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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year-old male with unknown medical history who presents as a transfer from ___ with ARDS and transfer for consideration of ECMO. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed In comparison with the study of ___, there has been placement of right IJ catheter that extends to the midportion of the SVC. No evidence of post procedure pneumothorax. Diffuse bilateral pulmonary opacifications, predominantly involving the central portions of the lung, again are consistent with the clinical diagnosis of ARDS. In the absence cardiac enlargement, the possibility of noncardiogenic pulmonary edema would have to be considered. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are unchanged, as is the appearance of the cardiomediastinal silhouette. Diffuse bilateral pulmonary opacifications predominantly involving the central portions of the lung appear less prominent than on the previous study. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. No sonographic evidence of cirrhosis identified. No focal liver lesions are identified. 2. No biliary dilatation. The gallbladder is moderately distended and contains sludge and tiny gallstones. Mild gallbladder wall edema is likely related to third spacing. 3. Small bilateral pleural effusions. 4. Mild splenomegaly. CHEST (PORTABLE AP) showed Lungs are low volume with stable stable pulmonary edema. Pneumomediastinum is slightly less apparent. Support lines and tubes are unchanged. Cardiomediastinal silhouette is stable. Bilateral perihilar opacities are also unchanged The patient was diagnosed with Acute respiratory failure, unsp w hypoxia or hypercapnia, Poisoning by heroin, accidental (unintentional), init encntr, Opioid abuse, uncomplicated, Oth places as the place of occurrence of the external cause, Hypoxemia. The patient was treated with Intubation CVL placement ___. At the time of discharge, the patient had PRIMARY DIAGNOSES ================= Acute hypoxic respiratory failure Aspiration pneumonia Opiate use disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with a history of opioid use disorder who was found down at home requiring CPR and intubation in the field. He was admitted to the ICU for ARDS and acute hypoxemic respiratory failure and was treated for aspiration pneumonia. #Acute hypoxemic respiratory failure: #Aspiration pneumonia: #ARDS: Patient developed ARDS after heroin overdose, likely in the setting of aspiration vs. inhalation injury given bilateral consolidation on CXR. Initially with worsening oxygenation after intubation. He was initially on Veletri and was transferred for ECMO consideration. He was also paralyzed and sedated with midazolam and hydromorphone (fentanyl did not sedate him adequately). Veletri and paralysis were successfully weaned and he did not require ECMO. He was given IV diuresis to minimize pulmonary edema and treated for aspiration pneumonia. He was extubated on ___. Given vancomcyin, cefepime, and azithromycin, narrowed to cefazolin when sputum culture grew MSSA. He was transitioned to cefpodoxime to complete a 14 day course which will finish on ___. #Opioid use disorder Discussed substance abuse resources with addiction psychiatry team and social work. He was initially started on methadone for pain management, however was weaned off when he expressed that he would not want this as a maintenance therapy. His last dose was 5 mg methadone on ___. He was found to be HIV negative. Quantiferon gold pending at time of discharge. #Chest pain Felt to be most likely related to bruising following CPR without evidence of rib fractures on radiology. His pain was initially managed with methadone then transitioned to acetaminophen/naproxen, which he was no longer requiring on discharge. #Acute transaminitis Unclear etiology, may be ___ downtime/mild ischemic liver injury in the setting of overdose and being found down. Hepatitis serologies negative (non-immune to Hep B), HIV negative, iron level low. RUQUS showed moderately distended gallbladder with sludge and tiny gallstones. His LFTs downtrended throughout the admission. Recommend outpatient HAV/HBV vaccinations. #Acute normocytic anemia Consistent with mixed iron deficiency/anemia of inflammation. No evidence of hemolysis. #CODE STATUS: Full Code #EMERGENCY CONTACT: Mother (___) ___ ___ Issues ==================== [] Cefpodoxime 400 mg BID should be continued until ___ to treat aspiration pneumonia. [] Continued discussion regarding substance abuse treatment. [] Recommend establishing with PCP as an outpatient [] Narcan prescribed on discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F hx of chronic fatigue, rheumatic heart disease with MVR with residual MS, chronic fatigue/dyspnea attributed to chronic RHfailure, (___ class III) with three pillow orthopnea, chronic R pleural effusion (exudative, Lymp ___ presenting from the ED with fatigue, malaise and hypotension. Radiology showed Stable opacity and effusion at the right lung base which has been previously seen and agree with recommendation on prior CT for pleural fluid analysis if not already performed. The patient was diagnosed with DEHYDRATION. At the time of discharge, the patient had Acute on chronic diastolic Congestive heart failure Mitral stenosis Acute on Chronic kidney injury. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ F hx of rheumatic heart disease and MS ___ MVR with residual stenosis of MR, TR ___ annuloplasty, chronic R sided heart failure, fatigue and malaise presenting with fatigue and hypotension. ACTIVE DIAGNOSES # HFPEF: No evidence of end organ hypoperfusion. Hypotention likely ___ to exacerbation of known right sided heart failure from MV stenosis. Initially we held pts lisinopril and BB, as pt was hypotensive, and pt was given IVF in the ED. Pts SBP improved. Pt was then diuresed with lasix drip, with decrease in peripheral edema and subsequent improvement in symptoms. Pt was restarted on BB at the time of discharge, but lisinopril was held due to increasing Cr. Pt was restarted on decreased dose of torsemide at time of dicharge as well. # Mitral valve stenosis: Most likely cause of her chronic and severe fatigue and dyspnea. Prior imaging demonstrates significant residual stenosis of the bioprosthetic mitral valve, which was again noted on repeat TTE while pt was in the hospital. Dr. ___ t/b with the pt as an outpt to discuss MVR. # ___: Baseline creatinine low 1.0's however in last 2 mo creatinine >1.5 on three readings. Concern for preprenal azotemia because of decrease in forward flow from right sided heart failure. Urine lytes were not checked in the ED and there was low utility of checkig once pt arrived to CCU, since she had received IVF. Plan to avoid nephrotoxic agents and stop lisinopril with outpt monitoring of Cr. CHRONIC DIAGNOSES # Lupus: Stable. # Gout: Stable, but allopurinol redosed for current renal clearance: 150 mg PO QD. # OSA: Stable. # HTN: Stable. # Depression: Stable.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old man with no significant PMH who presents with subjective fevers, productive cough and dyspnea for past ___ days. Pt reports that he was hospitalized at ___ months ago for PNA. Radiology showed 1. No evidence of pulmonary embolism or aortic abnormality. 2. Moderate pericardial effusion with pericardial enhancement concerning for pericarditis. 3. Multifocal areas of ground-glass nodular opacities as well as consolidated opacities, concerning for infectious/ inflammatory etiology superimposed over atelectasis. 4. Small bilateral pleural effusions. 5. Multiple enlarged hilar and mediastinal lymph nodes. Bilateral axillary adenopathy. While these are likely reactive, Follow-up to resolution is recommended. 6. Metallic foreign body at the T3/4 erector spinae, with multiple smaller adjacent metallic fragments as well as calcific right pleural plaques, compatible with a bullet and sequelae along its trajectory. RECOMMENDATION(S): Follow-up to resolution is recommended for the air space opacities as well as hilar and mediastinal adenopathy. Repeat CT can be performed in 3 months time. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 12:25 ___, 5 minutes after discovery of the findings. KNEE (AP, LAT AND OBLIQUE) LEFT showed Moderate effusion. Nonspecific increased density in the proximal tibial metaphysis may reflect remote injury however if there is could surrounding clinical feature for nondisplaced fracture, and insufficiency fracture could have this appearance. RECOMMENDATION(S): If clinically indicated, findings could be further evaluated with MRI. If concern for infection, arthrocentesis is suggested. NOTIFICATION: The impression and recommendation above was entered by Dr. ___ on ___ at 08:54 into the Department of Radiology critical communications system for direct communication to the referring provider. CT LOW EXT W/O C LEFT showed No acute fracture is seen. There is moderate large knee joint effusion of indeterminate cause. If any concern for infection, aspiration is suggested. CT CHEST W/O CONTRAST showed Mild increase in pericardial effusion. Unchanged generalized lymphadenopathy. Unchanged right basal predominant pneumonia. CHEST (PA AND LAT) showed 1. Hazy opacification in the right lower lobe may represent pneumonia. 2. There is a moderate left pleural effusion. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had Primary: Sepsis Pneumonia Pericarditis HIV Lymphadenopathy Secondary: Reactive arthritis Anemia Alcohol abuse Acute renal failure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old man with a history of homelessness and GSW several decades ago who presented with hypoxemia, cough, and infiltrate c/f pneumonia. Patient was found to have multifocal pneumonia, pericarditis, left knee effusion, and newly diagnosed HIV along with lymphadenopathy concerning for TB vs lymphoma, with TB ruled out and preliminary pathology and cytology encouraging for no lymphoma. # HIV: HIV status checked due to pt being intermittently homeless with recurrent multifocal PNA and pericarditis and was found to be positive. No h/o IVDU. Sexually active with women only. Per pt, ex-girlfriend died recently of unknown causes. CD4 289. Viral load 1,160,000 copies/mL. Cryptococcus antigen negative. RPR negative. Urine GC/chlamydia negative. HBV serologies negative for infection and immunity. Given first dose of HBV vaccine in-house. HCV negative. HAV Ab positive, IgM negative, indicating either prior infection or vaccination. Toxoplasma antibody negative. Baseline Hgb A1c 5.8%. Lipid panel: TC 83, HDL 22, LDL 42, Trig 93. G6PD WNL (11.4). Per ID consult, started HAART in-house with Truvada 1 tab daily, darunavir 800mg daily, and ritonavir 100mg daily. SW followed while in-house and gave pt information about AIDS Action Committee for ___ ___. Pt instructed to keep in contact with ___, the case worker at AIDS ___ ___ number ___ main number ___. Pt asked to notify AIDS Action Committee about any location changes or any change in living situation. # R/O TB: Given HIV+, homelessness, multifocal PNA, and hilar LA on CTA ___, pt placed on TB isolation precautions on ___. AFB smears negative x4. Quant gold indeterminate. NAAT negative x2. Airborne precautions d/c'ed ___. AFB cultures from ___ and ___ pending on discharge. LN biopsy AFB culture pending on discharge. # MEDIASTINAL AND HILAR LYMPHADENOPATHY: CTA ___ and non-con CT chest ___ showed extensive mediastinal and hilar lymphadenopathy. Most likely not TB, given negative AFB smears x4 and negative NAAT x2. Given LA on CTA ___, histoplasmosis antibody and antigen ordered on ___ and were negative. Per radiology, chest CT is concerning for lymphoma, Castleman's disease less likely given radiographic appearance. LDH WNL (147). Beta2-microglobulin elevated at 5.4. Cytology from L axillary LN biopsy without monoclonal cell line that would be concerning for lymphoma, and had polytypic cells c/w reactive process. Cytogenetics karyotypically normal. Pathology found no granulomas or necrosis that would be c/f TB and no e/o high grade lymphoma. Lymphoproliferative studies pending on discharge. LN biopsy AFB culture pending on discharge. # KNEE PAIN: Pt reports recent fight/fall ___ days PTA. On admission, AROM only to about 15 degrees, full PROM, but unable to weight bear on left leg on admission. Small area of suprapatellar effusion vs. edema, c/f septic arthritis i/s/o possible bacteremia from PNA. Knee x-ray showed moderate knee joint effusion with no fracture. CT scan confirmed suprapatellar joint effusion but no fracture. MRI contraindicated due to retained bullet fragments in chest. Performed L knee arthrocentesis on ___. Joint fluid showed ___ WBCs, 875 RBCs, 91% PMNs, no crystals, no organisms on Gram stain. Fluid culture NG (final). Most likely trauma vs. reactive arthritis and not septic arthritis, given that would expect WBC count to be higher and organisms to be seen on Gram stain and/or culture (although was treated with 3 days of antibiotics prior to arthrocentesis, so septic arthritis could have been partially treated and no longer show organisms). Abx: vanc/cefepime (___), PO levofloxacin (___), IV ceftriaxone (___). Per ID, no need to continue treating for septic arthritis. ___ consult saw him and found that he was partial weight bearing with crutches and has no further acute ___ needs. Pt now with full AROM and able to walk short distances without crutches. Pt should continue taking acetaminophen PRN for pain. # Anemia H&H low (9.2/26.2) on admission and slowly downtrending during admission. H&H 7.9/24.2 on discharge. Pt denies melena or BRBPR. Ibuprofen d/c'ed on ___ in case it was contributing. Iron studies c/w ACD. Stool guaiac negative x3. Therefore, PPI was not initiated. # PERICARDITIS: Pleuritic CP, cardiomegaly on CXR, STEs on ECG, and CTA chest showing pericardial effusion. Possible viral infection superimposed on bacterial PNA. TSH WNL (0.64). HIV positive. Pulsus ~6 (WNL), so no exam e/o tamponade. TTE ___ showed pericarditis and small to moderate pericardial effusion without e/o tamponade. In-house treated with ibuprofen 400mg q8h and colchicine 0.6mg BID. Received 2.5 weeks of colchicine, which was d/c'ed prior to discharge due to potentially severe drug-drug interaction with HIV medications. # SEPSIS: ___ SIRS criteria on admission (tachycardic to 110s, WBC 17, RR >20) with normal lactate (1.8 -> 1.4). Improved s/p fluid resuscitation with 4L NS and antibiotics. Most likely source is PNA. Blood cx negative. Sputum culture heavily contaminated with upper respiratory secretions. Urine legionella and Strep pneumo negative. Initially treated with ___ for HCAP (treated for pneumonia at ___ ___ several months ago) and flagyl for possible aspiration pneumonia given heavy alcohol use. Antibiotics were narrowed to levofloxacin 750mg PO daily on ___, which was d/c'ed on ___ given c/f TB i/s/o newly diagnosed HIV. Pt was started on IV ceftriaxone and PO azithro on ___. Antibiotic course was completed on ___. Pt developed diarrhea while in-house, Cdiff negative. # PNEUMONIA: Patient with leukocytosis, hypoxemia, sputum production, and CXR with RLL opacity. ABG on admission c/w respiratory ___. Reported having been treated at OSH several months ago for PNA, no records available, so empirically treated for HCAP +/- aspiration with vanc/cefepime/flagyl (___), which was narrowed to PO levofloxacin on ___. Lefloxacin was d/c'ed on ___ given c/f TB i/s/o newly diagnosed HIV, and pt was started on IV ceftriaxone and PO azithro on ___. Antibiotic course was completed on ___. Urine legionella and Strep pneumo negative. Sputum culture was heavily contaminated with upper respiratory secretions. Pt also with bilateral wheezing, significant smoking history, and emphysema on CTA chest. Gave PRN albuterol and ipratropium nebs for reactive airway disease/COPD and PRN guaifenesin for cough. Was no longer requiring breathing treatments or cough suppressants on discharge. # TACHYCARDIA: Resolved on HD2. Possible etiologies include sepsis from PNA, alcohol withdrawal, and pericarditis. PE ruled out by CTA ___, which did show e/o pericarditis and pericardial effusion. Fluid resuscitated with 2L IVF in ED and 2L NS on floor and given broad-spectrum antibiotics. Was on ___ protocol x4 days with PRN diazepam, which he never required. Treated with ibuprofen 400mg q8h and colchicine 0.6mg BID for pericarditis while in-house. # ECG CHANGES: Most likely due to pericarditis given pleuritic CP, cardiomegaly on CXR, sepsis, STEs on ECG, CTA chest showing pericardial effusion, and TTE showing pericarditis and small to moderate pericardial effusion without e/o tamponade. No prior ECGs in our system. ACS ruled out with trop x2 negative. TTE revealed normal EF (61%), no regional wall motion abnormalities, mild symmetric LVH, and no pathologic valvular flow. # ALCOHOL ABUSE: Pt reports drinking >1 pint hard liquor/day, last drink ___ days PTA. Pt tachycardic on admission but CIWA never >8, and pt never required diazepam. CIWA protocol was d/c'ed on ___. # RENAL FAILURE: Cr downtrended 1.5 -> 1.0 after 2L NS, so most likely ___ from prerenal etiology.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ year-old man with hx of trauma to his back years ago, s/p extensive thoracic, lumbar and S1 surgery including laminectomy and fusion and revision, presented to ED as a transfer from ___ with worsening of back pain and 2 episodes of fecal incontinence which happened yesterday evening. CT L-SPINE W/O CONTRAST showed Lumbar spine hardware and moderate canal stenosis the L2-L3 stenosis. Evaluation of the intrathecal sac is limited by modality. CT of the thoracic and lumbar spine post intrathecal injection of contrast. showed 1. Postoperative changes, as described, including multilevel laminectomies and stabilization hardware at L3-L4. 2. Disc bulge, disc protrusion, bilateral facet arthropathy, and ligamentum flavum thickening at the L2-L3 level which causes severe spinal canal narrowing. Fluoroscopy guided lumbar puncture and myelogram. showed 1. Successful fluoroscopically guided lumbar puncture with intrathecal injection of nonionic contrast for lumbar and thoracic myelogram. 2. AP and oblique views demonstrates spinal canal narrowing at the L2-L3 level. Please see CT report for further details. Radiology showed As above. CHEST PORT. LINE PLACEMENTCHEST PORT. LINE PLACEMENTi showed Right subclavian catheter ends in the low SVC. No pneumothorax pleural effusion or mediastinal widening. Lungs clear. Heart size normal. An orthopedic device projects over the midline lower thoracic spine. Additional surgical materiel projecting over the left upper abdominal quadrant has been present since ___, but I cannot identify it. Has the patient had bariatric surgery? The patient was diagnosed with BACKACHE NOS. The patient was treated with revision laminectomy of L3, laminectomy of L2 fusion with instrumentation and autograft L2-L4. At the time of discharge, the patient had lumbar spondylosis and spinal stenosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year-old man with history of trauma to his back years ago, s/p extensive thoracic, lumbar and S1 surgery including laminectomy and fusion and revision, presented to ED as a transfer from ___ with worsening of back pain and 2 episodes of fecal incontinence c/f spinal root impingement. CT lumbar spine without contrast revealed disc bulge, disc protrusion, bilateral facet arthropathy, igamentum flavum thickening at the L2-L3 level (level above previous fusion), causing severe spinal canal narrowing. The patient was then admitted to the ___ Spine Surgery Service and taken to the Operating Room on for a posterior spinal fusion L2-L4. Refer to the dictated operative note for further details. The surgery was performed without complication, the patient tolerated the procedure well, and was transferred to the PACU in a stable condition. TEDs/pneumoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initially, postop pain was controlled with a dilaudid PCA and epidural. The epidural was removed POD1. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2 and the patient was voiding well. Post-operative labs were grossly stable. A hemovac drain that was placed at the time of surgery was also removed on POD#2. Physical therapy was consulted for mobilization OOB to ambulate. A lumbar corset brace was fitted for the patient. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI:Patient is a ___ year old male with pmhx significant for prostate cancer w/ mets to spine and ribs s/p T-8-T12 vertebroplasty, A-fib(Xeralto), and prior falls x3 causing prior superficial head injury and left hip fx s/p left hip arthroplasty w/ revision who presents to ___ following an unwitnessed ground level fall towards his right side, unknown LOC and + headstrike, while attempting to turn with rolling walker. Pt. states first struck his head against the wall before landing with hands outstretch on a carpeted floor. Per son, who is at bedside, pt. believed to be down between 7 p.m. last night and 4:00 p.m. this afternoon before being discovered by his cousin. Patient suffered a 4cm laceration to posterior scalp around the region of the right occiput w/ associated subgaleal hematoma, C7 and L1 burst fx, abrasions to right inguinal region, and left lateral orbit. Of note there mild abrasions to blt toes and right foot. MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE. showed 1. Multiple osseous lesions throughout the spine and involving the posterior twelfth ribs, consistent with metastatic disease. 2. Pathologic burst fracture of the C7 vertebral body with associated 50% loss of height and 2 mm retropulsion of bony fragments resulting in mild canal narrowing with flattening of the anterior cord and possible mild increased T2/STIR cord signal. There is disruption of the anterior longitudinal ligament at the C7 level. 3. Pathologic burst fracture of the L1 vertebral body with approximately 60% loss of central height and retropulsion of bony fragments up to 7 mm resulting in moderate canal narrowing and compression of the anterior thecal sac. The conus medullaris terminates just above this level and there is no abnormal cord signal. There is destruction of the anterior longitudinal ligament at this level. 4. Acute superior endplate of the L2 vertebral body, with suspected underlying metastatic lesion. 5. Acute to subacute nondisplaced fracture of the inferior anterior endplate of the T7 vertebral body without loss of height. No extension to the posterior vertebral body or retropulsion of bony fragments. 6. Kyphoplasty changes at T8, T9 and T10. 7. Additional degenerative changes as described. FOOT AP,LAT AND OBL LEFT showed No previous images. Significant hammertoes make it extremely difficult to evaluate this region for possible fracture. The metatarsophalangeal joints are very difficult to assess due to flexion. On one view there is suggested erosions on the medial aspect of the base of the proximal phalanx and head of the first metatarsal. There is also soft tissue prominence, raising the possibility of underlying gout. HAND (PA,LAT AND OBLIQUE) LEFT showed No previous images. No evidence of acute fracture or dislocation. There are moderate degenerative changes involving the first CMC joint and triscaphe joint. Relatively mild degenerative changes are seen in the interphalangeal joints. On one view, there is widening of the scapholunate interval, raising the possibility of ligamentous disruption. The patient was diagnosed with Traumatic ischemia of muscle, initial encounter, Unspecified fall, initial encounter. At the time of discharge, the patient had PRIMARY DIAGNOSES: #Multiple acute vs pathologic spinal fractures #Spinal metastases #Rhabdomyolysis #Sacral decubitus ulcer #Fall SECONDARY DIAGNOSES: #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>___ h/o metastatic prostate CA and multiple falls admitted for fall and 21hr downtime, found on imaging to have multiple spinal acute vs pathologic fx including C7,L1,L2,T7 and evidence of bony infiltrates, as well as scalp laceration and rhabdomyolysis. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with PMH of HCV cirrhosis MELD7 ___ A, HIV with reported CD4 count ~___s of ___ this year, history of narcotic abuse, and chronic pain, and chronic dizziness who presents to the hospital from the ED with chief complaint of fall with head strike. Patient was feeling in his usual state of health when sitting on his steps in front of the his domicile. He got up abruptly, fell forward and struck his right forehead against the step. He reports having a brief moment of vision going black that was transient and without LOC. He hurt his forearms by reaching out in front of him to brace his fall on the way down, and has superficial scrapes as a consequence. Subsequently he had nausea and headache. He reports no SOB, no cough, no chest pain, no vomiting. He does endorse chronic difficulty with ambulation stating he "walks like a drunk". He endorses chronic pain in the lower back. In the ED, initial vitals were T99.2 80 120/75 18 94% RA. ECG showed NSR with RSR pattern in V1-V2, no significant changes. Labs revealed stable thrombocytopenia at 55. Non-dedicated Chest X-ray showed no rib fractures. X-rays of the hip and pelvis were negative for fractures. He was admitted to hepatorenal medicine for workup of fall. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed 1) No evidence of acute cardiopulmonary process. 2) No rib abnormalities are identified on this nondedicated exam. If concern for rib injury remains, dedicated exposures and views are recommended. Radiology showed No acute intracranial process. The patient was diagnosed with SYNCOPE AND COLLAPSE, OPEN WOUND OF FOREARM, UNSPECIFIED FALL. At the time of discharge, the patient had Primary: Fall with head strike Secondary: Cirrhosis, Encephalopathy, Balance disturbance. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PRIMARY REASON FOR HOSPITALIZATION: Mr. ___ is a ___ male with PMH of cirrhosis from HCV/hemachromatosis, chronic dizziness/lightheadedness, HIV (reported undetectable viral load and CD4~400) who presents from home with fall and head strike without LOC. CT head was negative for bleed and he was steady on his feet during hospital stay. He was discharged to PCP followup with plan to wean sedating medications.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with a history of painless jaundice and CT concerning for pancreatic mass abutting celiac axis/splenic vein, all concerning for locally advanced pancreatic cancer. He initially had a PTC on ___ (ERCP unsuccessful) with placement of an internal/external biliary drain, but TBili failed to decrease lower than 9 from 15. He had a repeat cholangiogram yesterday ___ showing no contrast to the duodenum, upsized an 8 ___ indwelling internal/external PTBD to a new 10 ___ internal-external drain. The patient was diagnosed with HYPERKALEMIA, HYPOTENSION NOS, LEUKOCYTOSIS, UNSPECIFIED , MALIG NEO PANCREAS NOS. The patient was treated with 1) Endoscopic ultrasound with biopsy and fiducial placement. At the time of discharge, the patient had 1. common bile duct stricture 2. dehydration 3. acute kidney injury. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old man who presented to the ED with symptoms of dizziness, lightheadedness, and emesis on ___ just prior to his scheduled exploratory laparoscopy and portacath placement for his recently diagnosed pancreatic mass. On the day prior he had undergone a cholangiogram and upsizing of his PTBD from an ___ to a ___ catheter, and while he did complain of one episode of dizziness and emesis the evening prior to his ___ procedure and an episode of dizziness in the car on his way to the procedure, he was doing well after his drain upsizing and both he and his family felt comfortable going home, so he was sent home with instructions to call Dr. ___ return to the ED if he had a return of his symptoms. In the ED he was afebrile but hypotensive to 89/61 with dizziness, and his labs were remarkable for a leukocytosis (WBC 15.6) with acute renal failure (creatinine 2.1 and K 6.2) and hyperbilirubinemia (total bilirubin 8.2). The decision was made to cancel his surgery and admit him for IV antibiotics and IV fluid rescusitation. He was immediately given one amp of D50 and 8 units of IV insulin, and an EKG was performed that did not show any T wave changes. He was placed on Unasyn. On HD 2 he remained afebrile, his blood pressure was normalized and he had not experiened any additional dizziness or emesis, and his labs were improved with a WBC 8.7, creatinine 1.3, K 4.4, and total bilirubin 6.6. He underwent an EUS with biopsy and placement of fiducials, with the EUS showing a 3.48 cm X 2.51 cm hypoechoic, heterogenous ill-defined mass in the head of the pancreas with findings suspicious for invasion of the portal vein. Following this procedure, he was given a regular diet and his IV fluids were discontinued. He tolerated his diet well, and on HD 3 his labs continued to show improvement with WBC 7.4, creatinine 1.1, K 4.5, and total bilirubin 5.7. He was feeling well without any symptoms of lightheadedness or dizziness and had no nausea or emesis. His biliary drainage catheter was working well with bilious fluid in the gravity bag, and he was making adequate urine. At this point, Mr. ___ was deemed stable for discharge home with services and a 7 day course of PO augmentin. He was still in need of a biliary stent for his common bile duct stenosis, and Interventional Radiology was contacted and made plans to call the patient the following week with an appointment time to come in for his biliary stenting procedure. Mr ___ was given instructions to await a call from Interventional Radiology regarding his stenting procedure, but that if he did not hear from them by ___ to call Dr. ___. He was instructed to also call Dr. ___ office to make an appointment for ___ weeks from the day of discharge, and to call his medical oncologist this coming week to schedule an appointment as well. He was also instructed to call Dr. ___ ___ return to the ED if he experienced recurrence of his presenting symptoms or any fevers, chills, or other concerning symptoms.</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 was brought to the emegency department status post fall. He has a history of hypertension, reportedly on anticoagulant medications and reports lumbar/low back pain. Patient states he had a mechanical fall down approximately 14 stairs striking his head. He is unsure if he lost consciousness. He does have lower lumbar back pain but denies any other pain. CHEST (PORTABLE AP) was done. CT HEAD W/O CONTRAST showed 1. 3 mm left parietal convexity acute subdural hematoma as described above. No midline shift. CT C-SPINE W/O CONTRAST showed 1. Acute fractures of C2 with extension to the right transverse process, crossing the course of the right transverse foramen. Neck CTA recommended to assess the vertebral arteries. Mild retrolisthesis of C3 on C4, C4 and C5, and C5 and C6. RECOMMENDATION(S): Neck CTA CT TORSO W/CONTRAST showed 1. Numerous fractures as described above, including the sternum, left ribs, T5 vertebral body, sacrum, and left ilium with extends into the left acetabulum. . Retrosternal hematoma. 2. Concern for active extravasation in the left iliacus and gluteus muscles as described above. CTA NECK WANDW/OC AND RECONS Q25 CT NECK showed 1. Focal narrowing and irregularity of the right vertebral artery in its C2 transverse foramen, consistent with injury. 2. Comminuted, nondisplaced fracture of the manubrium extending into the left first costochondral junction. 3. Unchanged, comminuted fracture of the right C2 lateral mass and transverse process. 4. Unchanged, comminuted, nondisplaced fracture of the left base of the odontoid process with extension into the C2 body. 5. Right thyroid lobe demonstrates a coarsely calcified 1.3 cm nodule. A 0.8 cm hypodense peripherally calcified left thyroid lobe nodule. RECOMMENDATION(S): Calcified thyroid nodules described above. This could be further evaluated with ultrasound as clinically indicated. CHEST (PORTABLE AP) was done. Radiology showed Successful trans arterial embolization of a left superior gluteal artery branch, the posterior division of the left internal iliac artery, a muscular branch of the internal iliac artery, and the left L5 lumbar artery. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is obscuration of the hemidiaphragm and hazy opacification of the multiple rib fractures are somewhat difficult to see and there is no evidence of pneumothorax. Although the cardiac silhouette is within normal limits, there are bilateral opacifications concerning for pulmonary edema. The left hemithorax, consistent with layering pleural fluid and basilar atelectasis. CT HEAD W/O CONTRAST showed 1. The exam is mildly degraded by patient motion and limited due to circulating contrast from patient's recent CTA neck. 2. Interval progression of subdural hemorrhages, now with bilateral convexity subdural hemorrhages measuring up to 3 mm noted. 3. Left parietal scalp soft tissue swelling with skin staples. MRI CERVICAL AND THORACIC showed 1. Only sagittal cervical spine images obtained. Examination is motion degraded. Within these confines: 2. STIR hyperintense marrow signal of the T1 and T3 superior endplates compatible with acute fractures, not visualized on prior CT examinations. 3. Re identification of known C2 fractures with very minimal prevertebral STIR hyperintense signal likely representing a small hematoma or edema. 4. No evidence for epidural hematoma or cord signal abnormality. 5. No definitive ligamentous injury of the anterior longitudinal ligament, posterior longitudinal ligament or ligamentum flavum. 6. STIR hyperintense signal of the paraspinal muscles and interspinous ligaments, compatible with injury. 7. Mild anterolisthesis of C2 on C3 and C7 on T1 with retrolisthesis of C3 on C4 and C4 on C5, which is almost certainly degenerative in nature given the lack of definitive ligamentous injury. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, there has been placement of an endotracheal tube with its tip approximately 3.5 cm above the carina. The tip of the left central catheter is at the level of the cavoatrial junction or possibly upper right atrium. There is some asymmetry of opacification at the left base. This could possibly represent posttraumatic hematoma. In the appropriate clinical setting, superimposed pneumonia could be considered. The cardiac silhouette is at the upper limits of normal. Some indistinctness of pulmonary vessels could reflect some elevation of pulmonary venous pressure. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little change in the monitoring and support devices and the appearance of the heart and lungs. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, the monitoring and support devices are essentially unchanged. Continued asymmetric opacification at the left base that could represent posttraumatic hematoma or, in the appropriate clinical setting, superimposed pneumonia. The cardiac silhouette is unchanged. There may be minimal elevation of pulmonary venous pressure. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Subdural collections are now predominantly isodense to hypodense, but have increased in size bilaterally as detailed above. No associated midline shift. No new hemorrhages or infarctions identified. CHEST (PORTABLE AP) showed Esophageal drainage tube ends in the upper stomach. ET tube and left subclavian line are in standard placements. Moderate left pleural effusion and small right pleural effusion have increased. Heart size is normal. Previously questioned atelectasis early consolidation in the superior segment of the left lower lobe is less apparent, and may have improved. Heart size normal. No pneumothorax. CHEST PORT. LINE PLACEMENT was done. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little change in the appearance of the monitoring and support devices. Little overall change in the appearance of the heart and lungs, though the degree of vascular prominence appears slightly less. HIP UNILAT MIN 2 VIEWS LEFT showed Fluoroscopic images show all placement of a fixation device about the left acetabular fracture. Further information can be gathered from the operative report. MR THORACIC SPINE W/O CONTRAST ___ MR ___ SPINE showed 1. Fractures of the T1, T3 and T5 vertebral bodies with no significant osseous retropulsion. High signal in the T9-10 disc space extending into the inferior endplate of T9, which is suggestive of a bony fracture extending into the disc space (acute traumatic Schmorl's node). No spinal cord injury. 2. Multilevel degenerative changes, as described above. 3. Moderate bilateral pleural effusions with associated atelectasis. Cystourethrogram showed No evidence of bladder or urethral leak. There is a left bladder diverticulum. Mild bilateral ureteral contrast reflux noted. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little change in the appearance of the monitoring and support devices. The cardiac silhouette is within normal limits and there is again layering bilateral pleural effusions with compressive atelectasis and some elevation of pulmonary venous pressure. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are stable. Cardiac silhouette remains within normal limits. AC opacification bilaterally is consistent with layering effusions and compressive atelectasis, probably with some element of elevated pulmonary venous pressure. Given the extensive pulmonary changes and the absence of a lateral view, it would be difficult to unequivocally exclude superimposed pneumonia in the appropriate clinical setting. CHEST (PORTABLE AP) showed There continue be layering bilateral effusions with appearance of superimposed mild to moderate pulmonary and interstitial edema. There is also likely bibasilar compressive atelectasis. Cardiac and mediastinal contours are stable. No pneumothorax. Right subclavian PICC, nasogastric tube and endotracheal tube are unchanged in position. Interval removal of the right internal jugular and left subclavian central lines. Stable thoracolumbar curvature. DX CHEST PORTABLE PICC LINE PLACEMENT showed In comparison with the earlier study of this date, there has been placement of a right subclavian PICC line that extends to the lower SVC at about the same level as the left subclavian catheter. Otherwise little change except for apparent removal of a right IJ sheath. . CHEST (PORTABLE AP) showed Endotracheal tube has its tip at the thoracic inlet. The right subclavian PICC line is unchanged in position. A nasogastric tube is seen coursing below the diaphragm with the tip not identified. Stable layering bilateral effusions with patchy bibasilar airspace opacities consistent with compressive atelectasis. There has been interval improvement in the mild interstitial edema. Overall cardiac and mediastinal contours are likely unchanged given patient rotation on the current study. CHEST (PORTABLE AP) showed Comparison to ___. No relevant change. Decrease in extent of the pre-existing pleural effusions. Decrease is more obvious on the right and on the left. Retrocardiac atelectasis persists. Normal size of the cardiac silhouette. No pulmonary edema. The monitoring and support devices are in unchanged normal position. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Normal sonographic appearance of the liver. 2. Partial visualized bilateral pleural effusions. CHEST (PORTABLE AP) showed Moderate bilateral pleural effusions increased since ___. There is also the suggestion of consolidation in at least the right mid and lower lung zone due to pneumonia, or alternatively atelectasis. Interstitial edema present elsewhere in the lungs is mild, but increased. Heart size is normal. Cardiopulmonary support devices in standard placements. . NOTIFICATION: Dr. ___ reported the findings to Dr ___ by telephone on ___ at 10:55 AM, 2 minutes after discovery of the findings. CHEST (PORTABLE AP) showed In comparison with the study of earlier in this date, there has been placement of a right pigtail catheter with apparent decrease in the layering pleural effusion. However, there also has been decrease in the layering effusion on the left, raising the possibility that some of the apparent improvement on the right is merely due to a more erect position of the patient. No definite pneumothorax. The endotracheal tube is been removed and replaced with a tracheostomy, which appears well seated without evidence of pneumomediastinum. Otherwise, little change. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. BILAT UP EXT VEINS US showed No evidence of deep vein thrombosis in the left upper extremity veins. Limited evaluation of the left internal jugular vein due to overlying bandages. CHEST (PORTABLE AP) showed In comparison with the study of ___, in there is little change. Right pigtail catheter remains in place and there is no evidence of pneumothorax or recurrent pleural effusion. On the left, the hemidiaphragm is not as sharply seen and there is hazy opacification at the base, consistent with layering effusion. Is unclear whether this change reflect a new development of pleural fluid or merely a more recumbent position of the patient. Radiology showed No significant interval change. CHEST (PORTABLE AP) showed Right pigtail pleural drainage tube is still in place. There is no appreciable right pleural effusion or pneumothorax. Moderate left pleural effusion and left basal atelectasis are unchanged. Right lower lobe consolidation has improved since ___, subsequently stable since ___. Tracheostomy tube is midline, right PIC line ends in the low SVC, esophageal tube passes into the stomach and out of view. Heart size is normal. No pneumothorax. Radiology showed 1. Peribronchiolar opacity within the right lower lobe with air bronchograms may reflect aspiration though infectious process is difficult to exclude. 2. Diffuse anasarca with bilateral layering and nonhemorrhagic pleural effusions, left greater than right. Partially imaged right chest tube with locules of air within the right pleural space. 3. No intra-abdominal or pelvic abscess or evidence of infectious process. Stool fills the colon without evidence of obstruction. 4. Re- demonstration of pelvic fractures and multiple displaced rib fractures. Near complete resolution of hematoma involving the left iliacus and gluteus muscles. CHEST (PORTABLE AP) showed As compared to previous radiograph from 1 day earlier, right pleural catheter remains in place, with no substantial pleural effusion. Unusual sharpness of right hemidiaphragm could reflect a basilar pneumothorax. Moderate to large layering left pleural effusion has apparently increased in size, although positional differences of the studies limit comparison. No other relevant change. CHEST (PORTABLE AP) showed As compared to previous radiograph from 1 day earlier, right pigtail pleural catheter remains in place, with no visible pneumothorax. Overall, no relevant change since recent study. CHEST (PORTABLE AP) showed AS COMPARED TO PREVIOUS RADIOGRAPH FROM EARLIER THE SAME DATE, A LEFT PIGTAIL PLEURAL CATHETER HAS BEEN PLACED WITH SUBSTANTIAL DECREASE IN LEFT PLEURAL EFFUSION BUT DEVELOPMENT OF A MODERATE SIZED LEFT HYDRO PNEUMOTHORAX WITH SUBSTANTIAL BASILAR COMPONENT. RIGHT PIGTAIL PLEURAL CATHETER ALSO REMAINS IN PLACE WITH INCREASING SMALL RIGHT PLEURAL EFFUSION AND ADJACENT RIGHT BASILAR ATELECTASIS. NO OTHER RELEVANT CHANGE. CHEST (PORTABLE AP) showed A bilateral indwelling pleural drainage catheters are unchanged in their respective positions. Only small pleural effusions remain, right improved since ___. No pneumothorax Bibasilar consolidation, probably mostly atelectasis on the left, conceivably aspiration pneumonia on the right has improved. There is no pulmonary edema. Heart size normal. Tracheostomy tube is slightly rotated. Right PIC line ends in the low SVC. CHEST (PORTABLE AP) showed Moderate right pleural effusion has increased. No appreciable left pleural effusion. No pneumothorax. Bilateral pigtail pleural drainage catheters are unchanged in their respective positions. Some of the worsening opacification in the right lower chest is probably due to concurrent atelectasis, possibly severe. The upper lungs however are clear. Heart size is normal. Tracheostomy tube is slightly turned in should be evaluated to see that it is appropriately positioned. A right PIC line ends in the low SVC. HIP 1 VIEW showed In comparison with the operative study of ___, there is little change in the fixation device about the left supra-acetabular fracture. No evidence of hardware-related complication. Of incidental note is residual contrast material within the rectosigmoid. CHEST (PORTABLE AP) showed Comparison to ___. The monitoring and support devices are unchanged, with the exception that the right PICC line has been removed. The bilateral pigtail catheters in the pleural space are constant. Improved ventilation of the right lung with decrease in extent of a pre-existing small pleural effusion. The left lung is stable. Borderline size of the cardiac silhouette persists. No new focal parenchymal opacities. CHEST (PORTABLE AP) showed Compared to prior chest radiographs ___ through ___ at 05:00. Previous mild to moderate asymmetric pulmonary edema has cleared from the left lung over the past day. Residual abnormality in the right lower lung is probably pneumonia. Small left pleural effusion persists despite the pigtail drainage catheter its on both sides. No pneumothorax. Heart size normal. Tracheostomy tube is persistently rotated, should be examined to make sure it is properly positioned. Radiology showed Since the prior study, there is a pacemaker on the left with leads projecting over the right atrium and ventricle. There is a pigtail catheter in the left chest centrally and a second catheter in the right base these are stable. There is no pneumothorax. Endotracheal tube tip is unchanged. There is no new consolidation. Radiology showed There is new patchy density in both lung bases. Tubes and lines are stable. There is no pneumothorax or CHF. Radiology showed There is improved aeration of the bases as compared to the earlier study. Tubes and lines are intact. There is no pneumothorax. Radiology showed The lungs are clear. There is no pneumothorax, effusion, consolidation or CHF. Degenerative changes are present in the spine. Radiology showed Both pigtail catheters have now been removed. There is no pneumothorax. There is persistent patchy density in both lung bases. There is a small effusion on the left. There is no CHF. The patient was diagnosed with Traum subdr hem w LOC of unsp duration, init, Unsp disp fx of second cervical vertebra, init for clos fx, Unsp fracture of left ilium, init encntr for closed fracture, Multiple fractures of ribs, unsp side, init for clos fx, Fall (on) (from) unspecified stairs and steps, init encntr. The patient was treated with ___ Embolized: 1. Left Superior Gluteal art (gelfoam) 2. Left posterior internal iliac (gelfoam) 3. Left gluteal branch off the common iliac (gelfoam + 2mm x 1cm hilal) 4. Left L5 Lumbar artery (gel foam) ___ Fixation of left anterior column acetabular fracture with supra-acetabular 7.3 mm screws. ___ PICC line placement right arm ___ Tracheostomy ___ Replacement of fresh tracheostomy ___ Tube thoracostomy of the right hemithorax ___ Tube thoracotomy of the left hemithorax ___ Pace maker placement. At the time of discharge, the patient had C2 transverse process fracture T1, T3, T5 vertebral body fracture T9 fracture extending into disc space Pelvic hemorrhage Left parietal subdural hematoma Left anterior column acetabular fracture Right sacral fracture Left ___ rib fractures bilateral super pubic rami fracture right inferior rami fracture left anterior acetabular fracture left iliac wing fracture with hematoma sternal fracture and substernal hematoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient is an ___ who was admitted s/p fall approximately 20 stairs with likely LOC with polytrauma and hemodynamic instability. Trauma evaluation and imaging revealed left parietal subdural hematoma, C2 transverse fracture, T5 vert body fx with hematoma, right sacral fracture, left ___ rib fractures, bilateral sup pubic rami fracture, right inferior rami fracture, left anterior acetabula fracture, left iliac wing fracture with hematoma, sternal fracture and substernal hematoma. FAST was negative. During the primary trauma evaluation, the patient's mental status deteriorated and he became hypotensive, and required packed red blood cell and platelet transfusions. He was taken to Interventional Radiology where several branches of left posterior iliac vein and L5 lumbar artery were embolized. He was transfused a total of 5 units packed red blood cells and 3 units fresh frozen plasma. Please see radiology report for details. Given the complexity of his injuries and his hemodynamic instability he was admitted to the trauma/surgical intensive care unit.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with a history of non-alcoholic cirrhosis and thrombocytopenia presenting with BRBPR. After a BM yesterday afternoon, she noticed that "all the water in the bowl was red." The second BM had blood covering the stool, and the third had only bright red blood on the toilet paper. She has not had a BM since then. No abdominal pain or increased distension. She reports dyspnea with exertion and increased leg edema over the last week. No fever/chills, chest pain, or dizziness. Two days of mild nausea last week but no vomiting. Last EGD in ___ (obtained for a few episodes of melena) showed portal hypertensive gastropathy. She denies recent melena and no prior episodes of hematochezia. Last colonoscopy in ___ at ___ showed rectal varices. In the ED initial vital signs: T 96.9, HR 86, BP 121/62, RR 24, SpO2 99% RA. Exam notable for soft abdomen, obese, NTND, rectal exam with external non-bleeding hemorrhoids, guaiac negative. Initial labs notable for WBC 3.2 Hg 10.0 (baseline ___ Hct 30.5 plts 32 (at baseline). INR 1.2. BUN 31, Cr 1.1, chemistry panel otherwise normal. LFTs normal. On repeat labs six hours later, Hg 8.5 Hct 26.0. She received no medications. CXR was performed (read pending). Hepatology fellow recommended admission to ET. ROS: Per HPI, denies fever, chills, night sweats, headache, cough, chest pain, abdominal pain, vomiting, diarrhea, constipation, melena, or dysuria. Radiology showed No definite focal consolidation. Mild vascular congestion. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Mild ventricular prominence. Otherwise normal study. The patient was diagnosed with Melena. The patient was treated with ___ - Colonoscopy. At the time of discharge, the patient had -Gastrointestinal bleeding -Nonalcoholic steatohepatitis Cirrhosis complicated by ascites. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ F w/ h/o NASH cirrhosis (c/b rectal varices, portal gastropathy, no h/o HE, SBP, esophageal varices) and thrombocytopenia presenting with BRBPR. Last EGD (___): portal hypertensive gastropathy. Last colonoscopy (___): rectal varices. # Acute blood loss anemia: Patient p/w BRBPR x3 with subsequent BMs showing minimal blood. Colonoscopy was preformed during hospitalization with no clear source identified. Upper GI studies not preformed given low likelihood as an etiology for BRBPR. Upon presentation, stool guaiac neg in ED. Rectal exam in ED showed non-bleeding external hemorrhoids. Hgb initially stable at 10.0 but later dropped to 8.5, pt hemodynamically stable. Pt was given Ciprofloxacin for SBP prophylaxis (Penicillin allergy) i/s/o NASH cirrhosis with c/f GIB. Infectious work up was negative. Pt was also given put on octreotide for known rectal varices on last colonoscopy (___). Colonoscopy (___) showed a polyp in the colon (not bx'ed given c/f bleed), grade 1 internal hemorrhoid, rectal varices, but no sign of active or recent bleeding. She had no further BRBPR and her Hbg remained stable throughout the rest of her hospitalization. # Prolonged anesthetic effect: Pt was obtunded, unresponsive to noxious stimuli ___ ___ upon arrival to floor after her colonoscopy. Colonoscopy was uncomplicated but she had been given midazolam 4mg, ketamine 40mg, propofol for GA maintenance during colonoscopy. NCHCT was neg for intracranial bleed. During NGT placement to try to give lactulose pt became aroused. NGT placement discontinued ___ pt rapidly becoming A&Ox3. Given lactulose Q2H PR until BMx1, given PO for bowel reg per patient's request. Patient remained at baseline mental status for the remainder of her hospitalization. # NASH cirrhosis: She has a history of ascites and is on diuretics. H/o rectal varices, portal gastropathy No history of HE, SBP, or esophageal varices. Pt's home Lasix and spironolactone were stopped on admission given c/f GIB. She was restarted on Lasix and spironolactone prior to discharge. # Thrombocytopenia: Chronic, likely due to splenic sequestration. Platelet count was at baseline throughout hospitalization and on day of discharge. # Diabetes: On U-500 sliding scale with breakfast and dinner at home. In hospital, patient was placed on HISS. On home U-500 sliding scale when eating on day of discharge (___). # Hypertension: Home lisinopril held in the setting of GI bleed, and restarted ___ given no e/o active bleed on colonoscopy and stability. # Asthma: Continued home albuterol prn. In hospital, placed on Symbicort vs. home Advair as not on formulary. # Hyperlipidemia: Pt was continued on home simvastatin. # Depression/anxiety: Pt was continued on home fluoxetine and prn lorazepam.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH of HIV/AIDS (self-discontinued salvage HAART ~4wks ago, VL ___, CAD (s/p stenting), who presented to ED w/ complaint of rapid heart rate, and cough, was started on treatment for PNA then admitted to medicine for further w/u and evaluation Last seen in ___ clinic in ___, where he described symptoms of pharyngitis, but was not given antibiotics. He was rec'd to continue his HARRT regimen unchanged given optimal control of VL recently. However, in the past several weeks, reported that he ran out, called for refills, but "never heard back from providers" so self discontinued all medications except tamsulosin and seroquel. Slightly before medication cessation occurred he reported starting to feel "achy and tired" w/ general malaise. In the two weeks prior to admission developed polyphagia/polyuria, but denied vision changes. In the last week he then developed a non productive cough described as "non-severe", occasionally rhinorrhea, and infrequent epistaxis. On the night prior to admission, was laying in bed, and felt his heart race, felt it difficult to breathe, checked his O2 sat at home was 96%RA and HR 150 so presented to ED for evaluation. On ROS denied fever, chills, sore throat, nausea, vomiting, abd pain, dysuria, rash, photo/phonophobia. He denied recent travel or change in his living situation (lives in assisted living). In the ED initial vitals were: 98.8 135 132/94 16 97% Nasal Cannula and FSG of 435. Exam notable for rhonchi in left lung. Labs significant for WBC of 5.2, Hgb 15, Plt 100, CHEM normal w/ exception of BUN 21 and Glc 500, Ca ___, Mg 1.8, Phos 2.8, Trop <0.01, Lactate 4.0, AST/ALT 99/162, LDH 279, Lipase 84, TBili 0.1, Alb 4.1, coags wnl. UA w/ Tr bld, Tr protein and 1000Glc. Flu Swab negative. CXR showed no acute intrathoracic process. He was presumed to have viral respiratory illness given cough, relatively benign CXR, and mild transaminitis but was given Levaquin to cover PNA as well. Pt was given 3L NS and HR decreased from 135 to 97. FSG decreased from 500 to 268 by time of transfer to floor and was given 4U Regular insulin prior to transfer. Repeat lactate following fluids was 2.4 Vitals prior to transfer were: 98.4 97 133/79 18 97% RA. On the floor, pt noted that he feels that his breathing is better. CHEST (PORTABLE AP) showed No acute intrathoracic process Radiology showed No evidence of acute cardiopulmonary process. CHEST (PORTABLE AP) showed Lungs are mildly hyperinflated, but clear. Heart is normal size. Pulmonary vasculature is more distended today than on ___ probably in indication of borderline left ventricular left heart dysfunction, but there is no pulmonary edema, consolidation, or pleural effusion. No pneumothorax. LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT showed 1. Coarse, hyperechoic hepatic parenchyma compatible with known diagnosis of steatosis. Coarsened and heterogeneous appearance may be suggestive of cirrhosis though not diagnostic. 2. Splenomegaly The patient was diagnosed with OTHER ABNORMAL GLUCOSE, CARDIAC DYSRHYTHMIAS NEC, HYPERTENSION NOS, ASYMPTOMATIC HIV INFECTION. At the time of discharge, the patient had Primary diagnosis: diabetes mellitus Secondary diagnoses: HIV infection, CAD, sCHF (EF 50-55%), HTN, HLD, IBS, MDD, vocal cord paralysis s/p reconstruction x2. The patient was given written instructions concerning 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 HIV (on salvage regimen, as below; VL UD/CD4+ 400s in ___, CAD (with DES to OM1) and sCHF (EF 40%) who presented with tachycardia, polydipsia, polyuria and weight gain, found to have diabetes mellitus and non-specific complaints consistent with viral-type illness. ACTIVE ISSUES # VIRAL ILLNESS, NOS: ___ reports malaise, diffuse & non-specific myalgias and arthralgias, with nasal congestion and changes in his voice caliber and quality. He has remained afebrile, without leukocytosis. The patient did present with transaminitis, which could be consistent with CMV infection (or EBV infection, though likely already IgG positive). CXR not concerning. Conservative management for his viral-type symptoms. CMV serology showed undetecetable viral load. EBV serology showed positive IgG. # TRANSAMINITIS: Found to be elevated on admission. The patient is without any stigmata of cirrhosis. As above, may be related to viral syndrome. HAV and HBV immune. LFTs trended up during admission. HAV and HBV documented immune. HCV Ab negative this admission. CMV and EBV serology as above. The patient has a history of hepatosteatosis, and does not report recent EtOH or APAP use/abuse. RUQ ultrasound demonstrated coarse, hyperechoic hepatic parenchyma compatible with known diagnosis of steatosis. Coarsened and heterogeneous appearance may be suggestive of cirrhosis though not diagnostic and splenomegaly. No clear cause of transaminitis was identified, however at the time of discharge, had been trending down (see above in # PERTINENT RESULTS). # HIV: ___ stopped his ARV regimen ___ weeks ago secondary to issues with prescription refills. His last VL was UD and CD4+ was 430 in ___. He has no history of OIs. While in house, HIV VL checked and found to be 75 copies/mL. Virtual phenotype and integrase inhibitor resistance panel sent while in house: results pending on discharge. ARV regimen restarted. # DIABETES MELLITUS: FSG under good control with SSI - FSG in range of 130s-180s. ___ consulted yesterday: good control with current SSI. SW saw patient for coping while in house. On discharge, the patient was sent on a regimen of 2.5 mg glipizide XR with planned follow up with ___ diabetic education. CHRONIC, INACTIVE ISSUES. # PSYCHIATRIC COMORBIDITIES: Currently euthymic, though having a difficult time with his new diagnosis of diabetes, given his poor support network. SW consult requested by the patient while in house. Continued quetiapine, lorazepam. # HTN: only on metoprolol as outpatient, normotensive on admission. This AM, BP 152/92, but had not received metoprolol yet. Continued home metoprolol. # CAD + compensated sCHF: ___ has a history of CAD s/p stenting w/ sCHF secondary to mild global hypokinesis (LVEF ~40%) on last TTE from ___. He was hypovolemic on admission likely secondary to volume loss from uncontrolled hyperglycemia. Tachycardia resolved with fluids and restarting of beta-blockade. Patient does report occasional orthopnea, however appears dry on exam. Not decompensated. Continued home metoprolol. # BPH: On tamsulosin at home, however, fosamprenavir decreases clearance of tamsulosin and can lead to hypotension. The patient has been taking these medications together without adverse effect. Educated the patient on the risks of these medications combined. As patient hasn't had symptoms of hypotension with these medications combined, continue currently & monitor for signs of interaction. *** TRANSITIONAL ISSUES **** - Optimization of CHF medication regimen - Follow up LFTs</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ pmhx of dementia, congenital blindness, severe scoliosis, HFpEF with pulmonary hypertension ___ restrictive lung disease iso severe kyphosis, HTN, Atrial fibrillation, primary hyperparathyroidism, with recent admission for aspiration pneumonitis @ ST E's who presents with hypoxia from facility. CHEST (PORTABLE AP) showed 1. Left basal abnormality could be pneumonia or atelectasis with a without small left pleural effusion. 2. Moderate cardiomegaly. The patient was diagnosed with Other pneumonia, unspecified organism, Hypoxemia, Unspecified dementia without behavioral disturbance. At the time of discharge, the patient had PRIMARY DIAGNOSIS ================== Aspiration pneumonia SECONDARY DIAGNOSIS ==================== Hypernatremia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>TRANSITIONAL ISSUES: ==================== [ ] He was hypernatremic intermittently during the hospitalization, likely due to poor PO fluid intake. Fluids should be encouraged when he is discharged (always nectar thick). [ ] He should have a diet of pureed solids and nectar thick liquids. He is at high risk for aspiration, so should be monitored with all feeding. [ ] He has follow up with his primary care doctor on ___ as listed above. #CODE:DNR/DNI #CONTACT: Sister in law (___) Next of Kin: ___,___ SERVICES Relationship: OTHER Phone: ___ Next of Kin: ___ Phone: ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ ___ woman with a history of DM II, CVA, cognitive impairment, atrial fibrillation, and recent NSTEMI who initially presented to ___ after a fall. She was found to have a fever and elevated troponins and was transferred to ___ for further management. Of note, patient was admitted to ___ from ___. During that admission, she had an NSTEMI, afib w/ RVR, and SOB that responded to lasix. Her afib w/ RVR was initially controled with a diltiazem drip, later changed to PO. She underwent a nuclear sress test that did not show ischemia, with LVEF 57%. Patient has been thought to not be a candidate for longterm anticoagulation given a brain aneurysm and a tendency to fall. A VQ scan showed low probability of PE. On discharge, creatinine was 1.1 and WBC was 7.7. Altered mental status, pain with movement of the left leg, suspected fracture. AP radiograph of the pelvis as well as two dedicated views of left hip were reviewed. There are extensive degenerative changes with no lytic or sclerotic lesions, as well as no evidence of fracture demonstrated. If the patient's symptoms persist, correlation with cross-sectional imaging might be considered. was done. Radiology showed 1. Vague hypoehoic lesion in the left lower pole of uncertain etiology. The significance is uncertain and it is not clear that this represents a true lesion, but an infectious etiology - although not drainable fluid - is possible or small solid nodule. Recommend MRI for further evaluation; if not feasible repeat targeted ultrasound could be considered for follow-up. 2. Trace fluid amount of fluid surrounding left kidney, non-specific. 3. Bilateral cysts. No hydronephrosis. Radiology showed Possible early basilar pneumonia, visualized only on the lateral radiograph. Radiology showed Uncomplicated ultrasound and fluoroscopically guided 4 ___ single-lumen PICC line placement via the right brachial venous approach. Final length is 38 cm internally, with the tip positioned in distal SVC. The line is ready to use. Radiology showed Mild dilatation of the pancreatic duct in the body and neck. This is of uncertain clinical significance as no discrete lesion is identified, but the duct is not seen in the head of the pancreas. If clinically indicated ,this could be further evaluated with endoscopic ultrasound given the patient's known renal impairment. The study is otherwise unremarkable. Radiology showed 1. Slight perirenal stranding bilaterally, perhaps related to pyelonephritis. Please correlate with urine analysis. 2. Small foci of air within the bladder; please correlate with recent instrumentation. 3. Asymetric "stranding" along the subcutaneous tissue on the right abdominal wall perhaps relating to the patient's pain. Clinical correlation to recent fall for the possibility of a hematoma is recommended. 4. Mild non specific axillary lymphadenopathy up to 1.2 cm in the left axilla. This can be followed with a repeat chest CT in 6 months. 5. Small right pleural effusion. 6. Hypodense lesion in the left lower pole is again present. It is not fully characterized on this non-contrast CT and as was recommended on ___, MRI can be obtained for further evaluation. If not feasible, a repeat targeted ultrasound could be considered for followup. Radiology showed 1. Mild vascular congestion. 2. Interval increase in the heart size, which remains at the upper limits of normal. Radiology showed Uncomplicated fluoroscopic-guided lumbar puncture, yielding 15 cc clear cerebrospinal fluid. The CSF samples were sent for labs as requested. The patient was diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE, ATRIAL FIBRILLATION, ACUTE KIDNEY FAILURE, UNSPECIFIED. The patient was treated with ___ Lumbar Puncture ___ guided). At the time of discharge, the patient had Primary Diagnoses: - Leukocytosis - Atrial fibrillation - HTN - Abnormal LFT's Secondary Diagnoses: - History of CVA. The patient was given written instructions concerning 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 ___ ___ speaking woman with a history of DM II, CVA, cognitive impairment, atrial fibrillation, and recent NSTEMI who initially presented to an OSH (___) s/p fall and was found to have elevated troponin, non-elevated CK-MB, and fever/leukocytosis. She was transferred to ___ for management of NSTEMI. Her initial exam was concerning for meningitis, but LP was negative. ACTIVE ISSUES 1. Fever/Leukocytosis: Patient's WBC was markedly elevated to 24 upon transfer, from a baseline of 7 on ___. Given nuchal rigidity, photophobia, and AMS on initial exam, patient's symptoms were initially concerning for meningitis and she was covered empirically with vancomycin, cepefime, Bactrim (for Listeria, given PCN allergy), and acyclovir. Her heparin gtt was held for 6 hours and she underwent ___ LP, showing just 1 WBC. Bactrim was therefore discontinued. Acyclovir was discontinued after 48 hours. Patient was continued on vancomycin and cefepime with improvement in her leukocytosis and in her fever curve. Blood cultures from ___ grew coag negative staph in 1 bottle, which was thought to be a contaminent. The etiology of her infection remained unclear; differential included pneumonia (though lung exam remained unremarkable), C. dif (though no diarrhea developed), and pyelo (given LL pole lesion on renal u/s, though UA's were unconvincing). Patient underwent abdominal ultrasound, which showed mild dilation of pancreatic duct but no clear infectious source. She was followed by the ID service. Sputum cultures were unrevealing. Antibiotics were stopped on ___ and patient remained afebrile and without leukocytosis. 2. LFT Abnormalities: Patient had elevated LDH and transaminases. Transaminases initially improved, then trended up again to 100's. This may have been due to a drug reaction, given exposure to multiple antibiotics including Bactrim early in hospitalization. CK was initially high but trended down. Lymphoproliferative disorder was also considered, especially given axillary LAD seen on CT scan, but patient had no clear evidence of malignancy. 2. AMS: Patient was altered upon presentation, A+O x 1 from a baseline of A+O x 2. Although there was initially concern for meningitis as above, her LP was negative. Her AMS was likely due to delerium in the setting of infection, as mental status rapidly improved to baseline with antibiotics. Seizure was considered given patient's history of seizure, but it was felt to be less likely given patient has been adherent to Keppra. 3. Troponin Elevation: Patient presented with troponin elevation and EKG changes initially concerning for NSTEMI. However, normal MB and rise in LDH suggested possibility of non-cardiac source, and these changes were most likely due to demand in the setting of severe infection. She was started on Plavix and a heparin gtt, which were both stopped as ACS became less likely. Giving climbing CK, atorvastatin 80 mg daily (started at outside hospital) was discontinued. CK downtrended. In order to simplify nodal blockade and because of renal failure, patient was transitioned from atenolol and diltiazem to metoprolol. She was continued on ___ 325 mg daily (high dose for a. fib). 4. Acute Kidney Injury: Patient's admission Cr was 2.2 from a baseline of 0.9. This was likely due to prerenal physiology in the setting of infection, which was supported by FeNa of 0.5%. Repeat uring 'lytes on ___ show no EOS, and FeNa had increased to 1.43%, suggesting an intrinsic renal process such as ATN. Patient received IV fluids and creatinine improved. 5. Atrial Fibrillation: Patient has a CHADS2 score of 6. She is on ___ 325mg daily but not systemically anticoagulated (per ___ notes, this is due to history of ICA aneurysm and high fall risk). Her predominant rhythm was a. fib, though she was intermittently in sinus. Her nodal blocade was changed from atenolol to metoprolol in the setting of renal failure and diltiazem was discontinued. As an outpatient, may consider risk/benefit of systemic anticoagulation. 6. Chronic Diastolic CHF: EF 57%. Patient was hypovolemic in the setting of infection. She received IVF. Home lasix was held due to ___. 7. Failed Speech & Swallow: Patient had a speech and swallow evaluation and was advised to be a strict NPO. This was discussed extensively with patient and family, who reported her swallowing deficits are from a prior stroke and unchanged from recent baseline. The risk of aspiratory pneumonia was discussed extensively with patient and family, who preferred for patient to continue to eat for comfort. 8. HTN: In final days of hospitalization, patient was increasingly hypertensive. Amlodipine was added to her regimen with good effect. CHRONIC ISSUES 1. DM II: Last A1C was 6.5% in ___. Patient's metformin was held and she received ISS. 2. HLD: Last LDL 140 in ___. Patient was initially started on high-dose atorvastatin for NSTEMI, which was then stopped given no evidence of cardiac event, elevated CK and transaminases. 3. Epilepsy: Patient has a history of seizure and takes levetiracetam. Her dose was reduced from 1000 mg BID to ___ mg BID because of ___. She resumed her home dose on day of discharge. TRANSITIONAL ISSUES - Trend Cr for stability and LFT's for resolution of elevation - Needs dental follow-up as outpt to complete infectious work-up - Recheck cholesterol panel as outpatient and consider need for statin if CK and transaminase return to normal levels - Consider risk/benefit of systemic anticoagulation with Coumadin - MRI vs targed ultrasound to evaluate hypodense lesion seen on CT and ultrasound - Repeat CT scan of chest in 6 months to monitor non-specific axillary lymphadenopathy - consider repeat RUQ US vs ERCP to re-assess and further work-up mildly dilated pancreatic duct seen on RUQ US - Pending studies at discharge ### CSF viral culture (___): pending ### Sputum fungal culture (___): pending</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ DM type 1 , ESRD on HD ( ___ HTN, HPL presenting w/ one day of abdominal cramping and pain to his mid epigastrium. The patient reports the onset of abdominal pain for last week ___ that has progressively gotten worse, reach peak initensity at 5 am the morning of admission. The pain woke him up, ___ describes as a " crampy, knot feeling". He had one episode of non-bilous, non bloody emesis, and intermittent nausea. Inability to take PO for the remainder of the day. He denies any associated diarrhea at home, or blood in stools. He reports compliance with his insulin regimen, but reports his sugars have been critically hight today. He had HD on ___, which he reports was uneventful. On ROS he denies any cough, fevers, or chills at home, no new rashes, or dysuria. He has ha chronic indwelling foley placed since his last hospitalization in ___ for urinary retention, he also had a PD cathether which he no longer uses. He denies any pain at the site of his HD line and PD cathether. Radiology showed Slight interval retraction of the dual lumen right sided central venous catheter. No acute cardiopulmonary process. Radiology showed 1. Acute segmental jejunitis. 2. No fluid collection or evidence of bowel obstruction, perforation. Radiology showed Uncomplicated replacement of right IJ tunneled hemodialysis line. The tip is located in the right atrium and the catheter is ready for use. The patient was diagnosed with ABDOMINAL PAIN EPIGASTRIC, DIABETES UNCOMPL JUVEN. The patient was treated with enteroscopy. At the time of discharge, the patient had Primary Diagnoses: Jejunitis Anemia Urinary retention Clostridium difficile infection Secondary Diagnoses: Diabetes Mellitus Type 1 Hypertension Hyperlipidemia ESRD Diabetic Retinopathy Erectile Dysfunction Depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Assessment and Plan: ___ year old male hx type 1 DM , ESRD on HD, HTN, HPL, admitted with hyperglycemia and jejunitis # Abdominal Pain: he had one week of progressive abdominal pain and vomitting and new onset diarreha in ED, with evidence of jejunitis on CT of admission. Differential included viral vs bacterial eneteritis. Gastroenterologists consulted and ___ cultures were sent. His abdominal pain improved during his stay, but intermittently painful requiring opiates. He remained afebrile with a normal WBC count. Given continued pain, enteroscopy was done which showed inflammation, and biopsies were sent, still pending. Given his duodenal ulcer history in ___, he was kept on a PPI and sucralfate. H pylori antibodies were negative. Stool cultures before discharge were positive for c. difficile and he was started on metronidazole. We ultimately felt that his abdominal pain was likely due to jejunitis. There was also concern that it may be from his PD catheter, but it improved over the course of his hospital stay. # Acidosis: admitted with mild acidosis concerning for diabetic ketoacidosis, but he didn't have an anion gap or urine ketone. His end-stage renal disease likely contributed to acidosis as well as his diarrhea and emesis. Sugar levels were quickly normalized with insulin drip. # Type 1 DM ( A1c 8% in ___: he reported several critically high levels of blood sugars on the day of admission, with non-anion gap acidosis as above. It was likely precipitated by his enertitis(see below). Hemodialysis and Peritoneal dialysis lines looked good. Lab values did not suggest hepatobiliary source, and chest x-ray was clear. Compliance had been an issue in the past, but he reported increased compliance with medications with his visiting nurse. Original hyperglycemia fixed with insulin drip and then the diabetes specialists followed him for appropriate control. He remained intermittently hyperglycemic, and required multiple adjustments to his insulin sliding scale. # HTN- The patient has a history of malignant hypertension, followed by Dr. ___, but remained at his baseline of 140-150's systolic. He was continued on his home medications, except briefly lisinopril during the time that he was hyperkalemic, but restarted after its resolution. # Urinary Retention: His foley catheter was removed for 2 days, but despite being on tamsulosin, he required straight caths and a foley had to be replaced for outpatient urological follow up. # Hyperkalemia- The patient was hyperkalemic on admission to 6.6 and agian to 7.2 on HD. EKG showed peaked T waves. He was treated with 30mg Kayexlate an lisnopril was held as above # ESRD- HD on ___ was continued. # HPL- LDL 75 ___. Was not on medication. # Anemia of chronic disease- there was no evidence of acute bleeding. received EPO and Fe with HD, but hematocrit dropped to ___ range, where he has been before, and he required one unit of blood.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old Male transferred from ___ after presenting with marked jaundice found with obstructing pancreatic mass. The patient was ___ by his primary care, Dr. ___ was adding a new insulin (toujeo) and was found to be markedly jaundiced. The jaundice is painless and he notes a 10lb weight loss, darkened urine for the prior month. He also notes recent onset pruritis. He has been having some recent diarrhea. At ___ he underwent CT scan of the abdomen which was notable for a dilated CB to 15mm and a pancreatic mass. His bilirubin was elevated to 16 along with mild transaminitis. CTA PANCREAS (ABDOMEN AND PELVIS) showed 1. An ill-defined mass in the pancreatic head with upstream pancreatic and biliary dilatation is concerning for malignancy. Adjacent fat stranding involves the duodenal sweep, the SMA and SMV as detailed above. Lymph nodes in the porta hepatis measuring up to 1.0 cm are noted, otherwise no evidence of remote disease. 2. Endoscopic ultrasound could better define the pancreatic lesion. 3. Sigmoid diverticulosis. The patient was diagnosed with Unspecified jaundice. The patient was treated with ___ -- ERCP with stent. At the time of discharge, the patient had Bile duct obstruction ___ pancreatic head mass s/p ERCP. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>1. Bile Duct Obstruction due to Probable Malignant Neoplasm - Pancreas. Seen on outside imaging. CA ___ elevated. On ___, patient had a CTA pancreas which redemonstrated the pancreatic mass with involvement of nearby vessels and enlarged lymph nodes. On ___ the patient had an ERCP with stent placement, as well as brushing of the bile duct. The patient's diet was advanced on ___, and by time of discharge he was eating a regular diet. His bilirubin had downtrended from 18 to 16 on day of discharge. His rivaroxaban was held after the procedure, and will be restarted on ___. He has follow up scheduled on ___, when he will be seen in ___ clinic. He will finish a five day course of ciprofloxacin on ___ - ___ cytology results - patient will be seen in pancreatic ___ clinic of ___ - ciprofloxacin 500 mg BID, last day ___ 2. CAD. Patient was continued on his home medications, with the exception of fenofibrate which was discontinued - Aspirin, Simvastatin, Lisinopril - Patient is status post pacemaker - STOP Fenofibrate 3. Chronic Systolic CHF. Euvolemic throughout hospitalization. - Lasix, Toprol XL continued (125 QAM, 50 QPM) - Keep euvolemic - LVEF of 35-40% with moderate global hypokinesis 4. Atrial Fibrillation. In the setting of his ERCP, rivaroxaban was held. It will be restarted on ___. Amiodarone was initially held but then resetarted on day of discharge. - Holding rivaroxaban until ___. 5 Type 2 Diabetes with nephropathy, CKD Stage 3. Patient was on his home insulin and ISS throughout the day.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of ETOH abuse, lower extremity burns s/p grafting (___), who presents after a fall. He reports that the fall occurred on ___ morning (however in other documentation the timing is unclear). He states he was in bed, tried to get up, his legs gave out and he lost consciousness. He hit his head. He states that he falls frequently. Today, he went to see his sister, and could barely stand up, so his sister called EMS. After the fall, he reports experiencing pain "over his entire body." He cannot localize the pain more specifically than that. CT CHEST W/CONTRAST showed Indeterminate bilateral pulmonary nodules. . Stable mild compression fractures T5, T6 vertebral bodies. Mild paravertebral edema T4-T5 level, may represent reactive change, possibly related to fractures if they are acute or subacute, or infiltrative process, . Stable indistinct bilateral T4-T5 facet joints, may be degenerative, consider septic arthritis if clinically suspected RECOMMENDATION(S): Consider further evaluation with tissue sampling. WRIST(3 + VIEWS) LEFT showed Stable exam. Consider inflammatory etiology, including reflex sympathetic dystrophy. Mild degenerative arthritis. WRIST(3 + VIEWS) RIGHT showed No periarticular osteopenia. Mild degenerative arthritis. JOINT OR CYST INJECTION/ASPIRATION showed 1. Imaging Findings - Hypervascular left wrist synovitis without evidence of effusion. 2. Procedure - No fluid could be spontaneously aspirated. 3 cc of sterile saline was injected into the radiocarpal joint and a trace amount of fluid was re- aspirated and sent to the laboratory for culture. There was insufficient fluid for fluid analysis (cell count). I Dr. ___ personally supervised the Resident/Fellow during the key components of the above procedure and I have reviewed and agree with the Resident/Fellow findings/dictation. MR WRIST ___ CONTRAST LEFT showed 1. Diffuse bone marrow edema of the carpal bones as well as the distal radius and ulna, associated with extensive synovitis of the DRUJ and carpal joints. A few scattered erosions noted. Findings are compatible with inflammatory arthropathy, including rheumatoid arthritis in other inflammatory arthritides. However, in the appropriate clinical setting, an indolent infection such as mycobacterial and non microbacterial TB can have a similar appearance. 2. Tear of the radial band of the TFCC, with synovitis in the distal radioulnar joint. . 3. Areas of osteoarthritis including the first CMC, triscaphe and radiocarpal articulations. s HAND (PA,LAT AND OBLIQUE) LEFT showed Pronounced periarticular osteopenia. Pronounced soft tissue swelling about the wrist, second MCP and second PIP joints. No definite erosion, though the IP joints are not well visualized due to flexion positioning on all three views. No periostitis identified. The differential includes inflammatory and infectious etiologies. Although soft tissue swelling is most pronounced about the wrist and finger, the periarticular osteopenia extends throughout the entire wrist and hand. However, no focal dominant bony osteolysis or periostitis is identified to suggest focal osteomyelitis. In the appropriate clinical setting, chronic regional pain syndrome (reflex sympathetic dystrophy) can have a somewhat similar appearance. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. There is no fracture. 2. There are degenerative changes in the cervical spine. 3. Extensive periodontal disease, dental cavities, dental consult recommended. CT T-SPINE W/O CONTRAST Q321 CT SPINE showed 1. Mild compression superior T5, T6 endplates. There is mild paravertebral edema at T4, T5 level, suggesting acute to subacute component of fracture at T5. 2. Abnormal bilateral T4-T5 facet joints, may be degenerative, consider infection if clinically suspected. CHEST (PA AND LAT) showed Heart size and mediastinum are stable. Lungs overall clear with no evidence of consolidation to explain symptoms. There is no pneumothorax. There is left pleural thickening versus small amount of pleural effusion. CT abdomen and pelvis with contrast showed 1. Indeterminate mildly enlarged pelvic, inguinal lymph nodes. . 2. Hepatic steatosis. The patient was diagnosed with Unsp fracture of T5-T6 vertebra, init for clos fx, Fall on same level, unspecified, initial encounter, Cellulitis of right lower limb, Cellulitis of left lower limb. The patient was treated with US and aspiration of Left Wrist - ___. At the time of discharge, the patient had Inflammatory arthritis T5 Fracture Alcohol use disorder Anemia Psoriasis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ y/o M with a h/o EtOH abuse, who presented s/p a fall and intoxicated, found to have T5 fracture, as well as fever, inflammatory arthritis, anemia, and hyperkeratotic rash. # T5 Fracture - Traumatic from falls while intoxicated. He was seen by Neurosurgery, who recommended no intervention. There is no need for any brace. He has no activity restrictions. # Palmoplantar Keratoderma (PPK) due to Psoriasis Presented with many hyperkeratotic lesions, and per Derm consultants this was consistent with "PPK". Skin biopsy was done and was consistent with Psoriasis. He was started on Clobetasol and Urea creams. He will follow-up with Derm in ___. This diagnosis its with his history of inflammatory arthritis, except for that you would not expect his hand x-rays to show ___ osteopenia with psoriatic arthritis. Extensive workup was done to ensure no other etiology of his PPK, and was negative: HIV/syphilis (negative), crusted scabies (not seen on biopsy), Reiter's syndrome (Gonorrhea/Chlamydia negative), arsenic poisoning (pending but unlikely), and HPV (not seen on biopsy). It can be drug induced but he has no offending meds on his list (digoxin, venlafaxine, verapamil, hydroxyurea, quinacrine, practolol, and chemotherapeutics). Paraneoplastic PPK also a possibility, but no evidence of cancer on CT scans, and PSA not elevated. # Arthritis: Presented with multiple painful, swollen joints. L wrist, bilateral elbows are the main joints involved. Rheum was consulted. L Hand XR showed pronounced periarticular osteopenia, no chondrocalcinosis. R Wrist XR for comparison did not show any periarticular osteopenia. Rheumatoid factor, ESR, and CRP were all markedly elevated. Anti-CCP and ___ were negative, SPEP and Cryo's negative, uric acid low. The lack of a symmetrical small-joint arthritis pointed against RA, despite the +RF. Joint fluid aspiration was attempted, little could be obtained, but what was obtained showed no organisms or cells on gram stain. Given the skin biopsy results showing psoriasis, this was felt to be most consistent with Psoriatic Arthritis. However, he will need outpatient synovial biopsy of left wrist to confirm the diagnosis. From there, we will follow up with Rheum to discuss treatment options. # EtOH abuse: Prior to admission had been drinking significantly. He was in withdrawal on arrival to floor. He was treated with PRN Diazepam via the CIWA protocol. This was discontinued several days into the hospital stay once he was no longer scoring. Significant drinking history and took very little PO nutrition prior to admission. Thus he was starting on vitamin supplementation, and Nutrition was consulted. # Anemia Retic B12 and Folate WNL. Ferritin WNL but may be falsely high in setting of acute inflammation. LDH/Bili suggest against hemolysis. Likely related to nutritional reasons in addition to anemia of chronic disease. Started on PO Iron. Hgb/Hct were completely stable during stay, and he never needed a blood transfusion. # Thrombocytosis: PLT count rose every day this admission, from 100's on admit to 501 on discharge. Consider unmasking of EtOH marrow suppression, vs secondary to underlying autoimmune inflammatory state. # Pulm nodules: He told the team of a history of multiple (9) pulmonary nodules, up to 5mm, which were monitored by a pulmonologist with serial CT scans, and most recent scans showed increase in size. He was then lost to follow up. CT chest here confirmed these nodules. - Will need outpatient follow up of these # Fall: Most likely this happened in setting of EtOH/intoxication and general failure to thrive. Also, he has significant skin lesions on his feet which would make walking very difficult. Thus, he has multiple reasons for a mechanical fall, and a cardiac cause of fall seems unlikely. Telemetry was unremarkable other than sinus tachycardia and was discontinued after several days. ___ preliminary report showed no depression of EF or valve disease. # Fever: He had a fever three times during this hospital stay. No clear source of infection. His impressive skin lesions did not appear to be infected or cellulitic, and biopsy confirmed this. Inflammatory markers ESR and CRP both elevated but likely due to autoimmune. UA/Urine culture negative, CXR without PNA, blood cultures no growth, HIV/RPR/GC/Chlamydia negative, CT C/A/P without infectious source, TTE without vegetation. Most likely a noninfectious fever, due to autoimmune disease, possibly worsened initially by withdrawal from EtOH. # Tobacco abuse - nicotine patch # Hep B non-immune: Based on labs done as part of arthritis workup. Hep B non-immune, got dose ___ of vaccine ___. - dose ___ or later - dose ___ or later # Pain control: Diffuse pain, likely multifactorial in setting of withdrawal, joint swelling, skin lesions. - Tylenol Q8 PRN - Ibuprofen Q8 PRN - Oxycodone PRN for breakthrough =================== TRANSITIONAL ISSUES =================== - The Hand Surgery team at ___ will contact his Rehab facility to discuss timing and scheduling of an outpatient wrist biopsy. From there, he will follow-up with ___ Rheumatology once the results of biopsy are known. - Found to be non-immune for Hepatitis B. Received vaccine ___ on ___. Needs dose ___ on ___ or later. Needs dose ___ on ___ or later. - Started nicotine patch for tobacco use - Needs continued encouragement and support for abstinence from alcohol - Started multivitamin, folate, and thiamine for nutritional support given history of alcohol use - Started daily Clobetasol (x2 weeks on, x2 weeks off), and daily Urea for Psoriasis. Has Derm follow-up in early ___ at ___ - Urine Arsenic level pending on discharge. It was sent as part of workup for his rash, but given biopsy showing psoriasis, now thought unlikely to be the etiology - On discharge, his Hgb was 7.9 and Hct 25.3. These were completely stable throughout stay and he required no blood transfusions. Could recheck as outpatient if clinically indicated. - Needs nonurgent screening colonoscopy - Needs nonurgent Outpatient CT chest to follow-up his pulm nodules. 6 month follow-up in ___ recommended - Sutures for his skin biopsies should be removed on ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year olf female with history of lap band ___ now with nausea, abdominal pain and fever for 24 hours prior to presentation. Patient was in usual state of health until four days prior to presentation when noted vague epigastric discomfort. This progressed in severity with pain characterized as dull with sharp intervals, moderate to severe in severity. No alleviating/aggravating factors. Accompanied by nausea and poor appetite. Day prior to presentation pt noted development of subjective fever and chills. Sought attention of PMD ___ and was found in office to have temperature to 102. Referral made to ___ ED and patient presents now for eval. CT scan obtained to evaluate for nephrolithiasis given hx recurrent nephrolithiasis and was found to have inflammation surrounding intra-abdominal portion of band appliance. Surgery consult obtained for question of lap band complication. Radiology showed No evidence of holdup or leak at the site of the prior lap band. Radiology showed Nonspecific bowel gas pattern without ileus or free air. Radiology showed 1. Status post removal of infected gastric band. A surgical drain is identified with tip location at the level of the gastrohepatic ligament. No drainable fluid collections are identified in the abdomen. 2. A moderate amount of ascites is identified in the pelvis. A subcentimeter tube-like structure is identified in the peritoneal space in the most dependent portion most likely representing a small foreign object. 3. There is mild dilation of the proximal small bowel without identifiable transition point most likely representing postoperative ileus. 4. Marked subcutaneous anasarca. 5. New bilateral pleural effusions with associated compressive atelectasis. DOSE REPORT: Total exam DLP is 814.83 mGy-cm. Radiology showed 1. PICC in low SVC. 2. Bibasilar atelectasis. 3. Gastric distention. The patient was diagnosed with INFECTION DUE TO GASTRIC BAND PROCEDURE, ABN REACT-SURG PROC NEC, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. The patient was treated with ___ laparoscopic removal of gastric band. At the time of discharge, the patient had Lap Band erosion with retained foreign body. The patient was given written instructions concerning 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 ___ at the suggestion of her PCP due to abdominal pain with associated fevers and hematuria. Upon arrival, intravenous fluids/ pain medication were administered and radiographic imaging was obtained. An abdominal CT scan suggested 'extensive inflammatory changes about gastric banding catheter tubing spanning approximately 10 to 11 cm with small amount of free fluid in the right hemipelvis' without fluid collection. Given the findings, intravenous metronidazole and ciprofloxacin were administered and the patient was taken to the operating room where she underwent laparoscopic exploration with lysis of adhesions, infected band removal, washout, and upper endoscopy. There were no adverse events in the operating room; please see operative note for details. The patient was extubated and taken to the PACU for recovery. Once deemed stable, she was admitted to the general surgical ward for further observation. Neuro: The patient was alert and oriented throughout her hospitalization; pain was initially managed with intravenous hydromorphone and tylenol and then transitioned to oral oxycodone and tylenol once tolerating clears. CV: The patient was persistently tachycardic to 110-120s on POD1, which responded to fluid boluses and aggressive IV fluid resuscitation. She remained stable from a cardiovascular stanpoint throughout the remainder of her hospitalization; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: She was initially kept NPO until an upper GI study was performed on post-operative day 1, which was negative for a leak. Therefore, her diet was advanced to a clears, however on POD2, the patient developed nausea with associated dry heaves and mild abdominal distention. Her nausea resolved by POD3 and she began passing flatus with + BM on POD4; she was subsequently able to tolerate diet advancement. She continued to report bloating and fullness which was relieved with Reglan. Of note, the patient had one left-sided JP drain placed intraoperatively. On POD4, drain output changed in character from serous/serosanguionous to dark brown, returning to serous over the next day. A JP amylase was 3263 and total bilirubin was 1.3. Patient was clinically improving but this prompted a CT abdomen on POD 5 which failed to demonstrate a a leak or abcess. However, it did continue to show pelvic fluid with a small foreign body in the dependent fluid with a tubular structure, thought to be a small piece of the trocar sheath, and the decision was made not to intervene. JP drain was discontinued POD 7 before discharge. Also, immediately post-operatively, urine output remained marginal requiring mulitple fluid boluses. A foley catheter, placed on POD2 for urine output monitoring, was discontinued on POD 4 due to adequate urine output after aggressive fluid resuscitation. Subsequently, the patient was able to void adequate amounts of urine throughout the remainder of her hospitalization. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. She was treated empirically with intravenous ciprofloxacin and metronidazole. This was changed to vancomycin once gram stain from intra-operative cultures showed gram + cocci in pairs/clusters. Cultures were consistent with strep anginosus; ID recommended starting ceftriaxone and resuming metronidazle for a total of 2 weeks. Patient received a PICC line on POD 5 in order to continue home abx therapy. WBC peaked at 15.6 on POD4, consistently normalizing throughout her hospitalization. Her abdominal drain was discontinued on POD 7 before discharge. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay; she was encouraged to get up and ambulate as early as possible. She also receieved a PPI thoughout her stay for GI prophylaxis. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with ___ services to assist her with her PICC line and IV antibiotics for a 2 week duration. 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: CT ABD AND PELVIS WITH CONTRAST showed 1. There is no evidence of suspicious masses or lesions within the abdomen/pelvis. 