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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old woman with history of
hypertension, obesity, asthma, headaches, seizure d/o on
lamotrigine, chiari 1 malformation s/p surgical decompression,
and chronic mobility and social issues, presenting on post
partum
day 6 after C-section for twins with respiratory distress s/p
intubation, found to have low ___ transferred to ___ and ED for
further management of peripartum cardiomyopathy. CHEST (PORTABLE AP) showed No comparison. The patient is intubated, with the tip of the endotracheal
tube projecting approximately 3 cm above the carinal. The course of the
feeding tube is unremarkable, the tip is not visualized on the image. Lung
volumes are low. Moderate cardiomegaly is present. The very extensive right
medial and basal parenchymal opacity with air bronchograms is visualized, the
location would be consistent with aspiration. There also is an accompanying
mild to moderate right pleural effusion. No evidence of pulmonary edema. Chest radiograph, portable AP semi-upright. showed 1. PICC line terminating in the lower superior vena cava. Endotracheal tube
terminating 3 cm above the carina. Orogastric tube terminating in the
stomach.
2. Suspected bilateral pleural effusions and pulmonary edema. Possibility of
developing pneumonia in the right lower lobe is doubted but if it is a
possible clinical concern short-term follow-up repeat radiographs may be
helpful. UNILAT UP EXT VEINS US RIGHT showed 1. No evidence of deep vein thrombosis in the right upper extremity.
2. Subcutaneous edema about the right forearm is nonspecific. No focal fluid
collection. Chest radiograph, AP portable upright. showed Marked interval improvement in pulmonary opacities. The patient was diagnosed with Oth complications of the puerperium, NEC, Heart failure, unspecified. The patient was treated with ___ Intubation
___ Extubation. At the time of discharge, the patient had Primary diagnosis:
Peripartum cardiomyopathy
Secondary diagnoses:
Non-sustained ventricular tachycardia
Supraventricular tachycardia
Anemia
Thrombocytosis
Acute hypoxemic respiratory failure
Seizure disorder
Asthma. The patient was given written instructions concerning 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 history of
hypertension, obesity, asthma, headaches, seizure d/o on
lamotrigine, chiari 1 malformation s/p surgical decompression,
and chronic mobility and social issues, presenting on post
partum day 6 after C-section for twins with respiratory distress
s/p intubation, found to have low ___ transferred to ___ for
further management of peripartum cardiomyopathy. ___ ___ showed
LVEF 15%, severe global LV hypokinesis c/w non-ischemic
cardiomyopathy, RV free wall hypokinesis, mild MR, and high PA
systolic pressure. She was extubated on ___ and was actively
diuresed and started on PO meds. New discharge meds included:
torsemide 10mg qod, metoprolol XL 200mg qd, Entresto 97mg-103mg
bid, spironolactone 25mg qd, apixaban 5mg bid for cardioembolic
prophylaxis given global LV hypokinesis. She will follow up with
outpatient PCP, ___, and Dr ___ with f/u ___
at that time.
ACUTE ISSUES:
=============
# Hypoxemic respiratory failure
# Peripartum cardiomyopathy
# Acute systolic HF exacerbation
# RML consolidation
Presented with sudden onset dyspnea and hypoxia requiring
intubation at OSH. This was ___ pulmonary edema in setting of
peripartum cardiomyopathy ___ edema, elevated BNP, orthopnea at
home) as resp status improved with diuresis. She was
successfully extubated on ___. CTA was negative for PE. She
received ceftriaxone for coverage of possible pneumonia, though
this was discontinued. She was started on apixaban 5mg bid for
cardioembolic prophylaxis, given EF<15%, global LV hypokinesis.
She was discharged on torsemide 10mg qod, metoprolol XL 200mg
qd, Entresto 97mg-103mg bid, spironolactone 25mg qd.
Discharge weight: 86.2 kg, 190.04 lbs (diuresis plan: torsemide
10mg qod).
# RUE Swelling
Noted to have tense and significant RUE swelling following
admission. RUE U/S unremarkable. Surgery consulted, and felt
this likely was related to her PIV. Her exam improved following
removal of PIV and elevation of the arm.
# Seizure disorder
Has history of seizures transitioned from oxcarbazapien to
lamictal, prior history of setting house on fire with seizure.
Seizures are usually absence, not generalized tonic clonic.
Stable since ___ on current lamotrigine dosing. Continued home
lamotrigine.
# Thrombocytosis
# S/p C-section and post-partum hemorrhage
# Normocytic Hypochromic Anemia
Recently underwent massive transfusion protocol in setting of
hemorrhage complications during delivery. Continued to have
slowly downtrending Hgb during admission, thought secondary to
continued slow post-partum hemorrhage. DIC labs negative. ___
consulted who felt no surgical intervention was required.
# Social
Estranged from parents, lives in public housing, concerns for
neglect on recent admission, father of baby is currently
imprisoned. SW was consulted.
# Asthma
Continued home inhalers, advair as symbicort not on formulary.
TRANSITIONAL ISSUES
====================
[]Discharge weight: 86.2 kg, 190.04 lbs (diuresis plan:
torsemide 10mg qod).
[]Has ___ and outpatient f/u scheduled with Dr ___
(Cardiology).
[]Discharged with life vest given low EF and recurrent episodes
of NSVT. Consider EP follow-up.
[]Recommend minimizing or d/c'ing use of albuterol given
recurrent episodes of NSVT (though pt on this for asthma). </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F PMHx significant for liver transplant ___ at ___
___ who presented with 1 day of abdominal pain,\ nausea and
bilious emesis. Per report, she was in her usual state of health
until 4:30AM on ___ when she awoke with nausea, epigastric
abdominal pain and emesis. She initially felt better but then
the epigastric pain, nausea and emesis recurred at 11am and
again at
1pm. At time of presentation, her last flatus was ___, her last
BM was ___ am. She has had no flatus or bowel movements since.
She describes the pain as similar to a contraction: intense,
focal in the epigastric region lasting for approximately
10seconds then relaxing. At those instances she feels like her
abdomen is slightly more distended. She denies any pain with
riding here in the car going over bumps. She also reports she
has had no prior episodes of this. In the ED her nausea resolved
with Zofran. She also reported mild improvement in abdominal
pain after administration of NGT. Radiology showed Interval improvement of small bowel obstruction seen on prior radiographs from
___. Prominent loop of jejunum in the left upper quadrant measuring
up to 3.1 cm, and scattered air-fluid levels within small bowel on the upright
view. The patient was diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst. At the time of discharge, the patient had small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented to the ED on ___ with acute onset
epigastric abdominal pain and emesis. CT showed small bowel
obstruction. Given her history of liver transplant in ___, Ms.
___ was admitted to the transplant surgery service for
management of her SBO, which was medically managed with NPO
status, an NG tube for suction, and IV fluid resuscitation. Ms.
___ continued to received her tacrolimus while inpatient. Her
stay was uneventful and she was hemodynamically stable
throughout her hospitalization. NG tube was dc'ed on ___ and
she was advanced from NPO to a clear liquid diet. Her pain
lessened and resolved with medical management-she did not
require pain medications during her hospitalization. She was
advanced to regular diet with appropriate return of bowel
function.
During this hospitalization, the patient ambulated early and
frequently, and actively participated in the plan of care.
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: ___ is a ___ year-old Right-handed man, pmh of
myasthenia ___ who is sent in by ___ neurology for
admission for plex for worsening myasthenia. History is per
patient, family, and outpatient neurologist, Dr. ___
(cell ___ office ___. Radiology showed No acute cardiopulmonary process. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. Severe multilevel degenerative changes as described above.
2. A 1.6 cm right thyroid nodule, for which further evaluation with ultrasound
is suggested by current ACR limitations for incidentally noted thyroid
nodules. CT L-SPINE W/O CONTRAST Q331 CT SPINE showed Severe multilevel degenerative changes with severe neuroforaminal narrowing at
L2-3 on the left, bilaterally at L3-4 and on the left at L4-5 and L5-S1. The patient was diagnosed with Diarrhea, unspecified, Myasthenia gravis without (acute) exacerbation. At the time of discharge, the patient had myasthenia ___
cervical spondylosis
lumbar spondylosis
urinary tract infection
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>___ was admitted for management of his myasthenia
___ and chronic diarrhea and workup of his progressive lower
extremity weakness and worsening gait, which was persistent
despite treatment for his myasthenia with 3 days of IVIG
treatment (___) and numerous changes in medications
(___). His examination is notable for mild myasthenic symptoms
(ptosis, fatiguable upgaze, minimal facial and neck flexion
weakness, and fatiguable weakness of proximal muscles). However,
on admission he was found to be weak in a cervical and
lumbrosacral radicular pattern and bilateral upper motor neuron
pattern lower extremity weakness in a distribution atypical for
NMJ disease. He was thought to have a multifactorial etiology of
his weakness with majority of his functional decline more
attributable to cervical spondylosis and stenosis, rather than
acute myasthenia flare. The neuromuscular service was consulted
and through discussions with his outpatient neurologist his
cellcept was decreased and prednisone was increased. His
myasthenic symptoms were stable after the change. His diarrhea
improved; he still had intermittent loose stools. He was found
to have a urinary tract infection and was treated with
ceftriaxone (4 days). His culture grew pansensitive klebsiella
and ecoli resistant to ampicillin and cefazolim and he will
complete his course of treatment with fosfomycin based on
sensitivities and his myasthenia.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ old man who had a traumatic fall from
80+ft in ___, for which he underwent an exploratory
laparotomy with drainage of retroperitoneal hematoma from a R
renal laceration as well as fixation of the anterior symphysis.
He had been recovering well from these injuries and surgeries
until now. He presents to the ED with abdominal pain, nausea and
vomiting of one day duration. The emesis was bilious,
non-bloody.
Imaging at ___ revealed an SBO, and an NGT was placed. He was
transferred to ___ for continued care because of his previous
surgical history at ___. Radiology showed 1. Interval improvement in small bowel dilation compared to prior abdominal
radiograph from ___, representing a resolving, ileus versus partial
small bowel obstruction.
2. PO contrast from prior CT study is seen predominantly in the cecum and
ascending colon. The patient was diagnosed with Unspecified abdominal pain. At the time of discharge, the patient had Small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ presented to ___ Department on ___ as a
transfer from an OSH. He had initially presented to OSH with
nausea/vomiting and intolerable abdominal pain. CT scan was
concerning for a small bowel obstruction, especially given Mr.
___ past surgical history of an exploratory laparotomy this
past ___ for a renal laceration s/p traumatic fall. An NGT was
placed at the OSH and he was transferred to ___ for further
care given his surgical history at this institution.
Given findings and the lack of peritoneal signs, the patient was
treated conservatively with NPO/IVF, NGT for decompression, and
awaiting return of bowel function. His pain was treated with IV
pain medications, and his nausea was addressed as well. With the
NGT decompression, he began to experience return of bowel
function on HD#1 with a KUB showing resolving ileus vs. SBO. On
HD#2, the NGT was D/C'd, he was passing flatus, and tolerating
full liquid diet with no nausea or vomiting. He was discharged
on HD#3, tolerating regular diet with no nausea/vomiting,
continuing to pass flatus, and with resolved abdominal pain.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ retired elementary school
___ with a PMH pertinent for osteoarthritis s/p bilaterally
TKR's, depression, asthma, HTN, GERD, morbid obesity, gout,
endometrial cancer s/p TAH-BSO (___), bilateral breast cancer
(R
stage 1 ER+ invasive ductal cancer, L DCIS) s/p lumpectomies
(___) & on letrozole who presented to the ED in the evening
___ for altered mental status, fever, LLE cellulitis. The
limited history was provided by husband/son given patient's
confusion. CHEST (PA AND LAT) showed 1. No focal consolidation to suggest pneumonia.
2. Pulmonary vascular congestion without frank pulmonary edema. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Faint ground-glass opacities in the lateral aspect of the right middle lobe
are nonspecific, and could be infectious or inflammatory in nature. CT HEAD W/O CONTRAST Q111 CT HEAD showed No evidence of acute intracranial abnormality. Basal cisterns are patent and
there is no mass effect seen. MRI ___ AND MRA NECK PT13 MR HEAD showed 1. No acute intracranial abnormality.
2. Suboptimally seen origin of vertebral arteries, probably mild bilateral
narrowing.
3. Moderate opacification mastoids, may be reactive, inflammatory, consider
otomastoiditis.
4. Acute paranasal sinusitis, most prominent at the right maxillary sinus..
5. 3 cm thyroid nodule, guidelines below.
RECOMMENDATION(S): Thyroid nodule. Ultrasound follow-up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or older.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150. The patient was diagnosed with Cellulitis of left lower limb, Disorientation, unspecified, Fever, unspecified. The patient was treated with LP ___ (failed). At the time of discharge, the patient had Hypoxemic respiratory failure
Cellulitis
Toxic metabolic encephalopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman with a complicated PMH including bilaterally
TKR's, morbid obesity, and recent bilateral breast cancer (R
stage 1 ER+ invasive ductal cancer, L DCIS) s/p lumpectomies
(___) & on letrozole who is admitted after presenting to the
ED in the evening ___ with fever to 102, encephalopathy, and
leukocytosis
#Acute metabolic encephalopathy
#Severe sepsis with unclear source
#Left-sided weakness, aphasia, dysarthria
There was initially concern for stroke or TIA on the second
hospital day, but these findings were not noted when she was
initially admitted or in the ER. At the time of discovery, she
had dysarthria, aphasia, and left-sided weakness (___), but she
was out of the window for possible tPA. Head CT ___ did not
show any acute process. She received ASA 325mg PO ___
MRI/MRA head and neck ___ showed no acute process either. (She
needed large MRI which caused 1-day delay). LP attempted on
___ AM out of concern for meningitis, but unsuccessful. In
particular, excess soft tissue made this difficult. ___ was then
consulted, but said that after someone has full ASA, they are
ineligible for LP for 5 days. At 5 days, study would be
non-diagnostic, so will not be pursued. Thankfully, towards the
end of the day on ___, the symptoms had largely resolved.
She was placed on Vancomycin and Cipro on ___ out of concern
for possible meningitis. Cellulitis was very notable on her LLE,
and there was possible PNA on CT (not very convincing) and no
evidence of UTI. Blood cultures were drawn and showed no
growth. Her WBC was as high as 22.6, but improved to normal
after receiving antibiotics. Ultimately, the possibility of
bacterial meningitis was low, so after receiving Vancomycin and
Cipro, this was changed to keflex and doxy on discharge for
extended course for cellulitis. Swallow consult for diet safety
had no issues on ___. With thrombocytopenia, viral illness is
also on the differential, but LFTs normal. Flu swab was
negative.
#Acute hypoxemic respiratory failure
She presented requiring 4L of nasal oxygen. CTA negative for PE
but did show atelectasis and possible aspiration or infection.
She received standing Duonebs, which seemed to help. OSA/OHS
and atelectasis were the likely largest culprits. She was able
to wean O2 to RA several days prior to discharge.
#Hx of bilateral breast cancer
Diagnosed late ___ with R stage 1 invasive ductal cancer and L
DCIS), now s/p lumpectomies/partial mastectomy (___) and now
on letrozole given cancer was ER-positive. Per review of
records,
patient was not recommended chemotherapy or radiation therapy.
Followed by Dr. ___ at ___ On___ (___). Last
seen in ___. She continued home letrozole 2.5mg daily
#Hypophosphatemia and hypomagnesemia - replaced
#Hypertension - continue home at atenolol 50mg daily
#Fungal skin rashes - skin care and anti-fungal cream ___
changed to Fluconazole 200mg PO x1 on ___ and then 100mg PO
daily ___.
# Morbid obesity - outpatient exercise program
# Gout - She continued home allopurinol ___ daily
#Outstanding issues
[]changed to keflex and doxy on discharge for extended course
for cellulitis (total duration of treatment ___ days)
[] For fungal rash started Fluconazole 200mg PO x1 on ___ and
then 100mg PO daily ___.
>30 min spent on discharge planning including face to face time</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ F well known to the neurosurgical
service for spinal cord stimulator placement placed on ___ ___ complicated by a wound infection requiring 3 admissons
for IV ABX and s/p a wound washout ___. Patient reports
purulent drainage coming from both mid back and low back
incisions beginning ___. She denies any fever , chills or
night sweats, weakness, numbness, tingling, nausea, vomiting. CHEST (PRE-OP PA AND LAT) showed PA and lateral upright chest radiograph reviewed
Heart size and mediastinum are stable. The PICC line has been discontinued.
Hardware is projecting over the spine. Lungs are clear. There is no pleural
effusion or pneumothorax CHEST PORT. LINE PLACEMENT showed Left PIC line can be traced as far as the origin of the SVC be on which it
would be obscured by spinal hardware. Lungs lung volume but clear.
Cardiomediastinal silhouette unremarkable. No pleural abnormality.
NOTIFICATION: PIC line position was discussed over the telephone by Dr. ___
with IV nurse ___. CHEST (PA AND LAT) showed Lateral view shows the left PIC line passes to the low SVC. On the frontal
view it is obscured by spinal hardware as noted on the report of the prior
study. Heart size is normal. Lungs clear. No pleural abnormality. The patient was diagnosed with DUE TO NERVOUS SYSTEM DEVICE,IMPLANT AND GRAFT, ABN REACT-SURG PROC NEC. The patient was treated with ___ - spinal cord stimulator removal and washout. At the time of discharge, the patient had Infected Spinal Cord Stimulator. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o F with history of spinal cord stimulator presents with
wound drainage. Patient is other intact. Cultures were obtained
on admission and vancomycin was started. On ___, she was
consented and pre-oped for the OR for wound washout and removal
of spinal cord stimulator. ID was consulted who agreed with
continuation of vancomycin.
On ___, the patient was taken to the OR for removal of spinal
cord stimulator and wound washout. Intraoperative cultures were
taken. ID continued to be involved.
On ___ She continued on vancomycin. A PICC line was ordered.
On ___, the patient was stable from a neurologic persepctive.
Infectious disease adjusted the patient's antibiotics based on
sesitivities and switched her to cefazolin 2g Q8h. She had an
episode of chest pain that did later resolve. An EKG was
ordered which was found to be unremarkable. Cardiac enzymes
were ordered as well which were unremarkable. DC was planned
___ after her AM dose of antibiotics. ID follow up was
scheduled.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yof with a history of mental retardation,
HTN and newly diagnosed CHF presenting with hypoxia. Patient was
seen two days prior to admission by her PCP for ___ routine visit.
She was found to be hypoxic to the low ___ on room air, she
declined an inpatient admission at that time. A chest x-ray
performed at that time showed no evidence of pneumonia but had
findings consistent with CHF. Night prior to admission, patient
was tachypnic and unable to sleep according to her sister, she
also has had a cough that was productive of sputum of unknown
color/consistency for past 5 days. She was seen by her PCP and
again found to be hypoxic to 82% on room air and was sent to the
ED. Patient did not check temperature at home. Patient has had
dyspnea with exertion for past year, and has not had much
lifelong PCP follow up. ___ has had decreased po intake and last
BM was at least 3 days prior to admission. Patient has orthopnea
and report of foul smelling urine. Per family, patient will
under report any symptoms. No falls at home.
In the ED:
-100.6 96 162/80 18 99% 5L
-Levofloxacin 750mg x1
On the floor: 98.0 156/84 HR 87 RR 18 sat 95% on 4L NC
ROS: no chest pain, dysuria, diarrhea or abdominal pain Radiology showed Moderate pulmonary edema. Radiology showed Marked improvement in pulmonary edema. Improving left
retrocardiac opacity, likely atelectasis, but continued followup may be
helpful to exclude underlying pneumonia given clinical suspicion for this
entity. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, UNSPECIFIED INTELLECTUAL DISABILITIES, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had CHF exacerbation, Pneumonia (CAP), UTI. The patient was given written instructions concerning 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 ___ yof with a history of mild mental
retardation, HTN and newly diagnosed CHF presenting with hypoxia
with pulmonary edema on CXR.
# CHF: Diagnosed ___. BNP elevated. Echo ___ shows
diastolic dysfunction, Mild to moderate (___) aortic
regurgitation and preserved EF.
-continued Lasix 20mg po daily, discharged on 40mg and should be
adjusted at next PCP visit pending lytes and volume status
-continued home Lisinopril
-We could not completely wean oxygen so was discharged with home
oxygen. Patient desatted to <88% on RA with ambulation. This was
discussed with family, and there is obvious concern with her
smoking at home. She agreed to stop, and lives with Nephew who
was going to be there as well. Patient and family was repeatedly
warned of risks with going home with O2, but this was preferred
to rehab by patient and family.
# Recent Fever: No fevers since admission. Possibly pneumonia
given productive cough with R>L lung sounds although not seen on
CXR. Repeat CXR after diuresis negative for PNA. UA negative but
urine cx ___ growing E.coli 10,000-100,000.
-completed 5 day course Levofloxacin (day 1 = ___
-completed Bactrim 3 days (day ___ for urine since E.coli
resistant to fluroquinolones
# Hypertension
-continued home Lisinopril
-continued Lasix
# Mental Retardation: Maintained at baseline mental status per
family.
# COPD
-continued home Combivent
# Hyperlipidemia
-continued home Simvastatin
# Social: Per sister, patient lives alone and likely requires
home care. Sister may try to be her full time caretaker.
-___ consult
-Case Management involvement
# CODE: Full-confirmed with HCP
# CONTACT: ___ (sister/HCP) ___
___son) ___
## TRANSITIONAL ISSUES:
-will follow up with PCP and check electrolytes
-please consider decreasing home Lasix from 40mg to 20mg at next
office visit pending her creatinine, electrolytes, and clinical
appearance on exam
-please re-eval need for home O2 at future visits, and discuss
risks with continued smoking</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ yo lady with HTN, HLD who ___ transferred
to
us from ___ with confusion that started yesterday and today
progressed to unresponsiveness, also noted to have a seizure at
___. Radiology showed Small left pleural effusion. No focal consolidation. Fluoroscopically-guided lumbar puncture showed 1. Successful fluoroscopically-guided lumbar puncture. CTA HEAD AND CTA NECK showed 1. No acute intracranial hemorrhage or mass effect.
2. Patent major intracranial arteries as described above, without focal
flow-limiting stenosis, occlusion or aneurysm more than 3 mm within the
resolution of the study.
Contour irregularity of the cavernous carotid segments on both sides, can
relate to atherosclerotic disease with or without any tiny aneurysmal
outpouchings.
Differentiation is difficult on imaging.
3. Calcification of the carotid bifurcations bilaterally with mild narrowing
of the right proximal internal carotid artery. No significant stenosis by
NASCET criteria.
4. Degenerative changes in the cervical spine with mild canal and moderate to
severe foraminal narrowing at multiple levels.
Other details as above. Radiology showed No acute infarct or mass effect.
Some degree of diffuse parenchymal volume loss and nonspecific cerebral white
matter changes. The patient was diagnosed with ALTERED MENTAL STATUS . The patient was treated with continuous EEG. 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>___ lady with HTN and HLD who presents with left side gaze
preference and left hemiparesis which progressed to
unresponsiveness. She was taken to OSH where workup was
unrevealing but reportedly was noted to have a tonic clonic
seizure. She received Ativan and Keppra and was transferred to
___. At ___, the patient was unresponsive to vocal stimuli,
eyes were shut and there was no gaze deviation. There was
spontaneous movement of the right arm but none on the left
although she did localize, grimace and moan to pain. Pupils were
1mm and minimally responsive. CT head was negative for acute
bleed or loss of gray white differentiaton and CTA head and neck
did not reveal any major vessel cuttoff. Lumbar puncture did not
reveal any signs of infection. She was initially drowsy, likely
secondary to medication effect, but eventually regained her
baseline level of arousal. She was started on Dilantin and had
no other seizure activity. She evaluated by ___ who
recommended discharge to a rehab. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with recent prolonged hospital course beginning in ___ for
bacterial and candidal endocarditis with flail mitral valve s/p
CABG/MRV with multiple complications incl. cardiac arrest,
respiratory failure s/p trach/peg admitted with positive
candical culture from his rehab today. The patient denies
fevers or chills. He complains of ongoing nausea, diarrhea, and
poor appetite since his discharge. He is very disheartened by
his lack of mobility and progress. Radiology showed 1. Sludge and stones within the gallbladder. No signs of cholecystitis. No
ductal dilatation
2. Right pleural effusion. The patient was diagnosed with MYCOSES NEC & NOS. The patient was treated with transesophageal echo
tracheostomy decannulation (___). At the time of discharge, the patient had Primary diagnosis: Candidemia
Secondary diagnoses: Clostridium dificile colitis, urinary tract
infection, gram-positive cocci bacteremia, seizure. The patient was given written instructions concerning 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 recent prolonged hospital course beginning in ___ for
bacterial and candidal endocarditis with flail mitral valve s/p
CABG/MRV with multiple complications including cardiac arrest,
respiratory failure s/p trach/peg admitted with recurrent
candidemia and diarrhea.
Active Diagnoses
# Candidemia: Found on surveillance cultures from rehab. The
patient's HD catheter was pulled in the ED as a likely source
(he had not required HD since discharge in early ___. CXR did
not show evidence of pneumonia. TEE was negative for
bioprosthetic valve vegetation. Ophtho was consulted and were
not concerned for endophthalmitis. The patient was treated with
iv Micafungin ___. He was switched to po fluconazole ___,
once weaned off Dilantin for his seizures. Per ID
recommendations, he will have a 7 day course of fluconazole
which should continue through ___ (to end on ___.
Blood cultures were negative for fungemia while in house. He
will need repeat fungal cultures one week after discontinuation
of fluconazole (to be drawn on ___.
# Possible Coag Negative Staph bacteremia: Grew out on ___ BCx
on ___. While it was possibly a contaminant, the patient was
started on iv vanc for a 7day course given his complicated
recent course of infections per recommendations of ID. Repeated
blood cultures did not grow out any bacteria.
# Seizures: Patient had EEG significant for epileptiform
activity with bitemporal activity. Neurology was consulted, and
they recommended weaning of phenytoin in favor of Keppra. He was
started on Keppra while weaning off of phenytoin without any
seizure-like activity during the bridging process. Last dose of
phenytoin was ___. The patient will be continued on Keppra 500mg
po bid.
#C. difficile colitis: This was thought to be likely secondary
to C. diff. Although it was not documented, the patient was
started on vancomycin PO at the rehab on ___, and is planned to
have a course to complete ___ after iv antibiotics complete
(this course should be continued through ___. Symptoms
mildly improved since initiating antibiotics though he continued
to have intermittent loose stool during the hospitalization.
# S/P hypoxic Respiratory failure: Patient was trach'ed during
prior hospitalization. Lasix held starting day 2 of admission
out of concern for impending hypovolemia. Per interventional
pulmonary consult, the cuff was removed and the trach was capped
on ___. After tolerating this for 48 hours with O2sat>96, the
trach was decannulated. The site was dressed with care. Healing
and improvement of the patient's voice is expected over the next
several weeks.
# ___: Last admission complicated by ___ secondary to
hypotension requiring HD, which he has not required since prior
hospitalization. He was noted to have residual impairment of
renal function on admission. Creatinine has improved throughout
hospitalization.
# Malnutrition: Patient with poor nutrition since his prior
complicated hospitalization course. During the hospitalization,
he has been on G-tube feeds at night. Speech and swallow cleared
the patient for regular diet, although he was fearful of
aspiration. Nutrition followed the patient throughout
hospitalization. As the patient continues to bolster his PO
intake, he tube feed requirements will need to be readdressed.
He should be evaluated by nutrition while in rehab.
# S/P cardiac surgery: Patient had recent complicated and
prolonged hospitalization course. After admission for bacterial
and candidial endocarditis c/b mitral flail, he had a CABG/MVR
complicated by respiratory failure and cardiac arrest. Staples
were removed from abdominal incision. Patient will need to
follow-up with Dr. ___. He was continued on his daily statin
and aspirin therapy.
CHRONIC DIAGNOSES
# Depression: Patient has been previously diagnosed wth
depression, and he noted difficulty coping with his complex
medical situation. In latter stages of hospitalization, the
patient's mood improved, as he expressed hope to regain mobility
and to be near his wife. He was continued on quetiapine.
#Atrial fibrillation: Patient had history of atrial
fibrillation. He was kept on amiodarone. He was monitored on
telemetry until ___, and he was in sinus rhythm without notable
events. Given prior GIB, the patient is not being started on
anticoagulation beyond aspirin.
#Asthma: Patient has been on steroids long-term for asthma. This
was continued at 10mg ___ and 5mg ___. There
was no asthmatic exacerbations during hospitalization. It is
recommended that the patient eventually undergo a long steroid
taper in the future.
#History of chronic hyponatremia: The patient had chemistries
trended with normal serum sodium throughout hospitalization. </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 a history of Down Syndrome
w/ trach, G-tube and foley, stage 4 sacral decub, who is
presenting from nursing home with fever and increased secretions
from his trach Radiology showed Increased opacification of the bilateral bases may represent atelectasis,
aspiration, or pneumonia in the appropriate clinical setting. CHEST (PORTABLE AP)CHEST (PORTABLE AP)i showed Mild pulmonary edema and small left pleural effusion are new. Patient is
rotated to his left. Leftward mediastinal shift is minimal, unchanged, left
hemidiaphragm still elevated. Findings suggest atelectasis in the left lower
lobe.
Tracheostomy tube is in standard placement, caliber substantially less than
half the diameter of the trachea. Clinical evaluation suggested to see if this
is appropriate. CHEST PORT. LINE PLACEMENT showed Interval placement of right subclavian PICC line which has its tip in the
distal SVC near the cavoatrial junction. The tracheostomy tube is unchanged
in position. No pneumothorax is seen. Streaky bibasilar opacities have
improved suggesting resolving atelectasis. No pulmonary edema. No
pneumothorax. Overall cardiac and mediastinal contours likely unchanged given
differences in patient positioning. The patient was diagnosed with SEPTICEMIA NOS, PNEUMONIA,ORGANISM UNSPECIFIED, SEPSIS , ACCIDENT NOS, TRACHEOSTOMY STATUS. At the time of discharge, the patient had Primary: Acinetobacter Baumannii Pneumonia
Psuedomonas Aeruginosa Pneumonia
Enterococcal colonization of the urine
Secondary: Chronic Tracheostomy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old gentleman, with a history of Down Syndrome
w/ trach, G-tube and foley, stage 4 sacral decub, who is
presenting from nursing home with fever and increased secretions
from his trach.
#SEPSIS: Patient's Tmax in the ED was 102. Patient meeting SIRS
criteria with likely source of infection. Given that he is
having increased secretions and CXR shows evidence of right
lower lobe consolidation, patient likely has new pneumonia.
Patient also tachypneic to the ___. CURB 65 score of 2, but
given increased secretions he required admission to ICU given
level of care. Patient placed on vancomycin, cefepime and flagyl
(given hx of prior resistant organisms), Day 1= ___. BAL
studies grwoing GNRs which speciated to Acinetobacter Baumannii
and Psuedomonas Aeurginosa. The Acinetobacter was found to be
multidrug resistant. Infectious Disease was consulted for
recommendations in antibiotic management. He was started on IV
Bactrim for the Acinetobacter for a planned ___dditionally, Ceftazadime was started for Psuedomonal coverage
for a planned 14 day course. The patient remained afebrile and
showed some evidence of improvement in respiratory status
(slight decrease in frequency of suctioning). He was
transitioned to oral suspension Bactrim given that he was
clinically very stable.
#SECRETIONS: Patient is s/p trach and G-tube on ___. ICU
transfer for increased secretions. Patient underwent frequent
suctionning and managed with scopolamine patch. Glycopyrrolate
was additionally added given that secretions are thick and
persistent.
#SACCRAL SORE: Stage 4 ulcer. Wound care advised was consulted
and recommended packing loosely with Aquacel Ag rope and
covering by 4x4's and an ABD. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male who presents to the ER with 40
hours of progressively worsening right lower quadrant abdominal
pain. He reports initially having some anorexia associated with
this, however over the last 24 hours has felt hungry. Does have
intermittent nausea which waxes and wanes, but no vomiting. He
denies fevers, chills, chest pain, shortness of breath, or
changes in bowel habits. No dysuria. CT ABD AND PELVIS WITH CONTRAST showed 1. Acute appendicitis. No drainable fluid collection or extraluminal gas.
2. Sigmoid diverticulosis without evidence of acute diverticulitis.
3. Splenomegaly. The patient was diagnosed with Unspecified acute appendicitis, Right lower quadrant pain. The patient was treated with Laparoscopic Appendectomy. At the time of discharge, the patient had Uncomplicated 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>The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed WBC was WNL at 7.9. The
patient underwent laparoscopic appendectomy, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating clears, and took
oxycodone for pain control. The patient was hemodynamically
stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and 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: Mr. ___ is a ___ male with a history of HFrEF (EF 40%),
HTN, HL, DM, AFib not on AC d/t hemorrhagic stroke, CKD, and
dementia admitted for CHF exacerbation and rib fracture. He was
recently admitted ___ for acute decompensated heart
failure, discharged home on torsemide 20 mg at 202 lbs. At his
follow-up appointment on ___ he was noted to be 212 pounds, his
torsemide was increased to 20mg BID. Per ___ clinic note, it
appears there was concern over dietary indiscretions at his
rehab facility. He was seen again in ___ clinic ___ with stable
weight of 212 with mild JVP elevation. Was also in persistent
afib with more rapid ventricular rates, and his metoprolol succ
was increased from 50mg to 75mg daily. Due to his recent gain
and concerns about medications and diet at the nursing home Dr.
___ him to the ED for admission. Radiology showed Cardiomegaly with mild CHF. Possible very small bilateral effusions. Radiology showed 1. Minimally displaced right posterolateral tenth and eleventh rib fractures,
similar to the CT from ___. No evidence of new traumatic injury
in the chest, abdomen or pelvis.
2. New right lower lobe subsegmental pulmonary embolism.
3. 15 mm left lower lobe pulmonary nodule. Recommend PET-CT for further
evaluation.
4. Bilateral adrenal nodules are incompletely evaluated and statistically
likely to reflect adenomas.
5. Similar aneurysmal dilation of the ascending thoracic aorta to 4.6 cm and
aneurysm dilation of the left common iliac artery.
6. Dilated pulmonary artery suggestive of pulmonary hypertension.
7. Cardiomegaly and trace bilateral pleural effusions.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:18 AM, 1 minutes after
updated findings. ___ DUP EXTEXT BIL (MAP/DVT) showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. There are no acute findings.
2. There are chronic multiple infarcts which are stable. MR HEAD W/O CONTRAST ___ MR HEAD showed 1. No acute infarct or acute hemorrhage.
2. Numerous chronic infarcts with associated volume loss, as described.
3. Numerous scattered areas of chronic microhemorrhage in the bilateral basal
ganglia, bilateral thalamus, brainstem and bilateral cerebellar hemispheres in
a distribution suggestive of chronic hypertensive etiology.
4. Moderate global atrophy with diffuse white matter signal abnormality
suggestive of chronic small vessel ischemic disease. The patient was diagnosed with Dyspnea, unspecified. At the time of discharge, the patient had Primary Diagnoses:
=====================
Acute on chronic systolic heart failure exacerbation
Right subsegmental pulmonary embolism
Secondary Diagnoses:
======================
Right rib fracture
Dementia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ male with a history of HFrEF (EF 40%), HTN, HL, DM,
AFib not on AC d/t hemorrhagic stroke, CKD, and dementia
admitted for CHF exacerbation and new R subsegmental PE.
#ACUTE ON CHRONIC SYSTOLIC HEART FAILURE EXACERBATION: After
last discharge in ___ gained approx. ___ pounds with
increasing edema and JVD. Despite cardiology instructions to
increase diuretics, it appears there were concerns about nursing
home medication compliance and dietary adherence. On admission
BNP 1600, stable from ___ admission for CHF. Patient was
diuresed with IV Lasix and transitioned to PO regimen of
torsemide 40 mg BID. For afterload, patient discharged on
lisinopril 30 mg (previous dose 40 mg; decreased for lower blood
pressures). Metoprolol succinate XL was increased from 75 mg
daily to 75 mg QAM and 50 mg ___ for better heart rate control.
