiple suicide attempts in the past, migraines, hypothyroidism, pelvic floor dysfunction, possible MS here with several weeks of nonspecific symptoms involving feeling unwell, several days of intermittently worsened b/l legs more than arm weakness leading to one fall, and increased b/l arm more than leg weakness today after ___ exercise stress test. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Previously seen confluent FLAIR signal hyperintensity in the left parietal central semiovale extending inferiorly along the periventricular white matter is slightly less conspicuous and does not show enhancement or slow diffusion. 2. Stable appearance of white matter FLAIR hyperintensity in the right anterior temporal lobe without enhancement or slow diffusion. 3. No new enhancing lesions or areas of T2/FLAIR signal abnormality. No hemorrhage or acute infarction. 4. A small enhancing lesion in the central pons is unchanged dating back to at least ___. 5. Possible sub cm hypointense lesion in the pituitary gland is unchanged. MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE showed 1. No abnormal T2 signal or enhancement in the cervical and thoracic spinal cord or evidence of cord compression. 2. Mild multilevel degenerative changes in the cervical and thoracic spine as described above without high-grade spinal canal or neural foraminal narrowing. The patient was diagnosed with Urinary tract infection, site not specified. The patient was treated with N/A. At the time of discharge, the patient had Generalized weakness 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>Patient presented with somewhat unclear, vague complaints of generalized, symmetric weakness, with the legs more prominent than the arms. For further evaluation, she had a metabolic and infectious workup that revealed grossly positive UA, in the context of dysuria and recent treatment courses for UTI with CIprofloxacin. She was started on Ceftriaxone and discharged to complete 5 day course with Cefpodoxime, given the recent Cipro course with persistent symptoms. Repeat urine culture was pending at the time of discharge. Given ___ increasing disability and exacerbation of symptoms, it is possible that this could represent a mild flare of MS. ___ pan-spine and brain MRI did not reveal any new lesions. ___ examination slightly improved on the morning following admission. She was able to stand and walk without assistance. On day of discharge, she also had ___ evaluation who determined patient was safe for discharge home, with plans to resume ___ baseline ___ services. She was also given a prescription for walker per ___ recommendations. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ woman with PMHx notable for anxiety, depression, chronic neck pain s/p C4-C5 laminectomy and C2-C6 fusion on ___ who presented from rehab s/p falling and hitting her head at ___. She had been having fevers. It was assumed secondary to UTI, even though negative U/A and negative urine culture, and was started on cipro. Her only other new symtom was been abd pain, though she had been moving her bowels. According to ___, the patient was febrile to 100.3 on admission, and reached 100.6 on the evening of ___, for which she was sent to the ED. CHEST (PA AND LAT) showed No acute cardiopulmonary process. Dilated bowel loops likely related to ileus. The patient was diagnosed with PARALYTIC ILEUS, ABN REACT-PROCEDURE NOS, FEVER, 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>___ year old woman with PMHx notable for anxiety, depression, chronic neck pain s/p C4-C5 laminectomy and C2-C6 fusion on ___ who presented from rehab s/p falling and hitting her head at ___ today and was admitted for work up of post-op fevers. ACUTE ISSUES ============ # Post Op Fevers: The patient is s/p C4-C5 laminectomy and C2-C6 fusion on ___ with fevers that were present post op according to the patient. Pt was placed on PO cipro prior to discharge despite having a negative U/A and urine culture with no growth. She presented to Rehab where she continued to be febrile with the highest documented fever of 100.6. In the ED, she had a mild temperature of 99.8. She had no signs of infection on exam and no WBC count. On the floor, the patient reported feeling well other than pain in her neck. She denied any shortness of breath, pain with breathing, dysuria or increased urinary frequency, pain or swelling in her legs. The ciprofloxicin was stopped, and Tylenol was discontinued to monitor the fever curve. No fevers occurred. A UA and urine culture was negative. Neurosurgery inspected the wound and reported that the wound was not infected. As no source of infection could be identified and the patient had no shortness of breath/chest pain, the most likely cause of the post-operative fever is atelectasis. The patient was given incentive spirometry and had no recurrence of fevers since admission. She will be discharged to ___, where she will continue to receive physical therapy and pain management. # Urinary retention: Likely related to opiate and other medications including cyclobenzaprine and amitriptyline. She was bladder scanned for >1000cc on two different occasions and was emptied with a straight catheter. Given the failure of the urinary retention to resolve, a Foley catheter was placed, which should remain in place for ___ days. # C4-C5 laminectomy and C2-C6 fusion: She achieved adequate pain relief from morphine ___ q6h prn. Neurosurgery recommended that the patient stay in a hard c-collar for 6 weeks or until cleared at her appointment with Dr. ___. # Post-op ileus: The patient was discharged with post-op ileus, and she has been taking a large number of bowel meds at rehab (8x daily miralax). She has been passing gas, having bowel movements, and is eating. As she returns to rehab, the goal should be to decrease pain medications as tolerated and to continue the aggressive bowel regimen. #s/p fall: per patient report, her "legs gave out" while walking. The cause of her fall is likely multifactorial, but medication effect may play a significant role. Would benefit from medication reduction in the future. CHRONIC ISSUES ============== # Depression: continued home antidepressants # Anxiety: Continued home medications TRANSITIONAL ISSUES =================== # Neurosurgery noted that the patient should remain in a hard c-collar for 6 weeks after the procedure or until her Dr. ___ her. # A Foley catheter was placed ___ due to urinary retention >1L. The Foley should stay in for 3 days and then a voiding trial should be conducted. # Please consider decreasing pain medications as tolerated in the setting of postoperative ileus. Presently, the patient requires a very aggressive bowel regmen to have bowel movements. # The patient and her PCP should review her medication list in detail. In particular, she remains on two benzodiazepines, and she is also on cyclobenzaprine and amitriptyline, which can cause urinary retention. She may benefit from a reduction in the number of medications she is taking. # Code: confrimed full # Emergency Contact: ___ (son), phone number: ___.</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 secondary sclerosing cholangitis due to biliary strictures, recurrent mpancreatitis, whipple surgery, surgical revision, redo Roux-En-Y hepaticojejunostomy in ___ and suppressive antibiotics who is being admitted for acute on chronic cholangitis. MRCP showed Stable examination when compared with the recent prior study with very mild acute on chronic cholangitis involving posterior aspect of segment VI and mild chronic cholangitis involving anterior aspect of segment II. No hepatic abscess or microabscess. CHEST PORT. LINE PLACEMENT showed Interval placement of right chest PICC line terminates in the upper SVC. The patient was diagnosed with Other cholangitis, Left upper quadrant pain. At the time of discharge, the patient had PRIMARY DIAGNOSES ================== Secondary sclerosing cholangitis due to biliary strictures SECONDARY DIAGNOSES ===================== Recurrent pancreatitis Chronic suppressive antibiotic therapy. The patient was given written instructions concerning 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 secondary sclerosing cholangitis due to biliary strictures, recurrent pancreatitis, whipple surgery, surgical revision, redo Roux-En-Y hepaticojejunostomy in ___ and suppressive antibiotics who presented with worsening abdominal pain, inability to tolerate PO consistent with acute on chronic cholangitis. Patient was started on IV antibiotics (D1: ___- planned end ___ TRANSITIONAL ISSUES =================== [] Should complete 2 weeks of IV antibiotics (D14: ___- subsequent supporession choice/course will be determined by patient's outpatient ID doctor (___). ACUTE ISSUES ============ #Acute on chronic cholangitis Patient has a history of chronic cholangitis and recurrent pancreatitis managed on suppressive augmentin. She has recently experienced worsening symptoms of abdominal pain, nausea, and inability to tolerate PO. She was initially managed outpatient with increased doses of her chronic augmentin but her symptoms did not resolve. She was referred to the ED where she underwent RUQ U/S without abscess. She was started on Zosyn and then transitioned to CTX/flagyl (D1: ___. She underwent MRCP ___ which showed stable mild acute on chronic cholangitis without evidence of abscess. Plan for 2 weeks of ceftriaxone 2 gm q24H + metronidazole 500 mg q8H ending ___ she will have ID follow up at that time to determine further course. ============== CHRONIC ISSUES ============== #Roux-En-Y Bypass Continued home Lansoprazole 30mg ___ ___ 150mg BID, Calcium citrate-Vit D (250-200) BID, Cholecalciferol 1000u daily, Lactobacillus, and Multivitamin-minerals-lutein CORE MEASURES ============= #CODE: Full, confirmed #CONTACT: ___, husband, ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a recent diagnosis of mono p/w worsening sore throat and difficulty swallowing. In ___ to ___ she developed sore throat with low grade fevers and night sweats. She was tested for strep and mono and was told that testing (at her college) was negative for both. She was given clindamycin and her sore throat and fevers resolved from this acute episode. She maybe had 5 episodes of sore throats lasting two days each up until recently. Her night sweats have continued since that time although have not been accompanied by weight loss. The patient was diagnosed with INFECTIOUS MONONUCLEOSIS PERITONSILLAR ABCESS, ACUTE PHARYNGITIS. The patient was given written instructions concerning 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 tonsilar swelling and exudates with tender cervical lymphadenopathy and positive monospot test with mild hepatitis overall consistent with a mono-like illness with decreased PO intake and reported dyspnea at night prior to admission. # Mono-like illness: Patient has a mono-like illness with some atypical features. However, her overall clinic presentation with abnormal LFTs, atypical lymphocytosis, tender cervical adenopathy, and tonsilar exudates and swelling with positive heterophile antibody are very suggestive of infectious mononucleosis. Acute HIV was ruled out with undetectable viral load. The differential would include autoimmune or malignant (lymphomatous) processes but these appear to be less likely based on history, exam, and LDH. They can be considered for further workup if symptoms persist unexpectedly. # Concern for airway obstruction: patient brought in with concern for night time obstructive symptoms related to her lymphadenopathy and tonsilar enlargement. Currently not at risk for pending airway obstruction. She was monitored overnight on telemetry with continuous O2 sat monitoring. She did not desaturate overnight on room air. She was given Prednisone 40mg daily for a planned 5 day course. # Odynophagia with decreased PO intake: Likely related to her mono-like illness with inflamed tonsils. She has been able to drink >1L of a liquid diet prior to discharge. Pain was initially controlled with roxicet elixir and ketoralac IV. Once her pain was under control and she could take pills without difficulty her regimen was changed to standing tylenol and ibuprofen pills with oxycodone ___ Q4H PRN. # Abnormal LFTs: Likely ___ suspected mono as above, was they were previously normal in ___. Potential related to weight and NASH vs. tylenol use but these were felt to be less likely. Her LFTs should be rechecked as an outpatient when she is recovering. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PA AND LAT) showed No comparison. The lung volumes are normal. Normal size of the cardiac silhouette. Normal hilar and mediastinal contours. No pneumonia, no pulmonary edema. No pleural effusions. No pneumothorax. CT HEAD W/O CONTRAST Q111 showed No evidence of acute intracranial process. The patient was diagnosed with Syncope and collapse. The patient was treated with N. At the time of discharge, the patient had PRIMARY DIAGNOSIS ================= Syncope. The patient was given written instructions concerning 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 =================== [ ] Patient to get outpatient TTE in the next week. The order has been placed in OMR for this to be performed at ___. [ ] Patient to get outpatient event ___ of Hearts) monitor for 2 weeks. The order has been placed in OMR for this to be scheduled by ___. [ ] Patient to follow-up with Dr. ___ at ___ Cardiology in ___ weeks to follow up on the results of the above studies. Patient to call office at ___ to make the appointment.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS: This is a ___ year old male with PMHx afib on coumadin, breast cancer s/p chemo/XRT/mastectomy, prostate cancer s/p prostatectomy, total right hip replacement ___, revision in ___, chronic right hip ulceration complicated by klebsiella bacteremia and septic joint, s/p total bursectomy and quadricep flap, presenting with right thigh and hip pain. Of note, the patient initially presented to ___ on ___ with fever and hypotension, found to have Klebsiella septicemia and right septic hip, thought to be originating from his right hip wound. He was transferred to ___ where he underwent ___ guided joint aspiration (which ultimately grew enterococcus and klebsiella) and OR joint washout. His ulcer was excised and later underwent total complete bursectomy and anterolateral flap reconstruction, as his hip capsule was found to be infection. He was discharged on Ceftriaxone and Daptomycin to complete a total of 6 weeks of IV antibiotics. He was readmitted with nausea, vomiting, and diarrhea on ___ which resolved on their own. Since he had completed a 6 week course of IV antibiotic at this time, he was discharged on Amoxicillin and Ciprofloxacin which he is still taking at this time. He is now presenting with two days of right thigh and hip pain. He reports that he has been able to work with physical therapy and walk with a walker until two days ago. He is unable to ambulate due to pain and reports pain to touch and with any movement. He originally presented to an OSH where initial lab work up was unrevealing other than an elevated sedimentation rate at 60. In the ED, initial vitals were: 98.0 87 129/81 18 95% - Labs were significant for: - BMP wnl, WBC 8.2, N:69.0 L:16.1 M:7.9 E:5.7 Bas:0.8 - ___: 29.3 PTT: 37.9 INR: 2.6 - CRP 38 - Lactate 2.6 - Imaging revealed: - Knee X ray: Right total knee arthroplasty changes are noted. There is no fracture. Enthesophytes seen at the quadriceps insertion on the patella. Scattered surgical clips are visualized in the right thigh. Intra medullary rod partially visualized involving the proximal right femur. - Patient was seen by ortho and plastics while in the ED and are recommended aspiration of joint - The patient was given: IV Dilaudid x 3 - Vitals prior to transfer were: 98.5 96 150/80 18 96% RA Upon arrival to the floor, the patient still reports excruciating right hip pain with any touch or movement. He reports that he has not had a bowel movement in two days because he is not able to sit on the toilet without having pain. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. Radiology showed No acute fracture. INJ/ASP MAJOR JT W/FLUORO showed 1. Imaging Findings - Interval dislocation of the acetabular prosthesis. 2. Procedure - Technically successful right hip joint aspiration, with a few drops of serosanguinous fluid re-aspirated. I, Dr. ___ supervised the Resident/Fellow during the key components of the above procedure and I have reviewed and agree with the Resident/Fellow findings/dictation. NOTIFICATION: Findings were communicated to Dr. ___ via phone by Dr. ___ on ___ at 1045am HIP UNILAT MIN 2 VIEWS RIGHT showed Superolateral migration of the acetabular prosthesis from the native acetabulum. There is also some lucency about the distal tip of the femoral stem which also suggests loosening. PELVIS (AP ONLY) showed Satisfactory alignment of visualized right hip arthroplasty. BLADDER US showed Postvoid residual bladder volume of 202.8 cc. Otherwise, unremarkable appearance of the bladder. CHEST PORT. LINE PLACEMENT showed 1. Left PICC malpositioned coils in left axilla before terminating in left subclavian vein. 2. Chronic elevation of the right hemidiaphragm. NOTIFICATION: The findings were discussed by Dr. ___ with ___ nurse ___ on the telephone on ___ at 11:50 ___, 3 minutes after discovery of the findings. PELVIS (AP ONLY) showed Superior dislocation of the right hip prosthesis. NOTIFICATION: The findings were discussed by Dr. ___ with ___ on the telephone on ___ at 11:34 AM, 5 minutes after discovery of the findings. Radiology showed Successful placement of a 54 cm PICC, 0 cm exposed. The tip of the catheter terminates near the cavoatrial junction. The catheter is ready for use. PELVIS PORTABLE showed In comparison with the study of ___, there has been removal of the total hip arthroplasty on the right. Otherwise little change. The patient was diagnosed with JOINT PAIN-PELVIS. The patient was treated with Right hip flap exposure Right THA revision with endoprosthesis Right hip irrigation & debridement Right hip Prosthesis retrieve Right hip I&D, VAC Right hip wound closure/tissue rearrangement. At the time of discharge, the patient had Primary Diagnosis Infected right revised THA Secondary Diagnosis Urinary Incontinence Atrial Fibrillaiton Orthostatic Hypotension Chronic Systolic Heart Failure Depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with