2. Mild dilatation of the common bile duct with smooth tapering to the ampulla with no evidence of discrete mass or obstructive lesion. If clinically warranted MRCP would better characterize this finding. The patient was diagnosed with Anemia, unspecified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx dysautonomia and chronic fatigue syndrome, depression/anxiety, possible Sjogren's syndrome vs undifferentiated autoimmune condition, chronic nausea, osteoarthritis s/p recent R TKA presenting with nausea and lightheadedness, admitted for acute on chronic anemia. # Normocytic anemia: # Iron deficiency: Hgb 11.2 in early ___, downtrended to 8.4 on ___ and nadired at 6.1 this presentation. Etiology unclear, but potentially concerning for slow UGIB given one guaiac positive stool this admission (in absence of gross melena/hematochezia) and mild iron deficiency (ferritin 48, Tsat 9%). Colonoscopy in ___ (and per patient a more recent colonoscopy) normal; EGD ___ showed non-erosive gastropathy. R knee without evidence of hematoma, and onset of anemia reportedly preceded her recent surgery. No e/o RP bleeding, hematuria, hemoptysis, or post-menopausal bleeding. No e/o hemolysis with nl bili, LDH, haptoglobin, and retic count. CRP WNL and ferritin 48, making anemia of inflammation unlikely as well. B12/folate WNL. Responded robustly to 2u pRBCs this admission, with Hgb 6.1 -> 9.4 on discharge. She likely warrants a repeat EGD +/- colonoscopy, which can be performed as an outpatient given absence of HD-significant bleeding and resolution of her symptoms. Previously arranged GI ___ at ___ is scheduled for ___. Would consider initiation of iron supplementation at PCP or GI ___. # Lightheadedness: # Palpitations: # Fatigue: # Dysautonomia: # Chronic fatigue syndrome: Presents with acute on chronic lightheadedness, palpitations, and fatigue in setting of suspected underlying dysautonomia and chronic fatigue syndrome. Suspect that these underlying conditions were exacerbated by concurrent anemia, as above, but low suspicion that anemia is directly/causally related. CTA chest and CTA head/neck in ED without e/o PE, CVA, or carotid stenosis. AM cortisol was negative. EKG NSR without e/o ischemia and cardiac enzymes negative. Telemetry without arrhythmias. TTE deferred in absence of murmur. Initial orthostasis resolved with fluids and transfusion, so no clear indication for pharmacologic intervention for dysautonomia at present (was previously on florinef and mestinon; midodrine had previously been considered but not initiated). Her home propranol was held in hospital and on discharge, to be resumed by PCP as deemed appropriate. She may benefit from ___ with Dr. ___ at ___ for further evaluation and management of chronic fatigue syndrome and dysautonomia. # Nausea: Unclear etiology despite extensive evaluation over years. In setting of possible slow UGIB, likely warrants repeat EGD, which can be pursued as an outpatient (GI ___ previously arranged for ___ at ___). At request of patient's PCP, CT ___ w/cont obtained, which preliminarily showed no suspicious masses/lesions and no e/o obstruction. Preliminary read comments on mild dilation of CBD, but normal LFTs argue against biliary obstruction. Could consider MRCP vs ERCP for further w/u as outpatient. Patient was tolerating a regular diet at discharge. # Osteoarthritis: # S/p R TKA: R TKA appeared to be healing well without e/o hematoma. Home oxycodone PRN continued. She will ___ with her orthopedic surgeon as previously scheduled. # Prior concern for Sjogen's: # Positive ___: Previously evaluated by rheumatology in setting of positive ___ with titer 1:320 (___), initially thought to have Sjogren's, which was then deemed less likely on subsequent evaluations. Had been on Cellcept, Plaquenil, and IVIG, not recently. No arthralgias, myalgias, or sicca symptoms to suggest active autoimmune condition, including Sjogren's. Absence of morning stiffness largely exonerates PMR, and no HA/claudication to suggest GCA (and CRP/ESR WNL). RF and CCP negative this admission. ___ positive with titer pending at discharge, but SLE thought less likely. Can consider further rheumatology evaluation as outpatient. # Depression: # Anxiety: Continued home clonazepam, brexpiprazole, paroxetine. # Possible EBV viremia: Reports that she was diagnosed with this by physician in ___ and started on valacyclovir. No clear marrow suppression reported from valacyclovir, which was resumed on discharge. # Emergency contact: ___ Relationship: Husband Phone: ___ ** ___ ** [ ] repeat CBC in ___ days to ensure stability; consider initiation of iron supplementation [ ] GI ___ for EGD +/- colonoscopy [ ] ___ final CT ___ read, pending at discharge; could consider ERCP vs MRCP for mild CBD dilation [ ] ___ titer, pending at discharge; could consider further rheumatology evaluation as outpatient [ ] home propranolol held on discharge; can be resumed by outpatient providers as deemed appropriate [ ] consider ___ with Dr. ___ at ___ for further management of dysautonomia/chronic fatigue syndrome</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ year old woman with history of hypertention, paroxysmal atrial fibrillation, history of esophageal spasms, who presents with unsteady gait, transient feelings of lightheadeness, transient shortness of breath and worsening tremors. Three days prior to admission she noted worsneing tremor, "feeling clumsy" and lightheaded along with transient episodes of shortness of breath. She measured her pulse which was normal but her blood pressure at home wa 220/110. Per patient she went to ___ ED where was was ruled out for MI and had had normal excerise stress test. She was feeling better after discharge from ___ ED but then on ___ night she woke up with night sweats and had shaking of her body and again feeling of lightheadedness. She called her PCP in the morning who asked her to go to ED. Other associated symptoms include feeling nauseous but no vomiting. She did not have any chest pain, headaches, focal weakness, numbness/tingling, dysarthria . Of note she was seen by gastroentergolost for evalaution of esophageal spasm who had switched patient from her metopolol to diltiazem. Patient attibutes her current symptoms to long acting diltiazem. . In the ED, patient's vitals were normal. She had CT head which did not show any acute intracranial process. She was seen by neurology who were not concerned about seizure or stroke and recommended low dose lorazepam for tremors and cervical dystonia. They recommended outpatient neurology appointment in movement disorder clinic. . Currenltly patient reports her symptoms have signifncatly improved. No shortness of breath, chest pain, lightheadedness, night sweats. Radiology showed No acute cardiopulmonary abnormality. Radiology showed No acute intracranial process. The patient was diagnosed with OTHER MALAISE AND FATIGUE, ABN INVOLUN MOVEMENT NEC. At the time of discharge, the patient had 1. Unsteady gait/lightheadedness. The patient was given written instructions concerning 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 history of hypertension, paroxysmal atrial fibrillation, history of esophageal spasms, who presented with unsteady gait, transient feelings of lightheadedness, transient shortness of breath and worsening tremors for past three days. . # Unsteady gait/lightheadedness: Patient reported feeling clumsy and lightheaded since being started on diltiazem few weeks ago albeit worse in the past ___ days prior to admission. She reportedly presented to ___ few days prior to this admission and was ruled out for MI and found to have normal stress test. During this admission she was not orthostatic; EKG was not concerning for any ischemic changes or any arrythmias. She was once again ruled out for MI with three sets of negative cardiac enzymes. She had CT head which did not show any signs concerning for stroke. Patient was also seen by neurology who felt her symptoms were unlikely to be caused by seizures, strokes or any other serious neurological problem. It is likely that her symptoms were caused from taking long acting diltiazem. Her 120mg long acting diltiazem was decreased to 30mg TID short acting diltiazem with some improvement in her symptoms. She was evaluated by physical therapy on the day of discharge, who recommended patient home physical therapy however patient refused to have any physical therapy services at home. She was encouraged to follow up with primary care physician, neurologist and cardiologist for further care. . # Worsening Tremors/shakiness: Benign essential tremor is the most likely etiology. Her symptoms were controlled with metoprolol in the past however three weeks ago she was switched from metoprolol to diltiazem which may have precipitated her tremors in patient who has history of anxiety and PTSD. She did not have other findings to suggest ___. As above patient was evaluated by neurology who did not have any concern for seizures and recommended outpatient follow up in the movement disorder clinic. She will follow up with PCP and neurologist who should consider restarting patient back on metoprolol for better control of tremors. . # Transient shortness of breath: Patient reported one episode of transient shortness of breath prior to presentation. As above she was ruled out for MI. She did not have any arrythmia on EKG. There was no sign of volume overload and CXR did not show any pulmonary process. Her transient shortness of breath was likely secondary to her anxiety. She did not have any further episodes of shortness of breath during this admission. . #Night sweats: Only happened once. She was monitored and did not have any localizing signs or symptoms of infection. Certainly anxiety may have contributed. . #Torticollis/Cervical dystonia: This is a long standing diagnosis for her; the etiology is unclear. She had previously considered botox injections but decided against that option. She will follow up in outpatient movement disorder clinic for further care. . # Paroxysmal afib: Patient was switched to lower dose of short acting diltiazem, as patient's lightheadedness may have been caused by long acting diltiazem. She was continued on aspirin. She remained in sinus rhythm during this admission. . #Esophageal spasm: She was recently started on diltiazem by her gastroenterologist with some control of her symptoms. During this hospital stay she was switched to short acting diltiazem as above. She was encouraged to follow up with her gastroenterologist for further care. . # CODE: Full code, confirmed # CONTACT: husband ___ ___, ___. .</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 notable for recent admission for secondary spontaneous pneumothorax with underlying stage IV COPD with significant bullous disease. She reports that last night (___) she sneezed and developed acute right sided chest pain and increasing oxygen requirement. She was last admitted from ___ to ___ for management of a right pneumothorax and was sent home on O2 with a pneumostat. On clinic follow up ___, the chest tube was removed and the post-pull film was negative for pneumothorax. Radiology showed Stable appearance of the right loculated pneumothorax. Mild new interstitial edema. CHEST (PA AND LAT) showed No evident pneumothorax. New opacities in the periphery of the right upper lobe could represent atelectasis or aspiration attention in followup is recommended The patient was diagnosed with SHORTNESS OF BREATH. The patient was treated with Right video assisted thoracoscopic surgery, pleurodesis. At the time of discharge, the patient had Recurrent 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>Briefly, Ms. ___ presented to the emergency department at ___ on the evening of ___ with a second pneumothorax (see admission note). In the ED, she was hemodynamically stable with O2 sats >92% on 3L nasal cannula. She had a CXR which showed a contained pneumothorax without tension. Given that she was comfortable, stable, and likely needed to go to the OR, she did not have a pigtail catheter placed at that time. However, overnight she became short of breath and was switched to a nonrebreather mask with pigtail catheter insertion as the pneumothorax was more prominent on CT. She remained stable throughout ___ and went to the OR the morning of ___ for a possible VATS blebectomy and mechanical pleurodesis. She received her morning dose of subcutaneous heparin, epidural placement, foley placement, and underwent sedation/intubation uneventfully. In the OR, findings were notable for numerous blebs, none of which were found to be the cause of her current pneumothorax. Therefore, a thorough mechanical pleurodesis was performed. She extubated uneventfully and was transferred to the PACU for continued recovery. Her chest tube remained to suction for 48 hours, was removed, and follow up chest xray showed no pneumothorax. Her post-operative course was notable for itching from her epidural, well controlled, but otherwise was uneventful. She was discharged in excellent condition with a mobile tank of O2 for travel, pain well controlled with PO pain medications, tolerating a full diet, and voiding well. She has a follow up appointment with Dr. ___ prior to her departure to ___. She was also given copies of her radiology images to take with her for follow up in ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female with DM and overlap AIH/PBC cirrhosis complicated by esophageal varices s/p banding several weeks ago and HE on lactulose/rifaximin without prior history of SBP recently presenting with fever and confusion. Multiple episodes of fecal/urinary incontinence in past few days per report of the family. Today found by daughter very altered. Has had hx of hepatic encephalopathy in the past. Has tried increasing lactulose dosing at home without improvement in her mental status. Pt complaining of R foot pain. A&O to name and place only. In the ED, initial vital signs were: 0 98.1 80 110/60 16 100% RA. Unable to provide history at the bedside given encephalopathy. Patient was not in acute distress in the ED. Non-tender abdomen on exam. She was noted to have a leukocytosis, elevated creatinine and hypokalemia. Patient was given IVF 1000ml NS, IV insulin for hyperglycemia, 40 meq K, Lactulose 30ml x2, and IV K. Upon arrival to the floor, patient's vitals were 98.6 140/73 77 18 97 on RA. The patient remained confused and was still A+Ox2 to name and place. The patient was unable to participate fully in interview, but did say she had no pain or complaints. She was able to walk with the nurse at the bedside. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Diffusely nodular liver consistent with a history of cirrhosis. 2. Sequelae of portal hypertension including splenomegaly and trace ascites. 3. The portal vein and its major branches are patent with appropriate directional flow. 4. Cholelithiasis. CT HEAD W/O CONTRAST Q111 CT HEAD showed No evidence of hemorrhage or acute territorial infarction. CHEST (PORTABLE AP) showed In comparison with the study of ___, there again are low lung volumes that accentuate the transverse diameter of the enlarged heart. No evidence of vascular congestion or pleural effusion. No acute focal pneumonia. CHEST (PORTABLE AP) showed In comparison to ___ chest radiograph, lung volumes are lower, accentuating the cardiac silhouette and resulting in crowding of bronchovascular structures, particularly in the lower lobes. Repeat radiograph with improved inspiratory level may be helpful to more fully exclude the possibility of a developing pneumonia in the lower lung, particularly on the left. The patient was diagnosed with Hepatic failure, unspecified without coma. At the time of discharge, the patient had Primary -Hepatic encephalopathy -Hypokalemia -Leukocytosis -Decompensated cirrhosis Secondary -Type 2 Diabetes -Chronic Kidney disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo female with DM and overlap AIH/PBC cirrhosis complicated by esophageal varices s/p banding several weeks ago and HE on lactulose/rifaximin without prior history of SBP recently presenting with fever, confusion, and leukocytosis. #ALTERED MENTAL STATUS: She had no further fevers at ___ and repeat WC was wnl. Infectious w/u including blood cultures, urine cultures negative. US w/ minimal ascites. She was hypokalemic which may have contributed to hepatic encepalopathy. Electrolytes corrected and lactulose increased and she improved such that she was more alert and was usually A&Ox3. However, she did at times wax and wane c/w hospital induced delirium. She may have some baseline cognitive deficits which will need further w/u with cognitive neurology. #GIB/VARICES: Last EGD (___) showed Grade 1 varices Repeat EGD done on ___: "3 cords of varices seen (1 cord of grade I and two cords of grade II/III) were seen in the lower third of the esophagus. The varices were not bleeding. 2 bands were successfully placed." Patient started on PPI and Carafate x 7 days. #PBC/AIH cirrhosis c/b varices, HE, ascites (minimal) and EGD ___ and then again on this admission (___) with varices s/p banding. -Continued lactulose/rifaximin and continued ursodiol. #T2DM: Continued home lantus. ISS. #CKD Stage III: Creatinine at baseline during hospitalization. Transitional Issues - Patient's delirium thought to be combination of HE, hospital induced delirium, and possibly an underlying cognitive dysfunction. She will need to follow up with cognitive neurology for evaluation (appt scheduled). - patient complained of bilateral foot pain c/w diabetic neuropathy. Consider increasing gabapentin as an outpatient - hepatology f/u as above - lactulose should be titrated to ___ BMs; discharged on QID dosing - labs should be drawn on ___ CBC INR LFTs Chem10 and faxed to ___ Hepatology ___ - new medications : omeprazole 40 mg qD, Carafate 1 mg QID x 7 days - Patient with varices banded on this admission. Will need repeat banding in ___ weeks.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male with a history of myxofibrosarcoma s/p cycle 3 AIM who is admitted with neutropenic fever. The patient states the fevers started overnight. He also has felt very fatigued. He denies any sore throat, cough, shortness of breath, nausea, abdominal pain, diarrhea, or dysuria. He is mildly constipated. Of note he was last admitted from ___ for cycle 3 AIM and gave himself pegfilgrastim at home after discharge. CHEST (PA AND LAT) showed No significant interval change when compared to the prior study. Persistent right basal pleural effusion and atelectasis. The patient was diagnosed with Neutropenia, unspecified, Fever presenting with conditions classified elsewhere. At the time of discharge, the patient had Neutropenic Fever Myxofibrosarcoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo male with a history of myxofibrosarcoma s/p cycle 3 AIM who was admitted with neutropenic fever.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with Crohn's disease, recently returning from vacation in ___, presenting with right lower extremity swelling, erythema, pain. Radiology showed No evidence of DVT in right lower extremity veins. Edema is noted within the right calf. The patient was diagnosed with CELLULITIS OF LEG. At the time of discharge, the patient had Primary: 1. Cellulitis . Secondary: 1. 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>___ M with Crohn's disease, recently returning from vacation in ___, presenting with right lower extremity swelling, erythema, pain. # Cellulitis: Due to the somewhat atypical appearance of the patient's cellulitis and his recent travel to ___, dermatology was consulted. Dermatology felt that the patient's exam was consistent with cellulitis, with possible superimposed contact dermatitis. The patient was treated with IV vancomycin, then transitioned to Bactrim and Keflex, which he tolerated well. The edema and redness were improving at the time of discharge. He will complete a total 10-day course of antibiotics on ___. Additionally, he was given a prescription for mupiricin ointment, to apply to the open area over his medial malleolus. He was advised to avoid adhesive bandages given the concern for contact dermatitis. The patient was advised to follow up with primary care and dermatology in ___ weeks. # RLE edema: Likely related to cellulitis. Lower extremity ultrasound negative for DVT. # Crohn's disease: Held Humira in setting of infection. The patient was instructed not to restart Humira until one week after the cellulitis had resolved. He was asked to discuss this with his gastroenterologist. # Tinea pedis: The patient was prescribed econazole cream # Psoriasis on scalp: The patient was instructed to use mupirin ointment and betamethasone lotion daily on the affected area, and to follow up with dermatology in ___ weeks. # Code status: FULL CODE, confirmed</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with hx of HTN on lisinopril, GERD, presents with hypertensive urgency associated with nausea, vomiting, diaphoresis, abdominal discomfort and headaches for 1 day. Radiology showed Diffuse slight prominence of the interstitial markings bilaterally suggests mild interstitial edema; underlying atypical infection is not entirely excluded in the appropriate clinical setting, but felt less likely. Slight blunting of the right costophrenic angle with overlying relative linear opacity most likely due to scarring/atelectasis. Radiology showed 1. No acute process identified in the abdomen or pelvis. No adrenal mass. 2. Old fractures of the left lateral seventh and eighth ribs, incidentally noted. Mild thoracolumbar spine degenerative changes. Other incidental findings, as above. CT HEAD W/O CONTRAST Q111 CT HEAD showed Paranasal sinus disease, as described. Otherwise normal study. US RENAL ARTERY DOPPLER showed Normal renal ultrasound. No evidence of renal artery stenosis. The patient was diagnosed with Essential (primary) hypertension, Dyspnea, unspecified, Nausea with vomiting, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS/ES: -Hypertensive Urgency SECONDARY DIAGNOSIS/ES: -Leukocytosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with hx of HTN on lisinopril, GERD, presents with nausea, vomiting, dyspnea, diaphoresis found to be HTN to 220s/120s requiring labetalol gtt. #Hypertensive urgency-considered pheochromocytoma vs paroxysmal hypertension (pseudopheochromocytoma) vs intoxication (cocaine, amphetamine). Has had negative 24 hr urine catecholamine study for pheochromocytoma workup but was asymptomatic at the time. Less likely panic disorder given anxiety appears to occur after nausea, vomiting. At discharge, he had several studies pending including aldosterone, renin, plasa metanephrines, renin, catecholamines, renal Doppler. He was continued on his lisinopril 5mg given that his blood pressure had normalized and he is thought to be very responsive to antihypertensives. ** It was advised that patient stay in-hospital for further diagnosis and treatment but patient opted to leave to attend a wake. He was able to state risks of leaving. #Leukocytosis-WBC elevated up to 17.2, though no symptoms on ROS (denies cough, dyspnea, diarrhea, dysuria). Blood and urine cultures were drawn and he was not initiated on antibiotic therapy. ___. Creatinine 1.2 on discharge. Left AMA as above. TRANSITIONAL ISSUES: - New Meds: None - Stopped/Held Meds: None - Changed Meds: None - Incidental Findings: None # CODE: Full # CONTACT: ___, MOTHER (___) [] Follow up rise in Creatinine with Chem 7 within 1 week of discharge [] Follow up aldosterone, renin, plasma metanephrines, catecholamines, renal Doppler, UDS</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ with h/o EtOH cirrhosis c/b recurrent variceal bleeding s/p TIPS (___), history of HCV, HTN, T2DM on insulin, COPD, seizure disorder, presents to the emergency department for alcohol use and melena. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. DUPLEX DOPP ABD/PEL showed Patent TIPS. Flow within the right anterior portal vein is toward the TIPS. Flow within the left portal vein is not well visualized, similar to prior. The patient was diagnosed with Restlessness and agitation. At the time of discharge, the patient had Alcoholic Cirrhosis Alcohol Use 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>Summary Statement for Admssion ___ with h/o EtOH cirrhosis c/b recurrent variceal bleeding s/p TIPS (___), history of HCV, HTN, T2DM on insulin, COPD, seizure disorder, presents to the emergency department for alcohol use and c/f melena with guaiac negative stool. Acute Medical Problems Addressed: ========================== # Alcohol-related cirrhosis: #Report of melena: MELD-Na 15 on admission. Historically complicated by EV & bleeding, s/p TIPs, and encephalopathy. Initial report of melena, though H/H stable and stools are guaiac negative, so low suspicion for clinically significant GI bleed. No reported episodes of melena since arrival. TIPS patent on US. No ascites or edema, no evidence of infection, and no encephalopathy currently, thus cirrhosis appears to be compensated. Abdominal exam benign with low c/f SBP. While inpatient we trended daily MELD labs, restarted his home medications of lactulose and rifaximin for encephalopathy prevention (though patient intermittently refused to take these). Restarted spironolactone, furosemide, and nadolol on ___ as Cr is very close to baseline. We restarted PO pantoprazole. # Alcohol Use Disorder, Alcohol withdrawal Last drink AM of ___. Unclear history of withdrawal seizures. We continued him on CIWA scale with several doses of lozarepam given per CIWA protocol. Patient would like to abstain going forward. Initially patient stated he was interested in an inpatient detox program however, he later decided that he would follow up with AA and go home. He was given supplemental MVI/thiamine/folate ___: Cr 1.2 on admission from 1.0 baseline Likely in the setting of poor PO intake with EtOH use. He is s/p 12.5 albumin in ED, and additional 12.5 g on ___ on floor. We restarted diuretics on ___ Chronic Issues: =========== #Thrombocytopenia: Chronic, related to liver disease and ongoing alcohol use. -Continue to monitor #Rash: Pruritic rash appears consistent with urticaria. Suspect recent allergic exposure. Improving since admission -Continue to monitor -Benadryl 25 mg q6, sxs resolving -Sarna lotion PRN #HTN: Previously on losartan - Will continue to hold in setting of slightly elevated Cr from baseline and stable BPs. - Continue amlodipine 10 mg PO daily #T2DM: Not taking any insulin at home; A1C 8.9%. Hyperglycemic on admission to 476, sugars now improving (133 last night, although up to 317 and 296 this morning) - Restart insulin at prior documented dose: 20 U NPH BID, with ISS - Monitor, may need up-titration of insulin regimen if sugars remain in high 200-300 range #Seizure disorder - Restarted prior dose of Keppra, 500 BID - Restarted gabapentin at lower dose (discharged in ___ on 800 mg PO TID), will restart at 200mg TID, can up-titrate as needed - Will need OP neurology f/u # Depression - Restarted fluoxetine at prior dose (20mg daily) #Medication reconciliation: Previously was also on acamprosate, sucralfate, and trazodone in addition to above. - Will not restart these medications to decrease pill burden, but continue to monitor symptoms Transitional Issues: [ ]EtOH use: Please continue to reinforce importance of sobriety [ ]Cirrhosis: Please encourage patient to follow up with hepatology [ ]Need for op neurology follow up. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is a ___ woman with a history of stage IB Grade 2 endometriod endometrial adenocarcinoma s/p TAH-BSO ___, HTN, history of DVT/PE in ___ who was transferred from ___ with syncope. Prior to today, she has had nausea and some loose stools for 4 days. She has been fatigued, and not eating well. Today, she was sitting on her couch when her doorbell rang. She got up to answer the bell, and suddenly passed out. She fell onto her right side. She had no preceding dizziness, nausea, or lightheadedness. She woke up immediately after, and her friend sat her down on the couch. No incontinence and no confusion after. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Bilateral symmetric hyperdensities likely along the cerebellar sulci is concerning for subarachnoid hemorrhage. Other considerations in the differential can include cerebellar calcifications. No new foci of hemorrhage. ATTENDIMG NOTE: Hyperdensities are bilaterally symmetric and essentially unchanged since the CT of ___ 20: 23.. This may be secondary to calcifications in the cerebellar nuclei. This can be further confirmed with comparison with any prior order studies or getting at 12:00 follow-up. NOTIFICATION: The revised findings of calcification and recommendations were discussed with ___, , NP by ___, M.D. on the telephone on ___ at 9:53 am, 5 minutes after discovery of the findings. The patient was diagnosed with Syncope and collapse, Hyperkalemia, Unspecified injury of head, initial encounter, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had Primary: Syncope, Orthostatic Hypotension, Subarachnoid Hemorrhage, Hypokalemia, Viral gastroenteritis Secondary: Stage IB Grade 2 endometriod endometrial adenocarcinoma, HTN, Asthma, Anxiety, Glaucoma, 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>Ms ___ is a ___ woman with a history of stage IB Grade 2 endometriod endometrial adenocarcinoma s/p TAH-BSO ___, HTN, history of DVT/PE in ___ who was transferred from ___ with syncope, and was found to have SAH on head CT. ACUTE MEDICAL/SURGICAL ISSUES ADDRESSED #Syncope #Orthostatic Hypotension Patient presented after fainting. Likely etiology is orthostatic hypotension in the setting of hypovolemia from GI illness. Physical exam positive for orthostatic hypotension. Her EKG was normal sinus rhythm on presentation. Patient was monitored with telemetry with no evidence of arrhythmia. Echo demonstrated normal function and structure with the exception of a mildly dilated ascending aorta. Pulmonary embolism was considered given patients history, but she denied any shortness of breath or chest pain. Head CT ___ with evidence suggestive of subarachnoid hemorrhage. Likely the SAH occurred traumatically after she struck her head when fainting and was not the cause of the syncope. She was hydrated with IVF and discharged home with services. # Subarachnoid hemorrhage: Patient presented with a fall & head strike. CT ___ notable for hyperdensities concerning for subarachnoid hemorrhage or cerebellar calcifications. Neurosurgery consulted and did not believe she required a surgical intervention. She had q4h neuro checks and a goal SBP <160. Her neuro exam was stable over the course of this admission. # Hypokalemia: Patient presented to OSH with K of 2. This likely resulted from potassium losses in her diarrhea in combination with HCTZ use. Her electrolytes were monitored and repleated as needed. # Nausea / Vomiting / Diarrhea: Patient presented after four days of nausea, vomiting and diarrhea. Likely due to a viral gastroenteritis. This issue resolved on day of admission. CHRONIC ISSUES PERTINENT TO ADMISSION # Stage IB Grade 2 endometriod endometrial adenocarcinoma - s/p TAH-BSO ___ refusing adjuctive vaginal brachytherapy. No further treatment at this time. # Hypertension: Discontinued home HCTZ. Continued Aspirin 81 mg PO DAILY # Asthma: Continued Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID and Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze # Anxiety: Continued LORazepam 0.5 mg PO BID:PRN anxiety # Glaucoma: Held home Betimol (timolol) 0.5 % ophthalmic (eye) DAILY as not on formulary. Continued Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS # Hypothyroidism: Continued home Levothyroxine Sodium 75 mcg PO 6X/WEEK (___) and 150mg on ___ Transitional Issues [ ] Patient should no longer take her HCTZ [ ] check her orthostatics on the next office visit. [ ] check a chem 10 on the follow up visit day. [ ] f/u neurological exam for any neurological deficit. [ ] On her echocardiography, there was evidence for mild ascending aorta dilation. New Medications: None Discontinued Medications: HCTZ >30 minutes spent on discharge planning </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ female with history of NSCLC (adenocarcinoma, EGFR exon 19 deletion) s/p adjuvant chemotherapy followed by ___ ___ Afatinib who developed recurrence with transformation to small cell lung cancer s/p multiple courses of chemotherapy currently on docetaxel who presents with episodic confusion at home and gait unsteadiness for two months as well as nausea/vomiting in the setting of recent chemotherapy found to have brain MRI multiple brain metastases. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed Irregular peripherally enhancing lesions as detailed above, with associated intralesional hemorrhage and vasogenic edema. No ventriculomegaly or herniation. These lesions are most consistent with hemorrhagic metastasis given the clinical history. NOTIFICATION: These findings were already known at the time of this dictation as documented in the electronic medical record. CHEST (PA AND LAT) showed No definite evidence for pneumonia. Extensive intrathoracic metastatic disease appears progressed from the previous chest radiograph, and better delineated on the prior CT of the chest. Radiology showed 1. New left adrenal mass measuring 3.1 cm concerning for metastasis. 2. Please see report from same day CT chest for description of the intrathoracic findings including the trace left pleural effusion and numerous new pulmonary nodules/masses. Non-small cell lung cancer with metastatic disease showed Progression of disease with substantial increase in size of the left thoracic inlet, mediastinal and hilar masses, as well as a mild increase in size of several of the pre-existing multiple pulmonary nodules. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed 1. Interval increase in the size of the left level IV mass encasing the left common carotid artery without occlusion, and similar degree of attenuation of the left internal jugular vein. 2. 7 x 3 mm lytic focus at the posterior aspect of the C7 vertebral body appears somewhat more evident than on the prior CT examination, and is concerning for osseous metastatic disease. If further characterization is warranted, a gadolinium-enhanced dedicated cervical spine MR can be obtained. 3. No significant interval change in the large mediastinal lymph node conglomerate, as well as a right level IV lymph node with nonenhancing center and right tracheoesophageal groove lymph node. 4. Unchanged asymmetric enlargement of the left laryngeal ventricle, possibly reflecting vocal cord paralysis. 5. Additional findings in the chest and brain are completely described on the concurrent chest CT and brain MRI of ___. RECOMMENDATION(S): Gadolinium-enhanced cervical spine MR if further characterization of the possible C7 vertebral body lesion is warranted. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Multiple irregular lesions consistent with metastases appear unchanged since prior MR. ___ evidence of hydrocephalus or hemorrhage, however evaluation for hemorrhage is limited by recent contrast administration. The patient was diagnosed with Secondary malignant neoplasm of brain. The patient was treated with ___- Whole brain radiation 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>Mrs. ___ is a ___ female with history of NSCLC (adenocarcinoma, EGFR exon 19 deletion) s/p adjuvant chemotherapy followed by ___ ___ Afatinib who developed recurrence with transformation to small cell lung cancer s/p multiple courses of chemotherapy currently on docetaxel who presented with episodic confusion at home and gait unsteadiness for two months as well as nausea/vomiting in the setting of recent chemotherapy found to have brain MRI with multiple brain metastases. Neurosurgery did not recommend surgical resection. Pt was started on keppra and dexamethasone. Radiation oncology was consulted and started WBRT with plans for 10 fractions. ___ evaluated patient and recommended short term rehab. Pt was discharged from the hospital in stable condition Active Issues =========== # Gait Unsteadiness: # Confusion: # Metastatic Brain Lesions: Pt had been having increasing symptoms of confusion and unsteadiness at home, so an MRI was done by her outpatient providers on ___, which showed multiple brain lesions both supratentorial and infratentorial, which were the most likely cause of her symptoms. She was transferred to the ER for further work-up and evaluation. Pt was seen by neurology, who started the patient on Dexamethasone 4mg q6h and Keppra 500mg q12. Pt continued to experience somnolence throughout the day and was difficult to arouse, so an EEG was done to evaluate for seizures in the setting of suspected post-ictal confusion. EEG did not demonstrate seizures, so urgent WBRT was started and she was give an extra dose of steroids and ritalin. The patient's mental status improved greatly and she was more alert. Radiation oncology then performed more formal mapping and pt received her second dose of WBRT on ___ with the plan for a total of 10 fractions. She continued to improve and only notable symptom that persisted on physical exam was horizontal nystagmus and a fine tremor. The patient did continue to have a flat affect, but remained AAOx3. # Small Cell Lung Cancer: Patient progressed on multiple prior rounds of chemotherapy, and was receiving docetaxel prior to admission, but had imaging consistent with multiple brain mets as above. The pt's outpatient oncologist Dr. ___ Dr. ___ ___ contacted, who recommended a CT head/neck and torso to assess for further disease progress to be used in treatment planning. Her disease had been found to progress. Dr. ___ ___ these finding and explained her poor prognosis and lack of effective treatment available at this point. She will continue her palliative radiation treatments, but not pursue any additional chemotherapy treatments. She was discharged with ___ Care. # Tachycardia: Unclear cause. Per patient, she has intermittent episodes of tachycardia which she was evaluated for as an outpatient without known cause. She is not symptomatic and denies chest pain and shortness of breath. ECG showed sinus tachycardia. The suspicion for PE remained low throughout the hospitalization, as the patient remained free from symptoms and did not require oxygen. It did improve to the high ___ to 100s after IVF hydration. # History of Knee Infection Patient was continued on home dose of doxycycline for suppression of infection. MEDICATION CHANGES: ====================================== STOPPED Medications/Orders Physician ___ ___ 10 mg PO DAILY NEW Medications/Orders Physician ___ ___ 650 mg PO Q6H:PRN Pain - Mild LevETIRAcetam 500 mg PO Q12H MethylPHENIDATE (Ritalin) 5 mg PO BID Sulfameth/Trimethoprim SS 1 TAB PO DAILY CHANGED Medications/Orders Physician ___ ___ 4 mg PO Q8H TraZODone 25 mg PO QHS:PRN insomnia TRANSITIONAL ISSUES: ====================================== - Pt is getting whole brain radiation and has gotten 5 out of 10 fractions while in house. Will complete 5 more fractions ___ as scheduled above - Patient was discharged with home ___ & ___ services and ___ ___ - MOLST was completed on admission. Patient is DNR/DNI, do not hospitalize unless for comfort CODE: DNR/DNI, do not hospitalize unless for comfort EMERGENCY CONTACT HCP: ___ (husband/HCP) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with past medical history notable for asthma who presents with c/o left leg swelling with concern for cellulitis. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. Left tibia and fibula radiographs, two views. showed No radiodense foreign body found or acute bony abnormality. The patient was diagnosed with Cellulitis of left lower limb. At the time of discharge, the patient had Cellulitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ female with past medical history notable for asthma who presents with left leg swelling with concern for cellulitis. # Left lower extremity erythema/swelling/likely cellulitis: # Leukocytosis: # Nasolabial folds erysipelas?: Patient's symptoms consistent with bacterial cellulitis of left leg. However worsened in the ED despite initial treatment with ceftriaxone (x24h) and as such broadened to vancomycin and ceftriaxone (for another 24h), with minimal improvement. LLE ultrasound ruled out DVT. No evidence of joint involvement to suspect septic arthritis. Of note nasolabial region also with new erythema concerning for erysipelas. This really seems to be clinically consistent with cellulitis based on appearance rather than inflammatory condition. ID consulted, recommended continuing treatment to cover both staph and strep. IV access lost on ___ therefore antibiotics switched to PO clindamycin, with plan to complete total 14 day course of antibiotics ending on ___.</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 ___ CAD (3vd with LAD/RCA occlusions but no option for PCI), ischemic cardiomyopathy with LV EF 30% s/p AICD for primary prevention, CVA (___), HTN, HLD, CKD (bl Cr 1.3-1/6), now admitted with vomiting and diarrhea. History was obtained from patient via telephone interpreter, and from ED/OMR notes. Patient was in his USOH all day on ___, until he developed a sudden episode of vomiting and diarrhea (at the same time) in the late afternoon. Neither the emesis nor the stool was bloody. Along with vomiting and diarrhea, he also felt lightheaded and diaphoretic. He denies any accompanying fevers, chills, abd pain, chest pain or SOB. He has not had any recent travel, known sick contacts or changes in his diet; however, he dose have eat some lunches that are prepared by other people (his wife eats these two and has been fine). After the episode, his wife checked his blood pressure, measured to be 80/44. He was then taken to the ___ ED via ambulance. In the ED, initial vitals were: 97.7 66 82/52 18 98%. His BP improved to 110s systolic with 2L IVF. Physical exam was notable for pale appearance, abd not tender to palpation, guiaic negative. Labs are unremarkable, with Cr 1.4 at baseline. CXR was negative. Bedside U/S was negative for free fluid. He was guaiac negative on exam. Blood cultures and C. diff PCR were sent. He was admitted for dehydration. VS on transfer: 97.9 79 110/69 14 100% on RA. On arrival to the floor, he was feeling okay, with no new complaints. Radiology showed No acute cardiopulmonary process. Low lung volumes. The patient was diagnosed with SYNCOPE AND COLLAPSE, HYPOTENSION NOS, NAUSEA WITH VOMITING, DIARRHEA, HYPERTENSION NOS. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year-old man w/CAD, ischemic cardiomyopathy with LV EF 30% s/p AICD for primary prevention, CVA (___), HTN, HLD, CKD (bl Cr 1.3-1/6), admitted with vomiting and diarrhea, found to have gastroenteritis. ACTIVE ISSUES # Gastroenteritis: Most likely viral process given the symptoms, and now resolved. His volume losses likely led to hypovolemia, leading to hypotension. Hypotension resolved after 2L IVF with NS. Stool culture and C. diff were sent which were negative. Symptoms resolved quickly by the following morning. # Hypotension: Likely related to volume loss in setting of N/V/D. Resolved with 2L IVF. Orthstatics negative on AM of discharge; patient ambulated without symptoms. Initially anti-hypertensives had been held. Home metoprolol was restarted, but lisinopril and HCTZ were held pending BP check as outpatient with PCP. CHRONIC ISSUES # CAD: Extensive history, with known RCA and LCA occlusions that were not amenable to intervention. No chest pain or EKG changes at this admission. Continued aspirin, plavix, statin. Restarted metoprolol after holding for a day, and held lisinopril as above d/t the hypotension, to be restarted by PCP when outpatient blood pressure check performed. # sCHF: Ischemic cardiomyopathy with LV EF 30% s/p AICD for primary prevention. No acute exacerbation at this admission. Continued ASA, statin, metoprolol. Held lisinopril d/t hypotension above, to be restarted as outpatient as long as blood pressure tolerates. # HLD: Continued statin. # BPH: Finasteride, tamsulosin continued. TRANSITIONAL ISSUES -ACEi and HCTZ will need to be restarted once blood pressure is confirmed to be stable at outpatient visit with PCP</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female who presents with a right ankle fracture after a mechanical fall down 3 stairs. Patient noticed immediate pain and deformity in the right leg. No head strike or loss of consciousness. Denies injury elsewhere. No numbness or tingling. ANKLE (AP, MORTISE AND LAT) RIGHT showed Intraoperative images were obtained during ankle ORIF. Please refer to the operative note for details of the procedure. The patient was diagnosed with Displaced trimalleolar fracture of right lower leg, init, Fall (on) (from) unspecified stairs and steps, init encntr. The patient was treated with Right ankle ORIF. At the time of discharge, the patient had Right ankle fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right ankle fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for Right Ankle 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. 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 with home ___ was appropriate. Of note, she had a hypotensive episode on POD2 while working with ___ which responded to fluid resuscitation. At the time of discharge the patient's pain was well controlled with oral medications, her splint was clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up 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: Patient is a ___ year old female with Crohn's, COPD, ___, Sarcoid, p/w cecal volvulus. She was taken to the OR on ___ for ex-lap and distal ileal resection and R colectomy with primary anastomosis. Some segments of small bowel was noted to be not perisatlasing, but was pink. She was thus left open in order to take a second look to make sure there is no developing ischemic small bowel. CHEST (PORTABLE AP) showed ET tube is in standard position. NG tube tip is in the stomach, could be advanced a few cm for more a standard position the side port is at the EG junction. Aside from minimal atelectasis in the left lower lobe, the lungs are clear. There is no pneumothorax or pleural effusion. Cardiomegaly is stable. Calcified mediastinal and hilar nodes are better seen in prior CT. Dilated bowel loops are also better seen in prior abdomen CT. Radiology showed No foreign bodies identified within the abdomen or pelvis. NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___ ___ telephone at 09:26 on ___, 3 minutes after discovery. Radiology showed New mild-to-moderate pulmonary edema and small right and likely small left pleural effusion. Followup of pulmonary edema. AP radiograph of the chest was reviewed in comparison to ___. Dobbhoff tube passes below the diaphragm terminating in the stomach. Heart size and mediastinum are unchanged. There is slight interval progression of pulmonary edema, moderate. Bilateral pleural effusions are redemonstrated, moderate. was done. Radiology showed No significant change in small-to-moderate bilateral pleural effusions. Previously seen pulmonary edema has decreased. The patient was diagnosed with VOLVULUS OF INTESTINE. The patient was treated with ___ Exploratory laparotomy, ileo cecectomy and right colectomy ___ Exploratory laparotomy with washout and closure. At the time of discharge, the patient had cecal volvulus. The patient was given written instructions concerning 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 very pleasant ___ year old female who presented with a cecal volvulus on ___. The patient was admitted to the Acute Care Surgical Service for evaluation and treatment. On ___ the patient underwent an Exploratory laparotomy, right colectomy with primary anastomosis, and temporary abdominal closure, which went well without complication (reader referred to the Operative Note for details). Intraoperatively she was discovered to have a region of bowel which peristalsed more slowly than the others, and so was left open for a second look. The patient arrived in the PACU intubated, and sedated floor NPO, on IV fluids and antibiotics. The patient was hypotensive. Ms ___ was tachycardic perioperatively, she takes calcium channel blockers at baseline and was trialled on a diltiazem drip, but became hypotensive with diltiazem drip. This was stopped. She got PRN albumin and IV fluids. In the afternoon of POD 1 she was taken again to the OR for a second look. All bowel was found to be satisfactorily perfused and the patient was closed. Please refer to the operative note regarding this surgery as well. The patient did well post operatively exceptfor a new weak voice and clinical aspiration. She had an ENT consult on ___. On that day she demonstrated hypomobility of her left cord with discoordinated adduction and glottic gap. It was recommended that she remain on a strict NPO diet and to be consulted by speech and swallow. Increase of her PPI to 40mg BID and discontinuation of nasal cannula and start humidification via shovel mask given the excoriation along her nasal septum and dry mucosa. On ___ she was seen by speech and swallow. Per their recommendation, she was advanced to a PO regular solids, nectar-thick liquids diet, PO meds: whole in puree (cut if large). Oral care three times a day was initiated. She was placed on standard aspiration precautions and she was followed by speech and swallow for the rest of her hospitalization for her dysphagia. On ___ she tolerated the regular solids, nectar-thick liquids diet and was ready to be discharged to a rehabilitation facility. She is to follow up with ACS and ENT in ___ weeks. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ gentleman with a history of developmental delay, chronic Hep B (on tenofovir), and Hep C exposure who presents with coffee ground emesis. History obtained from patient and a caretaker from his group home. Patient was in his USH until this afternoon. He was drinking tea at his group home and had an episode of emesis that looked like "dirt" to the staff. Patient reported he vomited 'twice' and had mild abdominal pain. In the ED initial vitals were: 99.8 74 155/74 18 99%. Patient had guaiac negative stool. NG lavage returned dark tea-colored liquid and coffee grounds (guaiac positive). Labs were significant for negative UA, leukobytosis to 12.2 (neutrophilic predominant), Cr 1.5, lactate WNL at 2.0. KUB showed no evidence of obstruction. Patient was given pantoprazole, Zofran. GI was consulted who recommended IV PPI, good access, and trending HCT. Likely EGD in AM. Vitals prior to transfer were: 2 100.7 77 137/80 16 RA. Of note, patient had an unremarkable colonoscopy in ___ at ___ and by report a normal EGD in ___ done at OSH due to heme positive stool. On the floor, patient's aid reports he has had several days of cough. Patient reports dysuria and pain in his belly (unknown timeline). He has a fever but denies chills, CP, current n/v/d, or shortness of breath. Radiology showed Nasogastric tube terminating in the stomach. No convincing evidence for small bowel obstruction. No free air identified. Evaluation of the patient after gastrointestinal bleeding with fever, leukocytosis and cough. AP radiograph of the chest was reviewed with no prior studies available for comparison. Heart size is normal. Mediastinum is slightly widened with minimal deviation of the trachea to the right, findings that potentially may be explained by distention of the aorta or other mediastinal vessels, but assessment with chest CT to exclude the possibility of lymphadenopathy in this area is required. Lungs are essentially clear with no evidence of pneumonia. There is no pleural effusion or pneumothorax. was done. Radiology showed 1. Possible accessory pancreatic tissue along the medial wall of the second portion of the duodenum with mild narrowing of the duodenum at this level. No definite neoplasm, expansile lesion, or clearly circumferential pancreatic tissue noted. Short-term imaging followup should be considered if duodenal biopsy is negative. It is possible that MRCP may be contributory regarding any possible accessory pancreatic tissue or very subtle mass lesion although a neoplasm is doubted. 2. Fluid-filled distal esophagus may be related to reflux or dysmotility or may be secondary to mild obstruction to gastric outflow. The patient was diagnosed with GASTROINTEST HEMORR NOS, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, UNSPECIFIED INTELLECTUAL DISABILITIES. The patient was treated with ___: EGD with biopsies. At the time of discharge, the patient had Primary diagnoses: # Severe esophagitis c/b UGIB # Duodenal stricture # Fever/Cough/Leukocytosis Chronic diagnoses: # Chronic Hepatitis B # CKD # History of HCV # HTN # Gout # Pernicious anemia # Peridontal disease # OA. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ gentleman with a history of developmental delay and chronic Hep B who presented with coffee ground emesis concerning for UGIB. # Severe esophagitis c/b UGIB: patient underwent an EGD on ___ after presenting with coffee-ground emesis and was found to have severe esophagitis, which is likely the source of his bleeding. He was placed on carafate slurry for protection as well as pantoprazole 40 mg BID. His H&H was trended daily and remained stable. #Duodenal stricture: based on results of EGD, concerning for possible malignant process. On CT abd/pelvis, possible excess pancreatic tissue compressing the duodenum. The patient was able to eat well with no signs of obstruction. GI will arrange for a follow-up appointment for consideration of an endoscopic ultrasound (EUS). # Fever/Cough/Leukocytosis: Negative UA makes urinary sources less likely. Suspect viral URI is responsible for cough. Also possible fever/leukocytosis secondary to bleeding. CXR unremarkable for acute infectious process. Patient placed on respiratory precautions and a nasopharyngeal swab ordered. The swab was unable to be interpreted, however. He was given guaifenasin and tylenol for pain and cough. Ucx negative, blood cx pending at discharge. Symptomatically, he felt improved at discharge. # Chronic Hepatitis B: Has Tenofovir listed as allergy (for renal failure side effect) but continues to take it under Dr. ___. Was continued on tenofovir and has hepatology f/u already scheduled. # CKD: Baseline appears to be 1.3-1.4. Cr 1.5 on admission. Trended daily, no increase with IV contrast. # History of HCV: Cleared; negative VL in ___ # HTN: restarted atenolol # Gout: restarted allopurinol # Pernicious anemia - Continued B12 # Peridontal disease - Continued Rx toothpaste # OA - Tylenol PRN # Emergency Contact: Group Home, ___, ___ # Disposition: Medicine for now </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of afib on warfarin, mild/moderate dementia with impaired short term memory, brought to ED by family for generalized weakness. Patient states that she has had difficulty walking for several days ___ generalized weakness without associated nausea, vomiting, SOB, chest pain, or cough. Daughter reportedly told the ED that pt was confused, and unsafe alone at home in this state. Pt denies dysuria, endorses chronic ___ edema that is unchanged. CHEST (AP AND LAT) showed No acute findings. CT HEAD W/O CONTRAST showed No acute intracranial process. Radiology showed New mild pulmonary edema and small pleural effusions The patient was diagnosed with OTHER MALAISE AND FATIGUE, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT. At the time of discharge, the patient had Viral upper respiratory infection Atrial fibrillation with rapid ventricular response 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>___ with hx of afib on warfarin, mild/moderate dementia with impaired short term memory, brought to ED by family for generalized weakness, most likely decompensated diastolic heart failure in the setting of viral URI. # Decompensated heart failure with a preserved EF: Patient was noted to have new oxygen requirement on admission. She also had lower extremity edema, bibasilar crackles, and pulmonary edema on chest x-ray. This was likely due decompensated diastolic heart failure in the setting of a viral URI, as well as due to IV fluid. Likely also exacerbated by atrial fibrillation with RVR. A TTE was performed that showed an EF of ~50%, but was limited by afib with RVR. She received IV furosemide for several days, with excellent urine output, decrease in weight from 61kg to 54.5kg, and resolution of hypoxia. After resolution of other issues that may have been contributing to tachycardia, her metoprolol was increased to improve heart rate control, and her furosemide was initiated back at her home dose. # Viral upper respiratory infection: Patient's initial weakness and hypoxia was likely partially due to viral upper respiratory infection. Patient had mild sore throat and laryngitis, suggestive of viral infection. This was improving, but not entirely resolved, at the time of discharge. # Generalized weakness: Most likely due to mild viral syndrome given diffuse weakness, myalgias, laryngitis. Pt denies localizing symptoms to suggest infectious etiology. CXR is without infiltrate, UA argues against UTI. Abdominal exam is benign. She denies headache. With respect to toxic metabolic etiologies, labs were unrevealing, with TSH 1.1, without leukocytosis or significant uremia. Na is WNL. She was not anemic. No focal neurologic deficits to suggest acute cerebrovascular event. No ischemic changes on EKG. # Atrial fibrillation: CHADS2 is 4 (hypertension, age, prior CVA). ___ hospital course significant for poorly controlled heart rate requiring metoprolol titration. She remained asymptomatic throughout. Metoprolol titrated up to total dose of 150mg daily. Continue to titrate as necessary to achieve adequate heart rate control. Consider adding additional agents if not adequately controlled. Continued warfarin, but had to lower dose due to supratherapeutic INR. Would monitor daily initially given labile INR. # ___: Baseline creatinine in ___ system appears to be 1.0-1.1, although she has had occasional values of 1.2-1.5. Improved to 1.0 by the time of discharge. # Dementia: Prior notes reference Aricept and Namenda, but patient is no longer taking these medications due to side effects. # Parkinsonism: Pt has known gait disturbance and Parkinsonism per prior ___ neurology notes. Per notes, prior adverse reaction to Sinemet and this may not have helped her symptoms. Per PCP, etiology is vascular Parkinsonism. # Hypothyroidism: TSH 1.1. - Continued levothyroxine 88mcg qd</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old man with a history of type 2 diabetes and ESRD (on dialysis since ___ who was referred to the ___ ___ from his outpatient vascular surgery clinic with a non-healing wound on the ___ digit of the right toe. FOOT AP,LAT AND OBL RIGHT showed Status post amputation of the third digit at the level of the metatarsophalangeal joint. Postoperative changes are noted as described above. The patient was diagnosed with Type 2 diabetes mellitus with foot ulcer, Non-prs chronic ulcer oth prt right foot with oth severity. The patient was treated with ___: Amputation of right third toe. At the time of discharge, the patient had Right third toe. The patient was given written instructions concerning 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 ___. Patient was found to have osteomyelitis of the right third toe. He was given broad spectrum antibiotics (vanc/cefepime/flagyl). He was taken to the operating room with podiatry and had a right third toe amputation. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___, previously admitted (___) for perforated appendicitis, now presents to the ED with new onset dyspnea on exertion and chest pain. Patient was discharged on ___ on a course of cipro/flagyl for his perforated appendicitis with plans for interval appendectomy. He had been doing well since then but began experiencing dyspnea when he was outside yesterday. This is associated with right chest pain with deep inspiration. No fever, chills, nausea, vomiting, abdominal pain, or GU symptoms. Per patient, he feels well other than sharp, nonradiating pain in his chest with inspiration. He had been compliant with the antibiotics course, and was on schedule for taking them in the ED as well. CHEST (PA AND LAT) showed Patchy bibasilar opacities, potentially atelectasis, with trace bilateral pleural effusions. Infection however is not excluded in the correct clinical setting. CTA chest pain and CT abdomen and pelvis showed 1. Re- demonstration of perforated appendicitis with multiple abscesses within the lower abdomen and pelvis including a 6.9 x 6.3 x 6.8-cm abscess within the right lower quadrant surrounding the ruptured appendix and appendicoliths, an 8.1 x 5.4 x 7.4 cm pelvic abscess, and a 2.2 cm abscess adjacent to the right lower quadrant abscess. 2. No pulmonary embolism or acute aortic pathology. 3. 7 mm left apex lung opacity with possible cavitation could be focal bronchiectasis with secretions or nodule, less likely septic embolus ; short interval follow-up in 3 months with chest CT. 4. Bilateral small nonhemorrhagic pleural effusions with moderate lower lobe atelectasis and mild lingula atelectasis. 5. Mild cardiomegaly and small nonhemorrhagic pericardial effusion. 6. Mild centrilobular emphysema. 7. Possible mild pulmonary arterial hypertension. RECOMMENDATION(S): Chest CT in 3 months to follow-up left apex opacity/nodule. CT-guided procedure showed Successful aspiration and drain placement into a right lower quadrant abscess. Successful aspiration and drain placement in a deep pelvic abscess. Successful aspiration only of a left paramedian abscess to completion. The patient was diagnosed with Peritoneal abscess. The patient was treated with ___: -CT guided aspiration of the deep pelvic abscess with an 8 ___ drain left in place. -CT guided aspiration of the right lower quadrant abscess with an 8 ___ drain left in place. - CT guided aspiration of the left paramedian smaller abscess. At the time of discharge, the patient had Intra abdominal fluid collection due to perforated appendicitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo M with history of perforated appendicitis managed nonoperatively with antibiotics who presented on ___ to the emergency department with new onset dyspnea on exertion and chest pain. CT imaging revealed multiple right lower quadrant abscesses, WBC was elevated at 14.5. The patient was admitted for bowel rest, IV antibiotics, and ___ consult. The patient was hemodynamically stable. On ___ the patient was taken to Interventional Radiology for drainage of the pelvic abscesses. Two drains were left in place. the patient tolerated the procedure well. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. Antibiotics were transitioned to oral. The patient voided without problem, and had a bowel movement. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home with ___ services for drain care. The patient received discharge teaching including drain 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: Pt is an ___ y.o male with h.o HTN, HL, recent H.pylori C.diff colitis who presented to ___ with sudden onset epigastric abdominal pain with chest pain. Pt reports that he developed intermittent diarrhea ___ weeks ago that improved with immodium. He then developed significant "heartburn" ___ days ago, and reports that his heartburn has been worsen recently leading him to use a 14day course of prilosec and then zantac. Both initially worked, then stopped working. On ___ ___, pt reports that he developed severe abdominal "Cramping" with chest pain that resolved. However, he reports that on ___ diffuse, sharp ___ lower abdominal LLQ>>RLQ pain with ___ chest burning/pressure with "heavy breathing" developed with 2 episodes of n/v and pt called ___ and was taken to ___ ___. Pt reports 2 episodes of diarrhea at ___. Pt reports he last experienced CP and abdominal pain in the afternoon on ___. Currently, pt denies any pain including abdominal pain, nausea, vomiting, diarrhea, constipation, melena, brbpr, dysuria, CP, SOB, palpitations, headache, dizziness, ST, URI, rash, paresthesias, weakness, change in weight or appetite, fever, chills. He denies any exertional component to his CP. Per report-OSH CT with gallstones within the distal CBD, distended GB and diverticulitis. U/S showing biliary sludge. Prior to transfer pt was given cipro 400mg, flagyl 500mg, zosyn 3.375mg and protonix 40mg IV. . In ___ ED: Pt was given zosyn, 1L IVF. ERCP and ACS teams were contacted. Initial vitals: T 99.1 BP 107/81, HR 87, RR 16, sat 96% on RA vitals prior to transfer: T 98.8, BP 113/54, RR 18, sat 97% on RA Radiology showed 1. Moderate intra- and extra-hepatic biliary ductal dilatation with a 1.2-cm hyperdense focus in the distal common bile duct, findings concerning for choledocholithiasis. 2. Distended gallbladder with mild wall thickening though no stones within it. 3. Mild uncomplicated sigmoid diverticulitis. 4. Moderate hiatal hernia. 5. 4.8-cm indeterminant cystic lesion arising from the lower pole of the right kidney. No complex features identified, however, attenuation values are indeterminate. Followup non-emergent renal ultrasound is recommended for further characterization as this lesion was not completely characterized on recent outside hospital right upper quadrant ultrasound. Acute findings regarding biliary obstruction and diverticulitis were discussed with the surgical team including Dr. ___ at 2:45 p.m. on ___ in person by Dr. ___. The patient was diagnosed with CHOLEDOCHOLITHIASIS NOS, DIVERTICULITIS OF COLON, HYPERTENSION NOS. The patient was treated with ERCP. At the time of discharge, the patient had choledocholithiasis diverticulitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is an ___ y.o male with h.o HTN, HL, who presented to OSH with abdominal pain, imaging concerning for obstructive choledocholithiasis, and diverticulitis. . #choledocholithiasis/obstructive jaundice/bile duct obstruction/transaminitis-?cholecystitis. Imaging was suggestive of biliary dilatation with stone present in the CBD. Gallbladder wall thickening was seen as well. ERCP was performed on ___ showing multiple large CBD stones. Unfortunately, stones were large and not all stones were able to be removed. A stent was placed and pt will need repeat ERCP in ___'s time to attempt stone removal/stent change. Pt was placed on cipro/flagyl. The ERCP and ACS teams followed the patient during admission. He will follow up with surgery for cholecystectomy. . #diverticulitis- uncomplicated sigmoid diverticulitis seen on OSH imaging. CT scan here confirmed it. Pt was initially NPO, and was given cipro and flagyl. Symptoms improved. He will complete a 10 day course. . #chest pain/GERD-Pt reported "chest burning" at OSH. EKG was non-ischemic appearing, cardiac enzymes x2 negative. Pt reports CP is due to "heartburn". There were no events on tele, EKG and cardiac enzymes negative. Pt was previously on zantac but reported much improvement on a PPI and was discharged on omeprazole. . #Acute on chronic renal failure- He presented with Cr 2.3 and CT findings suggestive of chronic renal disease. At the OSH a Cr of 2.6 was recorded. Cr per outpt records 1.6-1.9. He was given IVF with improvement. Urinalysis did not suggest infection. Cr was 1.4 at discharge. . #HTN, benign-continue betablocker, converted atenolol to metoprolol given GFR, held lisinopril for now. Held ASA . #HL-Simvastatin was held given transaminitis but can be resumed as an outpatient. . #h.o c.diff infection-The pt reports he was on abx therapy for 6 months in the last year. He reported a few episodes of loose stools while in the hospital. C.diff toxin was negative. . #peripheral arterial ___ reports a hx of claudication without any interventions. His aspirin and cilostazol was held in the setting of getting a sphincterotomy. He may resume aspirin and cilostazol after 5 days. ERCP recommended stopping cilostazol 3 days before ERCP. . </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo RH M with h/o HCV, IVDU, psychosis, and recent admission (___) for cryptogenic stroke presumed multi-embolic to several vascular distributions in right hemisphere in setting of +PFO and hyper-homocysteinemia, who now re-presents to ___ ED with new neurologic symptoms concerning for recurrent ischemic event. Radiology showed 1. Expected interval encephalomalacic change from the known right hemispheric multifocal embolic infarcts. 2. No acute intracranial hemorrhage. 3. Major cervical and intracranial vessels patent, with no intracranial aneurysm larger than 2 mm, flow-limiting stenosis, or significant atherosclerotic disease and anatomic variants, as noted. Radiology showed 1. Expected evolution of the known right hemispheric multifocal embolic infarcts. 2. No evidence of acute infarction or intracranial hemorrhage. The patient was diagnosed with APHASIA, SKIN SENSATION DISTURB. At the time of discharge, the patient had ACUTE ISSUES: 1. Left face tingling, word finding difficulties - suspect TIA CHRONIC ISSUES: 1. Embolic right cortical stroke 2. Hepatitis C 3. Patent foramen ovale 4. Polysubstance abuse. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to the Stroke service for further imaging and work-up of his new neuro symptoms. CTA head/neck were performed, showing expected encephalomalacia secondary to his prior right hemispheric strokes but no acute ICH or cervical/intracranial vessel aneurysm/flow limiting stenosis/significant atherosclerotic disease. MRI showed no acute stroke on DWI/ADC; only expected evolution of prior stroke. The following morning, patient's subtle neuro deficits had resolved on exam, with the exception of mildly INCREASED sensation to pinprick on his left face. Given his symptom improvement and unchanged imaging, it was suspected that he had likely had a TIA. In the setting of his risk factors for recurrent stroke -- specifically the PFO and his hyperhomocysteinemia -- his ASA was increased from 81mg to 325mg daily. His folic acid/B6/B12 were continued. The patient was also strongly advised to never use anabolic steroids again (has h/o abuse in the past) as this too increases his coagulopathic state. Finally, the possibility of future percutaneous PFO closure was raised and discussed extensively with patient. Given that he is in a population not studied in the CLOSURE trial (hypercoagulable patients), and has increased risk of paradoxic embolism with Valsalva given his hobby of weightlifting, he could potentially be a good candidate for PFO closure. He will follow up as an outpatient with Dr. ___ cardiac surgery and his neurologist Dr. ___ to continue exploring this option. ===================== TRANSITION OF CARE: -Studies pending on discharge = cryoglobulins (looking for cold agglutinin disease) -Patient needs homocysteine levels rechecked as outpatient </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o G1P0 who is 9w2d by LMP who presented to the ED for nausea and vomiting. She reports that she has had nausea and vomiting for two weeks, but has not reached out to an OB/GYN so as a result has not been started on antiemetics. She states that her LMP is ___, and did have regular menses in ___ and ___. EARLY OB US <14WEEKS showed Intrauterine gestational sac with embryo that does not demonstrate cardiac activity concerning for fetal demise. CHEST (PA AND LAT) showed No acute intrathoracic process. The patient was diagnosed with Nausea with vomiting, unspecified. The patient was treated with D&E. At the time of discharge, the patient had septic abortion hyperthyroidism chlamydia. The patient was given written instructions concerning 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 ___ G1P0 admitted to the postpartum service from the emergency department after being diagnosed with an intrauterine fetal demised with presumed septic abortion. She presented at 9w2d by LMP with two weeks of nausea and vomiting. Her LMP, however, was unclear due to irregular menses. In the emergency department, she was afebrile with tachycardia ranging from 112-161 with otherwise normal vital signs including a normal blood pressure. Her abdomen was non-tender and non-distended with no rebound or guarding. Speculum exam showed no evidence of blood in the vault and a closed cervix. There was no adnexal tenderness or fundal tenderness. Labs were done in the emergency room which were significant for a leukocytosis of 16.0 and a lactate of 2.9. Urine toxicology screen was negative. A TSH was drawn and was pending upon admission. Electrolytes were significant for a potassium of 2.4, sodium 127, a chloride of 77, bicarbonate of 27, creatinine of 1.0, and an anion gap of 25. A pelvic ultrasound was done which demonstrated no cardiac activity. Fetal biometry was not done but visually the fetus appeared to be in the ___ trimester. Bedside transabdominal ultrasound done once patient was admitted showed a fetus roughly 13 weeks in gestational age. In the emergency room, she was aggressively fluid resuscitated and received 1g ceftriaxone for presumed early sepsis. Her potassium was repleted and she was started on fluids with potassium supplementation. OB/GYN was consulted who recommended starting ampicillin and gentamicin for a presumed septic abortion in the setting of an undiagnosed IUFD of unclear length of time. An immediate dilation and evacuation was recommended. The patient was made NPO, started on antibiotics, and continued on fluids and admitted to the postpartum service for further management. MFM was consulted and the patient underwent an uncomplicated dilation and evacuation. Patient's blood type was B positive so Rhogam was not indicated. Her pain was controlled with oral pain medications of Tylenol and ibuprofen. She was treated with ampicillin, gentamicin, and clindamycin for 48 hours post-procedure. She was transitioned to oral levofloxacin and flagyl for an additional 10 days. She was continued on 20mEq potassium D5LR until her resolution of her hypokalemia. Electrolytes were trended and repleted prn. Labs were trended which were notable for a resolved hypokalemia with a serum potassium of 3.6, a resolved leukocytosis with a white count of 7.5, and a resolving lactate of 2.9 down from 5.2. Chlamydia culture returned as positive for which she was treated with a 1g does of PO Azithromycin. Thoughout her hospitalization she remained persistently tachycardia ranging from the 100-120s with episodes up to the 150s with ambulation despite aggressive fluid hydration and antibiotic treatment of her infection. Thyroid function tests were done which were significant for a TSH of 0.01 and an elevated free T4 of 3.6. A full panel of thyroid function tests were performed which were consistent with hyperthyroidism likely secondary to hyperemesis gravidarum secondary to severe nausea for the past month. On exam, she was euthyroid with no signs of Grave's disease including ophthalmopathy. FT4 and TT3 improved after the D&E; TPO, anti-thyroglobulin antibodies, TSI and TBII all returned as negative further suggesting against Grave's disease and favoring hyperemesis as the likely etiology. She was started on 25mg of Atenolol for heart rate control and discharged home with recommendation to follow-up with Endocrinology within one week of discharge. By postoperative day 3, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was afebrile with stable vital signs. She was then discharged home in stable condition with outpatient follow-up scheduled.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female with a history of ESRD on HD dialyzed MWFS at ___. ___ via a R fistula, s/p bilateral BKAs, DM, HTN who presents with a infection of his left thumb. the patient reports he began to notice pain and swelling in his thumb along the nail approximately 2 weeks prior to admission. He denies any associated edema but does not associated erythema. He denies any fevers or chills. He did vomit 3 time the night prior to admission. Vomit was non bloody in nature. He was scheduled to see surgery but showed up late to the appointment and was sent to the ED instead. . In the ED, initial VS were 98.4 80 132/58 16 94% RA. Labs were notable for a creatinine of 6.3. He was seen by plastic surgery who drained his left thumb paronychia. He was given IV unasyn and admitted to medicine given his history of diabetes and concern for spread to systemic infection. . Currently patient denies any pain, chills or other discomfort. He did miss his dialysis today but denies any significant chest pain or shortness of breath. He denies diarrhea but states he is frequently constipated with bowel movements every other day, last yesterday. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain,diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed Soft tissue irregularity along the thumb but no definite evidence for bone destruction. Demineralization and vascular calcifications. The patient was diagnosed with ONYCHIA OF FINGER, DIABETES UNCOMPL ADULT, END STAGE RENAL DISEASE, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE. The patient was treated with Incision and drainage of L thumb paronychia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo male with a history of DM, ESRD on HD, PVD who presents with a L thumb infection. . # Paronychia- Patient presented with a paronychia of the left thumb. He was seen by plastic surgery in the ED who removed his nail. He was initially started on IV unasyn and admitted to medicine for monitoring. There were signs of systemic infection on exam. Additionally patient was afebrile with a normal white blood cell count throughout admission. Blood and wound cultures were pending at the time of discharge. He was transitioned to oral augmentin for a planned 14 day course. Pain was managed with oral tylenol. The patient was instructed to complete betadine soaks three times a day. He will follow-up with Plastic surgery and his PCP. . STABLE ISSUES . # Diabetes- Last A1C 6.8 in ___. Patient was continued on his home regimen of lantus and humalog sliding scale. . # Hypertension- Patient was continued on his home regimen of amlodipine and labetalol . # ESRD- Patient is on hemodialysis MWFS via a R sided fistula. The patient had missed dialysis the day of admission however there were no current signs of volume overload on exam. He was dialyzed the day of admission. He was continued on his home nephrocaps and phos binder. . # Mild chronic diastolic congestive heart failure- Patient did not have signs of volume overload. He was continued on his home beta blocker. . # Hyperlipidemia- Patient was continue on his home statin however the dose was decreased to 20 mg is also on amlodipine. . # PVD- Patient with history of significant PVD, s/p bilateral BKAs. He was continued on his home aspirin and plavix . # Hypothyroidism- Patient was continued on his home levothyroxine . TRANSITIONAL ISSUES - Patient was DNI ok to resuscitate - Blood and wound cultures were pending at the time of discharge - Patient will follow up with Plastic surgery on ___ and his Primary Care Physician </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo F visiting ___ from ___ with PMH of asthma, CAD s/p stents, HTN, multiple UTI's, and OSA (not treated) who initially presented to ___ on ___ with T 104.5, left sided neck pain, and hypotension. She reported sore throat 2 days prior to admission and noticed a swollen lymph node in her left neck. She initially denied headache or confusion. She reports that she had dental work about 2 weeks prior to admission. She did report some left sided neck pain. On the day of admission she was travelling to ___ when she developed nausea, vomiting, and confusion. At OSH given the neck pain there was concern for meningitis but reportedly pt refused a lumbar puncture, although the patient states they never asked to do one. She had a CXR which showed bibasilar infiltrates concerning for pneumonia vs atelectasis and she was given CTX/azithromycin. She was also found to be hyperglycemic with BG of 198 for which she was started on insulin in the hospital. She had a Blood cultures grew N. meningitidis after which the dose of ceftriaxone was increased. She was also started on prednisone and nebulizers due to history of asthma. She was noted to be in atrial fibrillation on the night of ___ and she was given magnesium and by morning had converted back to sius rhythm. She has been in the hospital since ___ and reportedly has not been improving from a respiratory standpoint and has requested transfer to ___. On Transfer Vitals were:99.3 71 138/61 14 95% RA CHEST (PA AND LAT) showed Heart size is top-normal. Mediastinal silhouette is unremarkable within the limitations of the CV air dextroscoliosis. Bibasal linear opacities are most likely consistent with atelectasis and there is no definitive evidence of pneumonia. Nodular opacities projecting over the right apex, 4.7 mm in diameter. This relatively dense and gas most likely represent calcified granuloma but comparison with prior studies is required. If not available, reassessment with chest radiograph in 3 months is recommended or alternatively chest CT for documentation of stability. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, BACTEREMIA NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS Neisseria meningitis Oxygen dependence SECONDARY DIAGNOSIS asthma hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F with PMH of asthma, CAD s/p stents, HTN, multiple UTI's, and OSA (not treated) who initially presented to ___ ___ on ___ with T 104.5, left sided neck pain, and hypotension. Started on ceftriaxone/azithromycin for PNA, found to have neisseria bacteremia in 1 blood culture on ___. Increased ceftriaxone dose to 2g Q12H on ___. Transferred to ___ ___ for further management of possible meningitis and respiratory management. # Meningococcal Meningitis: Since transfer pt afebrile, hemodynamically stable, mentating well. Finished course of ceftrixone last dose 2g IV on ___ in the AM for total 7 day course from first dose. Also finished 2 day course of rifampin PO 600 mg BID for nasal decolonization. Close contacts on prophylaxis. # PNA vs atelectasis on outside CXR: Pt initially started on ctx/azithro, ctx increased for meninigitis and azithro held on transfer out of less concern for pna. Repeat CXR shows atelectasis only, lungs CTAB throughout stay. # Asthma: Pt with cough variant asthma. No wheezing on exam but pt desats on ambulation to 88 on room air. Pt states she has been told she needs oxygen in the past but has not used it except while flying, which she is very concerned about. Plan for home oxygen and for flight home. # CAD s/p stents: Without symptoms. Continued aspirin, plavix, statin, beta blocker # HTN: Normotensive. Continued spironolactone without need for potassium supplementation. # Paroxysmal atrial fibrillation- Found to be in a fib at OSH, converted to sinus with mag administration. CHADS2 score 2 (although borderline diabetes hx). Has been in sinus during stay here. Deferred to outpt ___. # Hyperglycemia at OSH: no hx of DM but has elevated a1c of 6.3 and pt states she has been offered metformin in the past but did not take it as her cardiologist told her not to. Was on sliding scale while in house. Transitional issue for PCP to ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with h/o SLE and peripheral vascular disease s/p bilateral aortobifem bypasses, s/p appendectomy and cholecystectomy, with previous C diff colitis and bowel obstruction who p/w right lower quadrant/groin pain. Ongoing x 3 days, intensifying. She reports the pain is very sharp, constant, and radiates to her groin only. The pain is worse with moving her right leg but otherwise movement does not make it worse. She has been having diarrhea which did not get better with immodium (which usually works for her). She also has been having some dark black stools even before the immodium use and some bilious emesis. Having 4+ loose stools per day and ___ emesis. Associated with some chills/fevers at home. Radiology showed New radiographic findings which could reflect an asymmetrical pattern of congestive heart failure superimposed upon chronic emphysema. Coexisting pneumonia should be considered, especially particularly in the left lower lobe. Followup chest radiograph after diuresis may be helpful for initial further evaluation. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, PERSISTENT VOMITING, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, SYST LUPUS ERYTHEMATOSUS, MYALGIA AND MYOSITIS NOS. At the time of discharge, the patient had Hip Pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F with h/o SLE and chronic steroids and PVD presents with abdominal pain x 2 days and elevated lactate.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with stage IIIC breast cancer on chemotherapy (last ___, s/p Neulasta on ___ who presents with two hours of fever, mouth sores and throat pain. Patient states that she had a fever of 100.4 at home about two hours ago and was instructed to come to the ED. Otherwise, she states she has been unable to eat because of a mouth ulcer she developed one day prior to presentation as well as throat pain. There is no chest pain, no cough, no difficulty breathing, no dysuria or abdominal pain, no nausea/vomiting, diarrhea/constipation. Patient also complains of bilateral heel pain, no calf pain or leg pain. Radiology showed No focal consolidation to suggest pneumonia. The patient was diagnosed with NEUTROPENIA, UNSPECIFIED , FEVER, UNSPECIFIED, HYPOKALEMIA. At the time of discharge, the patient had PRIMARY: Febrile neutropenia SECONDARY: Breast 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>___ year old female with stage IIIC breast cancer on chemotherapy (last ___, s/p Neulasta on ___ who presents with two hours of fever, mouth sores and throat pain. # Neutropenic fever: no source at this time. CXR unremarkable, UA unremarkable. No skin findings, port site looks OK. Given hard palate, labial, lateral lingual lesions HSV likely. She was treated with IV acyclovir and cefepime, with discontinuation of cefepime when no longer neutropenic. Her fevers were attributed to HSV (mucocutaneous) and she was discharged with valacyclovir 1g BID x5 more days. She may benefit from prophylactic valacyclovir with further chemotherapy. She was also discharged with viscous lidocaine. # Heel pain: patient with right-sided heel pain and hypothenar erythema/blistering. This is most suggestive of palmoplantar erythrodysesthesia, commonly seen with doxorubicin. # Anemia: Hgb ~8. Likely related to bone marrow suppression from chemotherapy. There were no signs of active bleeding. # Breast cancer: Stage IIIc. EGFR+. S/p 4 cycles doxorubicin/cyclophosphamide + Neulasta as neoadjuvant tx. Planned for further neoadjuvant and then surgical removal of primary mass. # Hyperlipidemia: appears not currently on therapy. # Hypertension: Normotensive here. Restarted home meds on discharge. # Anxiety: continued home lorazepam</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with CAD, HTN, HLD, ___, CKD, AF on warfarin who presents from a nursing facility complaining of chest pain onset about one hour prior to presentation with radiation down the right arm. On arrival for EMS, patient was hypotensive and hypoxic 89% on nonrebreather. Further details of the history are not clear. Radiology showed Moderate cardiomegaly, mild pulmonary edema, bibasilar atelectasis and possible pneumonia/aspiration or pulmonary hemorrhage. Radiology showed Satisfactory placement of the ET tube with no other interval changes. Radiology showed 1. Satisfactory placement of a right internal jugular line with tip terminating in the mid SVC. No pneumothorax. 2. An enteric tube should be advanced several centimeters to guarantee positioning of the sideholes in the stomach. 3. Moderate cardiomegaly, mild pulmonary edema, bibasilar atelectasis and increasing possible pneumonia/aspiration or pulmonary hemorrhage. Radiology showed Moderate sized knee joint effusion, unchanged from prior study. Evaluation of the patient with respiratory failure. Portable AP radiograph of the chest was reviewed in comparison to ___. The ET tube tip is 5 cm above the carina. The NG tube passes below the diaphragm. Heart size and mediastinum are grossly unchanged as compared to the prior study. Slight improvement of multifocal opacities is noted. was done. Radiology showed Worsening right mid lung opacity concerning for pneumonia. Radiology showed No pneumothorax. Persistent left lower lobe consolidation and vascular congestion. The patient was diagnosed with ACUTE RESPIRATORY FAILURE. The patient was treated with Endotracheal Intubation Left knee arthrotomy, debridement and irrigation, synovectomy and revision of polyethylene component for infection, deep cultures PICC line placement. At the time of discharge, the patient had Primary diagnosis: -Septic arthritis -Septic shock -Hemarthrosis -Supratherapeutic INR -Healthcare associated pneumonia -Delirium Secondary diagnoses: -Diastolic heart failure -Atrial fibrillation -Hypertension -Chronic kidney disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with dCHF, HTN, HLD, CAD, CKD, AF on warfarin who presents with dyspnea and chest pain, found to have HCAP with septic shock requiring intubation, septic arthritis of the left knee s/p washout, and supratherapeutic INR. ACUTE ISSUES #Healthcare associated pneumonia complicated by septic shock and hypoxic respiratory failure: Patient presenting with dyspnea and found to have LLL pneumonia, treated empirically for HCAP with vancomycin, cefepime, and levofloxacin. Upon presentation in the ED, the patient was intubated for hypoxic, hypercarbic respiratory failure. Patient developed hypotension refractory to volume resuscitation and was started on pressors with the presumed etiology being pneumonia vs. septic arthritis. Patient was successfully extubated with stabilization of his hemodynamic status. The patient completed a full course for HCAP during his hospitalization. #Septic arthritis: Patient reportedly had knee pain prior to admission, was found to have WBC 15,000 on arthrocentesis, though no culture growth. Patient taken to the OR by Orthopedics on ___ for washout. Patient previously had knee replacement in the same joint. Culture of the intraarticular material from the washout grew enterococcus. The patient had a PICC line placed and was started on vancomycin. Infectious Disease was consulted and recommended a beta-lactam antibiotic citing evidence that beta-lactams had superior outcomes, but transition to a beta-lactam was limited to the patient's reported penicillin allergy. Allergy evaluation and testing was arranged for after hospitalization with the plan of undergoing penicillin allergy testing, and if possible, transition to a beta-lactam. IV antibiotics required for an extended duration, likely six weeks. The patient has also been arranged for Orthopedics follow-up. #Metabolic Encephalopathy: Patient had episodes of confusion after extubation while in the ICU which persisted during his stay on the general medicine floor. This was attributed to his hospital stay as well as his infection. The patient did require occasional antipsychotics for agitation. His delirium improved during the course of his stay, though at discharge, was still off from baseline. The patient was started on standing qhs olanzapine with improvement in his agitation. #Rash: Patient found to have a maculopapular rash with excoriations on his back. Given the distribution, it was thought that this represented a dermatitis from being in bed. Other etiologies considered included drug rash, though the distribution favored a contact-type etiology. The patient was trialed on topical corticosteroid during his stay. #Chest pain: Patient reported chest pain upon admission in setting of known CAD. His troponin was found to be mildly elevated to 0.02, but remained stable with normal MB component. Given the stability in the enzymes and lack of EKG changes, there was low suspicion for ACS. CHRONIC ISSUES #CKD Stage 3: Patient with known chronic kidney disease, with baseline creatinine of 1.5. During hospital course, creatinine rose to 2.9, likely secondary to ATN in setting of hypotension. His creatinine improved over the course of his hospital stay. #Afib on warfarin: Rate well controlled during his stay. The patient was continued on his rate-control and anticoagulant agents. #Chronic Diastolic CHF: Patient with known diastolic dysfunction. The patient was continued on an adjusted course of torsemide, though metolazone and spironolactone was held with no evidence of volume overload. These agents might need to be added in the future should he develop symptoms of fluid overload. #Gout: Patient with history of gout, continued on home allopurinol. TRANSITIONAL ISSUES -Patient will continue on IV antibiotics for extended period, please maintain PICC until course complete. -Patient will follow-up in ___ clinic. Please send weekly CBC with differential, chem-7, vancomycin trough (prior to dose) and ESR/CRP faxed to ___. -Patient has an Allergy appointment scheduled in early ___, please notify ID at ___ once the testing is complete. -Patient CANNOT have antihistamines one week prior to allergy testing (montelukast is OK) as this will affect the test. -Please discontinue the olanzapine once the patient's delirium resolves.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F restrained driver, significant impact, + 40 mph, lost control of car, airbag deployed, no LOC, pinned by rear seat passenger. extricated by EMS. At OSH, ___, had CT head, Cspine, Chest, Abd/ Pelvis- suggestive of liver lac. Transferred for liver lac GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT showed No fracture or dislocation. The patient was diagnosed with Laceration without foreign body of lip, initial encounter, Car driver injured in collision w car in traf, init. At the time of discharge, the patient had Grade 1 liver laceration. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ y/o F who was involved in ___ as the restrained driver, extricated by EMS. At OSH in ___ the patient had a CT head, Cspine, Chest which were negative, and a CT abdomen/pelvis suggestive of a liver laceration. She did have a head laceration which was repaired with staples at the OSH. The patient was transferred to ___ for further hemodynamic monitoring. Serial abdominal exams were performed and HCT was trended. HCT remained stable. The patient did report some vaginal bleeding, however, this was not felt to be traumatic in cause and was believed to be due to menstruation. Upon arrival to the surgical floor from the ED, the patient was agitated and stated she wanted to leave AMA. The surgical team met with her to discuss her plan of care and, given the patient's history of mood disorder, ___ ___ from ___ visited with the patient and her parents. A home medication regimen was obtained and the patient was prescribed her home psychiatric medications. Social work also met with the patient and her parents. Diet was advanced to regular which she tolerated. IVF were discontinued. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ p/w 4 foot fall from truck onto face, becoming entangled in a piece of iron that had been in his truck bed as he fell. Witnessed by family. +LOC briefly at scene, ___ 15 on arrival to ___ and ___. He noted that when he awoke, he could not move or feel his body below his neck; this began to improve almost immediately. Arrives complaining of severe bilateral arm pain and dysesthesias with concern for possible spinal cord injury. Also noted to have a large R scrotal laceration. MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE showed 1. Minimally displaced subtle fracture through a C6 superior endplate anterior marginal osteophyte with associated prevertebral soft tissue edema. This presumably injure is a the anterior longitudinal ligament at this level. 2. There is highly equivocal increased cord signal at C3-C4 on STIR imaging, not confirmed on sagittal or axial T2 imaging. This is felt likely to be artifactual however correlation with clinical symptoms is recommended. 3. Multilevel degenerative changes are most prominent at C3-C4 where there is severe spinal canal narrowing, remodeling the cord. Bilateral severe neural foraminal narrowing is seen at C3-C4 through C5-C6. 4. No ligamentous injury involving the tectorial membrane, posterior longitudinal ligaments, ligamentum flavum or interspinous ligaments. The paraspinal muscles appear unremarkable. 5. Additional findings described above. MR CODE CORD COMPRESSION PT27 MR SPINE showed 1. No evidence of high-grade spinal canal or neural foraminal narrowing. No cord compression. There is no cord signal abnormality. 2. Grade 1 anterolisthesis of L5-S1 with bilateral spondylolysis. 3. Degenerative changes of the thoracic and lumbar spine, worst at L5-S1. At L5-S1 there is moderate to severe right neural foraminal narrowing, flattening the exiting right L5 nerve root. 4. Subcentimeter cystic lesion in the right kidney. 5. Please refer to concurrent MRI cervical spine for additional details. RECOMMENDATION(S): Management of Incidental Renal Cyst Completely Characterized on CT or MRIBosniak I or II- No further workup CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS showed 1. Comminuted fractures of the bilateral nasal bones and frontal processes of the bilateral maxillae. 2. Minimally displaced left orbital floor fracture which extends into the infraorbital canal. No evidence of extraocular muscle entrapment. 3. Mildly displaced left lamina papyracea fracture. 4. Paranasal sinus disease, as described above. The patient was diagnosed with Central cord syndrome at C4, init, Other fall from one level to another, initial encounter, Fracture of nasal bones, init encntr for closed fracture, Laceration w/o foreign body of scrotum and testes, init. The patient was treated with ___: Complex right perineal and scrotal closure. At the time of discharge, the patient had Central cord syndrome Complex right perineal and scrotal closure Left inferior orbital floor fracture Bilateral nasal bone fractures Left lamina propecea 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>Mr. ___ presented to the Emergency Department on ___ as a trauma activation as described in the HPI above. He was evaluated immediately upon arrival. Between ___ and our institution he received CT head, CT C-spine, CT chest, CT maxillofacial/sinus, and MR of the C/T/L spines. His injuries were found to be a right perineal/scrotal laceration, nasal bone fractures, left orbital floor fracture without entrapment, left lamina papyracea fracture, C3-C4 narrowing felt to be possibly degenerative changes however with clinical symptoms most consistent with central cord syndrome, C6 superior endplate fracture, and scalp abrasion with underlying hematoma. Neuro/MSK: The patient was alert and awake throughout his hospitalization with appropriate mental status. He was seen by neurosurgery and ___ for his central cord syndrome and C6 superior endplate fracture. He was initially admitted to the ICU for pressor support to achieve MAP goal of >85 while awaiting final determination of whether he had any spinal cord injury. Ultimately the spine service determined that he should be managed with at least 1 month of cervical collar, outpatient f/u, and required no logroll precautions or elevated MAP goal; he will follow up as an outpatient and may be a candidate for elective surgery for his C3-C4 area of narrowing. He was therefore transferred from the ICU to the floor on hospital day 2. His symptoms gradually improved over the course of his hospitalization and at discharge he was ambulating independently with improved motor control of his upper extremities. He continued to have paresthesias and some weakness of his arms and hands. Occupational Therapy worked with him multiple times and recommended additional rehabilitation. His pain was managed with IV medications and subsequently transitioned to PO medications. At his request, narcotics were minimized given his prior history of substance use disorders. He was also noted to have facial fractures as above for which plastic surgery was consulted; they recommended elevating HOB and conservative management. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: He was seen by urology in the ED for his complex scrotal and perineal laceration; his testicle was determined not to be violated and they recommended washout and repair per ACS vs. plastic surgery. He was therefore taken to the operating room early in the morning on ___ for washout, drain placement, and closure of his scrotal and perineal laceration. There were no adverse events in the operating room; please see the operative note for details. Pt was extubated, taken to the PACU until stable, then transferred to the ICU for observation. After leaving the operating room, diet was advanced sequentially to a regular diet, which was well tolerated. Patient's intake and output were closely monitored. His Foley catheter was removed and bladder scans were monitored in case of any neurogenic bladder issues; he was able to void successfully and spontaneously. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. He received 5 days of Ancef for his contaminated scrotal laceration. On discharge he was transitioned to Keflex to complete the 5 day course. 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 venodyne 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: ___ is a ___ male who presents to ___ on ___ with a moderate TBI. He takes Xarelto for atrial fibrillation. Patient was walking to his car to drive to work today when he slipped on the ice, falling backwards and striking his head. He denies LOC. EMS was initated and he was taken to ___. CT there revealed R acute on subacute SDH. He was given 500u of Kcentra at OSH. He was transferred here for Neurosurgical evaluation. CT HEAD W/O CONTRAST showed 1. Slight interval increase in right hemispheric mixed density subdural hematoma. 2. Similar size and appearance of acute right tentorial subdural hematoma. 3. Slight interval increase in right to left midline shift with enlargement of the left lateral ventricle concerning for a trapped lateral ventricle. 4. Slight interval decrease of CSF visualized in the basilar cisterns without evidence of frank herniation. CHEST (PORTABLE AP) showed Small left pleural effusion. Mild bibasilar opacities, likely atelectasis in the setting of shallow inspiration, consider pneumonia if clinically appropriate. CT HEAD W/O CONTRAST showed 1. Postsurgical changes from right frontoparietal craniotomy and subdural hematoma evacuation. Small amount of acute blood product within the evacuation cavity. 2. Stable subdural hematoma layering along the right tentorium. No new hemorrhage. 3. Improved local mass effect and midline shift compared to prior. CT HEAD W/O CONTRAST showed 1. Acute blood product within right subdural evacuation cavity has increased as compared to head CT ___. 2. Increased local mass effect and increased and leftward midline shift now measuring 7 mm, previously 4 mm on head CT ___. 3. Stable subdural hematoma layering upon the right tentorium. NOTIFICATION: The findings were discussed by Dr. ___ with ___ ___ on the telephone on ___ at 5:20 pm, 5 minutes after discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Status post right craniotomy and evacuation of right subdural hematoma with similar appearance of fluid collection and acute blood. 2. Unchanged subdural hematoma tracking along the falx and right tentorium. 3. No new hemorrhage. 4. Unchanged midline shift toward the left. The patient was diagnosed with Nontraumatic acute subdural hemorrhage, Unspecified atrial fibrillation, Long term (current) use of anticoagulants. The patient was treated with ___: Right Mini-craniotomy for ___ evacuation. At the time of discharge, the patient had Subdural hematoma 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>On ___, Mr. ___ presented to the ED at an OSH after a fall. ___ showed a right subdural hematoma; he was given KCentra and transferred to ___. #Subdural Hematoma The patient was admitted to the ___ for close neurologic monitoring of his subdural hematoma. Anticoagulation was held in the setting of acute hemorrhage. Repeat CT showed stable hematoma. The patient was taken to the OR on ___ and underwent a right craniotomy for subdural hematoma evacuation. He tolerated the procedure well and was extubated in the operating room. He was later transferred to the ___ for close monitoring. On ___ the patient was transfused with one unit of FFP, and his subdural drain was removed. #Atrial Fibrillation The patient has a history of atrial fibrillation on xarelto, which was held on admission. The patient was noted to be in atrial fibrillation with a right bundle branch block on EKG with frequent PVC's. Cardiology was consulted who recommended changing his long acting metoprolol to Q6H dosing. He was cleared from a cardiovascular standpoint for surgery on ___. He should remain of Xeralto until cleared by Neurosurgery, this will be determined at his follow up appointment in 4 weeks. #Thrombocytopenia Hematology was consulted for recommendation regarding anticoagulation reversal and recommended a full dose of KCentra due to history of CLL and chemotherapy. Hematology recommended a platelet transfusion in the OR for surgery on ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old woman with a history of congenintal hepatic fibrosis and polycystic kidney disease discharged to ___ Hosp on ___ s/p ICU admission for right colonic colitis/collapse leading to Klebsiella bacteremia/sepsis, complicated by acute inferior lateral STEMI, anemia and thrombocytopenia, line-associated left arterial thrombus, RUE line-associated superficial thrombus presents with several days of chest and back pain. Of note, the patient recently completed a 2 week course of ceftriaxone that ended on ___. Radiology showed Small bilateral pleural effusions; these appear decreased, however, since the most recent prior examination. Radiology showed Deep vein thrombosis seen within the two peroneal veins of the right calf. No additional DVT identified. Findings of right calf DVT were discovered at 12:45 on ___ and were conveyed by telephone to Dr. ___ at 14:14 on the same day. Radiology showed 1. Increasing right pleural effusion with associated atelectasis of the right lower lobe. 2. Increasing but small simple pericardial effusion. 