Discharge weight 91.9 kg.
#R SUBSEGMENTAL PE: New subsegmental PE seen on CT angiogram
performed in the Emergency Department. He has atrial
fibrillation but has only been on aspirin due to a history of
cerebral hemorrhage ___. HDS, no O2 requirement, no signs of R
heart strain on ECG on admission. Neurology was consulted given
history of intracranial hemorrhage. Recommended heparin drip w/o
bolus and MRI to help in determine risks of longterm
anticoagulation. However, based on discussions with patient's
outpatient cardiologist (Dr. ___ and patient's son, the
decision was made to defer antiocoagulation due to patients CVA
hemorrhage and frequent falls. Patient remained HDS throughout
hospital course.
# UTI: Patient had complaint of abdominal pain in RLQ to
suprapubic region. UA, UCx revealed E. coli and proteus. Patient
initially started on IV ceftriaxone ___ but narrowed to
ampicillin when sensitivities resulted. He will complete course
of ampicillin ___.
#AFIB: History of afib, recently persistent. CHADSVASC of 6,
however has not been on full anticoagulation given history of
intracranial hemorrhage in ___. Patient was monitored on
telemetry during hospital course and had rates up to 140s. The
decision was made to increased Metoprolol succinate XL from 75
mg daily to 75 mg QAM and 50 mg QPM for better rate control.
#RIB FRACTURE: Reported frequent falls at rehab, and per OSH
records no bed alarms at rehab facility. s/p rib fracture from a
fall. Stable R rib fracture with pain on exam. Pain controlled
with Tylenol and lidocaine patch as needed.
___ on CKD stage 3: baseline 1.1-1.6. Cr monitored while
inpatient. Did have rise in Cr to 1.9. Improved by withholding
Lasix dose. Cr on discharge 1.7. Please check BMP day after
discharge and fax to ___ clinic: ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with COPD, CAD s/p CABG, and
HTN who was brought to OSH via EMS after being found down.
History obtained per report as patient does not remember what
happened. She lives alone in elderly housing, and her neighbor
saw her out yesterday afternoon. Her neighbor found her today on
the floor of her living room in a puddle of urine. Unknown how
long she was on the floor, but neighbor thinks she fell only
5min
prior. When EMS arrived, she was talking and denied any head,
neck, or back pain. She was found with her left arm under her.
She is not on any blood thinners. MR HEAD W AND W/O CONTRAST ___ MR HEAD showed 1. Redemonstrated large right MCA territory late acute to subacute infarct to
include the right lentiform nucleus where there is evidence of hemorrhage
centered within the putamen.
2. Scattered foci of late acute to subacute infarct involving the left centrum
semiovale and genu of the left corpus callosum.
3. Loss of the normal flow void of the right intracranial ICAs compatible with
slow flow versus occlusion correlating with that seen on the recent CTA head.
4. Evidence of an old right occipital lobe infarct.
5. Extensive white matter chronic small vessel ischemic disease.
6. Generalized parenchymal volume loss, likely age related. Radiology showed Lung volumes have improved. Cardiomediastinal silhouette is stable. There is
no pleural effusion. No pneumothorax is seen. There is no evidence of
pneumonia. No evidence for edema CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Evolving acute infarct in the right MCA territory, in the region of
decreased blood flow seen on CTA. There is localized mass effect with sulcal
effacement. No midline shift. Basal cisterns remain patent.
2. No significant change in small area of hyperdensity in the right basal
ganglia indicating hemorrhage . No new intracranial hemorrhage.
3. Unchanged dense right middle cerebral artery. Radiology showed The Dobhoff tube projects over the stomach. Lungs are clear. Heart size is
normal. There is no pleural effusion. No pneumothorax is seen CT L-SPINE W/O CONTRAST Q331 CT SPINE showed 1. Inferior compression deformity of the L1 vertebral body, and superior
endplate compression deformities of the L2, L3 and L4 vertebral bodies, are
likely chronic in nature. There is no prevertebral soft tissue swelling to
indicate acute injury. No retropulsion of bony fragments into the spinal
canal.
2. Multilevel degenerative changes, worst at T12-L1 where there is moderate
spinal canal narrowing. Radiology showed Trace bilateral pleural effusions and subjacent atelectasis. A superimposed
pneumonia, particularly at the left lung base would be hard to exclude in the
proper clinical context. Radiology showed Increased size of the left pleural effusion and subjacent opacities. These
may reflect atelectasis however superimposed pneumonia would be hard to
exclude. CHEST (PORTABLE AP) showed No significant interval change from prior day's radiograph, with stable
appearance of small left pleural effusion with subjacent atelectasis. The patient was diagnosed with Cerebral infarction, unspecified. At the time of discharge, the patient had Right basal ganglia infarct
Infarct involving the left centrum semiovale and corpus callosum
Hemorrhagic conversion. The patient was given written instructions concerning 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 COPD, CAD s/p CABG, and
HTN who was found down and was confused and had left-sided
weakness. She was taken to ___ where a ___
showed a right basal ganglia infarct with hemorrhagic
conversion. EKG at ___ also showed diffuse
hyperacute T waves, deep TWI in leads V1, V2 and aVL, QTC 516
mSec. She was transferred to ___ on ___. In the ___
emergency room, EKG confirmed results of previous EKG and she
was noted to have elevated CK 3005, mild elevation in troponin
T(0.07) and elevated CK-MB (98+) revealing evidence of
rhabdomyolysis and NSTEMI. Cardiology was consulted and ECHO
showed EF>75% without evidence of thrombus. CTA head and neck
showed right M1 & M2 defects of MCA suggestive of emboli,
hemorrhagic transformation in right basal ganglia, and complete
occlusion of right ICA. MR ___ confirmed a large R MCA
territory stroke, hemorrhage of right putamen, foci of infarct
involving the left centrum semiovale, and infarct of the genu of
the left corpus callosum, old right occipital lobe infarct, and
extensive chronic small vessel ischemic disease. Although
atheroembolic disease would explain the R MCA stroke, it would
not explain the left-sided infarcts. Therefore, a more proximal
source (cardioembolic) is likely. Her mental status
progressively worsened. A Doboff was placed for feeding and
medication due to AMS and swallowing deficits. A family meeting
including HCP resulted in the choice to make her comfort
measures only. Medications and Doboff were discontinued. She was
kept very comfortable and discharged to hospice.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female with recent SBO s/p ex-lap
with extensive lysis of adhesions no ___ now with days of
abdominal pain associated with one week of constipation, nausea,
and vomiting. CHEST (PORTABLE AP) showed Mild pulmonary edema and vascular congestion. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism, noting that distal segmental and
subsegmental branches in the bilateral lung bases are not well assessed
secondary to respiratory motion and suboptimal timing of the contrast bolus.
2. Scattered bandlike opacities within the right middle lobe, lingula, and
bilateral lower lobes favor atelectasis, though superimposed infection is not
excluded.
3. Subtle peribronchovascular ground-glass changes in the bilateral upper
lobes, which could be infectious or inflammatory.
4. Bilateral pulmonary nodules measuring up to 3 mm. See below for
recommendations.
RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules
smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT follow-up in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___ LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT showed 1. Cholelithiasis with a 9 mm nonmobile stone in the gallbladder neck.
However, there is no gallbladder wall thickening, distension, or other
findings of acute cholecystitis.
2. Echogenic liver, consistent with steatosis. The patient was diagnosed with Hypoxemia. At the time of discharge, the patient had Primary diagnosis
================
Constipation
Nausea
Hypoxia
Secondary diagnosis
===================
Diabetes Mellitus Type II
Rheumatoid arthritis
Hypertension
Hyperlipidemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female with recent SBO s/p ex-lap
with extensive lysis of adhesions on ___ who presented with
abdominal pain, emesis, and constipation with concern for SBO.
TRANSITION ISSUES
=================
[] 9mm stone noted on RUQ, consider additional biliary workup if
patient experiences RUQ pain
[] Consider outpatient sleep study to evaluate for OSA, new O2
equirement on admission
[] A1c 9.3 on admission, continue to titrate insulin and
consider swallow study for possible gastroparesis if
nausea/abdominal pain persists.
#CODE: FULL CODE presumed
#CONTACT: ___ ___
ACUTE ISSUES
============
# Nausea, vomiting, and constipation
# Recent SBO s/p ex-lap w/ LOA
CT a/p showed post-surgical changes but no acute abnormality and
no evidence of obstruction. She had enema in the ED with
significant bowel movement so presumably does not have
significant constipation on arrival to the floor. Likely some
contribution for gastroparesis given poorly controlled diabetes.
In addition, ___ have had mild ileus. Of note, she is also on
chronic prednisone for her rheumatoid arthritis so may have
secondary adrenal insufficiency with inadequate response to
stress. She takes Tylenol at home for pain but has not been
taking any constipating opioids. She does follow a bowel regimen
at home. RUQUS with so evidence of cholecystitis or biliary
dilation but does have a 9mm stone lodge in the neck. Started
with clear liquids now advanced to full diet. Due to wound
deheisence, a wound vac was placed. She was treated with IV
zolfran and prochlorperzine for nausea and emesis along with
agressive bowel regimen, which included enema. Pain control was
achieved with tylenol 1g and low dose oxycodone.
Has wound vac in place per surgical service.
#Hypoxia
#New O2 requirement
Patient found to be hypoxic while in the ED, but she was
reportedly asymptomatic and awake. CTA PE showing no PE but
showing nonspecific opacities and ground glass changes. She
denies any cough or respiratory distress. Differential includes
atelectasis (recent long hospital stay) vs. obesity
hypoventilation syndrome vs aspiration pneumonia vs. pneumonitis
in the setting of recurrent emesis vs. underlying sleep apnea
that may not have been diagnosed (reports history of snoring).
She has no known COPD but did smoke for ___ years in the past.
Patient iniately required 3L NC, but was quickly wean to RA
without much difficulty.
# Rheumatoid arthritis
- Continued home prednisone 10mg daily
- Note that she has not had any stress dosing. If her abdominal
discomfort, nausea and emesis persists, consider stress dosing
for relative adrenal insufficiency with prednisone 30mg x 3 days
and then re-evaluate
# Diabetes: Her A1c is 9.3 on this presentation
On insulin at home: Humalog ___ 54U breakfast and 26U dinner;
initially held given poor PO intake and stable sugars. Restarted
on Insulin and titrated back to home regiment prior to
dishcarge.
TI: Needs close follow-up on discharge
CHRONIC ISSUES
==============
# History of PE, lupus anticoagulant syndrome: Last event ___.
Previously on warfarin but this was discontinued about ___ years
ago.
# GERD
- Continued omeprazole
# Hypertension
- On lisinopril at home; initially held given recurrent emesis
and relative soft blood pressures, restarted prior to discharge
# HLD
- Continued rosuvastatin
Patient seen and evaluated in the morning. Reports feeling
well. No nausea vomiting abdominal pain today. Ambulating
independently at her baseline. Wound VAC functioning fine,
replaced with a portable unit. Medically stable for discharge
today. Discharge plan discussed with patient in detail, she
understands and agrees. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ year-old R-handed F w/ PMH of HTN and DMII who
presents with seizure-like events x 2. Hx obtained from pt and
husband at bedside. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed 1. The study is significantly degraded by motion artifact.
2. No intracranial mass, hemorrhage or infarct. CHEST (PORTABLE AP) showed In comparison with the study of ___,, the cardiac silhouette is slightly
more prominent and there is engorgement of ill defined pulmonary vessels
consistent with elevated pulmonary venous pressure. No evidence of pleural
effusion or acute focal pneumonia. Mild elevation of the right
hemidiaphragmatic contour. The patient was diagnosed with Hypo-osmolality and hyponatremia. At the time of discharge, the patient had Seizure
Hyponatremia
Rhabdomyolysis. The patient was given written instructions concerning 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 R-handed F who presented with
multiple seizure-like events. Her evaluation was notable for
hyponatremia to as low as 119 on admission, which is the most
likely cause of her seizure. Seizures consisted of episodes of
an aura of "strange thoughts" and gustatory sensation, followed
by UE tremors w/ fixed gaze, then eyes rolled back. Postictally
she had lethargy/confusion.
# Seizure: Likely provoked by hyponatremia, although her family
history of seizure as well as prior episodes of "strange
thoughts" does raise concern for a primary epilepsy. MRI showed
no structural cause for seizure. EEG has been normal with no
epileptiform discharges. She did not have any further seizures
during admission. As this is felt to be a one-time, provoked
seizure occurrence, she was not started on anti-epileptic
medications.
# Hyponatremia: as above, this is felt to be the most likely
cause of her seizures. Her urine Na on admission was <20, with
initially concentrated urine, suggesting hypovolemia as the
cause of her hyponatremia. Her diuretic use as well as extensive
time spent outside in the hot weather may explain the
hypovolemia. After volume replenishment, her Na corrected to 130
on ___. This was slightly quicker than the recommended
correction of 8mEq in 24 hours, so D5W was started to prevent a
rapid rise in her sodium. Her sodium afterwards remained stable.
Furthermore, her blood pressure was persistently in the low 100s
early on in her hospitalization, despite all of her
anti-hypertensives being held. This again argues for significant
volume depletion.
# Rhabdomyolysis: On ___, CK was noted to rise, with subsequent
myoglobinuria on UA. Her renal function remained stable. She had
significant thigh pain but was otherwise asymptomatic. She was
hydrated as above with D5W. CK peaked at ___ and then
downtrended to ___ prior to discharge. Etiology is likely
seizure.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ year old male with PMH notable for HTN, HLD,
DM2, and history of paroxysmal complete heart block presenting
with dyspnea and fatigue and found to be in 2:1 AVB. CHEST (PA AND LAT) showed Compared to chest radiographs in ___.
New left trans subclavian right atrial and right ventricular pacer leads
follow their expected courses from the new left pectoral generator. No
pneumothorax pleural effusion or mediastinal widening. Heart size is normal.
No pulmonary edema. The patient was diagnosed with Bradycardia, unspecified. The patient was treated with Permanent pacemaker ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ year old male with PMH notable for HTN, HLD,
DM2, and history of paroxysmal complete heart block presenting
with dyspnea and fatigue and found to be in 2:1 AVB.
#) SYMPTOMATIC BRADYCARDIA: Most likely etiology at his age is
senescence of conduction tissue. Despite provocative maneuvers
at bedside (bearing down, carotid sinus pressure), arm exercise,
there was no effect on AVB, and PR interval appeared constant on
telemetry. Patient has evidence of other conduction disease with
incomplete RBBB and LAFB and has relatively preserved PR
interval (226 ms), which is suggestive of infranodal block. TSH
was within normal limits and lyme serologies were negative.
Given concurrent symptoms, patient was considered a candidate
for permanent pacemaker, which was placed on ___.
Post-procedurally patient was stable, unremarkable interrogation
by EP, without events on telemetry, and a CXR confirmed
placement of permanent pacemaker.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ RHD with 3 d h/o worsening right elbow pain and swelling
with increasing limited range of motion. Reports subjective
fevers, chills. Denies recent injury or trauma, no similar sx
in the past, has h/o elbow dislocation ? fracture as a teenager
treated with surgically in ___, no hardware that he can recall
as none was removed, with right elbow asymptomatic since. Right
elbow joint aspirated by ED with wbc 335k with 87% polys.
Orthopaedic surgery consulted for evaluation and treatment. Radiology showed Anterior and posterior joint effusions with irregularity of the
elbow joint is concerning for septic arthritis, particularly in the absence of
trauma. Joint effusions can also be seen in the setting of acute fracture-no
fracture line is seen, but an occult fracture could be present. Radiology showed AP chest reviewed in the absence of prior chest radiographs:
No radiopaque central catheter is seen. Heart size top normal. Lungs clear.
No pleural abnormality. Dr. ___ and I discussed these findings by
telephone. elevated LFTs
COMPARISON: None
TECHNIQUE: Sonographic grayscale and Doppler images were obtained of the
abdomen.
FINDINGS:
The liver demonstrates normal contour, echogenicity and architecture. No
focal lesions are identified. Portal vein is hepatopetal and patent. However,
there is some noted lack of respiratory wave in the portal vein which could
suggest underlying increaseing liver fibrosis.
The gallbladder is distended without cholelithiasis, gallbladder wall
thickening or pericholecystic fluid. No intrahepatic or extrahepatic biliary
ductal dilatation. The common bile duct measures 3 mm.
The visualized portions of the midline structures are partially obscured by
overlying bowel gas. No gross abnormality about the pancreas.
The spleen measures 8.8 cm in craniocaudal dimension.
The right kidney measures 10.7 cm in craniocaudal dimension. The left kidney
measures 11.6 cm in craniocaudal dimension. No evidence of hydronephrosis,
nephrolithiasis or obvious mass in either kidney.
The visualized portions of the aorta and IVC are normal.
Both lower quadrants demonstrate no evidence of ascites.
IMPRESSION:
Noted lack of respiratory wave in the portal vein which could suggest
underlying increaseing liver fibrosis. Otherwise, portal vein is patent. No
focal liver lesions. showed Noted lack of respiratory wave in the portal vein which could suggest
underlying increaseing liver fibrosis. Otherwise, portal vein is patent. No
focal liver lesions. The patient was diagnosed with PYOGEN ARTHRITIS-UP/ARM, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with ___ - Irrigation and debridement right elbow septic
arthritis.. At the time of discharge, the patient had Right elbow septic arthritis. The patient was given written instructions concerning 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. A joint aspiration was
performed and the patient was found to have right elbow septic
arthritis and was admitted to the orthopedic surgery service.
He was started on empiric vancomycin, and he was taken to the
operating room on ___ for irrigation and debridement of
right elbow infection, 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. Blood cultures
drawn at the time of presentation were positive for beta
streptococcus group b, and the infectious disease team was
consulted. Per the recommendations of the infectious disease
team, the patient's antibiotics were changed to Nafcillin and a
TTE was obtained that showed no cardiac involement. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined
that discharge to home was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
right upper extremity with range of motion as tolerated. The
patient will follow up in two weeks with Dr. ___ 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: ___ y/o F with history of ETOH cirrhosis presents to ED after
found to have hgb of 7.7.
Patient denies any sob, cp, dyspnea, abdominal pain, diarrhea,
hematemesis, coffee ground emesis, black stools, BRBPR. Had last
___ last ___ after receiving FFP and platelets.
In the ED, initial vitals were: 98.2 74 138/43 20 100%
- Labs were significant for Hgb 7.2 (baseline 7.4-8), INR 2.5
- CXR revealed small R pleural effusion, likely right lower lung
atelectasis, difficult to exclude pna
- The patient was given pantoprazole 40mg IV
Vitals prior to transfer were: 97.8 94 127/37 20 100% RA
Upon arrival to the floor, patient has no complaints. CHEST (PA AND LAT) showed Small right pleural effusion, likely right lower lung atelectasis, difficult
to exclude pneumonia. UNIAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the left lower extremity veins. US INTERVENTIONAL PROCEDURE showed Ultrasound-guided thoracentesis deferred until the patient can receive blood
products to correct coagulation abnormalities. US INTERVENTIONAL PROCEDURE showed Therapeutic paracentesis deferred for lack sufficient ascites. Radiology showed 1. Ultrasound guided therapeutic right thoracentesis with removal of 1.3 L of
right pleural fluid.
2. Insufficient fluid for paracentesis. No paracentesis performed. CHEST PORT. LINE PLACEMENT
TECHNIQUE: Portable Chest radiograph, frontal view
COMPARISON: Chest radiograph ___
FINDINGS:
Left PICC loops within the left brachiocephalic vein and terminates in left
brachiocephalic vein at the level of left clavicular head. Elevated right
hemidiaphragm is chronic. There is at least small right pleural effusion.
There is no pneumothorax. Cardiac silhouette is normal size.
IMPRESSION:
Left PICC loops in the left brachiocephalic vein and terminates in left
brachiocephalic vein at the level of left clavicular head. showed Left PICC loops in the left brachiocephalic vein and terminates in left
brachiocephalic vein at the level of left clavicular head. CHEST (SINGLE VIEW) showed In comparison with the earlier study of this date, there is been little change
in the malpositioned left PICC line, which extends into the brachiocephalic
vein before coiling about on itself with the tip in the subclavian vein.
Otherwise little change. Radiology showed Successful repositioning of existing 46 cm left arm approach single-lumen PICC
into the distal SVC. The line is ready for use. CHEST PORT. LINE PLACEMENT showed As compared to the prior study of several hr earlier, a left PICC has been
successfully repositioned, terminating in the lower superior vena cava. No
other relevant changes. The patient was diagnosed with ANEMIA NOS, MELENA, ALCOHOL CIRRHOSIS LIVER. The patient was treated with #Thoracentesis by interventional radiology (___)
#___ line placed by ___ team, repositioned by interventional
radiology (___). At the time of discharge, the patient had #Cirrhosis complicated by diuretic-refractory ascites and
hydrothorax
#Anemia, acute on chronic
#Coagulopathy, secondary to chronic liver 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>___ w/ h/o EtOH Cirrhosis c/b diuretic-resistant ascites,
diuretic-resistant hydrothorax, SBP, hepatorenal syndrome, HE,
and esophageal varices, who presents with acute on chronic
anemia now s/p PRBC tranfusion, thoracentesis and PICC line
placement.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ M with a history of ESRD due to PKD s/p
DDRT in ___ who presented to the ___ today with fevers and
concern for urinary tract infection.
He was in his usual state of health up through about ___ days
ago when he developed dysuria, as well as urinary frequency and
sensation of incomplete bladder emptying with urine dribbling.
He had nocturia x 2 nightly. This prompted concern re: UTI and
he presented to his PCP, where his RLQ allograft was reportedly
tender to palpation. The patient feels that he always has a
certain degree of tenderness when the graft is pushed hard
enough. He was started on ciprofloxacin. He underwent CT scan as
well evaluating for possible appendicitis- we do not have these
results but apparently there was neither evidence of
appendicitis or pyelo on the CT scan. Radiology showed Normal renal transplant ultrasound. The patient was diagnosed with URIN TRACT INFECTION NOS. At the time of discharge, the patient had Primary Diagnosis: Urinary Tract Infection, End Stage Renal
Disease secondary to Polycystic Kidney Disease s/p Renal
Transplant
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>Mr. ___ is a ___ year old male s/p DDRT ___ here with
fevers and symptoms of urinary tract infection, possibly
pyelnephritis versus cystitis.
ACTIVE ISSUES
# FEVERS/DYSURIA
Patient presents with positive UA, fevers consistent with UTI.
Pt with pain over grafted kidney so pyelo is a possibility
however he says this is baseline and CT scan from OSH negative
for pyelo. Urine culture had no growth. Was initially treated
with ceftriaxone and transitioned to cefpodoxime with clinic
improvement and a plan for 1 ___HRONIC ISSUES
# S/P DDRT
Creatinine appears to fall within the range of his normal over
the past few years. It is elevated from two days ago, likely
reflecting some ___ in response to systemic inflammation.
Continued CsA, MMF, and prednisone.
# HTN
Continued home amlodipine.
# HYPERPARATHYROIDISM
Continued home sensipar.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with history of HLD, HTN and prior traumatic
anterior dislocation of the left shoulder who presents with
complaint of left shoulder dislocation. States that yesterday he
had episode in which when he reached over his head he felt a
popping sensation and then felt his shoulder pop back into
place.
Today a similar event occurred around 9AM. He denies any trauma.
No numbness/weakness. Radiology showed Anterior, inferior left shoulder dislocation. Chest: Frontal and lateral views showed No acute cardiopulmonary process. Left shoulder dislocation. CT left shoulder without contrast. showed 1. Anteriorly inferior dislocated left humeral head and impacted on the
anterior inferior glenoid, alignment similar to prior x-ray. Small ___
deformity and likely tiny bony Bankart abnormality.
2. Healing fracture of the anterior portion of the left fourth rib.
3. Dense calcifications of the coronary arteries.
4. Air-fluid level within the esophagus may represent underlying esophageal
dysmotility. Is there clinical concern for aspiration? Radiology showed There has been relocation of the previously seen left anterior shoulder
dislocation. No definite fractures are seen. Please refer to the procedure
note for additional details. The patient was diagnosed with Inferior dislocation of left humerus, initial encounter, Overexertion from prolonged static or awkward postures, init. The patient was treated with L shoulder closed reduction. At the time of discharge, the patient had left shoulder dislocation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left dislocated shoulder and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a closed shoulder reduction 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's preoperative Na was 124. His home HCTZ was
held and he was advised to not take it until he follows up his
PCP. His postop Na was 119. He was free water restricted and
given a sodium tablet. His Na was rechecked 3 hours later and
found to be 120. Throughout, he had no changes in mental status.
Of note, he drank lots of alcohol two days prior and drinks ___
drinks daily.
The plan for the patient was to continue free water restriction
and start IV NS at 75cc/hr. The patient declined to stay and
wanted to leave against medical advice because he runs a local
newspaper and could lose thousands of dollars if he did not get
home tonight. It was explained to the patient in detail why we
thought he needed to stay in the hospital. The patient still
wanted to leave. He was advised to follow up with his PCP as
soon as possible regarding his HCTZ and low sodium. He will
follow up with Dr. ___ in clinic in 2 weeks. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with history of acute right limb
ischemia
due to popliteal occlusion s/p arterial lysis (___) now
presenting from outpatient clinic with 3 days of worsening
claudication and findings of right popliteal artery occlusion on
duplex ultrasound (OSH). He states that he has been at his
baseline state of health until 3 days ago when he suddenly had
worsening right lower extremity claudication. He is unable to go
more than 300 feet without right leg/calf pain, needing to stop
walking to relieve the pain. He has been noncompliant with his
medications. He has not taken any home medications for more than
a few months, including aspirin and atorvastatin. He denies
symptoms of rest pain or leg weakness. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with LOWER EXTREMITY EMBOLISM. The patient was treated with ___: tPa pulse spray, angiojet thrombectomy x2, popliteal
artery percutaneous angioplasty and stent placement. At the time of discharge, the patient had Right popliteal artery rethrombosis. The patient was given written instructions concerning 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 from clinic with a three day history
of new-onset RLE claudication and R popliteal artery occlusion
demonstrated on duplex US. He was taken to the endovascular
suite and underwent an arterial angiogram which confirmed the
popliteal occlusion and also showed some collateralization
suggecting acute-on-chronic disease. A tPa pulse spray and
angiojet thrombectomy x2 was performed, followed by an
angioplasty and stenting of the right popliteal artery. The
procedure was uncomplicated and Mr. ___ tolerated it
well. The post-intervention angiogram demonstrated an open
politeal artery, a ___ open to the foot, diminutive AT occluding
above the ankle and a peroneal occluding at the midleg,
consistent with his pre-operative status. Following the
procedure he was loaded with 300 mg of Plavix and restarted on a
heparin drip. He recovered quickly from surgery and by POD 1 was
eating, walking and voiding. He had no hematoma or bleeding
from his groin puncture site and his pain was well controlled on
PO medication. With all goals of care met and doing well
clinically, he was discharged on a 1 month course of Plavix and
a new ongoing regimen of Xarelto. After 1 month he will replace
the Plavix with Aspirin and will be on a Aspirin/Xarelto regimen
indefinitely.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of chronic subdural, mild cognitive impairment, DM
presents with cognitive decline and hyponatremia over the past
few weeks. Radiology showed No acute cardiopulmonary process. Radiology showed No acute intracranial abnormality. Radiology showed Chronic changes as described above. No evidence of hemorrhage. The patient was diagnosed with ALTERED MENTAL STATUS . The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old woman with history of subdural bleed, cognitive
decline, afib on metop and amiodarone, presenting with cognitive
decline secondary to worsening dementia and hyponatremia. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ yo RH F with h/o migraine
headaches, strabismus, and possible prior TIA who was referred
to
our ED by her outpatient neurologist Dr. ___ expedited
workup of rapidly progressive cognitive decline and
hallucinations over the past 9 months concerning for ___ Body
Dementia. CHEST (PA AND LAT) showed No evidence for pneumonia. Small bilateral pleural effusions. MR HEAD W AND W/O CONTRAST showed 1. No acute intracranial abnormality.
2. Scattered FLAIR hyperintensities in the white matter, nonspecific but
commonly seen due to mild chronic small vessel ischemic disease. Brain volume
appears normal for age.
3. Right parietal and left frontal calvarial lesions, not well characterized
and indeterminate in nature. These lesions may be hemangiomas. Other
etiologies, such as metastatic disease, cannot be excluded. If further
characterization is clinically relevant, noncontrast CT of the head could be
performed for better evaluation of the calvarium. Radiology showed 1. No acute intracranial abnormality.
2. Unchanged right parietal and left frontal calvarial lesions, that appear
typical of hemangiomas. The patient was diagnosed with ALTERED MENTAL STATUS , HALLUCINATIONS. The patient was treated with Lumbar puncture. At the time of discharge, the patient had ___ Body Dementia
Eosinophilia, etiology unknown
REM sleep behavior 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>Ms. ___ is a ___ yo RH F with migraines and possible
prior TIA (L sided weakness at the time) who was referred by Dr.
___ for workup of rapidly progressive cognitive
decline. In fact, the patient's cognitive decline is less
rapidly progresive than initially thought. She has reported
memory loss over the past ___ years, hallucinations of
women/children smaller than true size for the past ___ year, and 3
falls within the past 6 months. The patient's memory problems
include remote and recent memory and word finding difficulty.
The hallucinations do not have an auditory component, do not
interact with the patient, and after the initial surprise of
having hallucinations, do not bother the patient. However, she
has called the police at night because she gets confused and
thinks she is unsafe. The falls are a combination of
unsteadiness and accidents (slipping on ice, etc). EEG showed
diffuse slowing but no epileptiform discharges, and LP was
bland, so this is unlikely to be seizures or
infectious/autoimmune encephalitis. The diagnosis for her memory
loss and hallucinations is ___ Body Dementia, although patient
does not have Parkinsonian symptoms at this time.
NEURO:
- MRI brain with contrast: some atrophy, extraparenchymal masses
possibly hemangiomas. Masses confirmed as hemangiomas on CT
___. Initial concern that these masses could be causing
seizures (manifesting as hallucinations) in this patient, but
this was not corroborated by EEG. cvEEG shows diffuse slowing
but no epileptiform activity.
- LP - traumatic tap but bland. CSF cx neg. A-beta and tau
pending.
- Effexor 75mg daily - will taper off this medication, as per
outpatient psychiatrist Dr. ___ (___), by
reducing dose by 50% for 1 week and then stopping, as this
medication can be worsening the patient's REM sleep behavior
disorder. SSRIs and SNRIs can exacerbate dementia in this
patient. In the future, her psychiatrist would like to consider
seroquel for hallucinations if not well controlled on donepezil.
- Continue donepezil 5 mg for dementia with memory
loss/hallucinations
- Continue trazodone 25 mg qhs to suppress REM sleep in this
patient with REM sleep behavior disorder
- will arrange for outpatient Neuropsychiatric evaluation
- will follow up in cognitive clinic with Dr. ___ and with
neurologist Dr. ___ (___)
HEME/ID: labs show WBC ___, with 40-60% eosinophils. She does
report recent UTI which was treated with an unknown antibiotic
which she believes begins with a "B". If she received Bactrim,
this could be sequellae of having a Sulfa allergy. Can also be
seen in some leukemias and lymphomas (but she has no other sx),
allergies and allergic reactions, and parasitic infections.
Since the eosinophilia has persisted since admission, drug
reaction may be less likely. Last CBC in ___ showed only
3% eosinophils, but there is concern for parasitic infection in
this patient with recent travel to ___ ___ and
3 days of diarrhea in ___ (although self-limited). There is
also concern for HIV, since patient has had new sexual contact.
- WBC count persistently elevated with eosinophilic
predominance.
- ID was consulted and recommended the following tests, which
are pending: ESR pending, CRP 4.6, HIV pending, ANCA pending,
cortisol 9.5, strongyloides pending, HTLV I/II pending, LFTs
elevated and should be followed as outpatient, stool O&P - 3
samples sent and ___ is negative with next 2 pending, CDiff
negative
- Serum tox negative
- UTox negative
- UA bland, urine cx neg
- will refer to ___ clinic as outpatient for continued workup
of eosinophilia, possibly to include bone marrow biopsy since
malignancy is a consideration in a patient of this age,
especially if ID workup results are negative (currently pending)
and AEC>1500
- will need follow up in ___ clinic if infectious workup returns
positive - PCP ___ need to refer patient.
CHRONIC PROBLEMS:
- Hyperlipidemia: continue simvastatin
- h/o TIA: continue clopidogrel
***Transitional Issues***
- taper off effexor in 1 week
- follow up neuropsychiatric evaluation
- may need referral to ___ clinic if infectious workup positive
- may need bone marrow biopsy for evaluation of eosinophilia</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ yo male with medical history notable for afib
and tachybrady syndrome s/p PPM on metoprolol and Xarelto, HTN,
aortic stenosis s/p AVR, CAD, nonhodgkin lymphoma on
surveillance
who presents w/x1 week of decreased appetite and po intake,
fatigue, generalized weakness, and chills. CT abdomen and pelvis showed 1. Gallbladder wall thickening with mucosal hyperenhancement with moderate
gallbladder distension. No intra or extrahepatic biliary ductal dilation.
Findings may reflect early acute cholecystitis. Further evaluation with
gallbladder ultrasound is advised.
2. Prominent lymph nodes and borderline splenomegaly likely reflect known
history of lymphoma.
RECOMMENDATION(S): US of the gallbladder.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 9:28 pm, 5 minutes after
discovery of the findings. CHEST (PA AND LAT) showed Mild cardiomegaly, hilar congestion. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed No evidence of acute cholecystitis. No biliary dilation. The patient was diagnosed with Right upper quadrant pain, Epigastric pain, Weakness. The patient was treated with ERCP with sphincterotomy ___. At the time of discharge, the patient had Cholangitis
Afib. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ male with medical history notable for afib and tachybrady
syndrome s/p PPM, HTN, aortic stenosis s/p AVR, CAD, non-hodgkin
lymphoma on surveillance who presents w/x1 week of decreased
appetite and po intake, fatigue, generalized weakness, and
chills found to have choledocholithiasis.
#Choledocholithiasis vs. cholangitis
Pt presented with chills, leukocytosis, and found to have
elevated LFT's, bili. CT a/p showed biliary sludge with mild
gallbladder wall edema. He was started on IV
zosyn->cipro/flagyl x7 day course for presumed cholangitis. He
underwent ERCP on ___ which showed multiple stones and
sludge in the CBD, removed and sphincterotomy performed. Pt
tolerated the procedure well with no post-procedural pain or
nausea. He was counseled to hold his xarelto for 1 week
post-procedure or unless otherwise directed by his Cardiologist.
He ___ also d/w his PCP and ___ prior to deciding on
ccy.
#Afib
#Tachybrady syndrome s/p pacer placement
Xarelto held for procedure and pt got 1x dose of 5mg IV vitamin
K and FFP for elevated INR: 2.9 prior to ERCP. Xarelto also
held for 1 week post-procedure unless otherwise directed by pt's
Cardiologist. Pt's HR controlled with Metoprolol.
#Hyponatremia: Mild. Likely in the setting of poor po intake,
hypovolemia, vomiting. S/p IVF in ED. Now resolved.