h/o afib on coumadin, prostate cancer s/p prostatectomy, breast cancer s/p chemo/XRT/mastectomy, total right hip replacement, revision in ___, chronic right hip ulceration, p/w right thigh pain ACTIVE ISSUES # Right Hip Prosthesis Dislocation: ___ and Hip X ray on admission showed interval dislocation of acetabular prosthesis. Joint aspiration was negative on ___ and fluid culture. He was continued on PO Amoxicillin and Ciprofloxacin which he was taking after completing a 6 week course of IV Ceftriaxone and Daptomycin for prior enterococcous/Enterococcus/Klebsiella septic R hip. He was evaluated by orthopedics and plastic surgery and underwent flap preservation and I/D with synovectomy of chronically infected right revision total knee replacement, removal of acetabulum cup insert and femoral head and insertion of endoprosthetic unipolar head on ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with M h/o of CAD, s/p CABG ___ and PCI to RCA ___, stable angina, CHF (EF = 30%), LV thrombus on coumadine, pacer + ICD, HTN, HLD who is admitted for epistaxis and chest pain. . Patient initially presented to the ED at 9PM with spontaneous epistaxis which started at 7pm, by the time he got to the ED, it stopped. MD removed gauze; there was no rebleeding. Patient was discharged from the ED but then spontanously restarted bleeding. Bleeding site in anterior right nostril; cauterized in ED. Patient then developed chest pain, that was typical of his chest pain at home. It resolved with ASA, and a SL NTG. Chest pain free at the time of admission. . Patient had recent admission ___ for hematuria which was attributed to coumadin treatment and cleared. Discharge summary not available. . Per chart, the patient saw his cardiologist ___ for slowly progressing exertional dyspnea (he can only walk a few ___ yards before experiencing chest pain, DOE. The rest of his cardiac ROS was ath the time negative. Most recent (date?) myocardial perfusion imaging is reported to have demonstrated only fixed myocardial perfusion defects without any evidence of reversible perfusion abnormalities. Known to have LVEF ___ with only mild mitral regurgitation as well as PHTN and right ventricular contractile dysfunction but without clinical signs of right heart failure (no peripheral edema). On that appointment the plan was treat angina medically: metoprolol dose was increased from 25 mg daily to 50 mg daily and to consider coronary angiography only if patient's symptoms became debilitating. Radiology showed Stable cardiomegaly with mild edema - may represent early heart failure. The patient was diagnosed with EPISTAXIS, CHEST PAIN NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had PRIMARY DIAGNOSIS: - Epistaxis (nose bleed) SECONDARY DIAGNOSIS: - Coronary Artery Disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>REASON FOR HOSPITALIZATION: ___ with M h/o of CAD, s/p CABG ___ and PCI to RCA ___, stable angina, CHF (EF = 30%), LV thrombus on coumadine, pacer + ICD, HTN, HLD who is admitted for epistaxis and chest pain. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ MEDICINE ATTENDING ADMISSION NOTE . Radiology showed No acute cardiopulmonary process. Radiology showed Expected continued evolution of the right posterior subdural hematoma with stable right occipital and left temporal lobe encephalomalacia. No new hemorrhage or other acute change. The patient was diagnosed with PSYCHOSIS NOS, HYPOTHYROIDISM NOS, HYPERLIPIDEMIA NEC/NOS, LONG TERM USE ANTIGOAGULANT. At the time of discharge, the patient had delerium/agitation due to medication (keppra) . H.o SDH and TBI afib CVA hypothyroidism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Assessment/Plan: ___ is an ___ y.o female with h.o AFib, CVA, s/p fall with hip fx and SDH, ?seizures, depression who was admitted for evaluation of encephalopathy and agitation. . #metabolic encephalopathy with agitation/aggression-EKG, EEG, head CT and laboratory testing were unrevealing. Considered possibility of CVA and behavioral changes related to SDH and TBI as well as possible seizure. However, her symptoms were felt to be likely due to medication effect from keppra. The geriatrics, neurology, and psychiatry teams were all consulted and recommended a keppra taper (750mg BID x3 days-complete, 500mg BID x3 days (Started ___, then 250mg BID x3 days, then 250mg QHS x3 days then off. These teams also recommended considering an ativan taper to off as well. However, she is currently on 1mg TID and doing very well with this regimen. Trazodone was also discontinued her her gabapentin dosing was changed to be renally dosed at 300mg BID. As the keppra taper was started, pt's symptoms markedly improved. She was calm, cooperative, and did not exhibit confusion from ___. There was never any evidence of seizure or CVA noted during admission. B12, rpr were unrevealing and dilantin level appeared to be apppropriate. The patient will need to follow up with the Traumatic Brain Injury clinic with Dr. ___ (___) as well as Drs. ___ in the General Neurology clinic (___) as planned during her prior admission. She should followup with Dr. ___ in the ___ clinic (___) at the beginning of ___ as previously planned planned. ++ Of note, after discussion with neurology, it was decided that pt should be therapeutic with an INR of 2.0 on her coumadin. Her coumadin dosing was increased to 3mg on ___. This should be continually uptitrated to reach an INR goal of about 2. ++Of note, her Free t4 was mildly decreased. Her levothyroxine can be further titrated in the outpatient setting. . #afib-continued coumadin. Increased dosing to 3mg daily as she was subtherapeutic. She should continue her coumadin with increasing uptitration to a goal INR of about 2.0 given her prior CVAs. She was not bridged with heparin or lovenox given her prior history of intracranial bleeding. Neurology agreed with this plan. -follow daily INR and continue to uptitrate coumadin carefully to INR of 2 . #h.o sub dural hematoma/h.o seizures?