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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> |