#CAD: Continued simvastatin
#HTN: hold valsartan
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: In brief, Ms. ___ is a ___ with PMHx of EtOH cirrhosis,
RNY gastric bypass (___), and chronic abdominal pain who
presents with multiple episodes of syncope and stable shortness
of breath x 1 month. She was recently discharged from the
hospital after an episode of intessesuption after which she has
had 5 episodes of syncope all in varying circumstances (some
episodes occurred in sitting and some while standing). The
syncopal episodes are sudden onset with no clear prodrome. LOC
lasts ___ minutes. Regains consciousness without ongoing
confusion or lingering symptoms. No loss of bowel or bladder and
no rhythmic shaking noted by observers. No palpitations or chest
pain and no changes in vision or headache. While in the hospital
last she was started on lyrica and cymbalta and she believes
this is the cause. The patient is on nadol for HTN treatment and
presented with a HR in the ___ but her dose has not been
changed. CT HEAD W/O CONTRAST showed No acute intracranial abnormality. Specifically, no evidence of hemorrhage. CHEST (PA AND LAT) showed No evidence of pneumonia. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild emphysema. MR FOOT ___ CONTRAST LEFT showed 1. Undisplaced fracture through the posterior calcaneus not extending to the
articular surface. The appearance suggests this may be due to a stress type
fracture rather than a traumatic fracture.
2. Fluid surrounding the flexor hallucis longus tendon distally consistent
with tenosynovitis.
NOTIFICATION: Findings discussed with Dr. ___ by telephone by Dr. ___
___ at 09:30 on ___ CT abdomen pelvis with oral and IV contrast. showed 1. Evidence of gastrogastric fistula in patient who is status post gastric
bypass surgery.
2. No evidence of high-grade bowel obstruction, however noting dilation of
small bowel proximal to the distal Roux anastomosis with decompressed loops
beyond the anastomosis, more prominent than on prior study, suggesting that a
functional/partial bowel obstruction may be present.
3. Stable common bile duct dilation without evidence of associated obstructive
lesion.
4. Right adnexal cyst. Recommend further evaluation with ultrasound if
patient is postmenopausal.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:43 ___. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had Primary Diagnosis: syncope, symptomatic bradycardia
Secondary Diagnoses: ___ fracture, chronic abdominal pain,
etoh cirrhosis, B12 deficiency, HTN, anxiety. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ with PMHx of EtOH cirrhosis, RNY gastric
bypass (___), and chronic abdominal pain who presented with
multiple episodes of syncope and stable shortness of breath x ___s left ankle injury.
Syncope thought to be due to a combination of bradycardia (on
nadalol for BP control, no evidence of varices on imaging, prior
documentation of HR in ___ and orthostatic hypotension
(history of gastric bypass and chronic abdominal pain, which
limits PO intake). Question remains regarding why LOC episodes
are so prolonged. Patient remained on telemetry for >48 hrs with
no events. Remained asymptomatic during hospitalization, and
heart rate improved to ___ while holding nadolol. Remained
normotensive.
Additionally, had sudden worsening of her chronic abdominal
pain; this was investigated with labs and a CTAP W IV contrast,
which did not show any acute findings. We continued her home
narcotics and ensured bowel regimen titrated to soft BM daily.
Had MRI this admission for ankle to determine disposition, as ___
felt would be safe for home if WB and would need rehab if NWB
LLE. MRI showed calcaneal fx; pt discussed with her outpatient
ortho, who recommended NWB, CAM boot, and outpatient follow up
with him in several weeks.
Re: ETOH cirrhosis, continues on home lactulose and rifaximin.
No hx varices (last EGD ___. D/c'ed nadolol and
spironolactone as above. Needs GI follow-up.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male history of COPD and BPH presented to his PCP's office
today for PFT's. Upon arrival, she noticed his heart rate to be
in the 180's. She sent him for an EKG and labs and then to the
ED.
.
The patient denies palpitations, changed shortness of breath, or
chest pain, throughout any of this. He reports occiasional
lightheadedness and noted that last week he felt as if he might
"fall in traffic while standing at a curb". He denies recent
fevers, chills, or cough, but notes increased daytime urinary
frequency. Patient drank his usual cup of coffee today. He
reports fatigue of unknown timeline that does not limit his
exercises. He is taking daily naps that are not refreshing. He
feels weak and exhausted. No change in weight or appetite. He is
not sleeping well largely due to urinary frequency and wakes up
___. Stream is slow as times. He had recent urologic eval
for hematuria which was negative.
.
In the ED, initial VS were 97.0 112 149/93 18 100% RA. He
received 30 MG PO dilt with rates still in 120s. He received an
additional 10 MG i.v. dilt. Atrius cardiology was consulted who
asked for him to be admitted overnight and started on lovenox
and coumadin with dilt 60 qid. One peripheral line was placed
with 1L of IVF given. Vitals prior to transfer were: T 97.9 hr
74 bp 133/83 sa 02 98% ra.
.
Currently, patient feels well upon arrival to the floor and did
not expect to be admitted today. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with ATRIAL FLUTTER. At the time of discharge, the patient had Primary diagnosis:
- atrial flutter
Secondary diagnosis:
- Chronic obstructive pulmonary disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo male with history of COPD who presents with new onset
a-flutter.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o female who presents to ___ after a
fall. She was at her usual job as a ___, left a
meeting and recalls getting to the top of a flight of stairs and
her last memory is waking up in the CT scanner at the hospital,
she estimates that she fell down 10 steps. Report indicated
that she may have had some seizure like activity but detail as
to the description of observed events in not available. Paitient
also incurred a left huumeral head fracture. She was admitted
to the inpatient service for further observation. Radiology showed Unchanged appearance of small subarachnoid hemorrhage. The patient was diagnosed with FX UP END HUMERUS NOS-CL, FALL ON STAIR/STEP NEC. At the time of discharge, the patient had - Left small subarachnoid hemorrhage
- Left proximal humoral head 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>Mrs. ___ was admitted to ___ on ___
after you sustained a fall at work. Per medical records, she
was observed to have seizure-like activity after falling down
approximately 10 stairs. She had also lost consciousness for
approximately five minutes. Upon further evaluation, she was
found to have a small left subarachnoid hemorrhage and a left
proximal humerus fracture. She was transferred to ___ for
further evaluation and management.
One at ___, Mrs. ___ was seen by Neurosurgery and
Orthopedics for her injuries. From a neurosurgical standpoint,
the patient did not require a surgical procedure. Her repeat
head CT was stable. She was started on Keppra for seizure
prophylaxis. She will follow-up in their office in one month.
Mrs. ___ did not require an operative procedure for her left
humerus fracture. She was instructed by Orthopedics to keep the
arm in a sling and not bear any weight with that extremity. She
will follow up with that service in approximately two weeks with
an x-ray prior to her appointment.
The patient's pain was managed well with oral narcotic and
non-narcotic analgesics. She was tolerating a regular diet
well. She was hypertensive at times with systolic pressures in
the 150 to 160s and diastolic pressures between 80 and 90. She
was instructed to follow up with her PCP to address this issue,
although the new onset pain could have exacerbated her blood
pressure.
Lastly, Mrs. ___ was seen by Physical and Occupational
therapy. Both services felt that she could be discharged home
with no additional services.
At the time of discharge, the patient was afebrile,
hemodynamically stable and in no acute distress. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o female with past medical history of DVT on coumadin,
COPD, GERD, dementia, PNA who sufferred from a mechanical fall
at home. Patient stumbled while getting out of a chair and fell
while at home. She was seen at an OSH and was noted to have a R
distal femur fracture and was transferred to ___ for surgery. Right femur fracture, pre-operative.
AP radiograph of the chest was compared to ___ obtained at 04:33
a.m.
Heart size is normal. Substantial prominence of the ascending aorta is
re-demonstrated as well as most likely dilated aortic arch. Chronicity
undetermined. Lungs are essentially clear except for biapical scarring. No
appreciable pleural effusion or pneumothorax is seen. Hiatal hernia present. was done. Radiology showed 1. No evidence of acute cardiopulmonary process.
2. Partially imaged left shoulder demonstrates high riding left humerus and
possible deformity of the left humeral head/neck junction. ___ consider
dedicated left shoulder radiographs for further evaluation, if clinically
indicated. The patient was diagnosed with PERI-PROSTHETIC FRACTURE AROUND PROSTHETIC JOINT, ACCIDENT NOS, JOINT REPLACEMENT-HIP. The patient was treated with Open reduction internal fixation of right femur [Lateral plating
with a 16 hole plate secured with cortical and locking screws.]. At the time of discharge, the patient had Femur Fracture
blood loss 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>___ y/o female with past medical history of DVT on coumadin,
COPD, GERD, dementia, PNA who sufferred from a mechanical fall
at home and is s/p ORIF for a right femur fracture performed on
___.
ACUTE ISSUES
# Femur Fracture - Patient suffered from a mechanical fall on
___ and was transferred to ___ for surgery. Surgery was
postponed until ___ due to elevated INR while on coumadin.
Admission INR was 2.7. Patient received 5 U FFP with appropriate
normalization of her INR. Patient went to the operating suite on
___ for an ORIF of her right femural shaft which included
lateral plating with a 16 hole plate secured with cortical and
locking screws. There were no complications during the
procedure. Patient returned to the floor and was transferred to
the medicine service for management. Pain was adequately managed
with acetminophen 1 g PO TID scheduled, oxycodone 2.5mg po TID
PRN for post op pain, and Morphine ___ mg IV q4 hrs for
breakthrough pain. Ortho monitored the wound daily and felt the
wound was healing appropriately. ___ was consulted on ___.
Lovenox 30 mg subcutaneous daily was given to the patient for
DVT ppx. Patient to be discharge to rehab facility and will
followup with ortho as outpatient.
# Fever, Leukocytosis - Patient had fever and leukocytosis
post-op. Patient denied chills, diaphoresis, cough. Most likely
post-operative findings. Had CXR which was wnl. Increased
pulmonary toilet and pulmonary ___. Patient was not able to
adequately use the incentive spirometry. Patient was afebrile on
discharge. WBC 9.6.
# Dementia - Patient was at risk for delirium given history of
post-op delirium. Patient did not become delirious during
hospitalization. Pain was managed adequately. at risk for
delirium
# Post Op Pain - Pain adequately controlled with the above
regimen. Will continue the acetaminophen 1 g PO TID scheduled
and oxycodone 2.5 mg po TID prn pain. Will not continue morphine
as outpatient.
# DVT history on coumadin - Patient was therapeutic on warfarin
on admission. Required 5 units FFP to normalize INR. Coumadin
was discontinued prior to surgery. Received lovenox 30 mg daily
as prophylaxis. Warfarin was restarted on ___ at 3 mg. Warfarin
was d/c on ___ due to drop in Hct from 27 to 20. Warfarin
restarted on ___ at 3 mg daily with lovenox 30 mg daily bridge.
INR 1.7 at discharge.
# Anemia - Patient required 3 units PRBC on ___ for Hb 6.5. Hb
normalized following transfusion. Received 2 units on ___ for
Hct 20. Post-transfusion Hct 29. Anemia most likely related to
blood loss during surgery and poor bone marrow response. Patient
did not have any signs of overt bleeding. Hemolysis labs (LDH,
Bili, haptoglobin, retic) were wnl. Hb 9.8 and Hct 28.4 on
discharge.
# Oliguria - Urine output declined after surgery. Foley catheter
was in place for UOP monitoring. Received IVF and urine output
increased. Renal function wnl. UOP decreased yesterday. Received
mainteance IVF. F/c was d/c on ___. Required 1 straight cath
was PVR 430cc. Patient was able to void on own at discharge.
CHRONIC ISSUES
# COPD - Patient has a diagnosis of COPD based on imaging. No
smoking history. Received duonebs q8h for post-op wheezing.
Patient was encouraged to use incentive spirometer multiple
times a day. Supplemental O2 was d/c within 12 hours post-op.
Sats >96% RA at discharge.
# HTN - Blood pressure stable during hospitalization. Held home
lasix. Continued home lisinopril.
# Osteoporosis: Ca and vitamin D administered as inpatient.
Continue as outpatient. Recommend outpatient DEXA scan.
# Nutrition - patient was able to eat a regular diet. Ensure
supplementation was given.
TRANSITIONAL ISSUES
- please check daily INR until therapeutic (goal 2.0-3.0)
- please continue lovenox as bridge to therapeutic coumadin at
30mg subcutaneously daily
- please evaluate volume status daily and restart home lasix
dose (20mg daily) if patient develops signs of volume overload
(lower extremity edema, pulmonary rales)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PRE-OP PA AND LAT) showed 1. Stable moderate left and small right pleural effusions.
2. Stable top-normal heart size.
3. Substantial paraesophageal hernia. Radiology showed No discrete pneumothorax identified. Small bilateral pleural effusions,
greater on the left.
Gas within a presumed hiatal hernia projects over the medial right lower
hemithorax. CHEST (PORTABLE AP) showed Moderate gastric distention. Stable left basilar consolidation with adjacent
pleural fluid, likely atelectasis, consider pneumonia if clinically
appropriate. CHEST (PORTABLE AP) showed Significant gastric distention, worsened since prior CHEST (PORTABLE AP)
volvulus of intrathoracic stomach. No mention in your report (my edit to
Impr). ___ d/w ___ and document. showed 1. Worsening left lower lobe collapse and right basilar atelectasis.
2. Persistent small left pleural effusion.
3. Worsening gastric distention since ___, though minimally changed
from ___, raises concern for gastric outlet obstruction or volvulus or
incarceration of the intrathoracic stomach.
4. Stable mild cardiomegaly.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:28 AM, 3 minutes after
discovery of findings. CTA chest showed CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The ascending aorta is mildly aneurysmal measuring up to 3.5 cm. The main
pulmonary artery is prominent consistent with pulmonary artery hypertension.
Thoracic aorta is without evidence of dissection or intramural hematoma.
Moderate pericardial effusion is again seen, unchanged compared to the prior
study.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: The left-sided pleural effusion is increased compared to the
prior study in the right-sided pleural effusion is new compared to the prior
study. There is no pneumothorax.
LUNGS/AIRWAYS: Mild biapical scarring is unchanged compared to the prior
study. Consolidation in the right suprahilar region is new since the prior
study and may represent an infectious process. Consolidation in the left
lower lobe may represent infectious process and volume loss, more prominent
compared to the prior study. There is mild right basilar compressive
atelectasis. Minimal secretions are noted in the right mainstem bronchus.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right adrenal gland is normal in size and shape. There is mild
thickening of the left adrenal gland without evidence of nodularity.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A 2.3 cm left renal cyst is slightly hyperattenuating and may represent a
proteinaceous/hemorrhagic cyst. Subcentimeter hypodensities in the right
kidney are too small to characterize, likely simple cyst. There is no evidence
of focal renal lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The esophagus is dilated. A large right-sided hiatal hernia
containing the entire stomach with air-fluid level is present. A gastrostomy
tube is new since the prior study. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement throughout. Diverticulosis of the
sigmoid colon is noted, without evidence of wall thickening and fat stranding.
The appendix is not visualized. A small amount of pneumoperitoneum is new
since the prior study, likely postsurgical.
PELVIS: The urinary bladder contains air which may be secondary to
instrumentation. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES AND SOFT TISSUES: Severe T12 compression deformity is unchanged compared
to ___. There is subcutaneous emphysema bilaterally, new since the
prior study, extending from the axillae down to the groin. A left-sided
inguinal hernia containing a loop of large bowel is noted.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Consolidation in the right suprahilar region, new since the prior study,
may represent an infectious process. Consolidation in the left lower lobe may
represent a combination of infectious process and volume loss.
3. The left-sided pleural effusion is increased compared to the prior study.
The right-sided pleural effusion is new compared to the prior study.
4. There has been interval placement of a gastrostomy tube. Large right-sided
hiatal hernia persists.
5. Subcutaneous emphysema extending from the axillae down to the groin
bilaterally and a small amount of pneumoperitoneum are new since the prior
study, likely postsurgical.
6. Moderate pericardial effusion is again seen, unchanged compared to the
prior study.
7. Left-sided inguinal hernia contains a nonobstructed loop of large bowel.
8. A 2.3 cm left renal cyst is mildly hyperattenuating and may represent a
proteinaceous/hemorrhagic cyst, unchanged since ___.
9. Severe T12 compression deformity is unchanged compared to ___. CHEST (PORTABLE AP) showed Comparison to ___. Minimally increased lung volumes with stable
perihilar opacity on the right and status post gastropexy. The presence of a
small left pleural effusion cannot be excluded. Bilateral apical thickening.
No other interval changes. CHEST (PORTABLE AP) showed In comparison with the study of ___, there again are extremely low
lung volumes with little overall change in the appearance of the heart and
lungs in this patient with previous gastropexy. Apical pleural thickening
again is seen bilaterally. CHEST (PORTABLE AP) showed 1. Worsening distension, intrathoracic, herniated stomach.
2. No new focal consolidation concerning for pneumonia.
3. Stable left lower lobe collapse with associated small left pleural
effusion.
4. Minimally improved right perihilar opacities, likely reflecting
atelectasis. CHEST (PORTABLE AP) showed Elevation of right hemidiaphragm is unchanged including the gas-filled bowel
in the right upper quadrant. Left retrocardiac atelectasis is unchanged.
Interstitial lung disease is unchanged. No new abnormalities within the lungs
demonstrated. CHEST (PORTABLE AP) showed No change from CXR done at 04:33 on ___ Radiology showed G-tube projects over a portion of the stomach and may be intraluminal however
there is no second view to confirm this.
Opacification of the left lung base may represent atelectasis or developing
pneumonia
Elevation of the right hemidiaphragm with a markedly distended stomach,
similar in appearance to ___. Recommend clinical correlation. CHEST (PORTABLE AP) was done. CHEST (PORTABLE AP) showed In comparison with the study of ___, there again is a huge air-filled
structure in the right lower chest consistent with a large hiatal hernia with
shift of the mediastinum to the left and associated atelectatic changes at
both bases. Again there are extremely low lung volumes.
In view of the extensive changes, it would be extremely difficult in the
appropriate clinical setting to exclude a superimposed pneumonia, especially
in the absence of a lateral view. CHEST (PA AND LAT) showed Compared to chest radiographs ___ through ___.
Left lower lobe collapse and small left pleural effusion are unchanged,
responsible for severe leftward mediastinal shift. Moderate distension of the
herniated stomach has improved. Right lung clear. Heart severely shifted to
the left by the combination of gastric herniation and left lower lobe collapse
is probably not enlarged. No pneumothorax. Right pleural effusion small if
any. CT abdomen/pelvis showed 1. No acute intra-abdominal pathology.
2. Other unchanged findings as above, including a large hiatal hernia and
gastrostomy tube in place, stable 0.6 cm probable IPMN in the pancreatic tail,
and severe chronic fracture deformity of the T12 vertebral body. CT CHEST W/CONTRAST showed Volume of distended stomach traversing the hiatus hernia into the right lower
paramedian chest has decreased.
Previous right upper lobe pneumonia has resolved.
New alveolar opacification superior segment left lower lobe could be recent
aspiration or early pneumonia.
Substantial bibasilar atelectasis unchanged. DX CHEST PORTABLE PICC LINE PLACEMENT showed Compared to chest radiographs ___ through ___.
Previous left basal atelectasis and perihilar edema have both improved, still
accompanied by small left pleural effusion. There is no longer any pulmonary
edema. No pneumothorax. Moderate cardiomegaly stable. Moderate distension
of the intrathoracic stomach has improved a great deal over the past several
days.
Right subclavian central venous catheter ends in the low SVC. Radiology showed Successful placement of a 18 ___ MIC gastrojejunostomy tube with its tip in
the jejunum. The gastric port should not be used for 24 hours. CHEST (PORTABLE AP) was done. Radiology showed No radiographic evidence of obstruction. CT ABD AND PELVIS WITH CONTRAST showed 1. Small amount of free intraperitoneal air, fluid, and a locule of air in
the left rectus muscle, adjacent to the GJ tube, is likely related to recent
tube exchange.
2. New left inguinal hernia containing loops of nondilated sigmoid colon. No
evidence of surrounding inflammatory change, wall thickening, or obstruction.
3. Persistent bilateral nonhemorrhagic pleural effusions, trace on the right
and small on the left. These have slightly decreased since the prior study.
4. Persistent large hiatal hernia containing the gastric fundus and body. Radiology showed 1. No pneumoperitoneum.
2. Mildly dilated small bowel could represent ileus. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Moderate to severe distention of the right paramedian portion of the
intrathoracic stomach is unchanged, still displacing the right lower lung.
However leftward mediastinal shift an with a complete collapse of the left
lower lobe have worsened. Upper lungs are grossly clear. No pneumothorax.
Small left pleural effusion is likely.
Right PIC line ends in the mid SVC. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Severe gaseous distention of the right paramedian intrathoracic stomach is
more pronounced, nearly as large as it was on ___, and further
compromising the volume of the small right lung. Left lower lobe still
collapsed. Left pleural effusion is small. Heart size is indeterminate, but
probably not large.
Right PIC line ends in the low SVC. No pneumothorax. Radiology showed 1. Normal bowel gas pattern.
2. No pneumoperitoneum. The patient was diagnosed with Upper abdominal pain, unspecified. The patient was treated with Exploratory laparoscopy, lysis of adhesions, partial hiatal
hernia reduction with plication to the left crus and
percutaneous gastrostomy tube, endoscopically guided ___
___
___ of Present Illness:
___ with PMH of hypothyroidism, HTN, bipolar disorder, and
breast ca with post-breast radiation BOOP and restrictive lung
disease who originally presented to the hospital about 2 weeks
ago for repair of a large paraesophageal hernia that was thought
to potentially be contributing to her increased WOB and choking,
particularly after eating. Had a lap fundo, gastropexy, and G
tube placed on ___ that was uncomplicated. However,
intermittently had episodes of hypoxia that led to BiPap
initiation and admission to the SICU before returning to the
floor. Had increasing WBC during her admission with a CT chest
revealing LLL and RUL consolidation that was initially covered
with vanc/cefepime before being changed to ceftaz per ID
recommendations. She subsequently was triggered on the floor for
desats requiring a brief period of NRB prompting transfer to the
SICU with request for MICU transfer. At the time of transfer,
patient had been changed to face tent with improvement of her
sats to 98% though with some reports of mild SOB still. Her
breathing was noted to improve after her TFs were clamped and
drained as well as with adequate pain control.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with PMH of hypothyroidism, HTN, bipolar disorder, and
breast ca with post-breast radiation BOOP and restrictive lung
disease who originally presented to the hospital for repair of a
large paraesophageal hernia, s/p MICU course after tx of PNA,
now s/p modified post-pyloric feeding tube but w/ worsening
abdominal pain and respiratory status despite all interventions.
SURGICAL COURSE
===============
Ms. ___ presented to ___ after an episode of apnea
in the setting of known large paraesophageal hernia with
previous episodes of apnea and planned repair on ___ ___. At ___, she had a CT chest which showed the hiatal
hernia, pleural effusions, and moderate pericardial effusion.
Her apnea resolved spontaneously, without intervention but
previous episodes she has required CPAP. She was transferred to
___ on ___ for interval management and operative
planning.
Medicine was consulted for risk stratification and medical
optimization in light of comorbidities and new pericardial
effusion. She was assigned intermediate risk of <5% for cardiac
complications, but surgery was not contraindicated. A TTE was
performed ___ that found mild mitral valve prolapse, mitral
regurgitation, and mild pulmonary artery systolic hypertension
with a small pericardial effusion and no signs of tamponade
physiology, please see report for further details.
Cardiology was consulted for pericardial effusion, and after
completion of TTE and evaluation of EKGs, recommendations were
made to discharge with ___ of Hearts monitor for one month
for a possible atrial fibrillation versus sinus rhythm with
multiple PACs on an EKG from ___. Also recommended was a one
month follow up TTE to evaluate for expected effusion
resolution, breast cancer follow up and monitoring, TSH
evaluation, and followup with cardiology in 2 months. There was
concern for possible malignant effusion.
In addition to consulting cardiology and medicine, she was
continued to be monitored on telemetry and continuous oxygen
saturation monitoring with surveillance labs. She was tolerating
soft mechanical regular diet, was ambulating with a walker, and
did not have further nausea, vomiting, chest pain, dyspnea, or
apnea episodes while planning for an operation.
On ___, her WBC 16.7, and she had a repeat pre-operative CXR
that found stable pleural effusions (moderate on left, small on
right) with a top normal cardiac size and previously known
hernia. She was taken to the operating room, and had an
exploratory laparoscopy, lysis of adhesions, partial hiatal
hernia reduction with plication to the left crus and
percutaneous, endoscopically guided gastrostomy tube placement.
She tolerated the procedure well, and after her stay in the PACU
was transferred to the floor after prolonged fatigue from
anesthesia. She was continued on telemetry and oxygenation
monitoring.
On ___, patient was transferred to the SICU for increased
work of breathing and found to have a RUL consolidation with WBC
of 24. A CTA was also done to rule out a PE, which was negative,
but was concerning for a RUL consolidation. She completed a
course of cefatzadime. The patient continued to have hypoxic
episodes w/ respiratory distress c/f multiple aspiration events,
went back and forth between the medicine floor and ICU for these
events. The surgery team saw her and felt that she might need
advancement of her G-tube to a G-J tube.
MEDICINE COURSE
===============
# Hypoxic Respiratory Failure
Reported baseline history of tachypnea prior to surgery thought
to be potentially related to large hiatal hernia but also has
known history of BOOP and restrictive lung disease ___ her prior
history of radiation for breast cancer therapy. Had multiple
aspiration events, completed a course of ceftaz for possible PNA
as above. Was seen by speech and swallow multiple times, was
ultimately cleared for just clear liquids for comfort. Patient
had worsening respiratory status every time tube feeds were
started, prompting discontinuation. Patient complained of
difficulty breathing throughout hospitalization w/ interval
CXR's demonstrating worsening paraesophageal hernia causing a
mediastinal shift to the left. Patient placed on low-dose
morphine w/ some improvement in symptoms.
# Abdominal pain/distension
# Hiatal hernia s/p plication and GJ tube placement: Patient
continued to have abdominal pain after the plication procedure.
G tube was modified to a GJ to allow for post-pyloric feeds
while simultaneously allowing for G tube venting, but did not
help symptoms. Tube feeds were attempted 3 times, and even
though they were started at very low rates, her pain and
abdominal distension would worsen w/in 24 hours of starting.
During hospitalization, was noted to have urinary retention, but
no pain relief from straight caths PRN, and retention
self-resolved after home oxybutynin was d/c'd. Patient was also
given aggressive bowel regimen. Despite all interventions,
patient continued to suffer from significant pain. Ultimately
decided to d/c tube feeds. Continued to leave G tube to vent,
morphine as above. Once tube feeds started, patient was placed
on TPN; however, given concerns for volume overload as well as
overall goals of care, this was stopped prior to discharge.
Family wishes to continue ongoing discussions re: TPN at ___
facility.
# Malnutriton: Pt with poor PO intake this admission ___
expansion of hernia with PO and resulting respiratory distress
as described above. Holding TFs as above, can get clear liquids
for comfort per speech and swallow recs. As above, TPN was
stopped prior to discharge.
# GOC: Patient w/ worsening respiratory and nutritional status
despite all interventions over this long hospitalization.
Multiple GOC discussions had w/ patient and family, they are
aware that further medical interventions are limited and likely
not to help. Ultimately decided on transitioning patient to
hospice care and comfort measures only. However, patient's
family not ready to d/c TPN, they are still discussing this
issue amongst themselves. Therefore, the patient was transferred
with a ___ line in place in case they opt for TPN moving
forward. Patient very lethargic during these meetings, and could
not offer much insight into how she would like to be treated.
# HTN: Continued home amlodipine
# Bipolar disorder: Continued home ___ (level 0.5), olanzapine.
# Hypothyroidism: Continued home levothyroxine
TRANSITIONAL ISSUES
===================
[ ] patient has been transitioned to ___, hospice care
[ ] family still undecided on whether to continue TPN, please
continue ongoing ___ discussions, specifically regarding this
issue
[ ] continue to keep G tube to vent, ok to clamp for 30 minutes
if administering meds
# Communication/HCP: ___ (daughter, ___)Phone
number: ___ Cell phone: ___
# Code: DNR/DNI, confirmed with patient and subsequently HCP</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female, s/p fall. Presents with right rib pain
for the past
24 hours. The patient reports that she was walking at home
when she misstepped and fell on top of a chair striking her
right ribs. She was initially okay, however, she later
developed significant pain in the right ribs and presents at
a hospital where she underwent CT scan which demonstrated
for her right-sided rib fractures. She was then transferred
to ___ for trauma evaluation. She denies any
shortness of breath. She denies any fever, chills, abdominal
pain, nausea, vomiting, dysuria, bowel changes. Of note, the
patient is anticoagulated on Coumadin CHEST (PORTABLE AP) showed Lung volumes are lower exaggerating interval engorgement of pulmonary
vasculature and increase in mild cardiomegaly compared ___. There is no
pulmonary edema, pneumothorax or appreciable pleural effusion. CHEST (PORTABLE AP) showed Known right lower chest rib fractures not well demonstrated radiographically.
No pneumothorax detected. Bibasilar atelectasis, minimal on the right, with
possible trace right pleural fluid. The patient was diagnosed with FRACTURE FOUR RIBS-CLOSE, UNSPECIFIED FALL, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT. At the time of discharge, the patient had Trauma: fall
right ___ rib fractures. The patient was given written instructions concerning 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 walking at home when she misstepped
and fell on top of a chair striking her right ribs. She did not
strike her head or lose consciousness. She later developed
significant pain in the right ribs and presented to an OSH where
she underwent CT scan which demonstrated right-sided rib
fractures. She was transferred here for management. The patient
was reportedly on coumadin.
Because of her multiple rib fractures, she was admitted to the
intensive care unit for monitoring. Initially she was
hypotensive. Her oxygen saturation was closely monitored and her
hematocrit remained stable. She clinically improved within 24
hours of admission and was transferred to the floor once her Hct
remained stable at ___. Her INR continued to rise following
admission despite holding of coumadin. Max INR was 4.0 on
___. Her only complaint at this time was urgency and
frequency with voids. UA was sent and found to be contaminated,
thus UA obtained via straight cath was resent and found to be
WNL. UCx was pending at the time of discharge, however her
urinary symptoms had already begun to subside at this time. Once
she met the appropriate criteria, Ms. ___ was discharged home
with the understanding that she would follow up with her PCP
___ 24 hours of discharge for INR check as well as per her
appointment scheduled with the cardiology and general surgery
clinics. On the day of discharge (___) her INR was 2.9 and
she received 1mg of coumadin.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant ___ w/ HTN, DL, asthma, and
lymphoblastic crisis of CML vs PH (+) ALL, favoring former, s/p
allogeneic SCT RI-MUD, Flu/Bu D+100 (___), LTBI on
INH/B6,
hx of C diff colitis (___) who, per the ED, is p/w one day
onset of N/V/D. CHEST (PA AND LAT) showed No acute intrathoracic process. Right IJ central venous catheter in
appropriate position. The patient was diagnosed with DEHYDRATION. At the time of discharge, the patient had Dehydration. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms ___ is a ___ F with CML vs PH+ALL s/p allo matched
unrelated donor SCT who presented to ___ on day +100 with 1
day of inability to tolerate PO, 1 episode of vomiting, and 1
episode of watery non-bloody diarrhea, with notable
post-transplant history of possible mild gvhd of colon and
c.diff colitis.
#) Nausea/Vomiting: Improved following 1 day of bowel rest,
zofran, ranitidine, and IVF. C.diff toxin result was pending at
time of discharge but clinically ruled out given formed stool.
Fecal cultures were pending at time of discharge but as she was
clinically improved, tolerating regular diet, she was cleared
for discharge. This episode was felt to be less likely GVHD or
infection given rapid improvement. She has chronic GI symptoms
of IBS-like complaints since her youth.
#) CML vs PH+ALL: She presented on day ___ s/p allogeneic
matched unrelated donor SCT. She is on dasatinib 100mg qhs at
home and tacrolimus 2mg PO q12h. On a clinic visit the day prior
to admission she was seen at Dr. ___ and had been
doing well with no new complaints. Her tacrolimus had been
increased from 1.5mg q12h to 2mg q12h. During admission, her
tacrolimus was continued at the new dose and trough levels were
monitored daily. Dasatinib was temporarily held as it interacts
with ranitidine. She was continued on prednisone 10mg PO for
history of possible mild GVHD of gut. Upon discharge, ranitidine
was discontinued and she was instructed to resume dasatinib. Her
tacrolimus serum level was 2.4, 4.6, 4.7 during this admission.
# Latent TB Infection: She was continued on isoniazid with
pyridoxine
# Citalopram: She was continued on citalopram 20mg PO daily. She
follows with Dr. ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of gross hematuria in ___ worked up by
urology and nephrology and felt to likely be due to stones now
with 24 hours of RLQ pain radiating to his right groin. He had
an
episode of pain yesterday that resolved, but this morning had
persistent nausea and emesis. He has recently returned from a 2
week trip to ___ and had an additional similar episode of RLQ
pain prior to leaving for his trip that resolved after a few
hours. He denies any recent illness, fevers, chills. He reports
normal bowel movements. He denies any dysuria, hematuria,
increased frequency or urgency. Radiology showed 1. 7-mm obstructing stone in the mid-to-distal right ureter with moderate
right hydronephrosis and perinephric stranding.
2. Non-obstructing stones in the left kidney, slightly enlarged from the
prior exam, as described above.
3. Mild hepatosteatosis. The patient was diagnosed with CALCULUS OF KIDNEY, CALCULUS OF URETER, HYDRONEPHPHROSIS. The patient was treated with Cystoscopy, right ureteroscopy and laser lithotripsy, right
ureteral stent placement. The patient was given written instructions concerning 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 Dr. ___ service from the
___ ED for overnight observation, pain control, and IV fluids.
He was continued on ceftriaxone for a UA with >182 rbc and
nitrite positive. On the morning of HD2 his pain was well
controlled and nausea had resolved. His wbc had declined from 19
to 9 and his creatinine had also declined from 1 to 0.7. Given
stone size and location as well as his UA and admission
leukocytosis and hydronephrosis, the decision was made to go to
the operating room for stent placement. He underwent cystoscopy,
right ureterscopy and laser lithotripsy with right ureteral
stent placement. There were no complications; please see OR
dictation for more detail. Post operatively, his diet was
advanced, pain was controlled on PO medications, and he voided
without difficulted. He was given 5 days of cipro, flomax for
stent discomfort, and nacrotics for pain control. He is given
explicit instructions to call Dr. ___ follow-up for
stent removal in 1 week.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is ___ year old gentleman transferred from acute
inpatient rehabilitation for weakness and low hematocrit. He
was discharged the day prior to admission from the hospital to a
rehabilitation facility. Routine labwork done at the
rehabilitation facility demonstrated that he had a hematocrit of
22, which though low is actually not significantly different
from his discharge hematocrit of 23.4. He reports a subjective
feeling of weakness. He denies frank dizziness or
lightheadedness. Radiology showed 1. No acute intracranial process.
2. Chronic small vessel ischemic disease and age-related involutional
changes.
Results were discussed with Dr. ___ at 4:50 p.m. on ___ via
telephone by Dr. ___. The patient was diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT, DIABETES UNCOMPL JUVEN, HYPERTENSION NOS. The patient was treated with ___ L Femoral Endarterectomy/Fem-AK pop BPG. At the time of discharge, the patient had Primary:
Anemia
Chronic kidney Disease
___ cellulitis
Type II Diabetes
Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old gentleman with DM2 complicated by neuropathy, HL,
HTN, PVD s/p L CEA in ___, CAD, CKD, CLL among other conditions
presenting with fatigue and low hematocrit (Hct 22, recent
discharge Hct 23.4). He was re-admitted to the ___ vascular
surgery service after recent discharge the previous day after an
uncomplicated left common femoral endarterectomy and left
femoral to above-knee popliteal bypass with Dacron graft on
___ for continued left lower extremity rest pain and
non-healing arterial ulcer. The patient is s/p radical
nephrectomy for renal cancer, has CLL with anemia of chronic
disease with biweekly injections of procrit. He had been
transfused 5 units of packed red blood cells prior to discharge,
with hematocrit upon discharge of ~23. He was discharged to a
rehabilitation facility in the interim; the facility had drew a
CBC without clear reason, with hematocrit noted to be 22. This,
in context of the feelings of weakness and fatigue, prompted
transfer of the patient back to ___ for further evaluation.