-Neurology was consulted. Pt's dilantin was continued a current dosing for seizure propylaxis. Dilantin levels were appropriate. Keppra titration to off was started. See above given pt's delerium and mood swings. Please see above for keppra instructions. Pt will need to follow up with neurology, TBI, and ___ clinic. . #HTN benign-continued metoprolol . #s/p CVA-continued coumadin (see dosing changes above under afib), statin . #Hyperlipidemia- continued statin . #neuropathy-gabapentin decreased to appropriate renal dosing at 300mg BID . #hypothyroidism-continued levothyroxine at current dosing. However, given slighly low free t4 (see results section above), may want to uptitrate. . FEN: regular . DVT PPx: hep SC TID while INR suptherapeutic while admitted. . CODE: DNR/DNI . Transitional care 1.continue keppra taper as outlined above 2.consider downtitration of ativan 3.pt will need f/u with neurology, ___ clinic, an neurosurgery 4.INR monitoring and uptitration of coumadin to INR goal of 2 . </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with history of gout, OSA on CPAP, psoriasis, recently diagnosed hyperthyroidism (treated with metoprolol with improvemen in symptoms, no antithyroid medications given), and myelodysplastic syndrome (followed by hematology for ___ years) for which she was recently started on treatment with azacitidine (finished first course 3 days prior to admission); who presented with ___ edema, SOB, ab fullness, and low grade temp 100.1. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the bilaterallower extremity veins. CHEST (PA AND LAT) showed Compared to chest radiographs since ___, most recently ___. Previous mild basal pulmonary edema has resolved. Mild cardiomegaly stable. No pleural abnormality. Upper lungs clear. The patient was diagnosed with Shortness of breath. The patient was treated with 2 units PRBC transfusion on this hospitalization ___, ___. At the time of discharge, the patient had Volume overload, peripheral edema 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>___ yo M with history of gout, recently diagnosed hyperthyroidism (treated with metoprolol with improvement in symptoms, no antithyroid medications given), and MDS ___ by hematology for ___ years) for which she was recently started on treatment with azacitidine (finished first course 3 days prior to admission); who presented with ___ edema, SOB, weight gain, and anemia. Her symptoms may be attributable to azacitadine (based on reading, ___ swelling may be seen in up to 19% of patients and SOB in up to 29%) however more concerning is that this may be new diastolic heart failure stemming from iron overload given her long history of multiple transfusions (ferritin recently >1,000). She may be a candidate for chelation therapy and/or consideration for bone marrow transplant. Will trial Lasix and check echo/BNP to confirm dx. Low grade temperature and ? infrahilar opacity raise the possibility of pneumonia however given clinical stability, lack of other respiratory symptoms of infection despite multiple recent courses of antibiotics, will observe and hold antibiotics for now and see for improvement with trial of diuresis as below. ___ edema/?New onset CHF: given history of iron overload, SOB, ___ edema, 8lb weight gain, with vascular congestion on CXR. Possible contributing factors of hyperthyroidism and recent steroid taper. Side effect of recent Vidaza may be contributing. PE is less likely given evidence of volume overload, negative ___ and positive CXR findings. Troponin was negative in the ED. Flu swab negative. Clinically and radiographically responded well to diuresis. TTE with normal LVEF, but does have mild elevated LV filling pressure. Has known moderate pulm HTN, which is confirmed on TTE. Responded well to 2 doses of IV Lasix (20mg x 1, 40mg x 1), with improvement in ___ edema, decrease in weight of 7 pounds and improvement on CXR. Per d/w ___ team, current ferritin level unlikely to be causing iron deposition related cardiomyopathy. Ultimately, her symptoms felt to represent volume overload due to multiple factors - prednisone course, hyperthyroidism, pulmonary HTN due to OSA and possible side effect of azacitadine. #Hyperthyroidism: At her PCPs office in ___, she was noticed to be anxious, tremulous, and with a rapid heart rate even at rest. Evaluation by her PCP found she was hyperthyroid (TSH 0.25 on ___ and 0.024 on ___, Free T4 elevated). She was referred to a local endocrinologist who placed her on metoprolol to control her symptoms, but held off on any treatment. She states she had a thyroid u/s at ___ which was reportedly normal but she has not had a RAI uptake scan per the patient. Palpitations had reportedly improved as well as her tremulousness. She was continued on metoprolol. TFT's were checked, with persistent low TSH but T4 only minimally elevated. She should follow-up with Endocrinology as previously scheduled. #MDS: -per outpatient notes, she learned recently that her sister is a match for allogeneic bone marrow transplant. "Ms. ___ is not ready to embark down that path." Hematologist is Dr. ___ ___ NP. #Anemia: sideroblastic anemia unresponsive to Epo per outpt notes. Consistent with known MDS +/- anemia of chronic disease (recent iron studies from ___ showed Fe 182 and ferritin >1000). Also note that EGD was performed on ___ which noted a small hiatal hernia but was otherwise normal in appearance. No evidence of bleeding was noted. Biopsies of the antrum and body were normal with negative stains for H. pylori. Duodenal biopsy was within normal limits. s/p 2 units PRBC during this admission. #CXR Abnormality: Ms. ___ was diagnosed with a multifocal pneumonia diagnosed in ___. She subsequently had a follow up CXR done locally by her PCP in late ___ to document resolution of a previous pneumonia which did show resolution of the opacity but revealed a new nodule for which she subsequently had a chest CT which according to her local pulmonologist, Dr. ___ in ___, which did not show a nodule, but reported "infiltrations" at the bases of her lungs. She was placed on a course of clindamycin and 5 day course of prednisone 30 mg daily, which she completed at the end of ___. She will need follow up imaging for abnormality seen on CXR this admission but would defer to her outpatient