3. Bilateral cystic renal disease, some of which demonstrates a complex nature and would be better characterized on ultrasound. 4. Hepatic hypodensities consistent with innumerable cysts as seen on prior MRI. Prominent varices presumably due to portal hypertension. Patency of portal vein limited on this noncontrast study. The patient was diagnosed with PAINFUL RESPIRATION, POLYCYSTIC KIDNEY, UNSPEC TYPE. At the time of discharge, the patient had Primary: deep vein thrombosis pleural effusion acute on chronic kidney injury Secondary: anemia of chronic kidney disease polycystic kidney disease congenital hepatic fibrosis thrombocytopenia (low platelet count). The patient was given written instructions concerning 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 PCKD, congenital hepatic fibrosis, recently admitted for Klebsiella sepsis with course c/b inferior STEMI while in the MICU, left arterial line thrombosis, and RUE line associated superficial clot who presented from rehab with chest pain x 2 days, found to have RLE DVT, now heparinized and with course complicated by acute on chronic renal insufficiency, hypovolemic hyponatremia and a decreased hematocrit. # RLE DVT and likely PE: The patient was found to have RLE DVT and given her presentation, likely that she has a PE; CTA was deferred given her renal function. The patient was started on a heparin drip; heme was consulted and said that a heparin drip was ok in the setting of her thrombocytopenia. The patient as monitored on tele. Her chest pain improved while she was continued on her heparin drip. She was also using supplemental O2 as needed for comfort. Her initial trops were 0.06-0.07 ___K-MB and there was no new ischemic changes on EKG or RV strain. The patient was ultimately bridged with heparing to warfarin with goal of being therapeutic with INR ___ for 2 days on both heparin and warfarin. She was discharged on warfarin. # Right sided pleural effusion: ddx includes secondary to pulmonary embolism or fluid overload from MICU stay. Patient deferred thoracentesis and preferred instead to followup with interventional pulmonology as outpatient. She had no fevers or leukocytosis suggestive of empyema. She will have follow-up with interventional pulmonology to monitor this issue. # hyponatremia: The patient developed hyponatremia during this hospitalization, with nadir of 125 without any neurologic symptoms. Unclear etiology. Renal was consulted and was thought that this could be due to consumption of large amount of free water, although exact etiology of her hyponatremia remains unknown. The patient did ultimately improve with addition of salt tablet, blood products, and free water restriction. # Anemia: The patient was found to have decreased hematocrit a few days into her treatment with heparin drip. No obvious source of bleeding was identified. She was transferred 2U PRBC after which hematocrits remained stable. # recurrent clots: The patient has history of multiple clots in the past, including DVT in the setting of OCPs and smoking s/p coumadin, arterial thrombus and PICC associated clot, both occurring on her previous admission, and now with likely PE. The patient was found to have positive lupus anticoagulant on last admission. Heme was consulted and the lupus anticoagulant, anti cardiolipin antibody, and anti phospholipid panel were sent. The patient will follow up as an outpatient with hematology to determine the duration of her anticoagulation, and ultimately discuss whether lifetime anticoagulation is indicated. # hypotension: The patient was triggered for hypotension initially on the floor, was thought to be related to IV pain medications, as well as possible vasovagal episode. Pressures were otherwise stable during the admission, and she was started back on low dose metoprolol. Her lisinopril was held in the setting ___ (see below). She was also monitored on tele. # CAD s/p STEMI: During recent hospitalization found to have STEMI, subsequent ECHO with EF of 40% with systolic dysfunction. EKG on this admission with no new ischemic changes, CK-MBs flat, trops 0.06-0.07 in the setting of her CKD. The patient was continued on her ASA. Her metoprolol and lisinopril were both initially held. The patient's metoprolol was restarted a lower dose, but her lisinopril was held in the setting of ___. She was continued on her atorvastatin 80 mg daily. # thrombocytopenia: Likely in the setting of her congential hepatic fibrosis and resulting portal HTN and splenomegaly. As per heme recommendations, it was ok to start heparin drip in the setting of thrombocytopenia. ___ in setting of PCKD: The patient has baseline creat 1.7-1.9, but notable for fluctuance in the past. Creat bumped to 3.2, renal U/S and doppler flow reassuring. Creat was trended and medications were renally dosed, and nephrotoxic agents were avoided. Upon discharge, the patient's creat had returned to its baseline. # congenital hepatic fibrosis: The patient has history of congenital hepatic fibrosis complicated by portal HTN, 2 cords of grade 1 esophageal varices, and splenomegaly. While she was anticoagulations, she was monitored for s/s of bleeding. # Depression/anxiety: The patient was continued on her home buproprion and sertraline. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ year old female with a history of AFib on Warfarin, hypertension, and hyperlipidemia now with unstable angina and an abnormal stress test yesterday at ___. She first noted the onset of chest pain about two weeks ago. She describes it as a central chest tightness without radiation that comes on with minimal exertion and goes away after a few minutes of rest. It is associated with dyspnea. Over the same time period, she was having increased symptoms from her atrial fibrillation with palpitations and tachycardia. Her Metoprolol succinate dose was increased from 100 mg PO daily to 150 mg PO daily and then to 200 mg PO daily. She saw her cardiologist, Dr. ___ also arranged for a stress test at ___ ___. The stress test was abnormal, and she was sent to the ___ for further evaluation. She was then transferred to ___ for further care. . In the ___ ___, she denied any current chest pain, tightness, or dyspnea at rest. Initial vital signs were T 97.3, HR 90, BP 158/93, RR 16, and SpO2 100% on 2L. Labs were notable for initial Troponin 0.01, second Troponin 0.02, mildly elevated K 5.4, and INR 1.6 below goal (held for likely cath). CXR showed moderate cardiomegaly without edema. EKG showed atrial fibrillation at 109 bpm, NA, NI, and nonspecific inferior ST-T changes. She was seen by Cardiology in the ___, who recommended admission and likely cardiac cath on ___. . She was admitted to Cardiology for further management of unstable angina with positive stress testing. Vitals prior to floor transfer were T 97.7 po, HR 103, BP 137/78, RR 28, and SpO2 97% on RA. On arrival to the floor, she reported feeling well with no current symptoms. In particular, cardiac review of systems was negative for current chest pain or dyspnea, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope, or presyncope. She does have mild ___ edema for which she takes Furosemide 40 mg PO PRN. She has not needed any recently. When tachycardic from her atrial fibrillation, she sometimes feels palpitations, but does not have any currrently. . On further review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools, or red stools. She denies recent fevers, chills, or rigors. She denies exertional buttock or calf pain. Radiology showed Moderate cardiomegaly, but no evidence for pulmonary edema. The patient was diagnosed with INTERMED CORONARY SYND, ABN CARDIOVASC STUDY NEC. The patient was treated with cardiac cath. At the time of discharge, the patient had unstable angina. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient is a ___ year old female with a history of AFib on Warfarin, hypertension, and hyperlipidemia who presents with new unstable angina and an abnormal stress test performed at ___ ___. . #Unstable Angina/CAD- The patient reported new exertional chest pain and SOB over the last two weeks prior to hospitalization. A stress testing at ___ was reportedly positive, and she was sent to ___ for further workup. She continued to have chest pain with minimal exertional with no EKG changes. Her troponin trending upward from 0.01->0.02->0.03->0.03. She was taken for cardiac cath that revealed two vessel coronary artery disease with severe apical LAD lesion and diffusely disease mid-distal LAD not favorable for PCI due to length of disease or CABG given absense of graftable target in the mid-distal LAD. She was started on aspirin 325mg daily, clopidogrel 75mg daily, atorvastatin 80mg dialy, and isosorbide mononitrate 30mg dialy. She will need further medical optimization as an outpatient. . #. atrial fibrillation- The patient has a history of atrial fibrillation treated with Warfarin, Metoprolol succ 200mg daily, and Sotalol. She had inadequate rate control and was uptitrated to metoprolol tartrate 200mg BID, which acheived good rate control (80-90's on tele). Her INR was subtherapeutic at 1.6 on initial labs, but was held pending cardiac cath. The patient was started on Pradaxa 150mg BID the night after her cath. She was discharged on sotalol 120mg BID and metoprolol succinate 400mg daily. . #. hypertension- The patient demonstrated elevated systolic blood pressure to the 170-180's. She was started on lisinopril and uptitrated to 20mg dialy prior to discharge. She was discharged on metoprolol XL 400mg, Imdur 30mg daily, and lisinopril 20mg daily for BP control. She should follow up with her PCP for further optimization for her hypertension. . #. Hyperlipidemia:She has been on Simvastatin 80 mg, but will be switched to Atorvastatin to optimize cardioprotection. . #. thalassemia- prior diagnosis. Her CBC demonstrated microcytic anemia with HCT in mid to upper 30's. She should f/u with her PCP for further evaluation and treatment.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Mr. ___ is a ___ with significant past medical history of HTN, schizophrenia who presented with a syncopal episode. Radiology showed The distal right clavicle may be minimally high-riding in relation to the acromion although not well assessed on this study. If there is clinical concern for right acromioclavicular joint injury, suggest dedicated imaging. Radiopaque foreign densities are seen projecting over the proximal left femur and proximal medial left thigh. No obvious fracture or dislocation is seen. SHOULDER ___ VIEWS NON TRAUMA RIGHT showed No previous images. There is separation of the AC joint with elevation of the distal clavicle, consistent with an AC subluxation. No evidence of acute fracture. CT HEAD W/O CONTRAST showed 1. Left linear temporal hyperdensity concerning for acute subarachnoid hemorrhage. Follow-up imaging recommended to ensure appropriate resolution status-post trauma. No mass effect. 2. Post-right frontal craniotomy changes and encephalomalacia. 3. No acute fracture. CT C-SPINE W/O CONTRAST showed 1. No acute fracture of the cervical spine. 2. Multi-level degenerative changes with mild anterolisthesis of C4 on C5, which may be chronic and degenerative; however acute process cannot be excluded without prior images. Correlate with clinical assessment to guide the need for further imaging. If ligamentous or spinal cord injury is of concern, MRI is more sensitive. The patient was diagnosed with TRAUMATIC SUBDURAL HEM, UNSPECIFIED FALL, ALTERED MENTAL STATUS . At the time of discharge, the patient had Primary Diagnoses ================== Syncope Orthostatic Hypotension Fall traumatic ___ Secondary Diagnoses =================== C4 on C5 anterolithesis Schizophrenia Delirium Abnormal EKG: RBBB, left anterior fascular block, ?nodal conduction disease Elevated CK 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>Mr. ___ is a ___ with history of HTN, schizophrenia transfered from ___ Unit after a witnessed syncopal episode. # Syncopal episode: Mr. ___ was folding laundry at ___ ___ when he fell and struck his head. He had LOC for 10 minutes and altered mental status. He had no witnessed seizure activity. He was transfered to ___ with stable vital signs. Labs taken the ED were unremarkable, and he was evaluated for trauma with CT-Head and Spine, CXR, Pelvic XR. CT Head showed a small subarachnoid hemorrhage, which was likely a result of his head strike and which would not have contributed to altered mental status. Neurosurgery evaluated the patient and made recommendation for Keppra seizure prophylaxis 500mg BID x7days, 24hr observation, but no other follow up needed. Cardiogenic cause of syncope was ruled out with EKG and ECHO. The patient was kept on tele and had no events. Patient tox screen was negative. The patient had orthostatic hypotension, and it's possible this was an orthostatic episode complicated by head strike. We repleted him with IV fluids. #C4 on C5 anterolithesis: CT C-spine showed multi-level degenerative changes mild anterolisthesis of C4 on C5 -probably degenerative, but acute process cannot be excluded without prior images. Patient had no spine tenderness, full range of motion, no neurlogic deficits, no distracting injuries, and C-collar was removed when his mental status stabilized. #Subarachnoid hemorrhage: Small traumatic subarachnoid hemorrhage was seen on CT Head. Neurosurgery evaluated patient and felt no acute intervention was appropriate given size of hemorrhage, and that such a small hemorrhage would not explain mental status change. Patient had q4h neuro checks x24 hours, and was placed on seizure prophylaxis, Keppra 500 BID x 7days, and seizure precautions. Ibuprofen held. # Schizophrenia: Patient has history of schizophrenia and was being treated at ___ for psychosis since ___. We continued his haldol 5mg PO BID, but he refused many doses. No other psychopharm was given to the patient due to his refusal. # Delirium: Patient had waxing and waning mental status consistent with delirium. He was seen by psychiatry who agreed with keeping his on haldol 5mg BID. Nursing measures were taken to reduce delirium risks. # Abnormal EKG: EKG showed RBBB and diffuse ST elevations with question of PR prolongations concerning for nodal conduction disease. TTE showed no wall motion defects, no valvular defects, nl HF. BNP and trops were neg x2. QTc 362. Patient had no episodes of arrhythmias on tele. No interventions were done. # Rhabdomyolysis: Patient had elevated CKP 1514, most likely do to use of physical restraints prior to ___ admission. He was given IVF, and Cr was stable 0.9-->0.7. CK trended down. # Right shoulder sublaxation: Noted on imaging. Had altrecation with ___ with resultant injury. Previously controlled with Ibuprofen, but held in setting of bleeding. Tramadol was given in house. Patient should have outpatient orthopaedics visit for further management. # Hypertension: cont'd home amlodipine, lisinopril # CODE STATUS: Presumed Full # CONTACT: ___ ___ ask for nursing supervisor, ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Mr. ___ is a pleasant ___ man with HTN who presents with a right facial droop. Radiology showed The tip of the nasogastric tube projects over the upper stomach. CHEST (PORTABLE AP) showed No acute pulmonary disease. Radiology showed Enteric tube can only be seen to the level of the low mediastinum though this may be due to overlying soft tissue structures. If desired upper abdominal film can be performed to clarify. CHEST PORT. LINE PLACEMENT showed Tip of the enteric tube can be reliably traced to just distal to the GE junction however suboptimal quality of the images make accurate assessment difficult. Radiology showed Consistent aspiration of thin liquids and intermittent aspiration of nectar thick liquids. Please note that a detailed description of dynamic swallowing as well as a summative assessment and recommendations are reported separately in a standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation Services). Radiology showed New enteric tube terminates within the stomach. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. 4.0 cm focus of intraparenchymal hemorrhage centered in the left external capsule, mildly increased in size. No midline shift. No evidence of an underlying vascular abnormality. No significant stenosis, dissection or aneurysm greater than 3 mm. 2. Moderate centrilobular emphysema at the lung apices. RECOMMENDATION(S): Multilevel degenerative changes throughout the cervical spine, more significant at C6-C7, and C7-T1 levels, partially evaluated in this exam, if clinically warranted correlation with MRI of the cervical spine is recommended. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed -Slight interval increase in size of left frontoparietal parenchymal hematoma, now measuring 4.5 x 3.5 x 2.6 cm, previously measuring 4.0 x 3.4 x 2.6 cm. -No abnormal enhancement to suggest underlying mass or evidence of arteriovenous malformation. -Finding of surrounding peripheral slowed diffusion could be secondary to pressure ischemia from the hematoma, although there is a 1.0 x 0.9 focus of acute ischemia along the posteromedial margin of the hematoma in the left centrum semiovale. -Likely small intraventricular hemorrhage layering in the right occipital horn. RECOMMENDATION(S): Repeat imaging in 3 months after resolution of the acute course of the patient's symptoms is recommended for the better evaluation of possible underlying mass. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 5:26 pm, 5 minutes after discovery of the findings. The patient was diagnosed with Weakness. At the time of discharge, the patient had left frontoparietal intraparenchymal hemorrhage. hyptertension oropharyngeal dysphagia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ man with history of uncontrolled HTN who initially presented with right face and arm weakness and was subsequently found to have a left frontoparietal intraparenchymal hemorrhage. #Left frontoparietal IPH: The hemorrhage was thought to be secondary to hypertension as patient's systolic blood pressures were initially greater than 200. He also has longstanding history of hypertension but has not been on medication because he has not regularly seen a doctor. Patient underwent MRI to evaluate for other causes of hemorrhage but there was no evidence of underlying mass or vascular malformation. A repeat MRI is recommended in 3 months. Patient was evaluated by speech therapy, occupational therapy, and physical therapy who recommended rehab. #Hypertension: Patient initially required nicardipine infusion to maintain SBP less than 150. He was then transitioned to oral antihypertensives. Blood pressures were well controlled on lisinopril and labetalol at time of discharge. Echo was done because of longstanding hypertension. Echo showed normal EF. IT also showed a mildly dilated ascending aorta. A follow-up echocardiogram is suggested in ___ year. #Oropharyngeal dysphagia: patient initially failed swallow eval so NG tube was placed. On subsequent evaluations, his swallowing improved and he was advanced to modified diet. He was tolerating modified diet so NG tube was removed. # Alcohol use disorder: Patient endorsed drinking several beers per night so he was initially placed on CIWA protocol. He never exhibited signs of withdrawal. ========================================================= Transitional Issues: [ ] monitor blood pressure. titrate medications as needed [ ] repeat MRI in 3 months [ ] PCP follow up [ ] Neurology Follow Up [ ] repeat echo in ___ year ========================================================= AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () 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? (x) Yes - () No </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ woman with a history of HTN and chronic pain, s/p spinal cord stimulator implantation with battery pack revision last month ___ wound dehiscence, presenting with a complaint of chest pain x10d. Patient fell 10 days ago and landed on her hands, causing her left elbow to impact her left side. Since that fall she has had pain and tenderness under her left breast, on the left side of her sternum, and more recently in the middle/upper back at midline. She denies head impact or LOC in the fall, said she felt briefly dizzy and weak but cannot identify other precipitant. Pain is worse with certain body positions and deep inspiration, relieved by repositioning and only minimally on her current pain regimen. Pt presented to ED today on recommendation from her pain ___ evaluation prior to being seen by a specialist here for adjustment of pain meds. She had no acute change in her condition that precipitated her visit. In the ED, initial vital signs were T97.8 P80 BP102/42 R16 O2 sat 100% on RA. Patient was given IV dilaudid 2mg x 3 and a dose of her home medications. Labs remarkable for CXR showed no fractures or acute processes. EKG was NSR. Plan was to discharge patient with outpatient follow-up for pain management, however prior to discharge bilateral lower extremity edema was noted. Per patient, she first noticed this last night. She denies fever/chills, recent cuts, or recent pain in her legs. She notes one lesion on middle of right shin that she thinks was a recent mosquito bite. She feels her anterior lower legs are tender bilaterally. Lower extremity dopplers were negative for DVT. Radiology showed No evidence of deep vein thrombosis in the right or left lower extremity. Peroneal veins not well seen. Radiology showed 1. No CT evidence of osteomyelitis in the thoracic spine. Please note intrathecal structures are not well evaluated with this modality and if there is continued concern, MR or nuclear medicine study can be considered if there is no clinical contraindication. 2. Stable positioning of spinal stimulator. No soft tissue abscess. Radiology showed No CT evidence of osteomyelitis or paraspinal abscess. Evaluation of intrathecal contents is limited with this modality. The patient was diagnosed with CELLULITIS OF LEG, CONTUSION OF CHEST WALL, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS. At the time of discharge, the patient had Primary Diagnosis: # SIRS related to cellulitis # Musculoskeletal chest pain Secondary Dianoses: # Chronic pain # Anxiety # Hypertension # Hypothyroidism # 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>___ woman with history of HTN, chronic pain, presenting with 10d chest pain s/p fall and found to have possible bilateral lower extremity cellulitis, managed with IV antibiotics, course c/b febrile episode with rigors, tachycardia and relative hypotension. Acute Issues ======== #Cellulitis c/b SIRS (sepsis): Though patient presented with chest pain, bilateral lower extremity edema was noted in the emergency room, prompting her admission to the hospital. She received 6 doses of IV vancomycin during her stay with rapid resolution of her erythema to her baseline venous stasis pattern. Patient was febrile to 102.9 overnight into HD2, with tachycardia and relative hypotension as low as SBP 105. She had received one dose of IV vancomycin prior to the episode. She rapidly defervesced and her hemodynamics stabilized. Blood cultures drawn during this episode were negative at time of discharge. She was seen by neurosurgery for evaluation of possible abscess or osteomyelitis related to her spinal stimulator, wound dehiscence, or recent battery pack relocation. Though ESR and CRP were elevated, CT of thoracic and lumbar spine were benign and showed her stimulator to be in place. Though patient had a recent tooth extraction, the surgical site appeared clean and non-erythematous. No other potential cause of her SIRS could be identified. She had been afebrile for 48 hours on day of discharge. She is being discharged on a course of PO antibiotics for cellulitis. #MUSCULOSKELETAL CHEST PAIN: Cardiac workup was negative, and her symptoms and history were consistent with her recent fall as the inciting event. She was continued on her home pain regimen and her discomfort was well-controlled throughout admission. #DYSKINESIA: Patient was given ropinirole initially on admission as this was on her medication list provided to our team. On the morning of HD2 she was noted to have intermittent myoclonus in the hands and feet. On further questioning, she reported having stopped her ropinirole some time ago. The medication was discontinued and her myoclonus rapidly resolved. Chronic Issues ========= #HTN: Patient was continued on her pre-admission amlodipine and lasix. #DEPRESSION/ANXIETY: Patient was continued on her pre-admission cymbalta, nortriptyline, and ambien. #CHRONIC PAIN: Patient was continued on her pre-admission pain regimen as above. Transitional Issues ============ - Patient would benefit from adjustment of her pain regimen, as she is reporting some unsteadiness, which may have contributed to her fall. - Please follow-up final results of blood cultures - complete course of antibiotics for cellulitis and f/u with PCP for resolution - f/u with ___ with Dr. ___ in approximately 2 weeks - referral to ___ Pain ___ (per pt request)</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p R ICA stent ___ c/b readmission for orthostatic hypotension (___) now xfer from OSH s/p fall in setting of presyncope. Pt underwent uneventful R ICA stent ___. Readmitted w presyncope ___. CTA obtained which showed widely patent stent. Found to be orthostatic. ACE inhibitor discontinued and diltiazem dose lowered. Discharged w ___ follow up with no documented episodes orthostatic hypotension through ___. This AM felt short of breath and dizzy. Reports that his "legs gave out" and he fell into stationary bike in his bedroom. Denies LOC. Took own BP after fall and claims it was "high." Brought by ambulance to OSH where CT head/neck was negative for acute process and CTA chest was negative for PE by report. Transferred to ___ for further management. Radiology showed mpression: Widely patent right ICA stent. Left ICA <40%. The patient was diagnosed with SYNCOPE AND COLLAPSE. At the time of discharge, the patient had 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>Mr. ___ was admitted for orthostatic hypotension. His blood pressure medications were adjusted. He was taken off flomax 0.8mg daily on this admission, and his diltiazem was decreased again from 120mg extended release daily, to 30mg short acting three times per day. His PCP, ___ was involved in the medication titration. He had a carotid duplex wich showed patent right internal carotid artery stent, and mild heterogenous plaque in the left common carotid with less than 40% stenosis. He continued to have some orthostasis with BP's on discharge of 131/180 hr 71 lying; 125/73 hr 75 sitting and 100/63 hr80 standing. He had very minor sypmtoms of a slight dizzy feeling when standing but this resolved when he rested for a few minutes. We educated him on the need to have his blood pressure checked often at home by a ___, as well as the need to rest for several minutes when transitioning from sitting to standing. Also once standing he needs to rest a minute before walking. He is able to comply with these instructions and is feeling well and stable for discharge home. He has close follow up with his PCP. He will follow up with vascular surgery in a month. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ year-old woman with a PMH of DM2, HTN, HLD who presented as OSH transfer with displaced left calcaneus fracture s/p fall from standing height. Patient was walking at home when she tripped and fell on a ___ rug, had immediate pain, swelling and inability to ambulate. Denied head strike or LOC. Taken to OSH where imaging revealed left calcaneus fracture and subsequently transferred to ___. Denied pain in any other anatomic location. Denied numbness, tingling, weakness. Radiology showed No evidence of acute cardiopulmonary process. CT left lower extremity. showed Fracture of the posterior superior calcaneus with a large avulsion fragment at the Achilles insertion. The patient was diagnosed with FRACTURE CALCANEUS-CLOSE, OTHER FALL. The patient was treated with ___: closed reduction and percutaneous pinning of left calcaneus. The patient was given written instructions concerning 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 directly transferred from an outside hospital and was evaluated by the orthopedic surgery team. The patient was found to have displaced left calcaneus fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for closed reduction and percutaneous pinning (CRPP) of the left calcaneus, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non weight-bearing in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ male with ___ Disease (s/p ileocolonic resection), h/o small bowel obstructions, admitted with progressive back and abdominal pain, consistent with prior small bowel obstructions in the past. He had an SBO in ___, but prior to that had gone a few years without any small bowel obstructions. . In regards to his ___ Disease, he is only on prednisone at present, with of pruritus from remicaid and skin cancer from imuran. He is in ongoing consultation with Dr ___ gastroenterologist here, regarding next plans for next therapies. . Abdominal pain much improved after receiving IV dilaudid. No fevers, nausea, vomiting, headache, mood changes, hematochezia. has severe pruruitus of bilateral Legs from knees down about 4x/week. No change in ostomy output. Radiology showed No acute intrathoracic process. Radiology showed Dilated small bowel 5.5 cm is concerning for possible small bowel obstruction despite air present in the colon. Consider CT or MRE for further assessment. Radiology showed Distended small bowel loops with associated air-fluid levels remain concerning for small bowel obstruction. Consider CT of the abdomen and pelvis for further evaluation, if warranted clinically. Findings communicated by telephone to Dr. ___ at 4:55 p.m. on ___ at the time of discovery. The patient was diagnosed with INTESTINAL OBSTRUCT NOS. At the time of discharge, the patient had 1. SBO 2. ___ 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>This is a ___ gentleman with a history of ___ disease, recurrent SBO admitted with abdominal pain. KUB shows dilated small bowel, but air remains in colon. # ABDOMINAL PAIN: Likely SBO in the setting of ___. Patient has had side effects from multiple ___ medications and as such, is just on prednisone. He will need to see his outpatient gastroenterologist about more definitive treatment for his disease. On this admission, patient was kept NPO and his diet was slowly advanced. Never had an NG tube placed. He was able to tolerate soft food on day of discharge. Of note, KUB on day of discharge did not demonstrate resolution of SBO and in fact, showed even less air in the colon. However, Mr. ___ felt well, had no pain or nausea, and was passing gas and having bowel movements. He insisted on going home although he was encouraged to stay one more night. Also told to just take in full liquids for now. He knows to call his outpatient GI team if his symptoms worsen. Mr. ___ requested a prescription for flagyl (he has used this for flares in the past) and was given this to take at home. Patient was taking prednisone 5mg QD at home. Dr. ___ was trying to taper this off. Patient received one dose of methylpred 20mg on admission, but no further steroids. He will be discharged without prednisone. GI had wanted patient to receive first dose of HBV vaccine during admission. Unfortunately, this was not coordinated before he was discharged. # PRURITIS: Treated with antihistamines and sarna lotion.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with asthma, menorrhagia/fibroids recently started on Provera here with calf pain since last ___. Pt had recent admission from ___ for symptomatic anemia and menorrhagia for which she received Provera and IV iron. Since that time she has been fatigued and less active around the house. ___ she noted acute onset of R-sided calf pain and swelling accompanied by subjective chills though no documented fevers. Denies antecedent trauma. She presented to the ER on ___ where U/S showed fluid collection, possibly a hematoma that was superinfected so she was discharged on Keflex. Since that time she has noted improvement of the swelling in her leg but progressive pain to the point where she was no longer able to put weight on her leg so she represented to the ER. No shortness of breath, cough, pleuritic chest pain, pain or swelling over ankle/knee joint, skin erythema, numbness/tingling, cold extremities. No personal or family history of clots. She has been less mobile due to fatigue over the past few weeks. Initial VS in the ED: 10 97.4 80 148/66 16 100% Labs notable for Hct 33 (improved from recent admission), all others wnl. RLE U/S showed 2.6x1.1 cm fluid collection (decreased in size) and possible adjacent DVT. Patient was given percocet x 2, lovenox and warfarin. On the floor, she notes ___ RLE pain, improved with elevation. Radiology showed 1. Previously described fluid collection in the right mid-to-distal posterior calf appears to correspond to a thrombosed deep calf vein, possibly the soleal vein. 2. Adjacent focal fluid collection measuring 2.6 x 1.8 x 1.1 cm. The patient was diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS. At the time of discharge, the patient had Primary diagnosis: deep vein thrombosis Secondary diagnosis: menorrhagia, iron deficiency anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx of asthma and menorrhagia on Provera here with R calf pain found to have a fluid collection and DVT on ___. . # DVT: Likely provoked by recent Provera use and relative immobilization from fatigue. Pt has no signs or symptoms of PE and no history of blood clots. She was started on lovenox bridge to warfarin. Her goal INR is ___. PCP office was contacted and appropriate follow up for anticoagulation was arranged. Pain was managed with standing tylenol and prn tramadol. . # ___ fluid collection: Unlikely to be infectious, more likely all related to DVT and decreasing in size. Discontinued Keflex. . # Menorrhagia: GYN team made aware of discontinuation of Provera. Iron supplements continued. Patient began to have withdrawal bleed on day of discharge which was mild. She was advised per the GYN team to call Dr. ___ she require more than one pad per hour for over one hour. . # Anemia: Follow up with GYN, continue iron supplements. Stable during this admission and has appointment with GYN on ___. . # Asthma: Continued home albuterol and monteleukast. . . Transitional Issues: - Communication: Patient, ___ (dtr) ___ - follow up with PCP, anticoagulation management - INR checks and warfarin dose adjustment</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: (History provided by the patient and his wife who are both ___ speaking but fluent in ___, and their son at the bedside) ___ WWII Veteran with PMHx of high risk prostate cancer treated with 12 weeks of radiation/hormonal therapy in ___ with residual generalized weakness who had 20 minutes of left sided weakness and garbled speech (he clearly was not making words properly, totally incomprehensible to his wife, he is unsure if he also had word finding difficulties). He woke up in his usual state of health at 9:30am. He took his omeprazole on schedule and had breakfast around 10am. He usual takes his verapamil after breakfast but yesterday he forgot. He got up, went to the bathroom where he urinated and had a bowel movement. Immediately after, he was getting ready to go to the bank with his wife when she found him walking in circles slouched over to the left as if he was searching for something. When he tried to talk, his words were garbled and he made no sense. He was still able to walk but was leaning to the left and appeared weak on the left side. She walked him over to the couch and gave him his blood pressure medication (verapamil ER 360). She believes his symptoms are secondary to him not getting his medication at the regular time. Within 20 minutes he was back to baseline. They told their son, whom they live with, that evening at 7:45pm. He told them to call his brother (their other son) who is a doctor in ___ for advice for what to do. The patient's son instructed them to see a doctor right away but the patient and his wife misinterpreted this to mean they should go call their PCP the next morning. When they called ___ this morning, the nurse instructed them to go to ___ ED immediately. Neurology was consulted for evaluation and work up of a possible stroke. CT HEAD W/O CONTRAST showed 1. No acute intracranial hemorrhage or mass effect. 2. Chronic small vessel ischemic changes and age appropriate atrophy. 3. Right mastoid and middle ear cavity opacification compatible with ongoing inflammation. RECOMMENDATION(S): MRI is more sensitive for the detection of acute infarction. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. MRI AND MRA BRAIN AND MRA NECK showed Small focus of diffusion abnormality at the left frontal convexity region could be due to a subacute infarct. No enhancing brain lesions. Mild atherosclerotic disease at the left carotid bifurcation otherwise normal MRA of the neck. Normal MRA of the head. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT, OTHER SPEECH DISTURBANCE, MUSCSKEL SYMPT LIMB NEC, SKIN SENSATION DISTURB. At the time of discharge, the patient had 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 ___ ___ WWII Veteran with PMHx of high risk prostate cancer, HTN, central retinal vein occlusion and fall with head strike without loss of consciousness one week prior who presented to the ___ ED one day after a 20 minute episode of sudden onset left sided weakness and garbled speech. Head CT was obtained that showed no acute intracranial hemorrhage, mass effect or any evidence of an acute large territorial infarction. However, because of the sudden onset and the left sided symptoms, he was admitted to the stroke neurology service for workup. MRI/MRA head was performed to assess for stroke with revealed a small focus of diffusion abnormality at the left frontal convexity region consistent with a subacute infarction. MRA of the head did not reveal any major abnormalities.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with H/O hypertension, NSVT who presents with cough and chest pain. CHEST (PORTABLE AP) showed As above. BILAT LOWER EXT VEINS showed Positive right calf acute deep vein thrombosis in at least one of the paired posterior tibial veins. NOTIFICATION: The findings were discussed with ___. ___ , ___. by ___. ___, M.D. on the telephone on ___ at 4:49 pm, 5 minutes after discovery of the findings. CT ABD AND PELVIS WITH CONTRAST; CT CHEST W/CONTRAST showed Large 4.8 x 2.7 cm hypodense lesion within the right atrium could represent a thrombosed however mass cannot be excluded. Correlation with ECHO and/or further evaluation with an MRI may be helpful for to distinguish between the 2. Small bilateral pleural effusions with bibasilar atelectasis. No evidence of a pneumonia. Consolidative opacity in the left lower lobe most likely represents subsegmental atelectasis. NOTIFICATION: The findings were discussed with Dr ___, M.D. by ___, M.D. on the telephone on ___ at 8:28 am, 2 minutes after discovery of the findings. CT ABD AND PELVIS WITH CONTRAST; CT CHEST W/CONTRAST showed Large 4.8 x 2.7 cm hypodense lesion within the right atrium could represent a thrombosed however mass cannot be excluded. Correlation with ECHO and/or further evaluation with an MRI may be helpful for to distinguish between the 2. Small bilateral pleural effusions with bibasilar atelectasis. No evidence of a pneumonia. Consolidative opacity in the left lower lobe most likely represents subsegmental atelectasis. NOTIFICATION: The findings were discussed with Dr ___, M.D. by ___, M.D. on the telephone on ___ at 8:28 am, 2 minutes after discovery of the findings. The patient was diagnosed with Unspecified atrial fibrillation. At the time of discharge, the patient had -Atrial fibrillation, paroxysmal, with rapid ventricular rate -Acute left ventricular systolic heart failure with reduced ejection fraction -Right atrial thrombus -Right calf acute deep vein thrombosis -Hypertension -Hyperkalemia -Musculoskeletal chest pain -Escherichia coli urinary tract infection -Vitamin D deficiency. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ yo woman with a history of hypertension who presented with cough and chest pain, found to be in atrial fibrillation with a rapid ventricular rate and acute HFrEF (LVEF 20%). Chest CT on ___ and then TEE on ___ showed a right atrial appendage thrombus and so cardioversion was deferred. Lower extremity ultrasound ___ showed right DVT, but CT torso with contrast with no signs of malignancy. Her atrial fibrillation and acute systolic heart failure were medically managed; patient discharged with PCP and cardiology follow up. # Atrial fibrillation with RVR: She has no known history of atrial fibrillation and presented with palpitations for the prior ~3 days. Unclear precipitant though could be secondary to recent URI and viral cardiomyopathy; history of negative coronary angiography in ___, so less likely to be ischemic. Of note, she complained of palpitations to her PCP in ___, though unclear whether these were undiagnosed atrial fibrillation vs. NSVT. She was initially given diltiazem in the ED, with plan for cardioversion. However, ___ demonstrated RA thrombus and so cardioversion was deferred given risk of pulmonary embolus. Additionally, amiodarone was deferred given 20% risk of chemical cardioversion. Therefore atrial fibrillation was managed medically with rate control and anticoagulation without attempt at rhythm control. She was initially difficult to rate control despite therapeutic digoxin and increasing doses of metoprolol tartrate, ultimately at 50 mg q6h. Due to persistent tachycardia in the 130s-160s, diltiazem was initiated on ___ and ultimately uptitrated to 30 mg q6h with good effect, keeping in mind her depressed LVEF, a relative contraindication to diltiazem or verapamil. At discharge, she continued to be in atrial fibrillation but was rate controlled well, with ventricular rates in the ___ at rest. For rate control she was discharged on digoxin 0.125 mg every other day and diltiazem ER 120mg daily. Her home metoprolol succinate dose was increased from 100mg to 200mg daily. She was anticoagulated with dabigatran 150 mg bid. She will follow up as outpatient with Dr. ___ potential outpatient TEE/cardioversion once anticoagulated x 4 weeks. # DVT and right atrial appendage thrombus: CT ___ and TEE ___ with 3x1.9cm RA thrombus, ___ ___ with right posterior tibial DVT. Given that the RA thrombus was nestled against the cardiac wall and not free-floating, and no signs of extension from the IVC, it was felt to be likely secondary to atrial fibrillation rather than an embolus from DVT, IVC, or elsewhere. The patient was initially started on rivaroxaban 20 mg daily but was subsequently switched to dabigatran 150 mg BID given potential for enhanced anticoagulation with BID dosing and higher potency. She tolerated this well with no issues. Diagnostically, these concurrent blood clots, with history of prior thrombophlebitis in ___, are concerning for a hypercoagulable state. The differential includes inherited/sporadic thrombophilia and malignancy. Antiphospholipid testing (cardiolipin Abs, beta-2-glycoprotein Abs, lupus anticoagulant) was negative. We deferred rest of thrombophilia workup to outpatient setting once clots resolve. In regards to malignancy, she had no evidence on CT chest-abdomen-pelvis, but could still ___ a cancer somewhere, such as the colon. She stated she is up to date on mammograms but not colon cancer screening or pap testing. Of note, she has had 10-pound weight loss since ___ and complains of decreased appetite. There is a family H/O gastric cancer in her mother. She was discharged on dabigtran 150 mg BID, a new medication. # Acute HFrEF. Previously normal LVEF (___), now with LVEF 20% on TTE ___, with elevated pro-BNP but normal troponin-T. The etiology was not entirely clear. Distribution of hypo-/akinesis somewhat consistent with Takotsubo; could be tachycardia-induced cardiomyopathy from atrial fibrillation with RVR. Alternatively, viral cardiomyopathy (given recent URI) might have triggered new atrial fibrillation. Cardimyopathy likely non-ischemic given reportedly normal coronary angiography ___. She had mild volume overload on exam with shortness of breath and received intermittent diuresis with furosemide boluses with good effect for her diastolic heart failure. She was also started on captopril, later switched to lisinopril 5mg, for afterload reduction given reduced EF, though this was discontinued on day of discharge due to hyperkalemia to 5.6. She was discharged home on furosemide 60mg PO daily, a new medication, as well as diltiazem, digoxin, and metoprolol succinate as above. # Hyperkalemia: Patient had potassium of 5.6 on ___, repeat whole blood sample was normal at 4.2. Chemistry ___ again showed hyperkalemia to 5.5, repeat whole blood sample was 4.9. This is most likely secondary to ACE-inhibition and so lisinopril was discontinued. BUN/Cr within normal limits therefore not due to renal insufficiency, also no signs/symptoms of digoxin toxicity and on a very low dose so dig toxicity highly unlikely. Potassium should be monitored as an outpatient, please check this value at PCP follow up on ___. # Chest pain: On admission, patient presented with atypical, nonexertional pain, with chest wall tender to palpation, and was diagnosed with musculoskeletal pain. Troponin-T and CK-MB were negative in the ED and again on ___ and ___, and EKG showed no acute ST changes. History of coronary angiography in ___ with reportedly no CAD. Therefore pain felt to be most likely musculoskeletal, secondary to coughing given persistent URI. She was given acetaminophen and lidocaine patches as needed with good effect. If chest pain persists as outpatient, cardiology can consider outpatient stress testing. # E. coli uncomplicated UTI: She spiked a fever to 102.2 on ___ and had UA with WBCs and +nitrites and urine culture growing E coli. She was asymptomatic, with no dysuria or flank pain. However, given her persistent atrial fibrillation with RVR, with cardioversion not an option, it was felt to be reasonable to treat a potential infectious source to limit any ongoing triggers for her AF and decrease her cardiovascular demand. She was initially started on IV ceftriaxone and then switched to Bactrim given pan-sensitive E. coli for a total 3-day course and remained afebrile and asymptomatic. # Hypertension: Patient has history of hypertension, on amlodipine and metoprolol at home. Amlodipine was stopped because of diltiazem use for synergy in rate control. Captopril was added for LVSD. She was discharged home on metoprolol succinate 200 mg daily as above (up from 100 mg on admission), diltiazem and captopril. TRANSITIONAL ISSUES [ ] Hyperkalemia on day of discharge (5.5) and day prior (5.6), so lisinopril discontinued. Please recheck K at PCP follow up on ___ to ensure normal value. [ ] Consider completing hypercoagulability workup: Protein C/S deficiency, factor V leiden, antithrombin deficiency, prothrombin gene mutation testing. For malignancy workup: colonoscopy, pap testing, mammogram. [ ] Dr. ___ office to arrange cardiology follow up [ ] New medications: Furosemide 60 mg daily, digoxin 0.125 mg q2d, dabigatran 150 mg bid, diltiazem ER mg 120 daily [ ] Changed meds: Metoprolol succinate 200 mg daily (from 100 mg daily) [ ] Discontinued meds: amlodipine [ ] Discharge weight: 59.2 kg [ ] Discharge Cr: 0.7 # CODE STATUS: Full code (confirmed) # CONTACT: ___ (daughter) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a pleasant ___ year-old gentleman with history of CAD s/p DES x1 several years ago who presents with left chest pain. The patient is a reliable historian, and was accompanied by his family, who provided additional details to this intake. The patient states that his symptoms began several months ago, with intermittent chest pain worsened by cough with occasional production of phlegm. He lives in ___ for several months of the year, and had these symptoms there and sought medical attention and was prescribed cough medicine that 'was too expensive' and thus did not pursue any care as aggressively within the next few months. Radiology showed 1. No acute intracranial abnormality. 2. No CT evidence of metastatic disease in the brain. The patient was diagnosed with CHEST SWELLING/MASS/LUMP, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had lung mass. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the thoracic surgery service with a new diagnosis of a lung mass. There was concern on the OSH CT chest of a pulmonary embolism but upon review with our radiologists this was not the case. While here he started a pre-op workup for lung mass resection. He underwent a CT head with contrast (final read pending). He also met with the interventional pulmonologists who scheduled an appointment for bronchoscopy on ___. He will go home and get the remainder of the requested studies there. (LFTs, VQ scan, PET scan) While in the hospital he remained afebrile with stable vital signs. He had serial tropnins which were negative. He tolerated a regular diet and had normal bowel and bladder function.