# Anemia: The patient presented with a hematocrit of 22 from
discharge of 23; he received one unit of packed red blood cells
as the patient was symptomatic. Hemolysis labs were not
suggestive of hemolysis. His reticulocyte index was 1.8
suggestive of hypoproliferation. Recent nutritional studies
including iron and B12 were within normal limits. His stools
were hemoccult positive on testing, but this is unclear if a
false positive in the setting of iron therapy. There were no
signs or symptoms of an occult or frank GIB. Overall, it was
favored that the patient's anemia was likely secondary to
hypoproduction related to chronic kidney disease among other
factors. His symptoms of fatigue are likely multifactorial and
not solely related to anemia. He had no active chest pain or
other disconcerting signs while hospitalization suggestive of
poor tissue oxygenation. He should have a repeat CBC and
chemistry panel on ___. If his Hgb is less than 7, chest
pain or other concerning symptoms, or evidence of frank blood or
dark stools, he should return to ___ for further evaluation.
His Hgb on discharge was stable at 8.6. In addition, he should
have updated healthcare maintenance including colonoscopy and
perhaps EGD to explore if a slow GIB could be contributing
factor. He should continue Epo injections as well. The patient
has a history of CLL and chronic anemia requiring intermittent
blood transfusions while taking Procrit once every two weeks. He
received 5 units total of blood during his admission for
hematocrits of ___. His procrit was resumed at 24,000 prior to
discharge, and increased to 30,000 units per recommendations by
his nephrologist; his hemoglobin was improved as above with his
last unit of blood transfused on ___. His last procrit
injection was on ___, Next ___.
# CAD/PVD:
The patient has a history of hypertension, hyperlipidemia in
addition to extensive peripheral vascular disease and was
resumed on his statin, beta-blocker and aspirin. He was started
on plavix for 30 days for anti-coagulation for his new left
lower extremity graft (end date: ___. The patient was
otherwise stable from a cardiovascular standpoint; vital signs
were routinely monitored. ASA 325 mg to be continued lifelong.
The patient is s/p left femoral endarterectomy and femoral-above
knee popliteal bypass with PTFE graft. Throughout his
hospitalization, he had good dopplerable signals bilaterally,
with a dopperable graft, and was weight-bearing as tolerated on
both extremities.
# ___ cellulitis: He developed some serous drainage
from his incision with mild erythema, for which he was placed on
bactrim in his previous admission, which was continued early in
his re-admission course, then switched to IV vancomycin for a
recommended one week course through ___. He also had a ?
surgical site infection at his graft site for which he was given
initially bactrim and changed to vancomycin. His vancomycin
level was drawn at the incorrect dose but the level is
suggestive that with another dose that his level will be
correct. He will receive two more doses as noted ___ and
___. His wound appearance has improved as documented in the
physical exam section.
# Hypertension: It was noted during his hospital to be
hypertensive. He is already on valsartan 320 mg daily in
addition to nifedipine 60 mg daily. In addition, he is on
carvedilol 6.25 mg twice daily. We did not uptitrate carvedilol
given HR 50-60's most of the time. Nifedipine CR was increased
to 90 mg daily. Change might be needed based on BP readings.
Hydrochlorothiazide was initially held given the increase in Cr
however this was restarted in the last 2 days of his hospital
stay.
# CKD, Stage 4: The patient has a history of renal insufficiency
s/p left radical nephrectomy, CLL with subsequent anemia of
chronic disease. The patient is also reliant on torsemide daily
for renal insufficiency; this was held in his previous admission
in light of a rising creatinine from his baseline of 3 to 3.7 at
its peak and was 3.6 prior to discharge, and was held again
during his current admission for similar reasons. Routine
electrolytes were followed, and his urine output remained
marginal ~25cc/hr in the absence of diuretics. Intake and output
were closely monitored. At discharge, he will continue his home
diuretics and regimen. His labs are stable with no acute
indications for dialysis. Of note, at this creatinine level, his
fluctuation is likely trivial given that eGFR remains the same.
He will follow-up with nephrology as scheduled for continued
planning for hemodialysis initiation.
# Diabetes type 2 complicated by neuropathy and nephropathy: The
patient has history of diabetes, with blood glucose levels
between 104-400 within his previous hospitalization. He was
restarted on his home dose of NPH in addition to an adjusted
insulin sliding scale. Due to hypoglycemia, his NPH was
decreased to 12 units with SSI.
# Fall: ___ ~ 4:30 pm patient had a fall in the bathroom
which seems mechanical per patient's description. He hit the
posterior portion of his skull. He denied palpitations, chest
pain, light-headedness, syncope or any other symptoms. He was
able to get up afterwards without any issue. His neuro exam was
non-focal. CT head without contrast didn't show intracranial
bleed (he is on aspirin and plavix). He remained asymptomatic
after the fall. He remained alert and oriented x3 with normal
vital signs. No apparent trauma. Telemetry did not reveal acute
events.
# Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
# CODE STATUS: Full
# CONTACT/ HCP: ___ SPOUSE Phone number: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ year old man with a history of CAD s/p
CABG
(___), severe TR s/p tricuspid valve clip (___) with
residual
mod 3+ TR, HFpEF, AF on eliquis, who is presenting as a transfer
from ___ with hypotension and c/f GIB. Chest radiograph, AP portable upright. showed PICC line terminating in the lower superior vena cava. CHEST (PORTABLE AP) showed Comparison to ___. No relevant change is seen. Moderate
cardiomegaly. Stable alignment of the sternal wires. Stable position of the
right PICC line. No pulmonary edema. No pleural effusions. No pneumonia. CHEST (PORTABLE AP) showed Comparison to ___, 5:16 a.m.. The tip of the endotracheal tube
projects 4.5 cm above the carinal. The course of the feeding tube is
unremarkable, the tip projects over the central parts of the stomach. Stable
moderate cardiomegaly. Mild retrocardiac atelectasis. No pneumonia, no
pulmonary edema, no pleural effusions. Correct position of the right PICC
line. BILAT LOWER EXT VEINS showed 1. No evidence of deep venous thrombosis in the right or left lower extremity
veins.
2. Nonspecific subcutaneous edema within the bilateral lower extremities. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with ___ EGD
___ intubation
___ extubation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ year old man with a history of recent
admission for enterococcal bacteremia, CAD s/p CABG, severe TR
s/p TV clipping (___), AF on eliquis, who presented from an
OSH with melena and hemorrhagic shock. The patient was
transfused total 4U pRBC. EGD revealed multiple non-bleeding
erosions of stomach. Home aspirin and Eliquis were discontinued.
Father ___ unfortunately had ongoing episodes of melena, and in
the setting of his advanced heart failure as well as ongoing
GIB, we held family meetings with regard to goals of care. At
the time of discharge, Father ___ expressed wish for no further
escalation of care, as well as no transfer to hospital. His goal
was to stay at ___ for as long as possible, surrounded by
his community, and to be comfortable. At the same time, he
continued to be interested in continuation of his current
medications, including antibiotics and cardiac medications. He
welcomed involvement of palliative care team and ___ and
further discussions regarding transition to hospice.
# Goals of care
Multiple family meetings were held with Father ___, his HCP
___, as well as niece ___. Father ___ expressed sadness
and frustration with his repeated hospitalizations. He shared
that he was tired of being in and out of the hospital, and that
his goal would really be to stay at ___ for as long as
possible, surrounded by his community. He would like to focus
his care on comfort at this time, and would not want further
invasive procedures; he also would not want to be back in the
hospital (even if this means that he should pass away sooner).
He notes that previously hospice had been mentioned, and he is
interested in hearing more- although isn't quite ready for this
yet. He remains interested in his current oral medications as
well as IV antibiotics.
Specifically, with regard to his GIB, he is not interested in
repeated endoscopies or transfusions. He would also like to
limit blood draws. We discussed his anticoagulation, and given
that he has ongoing bleed with no plan for intervention, this
will be held, understanding the risk of clots/stroke given
atrial fibrillation.
He is confirmed to be DNR/DNI, no invasive procedures, no
transfer to hospital. He would be interested in further
discussion with the palliative care team at ___, with
potential for eventual transition to hospice. MOLST form was
filled out with these wishes.
# Hemorrhagic shock
# Likely UGIB from erosions in stomach
Presented with most likely UGIB with multiple small nonbleeding
erosions seen in the stomach on EGD ___ which is most likely
source. S/p 4u pRBC total per prior notes, including total of 2u
pRBC here. Family meeting was held, during which we discussed
best way forward for management of his GIB. As above, he was not
interested in repeated endoscopies, blood transfusions, and
wished to limit blood draws. After discussion of risks/benefits,
home apixaban was held, understanding risk of stroke given
underlying atrial fibrillation. Last Hgb was 7.2.
# Atrial Fibrillation
Patient was frequently tachycardic. Home metoprolol and digoxin
were initially held due to hemorrhagic shock, restarted once BP
stabilized. Apixaban held due to GI bleed. He was sent home on
fractionated metoprolol 6.25 mg BID with holding parameters,
would continue to discuss need for this medication.
# Delirium
Patient noted to have mild hyperactive delirium post-extubation
with agitation. Resolved. He was maintained on half of home
quetiapine.
# ___
Creatinine 2.3 on admission from baseline ~1.6. Likely pre-renal
in setting of hemorrhagic shock. Improved to 1.4 at time of last
check.
# HFpEF
Home torsemide and Metolazone were initially held in setting of
hemorrhagic shock. When restarted at 120 mg torsemide BID,
patient was net negative ___. Hence this was restarted at
lower dose of 120 mg daily, on which weight was stable and net
negative 300 mL. Discharge weight is 123.9 lbs.
# Enterococcal bacteremia
# C/f new infectious source
Recent admission for enterococcus faecalis bacteremia (blood cx
+ @ BI-N on ___, negative since ___. Etiology unclear at last
admission given CT A/P unremarkable and no obvious GI/GU source
and TEE without obvious endocarditis/vegetation. Given recent TV
clipping, ID plan to treat for endocarditis/clip involvement and
OPAT orders for IV ampicillin 2g q6h and CTX 2g q6h through
___.
- Continue ampicillin and ceftriaxone till ___ to complete 6
week course (he is still interested in this)
# Type II NSTEMI
# CAD s/p CABG (___)
# Transaminitis
Trop on admission to 0.09 although denies any chest pain. Likely
Type II NSTEMI in setting of hemorrhagic shock and demand
ischemia also with elevated LFTs (now downtrending) likely
related to hypotension. TTE reassuring. trops stable. Restarted
atorvastatin at low dose of 20 mg, but ongoing discussion wrt
medications given overall goals of care. Aspirin discontinued
(discussed with cardiology).
# B/l ___ pain
Reported some b/l thigh pain x ___ year with weakness. Also
endorsing b/l calf pain. B/l LEs are warm with 2+ pulses. LENIs
negative for DVT. B12 normal. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Eu Critical, ___, aka ___, was last seen normal by
her daughter at ___ on ___. She had been complaining of a
headache for the past day, after being hit in the head with a
box while at work at ___. She told her daughter that she
could not go to work as she did not feel well and was dizzy, and
laid on the ground where she was noted to have a facial droop
and started to slur her speech. Her daughter called ___ where
EMS noted to her to be flaccid on the right and a decreasing
mental status en route. She was brought to ___
where she was intubated and a CT head showed a large left sided
intraparenchymal hemorrhage. She was then sent to ___ for
further neurosurgical management. Upon arrival at ___, her
pupils were non-reactive and anisocoric and she had extensor
posturing in all four extremities. She was given 100g Mannitol
and 1000mg Keppra. A Nicardipine gtt was initiated to maintain
SBP<140. Radiology showed Lungs are low volume with bibasilar atelectasis. Support lines and tubes
unchanged. Cardiomediastinal silhouette is stable. There is no pleural
effusion. No pneumothorax is seen PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD showed Interval craniectomy. Large acute hematoma centered on left frontal lobe has
mildly increased along its upper extent, and contains small area of hyperacute
component of bleed along the upper margin.
Improved left uncal herniation. Improved midline shift, measuring 1.7 on
current study. Worsened intraventricular component of hemorrhage, with mildly
improved hydrocephalus.
Remainder as above Chest radiograph showed Left PICC line terminating in the distal SVC. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Postsurgical changes status post left decompressive hemicraniectomy.
2. Grossly stable sized large left frontal intraparenchymal hemorrhage with
varying chronicity of blood products and intraventricular extension, with no
evidence of definitive underlying lesion.
3. Slight interval decrease in rightward midline shift, now 13 mm, previously
17 mm.
4. Similar degree of left ventricular effacement and mild left uncal
herniation, with grossly stable intraventricular hemorrhage.
5. No evidence of enhancing parenchymal lesions or new areas of hemorrhage.
6. Findings concerning for acute to subacute left cingulate gyrus adjacent
frontal lobe infarct medial to area of intraparenchymal hemorrhage, with
questioned associated areas of hemorrhage. Radiology showed No evidence of malignancy in the chest, abdomen, or pelvis.
Substantial stool burden in the distal colon and rectum. Radiology showed No evidence of malignancy in the chest, abdomen, or pelvis.
Substantial stool burden in the distal colon and rectum. CHEST (PORTABLE AP) showed Compared to a chest radiographs ___.
Tip of the endotracheal tube is now at the upper margin of the clavicles,
approximately 6 cm from the carina. This is standard position if the chin,
not in the field of view, is elevated. Nasogastric drainage tube ends in the
upper stomach.
Lungs clear. Normal cardiomediastinal and hilar silhouettes and pleural
surfaces. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
ET tube, nasogastric tube, left PIC line in standard placements. Lungs clear.
Heart size normal. No pleural abnormality. PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD showed 1. Evolution of the large intraparenchymal frontal lobe hemorrhage with
interval increase in the intraventricular extent, without significant change
in mass effect.
2. Trace subarachnoid hemorrhage layering in the right sylvian fissure,
presumably secondary to redistribution. No evidence of new areas of
hemorrhage or large territory infarction.
3. Additional findings as described above, including unchanged
ventriculomegaly and 1 cm rightward midline shift. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices
are stable. No evidence of pneumonia, vascular congestion, or pleural
effusion. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices
are unchanged. No evidence of pneumonia, vascular congestion, or pleural
effusion. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Similar appearance of an evolving large left frontal lobe intraparenchymal
hemorrhage with surrounding edema. Few fluid fluid levels within hematoma may
be from liquefaction or coagulopathy. Hemicraniectomy. Approximately 10 mm
of rightward midline shift is similar. No evidence of new or increasing
hemorrhage.
2. Stable dilatation of the right lateral ventricle. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Lungs are clear. Heart size normal. No pleural abnormality.
ET tube ends at the thoracic inlet with the chin down; a should not be
withdrawn any further. Left PIC line ends in the low SVC. Nasogastric
drainage tube ends in the upper portion of a nondistended stomach. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring support devices
are unchanged. Cardiac silhouette remains within normal limits and there is
no vascular congestion, pleural effusion, or acute focal pneumonia.
Specifically, the tip of the endotracheal tube lies approximately 3 cm above
the carina. Radiology showed 1. The endotracheal tube terminates in approximately 4.6 cm above the carina,
unchanged.
2. No acute cardiopulmonary process. CHEST (PORTABLE AP) showed Comparison to ___. The endotracheal tube has been removed, new
tracheostomy tube is in correct position. No pneumothorax or
pneumomediastinum. Minimal right basal atelectasis. Normal size of the
heart. No pleural effusions. Radiology showed No significant interval change since the prior chest radiograph. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. Radiology showed -No evidence of pulmonary embolism.
-Moderate quantity of secretions in both lower lobes airways but no evidence
of pneumonia.
-New focally dilated subsegmental bronchus in the right lower lobe with distal
nodular opacification possibly reflecting mucous plugging within the distal
airway and upstream dilatation. Attention on follow-up imaging is
recommended.
-Limited images of the upper abdomen show minimal quantity of free air,
possibly related to the recent PEG, for clinical correlation. Chest radiograph showed The lungs are clear without evidence of effusion or consolidation. There is
no definitive evidence of mucous plugging. Radiology showed No evidence of pneumonia or atelectasis. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Normal abdominal ultrasound. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Lung volumes are low but there is no focal pulmonary abnormality. Heart size
normal. No pneumothorax or pleural effusion. Tracheostomy tube midline. CHEST (PORTABLE AP) showed Comparison to ___. Tracheostomy tube in situ. Normal size of
the heart. No pleural effusions. No pulmonary edema, no pneumonia. Normal
hilar and mediastinal contours. MR HEAD W AND W/O CONTRAST ___ MR HEAD showed Multiple punctate areas of restricted diffusion in the right temporal,
parietal and frontal lobes in keeping with acute embolic infarcts.
Filling defect in the left transverse sinus suggestive of dural venous sinus
thrombosis, which is new compared to prior.
The patient is status post left frontotemporoparietal decompressive surgery.
The hematoma is decreased in size and there is decreased mass effect. The
amount of transcranial herniated brain tissue is slightly increased compared
to prior.
There is two small rim enhancing extracranial collections anterior to the
transcranial herniated brain tissue as described above. These are nonspecific
and may represent rim enhancing hematomas, but infection/abscesses should be
considered in the differential diagnosis.
NOTIFICATION: The findings were discussed by Dr. ___ with
Dr. ___ on the ___ ___ at 9:35 am, 10 minutes after
discovery of the findings. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Acute pulmonary embolus left upper lobe.
2. Multifocal areas of intracranial arterial narrowing, may represent
vasospasm,, differential diagnosis is vasculopathy.
3. Grossly stable appearance following left craniotomy and decompression with
persistent extracranial brain herniation. Minimal interval decreased size of
rim enhancing left parenchymal subacute hematoma. Follow-up recommended to
document resolution.
4. Stable mass effect, hydrocephalus.
5. Multiple punctate infarcts are stable.
6. Transverse sinuses better evaluated on prior MRI.
7. No significant narrowing CTA neck.
8. Diffusely enlarged thyroid gland, consider thyroiditis.
RECOMMENDATION(S): Consider CTA chest with contrast, pulmonary embolus
protocol.
Follow-up brain MRI to document resolution.
NOTIFICATION: The findings were discussed with ___ , M.D. by
___, M.D. on the telephone on ___ at 2:19 pm, 5 minutes
after discovery of the findings. CHEST (PORTABLE AP) showed In comparison with the study of ___, the the tracheostomy tube remains
in good position. Cardiac silhouette is within normal limits and there is no
vascular congestion or acute focal pneumonia. Mild atelectatic changes are
seen at both bases, more prominent on the left. CTA CHEST WITH AND WITHOUT CONTRAST showed 1. There is a re-demonstrated nonocclusive pulmonary embolism in the segmental
branches of the left upper lobe as seen on the head and neck CTA performed
earlier today. No additional pulmonary emboli are visualized. No imaging
evidence of right heart strain.
2. Emphysema.
3. Additional findings above. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. The patient was diagnosed with Other nontraumatic intracerebral hemorrhage. The patient was treated with ___ - Left decompressive hemicraniectomy
___ - Trach/PEG. At the time of discharge, the patient had Intraparenchymal Hemorrhage
Seizure
Nonocclusive Pulmonary Embolism
Multiple Embolic Strokes
Venous Sinus Thrombosis
Tachycardia
Hypertension
Pneumonia, H. Flu
Thrombocytopenia
Respiratory Failure
Transaminitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ year-old woman with HTN who presents
with acute onset dizziness followed by fall found to have large
left temporoparietal ICH at OSH that increased on repeat imaging
here at ___ with rightward midline shift and subfalcine
herniation, s/p decompressive craniectomy on the left ___.
#Left Intraparenchymal Hemorrhage
The patient was transferred intubated from OSH with a left sided
intraparenchymal hemorrhage with surrounding edema. A repeat
head CT was obtained upon arrival to ___ that showed worsening
hemorrhage with increasing midline shift and herniation. A
meeting was had with the family offering a surgical
decompressive craniectomy as well as discussing her poor
prognosis. It was decided to proceed with surgical intervention.
She underwent an emergent left sided decompressive
hemicraniectomy on ___ and was admitted to the Neuro ICU
post-operatively for close neurologic monitoring. She was
started on Keppra x7 days postop for seizure prophylaxis. Postop
head CT showed minimal increase in IPH, with improved uncal
herniation and MLS. She was started on 3% hypertonic saline for
cerebral edema. She was maintained on hypertonic saline.
Hypertonic saline d/c'd ___. CT torso was done to look for
underlying malignancy, which was negative. MRI performed to look
for underlying etiology of bleed, but was unrevealing. On ___,
the patient underwent a NCHCT and a family meeting was held in
the afternoon, in which patient's prognosis at this point was
discussed. Repeat CT on ___ was stable. On ___, the staples
from the incision were removed. On ___ patient was noted to
have left arm, left shoulder twitching and was restarted on
Keppra 1gm BID. She was placed on continuous EEG for 24 hours
which showed continuous focal slowing over entire left
hemisphere, no seizure activity. On ___, she was again noted
to have facial twitching and left shoulder twitching, concerning
for seizure activity. Keppra was increased to 1250mg BID and
restarted on continuous EEG, which was negative for seizure
activity. EEG was again DC'd on ___ and she was maintained on
Keppra 1250mg BID. Patient's neurologic exam remained stable.
#Embolic Infarcts /Dural venous sinus thrombosis
Neurology was consulted for new right MCA territory
embolic-appearing infarcts and developing venous sinus
thrombosis on MRI ___. Neurology recommended TTE with bubble,
which identified no cardiac source of embolism. Left transverse
sinus VST is small and now flow limiting, thought to be related
to pressure due to IPH and swelling. Anticoagulation was
deferred. CTA Head/Neck from ___ showed multifocal cerebral
arterial narrowing concerning for vasospasm vs vasculopathy.
Cardiology was contacted regarding optimality of TTE study, who
recommended obtaining a TEE, which would be a better study to
further evaluate for possible source of emboli. Family
discussion determined to not proceed with further workup of
infarcts.
#PE
The same CTA head/neck on ___ discussed above also showed a
small PE in the left upper lobe. A CTA chest confirmed
non-occlusive PE in left upper lobe, for which anticoagulation
was deferred because of the IPH and the patient's respiratory
status remained stable. LENIs were negative for DVT. She was
closely monitored for physiologic signs of worsening of PE.
#Hypertension /Intermittent SVT
SBP into the 170s, requiring nicardipine drip intermittently.
Intermittently tachycardic, so given fentanyl boluses for
discomfort and started on metoprolol 25mg Q8H for both blood
pressure control and intermittent SVT. Lopressor was increased
on ___ due to persistent tachycardia. Cardiology was consulted
for recommendations regarding rate control; metoprolol was
adjusted.
#Respiratory Failure
The patient was intubated on arrival and remained intubated
during her ICU stay. Mini BAL was performed on ___ gram stain
grew GNR's. Cultures grew H flu, antibiotics narrowed to
ceftriaxone completed on ___. She failed to be weaned from the
ventilator and tracheostomy was placed on ___ and weaned off
vent. On ___ patient required increased in secretions and
required frequent suctioning. She was started on Glycopyrrolate
with much improvement in secretions. She was noted to have
yellow secretions on ___, sputum culture was collected. Final
results were still pending on discharge however the patient's
respiratory status was stable, WBC WNL, and patient afebrile.
Repeat cultures may be followed-up on as an outpatient if
needed.
#Thrombocytopenia
Per PMD documentation, patient had recent weight loss; could not
obtain recent bloodwork from PCP. Some hematologic abnormalities
were noted, including thrombocytopenia. On admission platelets
100, trended down to ___. She did not require transfusion and
platelet count improved. Outpatient heme records received, show
mild baseline elevation of MCV and thrombocytopenia which was
being monitored outpatient.
#Nutrition
OGT was placed. Tube feeds were at goal, and on ___ she was
noted to have hypophosphatemia; concern for refeeding syndrome
so decreased rate of tube feeds and repleted electrolytes,
contact dietary for tube feeding recommendations. They
recommended titrating up on tube feeds very slowly and repleting
electrolytes as needed. Thiamine and folate were added. On
___, the patient underwent placement of a PEG tube. Tube feeds
were restarted Jevity 1.2 cal. Due to an uptrending serum
calcium level, tube feeds were changed to Glucerna 1.2 cal on
___. She was noted to have skin breakdown at the PEG site with
ulceration and ACS was made aware on ___ and they placed a 2x2
gauze under the bumper. ACS was paged again to re-evaluate the
PEG site as 2 sutures remained in place on ___ and patient
continued with skin breakdown despite 2x2 gauze. 2 sutures were
removed and the bumper to the PEG was rotated. It was
recommended to leave open to air or use a thin gauze if a
dressing was indicated.
#Fever
The patient was febrile intermittently during her ICU stay and
was pancultured. Mini BAL on ___ with GNR's on gram stain. She
was started empirically on vanc/cefepime on ___. Patient with
sputum cultures grew H.influenzae and completed course of
ceftriaxone on ___. On ___ patient was febrile up to 102.4,
urinalysis, chest xray and LENIs were negative. Obtained blood
cultures, PICC line removed and tip of catheter was cultured. On
___ patient persisted with fevers up to 101.9. Infectious
disease was consulted for further management, Vancomycin and
cefepime was started. Two Sputum cultures was obtained, which
were both contaminated with respiratory flora. An induced sputum
culture, suctioned from trach site was obtained, which... She
was febrile again on ___, and UA/CXR were ordered, both
negative for acute process. On ___ ID recommended
discontinuation of antibiotics with close monitoring, for
possible drug fever. She continued to be febrile after
antibiotics discontinued. MRI was obtained ___ which was
negative for infection but showed right embolic infarcts and a
developing dural venous sinus thrombosis. Once PE identified, it
was determined that is the likely cause of her intermittent
fevers. No further fever workup obtained.
#Mucous Plug
Patient underwent a CTA Chest to rule out pulmonary embolism on
___ which revealed no evidence of pulmonary embolism and new
focally dilated subsegmental bronchus in the right lower lobe
with distal nodular opacification possibly reflecting mucous
plugging within the distal airway and upstream dilatation. Chest
physiotherapy and aggressive suctioning ordered, the patients
respiratory status remained stable on discharge.
#Elevated LFTs
Medicine was consulted for elevated ALT/Lipase/Amylase in the
setting of fever on ___, who recommended Hepatitis B/C
serology, Fe/Ferritin/TIBC, TSH/Free T4, and a RUQ ultrasound as
workup. Aside from a slightly elevated Ferritin, this workup was
overall negative for any acute/subacute hepatic process, and the
elevated LFTs were stable on ___. This was attributed to a
medication effect, likely either beta-blocker or cephalosporin.
#Dispo
Patient was evaluated by ___ and OT who recommended rehab. </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 ESRD ___ FSGS on HD ___
by cath, MI in setting of cocaine use, and OSA who presents with
fever concerning for HD line infection. Radiology showed Right chest wall central venous catheter tip in the low SVC. Radiology showed Successful removal of a right chest tunneled line. The patient was diagnosed with Fever, unspecified. The patient was treated with ___ - ___ removed TdC. At the time of discharge, the patient had PRIMARY DIAGNOSES:
Klebsiella oxytoca bacteremia
HD line infection
End State Renal Disease secondary to Focal Segmental Glomerular
Sclerosis
Macrocytic anemia
SECONDARY DIAGNOSES:
History of myocardial infarction related to cocaine
Hypertension
Benign prostatic hyperplasia
Obstructive sleep apnea
Consipation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old incarcerated male with past medical
history of ESRD secondary to FSGS, cocaine-induced MI, OSA,
admitted ___ with sepsis and klebsiella bacteremia,
thought to be secondary to his tunneled line, treated with
antibiotics and tunneled line removal, tolerating HD via AV
fistula, able to be discharged back to custody ___
# Klebsiella oxytoca sepsis secondary to acute blood stream
infection
# Complication of indwelling tunneled HD catheter
Patient presented with fever and malaise from his ___ clinic.
Blood cultures from admission on ___ grew Klebsiella oxytoca,
as did blood cultures from ___. He was started on broad
spectrum antibiotics, subsequently narrowing based on
sensitivities. On ___ he underwent removal of his tunneled HD
line. Source of infection thought to be his line. Workup did
not reveal other potential pulmonary, GI, GU sources. TTE was
obtained given concern from one provider for ___ possible murmur,
however no valvular pathology was identified. Subsequent blood
cultures remained without growth at time of his discharge.
Discharged with plan to complete total 2 week course (from last
negative blood culture) of PO Ciprofloxacin.
# ESRD ___ FSGS on HD MWF:
Presenting weight 92kg. Discharge weight 90kg. No evidence of
volume overload on exam. His HD line as pulled as above, but he
was able to be dialyzed via RUE AVF. Continued sevelamer 1600
TID. Continued Vitamin B complex supplementation.
# Hx of MI related to cocaine: Decreased metoprolol tartrate
50mg BID to 37.5 BID as occasional heart rates in ___,
asymptomatic. Continued atorvastatin 10mg daily.
# Hypertension: Continue amlodipine 10mg daily
# Constipation: Continue docusate, senna
# BPH: Still making urine, Continue Tamsulosin, Continue
oxybutynin which was changed from daily to twice daily for
better control.
# Obstructive sleep apnea: Not on cpap. Consider evaluation for
CPAP
====================
TRANSITIONAL ISSUES:
====================
[ ] Please continue Ciprofloxacin 500 daily for EOT date
___.
[ ] Decreased Metoprolol from 50 BID to 37.5 BID as heart rates
were in ___.
[ ] Consider evaluation for CPAP given prior diagnosis of sleep
apnea
[ ] Of note, TTE incidentally showed small secundum type atrial
septal defect with intermittent left-to-right flow. EF of 68%.
Consider outpatient cardiology referral.
#CODE: FULL CODE presumed
#CONTACT: ___
> 30 minutes spent on discharge</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ male ___ man h/o ETOH dependence
and possible suicide attempts (last hospitalized in ___ for
detox treated per Valium detox protocol; at that time was also
found to have BRBPR thought to be iso hemorrhoids; hgb 9.7) who
presents with persistent weakness x 7 days with intermittent
abdominal pain with some epigastric pain, nausea, and fevers for
the past 4 days. Radiology showed No pleural effusion or focal pneumonia. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Echogenic liver consistent with steatosis. Other forms of liver disease and
more advanced liver disease including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. No focal hepatic mass.
3. Normal gallbladder and no biliary ductal dilation.
4. No obvious pleural effusions. The patient was diagnosed with Acute pancreatitis without necrosis or infection, unsp. The patient was treated with EGD ___. At the time of discharge, the patient had # acute pancreatitis
# liver cirrhosis
# hypertensive gastropathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ male ___ man h/o ETOH dependence and
possible suicide attempts (last hospitalized in ___ for
detox
treated per Valium detox protocol; at that time was also found
to
have BRBPR thought to be iso hemorrhoids; hgb 9.7) who presents
with persistent weakness x 7 days with intermittent abdominal
pain with some epigastric pain, nausea, and fevers for the past
4
days.
# acute pancreatitis
Lipase on admission was 300. In combination with this upper
abdominal pain treatment diagnostic criteria for acute
pancreatitis, most likely in the setting of this history of
significant alcohol consumption. Right upper quadrant abdominal
ultrasound did not show any signs of gallstones or biliary duct
dilatation and a T bili was normal. There were no signs of
endorgan damage. He was aggressively resuscitated with IV
fluids. His pain was well controlled on minimal doses of IV
Dilaudid and quickly subsided with supportive treatment. The
patient was initially kept n.p.o. pending a gastroscopy as
below. Following his procedure, his diet could be advanced with
good tolerance. On discharge, the patient was asymptomatic,
eating normally, and without abdominal pain.
# Upper GI bleed
# hypertensive gastropathy
The patient has chronic anemia with a hemoglobin of ___. This
current presentation with dark stools and an initial drop in his
hemoglobin was consistent with an upper GI bleed. He underwent
an EGD ___, which demonstrated hypertensive gastropathy,
likely secondary to his hepatic cirrhosis as below, as the
source of his upper GI bleed. Hepatology was consulted for
further management and recommended antibiotic treatment with
ceftriaxone until discharge. No need to treat with octreotide
or a prophylactic beta-blocker. No need to treat with PPIs.
Outpatient follow-up with hepatology is recommended (see below).
# liver cirrhosis
Patient found to have positive HCV Ab with elevated viral load
of
7.1 log 10 IU/mL. Unknown transmission without significant risk
factors including no prior history of past transfusions (other
than one ___ years ago), tattoos, or hospitalizations. Likely with
cirrhosis with evidence of portal hypertension with portal
hypertensive gastropathy. ETOH may be playing a component as
well. Outpatient follow up with hepatology is recommended.
Work-up including ___, ANCA, immunoglobulins, Ferritin,
TIBC, Fe, viral hepatitis panel, and HCV genotype was ordered.
The patient was seen by nutrition and social work. The patient
was counseled on the necessity to abstain from alcohol.
MEDICATION CHANGES
==================
*** NEW Medications/Orders ***
Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours
as needed Disp #*100 Tablet Refills:*0 This is a new medication
for pain
FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*12 This is a new vitamin
Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*12 This is a new vitamin
Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*12 This is a new vitamin </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 history of coronary
stents who presents with fevers and abdominal pain. He underwent
upper endoscopy for GERD and screening colonoscopy on ___
which demonstrated gastritis, esophagitis, and two colonic
polyps
which were removed. That evening he felt fatigued and took his
temperature which was 101. Over the following two days he
continued to check his temperature which ranged from 99-101. On
___ he developed Right sided back pain which progressed to RUQ
and epigastric pain. He has had some small loose bowel movements
since his colonoscopy. He has no nausea. CHEST (PA AND LAT) showed Ill-defined bilateral hila could represent bronchial disease. CT CHEST/ABD/PELVIS W/ CONTRAST showed 1. Liver steatosis.
2. Diffuse gallbladder wall thickening and a partly full gall bladder. This
is nonspecific but could be seen with acute cholecystitis in the appropriate
setting, among other possible causes of gallbladder wall thickening and edema
such as fluid overload or liver disease. Probable cholelithiasis.
Correlation with clinical findings is recommended.
3. No free intraperitoneal air or splenic injury.
4. Mild bronchial wall thickening.
5. Mild paraseptal emphysema.
6. Left adrenal nodule, indeterminate by imaging criteria although likely to
represent an adenoma. Follow-up MR or CT with adrenal protocol is recommended
to reassess in ___ year. Biochemical correlation may also be appropriate. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Echogenic liver and diffusely thickened gallbladder wall without distension or
pericholecystic edema. Findings could be secondary to liver disease or fluid
overload. Acute cholecystitis seems unlikely in the absence of oral and a
clinical findings.
RECOMMENDATION(S): Correlation of gallbladder resolved with clinical findings
is recommended. The patient was diagnosed with Acute cholecystitis. The patient was treated with ___: Laparoscopic cholecystectomy. At the time of discharge, the patient had Acute cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of abdominal pain. Admission RUQ
ultra-sound showed diffusely thickened gallbladder wall and
abdominal/pelvic CT also revealed gallbladder wall thickening
and probable cholelithiasis. The patient underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating clears, on IV fluids, and oral analgesia for pain
control. The patient was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
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: ___ HIV/HCV cirrhosis, decompensated with HE and variceal
bleeding p/w new ascites and ___ edema. He has not had ascites
previously and has been compliant with his spironolactone. He
denies abdominal pain, fevers, or chills. Since his recent car
accident, he has been eating more packaged food. He denies SOB,
orthopnea or chest pain. He has not noted dyspnea with exertion.
In the ED, initial vitals were 98.8 92 118/73 24 94%. Labs were
significant for hct 35.1 and plts 81 (both approximately at
baseline). His Na was 132, which is down from recent labs. His
MELD on admission was 21. A diagnostic para was performed which
was negative for SBP. Vitals prior to transfer were 97.8 88
128/75 18 96% RA.
Currently, the patient reports feeling well. He is lying flat
without difficulties. He has some soreness at the site of para,
but denies abdominal pain. Radiology showed 1. Small, coarse nodular liver compatible with given diagnosis of cirrhosis.