pulmonologist or PCP. This was discussed with patient and letter also sent to PCP. #Gout: continue allopurinol, will need to renally dose if Cr worsens. Currently asymptomatic. #HTN: continue home amlodipine/metoprolol #OSA: pt has her own variable pressure CPAP which she has brought #Transitional: -CXR abnormality: Note region over left lung requires short term follow up. Can be monitored by PCP or outpatient pulmonary MD -___ f/u to discuss chelation therapy and BMT -She has follow up with Endocrinology scheduled in early ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with metastatic pancreatic CA discharged yesterday after a hospitalization for a partial SBO presents again with abdominal discomfort, distension and nausea earlier today after eating a egg salad. He had been on a pureed diet prior to discharge and reports that he chewed the egg salad well. No vomiting. No other new symptoms. He was seen in clinic today for Neulasta. He has felt very fatigued since receiving chemo during his last hospitalization but feels his energy is mildly improved now. Radiology showed No acute intrathoracic process. Radiology showed Gastric and duodenal dilation up to an abrupt transition point in the distal duodenum, which may indicate early or partial small bowel obstruction. The duodenal stent is patent. The findings may also be due to insufficient transit time of contrast. A delayed scan may be obtained to assess for interval progression of p.o. contrast. Otherwise, stable examination from prior study, including a large pancreatic head mass with probable involvement of the SMV and other incidental findings as outlined above. Radiology showed Uncomplicated fluoroscopy-guided placement of a 12 ___ ___ gastric tube with its retention pigtail loop in the gastric lumen. Prior to it, attempts were made to place a 16 ___ MIC GJ and a 14 ___ ___ transgastric jejunal tube; however, we were unsuccessful. Findings were discussed over the telephone with Dr. ___, GI fellow at 12:37 p.m. on ___. The patient was diagnosed with INTESTINAL OBSTRUCT NOS, MALIG NEO PANCREAS NOS, ATRIAL FIBRILLATION, SARCOIDOSIS. The patient was treated with Gastric tube placement. At the time of discharge, the patient had pancreatic 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>___ yo M with hx of advanced unresectable pancreatic ca (s/p palliative choledochojejunostomy & gastroenterostomy) with hx of SBO s/p duodenal stent with multiple recurrent partial SBOs who presented 1 day after discharge with recurrent abdominal pain and symptoms of bowel obstruction. # Partial SBO - The patient presented with his ___ partial SBO despite stent placement in ___. He was initially made NPO and his abdominal pain was relieved with NGT placement (and put to suction). A repeat CT was again concerning for a pSBO and ultimately the patient was taken to ___ for G-J tube placement. A J tube was unable to be placed due to the duodenal stent, but a G-tube was successfully placed. The patient was started on tube feeds, but will limited success due to developing bowel discomfort. Ultimately we attempted to perform tube feeds at night and venting during the the day via the G-tube, but he remained unable to tolerate this. Pain and nausea were controlled as needed with medication. He was transitioned to hospice and goals of care were shifted to comfort measures only. # Pancreatic cancer - The patient underwent cycle 2 of FOLFIRINOX starting on ___, and completed treatment on ___ without complication other than low counts. No obvious clinical improvement and pt unwilling to continue with chemotherapy in the absence of evidence of clinical benefit. A pallative care consult was obtained and he switched to comfort measures only. His CODE status was made DNR/DNI. # History of Nonsustained VT and bradycardia: He evaluated by cardiology during a prior hospitalization. Cardiology previously documented that there is "no indication for pacemaker or ICD, given lack of symptoms and patient's poor prognosis and short life expectance; No need to obtain echocardiogram, as this would not change management." They recommended avoiding BB, CCB and reccommended caffeine intake. Electrolytes were repleted in the usual fashion # Atrial flutter: CHADS2 score 0, had been on ASA in the past, currently not anticoagulated due to thrombocytopenia. # Achalasia and GERD: Continued outpatient PPI BID.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with no significant medical history (he reports having not seen a physician in ___ years) who noted acute onset of light-headedness and dysequilibrium followed by left sided-weakness and significant dysarthria at 7:30 AM after taking a shower. Code stroke called given his significant acute deficits. Radiology showed No fractures or dislocations. Mild degenerative changes seen in the ankle and tarsal joints. Radiology showed No evidence of rib fracture; however, since this technique is not dedicated for evaluation of bones, should the clinical concern for rib fracture persists, dedicated rib views are recommended for further evaluation. Radiology showed 1. No acute intracranial hemorrhage or mass effect. 2. Large area of perfusion abnormality in the right middle cerebral artery territory. 3. The large area of ischemia along with a possible small area of acute infarction. If there is continued concern, for the extent of infarction, MRI can be considered. 4. New total occlusion of the right cervical internal carotid artery, occlusion of the right petrous, and the intracranial segments of the internal carotid artery and the right middle cerebral artery. Possibilities include dissections/thrombosis. Partial occlusion of the right A1 segment. Please see the subsequent conventional angiogram study. Short segment narrowing of the left distal vertebral artery from calcified plaques, moderate degree. 50-60% narrowing of the left common carotid artery at the bifurcation. Other details as above. Wet read was entered on the OMR soon after the study. Radiology showed No acute cervical spine fracture or malalignment. Multilevel degenerative changes with foraminal narrowing. Correlate clinically to decide on the need for further workup. Radiology showed 1. Unsuccessful catheterization and recanalization of the proximal right internal carotid artery. 