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ w/ hx of afib (recently started on warfarin and sotalol 2 weeks ago), hx of dvt, who s/p bunionectomy on left foot on ___ who presents with n/v, inability to tolerate po meds, and dyspnea. Pt had been feeling well until mid day ___ when she developed nausea and overnight had several episodes of non-bloody emesis. She has been unable to tolerate meds and has developed ___ pain at left bunionectomy site. She has not experienced any diarrhea, has not passed stool since surgery. She has not experienced any sf/chills/sweats. No sick contacts. Additionally, she has also developed progressive dyspnea since operation. She notes feeling slight sob following procedure but became much worse on ___. Dyspnea worse with exertion. Not associated with chest pain, lh, dizziness. She has experienced episodes of palpitations. ___ came to her house on sat and found her to be bradycardic between 45-50. She has not had any complications at surgical site aside from pain. On arrival to the ED, intial vitals 9 98.6 60 118/53 18 98%. Labs were notable for nml chem 7, hgb 11.2, no leukocytosis, BNP 1546, trop neg. She was intially give a 1L NS bolus but was subsequently found to have CXR and exam consistent with pulmonary edema. Following bolus, she transiently dropped sat to 78 but improved with 20mg IV lasix. She was given 2mg dilaudid, 1g cefazalin, aspirin, sl ntg, and zofran. On arrival to the floor, she is feeling improved. Dyspnea, nausea, and foot pain are all doing better. She denies any cp,lh, dizziness, abdominal pain. Radiology showed 1. Findings suggestive of mild pulmonary edema and right greater than left effusions. 2. Calcific density projecting over the abdomen on the lateral view is of uncertain etiology. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. Radiology showed 1. No findings to suggest pulmonary embolism. 2. Moderate bilateral pleural effusions with bibasilar atelectasis. 3. Multiple small hypodensities seen within the liver, which are incompletely characterized, abdominal ultrasound is recommended for further assessment of these liver lesions. 4. Right lobe of thyroid nodule, for which a thyroid ultrasound is recommended for further evaluation. 5. Nodular asymmetry within the left breast, for which correlation with mammography is recommended. Findings discussed with Dr. ___ at 14:30 on ___, 1 hour after discovery of the findings. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, PAIN IN LIMB, ABN REACT-PROCEDURE NOS. At the time of discharge, the patient had Primary diagnosis: - acute diastolic congestive heart failure - atrial fibrillation - constipation Secondary diagnoses: - 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>PRIMARY REASON FOR ADMISSION: Ms. ___ is a ___ with a history of atrial fibrillation (recently started on warfarin and sotalol 2 weeks ago) and DVT many years ago who had a bunionectomy on left foot on ___ who presented with shortness of breath and evidence of heart failure on exam. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old healthy male who presents with right ankle pain and swelling after rolling his ankle while hiking in ___ 2 days ago. He reported immediate pain and inability to bear weight following the injury. He chose to postpone seeking care until arriving home. He reports significant ecchymosis and swelling. He denies any numbness or tingling distally. This is an isolated injury, he denies pain elsewhere. Intraoperative fluoroscopy of the right ankle. showed Open reduction internal fixation of the distal fibula. CT LOW EXT W/O C RIGHT Q61R showed 1. Comminuted fracture of the right posterior malleolus with intra-articular extension. The main fracture fragment measures up to 2.4 cm. 2. Obliquely oriented fracture of the right distal fibula with mild posterior inferior displacement of the distal fragment. A 1.2 cm fracture fragment anterolateral to the talus likely originates from the distal anterior fibula. 3. 7 mm fracture fragment in the expected location of the anterior talofibular ligament may reflect an avulsion injury. ANKLE (AP, MORTISE AND LAT) RIGHT showed Acute, mildly displaced posterior malleolar fracture with evidence of ankle instability, including suspected injury to the distal tibiofibular syndesmosis and deltoid ligament. Nondisplaced distal fibular fracture. DX TIB/FIB AND ANKLE showed Status post closed reduction of posterior malleolar fracture with intra-articular extension, now in near anatomic alignment. No proximal fibular fracture is seen. Distal fibular fracture is better assessed on the prior CT scan. The patient was diagnosed with Displaced bimalleolar fracture of right lower leg, init, Overexertion from prolonged static or awkward postures, init. The patient was treated with Status post right ankle ORIF. At the time of discharge, the patient had Right trimalleolar ankle fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right trimalleolar ankle fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right ankle 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'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 nonweightbearing in the right lower extremity, and will be discharged on lovenox x2 weeks then asa 325 x2 weeks for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old woman s/p MVR on ___ with a mechanical valve with Dr. ___. She now returns to the emergency department with shortness of breath and inability to lie flat. A bedside echo completed by residents in the ED showed a moderate pericardial effusion. Her vitals are as follows: HR 66 BP 126/65 RR 18 O2Sat 98%RA NSR. She appears comfortable, lungs are clear to auscultation bilaterally, heart sounds regular, normal active bowel sounds, 1+ ___ edema. Her wound is clear, dry, intact. Her sternum is stable. Her chest radiograph revealed a small left effusion. Radiology showed Persistent bilateral pleural effusions, not significantly changed. The patient was diagnosed with Dyspnea, unspecified. At the time of discharge, the patient had AFib - Mitral regurgitation - Pulmonary Hypertension - Hypertension - Asthma with DLCO decrease, no recent PFTs - Hyperlipidemia - History of TIA ___ (thought to be secondary to tamoxifen) - History of left temporal CVA ___ - reports ongoing mild cognitive delays, difficulty focusing, and difficulty with reading. - GERD - History of Hodgkin's Lymphoma ___, s/p radiation - Diabetes, new diagnosis not yet started on any medications - Chest pain syndrome - LCIS / breast calcification- treated with Tamoxifen for chemoprevention - Anemia, no GI source identified, now resolved - Depression/Anxiety - Hypothyroid st Surgical History: s/p Splenectomy s/p Hysterectomy s/p Myomectomy s/p C7 fusion s/p Nissen fundoplication ___ s/p Tonsillectomy s/p Appendectomy. The patient was given written instructions concerning 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 for further evaluation. Echo done by Cardiology showed no tamponade physiology. Coumadin continued for mechanical valve. She developed AFib with rapid response. EP was consulted. Amiodarone started. She became tachy-brady and lopressor was discontinued. EP did not recommend a permanent pacer. She will be discharged with ___ of Hearts monitor to be managed by Dr. ___. She is discharged on hospital day five with follow-up instructions. Dr. ___ continue to manage anti-coagulation. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year-old-woman in senior living housing with ___ weekly ADL assistance as well as PMH of HTN, well controlled Diabetes Mellitus, hypothyroidism bilateral knee replacement who presents with left knee pain and shoulder pain after falling while using her walker at home. CT HEAD W/O CONTRAST Q111 CT HEAD showed Small amount of induration overlying the left frontal and parietal calvarium. No evidence of underlying fracture or intracranial hemorrhage. CT C-SPINE W/O CONTRAST Q311 showed Minimal anterolisthesis of C4 on C5, likely degenerative, however there are no priors for comparison. No evidence of fracture. KNEE (AP, LAT AND OBLIQUE) BILATERAL showed Bilateral knee prostheses, in near anatomic alignment without evidence of hardware related complications or periprostatic fractures. The patient was diagnosed with Acute kidney failure, unspecified, Anemia, unspecified, Weakness, Syncope and collapse. At the time of discharge, the patient had Fatigue Fall. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year-old-woman in senior living housing with ___ weekly ADL assistance as well as PMH of HTN, well controlled Diabetes Mellitus, hypothyroidism bilateral knee replacement who presents with left knee pain and shoulder pain after falling while using her walker at home. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ year old woman with history of microcephaly, global developmental delay (nonverbal at baseline and completely dependent on others for all ADLs), cerebral palsy, spastic quadriparesis and wheelchair bound, who presents with brekathrough seizures in the context of nausea/vomiting. History provided by collateral from caretaker from facility. Radiology showed No evidence for bowel obstruction or ileus. CHEST (PORTABLE AP) showed Low lung volumes with hazy bibasilar opacification, likely atelectasis, without focal consolidation. Radiology showed Lungs are low volume with bibasilar atelectasis. There is stable elevation of the right hemidiaphragm. Heart size is normal. There is no pleural effusion. No pneumothorax is seen The patient was diagnosed with Local-rel symptc epi w cmplx prt seiz,not ntrct,w/o stat epi, Vomiting without nausea. At the time of discharge, the patient had Seizure Gastroenteritis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ woman with severe intellectual disability, microcephaly, and spastic cerebral palsy, intractable epilepsy with frequent seizure clusters and status epilepticus in the setting of infection (likely gastroenteritis), now admitted with a cluster of seizures and vomiting. #Breakthrough seizures Infectious workup was unremarkable (UCx, CXR, BCx). She was on Unasyn for several days but this was stopped given no clear infectious etiology. Her Keppra 2g BID and Vimpat 150 mg BID were switched to IV formulation given her emesis. Her zonisamide 400 mg QHS was continued in G tube formulation. Her EEG showed no seizures, but did show generalized R>L spike and spike and wave discharges and slowing R frontal central area. Her tube feeds were resumed and after she tolerated feeds for 24 hours, Vimpat and Keppra were returned to G tube formulation. She remained without further emesis throughout her hospitalization. She has brief eye deviation to the right at times throughout the day, which her mother reports are seizures. These are at baseline. #Constipation She intermittently had constipation which was resolved with a bowel regimen (see medication worksheet). She was having near daily bowel movements prior to discharge. TRANSITIONAL ISSUES: ==================== Follow-up with epilepsy as an outpatient No changes made to her AEDs Ensure daily bowel movement Check chem 10 once a week to assess need for mag or K+ repletion</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 recent hospitalization for abdominal pain s/p abdominal mass biopsy who now presents due to odynophagia and inability to tolerate PO intake. Patient was discharged on ___ after a 10 day stay ___ - ___ for abdominal pain of unknown etiology. She has known abdominal mass abutting stomach which was biopsied in ___ (pathology inconclusive) and re-biopsied ___ (FNA negative for malignancy), one day prior to recent admission. Post biopsy she was experiencing ___ abdominal pain and was admitted for further work up. Multiple services were consulted during recent admission, including GI and surgery and ultimately it was felt that her pain was likely unrelated to mass. She was discharged with plan to complete 14d course of Cipro/Flagyl for possible infected cyst, with close surgery/GI follow up. Of note, patient has prior admissions and history of abdominal pain dating back years thought to be due secondary to IBS vs somatoform symptom disorder vs gastroparesis vs postcholecystectomy syndrome vs constipation. She also has extensive psych history and her outpatient psych NP has expressed concern that she is drug seeking. Patient returned to ___ one day post discharge and was diagnosed with thrush, started on Nystatin PO. She returned today with complaints of aspiration and persistent severe pain with swallowing solids and liquids. In the ED, initial vitals: afebrile, normal bp, no tachycardia, on room air - Exam notable for: "Severe thrush to posterior palate" - Labs notable for: Lactate 2.2, WBC 9.4 N 74, BMP at her baseline - Imaging notable for: CXR showing minimal nodular opacity in the right mid lung likely reflecting trace aspiration. - Pt given: Zofran and admitted to medicine for further work up. On arrival to the floor, pt reports pain with swallowing both solids and liquids which began the night she was discharged from the hospital. This morning she felt as if her antibiotic pills got "stuck" on the way down. Pain extends from her throat, down her esophagus and is constant in nature. She tried nystatin x 1 but vomited after swallowing it and has not used it since. No fevers, chills or cough and abdominal pain is at baseline. CHEST (PA AND LAT) showed Minimal nodular opacity in the right mid lung likely reflecting trace aspiration. The patient was diagnosed with Pneumonitis due to inhalation of food and vomit. The patient was treated with EGD ___. At the time of discharge, the patient had Primary: Thrush Odynophagia Secondary: Abdominal mass Depression/Anxiety Asthma 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>Ms. ___ is a ___ year-old woman with recent prolonged hospitalization for abdominal pain, s/p biopsy of benign abdominal mass, OSA, morbid obesity, asthma, GERD, depression, and anxiety, who now presents due to odynophagia and inability to tolerate PO intake. ACTIVE ISSUES ================= # Odynophagia # Thrush Following a prolonged hospitalization at ___ ___, she now presents with difficulty taking PO and Odynophagia, and a feeling of pills/food getting "stuck" in her throat. This was new since her last hospital stay, but unlikely to be related to her abdominal mass. A1C/TSH normal, HIV negative. In setting of thrush in oropharynx, antibiotic use, and chronic inhaled corticosteroid for asthma, the dx of ___ esophagitis was considered (also HSV esophagitis given h/o perioral HSV). She thus underwent EGD with biopsy on ___. Fortunately, no evidence of esophageal infection or abnormality was found. She was given Nystatin QID for thrush, as well as Magic Mouthwash. # Difficulty taking PO She was initially resuscitated with 2L IVF, but taking stable PO intake prior to discharge. Of note, she does have long history of abdominal pain, thought to be possibly somatoform vs IBD vs gastroparesis. Also, worth noting low BUN and albumin, indicating likely poor nutritional status overall. - Continue home Morphine, Omeprazole, Sucralfate # Abdominal Mass: She was discussed at a joint GI/Surgery conference on ___. Plan is ultimately for definitive surgical management in the future as outpatient, and this appointment is scheduled. She completed her 14 day course of Cipro/Flagyl for ? infected mass post-biopsy while inpatient. # Thrombocytopenia: PLT 125-142, from 150-200's during prior hospital stays. No evidence of bleeding. Recommend outpatient recheck # Coagulopathy: INR 1.3-1.4, from 1.2 last admit. Likely nutritional given poor PO intake overall. Recommend outpatient recheck. CHRONIC ISSUES ================= # Depression/Anxiety: - continue home fluoxetine 20mg DAILY, lamotrigine 125mg DAILY, trazodone 100mg QHS, Ativan 1mg PO BID - held brexpiprazole 2mg QHS as not on formulary, but OK to resume on discharge - continue nighttime Prazosin 3mg QHS # Asthma - continue Fluticasone Propionate 110mcg 2 PUFF IH BID - continue Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing # Obstructive sleep apnea - continue home BIPAP TRANSITIONAL ISSUES =================== - Was previously on Cipro/Flagyl for coverage of a possibly infected mass that was recently biopsied. Completed this course in house. - Discharged on Nystatin oral suspension QID to treat thrush, 5 more days as od ___ - No changes made to any of her other chronic home medications - EGD biopsy results pending on discharge - Mild thrombocytopenia, platelets of 142,000 on day of discharge. Recommend outpatient recheck. - Mild coagulopathy, INR 1.3 on day of discharge. Likely nutritional. Recommend outpatient recheck.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ male who presents to ___ on ___ with a moderate TBI. Hx significant for etoh cirrhosis, Hep C, esophageal varices, Hyponatremia, afib with RVR, who was drinking today and tripped and fell, striking his head. Bystanders called EMS and the patient was taken to OSH where head CT showed bilateral acute on chronic SDH, left greater than right, with significant mass effect and midline shift. Pt was transferred to ___ for further evaluation. CHEST (PORTABLE AP) showed No pneumonia. PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD showed 1. S/p evacuation of left sided subdural hematoma with expected postoperative changes. 2. 3. Stable overall size of the 1.5 cm wide right mixed attenuation extra-axial collection with a more conspicuous fluid-fluid/fluid-hematocrit level. 4. No evidence of new hemorrhage or of infarction. 5. Improved mass effect including 0.5 cm (previously 0.7 cm) rightward shift of midline structures. No herniation or ventricular entrapment. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 11:42 am, 5 minutes after discovery of the findings. CEREBRAL EMBOY347HEADXA The patient presented as . The patient was brought down for . The following vessels were selectively catheterize injected: Ultrasounded right femoral artery was accessed. There was a single noncompressible arterial pulse total lumen. There is evidence of access of the Y into the lumen. Images was saved. Right common carotid artery new Right external carotid artery Right middle meningeal artery Left common carotid artery Left external carotid artery Left middle meningeal artery Right common femoral artery showed 1. Successful right and successful left middle meningeal artery embolization I was personally present and participated in the entirety of the procedure; I have reviewed the above images and agree with the findings as stated above. RECOMMENDATION(S): 1. Follow-up CT in Outpatient Clinic in 1 months time The patient was diagnosed with Traum subdr hem w/o loss of consciousness, init, Fall same lev from slip/trip w/o strike against object, init. The patient was treated with ___ - Left ___ for subdural hematoma evacuation ___ - bilateral MMA coil embolization. At the time of discharge, the patient had Bilateral acute-on-chronic subdural hematomas. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#Moderate TBI #Bilateral acute-on-chronic subdural hematomas, left > right ___ male transferred from OSH with bilateral acute-on-chronic subdural hematomas, left bigger than right, after an intoxicated fall down the stairs. He was found to have 7mm of rightward midline shift on his initial scan. He was urgently taken to the OR with Dr. ___ left ___ for subdural hematoma evacuation - please see Dr. ___ report for further details. A subdural drain was left in place that was hooked up to an EVD set-up and leveled at the iliac crest. It was removed on ___. He was extubated and brought to the Neuro ICU for close post-operative monitoring. A post-operative NCHCT was done on POD1 that showed expected post-operative changes as well as an improvement in the rightwards midline shift. Course complicated by ETOH withdrawal and ongoing nausea for which he was treated with Compazine with good effect. On ___ patient underwent bilateral MMA coil embolization for management of his chronic subdural collections. Patient tolerated the procedure well and was transferred back to the ICU post operatively. His neuro exam continued to improve, and patient was called out of the ICU to the floor on ___. Physical Therapy worked with the patient during his admission and progressed him for discharge home. Patient was medically stable for discharge on ___. #Alcohol use disorder complicated by ETOH withdrawal On POD1, the patient was scoring on the CIWA scale and received a Phenobarbital load. He was also started on daily Thiamine, Folic acid and a Multivitamin and resumed on his home Lactulose at 30mg TID. Loaded with phenobarb for ETOH withdrawal on ___ and required rescue dose on ___. Addiction consult was placed for recommendations and recommendations were appreciated. He remained stable through remainder of admission. #Afib Patient continued on his home diltiazem on a split dose of 30mg Q6 hrs. Upon discharge he can resume his normal home dose of 120mg ER daily. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female with a history of pancreatic cancer admitted with diarrhea and fevers. The patient states she started having diarrhea 3 days ago up to ___ times per day. She started having fevers today as high as 103. She also has had some abdominal pain. She denies any nausea, shortness of breath, or cough. She denies any sick contacts or taking antibiotics recently. In the ___ she was found to be febrile to 100.4. A CT abdomen was significant for colitis. A rapid flu test was negative. Labwork was notable for potassium 3.2, WBC 2.9, and Hgb 9. She was given IV fluids, Tylenol, Zofran, morphine, potassium, and cipro. CT ABD AND PELVIS WITH CONTRAST showed 1. Findings compatible with nonspecific ascending and transverse colitis. 2. Otherwise, grossly unchanged appearance of the abdomen and pelvis. CHEST (PORTABLE AP) showed In comparison with the study of ___, the cardiac silhouette remains within normal limits and there is no evidence of vascular congestion. Opacification at the right base suggests small pleural effusion with atelectatic change. No evidence of acute focal pneumonia. However, if this is a serious clinical concern, a lateral view could be helpful if the condition of the patient permits. The patient was diagnosed with Noninfective gastroenteritis and colitis, unspecified. At the time of discharge, the patient had Sepsis Acute Bacterial Colitis Pancreatic insufficiency Chronic hypotension / Orthostatic hypotension Stage III Pancreatic Cancer Portal Vein Thrombosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PRIMARY ONCOLOGIST: ___, MD ___, MD PRIMARY CARE PHYSICIAN: ___, MD PRIMARY DIAGNOSIS: Stage III pancreatic cancer, unresectable TREATMENT REGIMEN: C3 Gemcitabine/pb-Paclitaxel (d1: ___ Mrs. ___ is a ___ year-old lady with stage III pancreatic cancer on C3 of gemcitabine/pb-paclitaxel complicated by PVT on enoxaparin presenting with fever, diarrhea and found to have colitis on imaging. #Sepsis #Acute Bacterial Colitis #Hypovolemia Patient presented with 3 days of high grade fevers, copious and frequent non-bloody diarrhea with mucus. CT Abdomen/Pelvis significant for ascending and transverse colitis. C.difficile NAAT was negative. Differential is broad but there is significant concern for bacterial etiology given high grade fevers and colonic involvement. Thus was covered with ceftriaxone and metronidazole (d1: ___ diagnoses include viral colitides, ischemic colitis (increased risk given PVT), idiopathic inflammatory colitides. Patient with fever, bandemia, tachycardia, hypotension meeting sepsis criteria. Significant need for volume repletion given volume loss due to GI losses. Patient defervesced on day 2 of admission. Diarrhea improved incompletely on day 3 of admission. Given mild eosinophilia consideration for helminthic etiology was given. Stool testing negative for coccidian and O&Px1. O&P#2 pending upon discharge. Patient was discharged to complete 7 day course of antibiotics. #Presumed Pancreatic insufficiency: Patient was empirically started on pancrelipase supplementation with vast improvement but not complete resolution of diarrhea. She was given a 30 day prescription for therapeutic trial. #Chronic hypotension and Orthostatic hypotension: Patient had BPs in low ___ in most of her clinic visits. At multiple times during admission dropped BP as low as low ___ while completely asymptomatic in bed. Upon review of vital flowsheets from prior admissions the same phenomenon was observed. During this admission was concurrently hypovolemic due to diarrhea, BPs responded to IVF boluses initially but not after 3 days. Cosyntropin stimulation test completed with appropriate response at 60min (>20). Given intermittent dizziness/lightheadedness while going to the bathroom and history of previous falls she was started on midodrine titrated to SBPs>90. #Anemia: Likely has anemia of chronic inflammation due to malignancy at baseline. ___ have had some blood loss from colitis but mostly hemodilution in setting of aggressive fluid resuscitation. Required 2U PRBC during admission. #Unresectable pancreatic cancer: On completed C3 of gemcitabine/pb-paclitaxel (___). Plan for next cycle when infection resolved and functional status improved. #Portal vein thrombosis: Like secondary to her tumor pancreatic tumor. Was continued on enoxaparin 100mg sc daily throughout her admission. #Bipolar disease: Well compensated during the admission. Continued aripiprazole 30mg daily and fluvoxamine 150mg bid. #Cancer-related pain: Secondary to likely neural invasion of mass. Was continued on oxycontin 30mg q12h standing and oxycodone 10mg q3h for breakthrough. TRANSITIONAL ISSUES: #Antibiotic course: To complete antibiotic course with cefpdoxime 400mg bid and metronidazole 500mg q8h through ___. #Helminth work-up: O&P #2 and Strongyloides IgG. Please follow-up and treat accordingly if positive. #Orthostatic hypotension: Discharged on midodrine 10mg tid. ___ be titrated down/off after completing antibiotics and fully reconditioned. #Pancrelipase: Discharged on 30-day therapeutic trial, may hold when diarrhea completely resolved to see if significant benefit. #Given patient's difficulty understanding medications and unclear home safety in terms of fall risk we strongly recommended her having a ___ but she declined. Please consider discussing this with her. ___ than 60 minutes were spent planning and coordinating the discharge of this patient. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female presents with the above fracture s/p mechanical fall. Other injuries include possible intraparenchymal hemorrhage, for which neurosurgery is following. CT HEAD W/O CONTRAST showed No hemorrhage. Left cerebellar cavernoma, stable since ___. CT Torso with contrast showed 1. Nondisplaced, fracture through the left femoral neck. 2. Contour irregularities in the right anterolateral fourth and fifth ribs may represent nondisplaced, incomplete fractures. Clinical correlation with point tenderness is recommended. 3. No evidence of visceral injury in the chest, abdomen or pelvis. HIP NAILING IN OR W/FILMS AND FLUORO LEFT showed Intraoperative images were obtained during left femoral neck ORIF. Please refer to the operative note for details of the procedure. The patient was diagnosed with Oth fracture of head and neck of left femur, init, Other fall on same level, initial encounter. The patient was treated with CRPP of left hip. The patient was given written instructions concerning 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 femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left hip CRPP, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. 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 weightbearing as tolerated in the left lower extremity, and will be discharged on home anticoagulation 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: ___ MD: CHEST (AP AND LAT) showed Complete collapse of the right middle and lower lobes with probable small right pleural effusion. DUPLEX DOPP ABD/PEL showed 1. Diffuse metastatic disease to the liver distorting and replacing the hepatic parenchyma without evidence of portal venous system thrombosis. 2. Extensive retroperitoneal and upper abdominal adenopathy with involvement of the pancreatic head and encasing the celiac axis including the common hepatic artery. NOTIFICATION: Findings were communicated with the ordering physician, ___ ___ MD, on ___ at 12:11 ___ via telephone. The patient was diagnosed with Right upper quadrant pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ F w/ a significant PMH of recurrent metastatic SCLC on nivolumab who presents for eval of worsening RUQ abd pain found to have significant transaminitis #RUQ Abd Pain #Acute Transaminitis Currently afebrile and HD stable; no leukocytosis; unknown etiology at this time with concern for worsening metastatic disease vs. immunotherapy induced hepatotoxicity. Hepatology consulted with recommendation to pursue ___ guided biopsy of healthy tissue (non-metastatic dz) to make this differentiation. ___ guided biopsy initially planned, however on additional review of imaging, ___ feels there is no healthy liver to biopsy. Further work up with AMA (negative), ___ (weakly positive), and HCV (negative). Patient was started on empiric prednisone 60mg qday for treatment of suspected immunotherapy related hepatic toxicity with outpatient follow up and anticipate prolonged taper depending on her response to steroids. She was also started on a PPI and calcium/vit D while on steroids. PJP was not started in the setting of acute hepatic failure, though could be considered if she will remain on high dose steroids for a prolonged period of time. #Metastatic NSCLC with transformation to small cell lung cancer - s/p 4 cycles of palliative carboplatin and etoposide - s/p C2 (of 4) of nivolumab [complicated by rising TSH] - s/p C3D1 (of 4) of nivolumab on ___ - hepatic and osseous lesions are progressing - c/w home inhalers and pain control - will follow up with outpatient Dr. ___ on ___ ___ for repeat LFT check and evaluation #Hypothyroidism - likely immune mediated adverse event ___ nivolumab - c/w home levothyroxine 137mcg PO daily #HLD - held home Atorvastatin 40mg PO qPM given transaminitis #MDD - decreased dose to 20mg fluoxetine PO daily in setting of hepatic impairment =====================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is a pleasant ___ yo F with hx COPD, HTN who initially presented to ___ with abd pain, was found to have elevated creatinine, leukocytosis and e/o acute gallstone pancreatitis on CT. She was started on IVF, flagyl, levo, dilaudid, zofran and transferred to ___ for ERCP eval. Radiology showed 1. Choledocholithiasis with at least ___ tiny distal common bile duct stones and mild central intrahepatic biliary dilatation. The degree of upstream biliary dilation is not significantly changed from the prior CT. 2. Unchanged edema within the pancreatic parenchyma and in the surrounding mesentery, compatible with mild acute pancreatitis. Mild dilation of the duct in the pancreatic head without obstructing lesion. No focal fluid collection. 3. Cholelithiasis without evidence of cholecystitis. 4. Bilateral small pleural effusions. UNILAT UP EXT VEINS US LEFT showed 1. No evidence of deep vein thrombosis in the left upper extremity. 2. Occlusive thrombus seen within the left cephalic vein in the antecubital region. NOTIFICATION: Findings of left superficial arm clot were discovered at 10:15 on ___ and were conveyed by telephone to Dr. ___ 0 at 10:29 on the same day. The patient was diagnosed with ABDOMINAL PAIN UNSPEC SITE. The patient was treated with ___: ERCP with Sphincterotomy ___: Laparoscopic cholecystectomy.. At the time of discharge, the patient had Gallstone Pancreatitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year-old female who was transferred from ___ to ___ on ___ with choledocholithiasis and gallstone pancreatitis. The patient had complaints of nausea and abdominal pain, as well as diarrhea. At ___ she had CT scan which was concerning for choledocholithiasis and pericholecystic fluid. She was given Levo,flagyl and transferred to ___ for further evaluation. ERCP was consulted and they recommended an MRCP. She was admitted to the Acute Care Surgery team for further medical evaluation. She was made NPO and given IV fluids and antibiotics. On ___, she had an MRCP which revealed choledocholithiasis, cholelithiasis and mild acute pancreatitis. On ___, the patient underwent an ERCP with sphincterotomy and stone removal. She tolerated this procedure well. On ___, the patient underwent a laparoscopic cholecystectomy. She tolerated this procedure well. She was started on a clear liquid diet and was evaluated by the Nutrition team to aid with increased caloric intake. Her diarrhea resolved spontaneously and her C. Diff test was negative. She was advanced to a regular diet and oral pain medicine which she tolerated. Pain was well controlled. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old man with known PE, afib on metoprolol and lovenox, status post discharge day 1 for ERCP and new diagnosis of pancreatic cancer presents status post syncope at ___ ___. He reports he was going to clinic to follow up with his physician about his recent hospital stay and while walking began to feel weak. Per the patient the next thing he remembers is waking up on the ground. He admits to LOC and fall but denies hitting his head. Denies pain in his body. He reports that dehydration triggers his afib. Notably he has been having trouble with PO intake since this past admission. He has had 3 vomiting episodes since 3AM, all non bloody and non bilious. His last dose of metoprolol was this morning. CHEST (PORTABLE AP) showed Mild atelectasis in the lung bases. Otherwise, no acute cardiopulmonary process. CTA CHEST WITH CONTRAST showed 1. Pulmonary emboli again seen, as above, but with significant decrease in overall clot burden compared to ___. No CT evidence of right heart strain. 2. Again seen subtle scattered small areas of ground-glass opacities bilaterally, which are nonspecific and less conspicuous than on the prior study, but may relate to bronchiolitis of an infectious or inflammatory etiology. 3. Partially imaged pneumobilia in this patient with a biliary stent. Mild prominence of the partially imaged pancreatic duct. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial process. The patient was diagnosed with Syncope and collapse. At the time of discharge, the patient had syncope orthostasis pulmonary embolism pancreatic adenocarcinoma anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with afib/aflutter s/p ablation, anxiety, hx of DVT with new bilateral PEs and newly diagnosed pancreatic adenocarcinoma s/p duodenal stenting and ERCP with CBP metal stent placement and duodenal stent placement with hospital course complicated by recurrent afib w/ RVR and hypotension requiring ICU admissions, now more recently slow GIB from tumor eroding into stent, readmitted with syncope presumably from hypovolemia +/- RVR.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant ___ with hx of metastatic, recurrent ovarian cancer presenting with diarrhea x5-6 episodes today and abdominal pain. Pt had diarrhea 6 days ago and went to an outside hospital where she had IVF with relief. Pt then did not have a BM for 3 days and took miralax, colase, ducolax, followed by more miralax. Today she had non-bloody diarrhea and cramping lower abd pain. Denies N/V, dysuria, fevers, back pain. Radiology showed Successful placement of a single lumen chest power Port-a-cath via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Radiology showed 1. No acute process in the abdomen or pelvis. 2. Stable appearance of right subdiaphragmatic nodularity, which may represent metastatic disease. Recommend continued attention on followup. Unchanged appearance of left pelvic sidewall soft tissue mass. No evidence of short interval disease progression. RECOMMENDATION(S): Stable appearance of right subdiaphragmatic nodularity, which may represent metastatic disease. Recommend continued attention on followup. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed No cholelithiasis. The patient was diagnosed with Unspecified abdominal pain, Diarrhea, unspecified. The patient was treated with placement of port with ___ ___. The patient was given written instructions concerning 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/ recently diagnosed recurrent metastatic high grade serous ovarian carcinoma w/ diffuse peritoneal disease (initially Stage IIc s/p total abdominal hysterectomy, b/l salpingo-oophorectomy, pelvic and paraaortic lymph node dissection, and omentectomy in ___, who presents with chronic crampy abdominal pain without acute findings as well as alternating constipation and diarrhea in the setting of pain and constipation medication management. She had port placed for planned outpt chemotherapy while in house. # Abdominal Pain Etiology is most likely due to extensive peritoneal malignant disease. As noted on her diagnostic lap on ___, she has "diffuse peritoneal disease, especially in the right upper quadrant, diaphragm with central tendon bulky disease, small bowel disease with adhesions to the umbilical area, left lower quadrant disease diffuse with adhesions of the large bowel to the pelvic sidewall." Admission CT did not reveal any acute process. By history, her pain is concurrent w/ her diagnosis of ovarian ca and has no provoking factors and constantly present, suggestive of disease related pain. She has had no acute change in the quality of her pain. She is moving gas and stool. RUQ U/S showed No cholelithiasis. Discussed with gyn/onc; no further role for surgery at this time. She was given bentyl PRN cramps and continued amitriptyline qhs, supportive pain control w/ po morphine, apap, avoid IV meds for dispo pending, and started on fentanyl patch 12 for longer duration of coverage. continued colace/senna, PRN milk of mag for constipation. regular diet tolerated well throughout admission. will follow up with outpatient onc, likely plan continuing chemotherapy as outpatient now that she is s/p PICC placement with ___. # Ovarian Cancer, Metastatic, Recurrent She is now on C1D12 of carboplatin every 3 weeks. She will be due for C2 on ___. Dr. ___ updated, will f/u outpatient. discussed with gyn/onc; will discontinue estrogen for optimization of response to chemo. Now s/p port placement ___ while patient inpatient. discharged after port for further outpatient care. Continued pain management and bowel regimen as above.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ Para 1 who presents at transfer from ___ to ED with VB. Patient had LMP started ___ and has continued to have heavy bleeding since then. She initially averaged 4 tampons and 1 ___ pad per day. However within the past ___ days, her bleeding has significantly worsened with clots so much so that within the last 24 hours, she has used 8 tampons and 2 maxipads. She also complains of little energy and some weakness. She has some dizziness, lightheadedness. Denies chest pain. She presented to ___ today where an H/H was checked and notable ___. She was transferred to ___ ED for GYN evaluation. Radiology showed 1. 3.1 cm structure within the endometrial cavity with internal vascularity could represent a submucosal fibroid, polyp or carcinoma. Recommend GYN evaluation with possible biopsy and/or sonohysterogram. 2. Fibroid uterus. Normal right ovary. The left ovary was not well seen secondary to the fibroid uterus. Findings were discussed with Dr. ___ the ___ clinical service by Dr. ___ telephone on ___ at approximately 8:00 ___. The patient was diagnosed with MENSTRUAL DISORDER NEC. At the time of discharge, the patient had vaginal bleeding firboid uterus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented to the emergency department for heavy menstrual bleeding she was then admitted to the gynecology service for observation. Her bleeding had become minimal on admission. She was monitored and her bleeding stoppped completely. Her vitals remained stable and she was asymptomatic from an anemia standpoint throughout her admission. She was started on iron and provera and discharged with close outpatient follow up scheduled.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Radiology showed Stable postoperative changes. No acute fracture or dislocation. Radiology showed No evidence of right lower extremity DVT. Radiology showed No drainable fluid collection deep to the recent surgical incision along the right lateral hip. Radiology showed 1. Large hematoma centered within the right gluteus medius extending inferiorly into the posterolateral aspect of the proximal right lower extremity. 2. No CT evidence for underlying soft tissue mass within the effected musculature, however follow contrast enhanced MR examination would provide further imaging evaluation upon resolution. 3. No drainable subcutaneous fluid collection. 4. No retroperitoneal hematoma. 5. Status post right total hip arthroplasty. Surgical hardware intact with no evidence for hardware loosening / failure. Sclerosis within the right acetabulum is unchanged. 6. Status post pinning of a left femoral neck fracture, surgical pins intact. 7. Heterotopic ossification versus myositis ossificans anteromedial to the right hip. 8. Small left ___ cyst. Preliminary findings conveyed to the covering medicine team via telephone at 5:30 pm on ___. Radiology showed Uncomplicated internal iliac, external iliac and selective superior gluteal arteriograms with expected postoperative hyperemia, but no evidence of active contrast extravasation, vascular malformation or pseudoaneurysm. Findings were conveyed to ___ ANP, immediately following the procedure. Radiology showed 1. No right lower extremity deep venous thrombosis. 2. Superficial thrombophlebitis in the right posterior calf. Radiology showed Right PICC line with tip in the low SVC. Otherwise, unchanged chest radiograph. Radiology showed Extremely limited evaluation of the hips due to patient positioning and body habitus. Interval removal of right total hip arthroplasty and placement of antibiotic impregnated cement femoral head and cemented metal wire in the femur. Proximal migration of the right femur.Prior left hip ORIF. Radiology showed Post-surgical changes of the right hip as described above. Radiology showed Limited examination. No definite fracture. If there is continued concern for a fracture, recommend dedicated three views of the ankle without obscuration. The patient was diagnosed with JOINT PAIN-PELVIS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. The patient was treated with Postoperative hematoma within right gluteus medius s/p ___ and evacuation of hematoma on ___ ___ right total hip arthroplasty s/p ___, explant of all components, cement spacer placement, and wound vac placement on ___ ___ and vac changes for septic right total hip arthroplasty on ___ ___, antibiotic spacer exchange and wound closure ___ ___. At the time of discharge, the patient had Right hip osteoarthritis s/p total hip arthroplasty ___ Postoperative hematoma within right gluteus medius s/p ___ and evacuation of hematoma on ___ ___ right total hip arthroplasty s/p ___, explant of all components, cement spacer placement, and wound vac placement on ___ ___ and vac changes for septic right total hip arthroplasty on ___ ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was initially admitted to the Medicine service for worsening right hip pain. A CT was performed showing a hematoma in the right gluteal region. The patient also developed parasthesias and weakness in the sciatic distribution with a true right foot drop. At that point he was transferred to the Ortho service with a symptomatic postoperative hematoma. He was taken to the OR by Dr. ___ evacuation of the hematoma on ___ at which time cultures were sent. These cultures ultimately grew MSSA and the patient was started on Nafcillin and taken back to the OR for ___, hardware removal, ABX spacer, and wound VAC on ___. These cultures showed proteus in the tissue and yeast in the fluid so ID recommended switching from nafcillin to cefepime with initiation of micofungin. Following further speciation micofungin discontinued & started on Voriconazole. After sensitivities returned on yeast, voriconazole changed to fluconazole. He was found to be bleeding from the wound and required serial transfusions. Postoperatively his VAC failed and due to persistent bleeding so he was taken back to the OR on ___ for repeat ___ and VAC placement. He continued to require multiple transfusions and resuscitation and ultimately was transferred to the Trauma ICU, with transfer to floor following stabilization. Patient underwent repeat ___ on ___ and interval repeat ___, antibiotic spacer exchange & wound closure on ___. *************** The patient was admitted to the orthopaedic surgery service and was taken to the operating room on multiple occasions for the procedures described above. Please see separately dictated operative reports for details. In general the patient tolerated the procedures well but had significant blood loss and ultimately required multiple transfusions and ICU monitoring. He received antibiotics as directed by the ID team.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old ___ man with CAD, HTN, HLD, BPH, and GERD, transferred from ___ for pancreatic lesion & CBD dilatation. Pt has had epigastric pain, nausea, vomiting x 4d. At ___ U/S showed CBD dilation to 1.7cm and 1.3cm complex cystic lesion in head of pancreas. Labs significant for Tbili 2.0, ALT/AST 253/136. Patient was transferred to ___ for MRCP. . In the ___ ED initial VS were 97.0, 58, 130/83, 16, 97% RA. No labs or imaging performed. . Currently, patient is comfortable and denies any nausea or abdominal pain. . ROS: As noted in HPI, otherwise unremarkable. Radiology showed 1. There is no solid or obstructing mass identified within the pancreatic head. Within the pancreatic neck there is a 1 cm cyst most compatible with a side branch IPMN as described above which corresponds to the abnormality seen on the ultrasound. Smaller cysts are seen in the pancreatic head. 2. There is dilatation of the common bile duct measuring up to 1 cm without evidence of obstruction. Pneumobilia is seen, status post ERCP and sphincterotomy. 3. Benign appearing lesions within the liver including a segment 6 hemangioma, and FNH/perfusional abnormalities as described above. 4. Trace pleural effusions. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, HYPERTENSION NOS. The patient was treated with ___: ERCP with sphincterotomy and brushings ___: MRCP. At the time of discharge, the patient had Primary: - 1.3 cm cystic pancreatic head mass - Biliary obstruction Secondary: - Hypertension - Non insulin dependent 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>___ year old man with several days of nausea, vomiting, and epigastric pain, found to have pancreatic lesion & CBD dilatation. Patient was admitted for ERCP and MRCP to evaluate a pancreatic mass found on imaging at an outside hospital. # Hematemesis: Had episode of coffee ground emesis on ___. Hematocrit remained stable. He was started on an IV PPI. # Pancreatic lesion/CBD dilation: Appears cystic though concern for malignancy as well. Based on MRCP findings, the lesion is cystic. Brushings of the CBD showed atypical glandular cells. This will require further evaluation to ensure there is no malignancy. # Hypertension: Well controlled at this time. The patient's blood pressure medications were stopped in the setting of hematemesis, blood pressures remained well controlled.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: (From admission note) Radiology showed Interval resolution of previously seen right-sided hydronephrosis. Mild urothelial thickening of the proximal right ureter potentially related to recent instrumentation, no evidence of urinary leak. No findings to explain patient's acute symptoms. The patient was diagnosed with Sepsis, unspecified organism, Urinary tract infection, site not specified. The patient was treated with N/A. At the time of discharge, the patient had Urinary 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 was admitted to the urology service. CTU showed no signs of obstruction or ureteral leak. Patient was started on empiric vanc/ceftriaxone and spiked his last fever on the early morning of ___. He was transitioned to cipro on the morning of ___ after his ___ cultures were found to have grown 50k E coli sensitive to cipro. Given that he remained afebrile through the evening of ___, he was discharged home at that point. At the time of discharge, he was voiding on his own, tolerating a regular diet, and had pain well controlled. He was given explicit instructions to follow up with urology. He was instructed to return to the ED if T >101.5.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: In brief, this is a ___ woman with history of metastatic neuroendocrine carcinoma of the gallbladder with mets to the liver and periportal nodes s/p cisplatin/etoposide (completed ___, s/p lymph node & liver segment resection ___, and s/p splenectomy who initially presented for fever to 100.9 and malaise. Chest: Frontal and lateral views showed No acute cardiopulmonary process. Radiology showed 1. Status post open cholecystectomy and segment ___ wedge resection, with a new 3.1 x 2.1 x 2.4 cm nonenhancing hypodensity within the right hepatic lobe associated with a surgical clip likely a postsurgical hematoma less likely an abscess given lack of peripheral enhancement. 2. There is periportal edema. Mild focal narrowing of the main portal vein at the porta hepatis without an associated thrombus. Ultrasound-guided aspiration. showed No drainable fluid noted in the liver to be aspirated. NOTIFICATION: The findings were discussed with ___, N.P. by ___ ___, M.D. on the telephone on ___ at 4:29 pm, 20 minutes after discovery of the findings. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. MR ___ AND W/O CONTRAST T___ MR SPINE showed 1. No evidence of epidural abscess or osteomyelitis. No suspicious marrow lesion. 2. Multilevel degenerative changes of the lumbar spine as described above. 3. A 1.5 cm right adnexal cyst, unchanged from most immediate prior CT examination, but significantly smaller when compared to examination ___. Abdomen and pelvis CT showed 1. Interval appearance of partial thrombosis in the right portal vein. Unchanged appearance of small fluid collection in the hepatic segment ___ surrounding a surgical clip, likely a postoperative small hematoma. No other significant interval change compared to prior study. NOTIFICATION: The findings were discussed with Dr ___, M.D. by ___, M.D. on the telephone on ___ at 6:10 pm, 5 minutes after discovery of the findings. Radiology showed No acute cardiopulmonary abnormality. Low bilateral lung volumes. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed 1. No acute intracranial process. MRI of the Abdomen showed 1. 2.5 cm fluid collection in the right hepatic lobe containing debris and associated with a surgical clip, likely postoperative seroma. Superimposed infection cannot be entirely excluded. 2. 