2. Patent main portal vein with hepatopetal flow without evidence of
thrombosis.
3. New large ascites.
4. Splenomegaly. Radiology showed Uneventful ultrasound-guided therapeutic paracentesis with
extraction of 3.8 L of fluid. The patient was diagnosed with CIRRHOSIS OF LIVER NOS. The patient was treated with Diagnostic and US-guided therapeutic paracentesis.
No PMNs in ascites.
3.8L of ascitic fluid removed.. At the time of discharge, the patient had Primary diagnosis:
1) Ascites
Secondary diagnoses:
1) Hepatitis C cirrhosis
2) Hepatic encephalopathy
3) HIV on HAART medications. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Dr. ___ is a ___ with HIV and HCV cirrhosis complicated by
hepatic encephalopathy, variceal bleeding s/p banding, who was
admitted to the hospital with new-onset ascites, most likely due
to increased sodium intake in recent weeks.
ACTIVE PROBLEMS
# Ascites and ___ edema. This is most likely from increased
sodium intake since he has been eating more packaged meals in
past few weeks due to recent car accident. It could also
represent progression of liver disease. Diagnostic paracentesis
revealed no PMNs. US-guided therapeutic paracentesis removed
3.8L of fluid. He received 25g of 25% albumin IV. UA showed no
UTI. His spironolactone was increased from 50mg daily to 50mg
BID. We have added furosemide 40mg daily.
CHRONIC PROBLEMS
# HCV Cirrhosis, complicated by hepatic encephalopathy and now
ascites. Patient is listed for Liver Transplant. We continued
his lactulose and rifaximin, aiming for ___ bowel movements per
day.
# GIB/varices. No esophageal varices in last EGD ___.
Patient's HR was in 80-100 range during admission. We did not
adjust his nadolol since he is already at a high dose of 60mg
and higher dose could cause kidney dysfunction.
# HIV. Patient was continued on HAART medications. No history of
opportunistic infections.
# Maxillary sinus mass. Evaluated by ENT on ___ and felt to
be right maxillary mucopyocele. Recommended removal, but will
need approval from Transplant and ID services and correction of
coagulopathy prior to surgery.
### TRANSITIONAL ISSUES ###
1) Spironolactone increased to 50mg BID. We added furosemide
40mg daily.
2) Please monitor electrolytes.
3) Encouraged low salt diet.
4) Follow up with Dr. ___ Dr. ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with a history of HTN presenting with five days of
intermittent left lower abdominal pain refered by his PCP. Radiology showed 1. Acute sigmoid diverticulitis. Extensive surrounding fat stranding and
phlegmonous changes without evidence of macroperforation or drainable abscess
formation.
2. Cholelithiasis without evidence of acute cholecystitis. The patient was diagnosed with DIVERTICULITIS OF COLON. At the time of discharge, the patient had Primary:
Uncomplicated diverticulitis
Cholelithiasis without evidence of acute cholecystitis
Secondary:
Hypertension
Benign prostatic hypertrophy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ M with a history of HTN presenting with five days of
intermittent lower abdominal pain found to have uncomplicated
sigmoid diverticulitis.
# Uncomplicated Diverticulitis:
Mr. ___ presented to the hospital with left lower quadrant
pain found to have uncomplicated diverticulitis with CT abdomen
showing localized localized diverticular inflammation and is
without evidence of abscess, obstruction, or perforation. He is
also without evidence of leukocytosis though exam was notable
for left lower quadrant tenderness with guarding though no
rebound. Patient's last colonscopy in ___ showed evidence of
sigmoid diverticulitis with polyps with need for repeat in ___
years. Mr. ___ was admitted to the hospital placed on clear
liquid diet, started on PO ciprofloxacin/flagyl with improvement
of his abdominal pain and ability to ambulate easily prior to
discharge. He was discharged with 10 day course of PO
cipro/flagyl, tylenol for pain, and zofran for nausea (Qtc of
418). He was instructed to continue clear liquid diet for ___
days and if tolerating without issue could transition to regular
diet.
# HTN:
Blood pressure remained well controlled and he was continued on
atenolol.
# BPH:
Continued on home tamsulosin QHS
#History of hematuria
Patient with prior history of hematuria that per his report had
resolved after treatement with amoxicillin possible secondary to
nephrolithiasis vs. hemorrhagic UTI. UA currently without
evidence of blood. Follow up with primary care doctor
#Cholelithiasis without cholecystitis
CT abdomen showing diverticulitis above noted cholelithiasis
though no cholecystitis</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ history of COPD on 2L O2, HFpEF, CKD
III, CAD, DM II, HTN, bullous pemphigoid on prednisone, beta
thalassemia trait, hard of hearing, recent admission to ___ for
COPD exacerbation and hypercarbic respiratory failure requiring
BiPAP, presenting from rehab facility with BRBPR and respiratory
distress. CHEST (PORTABLE AP) showed Essentially nondiagnostic exam due to patient positioning. CR - CHEST PORTABLE AP showed The lungs appear hyperinflated which may represent chronic emphysematous
changes. There is mild blunting of the left costophrenic angle which may
represent a small pleural effusion or atelectasis. There is no focal
consolidation or pneumothorax. The cardiac silhouette is mildly enlarged.
There is central pulmonary vascular congestion without overt pulmonary edema.
No acute osseous abnormalities are identified. DX PELVIS AND HIP UNILATERAL was done. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Please note that the exam is significantly limited by extensive motion
artifact. Within these limitations, no obvious intracranial hemorrhage or
midline shift.
2. Evaluation for fractures limited, however, no obvious displaced fracture
identified. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. Please note that significant motion artifact limits evaluation of the
cervical spine. Evaluation for subtle fractures limited. Within this
confines, no obvious displaced fracture or traumatic subluxation.
2. Additional findings described above.
RECOMMENDATION(S): If there is high clinical concern of fracture, the study
should be repeated with CT or MRI. CHEST (PORTABLE AP) showed Lungs are low volume with small bilateral effusions and bibasilar atelectasis.
Interstitial abnormality in both lower lobes is unchanged. Overall
constellation Findings related to congestive heart failure. Cardiomediastinal
silhouette is stable. No pneumothorax is seen. CT CHEST W/O CONTRAST showed 1. Focal airspace opacifications are seen in both lower lobes and right upper
lobe, suggestive of multifocal pneumonia. Recommend re-imaging after treatment
to ensure resolution.
2. Trace bilateral simple pleural effusions are seen, with associated
subsegmental atelectasis. They are too small for thoracentesis.
RECOMMENDATION(S): Recommend follow up imaging after treatment to ensure
resolution of the multifocal opacities. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSES
=================
HYPOXIC RESPIRATORY FAILURE
COPD EXACERBATION
PNEUMONIA
SECONDARY DIAGNOSES
===================
Altered Mental status
Lower gastrointestinal bleed
Hypernatremia
Type II Diabetes Mellitus
Hypertension
Chronic Kidney Disease
Heart failure with preserved ejection fraction
Elevated troponin
Chronic pain
Bullous pemphigoid
Coronary Artery Disease
Hyperkalemia. The patient was given written instructions concerning 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 ___ history of COPD on 2L O2, HFpEF, CKD
III, CAD, DM II, HTN, bullous pemphigoid on prednisone, beta
thalassemia trait, hard of hearing, recent admission to ___ for
COPD exacerbation and hypercarbic respiratory failure requiring
BiPAP, presenting from rehab facility with BRBPR and respiratory
distress admitted with possible LGIB and COPD exacerbation. </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 a history of gastric bypass
(___), gastrojejunal anastomotic ulcer, H. pylori,
polysubstance abuse, who presents with an episode of
hematemesis. She had some nausea upon waking up this morning,
which is her baseline before she eats. She took her morning dose
of Wellbutrin with some water, and had a single episode of
clear/mucus emesis
about 20 minutes after the same. She had another two episodes
following the initial one, the second of which was bloody. Per
patient, she noticed blood on her lips and teeth, and bright red
blood in the toilet bowl. Did have some transient dizziness upon
seeing the blood, but denies any palpitations, shortness of
breath or loss of consciousness. Shortly after the episode of
hematemesis, she began to have ___ stabbing epigastric pain
that radiated towards her back; similar to prior episodes of
pain that have prompted hospitalization in the past. She went to
___ ER for evaluation and was transferred here for
further evaluation after she was found to be hemodynamically
stable and given Protonix 80mg IV. She has not had any episodes
of emesis after 9am.
Of note, patient was last admitted at ___ from ___ to
___ for a suicide attempt and severe epigastric pain.
Workup at that time was significant for a gastrojejunal ulcer
and gastrogastric fistula seen on EGD. She was also found to
have H. pylori and treated for the same, although per patient
treatment was not completed. Patient was discharged to an
extended care psychiatric facility, where she was until
recently. Since her discharge, she has continued to have nausea
upon awakening, and intermittent stabbing epigastric abdominal
pain, exacerbated by acidic and spicy foods. She does report
that any food that "makes her chew" causes abdominal discomfort,
and her diet has consisted of fluids, yoghurt and soup for the
most part. She has not
consumed any alcohol since ___. She has not taken Zofran and
sucralfate (which do provide symptomatic relief) because she did
not have prescriptions for the same when discharged from the
ECF. Over the past two weeks, she has had laryngitis, cough and
a cold. Cough is productive of clear-yellow sputum, accompanied
by fever initially. However, denies any vigorous coughing this
morning. She has not seen any healthcare provider since her
discharge.
At this time, patient denies any nausea or further episodes of
emesis. She continues to have epigastric pain that is controlled
with Dilaudid. Review of systems is negative for
lightheadedness, palpitations, dysphagia, constipation, melena
or bloody stool. Radiology showed 1. Post-surgical changes related to Roux-en-Y gastric bypass surgery. Oral
contrast is not seen in the excluded stomach and pancreaticobiliary limb of
the small bowel, as was seen on ___ and ___ CT exams. However,
this may in part relate to timing of the study, as oral contrast is more
distal in the bowel and any oral contrast through a gastro-gastric fistula may
have passed more distal than the afferent limb. No bowel obstruction.
2. Persistent dilation of the common bile duct, likely related to prior
cholecystectomy. The patient was diagnosed with HEMATEMESIS, ABDOMINAL PAIN EPIGASTRIC, BARIATRIC SURGERY STATUS . At the time of discharge, the patient had Marginal ulcer
H. pylori infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was transferred from an OSH with complaints of abd
pain, nausea and emesis x 3, one of which contained blood. Upon
arrival, the patient's vital signs and hematocrit were stable
(Hct 44.2); Abd/pelvic CT was unrevealing. The patient was
subsequently admitted to the ___ Surgical Service for
administration of PPIs, carafate, re-initiation of H. pylori
treatment with intravenous levofloxacin and metronidazole.
On HD2, the patient's diet was advanced to stage 3 and well
tolerated. Her H. pylori regimen was transitioned to oral
bismuth, omeprazole, metronidazole and doxycycline (pt w/ PCN
allergy). Gastroenterology was in agreement with these
recommendations, and added that she should get a follow-up EGD 6
weeks after initiation of treatment. Vital signs remained stable
and the patient did not experience any further vomiting. Her
primary care provider was contacted, and he reported that
patient had not followed up with him following her previous
discharge, and that he would be happy to follow her. He also
noted that she had a history of being adherent with only
narcotic pain medication.
At the time of discharge, patient was hemodynamically stable, no
emesis since the unwitnessed episodes at home, with improved
pain and ability to tolerate a diet. She was discharged home on
a 2-week course of h. pylori treatment with follow-up with her
PCP and gastroenterology. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with PMH of HCV cirrhosis and colon cancer s/p resection
and colostomy ___ years ago who was transferred from ___
___ for anemia and bleeding at colostomy site. Radiology showed 1. Cirrhotic liver with stigmata of portal hypertension including large
volume ascites, splenomegaly, and extensive varices, including esophageal,
periesophageal, perigastric, and peristomal. The peristomal varices are a
potential source of bleeding, though there is no evidence of active
extravasation.
2. Two incompletely characterized hypodensities in the liver are likely
cysts, or possibly regenerative nodules. Given the history of colon cancer,
this could be confirmed with ultrasound or short-term follow-up as metastases
cannot be completely excluded. No evidence of HCC.
3. Ascitic fluid under the abdominal wall hernia, parastomal hernia, and
bilateral inguinal hernias. A loop of small bowel is present in the abdominal
wall hernia, though there is no evidence of obstruction or strangulation.
4. Filling defect in right lower lobe pulmonary artery, best identified on
the venous phase, consistent with pulmonary embolism. Dedicated CTA of the
chest is suggested to assess the extent of emboli.
5. Diverticulosis without evidence of diverticulitis.
6. Moderate body wall edema, including skin thickening at the ostomy sites,
without discrete fluid collections to suggest an abscess.
Results were discussed with Dr. ___ on ___ at 20:50 via telephone by
Dr. ___ at the time of the findings were discovered. Radiology showed No evidence of deep vein thrombosis in bilateral lower extremity. Radiology showed 1. Successful TIPS placement and embolization of stomal varices.
2. Infrarenal IVC filter placement (Option retrievable filter).
3. Temporary right internal jugular vein triple-lumen catheter placed.
4. Ultrasound-guided paracentesis. Evaluation of the patient with central venous line
placement and known gastrointestinal bleeding.
AP radiograph of the chest was reviewed with comparison to ___ CT
abdomen.
The central venous line tip is at the level of low SVC. Heart size and
mediastinum are stable. Mild vascular engorgement cannot be excluded, but no
overt pulmonary edema is seen. No pneumothorax is present. was done. The patient was diagnosed with ANEMIA NOS, OTHER COLOSTOMY COMP, MALIGNANT NEO COLON NOS, CIRRHOSIS OF LIVER NOS, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, HYPERTENSION NOS. The patient was treated with EGD and colonscopy (___)
Paracentesis with removal of 4 L (___)
TIPS, IVC filter placement, stomal varices embolization (___). At the time of discharge, the patient had Primary diagnoses:
- ___ varices
- Acute blood loss anemia
Secondary diagnoses:
- Pulmonary embolism
- Contrast-induced nephropathy
- HCV cirrhosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with PMH of HCV cirrhosis and colon cancer s/p resection
and colostomy ___ years ago who presents on transfer from OSH with
anemia and bleeding concerning for variceal bleed.
ACTIVE ISSUES
# ___ variceal bleeding: Unclear etiology on admission.
EGD and colonoscopy were unremarkable. CTA showed ___
varices which were thought to be the most likely source. Patient
was managed with pantoprazole and octreotide drips and
ceftriaxone for SBP prophylaxis. Frank blood from ostomy on
___ with hypotension. Resuscitated and taken for TIPS on
___. The ___ varices were embolized. Low
post-procedure portosystemic gradient. Observed in MICU
overnight no events. Patient had no further issues with
bleeding. Patient received total of 6 units pRBCs and 2 units of
platelets from ___ to ___. He Hct remained stable after TIPS
and embolization of varices.
# Acute kidney injury: Cr 1.6 on admission. Unclear baseline.
Likely pre-renal azotemia in the setting of acute bleed on
admission. Cr remained elevated after patient was taken for TIPS
and was slow to improve with IV fluids. This was attributed to
contrast-induced nephropathy in the setting of TIPS. Patient was
given more IV fluids and Cr had begun to trend down on
discharge. Home diuretics were held on admission and were
restarted on discharge.
# Pulmonary embolism: RLL pulmonary artery filling defect that
was incidentally found on CTA abdomen/pelvis. Unable to
anticogulate in setting of GI bleed. Bilateral ___ studies
negative for DVT. TTE as part of pre-transplant workup showed no
PFO. Patient had retrievable IVC filter placed with TIPS on
___.
# Hepatic encephalopathy: Patient with mild encephalopathy may
be his baseline. There was no evidence of exacerbation of
encephalopathy after TIPS with the exception of mild asterixis.
CHRONIC ISSUES
# HCV cirrhosis: Reportedly there is no history of SBP or HE;
however, he is on rifaxamin, nadolol, diuretics chronically.
Diagnostic paracentesis was with no SBP. CTA on ___ notable
for ___ varices. Patient underwent TIPS which resulted
in an improved gradient as above. Continued home rifaximin.
Continued nadolol initially but was held in MICU given soft
blood pressures. Restarted on discharge. Diuretics were held in
the setting of unstable blood volume but were also restarted on
discharge. Nutrition was consulted.
# Thrombocytopenia: Likely due to chronic liver disease.
Transfused to Plt > 50. Given 2 units of platelets in the
setting of TIPS.
# Colon cancer: Patient s/p surgery and chemotherapy ___ years
ago. Not being actively treated for this.
TRANSITIONAL ISSUES
- Patient successfully underwent TIPS
- Will need abdominal US every 6 months for ___ screening
- Given Rx for outpatient lab work
- Monitor mental status given risk of hepatic encephalopathy
- PCP ___ scheduled
- ___ Liver Clinic ___ scheduled
- ___ gastroenterologist ___ scheduled</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with background of developmental delay and HTN,
presented with symptoms of nausea, vomiting, abdominal
distension
and food intolerance for 48 hours. He is unable to provide a
history and information is provided by mother. She noted him
becoming increasingly uncomfortable and rememebered he last had
a
normal bowel movement on ___. She also noted that he was
expressing tenderness in his left scrotum which started at
around
the same time. He has never experienced a similar episode in the
past and she thinks he had a temperature prior to presentation. SCROTAL U.S. showed 1. No evidence of testicular torsion.
2. Small right hydrocele. CT ABD AND PELVIS WITH CONTRAST showed 1. Appendicolith, with mild dilation of the distal appendix. Although there is
no wall thickening, hyperenhancement of the wall of the appendix and mild
surrounding stranding are suggestive of appendicitis.
2. Wall thickening and hyperenhancement of the terminal ileum are likely
ileitis reactive to the appendicitis rather than inflammatory bowel disease.
3. Fluid collection in the cecal mesentery is also likely reactive.
4. Mild dilation of the distal small bowel, with a transition point seen
within the right pelvis, consistent with a partial small bowel obstruction,
possibly secondary to 1 & 2 above. Air and stool are seen within the distal
colon. CHEST (PORTABLE AP) showed Cardiac size is top normal, accentuated by low lung volumes. ET tube is in
standard position. NG tube tip is in the stomach. There is crowding of the
bronchovascular structures. opacities in the lower lobes left greater than
right could be atelectasis and or aspiration. There is no pneumothorax or
pleural effusion. Partially visualized oral contrast from prior CT within the
abdomen. CHEST (PORTABLE AP) showed Cardiac size is top-normal accentuated by the low lung volumes. Worsening
bibasilar opacities larger on the left side are worrisome for aspiration.
Opacities in the upper lungs right greater than left have nodular appearance.
These could be part of aspiration but septic embolism is not excluded given
the nodular appearance, CT is advised. There is no pneumothorax. If any there
is a small left effusion. NG tube tip is in the stomach, the side port is
probably at the GE junction and should be advanced for more standard position
NOTIFICATION: The findings were discussed by Dr. ___ with ___ on the
telephone on ___ at 10:00 AM, 40 minutes after discovery of the
findings. CHEST (PA AND LAT) showed In comparison with the study of ___, there are even lower lung
volumes, which accentuates the transverse diameter of the heart. Bilateral
areas of increased opacification processed, so they appear less prominent than
on the previous study. This could reflect some improving vascular congestion
superimposed on underlying multifocal pneumonia. Abdomen showed NG tube tip is in the stomach. Radiology showed 1. Irregular intra-abdominal fluid collection with enhancing walls in the
right lower quadrant with largest pocket measuring 2.8 x 1.6 x 2.3 cm. No
extraluminal oral contrast or pneumoperitoneum.
2. Subcutaneous fluid immediately deep to right lower quadrant abdominal wall
surgical staples likely represents postoperative seroma but given enhancement
along its lateral margin, a developing abscess cannot be excluded.
3. New moderate bilateral pleural effusions with adjacent bibasilar
atelectasis, incompletely imaged.
NOTIFICATION: The findings were discussed via telephone by Dr. ___ with
___, surgical resident, on ___ at 3:49 ___, 10 minutes after discovery
of the findings. The patient was diagnosed with INTESTINAL OBSTRUCT NOS. The patient was treated with laparoscopic converted to open appendectomy. At the time of discharge, the patient had 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. ___ was admitted to ___ after having nausea and
vomiting. He was found to have appendicitis. He was taken to the
OR and had a lap to open appendectomy. However, pre op he
developed a-fib with RVR. He was treated pre op and this
continued through out the operation. However, he tolerated the
procedure well. He was admitted to the ICU post op for
management of his a-fib. He was transferred to the floor after
his rate was controlled. He was evaluated by cardiology and he
was continued on IV to PO metoprolol. He had another episode of
A-fib while he was on the floor. He was transferred to a
cardiac floor for a dilt drip. HE was hemodynamiclly stable
during this episode. He continued to have abdominal distention
during his stay and had constipation. He had a repeat CT scan
which showed an abscess. He was continued on antibiotics. He was
discharged with follow up and will follow up with his own
cardiologist. He was tolerating PO, ambulating and doing well at
the time of discharge </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with COPD not on home O2, CAD s/p CABG, HTN, HL, pAF, h/o
CVA, alcohol abuse, presents with fever, cough, and chest pain
concerning for community-acquired pneumonia. CHEST (AP AND LAT) showed Continued chronic changes within the right upper and mid lung fields as well
the left lung base. Slightly increased opacification in the retrocardiac
region could reflect worsening left lower lobe atelectasis though infection
cannot be completely excluded. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cholelithiasis, without sonographic evidence of acute cholecystitis.
2. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study. CT abdomen pelvis with contrast showed 1. Likely pneumonia in the left lung base.
2. Mild SMA ostial stenosis.
3. Gastroesophageal reflux.
4. Persistent smooth thickening of the pylorus.
5. Rectal stool ball without colitis.
6. Cholelithiasis. UNILAT UP EXT VEINS US LEFT showed 1. No evidence of deep vein thrombosis in the left upper extremity. The
cephalic vein was not visualized.
2. Slow flow was seen throughout the venous structures in the left upper
extremity.
3. Diminutive/diffusely stenotic left internal jugular vein similar in
appearance to prior CT. CHEST (PORTABLE AP) showed Status post median sternotomy with stable cardiac and mediastinal contours
given differences in patient rotation. Stab;e widened right paratracheal
stripe consistent with known lymphadenopathy. There continue be scattered
patchy ill-defined opacities at the left lung base as well as throughout the
right lung with no definite change to suggest an acute infectious process.
The patient's mandible obscures the apices. No obvious pneumothorax. CHEST PORT. LINE PLACEMENT showed Interval placement of a right subclavian PICC line which courses cephalad in
the neck and the tip is not visualized on the image. Repositioning is
recommended. Status post median sternotomy with stable cardiac and
mediastinal contours. Stable slightly widened right paratracheal soft tissue
consistent with known lymphadenopathy. Scattered patchy ill-defined opacities
in the left lung base and throughout the right lung are stable. No
pneumothorax. No pleural effusions.
NOTIFICATION: Results were communicated by phone to the IV nurse, ___, on ___ at 16:25 at the time of discovery. DX CHEST PORTABLE PICC LINE PLACEMENT showed The right subclavian PICC line again courses cephalad with the tip now
identified within the right internal jugular vein. Repositioning is
recommended. Right paratracheal soft tissue is stable consistent with known
lymphadenopathy. Ill-defined patchy opacities the left base and throughout
the right lung are stable. Status post median sternotomy with stable cardiac
and mediastinal contours. No pneumothorax. , though showed Heterogeneous opacities throughout the right lung and left lung base have
worsened. Given waxing and waning over serial radiographs, there is concern
for recurrent aspiration/aspiration pneumonia. Radiology showed Aspiration of thin liquid.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations. CHEST (PORTABLE AP) showed Radiographs and chest CT scans since at least ___ documente asymmetric
pulmonary abnormality consisting of fibrosis and intermittent consolidation in
large parts of the right lung and left lung base, with relative sparing of the
left upper lobe. Most recently, since ___ and ___, a component
of mild pulmonary edema has improved and lung volumes have increased. There
is no pneumothorax or appreciable pleural effusion. The chronic abnormality
in the right lung is more abnormal now than it was in ___.
The alignment of sternal wires, some which are fractured, has not changed
since at least ___. Radiology showed Successful placement of a 40 cm right arm approach single lumen PowerPICC with
tip in the distal SVC. The line is ready to use. The patient was diagnosed with Pneumonia, unspecified organism. The patient was treated with ___ placement ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Community acquired pneumonia
Chronic alcohol abuse
Constipation
Gastric ulceration and edema of the pylorus.
Poor nutritional status
Hyponatremia
Recurrent aspirations
SECONDARY DIAGNOSIS:
Anemia
Atrial fibrillation
COPD
BPH. The patient was given written instructions concerning 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 COPD not on home O2, CAD s/p CABG, HTN, HL, pAF, h/o
CVA, alcohol abuse, presents with fever, cough, and chest pain
concerning for community-acquired pneumonia, which improved with
CAP treatment; he was then kept for constipation/diffuse
abdominal pain which improved; he then developed SIADH in the
setting of recent PNA and hypothyroidism.
# Hyponatremia/SIADH: initially did not improve despite 1L IVF
challenge initially; Ulytes afterwards were suggestive of SIADH,
likely in setting of hypothyroidism (TSH ~20) and recent CAP;
fluid restriction was started. Pt was euvolemeic. Likely
exacerbated by poor PO intake and alcoholism/poor solute intake.
Renal followed and recommended salt tabs 1g TID with 1L fluid
restriction. Na stabilized to 129 at time of discharge.
# Hypothyroidism: TSH checked ___ given lower BP's and
hyponatremia was 20. Pt's levothyroxine was increased to
150mcg/day; may not have been dosed appropriately at home. Will
need repeat TSH in ___ weeks post discharge.
# PNEUMONIA, community-acquired vs ?aspiration in the setting
of alcohol abuse. His CXR on admission was not entirely
definitive. Presumed CAP given fever, mild tachypnea, and
dyspnea. Note that he has longstanding dyspnea and chest pain
which has been worked up in past without clear cause. Finished
7 day course of oral cefpodox and azithromycin, last day
___.
# Fever, recurrent aspiration: Patient developed temperature to
101.2 in am ___, afebrile afterwards, and 101.3 on ___.
Panculture was unremarkable. Initial fever on ___ resolved
without any intervention. There was concern for recurrent
aspiration and speech and swallow evaluated. Patient aspirating
significantly on video swallow. Isolated fevers thought to be
secondary to aspiration events. Decision made not to treat with
antibiotics as patient was always hemodynamically stable and
events resolved on their own. Felt that adding antibiotics when
he wasn't decompensating, would be putting him at risk for c
diff and resistance. Speech and swallow recommended nectar thick
liquids and soft dysphagia diet. They also recommended SLP ___
and further evaluation and treatment as an outpatient (pt should
call ___. The patient was given packets of information
and individual counseling regarding his diet and how to prevent
further aspiration.
# CHEST PAIN. Tenderness to palpation of ribs/sternum suggests
MSK etiology. ACS ruled out with nonspecific EKG changes,
negative tropx3. Pt has presented with similar complaints in the
past.
# Abdominal discomfort: diffuse and migrating abdominal pain,
most likely due to severe constipation. Had many small bowel
movements during hospitalization but still large stool burden on
CT. CT also showed thickened duodenum and pylorus so EGD was
performed that showed a gastric ulcer and a deformity of the
pylorus (biopsied). Pylors biopsy results were wnl. Ferrous
sulfate stopped as thought to contribute to constipation. Iron
>100.
# Electrolyte abnormalities (hypophos, hyperkalemia, hypomag):
likely due to a "refeeding syndrome" in the setting of chronic
poor nutrition and alcohol abuse. Repleted often during
hospitalization. Encourage nutrition (with ensures) on
discharge. Discharged on magnesium 400mg BID.
#Left arm edema: diagnosed on HD 5. Unclear etiology, upper
extremity US was negative other than for slow flow, so this is
likely a result of blood draw trauma.
# Anemia: Patient with 10 pt hct drop in 36 hours at beginning
of hospitalization. No evidence of bleeding. Most likely due
dilution with underlying bone marrow suppression from chronic
alcohol use + dilutional effect. Retic index was 0.8, Hgb
remained stable. Iron stopped as thought to be contributing to
abdominal pain. Hgb on discharge 8.1. Would consider outpatient
iron infusions. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with a history of Crohn's disease
presenting with abdominal pain and free air after a colonoscopy. CHEST (PORTABLE AP) showed 1. Pneumoperitoneum, large quantity.
2. No acute intrathoracic process.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:11 pm, 2 minutes after
discovery of the findings by the attending physician. Earlier a wet reading
had been provided with flagging for urgent attention. CT ABD AND PELVIS WITH CONTRAST showed Large volume pneumoperitoneum without extraluminal contrast leak or pooling
identified. No abnormal colonic wall thickening or site of bowel perforation
identified. The patient was diagnosed with Oth postprocedural complications and disorders of dgstv sys, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause. At the time of discharge, the patient had pneumoperitoneum. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male who was admitted to the hospital with abdominal
pain after having a colonoscopy. Upon admission, the patient
was made NPO, given intravenous fluids, and underwent imaging.
A cat scan of the abdomen was done which showed pneumoperitoneum
which was concerning for a bowel perforation.
The patient was placed on bowel rest and started on a course of
ceftazadime and flagyl. After his abdominal pain decreased, he
resumed a regular diet. He was transitioned to a 14 day course
of augmentin. He was ambulatory and voiding without difficulty.
He resumed his home medications.
The patient was discharged on HD #3 with stable vital signs and
a stable hematocrit. He was instructed to follow-up with his
primary care provider and his ___. The patient
was provided with the telephone number to the acute care clinic
with any questions or concerns.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o HTN, HLD, DVT (a few years ago, unclear if provoked, not
currently anticoagulated) who presents as polytrauma after a
mechanical fall. Chest radiograph showed 1. Small left-sided pleural effusion and adjacent atelectasis. Lungs are
otherwise grossly clear.
2. Multiple rib fractures and left scapular fracture are better assessed on
same-day CT. CT abdomen and pelvis with contrast showed 1. No acute intra-abdominal or pelvic findings.
2. Moderate left and trace right nonhemorrhagic pleural effusions, small
volume nonhemorrhagic ascites and diffuse superficial soft tissue edema, may
be reflective of anasarca.
3. Acute burst fracture of the T11 vertebral body with 4 mm retropulsion.
4. Chronic compression deformities of T8, T9, L2, L3 and L5 vertebral bodies
with partial visualization of several subacute and chronic lower rib
fractures.
5. Pelvic floor descent.
6. 5 mm cystic pancreatic lesion, statistically likely to represent IPMN. MRI CERVICAL AND THORACIC PT21 MR SPINE showed 1. Severely limited examination of the axial reformats for the cervical and
thoracic spine secondary to patient motion artifact.
2. No evidence of acute cervical spine fracture or acute ligamentous injury.
3. Stable T11 vertebral body burst fracture with probable edema.
4. Mild T11 spinal canal stenosis secondary to 8 mm retropulsion of the
superior posterior fracture fragment.
5. Stable T8 and T9 vertebral body chronic compression fractures.
6. Stable L2 on L3 vertebral body compression deformities. SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA RIGHT showed Severe degenerative changes at the right glenohumeral joint as detailed above. The patient was diagnosed with Multiple fractures of ribs, left side, init for clos fx, Fracture of unsp part of scapula, left shoulder, init, Stable burst fracture of T11-T12 vertebra, init for clos fx, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had Fall
Rib fractures
Left scapular fracture
T1 retropulsion. The patient was given written instructions concerning 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 ___ as a Basic trauma from ___
___. Appropriate primary and secondary survey were performed
per trauma protocol. She was found have the following injuries:
Left scapular fracture
T11 burst fracture with 8mm retropulsion
multiple Rib fractures
chronic T8 & T9 compression fractures.
Orthopedic surgery was consulted for spinal injury and for
scapular fracture. They recommended activity as tolerated and
did not recommend a brace. C spine was cleared with MRI which
was negative for Cspine injury, thus hard collar was removed. IS
was encouraged and pain was controlled with oral pain medication
due to her rib fractures. She was successfully weaned off oxygen
on the day of discharge. Physical therapy and occupational
therapy were consulted and they recommended rehabilitation. Her
diet was advanced and she tolerated a regular diet without
difficulty. The patient was discharged on ___ to rehab. At
the time of discharge, she was off oxygen, pain was controlled
with oral pain medication, and she was tolerating a regular diet
and urinating and stooling normally. She was discharged to rehab
with plan to remain in rehab for less than 30 days, and plan to
follow up with ACS, Ortho spine, and ortho trauma in ___ weeks
after discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ prior external and internal drainage of pancreatic
fistula both ___ ___, and OR I&D of abdominal wall abscess ___
___ coming to the ED today because of new abdominal wall
drainage from his incision since 4am this morning. The patient
notes that he has felt general malaise and fatigue since 1 week
ago when he had a drinking binge (approx ___ drinks). He has
had some worsening epigastric abdominal pain radiating to the
back since that episode. The patient was admitted for further
evaluation. Radiology showed Multiloculated collection between the pancreas and the posterior wall of the
stomach, which measures 4.4 x 6 x 3.3 cm and has a slightly thick enhancing
rim. This is new compared to the prior study of ___, where only
phlegmonous changes without discrete collections.
Apparent track from this new collection traversing into the anterior abdominal
wall and also into a very small subfascial collection with predominantly gas.
The previously seen anterior abdominal wall collection is resolved post
drainage.
There are mild inflammatory changes surrounding the inferior aspect of the
pancreas with a small area of hypoenhancement within the medial aspect of the
tail without necrosis. Radiology showed CT-guided replacement of an 8 ___ catheter inside the
peripancreatic collection. Material was removed from the collection and sent
to microbiology. The patient was diagnosed with OTHER POST-OP INFECTION, ABN REACT-SURG PROC NEC. The patient was treated with ___: CT-guided replacement of an 8 ___ catheter inside
the
peripancreatic collection.. At the time of discharge, the patient had Pancreaticocutaneous fistula. The patient was given written instructions concerning 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 well known for Dr. ___ was admitted to
the HPB Surgical Service for evaluation of his new abdominal
wall drainage. On ___, the patient underwent abdominal CT
scan, which demonstrated multiloculated collection between the
pancreas and the posterior wall of the stomach with apparent
track from this new collection traversing into the anterior
abdominal wall (please see Radiology report for details). The
patient was started on IV Zosyn, made NPO and ___ was called for
consult. On ___ patient underwent CT-guided placement of an 8
___ catheter inside the peripancreatic collection. Midline
fistula was covered with ostomy bag for drainage. The patient's
peripancreatic fluid was sent to microbiology for analysis.
Fluid was positive for Streptococcus Milleri group and
Haemophilus species, ID was called for consult. Patient's wound
was packed with dry gauze daily. The patient's WBC started to
downward and he was afebrile. Diet was advanced to clears on
___ and diet was well tolerated. The patient underwent wound,
ostomy and drain care while ___ hospital, and he demonstrated
understanding. Prior discharge on ___, patient's WBC returned
within normal limits, he remained afebrile and fistula/drain
output subsided. The patient was hemodynamically stable.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female with recently diagnosed
Stage IVB ovarian adenocarcinoma who presents to the ED with leg
weakness and difficulty ambulating 5 days after starting
treatment with carboplatin/paclitaxel. MR HEAD W AND W/O CONTRAST T___ MR HEAD. showed 1. Small area of T1 hypointense signal in the dens, could represent a bone
island, but a marrow replacing process, including metastatic disease can't be
excluded. Diffuse intermediate T1 signal throughout the calvarium, likely
represents red marrow reconversion, although this could obscure an underlying
metastatic calvarial lesion. These findings could be further evaluated with a
CT of the head, extending through the C2 vertebral body if clinically
indicated.
2. No intracranial evidence of metastatic disease or abnormal enhancement
after contrast administration.