2. 2 mg of TPA was introduced into the proximal right internal carotid artery. Radiology showed 1. Early subacute infarct with small central component of hemorrhagic transformation, involving the right basal ganglia and posterior limb of the internal capsule, with extension into the right corona radiata, as described above. 2. Multiple small scattered foci of slow diffusion in the right MCA distribution, concerning for acute embolic infarcts. 3. Chronic lacunar infarct in the right centrum semiovale. 4. Persistent right ICA occlusion with reconstitution of the right ACA and MCA. However, the right MCA appears attenuated with an overall paucity of distal cortical branches. Radiology showed No evidence of pseudoaneurysm, AV fistula, or adjacent hematoma involving right common femoral vessels. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT. The patient was treated with ___ - Cerebral Angiogram with unsuccessful catheterization and recanalization of the proximal right internal carotid artery. At the time of discharge, the patient had Primary Diagnoses: - infarct with small central component of hemorrhagic transformation, involving the right basal ganglia and posterior limb of the internal capsule, with extension into the right corona radiata - embolic infarcts in the right MCA distribution in the setting of Right Internal Carotid Artery Occlusion, Right Middle Cerebral Artery Occlusion (since recanalized) Secondaty Diagnoses: Hypertension, 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>Mr. ___ is a ___ RHM with no significant medical history (he reports having not seen a physician in ___ years) who noted acute onset of light-headedness and dysequilibrium followed by left sided-weakness and significant dysarthria at 7:30 AM (___) after taking a shower. He presented to the ___ ___ and was admitted to the Stroke Service for further evaluation and care. He was discharged on ___ to rehabilitation. . #Right Basal Ganglia Infract from Right Internal Carotid Artery Occlusion (and Right Middle Cerebral Artery Occlusion - since recanalized): Initially on admission a code stroke called given his significant acute deficits. At ___ ED, the patient was hypertensive to 190s and initial NIHSS was 17 with left hemiplegia, hemisensory dusturbance, neglect, and right gaze deviation. There was evidence of a right MCA and ICA occlusion on CTA concerning for dissection. CTP showed a large area of right MCA hypoperfusion. He was administered IV tPA at 9:12 AM. After this, his symptoms initially significantly improved with good antigravity on the left with NIHSS then 3. However, as his blood pressure dipped to SBP 140-160s, his weakness worsened and the gaze deviation reappeared, with evidence of left hemisensory deficit. Accordingly, the Neurointerventional radiology team was called and he was taken to the angiosuite given the worsening deficits. Unfortunately, the ICA could not be opened. (The difficulty passing the catheter through the ICA was thought to be suggestive of an occlusion from plaque rather than dissection.) . The patient was started on heparin gtt. A subsequent MRI showed patent R MCA later that night. His goal PTT was 50-70, and was checked every 6 hours. Dosing adjustments were made accordingly. In the acute setting the patient required a nicardipine gtt with goal SBP 140-190's, he eventually did not require this anymore. After his first two hospital days, the patient was started on lisinopril which was uptitrated to 20mg QD with a goal SBP of 140-180; some degree of autoregulation was desired to maintain adequate cerebral perfusion in the setting of the fixed deficit (ie the persistent R ICA occlusion). He was continuually monitored on cardiac telemetry without any adverse events or evidence of cardiac arrhythmias. . His stroke risk factors were assessed: FLP 175, ___ 76, HDL 47, LDL 113, A1C 5.4. As his LDL was not at goal <70 the patient was started on high dose Atorvastatin 80mg QD. A TTE was obtained (see full report above) which did not show an ASD/PFO/thrombus, and the patient had a preserved EF. A Speech and Swallow evaluation was obtained, and the patient was cleared for a regular diet. The patient was evaluated by Physical Therapy and Occupational Therapy, and has been recommended for ___ rehab. Also, the patient will have a follow-up CTA in 3 months, to be reviewed at his follow-up appointment with Dr. ___ in Neurology (scheduled prior to discharge). . #Hypertension: Patient has had goal SBP 140's-180's, he previously was not on any anti-HTN medications. We started the patient on lisinopril and uptitrated to 20mg QD. We have maintained an elevated blood pressure in order to maintain his cerebral perfusion. In about 2 days post discharge (___) his SBP range can be lowered to 120-140's, with uptitration of his lisinopril. . #Left Rib Pain, Left Ankle Pain s/p fall: Patient had a CXR and a Left Ankle Xray without evidence of fracture. He was treated with acetaminophen for pain and tolerated this well. . #Antiocoagulation: Patient will need anticoagulation for his occlusion for at least 3 months. His goal INR is ___. His INR was 2.2 on day of discharge, and he will continue his coumadin dosing and management at his rehabilitation facility. .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ y/o M with no significant PMHx, who presented to ___ with epigastric pain x 3 days. Pain was initially sharp, located in the epigastrum and RUQ, non-radiating. Associated with diaphoresis. Pain initially resolved after a few minutes. Then, on the following day, pain returned, less intense but more persistent. Pain has been present since then. No nausea/vomiting. Pain is not worsened by eating. Radiology showed 1. 8 mm choledochocele with mild mass effect against the adjacent pancreatic duct and mild upstream pancreatic duct dilation to 5 mm. The CBD measures up to 6 mm. Mild prominence of the intrahepatic bile ducts. 2. No concerning intrahepatic or pancreatic mass. Small hepatic cysts or biliary harmartomas and hemangiomas. 