2 cm right hepatic fluid collection containing heterogeneous material on the prior study may represent an area of fat necrosis. 3. Multiple suspicious hepatic masses primarily within the hepatic hilum with scattered satellite lesions in the left hepatic lobe are highly suspicious for recurrent malignancy, increased in size and number from prior studies. 4. Similar near occlusive thrombus involving the main and right portal veins. 5. Filling defect in the proximal celiac axis with possible low-level enhancement worrisome for tumor thrombus within the celiac artery. CR - CHEST PORTABLE AP showed 1. The right upper extremity PICC terminates in the left brachiocephalic vein. 2. No pneumonia or acute cardiopulmonary process. NOTIFICATION: The findings were discussed with ___, R.N. by ___ ___, M.D. on the telephone on ___ at 5:43 pm, 2 minutes after discovery of the findings. Radiology showed Successful placement of a 39 cm right arm approach double lumen PowerPICC with tip in the cavoatrial junction. The line is ready to use. DUPLEX DOPP ABD/PEL showed 1. No findings of intrahepatic biliary dilatation. 2. Hypoechoic hepatic masses adjacent to the porta hepatis measuring up to 3.9 cm in better characterized on MR from ___ concerning for recurrent malignancy. 3. Venous thrombosis at the portal venous confluence, as on prior MR. ___ of the right anterior portal vein and superior mesenteric vein. 4. Complex fluid collections in the gallbladder fossa and along the falciform ligament as demonstrated on prior MR. 5. Elevation of the hepatic arterial velocity with a main hepatic artery peak systolic velocity of 253 centimeters/second. Chest radiograph, portable AP upright. showed No evidence of acute cardiopulmonary disease. CHEST (PORTABLE AP) showed The tip of the right PICC line projects over the mid SVC. There are low bilateral lung volumes. Elevation of the right hemidiaphragm is again noted. There is a probable small right pleural effusion with subjacent atelectasis. No pneumothorax. There is no focal consolidation, pleural effusion or pneumothorax on the left. The size of the cardiomediastinal silhouette is within normal limits. DUPLEX DOPP ABD/PEL showed 1. No new intrahepatic biliary dilatation. Unchanged mild central intrahepatic biliary dilation is similar compared to multiple prior exams. 2. Lack of visualization of the right portal vein likely due to occlusion. Left portal vein is patent with hepatofugal flow. Main portal vein appears patent with hepatopetal flow. 3. Hypoechoic hepatic masses adjacent to the porta hepatis are better visualized on MRI from ___. 4. Complex fluid collections in the region of the gallbladder fossa and along the falciform ligament are unchanged and better visualized on MRI from ___. CHEST (PORTABLE AP) showed In comparison with the study of ___, there again are low lung volumes with elevation of the right hemidiaphragmatic contour and atelectatic changes above it. No evidence of vascular congestion, left pleural effusion, or acute focal pneumonia. MRCP. showed 1. Increased sizes of dominant hepatic hilar mass and hepatic/regional metastases with extensive necrotic components. 2. New extrahepatic biliary stricture associated with this appearance including obliteration of the duct over a segment of nearly 2.5 cm. Moderate new intrahepatic biliary dilatation upstream. 3. Slight decrease in postoperative collection at the hepatic resection site near the gallbladder fossa. Mild increase in a collection along the falciform ligament which is very unlikely to represent an infectious process. 4. Similar occlusive thrombosis of the central portal venous system aside from mildly increased proximal extension of bland component. 5. Continued patency of hepatic arterial system with similar nonocclusive filling defect along the celiac axis. NOTIFICATION: Findings discussed with Dr. ___ at 9:20 pm by telephone on ___. CHEST (PORTABLE AP) showed Comparison to ___. Stable correct position of the right-sided PICC line. Stable platelike atelectasis at the right and left lung bases. No evidence of pneumonia. No pleural effusions, no pulmonary edema. The patient was diagnosed with Fever, unspecified. The patient was treated with ERCP with stent placement ___. At the time of discharge, the patient had PRIMARY DIAGNOSES: ================== Common hepatic duct stricture Occlusive thrombosis of the central portal venous system Metastatic gallbladder adenocarcinoma Fever related to malignancy SECONDARY DIAGNOSES: ==================== Coagulopathy Normocytic anemia Thrombocytopenia Dyslipidemia Type 2 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>SUMMARY: ========= ___ w/ metastatic gallbladder adenocarcinoma now C1D6 on FOLFOX, PMHx of metastatic neuroendocrine carcinoma of the GB s/p 8 cycles of cisplatin/etoposide (___) and open resection of gallbladder and liver segment 5 (___), admitted for FUO with hospitalization c/b partial R portal vein thrombosis now on Lovenox and atypical chest pain during ___ infusion, now s/p successful ___ challenge, with course further complicated by thrombocytopenia and hyperbilirubinemia, found to have biliary stricture, now s/p ERCP with fully covered metal stent to common hepatic duct on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: PCP: ___ . CC: ___ . HISTORY OF PRESENT ILLNESS: ___ y/o woman with PMHx HTN, LVH and mild AS (mean gradient 12mm Hg) presenting to the ED with HA. She states the HA is dull and posterior - does not typically have headaches. She thinks the HA was associated with blurry vision. She subsequently took her BP, and noted it was 200s systolic. She states she took her Lisinopril this morning as prescribed, but thinks she has been eating more salt that usual recently. She denies CP/SOB/N/V/D. Denies HA or blurry vision currently. Radiology showed Mildly dilated, tortuous aorta. Moderate cardiomegaly. No acute cardiopulmonary abnormality. The patient was diagnosed with HYPERTENSION NOS. At the time of discharge, the patient had primary: hypertension secondary: left ventricular hypertrophy and 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>**consider repeat outpt TTE for eval of AS and LVH** ___ y/o woman with PMHx HTN, LVH and mild AS (mean gradient 12mm Hg) presenting to the ED with hypertensive emergency. . # Hypertensive Emergency: Likely related to increased NaCl intake and undertreated HTN given LVH. Given blurry vision, concern for end organ damage. When I saw patient she no longer had headaches. We continued home lisinopril 40 and started amlodipine 5 and was given IV labetalol (while in ER) and when on the floors was given PO 100TID. Cardiac enzymes checked adn were negative. Nutrition consulted to educate patietn about low salt diet. She is discharged on lisinopril and amlodipine and will check her BPs at home regularly and follow up with her PCP. # Aortic Stenosis: Last echo ___. Patient has a cardiologist who she sees as follow up . Recent echo from ___ showing Aortic Valve - Peak Velocity: *2.5 m/sec Aortic Valve - Peak Gradient: *25 mm Hg Mild to moderate (___) aortic regurgitation was also seen. She also has LVH. Patient will follow up with her cardiologist, and should have echo done ___. . # Positive UA: Given she was asymptomatic, no indication to treat so we did not start antibiotics. . # R Knee Effusion: Likely related to miniscal tear, as patient endorses swelling after skiing assocaited with "clicking" and decreased ROM. No erythema or warmth to suggest infection or crystal arthropathy. ROM is currently back to baseline. Patient will follow up with ortho TRANSITIONAL ISSUES #R knee effusion: patient should follow up with ortho #HTN: should be followed and amlodipinen should be increased as needed.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ yo with a history of metastatic NSCLC (mets to brain and bone), multiple GI bleeds ___ angioectasias, diverticulosis, CAD s/p CABG, Afib, AVR in ___, ___ (last ECHO showing EF 50-55% in ___ is presenting with acute onset of SOB in the setting of watery diarrhea. The patient was seen at her PCP's office on ___ where she noted constipation x1 week. She had finally had 1 BM at that point with good relief. She had no N/V/diarrhea/abdominal pain at that time. She did have a mild cough but no other URI symptoms, no chest pain, SOB, sputum production or hemoptysis. The patient was instructed to continue aggressive bowel regimen and her pain medications were renewed at that time. Radiology showed There is no pneumothorax or substantial recurrence of previously tapped left pleural effusion. Left upper lung is largely replaced by tumor and discrete metastatic mass is seen in the right upper lobe. Cardiac silhouette is partially obscured, but enlarged compared to ___, raising concern for pericardial effusion. Interstitial abnormality in the right lung has not cleared following interval worsening from ___ to ___. It should be considered edema in terms of therapeutic intervention, but there may already be a component of hematogenous dissemination of tumor with lymphatic invasion. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, MAL NEO BRONCH/LUNG NOS, ANEMIA NOS, GASTROINTEST HEMORR NOS, ATRIAL FIBRILLATION. At the time of discharge, the patient had Primary: pneumonia, malignant pleural effusion Secondary: metastatic non small cell lung cancer, atrial fibrillation with rapid ventricular rate. The patient was given written instructions concerning 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 ___ yo with a history of metastatic NSCLC (mets to brain and bone), multiple GI bleeds ___ angioectasias, diverticulosis, CAD s/p CABG, Afib, AVR in ___, ___ (last ECHO showing EF 50-55% in ___ admitted with acute onset of SOB in the setting of watery diarrhea found to have pneumonia with associated malignant pleural effusion. Treated with levofloxacin and had a thoracentesis for pleural effusion drainage with symptomatic relief. # Community acquired pneumonia: Treated with a 7-day coruse of levofloxacin with symptomatic improvement. She remained afebrile and hemodynamically stable. # Malignant left sided pleural effusion: Underwent thoracentesis on ___ and cytology with malignant cells consistent with known metastatic NSCLC. Had significant symptomatic relief after thoracentesis. Repeat CXR on ___ without evidence of reaccumulation of effusion. However, given that this is malignant it is likely to reaccumulate and has follow-up scheduled in the interventional pulmonology ___ clinic. # NSCLC with progression/Goals of care: Patient has known metastatic NSCLC with right hip metastasis now s/p XRT. CXR from ___ shows high left lung tumor burden and as described above also with malignant pleural effusion. After discussion with patient's HCP and in conjunction with PCP's notes, goals have been to move patient towards hospice and ___, but was not officially made "comfort measures only". Several unnecessary medications were discontinued we focused on pain control. Right hip pain was her primary complaint and long-acting narcotics were carefully uptitrated with improved pain control. # Atrial fibrillation with rapid ventricular rate Patient has a known history of Afib, not currently anticoagulated given goals of care. CHADS2 score of 3, was previously anticoagulated on aspirin but given goals of care discussion as detailed in patient's PCP note from ___, unnecessary medications were discontinued. Patient came in with Afib w/RVR associated with shortness of breath and some dizziness. Patient did take her Metoprolol Succinate 100mg at home per report on day of admission and did not receive further rate control in ED. Was in sinus on transfer to MICU. Was restarted on home metoprolol and called out to floor where her rate was well controlled.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year-old right-handed woman with HTN, HLD, inflammatory bowel/diverticulitis s/p resection, strong family history of hypercoagulability who presents with perisistent vertigo, acute occipital HA, and episode of confusion. MRI AND MRA BRAIN AND MRA NECK showed 1. No intracranial hemorrhage or acute infarct. 2. Multiple scattered T2/FLAIR hyperintensity is in the cerebral white matter. These are nonspecific and are commonly seen due to chronic small vessel ischemic disease. 3. Normal MRA head with developmental variants detailed above. 4. No dural venous sinus or major cortical vein thrombosis. 5. Mild atherosclerosis of the left proximal internal carotid artery, unchanged from CTA on ___. 6. Hypoplastic left vertebral artery, as seen on recent CTA. The patient was diagnosed with VERTIGO/DIZZINESS. At the time of discharge, the patient had 1. Benign Paroxysmal Postional Vertigo 2. Hypertension 3. Hyperlipidemia 4. Diverticulitis s/p colon resection 5. Aortic insufficiency 6. Arthritis 7. Obstructive Sleep Apnea 8. History of head trauma as a teenager. The patient was given written instructions concerning 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 right-handed woman with HTN, HLD, inflammatory bowel/diverticulitis s/p resection, strong family history of hypercoagulability who presents with perisistent vertigo, acute occipital HA, and episode of confusion. Initially, her exam is with minimal abnormality-- there is right torsional nystagmus on right gaze, +head-impulse to R, and she is falling to R on exam but has intact cerebellar exam, normal strength, vision, and fundi. Her dizziness improved with meclizine and zofran in the Emergency Room. Her dizziness was resolved with the Epley manuever in the Emergency Room. Although it appears she has many symptoms consistent with peripheral vertigo, the acute occipital HA, episode of confusion and severe vertigo in the context of familial hypercoagulability is concerning for possible sinus venous thrombosis. Ms. ___ has a MRI/MRA/MRV which was showed no sinus venous thrombosis or stroke. Ms. ___ symptoms completely resolved. She is able to walk without assistance. Thus, she was discharged home with meclizine prn and asked to follow up with her primary care doctor in next few weeks.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ presented to an OSH today with headache and nausea. She had been drinking beers and shots this afternoon and last remembers being on the phone with her friend and then waking on the floor with a headache and nausea. She claims her boyfriend was with her and said she was lifting weights and hit her head. The exact events are still unclear. She presented to ___ with headache and nausea and a CT performed demonstrated a SAH and she was transferred to ___. She was neurologically intact without any evidence of weakness, change in vision or sensation. Radiology showed 1. Diffuse subarachnoid hemorrhage filling the suprasellar, perimesencephalic and basal cisterns, foramen magnum, and bilateral sylvian fissures, with intraventricular extension, as described above. 2. Focal fusiform enlargement within the distal portion of the V4 segment of the right vertebral artery, with appearance suggestive of pseudoaneurysm. The right ___ from the proximal aspect of the focal enlargement. A gradual tapering of the vessel lumen is seen both proximal and immediately distal to this focal dilatation, raising the possibility of underlying focal dissection with pseudoaneurysm formation and secondary rupture. COMMENT: These findings were relayed to Dr. ___ (Interventional Neuroradiology service) through Ms. ___, N.P., by Drs. ___ ___ the catheter angiography in the AM on ___. Radiology showed ___ underwent cerebral angiography and coil embolization of a dissecting vertebral artery aneurysm. There were no complications. The ACT was maintained at around 250 during the procedure with IV heparin. Radiology showed 1. No evidence of new hemorrhage. 2. Resorption and redistribution of subarachnoid hemorrhage with layering of blood products in the occipital horns of the lateral ventricles and fourth ventricle. Radiology showed No evidence of DVT. Radiology showed 1. Slow diffusion in the right cerebellar distribution that most likely is due to residual subarachnoid blood but cannot exclude an ischemic process. 2. Occluded distal portion of V4 segment of the right vertebral artery, consistent with recent coil embolization. The patient was diagnosed with TRAUM SUBARACHNOID HEM, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT, ACTIVITY INVOLVING FREE WEIGHTS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with ___ Cerebral angiogram. At the time of discharge, the patient had Subarachnoid Hemorrhage Right vertebral Artery Aneurysm hydrocephalus / mild Intraventricular hemorrhage Headache Alcohol withdrawal Delirium. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to the Neurocritical care unit for close neurological monitoring and critical care in the setting of Subarachnoid hemorrhage and ruptured aneurysm. She was started on Nimodipine for vasospasm prophylaxis and dilantin for seizure prophylaxis. Systolic blood pressure was maintained less than 140. She underwent cerebral angiogram on ___ with coiling of the diessecting right vertebral artery aneurysm. She was recovered in the ICU on a heparin gtt for 48 hours. Systolic BP post procedure was maintained strict under 140 to reduce chance of migration of coils. Plain skull images were done the following am and were compared to the intra-angiogram images. No coil migration was noted. She remained stable neurologically and follow up CT imaging does not demonstrate any cerebral infarct on ___. Headache management has been a challenge. There also was concern that she was exhibiting signs of alcohol withdrawal on hospital day #5 and small doses of Ativan were given. Her TCD's remained stable. She remained in the Neuro ICU with a stable exam. On ___ she had an episode of bradycardia during which she was normotensive. Followup EKG was normal and she had no further episodes. On ___ she was stable in the ICU with increasing urine outputs so labs were done to assess for any endocrinologic abnormalities that could be causing this and she was placed on florinef by the ICU. MRI/A imaging on the ___ was stable. Screening Lower extremity dopplers were negative for DVT. On ___, dilantin was discontinued. On ___, patient remained nonfocal on examination and was transferred to the floor. Her foley was discontinued. Now DOD, she is afebrile VSSS. She is tolerating a good oral diet and pain is well-controlled. She is set for discharge home in stable condition. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o CAD s/p STEMI, HFpEF (EF 50-55%), recurrent VTE c/b chronic venous stasis ulcers (on Coumadin), opioid dependence on methadone, CAD s/p stents, HFpEF, COPD on home O2, recent admission for ___ leg pain felt to be due to venous stasis presenting again with worsening bilateral leg pain. Patient is a poor historian, but states that he has not been able to walk due to pain since a few days after his discharge at end of ___. He says that his legs look different as well but is not able to say how. The pain goes up into his ___ thighs. His respiratory status at baseline. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. Right common femoral AV fistula again noted. The patient was diagnosed with Other specified soft tissue disorders. The patient was treated with N/A. At the time of discharge, the patient had Chronic pain Opioid Use disorder Chronic DVT. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ PMH of CAD s/p STEMI, HFpEF (EF 50-55%), recurrent VTE c/b chronic venous stasis ulcers (on Coumadin), occluded IVC filter (since ___ opioid dependence on methadone, CAD s/p stents, HFpEF, COPD on home O2, recent admission for ___ leg pain felt to be due to venous stasis presenting again with worsening bilateral leg pain. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with CAD, HTN, DM2 here for workup of newly found brain metastases. Pt was in his usual state of health and developed severe frontal headaches for hte past 10 days. His primary medical doctor in ___ arranged for a head MRI which showed three brain lesions in the R parietal, L frontal, and L occipital lobes concerning for metastatic disease. He was taken to the ED at ___ from the radiology suite and was given 10 mg of decadron and transferred to ___ ED for neurosurgical evaluation. CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS showed 1. No evidence of malignancy in the abdomen or pelvis. 2. Diverticulosis without diverticulitis. 3. CT chest reported separately. CT CHEST W/CONTRAST showed 1. 13 mm spiculated mass in the anterior segment of the right upper lobe is highly suspicious for primary pulmonary malignancy, with pleural tethering, as described above. 2. Centrally necrotic right upper paratracheal nodal conglomerate is likely metastatic, and appears amenable to transtracheal biopsy. 3. Moderately severe coronary arterY atherosclerosis. 4. Mild background centrilobular predominant micronodulation, more conspicuous in the upper lobes, compatible with respiratory bronchiolitis. CTA HEAD WANDW/O C AND RECONS showed CT HEAD WITHOUT IV CONTRAST: Right parietal and left frontal mass lesions with moderate-marked surrounding edema, better assessed on prior MR. ___ HEAD WITH IV CONTRAST: No obvious significant vascular abnormality is noted in the location of the right parietal and left frontal mass lesions. A few non-dilated vascular structures are noted in the mass lesions, related to the vessels supplying the lesions are noted. No focal flow-limiting stenosis, occlusion or aneurysm more than 3 mm within the resolution of the study. Other details as above. The patient was diagnosed with SWELLING IN HEAD & NECK, HYPERTENSION NOS. At the time of discharge, the patient had Brain mass, likely metastasis Lung mass. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with HTN, CAD, DM2 here with new brain lesions concerning for metastatic disease found to have concerning lung lesion. # Metastasis, brain # Lung mass Presents with new brain lesions most concerning for metastatic disease. The patient underwent CT torso for staging. Chest CT with evidence of suspicious speculated mass and upper lobe, speculated paratracheal nodal conglomerate. Neuro-oncology, Neurosurgery and interventional pulmonary were consulted. Given appearance and location of brain masses, they are amenable to surgical resection. Given small chance of an alternative diagnosis, recommendation was made to peruse biopsy of lung lymph nodes. The patient will undergo EBUS with biopsy. He also hat CTA brain for neurosurgical planning and will undergo functional MRI as an outpatient. He was continued on Decadron 4mg TID per Neurosurgical recommendations. Given overall clinical stability and patient preference, he was discharged home to complete these procedures as an outpatient. Plavix was held in preparation for procedures. The patient was advised to continue baby ASA. The above was communicated to the patient's PCP by phone on the day of discharge. # CAD, native vessel Per note in chart had BMS placed at ___ in ___. Given this is ___ after ___ placement, plavix was held. The patient continued ASA 81mg which was OK with Neursurgical attending, Dr. ___. He was also continued on his Statin. #Hypertension, benign Continued home medications #Diabetes, Type II controlled without complications Continue home medications #Code - full #Contact: Niece ___ speaks ___- ___. Patient says we can communicate with her- Family (daughter, sister and niece) updated extensively at bedside. All questions answered to their apparent satisfaction on the day of discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with history of senile/vascular dementia (baseline AAOx1), sick sinus/syncope s/p PPM, moderate AS (TTE in ___, and prior MRSA pneumonia, referred to ___ ED from her nursing home ___ ___ with a 1-week history of lethargy and "abnormal labs", with only BUN slightly elevated. He was managed with IV hydration for a few days and initially improved, but then noted to have decreased O2 sats (rehab unsure how low they went on room air). He is on aspiration precautions and given nectar-thickened liquids at his nursing home. He was placed on O2 and noted to be 88% on 2L NC with increased RR to 24 and noted decreased PO intake. He is normally oriented to himself, but generally confused and tolerates PO intake well. He has a CBI catheter with irrigation in place since last year for frequent UTI with recent change after a malfunction last week. He is completely dependent with ADLs. Radiology showed Small right pleural effusion with right lower lung opacity, which could represent atelectasis, aspiration, or pneumonia. Findings discussed with ___ by Dr. ___ by telephone at 1:02 p.m. on ___ at the time of discovery of this finding. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, URIN TRACT INFECTION NOS, SHOCK NOS, SENILE DEMENTIA UNCOMP, HYPERTENSION NOS. At the time of discharge, the patient had Aspiration pneumonia Dementia Seizure disorder Leukopenia, possibly related to anti-seizure medication. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Impression: The patient is an ___ year old man with history of dementia, sick sinus syd s/p PPM, moderate AS, prior MRSA pneumonia and C. diff colitis, with indwelling catheter, and a seizure disorder, presenting with sepsis secondary to likely pulmonary sources. He was initially admitted to the ICU for early goal-directed therapy for the sepsis, and was later transitioned to the hospital medicine service once the sepsis had been stabilized, and continuosly improved until discharge back to his long term nursing home. Acute Issues # Sepsis: Upon admission, the most likely source was the urinary tract given his chronic 3-way urinary catheter at rehab and his UA with >182 WBCs. Aspiration PNA may also have played a role given his RML/RLL infiltrates on CXR and his poor mental status with high risk for aspiration. There was no report of fevers or diarrhea at rehab. He was mildly hypotensive on arrival to the FICU with SBP in the ___ on no pressors. His BP's improved to the 100-120s after about 1L total of fluids, and he received empiric vanc/Zosyn for presumed urosepsis as well as MRSA covereage given the concern for aspiration PNA. Urine culture was negative, and therefore cause of symptoms presumed due to aspiration pneumonia. He will complete a course of augmentin at his facility for pneumonia. # Acute encephalopathy on admission Patient was reportedly more lethargic than usual, per direct discussion with the ___ staff. His baseline MS is ___ to self, thought to be from vascular dementia. The most likely cause for his AMS was sepsis from UTI, but may also have been ___ to starting lamotrigine recently, although it would not have been expected to resolve as quickly as was noted if due to medications. We held his seroquel and trazodone initially, but continued Celexa. He was resumed on home trazodone and seroquel at discharge. # Leukopenia: Unclear etiology, may be related to Keppra. He is currently being transitioned from Keppra to lamotrigine in an attempt to improve his leukopenia. His underlying infection/sepsis may be acutely lowering his WBC, although he has evidence of leukopenia prior to his presentation for sepsis. ANC at admission is 1300 and he is very mildly neutropenic, so concern for atypical infections was low. The transition off keppra was continued, after discussion with his neurologist, and the Keppra was decreased from 500 mg twice daily to 250/500. The recommended plan was to continue to decrease the keppra by 250 mg a week (ie: next dose would be 250/250) as the lamotrigine was increased by ___ each week until goal of 150 mg po bid. At this time, we increased his lamotrigine to 75/75mg doses. # Aortic stenosis: Valve area 0.8cm2 in ___. He appears somewhat volume depleted on exam, he has no edema or crackles on exam. His cardiac exam is consistent with a decreased S2, suggestive of critical AS. Repeat TTE showed progression of his aortic stenosis, to severe. As a result, he is likely to be very sensitive to low blood pressures. # Hematuria and CBI: Patient presented from rehab with a 3-way Foley and CBI. His rehab states that he has been on this for at least a year and plan to continue it indefinitely. He had not been seen by urology at ___ for ___ years. Has had negative cystoscopy and CT urogram with no clear cause for his hematuria. We stopped the CBI, with no hematuria, and changed his foley to a regular foley prior to discharge. CBI SHOULD NOT BE RESTARTED. If he develops hematuria after a foley catheter change, this should be monitored for evidence of obstruction. If he continues to have hematuria or obstruction, CBI can be started for ___ hours as needed until his urine clears again, at which point it should be stopped. He should follow up with urology as needed if this persists. # Goals of care: Upon admission, the ___ team spoke with the patient's brother, ___, who states that he is the health care proxy and makes decisions for the patient. He stated that the patient has expressed that he would like everything done for him, including resuscitation, intubation, pressors and invasive procedures. This should be re-addressed with the brother again given severe aortic stenosis, and his degree of cognitive dysfunction. </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 a history of CAD s/p DES (___), DM, and HTN presenting with one day of severe chest pain and heaviness. The patient reports that for the past two months she has noticed increased chest pain with exertion, specifically while swimming or walking. She states that two months ago she used to be able to swim 500m without problems, and now she can only swim ___ and she has to stop secondary to chest pain. Yesterday she developed central chest heaviness. Denies any radiation with the heaviness, although does report some shortness of breath. She saw her PCP, who referred her to the ED. Prior to admission, pt received ___, and nitro. In the ED, her vitals were 97.6 60 144/56 16 97%RA. Initial ECG was unremarkable. Troponins were negative x 2. She went for nuclear exercise stress test today, which was positive for ___ chest pain and 0.5-1mm ST elevations with ST scooping, as well as a mild perfusion defect involving the LAD territory. Left ventricular cavity size and systolic function were normal. Due to positive stress test, she was admitted to the floor for cath tomorrow and started on heparin gtt. Currently on the floor, the patient triggered for chest pain. ECG with continued ST scooping. Pt placed on oxygen and her chest pressure resolved entirely. Troponin sent. She denies any shortness of breath, palpitations, light-headedness, arm pain, jaw pain, or nausea. ROS is otherwise negative. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with CHEST PAIN NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT. At the time of discharge, the patient had Primary Diagnosis: Unstable angina, coronary artery disease Secondary Diagnosis: Hyperlipidemia, hypertension, diabetes mellitus II. The patient was given written instructions concerning 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 female with a history of CAD s/p DES (___), DM, and HTN presenting with a history of worsening chest pain on exertion and decreased exercise tolerance, with one day of severe chest pain and heaviness found to have positive stress test. Admitted for cardiac catheterization. # Unstable angina/CAD: Ms. ___ is an ___ year old female with a history of CAD s/p DES (___), DM, and HTN presenting with worsening chest pain on exertion with exercise intolerance, and one day of severe chest pain. At home on aspirin, ___, atovastatin, and metoprolol. She presented to the ED and was found to have initial normal ECG with trops<0.01 x 2. She went for pharmacologic nuclear stress test on ___, which showed a reversible, medium-sized, mild perfusion defect involving the LAD territory. The pt also reported ___ chest pain and was noted to have 0.5-1 mm of ST segment scooping on ECG. She was admitted for cardiac catheterization planned for ___ and placed on heparin gtt. As pt felt well on ___, she declined the cardiac catheterization as she felt that it took her a long time to recover from her cath in ___. Discussed at length that the patient is probably putting herself at increased short term risk of an MI or urgent revasc without an invasive strategy (the risk is actual much less clear in women with negative biomarkers where the benefit of an early invasive strategy is blunted in clinical trials. Her burden of ischemia on the nuclear perfusion study is mild to moderate and if in the moderate category revasc may be more beneficial). She understood this risk and is requesting to go home. To help with her anginal symptoms, her metoprolol was increased to 100mg po daily, and she was started on imdur 30mg po daily and given sublingual nitroglycerin for home as needed. She was instructed that if she develops chest pain, she should go to the Emergency Department immediately. CHRONIC ISSUES # Hyperlipidemia: Continued on home atorvastatin. # Diabetes mellitus: At home on glipizide. During hospitalization started on insulin sliding scale and glipizide was held. This was restarted on discharge. # Hypertension: At home on metoprolol succinate 75mg po daily. This was increased to metoprolol succinate 100mg po daily as above. Imdur 30mg po daily was also started. ***TRANSITIONAL ISSUES*** - Pt informed that if she has chest pain she should report to the ED ASAP - New medications: Imdur 30mg po daily - Change medications: Metoprolol succinate increased from 75mg po daily to 100mg po daily - Code: FULL</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ known to the ___ service from a complex surgical history, including diverticulitis s/p multiple exploratory laparotomies (for a total of 8 abdominal operations thus far), colostomy, colostomy takedown, and diverting double-barrel ileostomy on ___ presenting with increased LLQ pain and drainage. He has had several admissions throughout his course for persistent high ostomy output. Complicated history of enterocutaneous fistula and fevers. AP radiograph of the chest was reviewed in comparison to ___. The left PICC line tip is at the level of low SVC. Heart size and mediastinum are stable. Lungs are clear. Linear atelectasis in the right mid and lower lung is unchanged. No new consolidations demonstrated. was done. Radiology showed Technically successful ultrasound-guided aspiration of an anterior abdominal fluid collection yielding 1 cc of greenish pus. The sample was sent to microbiology for analysis as requested. The patient was diagnosed with OTHER POST-OP INFECTION, ACCIDENT NOS. The patient was treated with ___: US-guided drainage of intraabdominal collection. At the time of discharge, the patient had Drainage from intraabdominal phlegmonous collection. The patient was given written instructions concerning 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 our institution given worsening abdominal pain and reported abdominal discharge from known phlegmonous collection in left lower quadrant. The fact that intraabdominal collections had not decreased in size, as well as the persistence of symptoms while on antibiotics was concerning. The interventional radiology team was consulted for possible aspiration of a small umbilical abscess/phlegmon additionally noted on imaging studies. Awaiting this procedure, patient was continued on meropenem and administered total parenteral nutrition as he had been receiving prior to admission. An ultrasound-guided aspiration of the anterior abdominal fluid collection was successfully done on hospitalization day #1. This yielded roughly 1 cc of greenish purulent material, sent to microbiology for analysis. Infectious Diseases was consulted for assistance in determining appropriate antibiotic regimen and duration in this patient. Differential for persistent collections included development of drug resistant organisms vs ongoing source of infection due to anatomical defects that would require surgical management. Given lack of response to meropenem therapy, decision was thus made to discontinue antibiotics and continue nutritional optimization for a planned surgical procedure in the coming months to attempt control of the source of infection. Upon improvement of symptoms, patient was deemed suitable to be discharged to home. Visiting nurse arrangements were made for daily TPN administration, and an appointment was made to follow-up as an outpatient. At the time of discharge Mr ___ was doing well, afebrile with stable vital signs. He was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with history of DMII, HTN, hypothyroidism, bipolar/depression, recurrent syncope thought to CT HEAD W/O CONTRAST Q111 CT HEAD. showed There is no evidence of acute intracranial process or hemorrhage. The patient was diagnosed with Syncope and collapse. At the time of discharge, the patient had PRIMARY DIAGNOSIS ================== Recurrent syncope Seroma Back pain SECONDARY DIAGNOSIS ==================== Diabetes Mellitus II Hypertension Functional Neurologic 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>Outpatient Providers: TRANSITIONAL ISSUES: ==================== [ ] PCP to adjust pain regimen [ ] Patient may choose to follow-up with providers from the chronic pain service to assist with adjusting opioids. #CODE: FC, confirmed #CONTACT: Deb(friend): ___. ==================== PATIENT SUMMARY: ==================== Ms. ___ is a ___ woman with history of DMII, HTN, hypothyroidism, bipolar/depression, recurrent syncope thought to be vasovagal, hx of sick sinus syndrome s/p pacemaker ___ years ago(taken out because of clots forming on the leads), L4-S1 laminectomy and recent MSSA bacteremia presenting with acute on chronic back pain and subjective saddle anesthesia/urinary incontinence, found to have normal neuro exam with MRI of her lumbar spine showing a benign paraspinal muscle seroma from her surgery. ==================== ACUTE ISSUES: ==================== # Acute on chronic lower back pain: Patient came in complaining of worsening lower back pain, saddle anesthesia, and difficulty holding her urine. She had been admitted and worked up extensively during prior admissions. She has previously had surgery to remove her spinal hardware. During her last admission, she had an aspiration of paraspinal fluid collection that showed a benign seroma. In this hospital admission, MRI lumbar spine showed the seroma is still present but is smaller. There was no concern for infection during her admission given the quality of her seroma, lack of fever, normal white blood cell count. Dr. ___ ortho spine doctor saw her and had low concern for infection or cauda equina syndrome given she had full strength and no focal deficits on neuro exam. Her pain was controlled with her home gabapentin, cyclobenzaprine, standing Tylenol, and oxycodone as needed. Although she received morphine and IV dilaudid in the beginning of her admission, she was taken off of IV pain medications. Chronic pain also saw her and recommended close follow-up with her PCP and with the chronic pain clinic. ___ was also consulted. # Syncopal Episodes Patient has had multiple episodes of syncope in past weeks in setting of severe pain. At beginning of hospital admission, patient was in MRI scanner, and a CODE BLUE was called. Patient had a vasovagal syncopal episode ___ pain. Pt has long history of syncopal episodes, etiology attributed to vasovagal physiology. During prior hospitalization episodes, vitals were normal and no events seen on tele, and patient was responsive right after the event. She did have one staring episode which occurred during this hospitalization, complained of "feeling off." During this time, her neuro exam was unchanged other than at first patient stated she was "in the supermarket." but then quickly corrected herself, and she returned to her baseline shortly thereafter. During this admission, she was also continued on tele and no events were seen, and no syncopal events occurred. # Reported head strike In the setting of her syncopal episodes prior to admission, she reported head strike. She mentated well and had intact CN ___ during admission. CT head w/o contrast ___ showed no evidence of bleed. # Diarrhea Patient reported fevers and loose BMs at home. Stool studies, O&P, C diff studies were ordered but were unable to be obtained as she stopped having loose stools during this hospitalization. ==================== CHRONIC ISSUES: ==================== # DMII: -Held home metformin -ISS # Hypertension: -Continued home enalapril # Hyperlipidemia: -Continued home statin # Hypothyroidism: -Continued home levothyroxine # Bipolar disorder/Depression: -Continued home alprazolam/duloxetine -Latuda is not on formulary</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ year-old R-handed man with a PMHx of seizure-like events (unclear from his prior workup if they are primarily epileptic or non-epileptic) who presents with 4 seizure-like events. The patient's mother reported much of the history as the patient didn't recall the events. At around 4am today she came into his room because he was "clearing his throat repeatedly, like he was choking". This noise lasted around 3 seconds, and during it his eyes were partly open, then his eyes opened completely and he looked at his mom, then fell asleep and didn't wake back up when his mom shook his shoulder. She also noticed that he had deep breathing "almost like snoring" for the next ___ mins. She then tried to tap him lightly on the shoulder again and he opened his eyes, screamed loudly and then his arms and legs began to shake, he urinated on himself, bit his tongue "there was blood all over the pillow" and then suddenly stopped the shaking after ___ seconds and fell asleep. The patient's mother did not try to wake him after this episode. Then at 7:30am he sat up in bed suddenly and looked at his mother. When she said "are you okay?" he didn't answer. He fell asleep shortly after that. Then at around 8:30am she went to check on him by tapping on his shoulder and asking "are you okay?" and he responded "completely normally" so she was reassured that he was back to his baseline and she let him sleep again. He slept until 1:30pm, which is unusual for him unless he has had a seizure, so his mother went to wake him up and tell him that they were going to the ED so he could get checked out. He seemed at his baseline when she saw him at 1:30pm. However, when she came to get him at 2pm expecting to see him dressed and ready to go, he was still in bed undressed. She then noticed that he was sitting, leaning forwards and his arms and legs were trembling and his eyes were wide open. This lasted for ___ seconds and then stopped. She went to dress him and he "hardly noticed" which is unusual for him as he usually does it himself. She brought him to the ED and by the time they arrived he was "back to normal". However, the patient's mother did think that when she touched him at around 2:30pm he "felt warm, but not burning up". The ED initially tried to contact the patient's outpatient neurologist, who was being covered by another neurologist who recommended an infectious workup. The patient's WBC returned elevated at 12.9 with a neutrophilic predominance. His CXR initially returned with a ? of possible pneumonia, but on repeat CXR this was felt to be atelectasis. However, given his elevated WBC and no other identified infectious source, he was admitted to the neurology service for observation given that the WBC elevation was more likely to be from a seizure. Of note, the patient's mother reports that his usual seizure frequency is ___ seizures every ___ months and that today's was unusual both because of the number of events and because his last seizure episode was on ___ of this year (where he sat up quickly in bed and looked at her, then went back to sleep). Per Dr. ___ and the patient's mother he has had numerous types of seizure-like events ranging from sitting up quickly in bed, looking around and going back to sleep to generalized convulsions with tongue biting and urinary incontinence. There are many other events that she describes where he has trembling of both arms, or stiffening of his arms and legs and sometimes "he just looks out of it". She denies that the patient could have missed any of his meds, as unbeknownst to him she counts his pills every day to make she he is taking them. She also doesn't think he has had any cold symptoms, fevers or chills (except maybe at 2:30pm today as above), nausea, vomiting, diarrhea, headache or any other infectious symptoms recently. Radiology showed Low lung volumes limit assessment of the lung bases. Streaky opacities in the lung bases could reflect atelectasis but infection, particularly of the right lung base, cannot be excluded. Consider repeat radiographs with improved inspiratory effort for better assessment of the lung bases. Radiology showed Slightly improved aeration of the lung bases with mild bibasilar atelectasis. The patient was diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY. At the time of discharge, the patient had seizures. The patient was given written instructions concerning 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 R-handed man with a PMHx of seizures who presents with 4 events concerning for seizure. # NEURO: On day of admission, patient had an episode of diffuse shaking accompanied by tongue biting and urinary incontinence out of sleep. Per history, most of his seizures are out of sleep. He has had episodes of seizures that sound frontal in etiology with fencing position and head turning but this is not a consistent seminilogy. Patient is compliant with his vimpat 200mg bid, no recent infectious symptoms, no sleep deprivation. Mr. ___ did have a leukocytosis on arrival in the ED yet no infectious etiology, further supporting that above event was epileptic in nature. Currently, his exam is at his known baseline and only remarkable for mildly impaired memory and orientation. He has been monitored on EEG and has not had any epileptiform discharges. Per discussion with Dr. ___ ___ epileptologist) will increased Vimpat from 200mg bid to ___ bid--he tolerated it well. # ID: CXR with no pneumonia, UA neg, remained afebrile. # CODE/CONTACT: Presumed Full; ___ (mom) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F with multiple medical problems including advanced dementia and stage 4 CKD, s/p fall 3 days ago at nursing home. Per report her pelvic xray was negative for fracture. Today on routine lab check she was found to have Hct drop and transferred to OSH. She had CT torso which was consistent with R acetabular and proximal femur fracture. She transferred to ___. She was agitated and non cooperative during the interview and refused to answer to questions. She tells that "everything hurts". Per reports she was not hypotensive or febrile at nursing home but was not able to ambulate since the fall. Radiology showed As above. The patient was diagnosed with Disp fx of greater trochanter of right femur, init, Unsp fracture of sacrum, init encntr for closed fracture, Oth fracture of right pubis, init encntr for closed fracture, Unsp fracture of right acetabulum, init for clos fx, Unspecified fall, initial encounter. At the time of discharge, the patient had PRIMARY DIAGNOSIS/ES: - Right displaced greater trochanter fracture - Right sacral fracture - Right inferior pubic ramus fracture - Right superior pubic ramus fracture w/ extension into acetabulum - Right hip/upper thigh hematoma - Anemia due to acute bleed (from hematoma) and nutritional deficiency - Acute kidney injury due to pre-renal azotemia - Chronic kidney disease, Stage IV - Acute toxic-metabolic encephalopathy SECONDARY DIAGNOSIS/ES: - Chronic Dementia - History of stroke complicated by seizures - Dyspohagia, unspecified - Hypertension - Hypercholesterolemia. The patient was given written instructions concerning 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 advanced dementia s/p fall 3 PTA, w/ R pelvic and proximal femur fracture deemed non-operative. She was transferred to the medical service, where she was managed conservatively for her pain and R thigh hematoma suffered during fall.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ MEDICINE ATTENDING ADMISSION NOTE . ___ Time: ___ _ ________________________________________________________________ CTA ABD AND PELVIS showed 1. 1.9 cm hypoenhancing pancreatic head mass worrisome for adenocarcinoma, with upstream ductal obstruction. Involvement of the common hepatic artery, GDA, main portal vein, and SMV. Pancreatic tumor table is provided. 2. Prominent GDA and retroperitoneum lymph nodes are identified. 3. No evidence of distant metastatic disease. Radiology showed No evidence of bowel obstruction or ileus. The patient was diagnosed with Nausea with vomiting, unspecified. The patient was treated with EUS. At the time of discharge, the patient had 1. Pancreatic mass 2. 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>The patient is a ___ year old female with HLD, hypothyroidism found to have a pancreatic mass with pancreatic ductal obstruction. . PANCREATIC MASS CONCERNING FOR MALIGNANCY Patient under went CTA pancreas that showed pancreatic mass concerning for adenocarcinoma. She also underwent endoscopic ultrasound for biopsy of this mass and result pending at the time of discharge. She will followup with a ___ clinic on ___ to obtain results and to discuss next steps in planning and treatment. Abdominal pain, Anorexia: Due to presumed pancreatic malignancy. She was started on oxycontin 20 mg po bid as well as oxycodone ___ mg every 6 hours as needed for breakthrough pain. She was given the phone number to call for ___ ___ care clinic for them to help adjust medications and help manage symptoms. She will need assistance from PCP/Pall care to titrate the dosages of these medications. She was also started on a bowel regimen and had bowel movements in the hospital Her appetite remained poor, and outpatient providers should address this as well. COLITIS: Seen on CT scan, patient asymptomatic. ANEMIA: No GI Bleeding, appears to be secondary to myelosuppresion from presumed malignancy . HYPOTHYROIDISM: Continued levothyroxine . DEPRESSION: Continued home regimen of SSRI and bupropion. . GERD: Treatment continued COPING: Patient recently suffered death of her mother. She expressed understandable anxiety and distress over her possible diagnosis. She is very well supported by husband and sister and she reported a very good experience with hospital chaplain. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed 1. Intervally placed right PICC catheter terminates in the middle SVC. 2. No substantial interval change in bilateral pleural effusions with worsening atelectasis on the right. Radiology showed Support lines and tubes are unchanged in position. Cardiomediastinal silhouette is unchanged from prior. Bilateral pleural effusions with compressive atelectatic changes. Mild interval worsening of right lower lobe airspace opacities which may represent developing infection and interstitial markings bilaterally. Low lung volumes. There are no pneumothoraces. CHEST (PORTABLE AP) was done. CHEST (PORTABLE AP) showed Pulmonary edema has improved. Right-sided PICC line projects to the SVC. Bilateral effusions have also slightly improved. Cardiomediastinal silhouette is stable. No pneumothorax. ABDOMEN US (COMPLETE STUDY) showed 1. Patent hepatic vasculature. Radiology showed The right-sided PICC line has been pulled back and the distal tip is within the brachiocephalic/SVC junction, previously within the proximal SVC. Sternotomy wires are seen. There is unchanged cardiomegaly. There has been worsening of the large left-sided pleural effusion. There is low lung volumes and mild pulmonary edema. There are no pneumothoraces. CHEST (PORTABLE AP) showed On the current image, the patient shows signs of moderate pulmonary edema. Moderate cardiomegaly persists. Mild to moderate left pleural effusion with subsequent left basilar atelectasis. No pneumonia. Stable alignment of the sternal wires. The right PICC line has been slightly pulled back, the tip now projects over the confluence of the brachiocephalic vein and the superior vena cava. CT HEAD W/O CONTRAST Q111 CT HEAD showed No evidence of acute intracranial abnormality including hemorrhage. Small probably chronic infarcts in the right thalamus and left basal ganglia. CHEST (PORTABLE AP) showed Mildly improved pulmonary edema. Stable moderate left pleural effusion with associated left lower lobe atelectasis. Chest radiograph, portable AP upright view. showed Similar finding suggesting pulmonary edema, bibasilar atelectasis and pleural effusions. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Moderate bilateral pleural effusions with adjacent compressive atelectasis. Moderate cardiomegaly, probable mild pulmonary edema. 3. Enlarged main pulmonary artery measuring 3.6 cm may reflect pulmonary arterial hypertension. CHEST (PORTABLE AP) showed Comparison to ___. Stable moderate bilateral pleural effusions. Stable signs of moderate pulmonary edema. Moderate cardiomegaly persists. Correct alignment of the sternal wires. No parenchymal changes in the well ventilated parts of the lung parenchyma. The patient was diagnosed with Pneumonia, unspecified organism. The patient was treated with TEE/Cardioversion ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS heart failure with reduced ejection fraction atrial flutter (resolved) SECONDARY DIAGNOSIS Upper gastrointestinal bleed (stable) Acute kidney injury (resolved). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>HOSPITAL COURSE: ===================== ___ year old woman with CAD ___ CABG, CVA, MR ___ bioprosthetic valve, HTN, DMII who presented to OSH with DOE for the past 3 weeks, found to have new HFrEF (30%) with new aflutter. She was initially started on diltiazem drip, transferred to ___ CCU for further management. She was IV diuresed until euvolemic, her atrial flutter was initially managed with esmolol drip resulting in low BPs, and she underwent a successful TEE/cardioversion. Her course was complicated with an UGIB that resolved without intervention, as well as recurrent episodes of somnolence with a preliminary diagnosis of OSA. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ woman with PMH of insulin dependent diabetes, hypertension, CKD, and CHF presenting with multiple complaints including uncontrolled blood sugars, dysuria, vaginitis, chest pain, and failure to thrive. CHEST (PA AND LAT) showed No pneumonia. The patient was diagnosed with Type 2 diabetes mellitus with hyperglycemia, Long term (current) use of insulin. At the time of discharge, the patient had Primary Diagnoses ================= UTI Vaginitis Hyperglycemia Constipation Chest pain Secondary Diagnoses =================== Chronic kidney disease Heart failure with preserved ejection fraction Hypertension Obstructive sleep apnea 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>This is a ___ woman with PMH of insulin dependent diabetes, hypertension, CKD, and CHF presenting with multiple complaints hyperglycemia, dysuria, vaginitis, and weakness, admitted to medical service for treatment of UTI and vaginitis as well as management of insulin regimen.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with acute leukemia diagnosed in ___ who is now s/p allo-SCT and most recently has evidence of graph failure and recurrent disease. She has recently started on decitabine therapy and presented today to the ED with presyncopal symptoms and a traumatic fall resulting in right hand trauma. Her hand is remarkable for a bruise and superficial skin laceration. Radiology showed No acute cardiopulmonary process. Radiology showed No fracture or dislocation. Radiology showed No acute intracranial abnormality. NOTE ADDED IN ATTENDING REVIEW: The hypodense focus in the right frontal lobe (2:13) likely represents partial-volume averaging of the adjacent sylvian fissure, as on the MR study of ___. There is bifrontal cortical and cerebellar atrophy, somewhat more than expected in a patient of this age; however, this appearance, too, is unchanged. The patient was diagnosed with SYNCOPE AND COLLAPSE, CONTUSION OF HAND(S), OTHER FALL, ACUTE MYELOID LEUKEMIA, IN RELAPSE, HYPERTENSION NOS. The patient was treated with -bone marrow biopsy ___. At the time of discharge, the patient had Primary: -Presyncope Secondary: -AML -Anemia -Neutropenia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with AML s/p allo transplant in ___ who now has graft failure and recurrent disease, recently started decitabine chemotherapy, who presented with presyncopal symptoms and fall. # Presyncope, fall, ?BPPV: No loss of consciousness or head strike. ___ have been due to volume depletion, though pt reported good PO intake and was not orthostatic. History was not consistent with vasovagal or cardiac etiology. Telemetry was unremarkable. Echo was unremarkable. CT head unremarkable. No known infectious symptoms; urine culture was negative, and blood cultures had no growth as of discharge. Pt may have BPPV, as reported feeling dizzy with lateral rotation of head. # AML, Neutropenia: S/p allo transplant in ___ who now has graft failure and recurrent disease. Started recently on decitabine (cycle 1, day 1 = ___. Pt has circulating blasts, indicative of continued disease. Had BM biopsy ___ to help guide next therapeutic step. If BM biopsy shows continued disease progression, will consider cytotoxic chemotherapy. If BM biopsy shows good response to decitabine, will likely continue decitabine. Continued on prophylaxis with acyclovir, Bactrim, moxifloxacin, voriconazole, and ursodiol. # Anemia, thrombocytopenia: Likely due to AML and its treatment. GI bleed less likely; guaiac negative stool ___. Pt received pRBC and platelet transfusions during admission. Developed hives with platelet transfusion, which resolved with Benadryl. # H/o HTN: Pt was on amlodipine 5mg daily previously, while on cyclosporine which can increase BP. Was normotensive during admission off amlodipine; planned to remain off amlodipine at discharge. ======================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old ___ speaking woman with HTN, HLD, hypothyroidism, anxiety, BPPV on meclizine, and admission to the stroke service ___ for lightheadedness with transient R sided weakness that was thought to be complex migraine or anxiety provoked, who presents with over 2 months of dizziness. UNILAT LOWER EXT VEINS RIGHT showed 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. Small ___ cyst. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Moderate stenosis at the origin of left vertebral artery secondary to atherosclerosis. 2. Mild atherosclerosis involving bilateral carotid bifurcations in bilateral cavernous carotid arteries without stenosis by NASCET criteria. 3. No evidence of vascular dissection. 4. No acute intracranial abnormality. 5. 1.7 cm isthmic thyroid nodule which has been characterized with ultrasound in ___. 6. Please note MRI of the brain is more sensitive for the detection of acute infarct. The patient was diagnosed with Dizziness and giddiness. The patient was given written instructions concerning 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 ___ speaking woman with HTN, HLD, hypothyroidism, anxiety, BPPV on meclizine, and admission to the stroke service ___ for lightheadedness with transient R sided weakness that was thought to be complex migraine or anxiety provoked, who presented with over 2 months of lightheadness and vertigo. She was admitted to the hospital because physical therapy recommended patient be discharged to rehab for functional conditioning, and she needed placement. #Lightheadness: patient presented with two separate symptoms of lightheadedness and vertigo. Patient was not orthostatic in the ED, and does not endorse symptoms of orthostasis. No reported carotid stenosis on prelim CTA head/neck read. Patient revealed she was taking 2x the amount of prescribed hydrochlorothiazide because she thought one was her synthroid. Therefore, her symptoms may be a result of too many antihypertensives. Her symptoms may also be a side effect of meclizine. Neurology was consulted, and recommended discontinuing meclizine. ___ was consulted, and recommended patient go to rehab for strengthening and functional conditioning. Patient and her family refused rehab, despite being told this was what was recommended by our ___ team. #Vertigo: patient endorsed vertigo as well, and this seemed to be a separate symptom, however it was hard to tease out with her history giving. CTA head/neck with no acute pathology to explain this symptom, and likely secondary to known diagnosis of BPPV. As above, neurology was consulted, and meclizine was discontinued for concern it was causing lightheadness. #Blurry vision: patient reports worsening blurry vision over the past few months in her right eye. She is not having blacking out of vision in this eye, just blurriness. She has no jaw pain or claudication, and describes global tension like headache. Concern for temporal arteritis low, but ordered ESR and this should be followed up as an outpatient. She should have ophthalmology as an outpatient. #HTN: Continued home prescribed regimen of hydrochlorothiazide, verapamil, valsartan. #HLD: Continued home atorvastatin. #Hypothyroidism: Continued home levothyroxine.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ transferred from ___ for acute liver injury, cocaine intoxication and hypotension. CHEST (PORTABLE AP) showed Low lung volumes with patchy opacities in the lung bases likely atelectasis. CT HEAD W/O CONTRAST showed No acute intracranial hemorrhage. CHEST (PORTABLE AP) showed 1. Standard positioning of the endotracheal and enteric tubes. 2. Worsening opacities in the lung bases suggestive of increased atelectasis. Aspiration is not excluded. ULTRASOUND ABDOMEN showed 1. Appropriate directionality of flow of the portal and hepatic veins. Patent main hepatic artery with normal waveform. 2. Large geographic areas of hypoechoic liver with echogenic portal triads compatible with acute hepatitis, likely ischemic or toxic given clinical history. 3. Distended gallbladder with pericholecystic fluid and wall thickening. These findings are nonspecific and typically seen in acute hepatitis. CHEST (PA AND LAT) showed As compared to the previous radiograph, the patient has been extubated, the nasogastric tube and the right internal jugular vein catheter were removed. New right pleural effusion, new small left pleural effusion. In addition, there is a focus of consolidation at the right lung base, consistent with either atelectasis or pneumonia. No pulmonary edema. Unchanged borderline size of the cardiac silhouette. CHEST PORT. LINE PLACEMENT showed New right jugular dual channel catheter ends in the mid SVC. No pneumothorax or mediastinal widening. Moderate right pleural effusion and basal consolidation or atelectasis have increased since ___. Moderate left infrahilar atelectasis is unchanged. No appreciable left pleural effusion. Conventional frontal and lateral radiographs would be helpful in assessing the relative contributions of pleural effusion to the appearance of the lower chest. Heart size normal. No vascular abnormality or edema. Radiology showed Successful placement of a 23cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Radiology showed Uncomplicated removal of a right internal jugular approach tunneled dialysis catheter. The patient was diagnosed with ACUTE & SUBACUTE NECROSIS OF LIVER, ACUTE KIDNEY FAILURE, UNSPECIFIED, RHABDOMYOLYSIS, ALTERED MENTAL STATUS . The patient was treated with intubation, dialysis line placed, removed. The patient was given written instructions concerning 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 ___ who overdosed on heroin, cocaine, EtOH, was found down, and transferred from ___ to ___ for acute liver injury, cocaine intoxication, and hypotension, and admitted to the ICU for hemodynamic instability, on pressors. He was intubated in the ED for hypoxemic respiratory failure secondary to likely aspiration from emesis, and started on broad spectrum antibiotics for concern for pneumonia. He was found to have shock, acute renal failure, rhabdomyolysis, cardiac ischemia/troponinemia, acute liver failure, and LLE weakness and sensory deficit. In the MICU, shock resolved, pressors weaned, and CNS depression resolved. Antibiotics discontinued as no clinical evidence of pneumonia. Transferred to floor, where he continued to have volume overload in the setting of oliguria and acute renal failure. Rhabdomyolysis resolved, with CK<5000, as did acute liver failure. Initiated hemodialysis on ___ because still with persistent oliguria and worsening acidemia. Required 9 days of dialysis, but urine output recovered and his dialysis line was removed on ___, with discharge on ___. # SHOCK: Patient was initially hypotensive to the ___ on arrival with elevated lactate. Patient had ___ SIRS criteria placing septic shock on differential. His H/H was stable but mucous membranes dry so hypovolemic shock was thought to be contributing. He was started on broad spectrum antibiotics (vanc/zosyn), which were discontinued as no infectious source was identified. His hypotension resolved with aggressive fluid resuscitation (up +15L in MICU course). # RESPIRATORY FAILURE: Patient intubated on ___ for airway protection after oxygen desaturation following an episode of emesis. Patient was on CMV, FiO2 100%, Tv 500 and PEEP of 5. Fentanyl/versed used for sedation. Patient was extubated the morning of ___. He had been empirically started on broad PNA coverage, but antibiotics were discontinued ___ because he had no clinical evidence of infection. Likely he had aspiration pneumonitis given the rapid resolution of hypoxemia. His persistent oxygen requirement on the general medicine floor was likely secondary to volume overload in setting of acute renal failure, and it resolved with hemodialysis. # ACUTE RENAL FAILURE: Likely secondary to acute tubular necrosis given urine sediment showing muddy brown casts. He presented to OSH with hypotension, which is the likely etiology of the ATN, though likely exacerbated by rhabdomyolysis. His poor urine output indicated that he was not clearing casts from his kidneys, and the persistently high CK likely made his ___ worse. Creatinine continued to rise with worsening acidosis, requiring hemodialysis ___. His urine output recovered with normalization of his electrolytes and downward trend of creatinine. HD line removed ___. # HYPERTENSION: Likely secondary to volume overload in the setting of persistent renal failure. Asymptomatic. Trending down with dialysis and subsequent autodiuresis. Did not treat with anti-hypertensives. # ACUTE LIVER INJURY: Most likely shock liver in setting of hypotension with componenent of cocaine toxicity and vasoconstriction. LFTs trended down to normal range. He completed a full course of NAC per liver, toxicology recs. His hepatits serologies, HIV, ___, AMA, Sm were all negative. # LEFT LOWER EXTREMITY WEAKNESS: Initially with L2 sensory deficit and left hamstring weakness, but recovered full strength and sensation. Likely lumbar plexopathy, secondary to compressive neuropathy. # THROMBOCYTOPENIA: Likely in setting of acute liver failure, alcohol intoxication, and profound illness. Platelet count rose to normal range. # POLYSUBSTANCE ABUSE: Patient overdosed with intranasal cocaine and heroin, as well as alcohol ingestion. His overdose resulted in multiorgan failure and significant medical issues. Seen by social work. Discussed extensively with patient. Has good family support, motivation to return to caring for his daughter and to go back to work. His drug use prior to this catastrophic event was intermittent.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is an ___ with PMHx of HTN, hematochezia, history of cardiomyopathy with recovered EF, CKD, Bipolar D/O, and PTSD with recent discharge from ___ ___ who presents from ___ after a fall. Per report from the ED, he patient was reaching for her walker and it was too far away of she fell at home. She denied LOC but stated that she was confused after the fall. She states that she fell and hurt her nose. Of note, the patient reports that she has fallen several times over the past few months. In the ED, the patient was A&O times 3 and was assisted to the bathroom with walker. ___ notes that the patient was drowsy on evaluation. The patient was recently hospitalied at ___ with encephalopathy. During that admission, the patient underwent infectious work-up with no evidence of infection being identified as a cause of her encephalopathy. Ultimately, her encephalopathy was attributed to seroquel. In the ED intial vitals were: 97.0 51 130/62 18 99% - Labs were significant for sodium of 135 and 129. Head CT showed no acute process. CT neck showed no fracture and stable soft tissue mass. EKG with no acute signs of ischemia. - The patient may have received Clindamycin as it is written as a medication on the dash though there is no administeration sticker in the patient's ED paperwork; patient's case was discussed with ___ fellow. ___ evaluated the patient in the ED who recommended that the patient could go back to her ILF. Vitals prior to transfer were: 98.3 44 130/84 14 97% RA When going to see the patient to admit to medicine, the patient was soundly sleeping and to sternal rub stated 'Ouch that hurts.' Unable to obtain further history. The patietn denies pain and trouble breathing. Radiology showed Mild cardiomegaly with mild pulmonary edema. Radiology showed No acute intracranial process. Radiology showed 1. No evidence of acute fracture or dislocation. 2. 2.0 x 1.7 x 1.3 cm right neck soft tissue mass, unchanged as compared to the prior exam. The etiology is indeterminate, and MRI could be performed for further characterization. 3. Heterogeneous appearing thyroid gland. Radiology showed Perhaps marginal interval improvement in pulmonary edema. The patient was diagnosed with SEMICOMA/STUPOR, OTHER FALL, HYPERTENSION NOS. At the time of discharge, the patient had Primary Orthostatic hypotension Secondary HTN CKD Bipolar disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient is an ___ with PMHx of HTN, hematochezia, history of cardiomyopathy with recovered EF, CKD, Bipolar D/O, and PTSD with recent discharge from ___ ___ who presents after a fall with confusion. # Encephalopathy: Resolved by the following morning. Medication effect seems most likely given resolution without intervention. Unclear how much seroquel patient is taking at home as patient is a vague historian. Imaging ruled out intracranial process. No signs of infection. Electrolytes normalized without intervention though creatinine was initially above baseline. In conjunction with her outpatient providers, we further decreased her seroquel dosing to 12.5mg daily and continued palmate. We also transitioned to blister-packing of her meds to reduce inappropriate medication administration. # s/p Fall: Orthostatics were positive and creatinine was slightly elevated on presentation supporting an element of hypovolemia. Patient is on BP meds and MAOI which can lead to postural hypotension. Head CT and cervical spine CT showed no acute injury as a result of the fall. Beta-blocker was dc'ed and amlodipine was halved. She was given compression stockings and given other advice about how to decrease the incidence of orthostasis. # CKD: Baseline 1.8. Patient slightly above baseline on admission though trended down by discharge. # Tachy/brady: Resolved. Tachycardia and bradycardia documented on arrival never recurred. Patient had frequent PACs and sometimes an ectopic atrial rhythm but rates remained normal and she was asymptomatic. Beta-blocker was dc'ed as above. # Hypertension: Well-controlled on reduced regimen of 2.5mg amlodipine. Could likely dc this medication all together to minimize orthostasis # Bipolar disease and PTSD: Continued palmate. She will follow-up with her outpatient psychiatrist # Code: Full # Emergency Contact: Guardian ___ (sister in law) ___ ___ ISSUES -Her amlodipine can likely be discontinued as an outpatient if her BPs remain well-controlled -She will follow-up with her outpatient psychiatrist for further titration of her insomnia meds -2.0 x 1.7 x 1.3 cm right neck soft tissue mass was incidentally noted on CT and is stable from prior imaging. MRI could be performed for further characterization. -CT also noted heterogenous thyroid gland. TSH was normal.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with h/o polymyositis, interstitial lung disease, OSA and CHF presents dyspnea and cough. She also has been having increasing proximal muscle pian and weakness, c/w prio polymiostits flares, x 1.5 week. She has been working with her rheumtologist, Dr. ___, to get rituximab, which helps her flares, but there have been insurance issues. In terms of the cough, patient reports 1 week of increased shortness of breath and cough productive of yellow sputum accompanied by fever with Tmax 100.4. Her sister has been sick with a cold recently. Radiology showed No definite acute cardiopulmonary process based on this limited examination. The patient was diagnosed with UNSPEC VIRAL INFECTION, HYPERTENSION NOS. At the time of discharge, the patient had viral bronchitis polymyositis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ F with polymyositis, ILD, multiple DVTs/PEs on Coumadin, morbid obesity who presents with productive cough and muscle pain and weakness. #. Polymyositis: Pt currently unable to ambulate ___ weakness. Pt states she typically gets rituximab infusions q6-8 weeks for her polymyositis, and it has been 8 weeks since her last infusion. Pt's case was discussed with rheumatology team. Given her CKs were in the 700s (rather than the 10,000s like previous flares), no changes were made to the patient's medications. Her outpt rheumatologist is continuing to work on getting rituximab approval. Pt states her pain typically responds well to ibuprofen, so this was used PRN pain. Her home dose of steroids and mycophenolate were continued, as was Bactrim for PCP ___. Given inability to walk, pt will be discharge to rehab for physical therapy as she is unsafe at home. She will need close rheum follow up and rituximab infusion when approved (will be arranged by rheum team). #. Acute bronchitis, viral: No clear infiltrate on CXR or focal crackles on exam, although both are limited by body habitus. No fever or leukocytosis to suggest PNA. Cough improved with nebs and Guaifenesin PRN. # Hx of DVT/PE: Pt had been taking 5mg warfarin on ___, and 7.5mg other days. INR was subtherapeutic ___, so she was given an extra 2mg warfarin that day. Would continue 7.5mg daily and check INR daily until stable. # recent unprotected intercourse: 2 weeks ago per pt, hCG negative in ED. HIV was negative. Urine chlamydia negative at the time of discharge. Pt should have pelvic exam for gonorrhea screening. Chronic and Transitional Issues: # chronic dCHF: Continued home torsemide and BBlocker to maintain euvolemia. Pt should follow up with Dr. ___ in Cardiology (appointment not currently scheduled). Prior to discharge from rehab, please help patient obtain 2 scales so she can stand on each and combine the weights. At home, pt should call Health Care Associates (___) if her weight increases by 2lbs. # glucose intolerance, morbid obesity: Per pt she is on metformin in the setting of high-dose steroids but does not have DM. Last A1c in ___ 5.9%. Given pt did not appear ill, metformin was continued in house. Pt would benefit from an intensive lifestyle modification program as due to her multiple medical problems, she is not a candidate for bariatric surgery at this time. Weight loss would significantly improve her mobility. # osteoporosis: Pt got her weekly alendronate here. Ca and vit D supplementation were continued. # Possible mood disorder: Upon discharge from rehab, pt should make an appointment for an initial visit with ___ by calling ___, option #2. # Home safety: Prior to discharge from rehab, pt needs to obtain another personal care attendant. Pt's mother is her current PCA and will soon be having orthopedic surgery and be unable to perform the necessary duties.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is a ___ woman with stage 4 lung cancer (60 pack year smoking history, non-operable, patient refusing chemo/radiation), severe AS (mean gradient 40 in ___, refusing intervention), mitral valve stenosis, and anemia (Hgb 9.3 in ___, who was transferred to ___ from Urgent Care for chest pain, concerning for STEMI. CHEST (PORTABLE AP) showed Small bilateral pleural effusions with bibasilar atelectasis. No overt signs of edema. The patient was diagnosed with STEMI involving oth coronary artery of anterior wall. At the time of discharge, the patient had PRIMARY DIAGNOSIS - Chest pain secondary to demand ischemia SECNDARY DIAGNOSES - Aortic stenosis - Lung carcinoma with metastasis to multiple lymph nodes - 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>SUMMARY: Ms ___ is a ___ woman with stage 4 lung cancer, severe AS, and chronic anemia, who was admitted for chest pain. Initially, her chest pain and mild ST elevations were concerning for STEMI, so she was taken to the cath lab. However, her pain and ECG changes resolved upon arrival to the cath lab, so she was admitted to the Medical Wards for further management of her anemia (Hgb 6.5 on admission) and for goals of care discussion. She was transfused 1 unit pRBC, with appropriate rise in her Hb, with improvement in her weakness and dyspnea on exertion. She was evaluated by cardiology, who felt that her symptoms were not concerning for ACS. Given her Stage 4 lung cancer, she is not surgical candidate for aortic valve repair. Team had an extensive goals of care conversation on ___ with patient and her son ___ was made Health Care Proxy & patient completed a MOLST form, and was made DNR/DNI. She will go home with home hospice. # CHEST PAIN: Initially, ST elevations in V1-V4 were concerning for STEMI, so patient was taken to the cath lab upon arrival to ED. However, her chest pain and ischemic changes on ECG completely resolved, so she was admitted to the medical service. Repeat ECG on floor showed 2mm ST elevated in V2 and 1mm ST elevation in V1. Pt received ASA 325 mg prior to admission and 81 mg PO x 1 upon arrival to the floor. She had originally been evaluated for possible cardiac catherization, however, per the cardiology fellow Dr. ___ declined all intervention. This decline of intervention seems consistent with prior desires as indicated in Atrius notes. Documentation of consent for cardiac cath was signed by the patient, and the patient endorsed that she "wanted everything done". Given resolution of her symptoms, she was admitted to medicine for further management. Given her downtrending troponins and normal ECHO, chest pain was thought to be demand ischemia, not ACS. She was monitored on telemetry and given ASA 81mg daily. Held beta blocker and heparin given severe anemia. Cardiology consulted, appreciate their recs. Per cardiology, patient is not a candidate for valve replacement. # ANEMIA: Patient has chronic anemia, with most recent Hgb 9.3 in ___. On admission, Hgb was 6.6. Patient denied signs and symptoms of bleeding. Per Atrius records, she has a history of a gastric ulcer and endorsed GERD symptoms. Also has a history of AVM per Atrius records. Given history of aortic stenosis, checked for active hemolysis, but hemolysis labs were normal. Hemoglobin remained stable after transfusion, and is 7.9 on discharge. # STAGE 4 LUNG CANCER: Patient has a 60-pack year smoking history, and known stage-4 lung carcinoma. The malignancy is non-operable, and the patient does not want chemotherapy or radiation. She is not on active treatment and does not require oxygen at home. Oxygen saturation was monitored, and remained stable throughout hospitalization. Goals of care were discussed, as below. # AORTIC STENOSIS: Patient has known AS prior to admission, with mean gradient 40 in ___. Per outside records, she had previously declined intervention; confirmed with cardiology that she declined intervention. Admission ECHO showed severe aortic valve stenosis (valve area <1.0cm2). Cardiology evaluated, appreciate their recs. Per cardiology, given the patient's stage 4 lung carcinoma and multiple other comorbidities, she would not be a candidate for valve replacement. # GOALS OF CARE: Prior to this admission, patient had multiple discussions with PCP (latest ___ to discuss goals of care with her metastatic lung adenocarcinoma. Per Atrius notes, " Adenocarcinoma, lung, unspecified laterality: Inoperable and she refused chemotherapy...She refused discussion regarding palliative care or hospice care and insisted on being full code... Today, I discussed with ___ the futility of intubation and mechanical ventilation in someone with inoperable lung cancer and critical valvular heart disease, yet she elected to be full code". Patient still has capacity. Team met with patient, her family, social work, and palliative care; she made her son ___ the HCP on ___. Had a very productive goals of care meeting on ___, and patient completed MOLST form; she is now DNR/DNI, and would not like to be hospitalized unless it is for comfort. She is very clear on what her wishes are. She would like to enjoy the time she has left, and would like to spend this time at home, not in a hospital. TRANSITIONAL ISSUES - ANEMIA: Patient has known gastric ulcer, and baseline Hgb ___, requiring 1 u pRBC, with appropriate rise in H/H. H/H subsequently stable and was 7.9 upon discharge. Can consider occasional monitoring with pallative transfusions as needed. - HOSPICE CARE: Patient would like to be comfortable and avoid future hospitalizations. She completed MOLST form and would like Home Hospice services. - GOALS OF CARE: Patient is DNR/DNI.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with metastatic RCC to the bone, lung, adrenal glands, liver, and brain which has progressed through multiple chemotherapy regimens who presented to the ED with lethargy. He was hospitalized from ___ with fevers and shortness of breath. It was felt that his dyspnea was multifactorial from tumor burden, anemia, and mild congestive heart failure and pleural effusions. He was initially treated for PNA, but since his fevers were thought to be secondary to malignancy, ABX were discontinued. He was treated with Lasix for new diagnosis of diastolic heart failure and discharged home on hospice given his poor preformance status and tumor progression. . His family states that he became drowsy lethargic around 5 ___ the day prior to admission and felt hot. He was brought to ___. ___ where he was found to have a fever to ___, and diagnosed with pneumonia on chest x-ray. He was transferred to ___ given that he is followed here by oncology. Prior to transfer CT head was negative, and he was given vancomycin. In the ER at ___, Vitals were 99.3 98 117/73 19 99% 2L NC; he was given Ceftazidime 1g, 3.5 liters of fluid. Radiology showed No evidence of acute intracranial hemorrhage or obvious mass effect. Please note that a non-contrast head CT is not sensitive for the detection of intracranial masses. If there is continued clinical concern and need for evaluation of parenchymal masses noted on the prior MRI, then a repeat MRI of the brain can be obtained with and without contrast, if not contra-indicated . The right lateral ventricle is slightly more concave-? related to orientation - attention on f/u. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, SEC MAL NEO BRAIN/SPINE, SECONDARY MALIG NEO LUNG. At the time of discharge, the patient had Primary Diagnosis: Metastatic Renal Cell Cancer Secondary Diagnosis: Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient is a ___ yo with a PMHx of metastatic RCC which has failed chemotherapy (with Sutent, Temsirolimus, and Bevacizumab) who presents with altered mental status and fever after going home ___ on hospice. . # Fever: Likely secondary to leptomeningeal disease and extent of malignancy. Given concern for post-obstructive pneumonia given CXR, we initially covered for HCAP. Lumbar puncture was deferred given his prior antibiotic treatment in the ED and low likelihood of meningitis given the rapid improvement in mental status and lack of meningeal signs. Vancomycin and ceftriaxone were initiated for a 7 day course. Urine cultures were no growth, and blood cultures demonstrated no growth during his stay, but final results were pending at the time of discharge. He had no further episodes of fever during his stay. He was discharged on Levofloxacin for oral coverage of possible pneumonia since IV antibiotics were not available on hospice. . # Encephalopathy: Differential diagnosis on arrival included cerebral edema vs leptomeningeal spread of disease vs sepsis vs overuse of narcotics. Cerebral edema was not visualized on imaging. Upon admission, narcotics were reduced from Oxycontin 40 mg TID to 30 mg BID. By day two of admission, his mental status had greatly improved. It is likely that the reduction of Oxycontin resulted in the improvement in mental status. Antibiotic coverage with Levofloxacin was continued on discharge since infection could not be completely ruled out. He was discharged on the reduced dose of Oxycontin with Oxycodone for breakthrough pain. . # Pain Control: He has had difficulty with pain control and adjustment of his narcotics doses for adequate relief without over narcotization. His Oxycontin likely contributed to his altered mental status and lethargy on admission. He was discharged on the reduced dose of Oxycontin 30 mg PO BID with Oxycodone 10 mg PO Q4H for breakthrough pain. He was also started on standing doses of Ibuprofen 400 mg PO Q6H and Acetaminophen 1000 mg PO Q8H. The addition of these non-narcotic pain medications appeared to have good effect with a reduced need for narcotics. His pain was well controlled without sedation or confusion during his stay, and he was discharged on this new regimen. He will likely neec close followup of his pain control regimen after discharge with care to avoid over escalation of his narcotics doses. . # Metastatic RCC: He is status post failure of two regimens, and per primary oncologist no further anti-neoplastic care is indicated. He recently went home on hospice on ___. Palliative care was consulted on admission for further teaching about the role of hospice and reevaluation for hospice services. He was discharged home with the same hospice service. . # Chronic diastolic CHF: He did not appear fluid overloaded on exam. His outpatient dose of Furosemide 20 mg PO daily was continued. . # Appetite / Nutrition: Patient was continued on Megestrol Acetate 400 mg PO BID and Ensure supplements with meals. . # DVT Prophylaxis: Heparin 5000 units SC TID .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old gentleman with PMHx significant for ETOH abuse (hx of DTs), and htn not currently receiving medical care who presents with symptoms of fatigue, mild cough and acute onset substernal chest pain. . Per ED report, he reports the onset of substernal chest pain was acute and associated with dyspnea and was pleuritic in nature. He reprots it occurred several times this morning while he was coughing and self resolved. In this setting he reports a progressive history of fatigue, maliase. He denies nausea, diaphoresis, emesis, diarrhea of constipation. He has not looked at his stool and cannot report BRB or melanotic stool. He does have chronic diarrhea. This history was confirmed on the ICU however history taking was limited secondary to somnolence. . The patient reports 2 gallons a day history of vodka per day. Last drink was at 7PM last night. He reports a positive history of DTs in the past and frequent admissions to ICU for detox. . In the ED inital vitals were, 97.3 ___ 24 100% RA. Physical exam was significant for clear lung exam, mild tenderness to the epigastrium. Labs demonstrated serum etoh 56, hct 34, creatinine 0.9, potassium 3.2, lactate 2.3 and troponin 0.01. A d-dimer was 1410. A serum toxic was otherwise negative. He was given 1mg Ativan po x2, 2mg ativan IV, potassium choloride repletion and folic acid. A CT abdomen and pelvis was obtained which demonstrated no acute intra-abdominal process and 2.8 cm hepatic lesion with recommendation for follow-up MRI. Of note he had many attempts at peripheral access which failed. A right IJ was placed under sterile conditions. Pulmonary embolism was considered on the differential however unable to perform CTA ___ access issues. . On arrival to the ICU, initial vitals were: T 99, HR 96, BP 184/111 18 97% RA with systolic BPs in the low 200s on arrival. he was chest pain free. He was given 10mg IV hydralazine with initial improvement in his SBPs in the 170s. He was started on a nitroglycerin gtt in the setting of reported chest pain, and blood pressure control. He was somnolent on exam, easily aroused but difficult to maintain mentation. A phone call to his wifes listed number revealed she had no phone. Radiology showed No acute chest pathology. Radiology showed Interval right internal jugular line placement, the tip of which is at the cavoatrial junction. There is no pneumothorax. Radiology showed 1. No acute intra-abdominal process. 2. Hepatic steatosis. 3. 2.8 cm hyperdense hepatic lesion in segment III of the liver which is not fully characterized on this study. Given the patient's history of liver disease, MRI of the liver is recommended for further evaluation. 4. Bilateral adrenal hyperplasia. 4. Diverticulosis without evidence of diverticulitis. The patient was diagnosed with CHEST PAIN NOS, ALCOHOL WITHDRAWAL, SHORTNESS OF BREATH, HYPERTENSION NOS. The patient was treated with Placement of right internal jugular line. At the time of discharge, the patient had Primary: Alcohol abuse New Liver mass Secondary: Hepatitis C Hypertension H/o delerium tremens ? Schizophrenia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old gentleman with PMHx significant for ETOH abuse (hx of DTs), and htn not currently receiving medical care who presents with symptoms of fatigue, mild cough and acute onset substernal chest pain. ETOH ABUSE: History of significant ETOH abuse with history of DTs. Unable to wean ativan requirement past q2hrs in emergency room and therefore not suitable for general medical floor given nursing requirements for management. Positive ethanol on tox screen. Last drink at 7pm the night prior to admission. Patient was placed on CIWA scale with valium. He was scoring ___ on the night of admission mostly for agitation and tremor. He was given thiamine and folate supplementation. Valium requirement was spaced out to q4h and he required a total of 15mg on HD1. - SW consult obtained and patient appeared pre-contemplative. He was given information about ___ for the Homeless Program to locate a caseworker to assist with findingpermanent housing, be referred to a primary care physician, and then be referred to a therapist and psychiatrist. ACUTE DYSPNEA/PLEURITIC CHEST PAIN: Patient complained of shortness of breath and pleuritic chest pain on arrival. Concern was for pulmonary embolism vs ACS/unstable angina. Cardiac enzymes were negative x 2 and EKG showed no ST depressions or elevations. Chest xray not concerning for mediastinal widening or infiltrate. D-dimer elevated concerning for PE/DVT, however, a CTA was not performed as very low suspicion for PE. Pain resolved on day of admission, and patient had no further complaints. HYPERTENSION: Hypertensive on admission to the FICU, unresponsive to hydralazine 10mg IV. He was started on a nitroglycerin drip which was discontinued shortly after arrival. He was started on clonidine 0.3mg po BID as home anti-hypertensive regiment was unclear. Patient received an additional 10mg of IV hydralazine with good blood pressure response. In addition, his pressures improved following valium for high CIWA scores. Per home pharmacy, patient is on nifedipine XR 60mg po daily which was restarted on hospital day 1. TRANSAMINITIS: Mild transaminitis noted on admission. Etiology is likely acute alcoholic hepatitis vs chronic viral hepatitis (history of hepatitis C) vs cirrhosis. Synthetic function was intact with INR 1.0. CT abdomen and pelvis notable for hepatic steatosis and hyperdense hepatic lesion. LIVER NODULE: Nearly 3cm discrete liver nodule seen on CT scan. In setting of significant etoh hx, poor medical care and recent fatigue concerning for underlying liver disease/malignancy. Pt informed of this at time of discharge but declined further evaluation. FATIGUE: History of progressive fatigue. Unclear etiology. Weight loss? Liver nodule concerning for malignancy. Normocytic mild anemia on admission. Upon arrival to the floor patient and wife insisted upon leaving. Despite this author repeatedly asking them to stay citing his current ___ problems along with the new liver mass seen on his CT of the abdomen. They both insisted on leaving at 10 pm at night from the hospital. (See OMR note for further details.) Pt appeared competent. He was able to walk independently. He was thus discharged against medical advice. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with PMHx significant for heart block s/p pacemaker, DM, CAD, and CKD, who presents with a chief complaint of recurrent hemoptysis. Radiology showed Right middle lobe opacity compatible with atelectasis and posssible infection. Radiology showed The left-sided pacemaker and wires are unchanged in position. There is a persistent right middle lobe opacity, stable. There is also prominence of the pulmonary interstitial markings which have worsened. There are no pleural effusions or pneumothoraces. There is extensive thoracic aortic calcification. Heart size is enlarged. Radiology showed Left-sided pacemaker with leads are unchanged in position. There is unchanged cardiomegaly. There is mild improved aeration. There remains prominence of the pulmonary interstitial markings. There is an opacity at the right medial heart border. This may represent pneumonia or aspiration. No pneumothoraces are seen. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. The patient was diagnosed with OTHER HEMOPTYSIS, LONG TERM USE ANTIGOAGULANT, CARDIAC PACEMAKER STATUS. The patient was treated with Bronchoscopy w/ electrocautery. At the time of discharge, the patient had Primary Diagnosis: hemoptysis Secondary Diagnosis: hypertension, recent pulmonary embolism, 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>___ year old female with heart block s/p pacemaker c/b pneumothorax requiring multiple chest tubes, DM, CAD, CKD, presenting with recurrent hemoptysis since ___ with previously observed clots on bronchoscopy. Recent bronchoscopy also showed evidence of large clots in the R mainstem and R middle bronchus with several areas requiring cauterization. #Hemoptysis: small volume. Chest film with no evidence of TB or other cavitary lesion, but demonstrated R. middle lobe opacification concerning for consolidation vs. atelectasis. There was also concern that this current episode of hemoptysis was precipitated by recent anticoagulation with coumadin that was initiated for treatment of pulmonary emboli discovered during the ___ bronchoscopy. Thus, her anticoagulation was held. The patient underwent repeat bronchoscopy on ___ with removal of clots and cauterization of several oozing areas of friable tissue. Lavage was performed and biopsy sent to pathology for further examination with results pending. #Anticoagulation: Coumadin will be held (per pulmonary) for the next four weeks until patient follows up with repeat CT Chest and bronch to allow time for her injured pulmonary tissue to heal. The tentative plan is to ultimately resume anticoagulation and complete full treatment of her PE. She has IVC filter in place. #Iron deficiency anemia: Hg 9.2 on admission and stable at 8.8 on day of discharge. Patient did not have any symptoms of anemia and was not transfused pRBCs. She was given a script to get her CBC repeated within the next week and prescribed oral iron supplements. #Stage II Sacral Ulcer: no sign or cellulitis; wound kept clean and dry. Patient rotated frequently to avoid continuous pressure. #Hypertensive urgency: Patient hypertensive to 204/99 in PACU following bronchoscopy most likely secondary to not receiving her home meds prior to procedure. Home meds given in addition to 20mg IV Labetalol and 5mg IV Metoprolol. Her blood pressure responded appropriately with no other episodes of significant elevations. *TRANSITIONAL ISSUES:* - Ms. ___ will ___ with her Interventional Pulmonologist for repeat CT and repeat bronchoscopy 4 weeks after discharge. - Ms. ___ was previously anticoagulated with Warfarin to treat PE. Per her Interventional Pulmonologist, this anticoagulation should be held for the next 4 weeks until repeat imaging and bronchoscopy have been completed at which point this should be restarted if bleeding risk minimized. - Please check a CBC at PCP ___ within ___ weeks of discharge. - Patient started on 325mg of iron at discharge. - Ms. ___ has an IVC filter in place. This should be removed once the patient has been safely restarted on anticoagulation. - Ms. ___ has a stage 2 sacral ulcer. Please evaluate for healing. - Patient's BP consistently in the 160s systolic throughout hospitalization; consider adjusting her outpatient regimen as appropriate. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: PCP: Dr. ___ (assigned, not yet seen) Current PCP: Dr. ___ GI: Dr. ___ (___) CHEST (PA AND LAT) showed Normal chest radiograph. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. Radiology showed No evidence of pulmonary embolism or aortic abnormality. MR ___ showed 1. Diffusely enhancing irregular segment of strictured terminal ileum extending to the cecum and replacing the ileocecal valve. While this may reflect masslike chronic fibrostenotic changes related to Crohn's disease (noting the recent biopsy results), underlying neoplasm cannot be excluded. 2. Multiple enlarged ileocolic mesenteric lymph nodes. While these may be reactive in the setting of inflammation, given the possibility of neoplasm, malignant lymphadenopathy is also a consideration. 3. Strictured terminal ileum causes at least partial obstruction with prestenotic dilatation of the proximal ileum and fecalization of the distal small bowel indicating stasis. RECOMMENDATION(S): 1. If further biopsy of the terminal ileum or surgery is not performed, short interval follow-up with MR enterography in 3 months is recommended. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 11:40 AM, 5 minutes after discovery of the findings. The patient was diagnosed with ANEMIA NOS, PALPITATIONS. The patient was treated with EGD Colonoscopy. At the time of discharge, the patient had Acute blood loss anemia Inflammatory bowel disease Palpitations. The patient was given written instructions concerning 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 Crohn's disease, who presented with profound symptomatic anemia, most likely related to subacute GI bleed in the setting of acute on chronic colitis. # Iron deficiency anemia, likely subacute, # Crohn's disease, # Palpitations: Patient initially presented with palpitations and was found to have a hemoglobin of 3.5, down from a baseline of ___. She had an elevated D-dimer, so a CTA was performed in the ED, which was negative for PE or other abnormalities. She required 3 units of PRBCs initially, and her hemoglobin remained stable for the remainder of her hospitalization. Patient was found to have profound iron-deficiency anemia, likely from a subacute GI bleed related to her colitis. She underwent EGD that only showed nonspecific scalloping of the antral mucosa, with normal biopsies of the antrum and duodenum. Patient then underwent colonoscopy that showed a polypoid, edematous, erythematous and ulcerated lesion in what was thought to be the cecum/appendiceal orifice. This was biopsied which show active colitis. TB was considered given her history of positive PPD and risk factors, but her recent quant gold was negative. She then underwent MRE that showed a “diffusely enhancing irregular segment of strictured terminal ileum extending to the cecum and replacing the ileocecal valve. While this may reflect masslike chronic fibrostenotic changes related to Crohn's disease (noting the recent biopsy results), underlying neoplasm cannot be excluded.” It also showed a strictured ileum with partial obstruction with prestenotic dilation of the small bowel to 7cm. The hospitalist and GI consulting team wanted patient to remain in the hospital for further evaluation, but she insisted that she be discharged and follow up in clinic with her gastroenterologist (Dr. ___ at ___. Dr. ___ was contacted to help arrange for urgent GI clinic follow-up and colorectal surgery consultation. At the time of discharge the patient had a stable hemoglobin and was tolerating a regular diet. She was having formed bowel movements without evidence of blood. She understood that she should return to the hospital immediately if she were to experience any chest pain, shortness of breath, or GI bleeding.</s>