RECOMMENDATION(S): Diffuse intermediate T1 signal throughout the calvarium,
likely represents red marrow reconversion, although this could obscure an
underlying metastatic calvarial lesion. These findings could be further
evaluated with a CT of the head, extending through the C2 vertebral body if
clinically indicated. The patient was diagnosed with Weakness. At the time of discharge, the patient had # Fatigue secondary to recent chemotherapy and
# stage IVB Ovarian Adenocarcinoma. The patient was given written instructions concerning 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 recently diagnosed Stage IVB ovarian adenocarcinoma who
presented to the ED with bilateral leg weakness and difficulty
ambulating 5 days after starting treatment with
carboplatin/paclitaxel.
# Lethargy/generalized weakness:
Patient presented with progressive fatigue and subjective leg
weakness. ___ at OSH prior to admission negative for DVT. Her
exam was reassuring against cord compression and therefore did
not warrant dedicated spine imaging. No major lab abnormalities.
TSH normal. Case discussed with outpatient oncologist who agreed
that symptoms most likely related to her recent chemotherapy,
particularly paclitaxel (initiated 5d prior to admission).
Orthostatics were negative by blood pressure criteria
(borderline
by HR criteria), and her initial symptoms resolved completely
with IVFs. She was asymptomatic with a normal neurologic exam at
discharge, tolerating a regular diet. Followup in ___
clinic
already scheduled for ___.
# Headache:
Endorsed new HAs ___. No other red flag symptoms, but given
known diagnosis of stage IV cancer, MRI obtained to exclude
brain
metastasis that did not identify parenchymal brain mets. There
was a question of an abnormal signal in the skull calvarium of
unclear significance. Per discussion with Dr. ___
imaging either with bone scan or dedicated CT will be determined
on follow up with Dr. ___ as outpatient.
# Ovarian Cancer:
Recently diagnosed and s/p total lap hysterectomy and b/l
salpingo-oophorectomy on ___. Started C1 of ___ 5
days prior to admission. As above, outpatient oncologist (Dr.
___ followed closely, and Ms. ___ will f/u in clinic ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with ESRD ___ Alport's Syndrome s/p living
related renal transplant (___), atrial fibrillation on
apixaban, s/p multiple left knee replacements (last at
___ with recurrent MRSA left knee arthritis who is
transferred from ___ with right knee pain/edema
and elevated creatinine.
The patient was riding a moped on ___ when his
knee began to ache. Since that time he has been unable to bear
weight on the extremity and developed NBNB emesis, subjective
fevers and chills. He presented to ___ ED on ___.
Patient was seen at ___ and found to have elevated
creatinine at 2.1 (baseline normally is 1.8). X-rays performed
were reportedly negative for fracture. RENAL TRANSPLANT U.S. showed Normal renal transplant ultrasound. A few small simple cysts in the
transplant kidney, measure up to 1.4 cm. FEMUR (AP AND LAT) LEFT showed No evidence of fracture, or periprosthetic loosening. KNEE (2 VIEWS) LEFT showed Status post total right knee arthroplasty with recent I&D and liner exchange.
Expected soft tissue postsurgical changes are seen. VENOUS MAPPING FOR DIALYSIS ACCESS showed Cephalic and basilic vein diameters as above. No arterial calcifications
identified. Radiology showed Successful placement of a single lumen 5 ___ PowerLine tunneled catheter
via the right internal jugular venous approach. The tip of the catheter
terminates in the right atrium. The catheter is ready for use. The patient was diagnosed with PYOGEN ARTHRITIS-LOWER LEG, KIDNEY TRANSPLANT STATUS. The patient was treated with Joint Arthrocentesis (___)
Ortho Joint Washout (___). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of multiple L TKR and revisions complicated by
MRSA bacteremia also with ESRD now s/p LRRT presenting with MSSA
septic prosthetic joint and bacteremia now s/p I&D. Course was
complicated by ___.
# SEPTIC PROSTHETIC JOINT/SEPSIS: Joint arthrocentesis WBC >100K
with PMN predominance. Negative crystals. Gram stain was
negative, but grew MSSA in joint and blood. In this patient with
a history of MRSA bacteremia, he was initially treated with
vancomycin/cefazolin for MRSA/MSSA coverage, and was
transitioned to cefazolin when his cultures grew MSSA. Patient
underwent TTE/TEE which were negative for endocarditis. There
was initial concern for seeding of his ortho back hardware and
pacemaker, but TEE and physical exam alleviated these concerns.
His CRP downtrended during hospitalization. He was followed by
Ortho, had joint washout and replacement of liner on ___. He was
followed by ID during hospitalization and planned for 6 weeks of
IV cefazolin (ending ___ All Bcx since those taken in the ED
have been negative. Pt underwent vein mapping ___ to kidney
transplant and poor general access, it showed poor venous access
in the upper extremities b/l, with better access on the Lt UE
that is being preserved in case the patient will require a
fistula for HD. ___ was c/s for PICC placement, they were
concerned about future venous access issues in the Rt UE as
well, so they placed a tunneled central line on ___. ID desired
Rifampin on discharge for better biofilm clearance, but since
patient required Tacrolimus for immunosuppression of his kidney
transplant, due to drug interactions, he will have to wait until
he is switched back to Rapamycin to start Rifampin. ID
recommends 6 months of PO Levaquin and Rifampin after 6 weeks IV
Cefazolin to avoid lifelong suppressive Abx therapy. Pt will f/u
at ___ for ID & Ortho and has OPAT weekly labs. ID will
contact ___ IV team over eventual DC of pt's tunneled central
line when it is no longer needed.
# ESRD s/p RENAL TRANSPLANT: Pt's initial renal transplant U/S
was normal. There was never any tenderness over his graft to
suggest infection. Pt was originally on Rapamycin and
Prednisone for suppression, he was switched to Tacrolimus ___ to
better wound healing after surgery. Tacro levels have been high
during his stay as Renal attempted to optimize his dosing (goal
tacro levels of ___, he is being discharged on 0.5 mg tacro BID
and prednisone 5mg daily. He will f/u with Renal Transplant at
___. Patient will likely need to be transitioned back to
rapamycin in the future.
# ACUTE KIDNEY INJURY: Patient presented with Cr 2.1. Pt's ___
was likely pre-renal given his history of poor PO intake and
labs showing urine sodium < 10, FeNa < 1% and urine osmoles >
500. However, the pt did have mildly active urine sediment with
proteinuria, few RBCs and few WBCs. Renal transplant ultrasound
was normal. Pt's Cr slowly improved to baseline over his
admission (baseline around 1.4-1.7). Cr on discharge 1.4.
Nephrotoxins were avoided and medications were renally dosed
over his admission.
# ATRIAL FIBRILLATION: Pt is on his home metoprolol and
apixaban. Apixaban was held briefly in the setting of his joint
I&D, and was restarted after his surgery
# NORMOCYTIC ANEMIA: His anemia is likely secondary to acute
illness, however there are no priors in ___ system. H&H has
been stable over the admission.
# OSA: Pt wears CPAP o/n w/o issue. No SOB or chest pain
overnight while wearing CPAP. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ male with h/o CAD s/p MI and 5 stents and 7
angioplasties, HTN, HL and mitochondrial disease who presented
from home today after two days of intermittent chest pain and
pressure. Yesterday, pt had sudden onset substernal chest pain
that lasted for about 1.5 hours. It was assoc with nausea and
heaving. Today, pt felt weak and dehydrated. He called his PCP
who recommended that he come to the Emergency Department for
work-up. Of note, patient is to undergo biopsies of tumors in
his legs and has been off Plavix for 5 days. The patient also
has mitochondrial disease that requires him to have regular IV
infusions secondary to dehydration.
.
In ED, inital VS were 98.2 89 150/94 20 98%. When he arrived,
his chest pain returned, and he was diaphoretic and short of
breath. His pain then come down to ___. Labs were remarkable
for Cr 1.5 (baseline 1.2-1.4). Troponin negative X1. EKG showed
sinus rhythm, ST depressions (1mm) laterally. CXR shows no acute
process. Pt was given IVFs, nitroglycerin SL, ASA 325, morphine,
zofran in ED. Vitals on transfer were 88, 160/66, 20, 100 RA,
98.5.
.
On arrival to the floor, pt appears comfortable in bed. Pt
states he is currently chest pain free. Admits to some residual
nausea, but no vomiting. Pt does complain of fatigue, states he
feels like he was "beaten up". Denies fevers. States he was
dizzy when getting up and feels his mouth is dry.
.
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough. Denies
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias. Radiology showed No acute intrathoracic process. The patient was diagnosed with DEHYDRATION, CHEST PAIN NOS. At the time of discharge, the patient had Mitochondrial Myopathy
Coronary Artery Disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old gentleman with ___ CAD s/p MI with 7
angioplasties and 5 stents, HTN, HLD, mitochondrial disease,
admitted with intermittent episodes of chest pressure, with no
EKG changes and three negative sets of cardiac enzymes.
.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Patient is a ___ year old woman who was transferred to ___
from an OSH for a left Subdural Hematoma. Per report she was
assaulted by a punch in the head and then fell striking her head
on the pavement. She initially lost consciousness but was awake
alert and oriented on scene and during transport to the OSH.
While there a CT head was done which showed a acute left
subdural
hematoma with midline shift. As a result of this it was
determined she would be transferred to ___ for further care by
Medflight. Upon medflight arrival she was intubated for airway
protection in the setting of bradycardia. Radiology showed 1. Enteric tube with the tip in the esophagus.
2. Endotracheal tube in satisfactory position.
3. Opacity at the right base is most likely atelectasis.
Results were discussed with Dr. ___ at 5:45 a.m. on ___ via telephone
by Dr. ___ at the time the findings were discovered. Radiology showed 1. Slight interval increase in size of the left cerebral subdural hematoma.
There is likely a small component of subarachnoid hemorrhage, particularly on
the right (2, 41).
2. Increasing mass effect with up to 10 mm of rightward shift of the normal
midline structures and increased compression of the left lateral ventricle.
There is persistent effacement of the basilar cisterns, concerning for uncal
herniation.
3. Slight interval increase in prominence of the right lateral ventricle.
This may represent early entrapment. Close followup is recommended. Radiology showed 1. Satisfactory position of the new right internal jugular central venous
catheter. No evidence of pneumothorax.
2. Unchanged position of the enteric tube with the tip in the distal
esophagus.
3. Improving right basilar consolidation, which is likely atelectasis. Radiology showed Gastric tube ends in the body of stomach with side port near the GE junction
below the diaphragm. Radiology showed Postoperative changes with a decrease in shift of the midline
structures, now 3 mm to the right, and improved patency of the basal cisterns. Radiology showed Status post left parietal craniotomy with postoperative changes. No new
hemorrhage or mass effect. The patient was diagnosed with SUBDURAL HEMORRHAGE, OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEM. The patient was treated with ___ craniotomy for ___ evacuation. At the time of discharge, the patient had Subdural hematoma
Methadone for withdrawal. The patient was given written instructions concerning 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 ___ year old female who was punched on the side
of her head and fell striking her head on the ground. A stat
head CT was obtained after arriving at ___ and showed a left
SDH with an 8mm MLS and poor exam. She was emergently brought to
the OR for a craniotomy for evacuation of her SDH. She was
brought to the neuro ICU for recovery, on post op exam she was
moving all extremities and following commands. She was extubated
and placed on nasal cannula. She was very agitated post
extubation and c/o pain, she was restarted on her methadone and
prn morphine.
On ___, she was awake and pleaseant this morning. Overnight she
had several episodes of trainsiently bradycardia down to the
20's with loss of her blood pressure, but spotaneously self
resolved. Since admission her heart rate as been in the 40's to
50's. Cardiology was consulted and reccomended discontinuing her
Methadone since it could cause QTC prolongation. Cardiology
expects heart rate to improve over the next several days. Later
in the afternoon she complained of severe headaches, dilaudid,
fentanyl and tylenol were given with no relief. A stat head CT
was obtained and it showed a small hyperdensity on the left
crani site with improved pneumocephalus and stable MLS. Chronic
pain is also following patient for pain and methadone
management.
On ___, on exam, L periorbital edema was resolved and she was
seen to have a L ptosis, but was otherwise intact. Ophthalmology
was consulted to rule out orbital injury from trauma and they
felt there was no acute itnervention that was required and
recommended outpatient followup. She was restarted on her
methadone at a lower dose after a stable EKG.
On ___ she remaiend stable and continued to have a elft ptosis.
She was trasnferred to the floor with telemetry and her
methadone was again decreased.
On ___ the chronic pain service was consulted. They recommended
decreasing the Methadone to 80mg daily. An EKG was ordered to
assess QTC interval. The EKG was reviewed by the cardiology
service who recommended discontinuing the methadone because of
increased QTC interval to .48. The Valium was discontinued and
the Methadone was changed to 60mg daily. A PICC line was ordered
due to the bradycardia and potential need for medication access.
On ___, The patients QTC was improved at .46. The patient serum
magnesium was low and repleated with 2 gm Magnesium sulfate. The
chronic pain service consulted and continued to have bradycardia
with heart rate at ___ when sleeping. Chronic pain service
recommended decreasing the methadone to 40 mg po qd and changing
the Dilaudid dosing to ___ mg po q 8 hours. and to repeat the
EKG the following morning. The patient had an ECHO which showed
mild aortic regurgitation with normal valve morphology as well
as mild symmetric left ventricular hypertrophy with preserved
regional and global biventricular systolic function.
On ___, The EKG QTC was stable. Chronic pain felt that the QTC
was stable and her pain/withdrawal was well controlled. She was
discharged to rehabilitation. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo man with a history of seizures after TBI
(gunshot wound in ___, followed by Dr. ___, who
presents for increased seizure frequency. Chest radiograph showed No pneumonia. The patient was diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY. At the time of discharge, the patient had epilepsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old man with history of TBI with
subsequent epilepsy who presented with 2 breakthrough seizures
with secondary ___. Admitted for increase seizure frequency and
AED management.
# Epilepsy:
No inciting factors were found for his breakthrough seizures. ___
was monitored on EEG and ___ had multiple partial seizures. ___
continued his dilantin and zonisamide. His keppra was weaned off
and ___ started oxcarbazepine.
# TBI: Continued home Tizanidine. ___ was seen by psychiatry, who
recommended for his behavior, Ativan 2mg IM/IV for acute
agitation episodes only if agitation rises to level of safety
concern. ___ did not require Ativan during admission.
# Pain: Continued home meloxicam
# GERD: continued PPI
# CV: continued aspirin </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with complex partial and at times secondarily generalised
epilepsy possibly secondary to a TBI age ___ ___
was previously well controlled on lacosamide, phenytoin and
phenobarbital, mild intellectual disability, h/o depression with
psychosis and h/o alcohol abuse presents with increased seizure
frequency after 3 seizures (at least one of these was a complex
partial seizure and report of others was of GTC) today with his
last seizure before this in ___. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY. At the time of discharge, the patient had Primary:
- Seizure 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>ASSESSMENT: The patient presents with breakthough seizures with
a subtherapeutic phenytoin level. He has a past history of
medication non-compliance but states that he has been taking his
correct AED doses. It is unclear how acutely his phenytoin level
has dropped as it was last checked on our system in ___.
# NEURO:
The patient was loaded with IV fosphenytoin with good effect
increasing his PHT level to 25. No further ictal activity was
noted. He will return for labs on ___.
# ID:
No infectious source was identified.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old male, with prior history of
Alzheimers' Dementia, and ___ Disease, who is minimally
verbal at baseline, who presents with increased leg swelling,
nonproductive cough, and an episode of ? chest pain this
morning. Patient is unable to provide medical history, and
history obtained from his wife and step ___. CHEST (PA AND LAT) showed No acute cardiopulmonary process. CHEST (PORTABLE AP) showed Vascular plethora likely due to fluid overload The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. At the time of discharge, the patient had PRIMARY DIAGNOSIS: 1. Viral Upper Respiratory Illness
SECONDARY DIAGNOSES: 1. ___ Disease 2. Alzheimer'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>This is a ___ year old male with past medical history of
Alzheimers Dementia, Parkinsons Disease, admitted ___ with
> 1 week of cough, low-grade fevers, CXR with poor visualization
of lung fields, treated empirically for pneumonia with
improvement and discharged home.
.
>> ACTIVE ISSUES:
# Community Acquired Pneumonia: Patient initially presented with
3 days of non productive cough, initially hypoxic in ED; CXR had
poor visualization of lung fields due to body habitus. Patient
was initially treated with IV Ceftriaxone and Axithromycin for
CAP coverage with subsequent improvement in symptoms. He was
transitioned to PO azithromycin. He had mild wheezing on exam,
so was provided albuterol inhaler with spacer with symptomatic
improvement. Team discussed with family re: his risk of
aspiration, and whether patient would benefit from
speech/swallow consultation. Family decided knowledge of
aspiration would not change their management, and they would
prefer to take home without swallow eval, and continue current
feeding regimen with 1:1 supervision. Risks of aspiration were
discussed with family, and voiced back understanding.
.
# Hyperkalemia: Patient initially found to be hyperkalemic,
unclear origin, without EKG changes. With IVF, patient had
repeat labs checked with normal potassium levels. No clear
offenders as far as medications, or renal disease. ___ have been
result of mild prerenal azotemia.
.
# ___ Disease: Patient continued to be at neurologic
baseline per family, and was continued on carbidop-levodopa.
.
# Depression: Patient was continued on paroxetine.
.
# GERD: Patient was continued on omeprazole.
.
# History of constipation: Patient was continued on outpatient
regimen.
.
# Hyperlipidemia: Patient was continued on simvastatin.
.
# Hypertension: Patient was continued on home atenolol.
. .
>> TRANSITIONAL ISSUES:
# Goals of Care: DNR/DNI.
# Contact Information: ___ (daughter): ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH COPD on ___ (4LNC per nursing ___, obesity
hypoventilation syndrome last FEV1 80%, OSA on BiPAP, morbid
obesity, presenting with malaise and intermittent SOB over the
past several days. Per daughter, nursing ___, has been nauseous
without much of an appetite the past couple of days, and she
endorses this as well. She denies any chest pain, vomiting,
lower extremity edema, abdominal pain. She reports last BM 2
days ago. Denies fevers or chills. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with HYPOXEMIA, NAUSEA, DIABETES UNCOMPL ADULT, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had Obstructive Sleep Apnea. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with PMH COPD on ___, obesity hypoventilation syndrome
last FEV1 80%, OSA on BiPAP, morbid obesity, presenting with
malaise and intermittent SOB over the past several days
presenting with nausea and malaise.
# Nausea, malaise: Patient with loss of appetitie and nausea
without vomiting, diarrhea in the few days prior to admission.
Attributed to a possible mild viral illness but without further
symptoms at this time. No known sick contacts. No evidence of
obstruction. She improved with anti-emetics, PPI dosing and
simethicone.
# Obesity hypoventilation syndrome: Given patient's body
habitus, favor obesity hypoventilation as primary cause of her
chronic hypercarbia and hypoxemia. She uses BiPAP when sleeping,
and has ___ ___ and is currently not requiring any more than
that. Following ICU admission, she was quickly transitioned to
her ___ oxygen regimen. Of note, she admitted that she had not
been using her BiPAP regularly over the past several weeks due
to a poorly fitting, somewhat uncomfortable facemask. She
endorsed the mask that we provided in the hospital was more
comfortable, and that she would use that mask at ___. As such,
she was provided that mask to take ___ with her to endeavor to
optimize her compliance with NIPPV at ___.
# COPD: No evidence of acute exacerbation. Patient is without
cough, wheezing, or change in sputum. No leukocytosis or
radiographic changes to suggest acute pulmonary process to drive
exacerbation. Not unlikely that patient has COPD component to
her respiratory disease, but FEV1 in ___ was 82%, suggesting
restrictive rather than obstructive process even then. No
steroids indicated this admission, we continued her inhaler
medications.
# Constipation: This has previously been an issue during her
hospitalizations. Therefore, aggressive bowel regimen to prevent
this with senna, colace, bisacodyl, lactulose.
# Hypertension: Continued ___ amlodipine, metoprolol and
ramipril.
# CHF: TTE in ___ with preserved EF, likely diastolic
dysfunction. CXR on ___ with fluid overload, but no suggestion
of volume overload this admission. We continued her ___
diuretic.
# Gout: We continued Allopurinol ___ mg PO TID.
# Depression: We continued Bupropion.
# GERD: Continued omeprazole as above.
# Hypothyroid: Continued Levothyroxine Sodium 25 mcg PO daily.
# Transitional Issues:
- repeat CT six months, unless clinical suspicion of possible
extrathoracic primary carcinoma is high enough to merit PET-CT
scanning</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman with history of hypertension, cirrhosis and
pancreatic cyst transferred from ___ for jaundice
and blood stools. Patient presented with 2 days of jaundice and
bright red blood per rectum with bowel movements. DUPLEX DOPP ABD/PEL showed Interval increase in size of pancreatic head/ uncinate process cyst (3.5 to
5.9 cm) with interval intra and extrahepatic ductal dilation consistent with
obstructive behavior (mass effect versus invasion). Given the elevated
bilirubin, elevated CEA from the cystic lesion aspirates back in ___, and
family history of pancreatic cancer, differential includes serous cyst
adenoma/adenocarcinoma and IPMN/malignant degeneration.
RECOMMENDATION(S): GI consult with potential CD stenting vs MRCP or CT
pancreas.
NOTIFICATION: The findings were discussed with ___ and ___
___, M.Ds. by ___, M.D. on the telephone on ___ at
10:45 AM, 30 minutes after discovery of the findings. MRCP showed 1. Large pancreatic cystic lesion in the head and uncinate process with
enhancing pseudoseptations is larger compared to the prior CT scan in ___.
There are additional millimetric cysts scattered throughout the body and tail.
No nodularity or duct dilation. This lesion most likely represents a
side-branch IPMN.
2. Cirrhosis without any evidence of portal hypertension or concerning
lesions.
3. Acute interstitial edematous pancreatitis is likely secondary to recent
ERCP. No peripancreatic fluid collections. The patient was diagnosed with Acute pancreatitis, unspecified, Gastrointestinal hemorrhage, unspecified. The patient was treated with ___ EGD and flexible sigmoidoscopy
___ ERCP/sphincterotomy
___ EUS/FNA of pancreatic lesion. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
1. Obstructive jaundice
SECONDARY DIAGNOSIS:
1. Alcoholic/NASH cirrhosis
2. Internal hemorrhoids
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>___ woman with a history of alcoholic and NASH cirrhosis
(liver biopsy ___, pancreatic head mucinous cyst (found in
___, CEA 385, ___ aborted given nodular liver),
hypertension, osteoporosis, and depression who initially
presented to ___ with jaundice, darker urine, and
BRBPR x 2 days, then was transferred to the ___ ED on ___
with CT findings of new 2.3cm CBD dilatation, dilated pancreatic
duct, and enlarging pancreatic cystic mass.
>> ACTIVE ISSUES:
# Biliary Obstruction:
She presented with new jaundice found to have direct
hyperbilirubinemia. OSH CT scan report was notable for intra and
extra hepatic biliary ductal dilation. Abdominal ultrasound here
confirmed biliary ductal dilation with CBD dilation up to 2.3
cm. This also showed interval increase in size of pancreatic
head/uncinate process cyst, 5.3 x 5.6 x 5.9 cm from 2.6 x 2.7 x
3.5 cm in ___. AFP was normal. CA ___ was elevated at 115. She
underwent ERCP on ___ which revealed a 3 cm tight, distal CBD
stricture with severe post-obstructive dilation. Sphincterotomy
was performed, brushings were obtained of the distal CBD
stricture which showed rare atypical glandular epithelial cells,
and a ___ Fr x 8 cm straight plastic biliary stent was placed
across the stricture. Given rising bilirubin levels post-ERCP,
MRCP was performed on ___ which showed enlarging pancreatic
mass since ___, a side-branch IPMN, and acute interstitial
edematous pancreatitis secondary to recent ERCP. She underwent
EUS with FNA of the pancreatic cystic lesion on ___. Forty cc
of fluid was drained from the pancreatic cyst and sent for
cytology which was pending on discharge. Fluid CEA was 244 and
Amylase was 4205. Her total bilirubin levels were downtrending
and she had improving jaundice, icteric sclera, and sublingual
jaundice prior to discharge.
>> RESOLVED ISSUES:
# Hypotension: Patient initially had BPs to the ___ in the
ED unresponsive to IVF so was admitted to the ICU. Her blood
pressures improved with 2U pRBCs and she did not require
pressors or any additional transfusions. Her hypotension was
felt to be secondary to hypovolemia from blood loss.
# Anemia, Hemorrhoidal Bleeding:
She reported intermittent bright red blood per rectum at home.
She was found to have a drop in Hgb from 11 to 9. She was
transfused 2U pRBC. She underwent EGD and flexible sigmoidoscopy
in the ICU which were notable for portal hypertensive
gastropathy and oozing internal hemorrhoids, not requiring
intervention. She was initiated on IV Pantoprazole 40mg Q12H,
which was transitioned to PO Pantoprazole 40mg QD on discharge.
She continued to have minimal bleeding from her internal
hemorrhoids during this hospital admission, though with stable
Hgb 9 and no additional blood transfusion requirements. She was
started on a hemorrhoidal suppository with good effect.
# Acute Kidney Injury: Patient initially presented with Cr 1.5,
which resolved to 0.9 with intravenous fluids and transfusion of
2U pRBCs. Post-ERCP, she had a Cr bump to 1.4. She received
100g total of 25% albumin on ___, with normalization of Cr to
her baseline of 1.0.
>> STABLE ISSUES:
# EtOH and NASH Cirrhosis:
___ Class B, MELD 10. Patient has biopsy-proven cirrhosis
with a combination of alcoholic (3 glasses of wine/day for 30+
years) and NASH etiology. For volume, the patient had no signs
of ascites and did not receive diuretics. For infection, she was
started on PO Ciprofloxacin 500mg BID x 5 days for
intra-abdominal infection prophylaxis after her ERCP on ___ and
after EUS on ___ (antibiotic course will be complete on ___.
For bleeding, the patient had decreasing episodes of BRBPR
during her admission (please see Anemia, Hemorrhoidal Bleeding
above). For encephalopathy, the patient was alert and oriented
without asterixis and did not receive Lactulose or Rifaximin.
# Coagulopathy:
Patient had a supratherapeutic INR of 1.5 on admission. She
underwent an IV vitamin K challenge with 5mg QD x 3 days with no
change in INR. Therefore her supratherapeutic INR is thought to
be secondary to synthetic dysfunction from cirrhosis.
# Hypertension: Patient's home Verapamil 120mg twice a day,
Valsartan-HCTZ 320-25mg daily, and Atenolol 25mg daily were
initially held in the setting of initial hypotension. BP meds
resumed at discharge with stable Blood pressures.
# Cardiomegaly: Patient has known cardiomegaly on CXR but no
history of heart failure, denying dyspnea and syncope. ___ TTE
showed LVH and "systolic anterior motion of the mitral valve
with significant outflow tract gradient." No history of heart
failure. Can consider cardiac MRI as outpatient to distinguish
hypertensive myopathy from hypertrophic obstructive
cardiomyopathy.
# Osteoporosis: Patient continued taking her home Raloxifene
60mg daily.
# Depression: Patient continued taking her home Escitalopram
10mg daily.
>> TRANSITIONAL ISSUES:
[ ] Repeat ERCP in ___ weeks (___) for removal of PD and
biliary stents and reevaluation: ERCP will contact patient to
schedule follow up
[ ] Repeat CA ___ in 4 weeks.
[ ] Given cardiomegaly, consider cardiac MRI (___) as
outpatient to distinguish hypertensive myopathy from
hypertrophic obstructive cardiomyopathy.
[ ]Follow up pancreatic mass FNA pathology results
[ ]Ciprofloxacin given prophylactically post EUS X 5 DAYS</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant, morbidly obese ___ w/ PMH ___
gastric bypass, opioid abuse, depression who syncopized
yesterday at work. She first noticed decreased peripheral
vision and lightheadedness moments before the event, began
drinking sugared soda to decrease her symptoms, but syncopized
regardless. She awoke surrounded by coworkers and paramedics,
who noted no incontinence, tongue laceration, or ___
confusion. they gave her juice and crackers and her sx abated.
She denied nausea, shaking, or palpitations preceding the event.
Pt declined transfer to medical care and proceeded home w/
boyfriend. ___ sx continued this morning, so she
decided to present to outpatient medical care, where she was
found w/ a [Glu = 65], and her PCP recommended transfer to the
___ ED. During transfer, she received glucose paste, had some
symptomatic relief, but then experienced quick return of
symptoms before arrival to the ED. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. The patient was diagnosed with HYPOGLYCEMIA NOS. At the time of discharge, the patient had Primary:
- Borderline hypoglycemia post gastric bypass
- Morbid obesity
- Candidal dermatitis
Secondary:
- Depression
- Anxiety
- Chronic pain
- Migraine headaches. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ ___ ___ gastric bypass, opioid abuse, depression
p/w recent increased fatigue and found to be hypoglycemic.
# HYPOGLYCEMIA: Likely secondary to recently decreased intake;
pt endorsed trying to reduce "junk foods" immediately prior to
onset of symptoms. HbA1c <6, indicating pt has not developed
DM2. Various endocrine pathologies considered included cortisol
deficiency, insulin antibodies, insulinoma, or ___
hyperplasia secondary to gastric bypass surgery
[nesidioblastosis], which appeared much less likely given
glucose stability in the hospital. AM cortisol WNL. Did not
become hypoglycemic on admission so no labs for insulin,
___, or ___ were drawn.
- STARTED ___ and cyanocobalamin 100 mcg PO/NG DAILY
___ ___ bypass
- Rx given for glucometer, lancets, and testing strips to
monitor FSBG when symptomatic
- Follow up with surgeons for further management of diet, workup
of NIPS
# Contaminated urinalysis: intially treated with nitrofurantoin
for ?UTI, though repeat without epis did not show e/o infection.
# NARCOTICS ABUSE: Lives in sober home. Has not used Percocet in
over one year and has agreements on her ___
medications. No narcotics, muscle relaxants, or benzos in the
house. Ibuprofen 600 mg Q8H:PRN pain.
# DEPRESSION/ANXIETY: H/o. Continue home citalopram 40 mg PO QD.
# MIGRAINES: H/o. Home ___
mg oral TID:PRN migraine, can get one/day here. Ibuprofen 600 mg
Q8H:PRN migraine.
# RIGHT HIP, LEG PAIN: H/o. Has had several imaging studies. No
narcotics, muscle relaxants, or benzos in the house. Ibuprofen
600 mg Q8H:PRN pain.
# CANDIDAL DERMATITIS: Physical exam shows erythematous, itching
rash below pt's inferior pannus. Pt describes long history of
rash, occasionally flaring. Candidal dermatitis thought most
likely given high incidence among obese patients and appearance
of rash. Miconazole Powder 2% 1 Appl TP BID
# TRANSITIONAL ISSUES:
- Dental hygiene is poor, needs f/u with dentistry
- Morbid obesity: needs to see gastric bypass surgeon,
nutrition___
- Blood glucose monitoring supplies given at discharge
- Code: FULL
- Emergency Contact: ___ (dad) ___ and ___
___ (mother) ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ yo male with history of Horner's syndrome
and lead exposure as a child who presented on ___ for
evaluation of nausea and emesis. He had multiple episodes of
emesis on the 2 days prior to admission; worst was the day prior
to admission when he had approximately ___ episodes of
non-bloody, non-bilious emesis. Unable to tolerate PO. Passing
flatus. No history of abdominal surgeries. He stated that this
was consistent with his prior episodes of vomiting. He had
approximately 5 episodes of similar nausea/vomiting over the
past ___ years, all of which seem to be brought on by work stress.
He endorses abdominal cramping earlier today but no abdominal
pain at present. No recent travel or sick contacts. RENAL U.S. showed No hydronephrosis. Mild fullness of the left renal pelvis without
hydronephrosis. 4 mm hyperechogenic focus maybe echogenic vessel wall,
calculus or sinus medullary fat. The patient was diagnosed with Acute kidney failure, unspecified, Vomiting without nausea. At the time of discharge, the patient had PRIMARY
=======
Cyclic vomiting syndrome
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>TRANSITIONAL ISSUES:
-Patient was counseled and given information on stress
management resources.
-Patient was counseled for marihuana cessation
-Will have PCP and GI follow up in the outpatient setting
___ year old male with history of Horner's syndrome who presented
on ___ with intractable nausea and vomiting over previous
several days prior. On admission he presented with ___
(creatinine 3mg/dL) and several laboratory abnormalities
including hyperphosphatemia, hypercalcemia, and hypokalemia.
These all resolved with IV fluids. His nausea was managed with
IV fluid, Ondansetron, and Lorazepam. By the day of discharge he
was able to tolerate oral food and liquids without signs of
dehydration. He met with a social worker and was given stress
management resources. He will follow up with his PCP and GI in
the outpatient setting.
# Cyclic vomiting syndrome
# nausea/vomiting: No reported history of recent ETOH
ingestion. No diarrhea. We could also consider cannabinoid
hyperemesis, given his marijuana use, but his symptoms are
neither relieved nor exacerbated by marijuana. Episodes likely
triggered by increased stressed as every episode he has had has
been during a time of increased stress at work. He was given
bowel rest, antiemetics and IVF with improvement in his
symptoms. He was discharged home with a short course of
lorazepam (10 tabs) and ondansetron. He was counseled to f/u
with his PCP and to contact stress management resources provided
by ___ while inpatient to possibly help prevent further episodes.
# Acute renal failure: also had hyperphosphatemia,
hypercalcemia, and hypokalemia likely in the setting of his ___.
Creatinine on admission was 3 mg/dL. Renal u/s showed a 4-mm
crystal at the calyx, but he denies any dysuria or hematuria.
Repeat labs showed rapid improvement in Cr after IV fluids.
Creatinine 0.7mg/dL on day of discharge.
# Polycythemia (resolved): Due to hemoconcentration given poor
PO intake. Improved to normal after IVF given for hypovolemia in
the setting of nausea/vomiting from likely ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ hx pericarditis c/b pericardial effusion ___ yrs ago (in
the setting of gallbladder surgery) p/w worsening CP and SOB x 6
weeks with worsening over last week and pericardial effusion.
Patient was first diagnosed with pericarditis in the setting of
hospitalization for cholecystectomy ___ years ago. She has since
had intermittent short courses of pericarditis ___ time per
year. In ___, she was hospitalized for pericarditis
with effusion. During that hospitalization she was given a
course of prednisone and started on colchicine. Since then,
patient has had frequent (most days) chest pain and worsening
SOB with exertion. Her exercise tolerance has severely
decreased. She had seen her cardiologist in ___ who
suggested that she follow up at ___ for evaluation with Dr.
___ w/RHC/LHC. She presented to ___ last week when she
got a cardiac MRI (results still pending). Over the last week
she has had increasing amount of pain. On the morning of
presentation she reported her typical left sided pain that was
worse with laying flat and deep inspiration with radiation to
her right side and jaw. This has been worse than before and
promted her to go to OSH for further evaluation. Her SOB and CP
worse with exertion and when lying supine. When walking 400m she
becomes lightheaded and feels like she is going to faint. Last
time she could exercise was 2 months ago (avid runner and
surfer). Denies fevers/ vomiting/ diarrhea/ coughing. Feels
nauseous. States she recently developed PVCs for which she is
taking mag oxide. Denies any joint pain or swelling.
In the ED, initial vitals were 97 80 114/87 14 97% RA Radiology showed No acute cardiopulmonary process. The patient was diagnosed with Chest pain, unspecified, Dyspnea, unspecified. The patient was treated with Cardiac catheterization (LHC/RHC) ___. At the time of discharge, the patient had Primary:
Costochondritis. The patient was given written instructions concerning 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 w/ a hx of pericarditis c/b
pericardial effusion ___ yrs ago p/w worsening CP and SOB x 1 week
and pericardial effusion on echo.