3. Mild non-specific gallbladder wall edema, but no evidence for acute cholecystitis. 4. Replaced left hepatic artery arising from the left gastric. 5. Accessory left renal artery. The patient was diagnosed with CHOLELITHIASIS NOS. The patient was treated with ERCP Biopsy of the choledocal cyst was performed after sphincterotomy.. At the time of discharge, the patient had Pancreatitis Choledocal cyst with sphincterotomy performed. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o M with no significant PMHx, who presented to ___ with epigastric pain x 3 days, found to have acute pancreatitis. # Acute Pancreatitis: The cause of the pancreatitis was found to be due to a choledochocele. An MRCP from ___ revealed an 8 mm choledochocele with mild mass effect against the adjacent pancreatic duct and mild upstream pancreatic duct dilation to 5 mm. The CBD measures up to 6 mm. Mild prominence of the intrahepatic bile ducts. The patient had an ERCP on ___, with sphincterotomy performed and biospy of the choledocal cyst done afterwards. The patient was also noted to have the presence of an abnormal pancreatobiliary junction. He was able to tolerate a normal diet the following day and made a bowel movement prior to discharge. The biopsy results will need to be followed up on and he will need a referral to a gastroenterologist specializing in endoscopy. His LFTs also downtrended post-procedure and are expected to normalize. A repeat check of LFTs in ___ weeks will be at the discretion of the patient's PCP.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HMED ATTENDING INITIAL NOTE DATE: ___ TIME SEEN 330 AM ================================== HPI: ___ yo female with history of pulmonary hypertension, multiple myeloma, presents after syncope. She was getting into her daughter's car when she was noted to be unresponsive, eyes rolling to the back of her head and was noted to have shaking movements. She was pulled out onto the curb and layed flat, she was noted to have continued shaking movements without enuresis. No fecal incontinence. After she recovered consciousness on the order of minutes she was noted to be oriented. Patient denies any prodrome other than "feeling funny" to the ED physician but to author she reports feeling very short of breath. She felt as though she was going to die. She denies feeling as though the curtains were closing and she was going to pass out. She denied shortness of breath with baseline activity but her dtr reported to her RN that she does get SOB with exertion. She reported L sided anterior ___ chest pain, worse with inspiration. She does not report other pains. She was wearing a scarf when this occurred but this is normal for her in the winter. No sx when she turns her head. She felt well prior to the incident and had eaten dinner approximately an hour before her daughter came to pick her up. She denies chest pain on exertion. At baseline she has lower extremity edema but this is improved compared to her baseline. She had a good full BM in the ED in the commode prior to coming to the floor. No report of dark or bloody stool. CTA CHEST showed 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Multiple thyroid nodules, measuring up to 1.2 cm on the right. 3. Diffuse pancreatic ductal prominence within area focal dilation measuring up to 8 mm, increased from ___. Recommend correlation with interval prior abdominal imaging, if available. Otherwise, recommend follow-up with MRCP (or CT pf thepancreas if patient cannot tolerate MRCP) to exclude an obstructing lesion. 4. Multiple thoracic vertebral body compression fractures at T3-T6 and T9-T10, similar to ___. Remote fractures of the left lateral second rib and sternum. RECOMMENDATION(S): Correlation with prior abdominal imaging to determine chronicity of pancreatic ductal dilation. If no recent imaging is available, recommend follow-up with CT or MRI to exclude an obstructing lesion. The patient was diagnosed with Syncope and collapse. At the time of discharge, the patient had Primary: orthostatic hypotension syncope. The patient was given written instructions concerning 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 old woman with a history of pulmonary hypertension and multiple myeloma who presents with syncope after getting into her daughters car. # Syncope: Highest on the differential is orthostasis vs cardiac etiology. Orthostatic signs are positive with precipitation of her symptoms. Concern for worsening RV function in the setting of pulmonary hypertension. No evidence of PE on CTA. EKG at baseline, troponins elevated on admission, though downtrended. CK-MB flat. Telemetry without evidence of arrhythmias. Low suspicion for seizure activity or vasovagal. ECHO revealed no changes from prior. # Orthostatic hypotension: Patient presented with symptomatic Orthostasis. Differential included worsening RV function as above vs autonomic dysfunction, vs adrenal insufficiency, aging, and the effect of medications. ECHO revealed no changes from prior. AM cortisol was wnl. B12 level was WNL. Home antihypertensives were initially held. She wore TEDS during her admission and HOB was kept elevated 30 degrees. Side effect of donepezil was also considered, but this was continued as her orthostatic hypotension resolved with fluids and improved PO intake. # Multiple myeloma: S/P induction velcade with clinical and laboratory response. Now off of treatment, though with evidence of multiple compression fractures throughout on CT. # Left sided chest pain: CTA with evidence of numerous fractures, including left sided 2nd rib fracture, which is consistent with where the patient is experiencing pain. Pain control with standing Tylenol, lidocaine patch, and tramadol PRN. # Memory impairment: Continued donepezil # Insomnia: Continued remeron ***TRANSITIONAL ISSUES*** - Pancreatic lesion: CTA at admission incidentally noted diffuse pancreatic ductal prominence with an area of focal dilation measuring up to 8mm, increased from ___. No interval imaging available for comparison. Consider MRCP for further evaluation as outpatient. Patient's lipase and LFTs overall unremarkable and patient was asymptomatic. </s>