# Chest pain, costochondritis: Pt has reported history of
pericarditis sarting ___ years ago with multiple subsequent
episodes. She presented with chest pain, SOB, and decreased
exercise tolerance for 3 months. She had a cardiac MRI that was
pending from week before discharge that showed small effusion
but no evidence of active inflammation or restrictive heart
disease. She underwent cardiac catherization with right and left
cath which showed no significan CAD and normal filling
pressures. Her left sided chest pain was reproducible on exam on
presentation. She was started on indomethacin with improvement
in her pain. Pain is likely musculoskeletal with costochondritis
most likely. She is being discharged on NSAID regimen.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ male with history of
non-insulin-dependent diabetes complicated by neuropathy and
necrotizing fasciitis of his right foot ___ ___ who
presents for evaluation of fevers and worsening left foot
pain. Patient is known to have a left diabetic foot wound that
is
currently being managed by Dr. ___ with collagen and
calcium alginate. 4 days ago, the patient noted significant pain
and swelling around the site of the wound. He states he has been
having intermittent fever since that time. Today, the
patient had a temperature to 102.1. Patient notes pain up to
his ankle, but denies any extension of his leg. Patient was
evaluated ___ the ED by podiatric surgery was determined to have
soft tissue gas extending to the dorsal midfoot. Due to his
systemic symptoms, elevated white count, and gas on x-ray,
patient was taken urgent to the OR for an incision and drainage
w/ radical debridement to soft tissue and bone. Patient will be
admitted to the podiatric surgery service and further managed.
Patient seen at bedside ___ PACU resting comfortably. Tolerated
anesthesia well. Micro and path sent from OR. Admits to ___
pain
to his L foot at this time. Denies any n/v/f/c/sob. Radiology showed There has been transmetatarsal amputation of the left forefoot. There is
overlying soft tissue swelling and bandaging material which limits fine bony
detail. No acute fractures are seen. There is a prominent inferior calcaneal
spur. DX CHEST PORTABLE PICC LINE PLACEMENT showed Right-sided PICC line terminates in the right atrium, although exact position
is difficult to estimate. If positioning at the cavoatrial junction is
desired, recommend withdrawal by 3 cm.
Low lung volumes and mild cardiomegaly, new from ___. The patient was diagnosed with Necrotizing fasciitis. The patient was treated with ___: DEBRIDEMENT LEFT FOOT DOWN TO AND INCLUDING BONE, TOTAL
AREA DEBRIDED = 84sq.cm. OPEN RAY AMPUTATIONS ___ & ___ TOES,
LEFT FOOT
___: INCISION AND DRAINAGE LEFT FOOT MULTIPLE SPACES BELOW
FASCIA/FASCIOTOMY, EXCISION OF EXTENSOR TENDONS, ___ METATARSAL
OPEN BONE BIOPSY
___: TRANSMETATARSAL AMPUTATION, LEFT FOOT APPLICATION OF 4
BY 5 INTEGRA GRAFT LEFT FOOT ACHILLES TENDON LENGTHENING, LEFT
FOOT. The patient was given written instructions concerning 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 podiatric surgery team. The patient was found
to have a necrotizing infection of the left foot and was taken
to the operating room immediately on ___. Afterwards, he was
admitted to the podiatric surgery service. For full details of
the procedures, please see the separately dictated operative
reports.
The patient was taken from the OR to the PACU ___ stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor for further management with packed-open
wound. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet by POD#1. On
POD2, ___, he was taken back to the OR for an incision and
drainage.
On ___, he was taken back for a definite left
transmetatarsal amputation, percutaneous tendo Achilles
lengthening with Integra graft to the dorsal foot. He was placed
___ a posterior splint and the dressing was left intact until
POD2, ___.
Initially, he was managed on IV Vancomycin, Metronidazole and
Clindamycin. Infectious Disease evaluated him and recommended a
final home course of 2 grams IV Ceftriaxone daily as well as PO
Flagyl through ___ (3 weeks from last surgical date). He
will have weekly surveillance labs (CBC/Diff, Cr, CRP, LFTs)
drawn weekly and sent to the Infectious Disease office. After
the three weeks of antibiotic treatment and final pathology
results are reviewed, the need for continuation of antibiotic
therapy will be reassessed.
Physical therapy was consulted. The patient worked with ___ who
determined that discharge to home was appropriate. The patient's
home medications were continued throughout this hospitalization.
The ___ hospital course was otherwise unremarkable.
The patient was given anticoagulation per routine for each
procedure and while an inpatient. 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 NWB to the LLE lower extremity. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y/o female with a PMHx of diastolic heart
failure and sick sinus syndrome who is presenting from her
assisted living facility with altered mental status. Her
daughter notes that she has had a worsening mental status over
the last 6 weeks, with a more acute decline over the last
several days. She was recently seen at her PCP's office for
worsening ___ edema L > R. She had a fever prior to that visit
which resolved with Tylenol but has not had any fevers since
then. Her home torsemide was increased. A b/l ___ ultrasound did
not show DVT (___). Blood work at that time had a WBC of 22
(baseline ___ and stable kidney function with Cr 1.1
(baseline 0.9-1.1). CHEST (PORTABLE AP) showed Worsening moderate right pleural effusion with adjacent atelectasis. Probable
effusion on the left. Underlying infection cannot be excluded in the
appropriate clinical setting. Radiology showed Successful placement of a right 39 cm basilic approach double lumen PowerPICC
with tip in the distal SVC. The line is ready to use. Radiology showed There are low lung volumes with bilateral effusions. There is mild pulmonary
edema. Left-sided dual lead pacemaker is identified.There is a new right-sided
PICC line with the distal lead tip in the distal SVC. Consolidation at the
right base would be difficult to exclude due to the pleural effusion. Radiology showed No acute fractures or dislocations are seen. There is severe medial
compartmental joint space narrowing which causes varus alignment of the left
knee. There is soft tissue swelling throughout the lower leg. No soft tissue
gas is seen.There is no periostitis to indicate acute osteomyelitis. CHEST (PORTABLE AP) showed Allowing for technical differences, there has been no significant interval
change. The patient was diagnosed with Altered mental status, unspecified. The patient was treated with ___ PICC placement. The patient was given written instructions concerning 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/ dCHF, HTN, prolapsed bladder with pessary, and Afib c/b
SSS s/p PPM who presented with altered mental status, initially
admitted to the MICU for sepsis, thought to be secondary to a
LLE cellulitis. She was treated empirically with Vancomycin ___ - ___ for which a PICC was placed. Following IV
fluid resuscitation, she was subsequently hypoxic, with labs and
exam consistent with acute decompensated heart failure. She was
diuresed with IV Lasix, after which she was resumed on home
torsemide. Given persistent leukocytosis, pessary was removed on
___ due to concern for infection. She will be discharged home
with a foley and will follow up with OBGYN for further
management of her pessary. Pt is ambulatory at baseline and
therefore would benefit from d/c to ___
rehabilitation to maximize functional potential and facilitate
return to PLOF. Family's wishes are for pt to return home with
increased support services.
# ACUTE METABOLIC ENCEPHALOPATHY:
Patient presented with progressive decline over last 6 weeks,
with acute worsening in days leading up to admission. Of note,
she was septic secondary to a LLE cellulitis and was found to be
in decompensated heart failure, which may have caused a
metabolic encephalopathy. CO2 normal on admission. No focal
neurologic deficits. She was initially admitted to the MICU due
to hypotensions requiring pressors. Once blood pressure was
stabalized, patient transferred to the floor on ___. Upon
arrival to floor, patient was alert, but not oriented to place
or time. Per her nursing age, her baseline was much better. She
was treated with Vancomycin IV for 7 days, and white count was
monitored closely. Also monitored for other infections, as
below. Sedating medications were avoided. At time of discharge,
patient is sleepy, but able to wake up. She is oriented to
person, place, and year.
# SEPSIS, LIKELY SECONDARY TO LLE CELLULITIS:
On admission, patient had bilateral lower extremity edema, with
redness, warmth, and erythema in LLE. WBC 30. Was admitted to
MICU, and treated with Vancomycin IV. Persistent leukocytosis is
concerning for another source of infection. Was briefly on
pressors for hypotension. Once blood pressure stabalized off
pressors, patient was transferred to floor on ___. Due to
persistently elevated white count, other infection was
considered. ___ CXR showed possible pneumonia. ___ plain
films tib/fib showed no signs of osteomyelitis. Consulted OB/Gyn
due to concern for pessary infection; appreciate their recs.
OB/GYN removed pessary on ___. Patient also received
Fluconazole for yeast infection. Wound care was consulted for
leg wound, appreciate their recs. Patient completed 10 day
course of Vancomycin (___). C dif was sent, but patient
has not been having diarrhea. At time of discharge, patient has
been afebrile and leukocytosis is downtrending.
# CHF:
Chronic, but with worse B/L ___ edema on exam. BNP ___ on
___, elevated from prior. Was taking Torsemide 20PO BID at
home, had recently changed to Torsemide 40PO qAM. Was net -400
in ICU, so basically euvolemic. Was actively diuresed with Lasix
160mg IV BID until patient received dry weight on ___. Was
placed back on home Torsemide 40mg daily.
# AFIB WITH SSS S/P PPM:
Metoprolol was fractionated to 50mg q6 originally, then switched
to home 200mg daily. On ___, she had episode of RVR with HR
130s, stable BP and subsequently remained rate controlled.
Patient is currently home Metoprolol 200mg daily and Apixaban 5
mg PO/NG BID. Heart rate upon discharge were stable in ___.
# HYPERTENSION:
Home antihypertensives originally held in the setting of sepsis
and subsequent diuresis, however, resumed prior to discharge.
Continued home Pravastatin 20 mg PO. Upon discharge, patient is
normotensive.
TRANSITIONAL ISSUES
- PESSARY REPLACEMENT: Patient has follow up with OB/GYN on
___ for pessary replacement. She will bring pessary to this
appointment.
- FOLEY CATHETER: Foley will remain in place until pessary is
replaced; after which, a voiding trial should be attempted.
- She was actively diuresed and subsequently discharged on home
torsemide; Cr with mild elevation to 1.3 upon discharge; Please
repeat BMP on ___ to ensure stable Cr and fax results to ___
___ at ___.
- Trend weights; further adjustments of diuretic regimen
deferred to PCP </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with a history of hypertension,
hyperlipidemia, chronic back pain who presents with back pain.
Patient states that since her fall 1 month ago she has had
chronic neck pain but now radiating throughout her entire back
and today started radiating to bilateral upper extremities.
States it acutely worsened today which is what her brought her
into the emergency room. She denies chest pain, shortness of
breath, abdominal pain, nausea vomiting, change in bowel or
bladder habits, weakness in the upper or lower extremities. Radiology showed 1. While no definite acute fracture is identified, the presence of a joint
effusion raises concern for a radiographically occult radial head fracture.
2. No dislocation.
3. Mild to moderate degenerative changes in the elbow. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. Prevertebral edema spanning from the levels of C2-C6, new as compared to CT
cervical spine ___. MRI cervical spine is recommended for further
characterization as these findings can be seen with ligamentous injury.
2. No acute fracture or change in alignment. Mild anterolisthesis of C3 over
C4 is unchanged as compared to CT cervical spine ___.
3. Moderate to severe multilevel degenerative changes of the cervical spine,
most severe at C4-C5 and C5-C6 with associated mild spinal canal narrowing at
those levels.
RECOMMENDATION(S): MRI of the cervical spine without intravenous contrast.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 4:33 pm, minutes after discovery of the
findings. CT T-SPINE W/O CONTRAST Q321 CT SPINE showed No acute fracture or malalignment. CT L-SPINE W/O CONTRAST Q331 CT SPINE showed 1. No new fracture or malalignment.
2. Subacute to chronic minimally displaced right L1 through L4 transverse
process fractures and right posterior twelfth rib are unchanged in alignment
as compared to CT torso ___.
3. Moderate multilevel degenerative changes of the lumbar spine, most severe
at L4-L5 and L5-S1.
4. Small disc bulges at multiple levels of the cervical spine, most severe at
L4-L5 and L5-S1, where there is mild to moderate spinal canal narrowing. MR ___ SCAN WITH CONTRAST ___ MR ___ SPINE showed 1. Prevertebral soft tissue fluid from C2 through C6 with suspected tears of
the anterior annulus fibrosus and perhaps the anterior longitudinal ligament
at C3-C4 and C5-C6.
2. Moderate multilevel degenerative disc disease, most pronounced at C4-C5 and
C5-C6.
3. Mild anterolisthesis of C3 on C4. The patient was diagnosed with Cervicalgia. At the time of discharge, the patient had #Acute on chronic back pain
#Lumbar radiculopathy
#UTI
#HTN. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old woman with PMHx of HTN, lumbar radiculopathy,
constipation, and hearing loss presenting with acute on chronic
back pain with radiation into bilateral upper extremities.
# Acute on chronic back pain
# Lumbar radiculopathy
Patient had an MRI 1 month ago after a fall which showed
moderate canal narrowing but no evidence of cord compression and
she has had continuous back pain since that time. On this
admission she presented with worsening of pain and radiation
into the bilateral arms. CT of the C/T/L spine showed no acute
abnormalities but chronic disease (see attached reports). As the
CT ___ showed some edema, MRI was obtained which did not
show any cord compression or acute ligamentous injury. CK
normal. Ortho was consulted and recommended soft collar. Her
pain resolved on her home medication regimen and she was
discharged in stable condition for follow-up.
#UTI
Found to have preliminary urine culture with E. coli, pending
sensitivities. In the setting of a limited history of symptoms
due to memory, the patient was started on a 5-day course of
Ciprofloxacin (END ___ for UTI. Follow-up final urine
cultures. Of note, her foley was discontinued and she was noted
to void spontaneously before discharge. Monitor for signs of
urinary retention.
#R Elbow XR findings:
Some concern for R elbow effusion on plain film. Given
resolution of pain and low likelihood of fracture, recommend
follow-up R elbow XR in 4 weeks.
#Anemia:
Iron studies as attached, with elevated ferritin and decreased
Fe/TIBC. Consider Fe repletion or further workup in the
outpatient setting.
# HTN: continued amlodipine 2.5 mg daily
# CAD: continued ASA 81mg and atorvastatin 40mg daily
# Osteoporosis: continued MVI, calcium, and vitamin D,
alendronate qweekly
# Esophagitis: continued sucralfate 1 gm PO BID
TRANSITIONAL ISSUES:
- Reassess need for soft collar pending improvement in pain, low
threshold to discontinue if not helping or no longer needed
- Started on a 5-day course of Ciprofloxacin (END ___ for
UTI.
- Follow-up final urine cultures.
- Monitor for signs of urinary retention (voiding well at
discharge).
- Recommend follow-up R elbow XR in 4 weeks.
- Consider Fe repletion or further workup of anemia in the
outpatient setting.
#CODE: DNR/DNI based on MOLST in OMR from ___
#CONTACT: ___
Relationship: Step Son
Phone number: ___
Cell phone: ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ dementia (nonverbal at baseline) sent in by PCP after
reporting ___ recent unwitnessed fall. History is obtained from
review of prior records, ED notes, and limited discussion with
pt's husband by phone overnight, whose primary language is
___. Radiology showed Focal opacity at the right lateral costophrenic angle which could be due to
atelectasis in the setting of low lung volumes though infection would be
possible in the proper clinical setting. Radiology showed No fracture. CT HEAD W/O CONTRAST showed 1. Severely motion limited examination.
2. Within limits of study, no intracranial hemorrhage or acute fracture
detected.
3. Severe frontotemporal and generalized atrophy, progressed from ___.
4. Paranasal sinus disease, as described. CT C-SPINE W/O CONTRAST showed No cervical spine fracture. No traumatic malalignment. The patient was diagnosed with Pneumonia, unspecified organism, Urinary tract infection, site not specified. At the time of discharge, the patient had Urinary tract infection
Aspiration PNA
Fall
Advanced dementia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>A/P: ___ w/ dementia (nonverbal at baseline) sent in
by PCP after reporting ___ recent unwitnessed fall, found to have
possible RLL infiltrate concerning for aspiration PNA and UTI
# UTI: Urine Cx was positive for Klebsiella and pt was treated
with
levofloxacin and completed a 5 day course prior to discharge.
# Possible Aspiration PNA: Pt had minimal cough and normal O2
sats.
Pt was seen by speech/swallow who recommended a ground dysphagia
diet with
thin liquids. There was no witness aspiration events and pt was
assisted with meals.
Pt was treated with a 5 day course of Levofloxacin.
# Fall: EKG reassuring and unable to obtain additional history
given baseline mental status. No associated trauma on films.
Husband
has noticed generalized weakness over the last few days. TSH
reassuring and this was felt likely related to UTI. Pt was seen
by ___
who recommended temporary SNF for rehab.
# Dementia: Pt has advanced dementia with frontotemporal
wasting. Pt
is followed by Dr. ___ who has been adjusting meds
recently.
She has a stereotyped behavior of tachypnea with pursed lip
breathing
when distressed that seems to resolve when pt is comfortable
and/or needs addressed.
Buspirone was started recently and was not felt to be helping,
this was
discontinued per Dr. ___. Pt was continued on home regimen of
Lorazepam 0.5mg qam, Alprazolam 0.5mg qhs, Donezepil 5mg and
Seroquel 100mg BID.
Pt has outpatient f/u scheduled with Dr. ___ in ___.
# Nocturnal polyuria: prescribed desmopressin for
nocturnal polyuria - will continue but trend Na daily
# FEN: Adv ground diet with thin liquid per speech
# Prophylaxis: Heparin sc
CODE: DNR/DNI - confirmed with HCP husband at bedside, ___
interpreter present
Dispo: likely SNF in ___ days.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with C1 and C2 fractures seen on CT of
c-spine in addition to increased atlanto-dental interval,
basilar invagination, likely chronic findings. No midline
tenderness. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Unstable fracture of the C1 arch and fractures of the C2 vertebral body
with extension to the bilateral transverse foramina as noted on the prior
dedicated cervical spine CT examination. There is probably moderate central
canal at C1 level. There is mild narrowing of the left vertebral artery
secondary to the left transverse foramen fracture fragment, though there is no
evidence of underlying vascular injury.
2. Bilateral scalp hematomas, as previously described, without underlying
calvarial fracture.
3. No intracranial hemorrhage or large acute territorial infarct.
4. Patent intracranial vasculature without significant stenosis, occlusion, or
aneurysm formation.
5. Otherwise patent cervical vasculature without significant stenosis,
occlusion, or dissection.
6. Scattered peribronchovascular ___ nodularity, nonspecific, which
may reflect infectious or inflammatory etiology.
7. Few small thyroid nodules, should be benign. Suggestion of exophytic 1.0
cm thyroid nodule, versus less likely parathyroid adenoma, clinically
correlate. TRAUMA #3 (PORT CHEST ONLY) showed In comparison with the study of ___, there is increased
opacification along the left lateral chest wall, which was considered
consistent with chronic pleural thickening and calcifications on the recent CT
study. The left lower lobe opacity interpreted as round atelectasis or
scarring is not as well identified as on the CT. As recommended on that
study, dedicated nonemergent CT is recommended within 3 months to evaluate
stability or resolution. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No intracranial hemorrhage or mass effect.
2. Moderate bilateral posterior scalp hematomas with a laceration and small
amount of subcutaneous emphysema on the left. No definite underlying
calvarial fracture.
3. Right arch of C1 appears to be fractured, which will be specifically
evaluated on the dedicated cervical spine CT from the same day. This is
unstable.
4. Probable sequelae of chronic small vessel ischemic disease.
5. Cortical atrophy. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. Unstable C1 fracture of the right C1 ring. There are fractures of the
bilateral lateral aspects of the C2 vertebral body with extension to the
transverse processes with extension to the transverse foramina. Associated
prevertebral soft tissue swelling. CTA is recommended to evaluate for injury
to the vertebral arteries.
2. Anterior subluxation of C1 vertebral body relative to the dens an widening
of the left lateral atlantodentals interval concerning also for ligamentous
disruption. MRI could be performed to further evaluate.
3. Bilateral minimally displaced C2 fractures extending into the neural
foramina. CTA is recommended to evaluate for injury to the vertebral
arteries.
4. Lucent lesion at the tip of the clivus could be a fracture fragment.
5. Multilevel degenerate changes of the cervical spine with mild
retrolisthesis of C4 on C5 and C5 on C6 which could be degenerative; however,
trauma cannot completely be excluded. MRI could further evaluate.
6. Spinal canal and cord is not well assessed on this exam. MR could be
performed to further evaluate.
7. Secretions in the partially imaged upper esophagus places the patient at
risk for aspiration.
8. Tiny right thyroid hypodensity, too small to require dedicated follow-up
in a patient of this age.
RECOMMENDATION(S): 1. CTA to evaluate vertebral arteries.
2. MRI to further evaluate ligaments and spinal canal/cord. This could also
for her assess possibility of injury to the clivus.
NOTIFICATION: The findings and impression as well as images were reviewed
and discussed in person by ___ with Dr. ___ on ___ at
1:10 ___, less than 1 minutes after discovery of the findings.
The findings and recommendation for CTA were also discussed via telephone by
___ with Dr. ___ on ___ at 420 pm, minutes after
discovery of the findings.
Recommendations for CTA again discussed with ___ on the telephone
at ___ pm on ___. Per our discussion, patient cannot get MRI due to
pacemaker. They will get a CTA now. ED Trauma torso showed 1. No evidence of acute fracture in the torso.
2. Trace left nonhemorrhagic pleural effusion. Pleural thickening with
calcifications suggesting chronic process. Associated left lower lobe opacity
could be rounded atelectasis and/or scarring, although underlying lesion
cannot definitely be excluded in the absence of prior exams. Dedicated chest
CT non emergently is recommended within 3 months to evaluate stability and/or
resolution.
3. Moderate to large L4-L5 disc herniation, along with other degenerative
changes resulting in severe spinal canal stenosis.
4. Small right gluteal soft tissue contusion/ecchymosis.
NOTIFICATION: The findings, images, impression, and recommendation were
discussed in person by ___ with Dr. ___ on ___ at
1:10 ___, 1 minutes after discovery of the findings. The patient was diagnosed with Laceration without foreign body of scalp, initial encounter, Fall (on) (from) unspecified stairs and steps, init encntr. At the time of discharge, the patient had C1/C2 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. ___ is a pleasant ___ year old female who was
transported to ___ ED on ___ from home by ambulance after a
fall down her cellar stairs, found to have cervical spine
fractures at C1 and C2.
#c1/c2 fracture
She was admitted to ___ service under Dr. ___. She was
initially placed in a c-collar, but this was cleared per Dr.
___ the nature of the fractures and no posterior
midline tenderness. Her neurologic exam remained intact. CTA of
the neck was negative for vascular injury. No operative
intervention was indicated.
#Pain
She developed increased left side skull pain radiating to jaw
and head, and her pain regimen was adjusted with little
improvement. Pain service evaluated her for further
recommendations. New regimen with Tylenol, PO morphine,
tizanidine, and gabapentin was initiated with good pain control.
She was discharged home with Tizanidine, Tylenol, and
gabapentin.
#Anticoagulation
Patient has a pacemaker and h/o Afib, and takes Coumadin at
home. This was initially held, but restarted when determined no
OR will be needed. Coumadin was restarted at home dosing and INR
was 3.0 at discharge. She will continue to follow up with her
PCP for monitoring.
#Hyponatremia
The patient was noted to be hyponatremic during admission and
treated with sodium chloride tabs, which were able to be weaned
to 1g daily at discharge. Her PCP ___ continue to monitor.
She was evaluated by physical therapy, who cleared her for
discharge home on ___. Pain was well controlled on PO regimen,
she was ambulating, and tolerating PO diet prior to discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of polycystic kidney disease presenting for
left
flank pain. Patient originally presented 2 days prior, and at
that point his symptoms included back pain that was midline
around the lumbar region radiating to both sides and not
associated with any neurological symptoms and no concern for
acute spinal cord syndrome. Patient had a CT abdomen pelvis at
the time to rule out any other abdominal causes of his pain,
which was significant only for known polycystic kidney disease
and constipation. He was given an enema and laxative and had a
bowel movement, which relieved his symptoms. He was discharged
home. He then developed more left-sided flank pain. The pain is
sharp, exacerbated by breathing, exacerbated by moving around,
not associated with any numbness, weakness, numbness, tingling,
changes in urination. Is localized to the left flank. Patient
has
not had any bowel movements, including diarrhea since his
discharge. RENAL U.S. PORT showed Large bilateral polycystic kidneys, without hydronephrosis. CT scan of the abdomen and pelvis without intravenous contrast showed 1. No evidence of mechanical bowel obstruction.
2. Grossly stable appearance of polycystic kidneys, within the limitations of
an unenhanced study.
3. Moderate pericardial effusion, similar to previous.
4. Stable interstitial changes at the lung bases. The patient was diagnosed with Polycystic kidney, unspecified. At the time of discharge, the patient had PRIMARY:
Flank Pain
Constipation
Polycystic Kidney Disease
Chronic Kidney Disease Stage V
SECONDARY:
Benign Prostate Hyperterophy
Chronic obstructive sleep disease
Hyperlipidemia
Gout
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>PATIENT SUMMARY
================
Mr. ___ is a ___ w/ PMHx of polycystic kidney disease and
probable RCC, CKD stage 5 with left AV fistula, BPH s/p TURP,
COPD, s/p upper
lobectomy presenting with constipation and L flank pain, likely
in the setting of gastroparesis (nausea, vomiting, constipation)
and heavy renal cyst burden (abdominal pain).
ACUTE ISSUES
=============
#Flank pain: Mr. ___ presented with multiple day history of
L-sided abdominal pain, worse with inspiration, that was
intermittent and "sharp" in nature. He also had chronic
constipation, and developed nausea/vomiting while hospitalized.
Underwent a CT on ___ which showed a 1cm increase in R kidney
size and 3mm increase in L kidney size, however no acute
findings to explain his symptoms. Admission renal ultrasound was
without hydronephrosis or obstructing stone. He developed
vomiting on ___, and as such had a repeat CT A/P that did not
demonstrate bowel obstruction. Overall, his symptoms seemed most
likely related to dysmotility (given chronic constipation and
h/o polycystic kidney disease), recurrent pain from cyst burden
iso PKD (pain worsened with increase intraabdominal pressure),
and potentially a musculoskeletal etiology given worsened pain
with palpation of the paraspinal muscles. Was thought to be less
likely to represent intermittent SBO (given no e/o obstruction
on repeat CT A/P), ruptured renal cyst (no free fluid on renal
ultrasound), or nephrolithiasis (no hematuria and no e/o on CT
A/P or renal US). Given concern for gastroparesis, we trialed
Metopclopramide 10mg TIDWM, which reduced his abdominal pain. We
aggressively and successfully treated his constipation during
his hospitalization.
# Polycystic kidney disease and
# CKD: As above, appears to have stable disease. Creatinine has
slowly increased over time, consistent with CKD. We continued
his home Sodium Bicarbonate, Sevelamer, Calcitriol, and
Torsemide.
CHRONIC ISSUES
===============
# BPH s/p TURP: Continued home Finasteride and Torsemide
# COPD: Continued home albuterol, advair, and supplemental O2
(goal SO2 88-92%)
# HLD: Continued home atorvastatin
# Gout: Continued home allopurinol
# HTN: Continued verapimil
TRANSITIONAL ISSUES
====================
[ ] Consider restarting home Verapamil after PCP follow up if
needed for HTN management
[ ] We are working on scheduling an appointment with Dr. ___.
Please call your PCP's office if you have not heard back by
___. You should be seen within 1 week.
[ ] An appointment was scheduled with Dr. ___ to discuss GI
dysmotility related to end stage renal disease and chronic
constipation on ___ at 1:30pm
[ ] New medications: Simethicone 120 mg PO/NG QID:PRN gas
[ ] Patient was encouraged to continue bowel regimen: Colace,
senna, miralax, bisacodyl, suppository and linzess. Home
lactulose was continued as well, though it may be contributing
to abdominal discomfort. Would consider substituting if felt
appropriate.
[ ] Changed medications: Allopurinol to 100mg PO daily (given
kidney function)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year-old healthy man presenting after syncopal
event at the ___ earlier this evening. He was sitting,
and reached below his seat to pick something up when he felt a
severe sharp pain in his right shoulder. He became dizzy and
sweaty, felt like he was going to pass out, so he put his head
between his legs. The next thing he remembers he woke up, and
felt slightly disoriented. Per his wife, he was out for ___
secs. He lost bladder function but had no witnessed shaking or
tongue biting, and no loss of his bowels. He denies any
preceeding CP, palpitations, SOB, cough, N/V. He had been
sitting in the shade, had one beer. Has had good PO intake.
Hasn't passed out since he was a child. Regarding the shoulder
pain, it was located over the anterior shoulder is a discreet
spot, he did not have any pain over the chest.
.
In the ED initial vitals were 96.8, 96, 137/77, 18, 100% on 2L.
ECG showed sinus tachycardia with isolated TWI in lead III and
J-point elevation in V2-V4. He was given 325mg and 2L NS. Labs
unremarkable, trop neg. CXR unremarkable. VS prior to transfer
were 98.0, 92, 121/77, 16, 100%RA.
.
Currently, he is comfortable and has no complaints. He has had
no further shoulder pain.
.
ROS: As noted in HPI. In addition, denies fevers, chills,
headaches, vision changes, cough, abdominal pain, nausea,
vomiting, diarrhea, constipation, melena, hematochezia, dysuria,
or hematuria. Radiology showed No acute chest abnormality. The patient was diagnosed with SYNCOPE AND COLLAPSE, ABNORM ELECTROCARDIOGRAM. At the time of discharge, the patient had Primary Diagnosis:
1. Neurocardiogenic (vasovagal) syncope
.
Secondary Diagnoses: None. The patient was given written instructions concerning 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: ___ with no significant past medical history who
presented following a syncopal episode at a baseball game.
PLAN:
# SYNCOPE - The patient leaned down and reached with his right
arm under his chair and turned his neck inciting sharp pain
without radiation of the right arm while at a baseball game.
Following sitting up he experienced lightheadedness and
dizziness with resulting syncope for ___ sec of LOC following
that. No head trauma or injury. Wife confirms his story. Some
mild bladder incontinence, but this can be seen with
neurocardiogenic syncope. Certainly seizure episode is of
concern given the bladder incontinence, but patient has no
strong family history and no prior seizure episodes. Similarly,
laboratory data reveal no metabolic derangements. He also had no
post-ictal concerns, no paralysis and no tongue biting. A TIA or
stroke is of slight concern in a male with a family history of
cardiac disease, obesity and some hyperglycemia on laboratory
data (without HTN, HLD, diabetes history). He has no focal
neurologic deficits or weakness and no carotid bruit on exam. A
posterior circulation TIA could present with a drop attack and
these symptoms, but again less likely. In terms of cardiac
etiologies, his EKG was reassuring with an isolated TWI in lead
III and sinus tachycardia with mild J-point elevation. He does
have family history of MI in his father, but again no documented
HTN, HLD, or diabetes is noted. Cardiac biomarkers reassuring in
the ED (two-sets) and no chest pain or trouble breathing. CXR
was also negative in the ED. He had no arrhythmia documented on
overnight telemetry and has no family history of sudden cardiac
death or early MI. Hypoglycemia unlikely in this patient.
Overall, this leaves a vasovagal episode (neurocardiogenic)
occurring in the setting of sharp and precipitous pain in the
right shoulder that resulted in hypoperfusion, inciting syncope.
He has had no issues similar to this previously. Of interest,
prior to discharge, his peripheral IV was removed and he
developed sinus bradycardia to 30 bpm with mild hypotension and
lightheadedness that rapidly improved, consistent with
neurocardiogenic syncope. An EKG was reassuring. He was
monitored on telemetry through the afternoon and was discharged
in stable condition.
# RIGHT SHOULDER PAIN - Currently pain free, with complete ROM
of shoulder. No history of trauma. Unclear precipitant though
may have been a muscle strain or outpatient brachial plexus
impingement or transient 'stinger'. No RUQ pain to suggest GB
pathology. We encouraged range of motion exercises and possibly
outpatient physical therapy evaluation
# HYPERGLYCEMIA - No prior history of diabetes or strong family
history. No HTN, HLD reported. Patient has evidence of obesity.
He presented with elevated serum glucose and glucosuria. Will
need outpatient fingerstick rechecked and HbA1c, blood pressure
monitoring and fasting lipid panel as an outpatient.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ yo right handed woman with a history of
HTN, HLD, and stroke in ___ who presents after being found down
at home. This morning her niece heard a thud and found the
patient on the floor in the bathroom. She was lying on her side
with eyes closed. Both her arms and legs were shaking and she
appeared to be having a seizure. Niece denied noticing gaze
deviation. It is unknown if she was incontinent. Her face was
bleeding. She was breathing. The niece called ___ and an
ambulance was sent. The niece believes the seizure activity
lasted <5 minutes and was over by the time of EMS arrival, but
she is unsure. Per their report, the EMS crew was dispatched at
08:39, arrived 10 minutes later, and "observed brief period of
seizure activity w/trismus airway and pupils deviated to the
left." CT HEAD W/O CONTRAST showed 1. No acute intracranial abnormalities.
2. Chronic appearance of infarctions involving the right occipital lobe of and
left centrum ovale, new since ___.
3. Left frontal face soft tissue swelling without underlying fracture. CT C-SPINE W/O CONTRAST showed 1. No acute fractures or traumatic malalignment.
2. Likely degenerative anterolosthesis of C7 over T1.
3. Moderate to severe degenerative changes of the cervical spine as noted
above. MRI and MRA Head, MRA of the neck. showed 1. No definite evidence of acute ischemic changes. Several foci of high
signal intensity are demonstrated in the subcortical white matter as described
bed, suggesting T2 shine through effect from prior ischemic changes
demonstrated on ___. Gyriform hyperintensity is demonstrated in the
right occipital lobe suggestive of pseudo laminar necrosis, related with
chronic infarction as described above.
2. Prominent ventricles and sulci suggesting cortical volume loss, confluent
areas of high-signal intensity in the subcortical white matter are nonspecific
and may reflect changes due to small vessel disease.
3. Arthrosclerotic changes are demonstrated left middle cerebral artery and
posterior cerebral arteries with mild segmental narrowing. No aneurysms are
identified. Radiology showed Atelectasis at the left lung base. No focal consolidation. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. Mild lower extremity soft tissue edema is noted. The patient was diagnosed with Epilepsy, unsp, not intractable, with status epilepticus. 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>Ms. ___ is a ___ F with a PMHx of HTN, HL, and
stroke (___) who presented after a fall at home and 3 events
concerning for seizure. On exam, she had facial bruising and was
initially obtunded with less movement of her left size. Her CT
and MRI brain did not show any evidence of new strokes or
hemorrhage, and her CT c-spine did not show any fractures or
acute injury. The following morning, she was alert, following
all commands, answering questions appropriately, and had fluent
speech. Additionally, her left-sided weakness had resolved.
Overall, our impression is that she seizures, and her old stroke
was the seizure focus. The obtundation was likely secondary to a
post-ictal state as well as the receipt of benzodiazepines. The
left-sided weakness was likely due to recrudescence of old
stroke symptoms or a ___.
She was started on Keppra 500mg BID. Her EEG showed evidence of
intermittent right posterior slowing and bitemporal slowing, but
there were no further seizures. She initially failed a bedside
swallow evaluation, but she passed a formal swallow evaluation.
She was continued on fall, seizure, and aspiration precautions.
Her LFTs, utox, stox, UA, and CXR were normal. ___ Dopplers
obtained for ___ swelling were also normal. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Radiology showed Stable small right sided pleural effusion. Radiology showed 1. No evidence of aortic aneurysm or any other acute intrathoracic or
intra-abdominal process. Please note that aortic dissection cannot be excluded
on the basis of this study.
2. Stable moderate nonhemorrhagic right-sided pleural effusion.
3. Nonunion of left pubic ramus fracture.
4. Chronic conditions include cholelithiasis, scoliosis, severe degenerative
changes of the lumbar spine, coronary artery atherosclerosis, and hiatal
hernia.
If clinical concern for aortic dissection is high, a thoracic MRA should be
pursued for further assessment. Communicated to Dr ___ telephone on
___ at 9:20 am by Dr ___ Radiology showed No relevant change from study 10 hours prior. Stable small right
pleural effusion. Radiology showed 1. No pulmonary embolism, acute aortic process, or ischemic colitis.
2. Distended gallbladder with small pericholecystic fluid and cholelithiasis.
This appearance may be related to a third-spacing state, but given the
suggestion of hyperemia of the liver adjacent to the gallbladder fossa and a
possible cystic duct stone, symptoms should be correlated clinically regarding
acute cholecystitis. If indicated, HIDA scan may be obtained for further
evaluation. US may assess for a possible cystic duct stone.
3. Moderate right pleural effusion, trace left pleural effusion, and trace
perihepatic and pelvic fluid.
4. Large fecal load.
5. Increased displacement of left inferior and superior pubic ramus fractures
without significant interval bony callus formation. All visualized right ribs
remain fractured.
6. Moderate-sized hiatal hernia
Findings were discussed by ___ with Dr. ___ via phone call
on ___ at 1730 pm. Hypercarbic respiratory failure.
COMPARISON: ___ chest radiograph and CT torso.
AP radiograph of the chest
Heart size and mediastinum are grossly stable. Interval increase in right
pleural effusion is suspected, although in part it may be related to different
character of that study being semi-erect as opposite to portable study on the
prior examination as well as more symmetric and not rotated image acquisition.
Left retrocardiac opacity might reflect area of atelectasis, slightly worse
since prior examination. It also might be due to large hiatal hernia.
Infectious process, developing in this location would be another possibility. was done. Central venous line placement.
Portable AP radiograph of the chest was reviewed in comparison to ___, obtained at 05:47 a.m.
The ET tube tip is approximately 5.2 cm above the carina. The right internal
jugular line tip is at the mid low SVC. Heart size and mediastinum are
grossly unchanged in appearance. Right pleural effusion is enlarged,
unchanged since the most recent prior. Small amount of left pleural effusion
is most likely present. Cardiomediastinal silhouette is stable. was done. The patient was diagnosed with ABDOMINAL PAIN EPIGASTRIC, CHEST PAIN NOS. The patient was treated with ___: Laparoscopic cholecystectomy - Dr. ___
___ of Present Illness:
Patient is an ___ year old male with multiple medical problems
including CAD s/p CABG in ___, prostate cancer s/p xrt and HLD
presenting to the ED with abdominal pain. Patient has been in
the
ED for greater than 12 hours when our service was consulted. Per
preexisting reports by emergency department patient presented
with epigastric pain versus chest pain and was ruled out for an
MI. He continued to have back pain as well as epigastric pain
thus the CTA of the torso was obtained to rule out aortic
dissection. Patient underwent a non-contrast CT scan prior to
the
CTA. He continued to have some abdominal pain versus discomfort
and received a total of morphine IV 15 mg by the time ACS
surgery
was called to examine the patient.. At the time of discharge, the patient had Acute Cholecystitis s/p Laparoscopic Cholecystectomy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ who presented to the ___ ED complaining of
lower abdominal pain. He was worked up for MI in the ED and
eventually underwent a CTA of his torso which demonstrated
possible cholecystitis. He became increasingly tachycardic and
hypotensive during his ED course and was started on levophed
prior to admission to the MICU. A right IJ was placed in the
ED.
After further evaluation, Mr. ___ was taken to the OR for
laparoscopic cholecystectomy, which he tolerated without
difficulty. He was admitted to the TSICU postoperatively for
hemodynamic monitoring given his initial decompensation in the
ED.
On ___, Mr. ___ was noted to be increasingly hypercarbic and
had a significant respiratory acidosis, and was intubated. He
required levophed with propofol, both of which were weaned off.
His ventillator support was weaned.
On ___ He was transferred to the floor and advanced to a
regular diet. On ___ his foley was discontinued and he voided.
His platelets were shown to be trending down at a nadir of 49 so
a HIT panel was sent, heparin was stopped and fondaparinux was
restarted. His antibiotics were also changed to po augmentin.
His Blood cultures grew back pansenstive Ecoli so we continued
him on that regimen. He was also shown to be fluid overloaded,
without respiratory compromise so we gave him 10 Iv lasix, which
he responded well. His home meds were also restarted. On ___ he
was dischrged home on PO augmentin. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with a history of
recently-diagnosed Burkitt's lymphoma, a PTLD status post renal
transplant in ___ who prsented to clinic on ___ for day #14
of his first cycle of EPOCH and was found to have bandemia and
dyspnea on exertion. History is obtained from the patient as
well as oncology note in ___. He reports an episode of night
sweats the night before admission which soaked his sheets but
denies fever or chills. He felt well until he walked down the
stairs in the morning and then felt short of breath. This was
not associated with any chest pain, chest tightness, associated
naisea, diaphoresis, lightheadedness, or dizziness. He does
endorse bilateral clavicular pain which he says is common with
neupogen. He denies orthopnea, weight gain, ankle swelling, or
PND. He notes a slight cough the morning of admission with some
white sputum. His daughter has a sore throat, but he does not
feel a sore throat, sinus pain, or rinorrhea. He has missed 2
doses of Lovenox because he was waiting to have his platelet
count checked. Radiology showed 1. No evidence of pneumonia.
2. Small left pleural effusion. The patient was diagnosed with NEUTROPENIA, UNSPECIFIED , LYMPHOMA NEC UNSPEC SITE, HYPERTENSION NOS, DIABETES UNCOMPL ADULT. At the time of discharge, the patient had atypical chest pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ man with a history of renal transplant
in ___ and newly diagnosed burkitt's lymphoma who presented on
cycle 1, day 14 of EPOCH chemotherapy with an episode of mild
cough and dyspnea on exertion.
.
#Dyspnea on exertion: Pt has atyical mild chest "pressure" w/
walking down the stairs, which he says was different from his
prior episodes of stable angina. Significantly, he has a history
of clincally diagnosed PE/DVT ___ (no CTA was done given his
baseline renal insufficiency and renal transplant) and has been
on treatment with enoxaparin. There is no significant historical
or physical change to suggest that his cardiac function has
changed from Echo preformed about 2 weeks prior to admission. MI
was ruled out with unchanged ECG relative to baseline and
negative troponins. Pt was started empirically on levofloxacin
for atypical PNA or tracheobronchitis given normal appearance of
chest film w/ only small L pleural effusion. Although he had
leukocytosis this was most likely due to his use of filgrastim
just prior to admission for neutropenia. He remained afrebrile
throughout his stay. He had a V/Q scan done, which showed no
evidence at all of a pulmonary embolism. By the evening of
admission, Pt stated that he felt completely well and had no
symptoms whatsoever. His ambulatory O2 saturation was 97% on
room air. His is unlikely to have any a true pneumonia or
bronchitis, and his antibiotics were discontinued on discharge.
.
# Leukocytosis - most likely due to Pt's use of filgrastim just
prior to admission for neutropenia. This was discontinued given
current WBC counts.
.
# Coronary artery disease status post CABG in ___ and DES; vein
graft in ___. Pt was ruled out for MI (see above). Pt was
continued on his home beta blocker and statin w/out issue.
# Diabetes type 2, complicated by retinopathy and neuropathy.
70/30 insulin BID and sliding scale as per home med.
#End-stage renal disease status post renal transplant in ___.
Continued home tacrolimus, level appropriate at 5.9, avoid
nephrotoxins. Continued home ACE-I and prophylactic bactrim
w/out issue.
# Peptic ulcer disease - continued home PPI</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ with afib recently off ___,
dCHF, HTN, CKD, alzheimer's dementia, schizophrenia, OCD,
depression, who presents after routine lab draw showed H&H of
23.7/6.9, decreased since ___ when HCT was ___. Per
record she may have had a RBC transfusion in the last week.
Denies bloody/black stools, hematuria, emesis,
CP/dyspnea/fatigue. She lives at ___
___. where her ___ and aspirin have been held since recent
admission to ___ where she was admitted ___ f
for hypoxia ___ aspiratoin PNA and possible pulmonary edema
treated with vanc/zosyn. Pro BNP was 6k, diuresed with IV lasix
until she no longer required o2. She was also in the ICU with
afib with RVR started on a dilt gtt then converted to PO dilt,
still with a rate in the 110's-120's so she was dig loaded and
started on 0.125 daily. However she was discharged off dig and
dilt with a plan to reintroduce toprol if HR uncontrolled. Radiology showed Hyperinflated lungs with evidence of biapical scarring, which
most likely relate to COPD. Large hiatal hernia. No focal consolidation. The patient was diagnosed with ANEMIA NOS, ATRIAL FIBRILLATION, GASTROINTEST HEMORR NOS. At the time of discharge, the patient had PRIMARY
Anemia
Atrial fibrillation with rapid ventricular response
Hypotension
SECONDARY
Schizophrenia
Dementia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with a history of rheumatic heart disease s/p AVR/MVR in
___, Afib on Coumadin, and CKD previously on HD (baseline Cr
1.2-1.6) who presents from nursing home with 5 days BRBPR and
dyspnea.
# Anemia: Patient was transferred from rehab to ___ ED for Hct
drop found at rehab. Repeat Hct in ___ ED was 27.5, showing
stable anemia from prior ___ ___ admission
(Hct ___ for GIB thought ___ to ___ tear.
Throughout this admission, patient was monitored and without
signs of active bleeding. Hct remained stable and was 27 at the
time of discharge. Most likely diagnosis is chronic blood loss
from low-grade GI bleed. Differential also included B12
deficiency (on B12 IM), and myelodysplastic
syndrome/myelofibrosis. Patient will need outpatient Hematology
and Gastroenterology follow-up 1 week after discharge for
further work-up and management of anemia.
# Potential GI Bleed: Patient had a recent admission to ___.
___ ___ for a concern of GI bleed thought ___
___ tear. Upon current presentation to ___ ED,
patient was found to have guaiac=positive stool. Throughout the
rest of the admission, the patient was without evidence of
active bleeding. Anemia was managed and monitored per above.
She will need outpatient GI follow-up for consideration of
EGD/colonoscopy.
# Atrial Fibrillation with Rapid Ventricular Response: During
___ ___ admission, patient received
diltiazem intravenously and orally and digoxin with good hear
rate response but was discharged off all rate-controlling
medications and anticoagulation in the setting of potential
bleed. Upon current presentation to ___ ED, digoxin was
started at 0.125mg daily and metoprolol was started and titrated
to 25mg BID based on blood pressure and heart rate. Heart rate
improved from 140s in ED to 80-100s at the time of discharge.
Her heart rate will need to be monitored as an outpatient.
Aspirin 325mg daily was initiated for anticoagulation, CHADS
score 1.
# Hypotension: Patient developed intermittent asymptomatic
hypotension on ___ and ___ to systolic blood pressure ___,
thought to be a combination of hypovolemia from decreased PO
intake and uptitration of beta blocker. Beta-blocker was
down-titrated (see above) and patient was administered 1 liter
of IV fluids, with stable blood pressure ranging systolic
110-120s at the time of discharge.
# Renal Insufficiency: Patient with unknown baseline renal
function. Creatinine was monitored and improved from 1.4 on
admission to 1.2 at the time of discharge, which was consistent
with recent baseline from rehab laboratory values.
# Thrombocytosis: Patient was found to have thrombocytosis to
platelet count of 600-700k during this admission. Differential
included reactive process vs. myelofibrosis. The patient needs
outpatient Hematology follow-up for further management and
work-up of thrombocytosis.
# Chronic Diastolic Heart Failure: Patient remained without
evidence of decompensation during this admission. She was
started on a beta-blocker per above.
# Schizophrenia, depression, OCD: Patient was continued on her
home psychiatric regimen including trazadone and fluvoxamine.
===================================
TRANSITIONAL ISSUES
===================================
MEDICATIONS
- STARTED Metoprolol tartrate 25mg BID
- STARTED Digoxin 0.125mg daily
- STARTED Aspirin 325mg daily
- STOPPED Potassium supplementation
FOLLOW-UP
- Repeat CBC in on week ___ to assess for stability of
anemia.
- Please monitor digoxin level and for signs of toxicity
- Please monitor patient's heart rate and ensure well-controlled
at 80-100
- Please down-titrate metoprolol to 12.5mg BID if blood pressure
is found to be sBP<90.
- Hematology follow-up needed in 1 week. Appointment needs to be
scheduled, ___ Hematology Department phone number provided.
- Gastroenterology follow-up needed in 1 week. Appointment needs
to be scheduled, ___ Gastroenterology Department phone number
provided.
OTHER
- Please continue goals of care discussion with patient's
gaurdian</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female with PMH significant for
ER+/PR-/HER2+ left ductal BrCa on anastrozole, brain lesions s/p
resection of right frontal lesion and prior CK, large left
occipital cystic lesion, recent grand mal seizure associated
with ICH, recent admission for focal seizure and
post-obstructive pneumonia, who presents with concern for
recurrent seizure. CHEST (PA AND LAT) showed No significant interval change in the right hilar mass with postobstructive
changes in the right upper lobe superimposed pneumonia cannot be excluded.
Postsurgical changes in the left chest. MRI CERVICAL AND THORACIC PT21 MR SPINE showed 1. Enhancing lesions in the T9 and T10 vertebral bodies concerning for
metastatic disease without significant vertebral body height loss,
retropulsion or soft tissue component. No evidence of leptomeningeal
enhancement or focal lesions in the cervical spine.
2. STIR signal abnormality along the anterior inferior endplates of T4 and T5
without corresponding abnormal enhancement may be related to degenerative
marrow changes.
3. Mild multilevel cervical and lumbar spondylosis without significant spinal
canal stenosis and mild neural foraminal narrowing bilaterally at C5-C6 as
detailed above.
4. New small bilateral pleural effusions when compared with the prior CT chest
from ___ and partially visualized airspace disease and pulmonary
nodules. Known right perihilar mass is better evaluated on prior outside
hospital CT chest of ___.
5. Partially visualized known enhancing cerebellar mass.
PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal, height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
___, et all. Spine ___ 26(10):1158-1166
Lumbar spinal stenosis prevalence- present in approximately 20% of
asymptomatic adults over ___ years old
___, et al, Spine Journal ___ 9 (7):545-550
These findings are so common in asymptomatic persons that they must be
interpreted with caution and in context of the clinical situation. The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus. At the time of discharge, the patient had Recurrent Focal Seizures
Post-Obstructive Pneumonia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female with PMH significant for
ER+/PR-/HER2+ left ductal BrCa on anastrozole, brain lesions s/p
resection of right frontal lesion and prior CK, large left
occipital cystic lesion, recent grand mal seizure associated
with ICH, recent admission for focal seizure and
post-obstructive pneumonia, who presented after 3 self-limited
episodes of left hand focal motor seizures, now initiated on
Keppra (from Topamax) and completed antibiotic treatment for
pneumonia.
TRANSITIONAL ISSUES
===================
[ ] Please continue to monitor for seizures on new AED regimen,
Keppra 1 g BID.
[ ] Recommend continued follow up with Dr. ___ your
seizures and brain lesions.
[ ] Recommend continued follow up with Dr. ___ your cancer
care.
[ ] Patient was offered home ___ services, but declined. She
would benefit from physical therapy if she is amenable.
[ ] She will complete 7 day course of antibiotics with augmentin
on the evening of ___. The final dose will be given prior to
discharge.
ACTIVE / ACUTE ISSUES
=====================
#Focal motor seizure
#Brain metastases
Presents with 3 self-resolving episodes of LUE twitching without
LOC or post-ictal state. There was family report of concern for
cyanosis. No ___ involvement or incontinence. Neurology consulted
in ED, suspect current seizures may be arising from prior R
frontal resection bed given seminology. She was recently
admitted with similar complaints, for which topiramate was
uptitrated to 100 mg BID. Seizure threshold may have been
lowered by concurrent antibiotic therapy. Imaging from most
recent admission with stable findings. Topiramate stopped and
Keppra 1000mg BID started. Has not had involuntary movements
since admission. Will continue levetiracetam 1000 mg BID on
discharge. There was no indication to pursue EEG.
#Ataxia
#Lower extremity weakness
She was noted to have left leg weakness and associated ataxia,
despite ___ motor strength testing on her neurologic exam while
in bed. MRI C/T spine was pursued. Final read pending at time of
discharge, however it was reviewed by attending
neuro-oncologist, Dr. ___ did not find any acute change
to account for her symptoms. Her symptoms improved and she was
evaluated by physical therapy. They felt she would benefit from
home ___, however she declined at this time. She was provided
with information for local ___ and ___ services and she will
pursue these in the outpatient setting on an as needed basis.
#R hilar mass
#Post-obstructive pneumonia
She presented on most recent admission with DOE, cough and
hypoxia found to have post-obstructive changes consistent with
pneumonia. She was discharged on levofloxacin/flagyl with plans
for 7 day course to complete ___. Given concern for
levofloxacin reducing the seizure threshold, she was
transitioned to doxycycline in the ED. She received 5 days of
atypical coverage before admission. Given QTc 512ms, will
complete course with Augmentin through ___ to complete 7 day
course.
#Non-gap metabolic acidosis
#Respiratory alkalosis
HCO3 14 with Cl 109. VBG with pH 7.39/pCO27 suggesting likely
respiratory compensation for metabolic acidosis. She has a
chronic component to non-gap metabolic acidosis, potentially
worsened by topiramate administration which can be associated
with decreased serum bicarbonate. Topiramate was discontinued
and her chemistry panel was trended daily.
#Metastatic HER2+ Breast Cancer
Followed by Dr. ___ T4N2M at diagnosis with
infiltrating, left ductal HER2+ BrCa. Prior treatment has
included taxol/Herceptin, followed by anastrozole/Herceptin and
most recently anastrozole monotherapy due to transaminitis. She
was lost to follow up in ___ after PET scan showed
worsening mediastinal and lung metastases. Upcoming plan was for
cyberknife with Dr. ___ to L occipital cystic lesion followed
by likely consent for study protocol ___ (HER-2 antibody
conjugate). She underwent MRI and CK planning with plans to
initiate CK on ___. She was continued on anastrozole 1 mg PO
daily. Drs. ___ were updated throughout the
admission.
CHRONIC ISSUES
==============
#Thrombocytopenia
Chronic, baseline 100-120. Currently at baseline. CBC was
trended daily.
#Hypothyroidism
Continued levothyroxine 100mcg daily.
#Hypertension
Lisinopril held on prior admission, Continued to hold as she is
normotensive.
#HCP/CONTACT: ___ (husband), ___
#CODE STATUS: Full, presumed</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx of Hodgkin's disease s/p chemo w/recurrent perirectal
abscesses since ___, fistula in ano now ___ s/p ___,
drainage of posterior midline abscess, ___ placement x2.
Patient intially was diagnosed with perirectal abscess when he
presented to ED ___ with perirectal pain, chills after MRI
showing perirectal abscess which was I+D'd at the bedside by
our service and was discharged home after 1 day observation. He
represented to ED 2 days later with fevers with what appeared to
be a well drained abscess however with continued fistula. He was
admitted, started on antibiotics with marked improvement. He was
discharged home the next day, and subsequently underwent an
elective ___, drainage of the posterior midline small abscess
pocket and 2 ___ placements. He tolerated the procedure well
and was discharged home the same day after an uneventful
recovery. MRI of the Pelvis showed Large ischioanal fossa abscess dissecting into the muscle fibers of the
external sphincter and the left puborectalis muscle, without extension into
the supralevator space. Two setons, one in the low sphincter at 6 o'clock
which is primarily surrounded by granulation tissue, and one in the
subcutaneous fat of the left gluteal cleft, which has a small amount of
surrounding fluid. Neither are in direct connection to the large abscess.
Short blind ending intersphincteric tract arising from the tract with the
___. No other fistula is identified. The patient was diagnosed with ULCERATIVE ILEOCOLITIS. The patient was treated with ___, abscess drainage, ___ placement. At the time of discharge, the patient had Perirectal abscess. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ underwent an ___, drainage of perirectal abscess and
placement of 2 setons on ___ after presenting with urinary
retention and being found to have lateral, anterior, posterior
and deep extension of his perirectal abscess. He tolerated the
procedure well with no complications. He was started on
Augmentin postop and this was continued for a 14 days course
total. A foley catheter was left in postop due to his urinary
retention but it was removed on POD#1 and he was voiding. His
diet was appropriately advanced as tolerated. His pain was
controlled on oral meds. He was deemed fit to discharge home on
Augmentin for 14 day course. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: History of Present Illness: Ms. ___ is a ___ woman
who was in her usual state of health until 2 weeks ago when she
started to notice progressive right-sided and central chest pain
which is typically worse with movement. She had run a mini
triathlon prior to this and thought that she may have provoked
an episode of costochondritis which she has had in the past. She
visited her PCP office and had temporary relief with pain
medication but noticed progressive worsening of pain and dyspnea
which prompted her to re-present to another provider at her PCP
office. She had an x-ray of her sternum which did not reveal
anything abnormal and was treated as though she had
costochondritis. Because of worsening symptoms and concern over
her heart she presented to the ___ ED. CHEST (PA AND LAT) showed Bilateral pneumonia right greater than left CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Moderate layering pleural effusions with lower lobe consolidation
concerning for pneumonia.
3. Pericardial effusion, small to moderate.
NOTIFICATION: The updated findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 6:58 ___, 5 minutes after
discovery of the findings. The patient was diagnosed with Pneumonia, unspecified organism, Pleural effusion, not elsewhere classified. The patient was given written instructions concerning 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 w/ a PMH of ___ and
multiple recurrent episodes of chest pain attributed to
costochondritis who presented with worsening dyspnea and chest
pain for over 2 weeks prior to admission with 2 episodes of
night sweats and a non-productive cough, febrile to 100.5 in ED,
with significant leukocytosis with CTA chest revealing bilateral
pleural effusions and consolidations consistent with CAP.
#Pneumonia. Pt presented with leukocytosis to 28.5 with
associated fever to 100.5 in the ED. CTA showed pleural
effusions R>L with a consolidative process c/f pneumonia.
Presentation was c/w community acquired PNA. Pleural effusions
are likely reactive ___ PNA and less likely ___ autoimmune
process given ___ weakly positive (1:40) and negative dsDNA,
also less likely malignancy. No c/f TB given no symptoms of
weight loss/hemoptysis and no exposure hx or travel to endemic
areas. Leukocytosis down-trending with antibiotics. Patient
initially treated with ceftriaxone/doxycycline out of c/f
tick-borne illness however given negative Lyme, transitioned to
augmentin/azithromycin for PO regimen 5 days total. Ambulatory
sat was 94% at time of discharge. Of note, interventional
pulmonology was consulted and the decision was made not to do
thoracentesis given small size of effusion on US and therefore
high risk for pneumothorax and patien'ts clinical improvement.
#Elevated ESR/CRP. Despite low c/f autoimmune process as primary
pulmonary process, significantly elevated CRP/ESR (greater than
expected for PNA) and history of
___ costochondritis was concerning.
Would recommend reechecking ESR/CRP after resolution of
pneumonia, consider sending RF, anti-CCP, C3/C4 as outpatient if
ESR/CRP persistently elevated or new sxs develop consistent with
rheumatologic disease.
#RUQ tenderness: Likely ___ rib pain from pleural effusion R>L.
LFTs notable only for elevated AlkP/GGT which is likely acute
phase reactant.
#Pericardial Effusion: Noted on CTA in ED. TTE ___ showed
trivial/physiologic pericardial effusion, thus low c/f
development of tamponade.
#Proteinuria. Resolved. Kidney function normal throughout stay,
BUN/Cr ___ on admission. U/A in ED showed proteinuria (also
hematuria possibly contaminant from menstruation). Repeat U/A on
___ showed no proteinuria or hematuria.
#Anemia: Guaiac in ED was negative and hemolysis labs were
negative. Fe studies c/f AOCD. H/H improving during admission to
___ on ___, though per ___ ___ atrius records she did not
have anemia.
#Coagulopathy. INR 1.4 on admission, improved to 1.2 on ___
#Thrombocytosis. Likely acute phase reactant
#Seasonal affective disorder. Pt was continued on home
fluoxetine </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with stage IV NSCLC adenocarcinoma with mets to brain
and bone who presents to the ED with left shoulder pain. Radiology showed Acute pathologic fracture of the left humeral neck. Radiology showed Bilateral lower extremity thrombosis as described above.
dw Dr. ___ at 9.30 am by Dr. ___. Radiology showed 1. New elevation of the left hemidiaphragm raises concern for phrenic nerve
palsy. Fluoroscopic or ultrasound evaluation recommended.
2. No evidence of pneumonia or congestive heart failure. The patient was diagnosed with PATHOLOGIC FX HUMERUS, MAL NEO BRONCH/LUNG NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with regional nerve block
regional nerve catheter pump placement. At the time of discharge, the patient had Primary: Left humerus pathological fracture
Secondary: ___
Bilateral DVTs. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF CLINICAL SUMMARY:
___ yo M with stage IV NSCLC adenocarcinoma with metastatic
lesions to brain and bone, who was admitted with a new
pathologic left humerus fracture. The patient completed a
5-episode radiation therapy protocol, with course complicated by
L arm pain that was refractory to large amounts of narcotic
medications. The patient had a brachial plexus block and
catheter placement by anesthesia/pain medicine, with good
effect. The patient was discharged home with the peripheral
catheter nerve block, with infusion support services. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ G2P0 at 31w5d by LMP c/w ___ US transferred from ___ ED
with abdominal pain. Patient reports that at 0200, she was
awakened from sleep with acute onset of colicky LLQ/flank pain.
The pain was initially ___ occurring every few minutes. She
took Tylenol and Pepcid without any relief. The pain intensified
around 0330 to ___ and was radiating to lower midline pelvis.
Presented to ___ ED. SVE performed there revealed closed
cervix/50% effaced/-3 station. RENAL U.S. showed Normal renal ultrasound. Specifically, no evidence of hydronephrosis or
nephrolithiasis. The patient was diagnosed with Oth pregnancy related conditions, third trimester, 31 weeks gestation of pregnancy. At the time of discharge, the patient had pregnancy at 31w6d
flank 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>Ms. ___ was admitted to the hospital with acute onset
colicky LLQ pain concerning for nephrolithiasis or preterm
contractions. She had a U/A that was within normal limits and a
renal ultrasound that showed no evidence of hydronephrosis or
nephrolithiasis. A workup including vaginal cultures and urine
culture were all negative.
She was observed and did not have any contractions, vaginal
bleeding, or rupture of membranes. Her pain resolved by HD#2.
After a period of observation, she was deemed stable for
discharge home with precautions. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ hx of ESRD s/p transplant ___ years ago c/b by BK viremia,
that is being managed with sirolimus/prednisone with her last BK
VL in ___ was >400,000 who is referred in for worsening
creatinine found on routine labs. She denies fever, chills, CP,
SOB, n/v/d/c, rash, dysuria. She endorses some foot swelling b/l
that she reports comes and goes chronically. She reports feeling
well overall. Radiology showed Ultrasound guidance for percutaneous right lower quadrant transplant kidney
biopsy. RENAL TRANSPLANT U.S. showed 1. Modestly increased resistive indices are now mildly elevated, with
unchanged waveform morphology.
2. Normal renal morphology without evidence of hydronephrosis or perirenal
collection. Radiology showed 1. No evidence of a perinephric hematoma around the transplanted kidney. No
retroperitoneal hematoma.
2. Small amount of nonspecific simple free fluid in the pelvis.
3. Atrophic native kidneys with multiple simple cysts.
4. Cholelithiasis. The patient was diagnosed with Acute kidney failure, unspecified. The patient was treated with Kidney biopsy ___. At the time of discharge, the patient had Primary Diagnosis:
Acute kidney injury - BK nephropathy
Hyponatremia
Secondary Diagnosis:
Diabetes mellitus, insulin dependent. The patient was given written instructions concerning 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 now ___ years s/p LURT who presents
with acute allograft dysfunction in the setting of worsening BK
viremia despite relatively low-dose immunosuppression. She has
no signs of overt bacterial infection, volume depletion, or
evidence of urinary obstruction which would explain her
worsening creatinine. Thus, the most likely causes are worsening
BK nephropathy versus rejection.
#***Please note: after patient was discharged, notified by
infection control that patient's roommate for <24 hours on
___ was found to be FluA positive***
#Acute renal failure- BK virus versus rejection
- Biopsy done ___ showing BK nephropathy
- Hold ASA, NSAIDs for biopsy; no anticoagulation or
antiplatelets for ___ days starting ___
- Hold lisinopril
- Dose medications for GFR < 10 ml/min
#Immunosuppression: Decreased home sirolimus and prednisone in
setting of BK nephropathy.
- Sirolimus 1.5mg and prednisone 4mg to be titrated by
outpatient transplant nephrology.
#Prophylaxis:
- Held TMP/SMX in setting ___ with hyperkalemia. No need for
PJP coverage at this time and was held on discharge.
- continued home vitamin D</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ with no significant PMHx who presents with
syncope. She states that she was eating dinner at a restaurant
when she began to feel lightheaded and nauseous. She then had a
witnessed syncopal event which lasted about 30 seconds.
Reportedly HR was in ___ (there was an MD at dinner with her who
checked her pulse). Per report, no seizure like activities. When
she woke up, she did not feel confused but did feel very
nauseous and weak. She then felt like she needed to go to the
bathroom. She fainted again while walking to the bathroom with
her sons and was seated in a chair. She states that while she
was in the chair, still unconscious, she had a bowel movement.
She then woke up and threw up many times. No head strike or
fall. She regained consciousness, but continued to feel weak and
was very sweaty. No tongue biting or confusion to suggest
post-ictal state. She had 2 glasses of wine with dinner.
She denies recent fever, chills, chest pain, shortness of
breath, palpitations, abdominal pain, diarrhea, melena,
hematochezia, urinary symptoms. No confusion, dysarthria. She
states that her dizziness resolved by the time she came to the
ED.
Patient had a similar episode ___ years ago. She fainted at her
son's house after feeling very dizzy. She had a facial
laceration at that time. She was admitted to ___ for
workup and she reports that workup was normal. She states that
she was diagnosed with vagal syncope. She states that she had a
stress test and ?CTA neck at that time.
In the ED, initial vitals:
97.8 64 86/61 16 100% RA
- Labs notable for: normal CBC, K 3.2, normal LFTs, trop neg x1
and lactate 3.4.
EKG: sinus, TWI I, II, aVL, V2-V6, no STE, NANI
- Imaging notable for: CXR normal.
- Patient given: 1L NS, Zofran, 324mg ASA. KCl 40mEq ordered,
not given.
On arrival to the floor, pt reports that her sons feel like the
food "didn't sit well" with them. She states that she feels
"practically" at her baseline. No palpitations, recent illness.
She has never had syncope with activity. She states that she
continues to feel "queasy". Also states that multiple people who
were at the dinner with her also now feel nauseous.
She states that she used to faint "a lot" when she was a
teenager and always had very low BP. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. The patient was diagnosed with Syncope and collapse. At the time of discharge, the patient had Primary diagnosis: vasovagal syncope. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with a PMH of vasovagal syncope who presented after an
episode of syncope.
#Vasovagal syncope:
Patient felt lightheaded and nauseous immediately prior to
episode of syncope. Regained consciousness briefly and began
walking to bathroom when she lost consciousness again; she was
seated in a chair and had a BM. When she regained consciousness,
she threw up several times and felt nauseous, weak, and sweaty.
Denied head strike, tongue biting, post-ictal confusion.
Patient's nausea and weakness subsided after she arrived at
___. Etiology of syncope thought to be vasovagal possibly
secondary to gastroenteritis or viral etiology given dehydration
(lactate 3.4 on presentation), vomiting, diarrhea. Other
possible etiologies include arrhythmia (pulse of 40 could
suggest bradycardia) or atypical angina equivalent. ED EKG
showed NSR with T wave inversion in leads I, II, avL, V2-V6, no
ST changes. Reassuringly, previous EKGs from years past had also
been notable for T-wave inversions. The patient also has a
history of negative stress test (___) and negative carotid
ultrasound. The patient was monitored on telemetry and no
arrhythmias were noted. Her symptoms completely resolved. Urine
and blood cultures showed no growth to date.
# Diffuse T wave inversion
Likely chronic given report of nonspecific T wave abnormality
during ___ admission in ___. Possible diagnoses
includes physiologic precordial t wave inversion, memory t
waves, type II demand ischemia, and LVH (given mild concentric
LVH on echo in ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o EtOH pancreatitis, recurrent torsades due to
electrolyte abnormalities s/p AICD placement in ___
admitted for abdominal pain and hypomagnesemia. Pt reports onset
of epigastric pain 3 days ago consistent with prior episodes of
pancreatitis with associated symptoms of reflux and n/v. She
also experienced a brief episode of sharp chest pain which she
thought may have been a shock delivered by her AICD. She had
been drinking between a fifth and a pint of liquor daily for the
last several months and has been trying to cut back. Last drink
was 3 days ago, she denies withdrawal symptoms. Epigastric pain
has gotten progressively worse, prompting her to present to ED. CHEST (PA AND LAT) showed 1. Unchanged position of the left pectoral single lead pacemaker.
2. No pleural effusion.
3. No acute cardiopulmonary process. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. No gallstones.
2. No sonographic evidence of complications of acute pancreatitis.
3. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen. Non
characteristic scarring at the right upper lobe. No evidence of pneumothorax,
pleural effusions or pulmonary edema. Unchanged position of the left pectoral
pacemaker wire. Normal size of the cardiac silhouette. Radiology showed 1. Increase in gaseous distention of the transverse colon and splenic flexure
in comparison to prior CT.
2. Evaluation for pneumoperitoneum limited due to supine technique. To
assess for free air, please obtain upright or left lateral decubitus views. The patient was diagnosed with ACUTE PANCREATITIS, CHEST PAIN NOS, HYPOKALEMIA. At the time of discharge, the patient had Primary:
- Alcoholic induced pancreatitis
- Alcohol withdrawal
- Accelerated hypertension
Secondary:
- Long QT syndrome c/b TdP/VT cardiac arrest; s/p single lead
ICD (Biotonik Ilesto VR-T) ___
- Alcohol abuse
- Discoid lupus
- GERD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman discoid lupus, GERD, ETOH abuse, long QT
syndrome c/b TdP/VF arrest s/p single lead ICD (___), now
with recurrent ETOH pancreatitis and alcoholic ketoacidosis.
She was treated for acute pancreatitis with IVF, bowel rest, and
antiemetics (using benzodiazepines to avoid QT prolonging
medications) with good results. Her ketoacidosis responded to
D5LR, and her alcohol withdrawal was managed by ___ with
diazepam, but she did not have significant withdrawal symptoms.
Throughout her stay she had marked asymptomatic hypertension
(SBP 160-180/DPB 100-130) which improved on an increased doses
of Toprol (25mg>50mg) and the addition of norvasc, but on the
day of discharge her BP was low normal (110/70), and because of
insurance issues requiring out of pocked expenditure and
concerns about noncompliance, she was discharged only on Toprol
(50mg). It may be that her hypertension while hospitalized was
precipitated by ETOH withdrawal, but this is unclear, and she
will need close follow up and monitoring.
HYPOMAGNESEMIA/HYPOKALEMIA: She had marked electrolytes
derangements which required aggressive repletion.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: As per HPI by admitting MD: CHEST (PORTABLE AP) showed 3.5 cm ovoid lucency projecting over the lateral right mid to lower hemithorax
may be artifactual, but a loculated pneumothorax is not excluded in the
appropriate clinical setting. Mild pulmonary vascular congestion. Patchy
opacity seen at the lung bases and right upper and midlung could be due to
multifocal pneumonia and/or aspiration. If patient able, dedicated PA and
lateral views would be helpful for further assessment. CT CHEST W/O CONTRAST showed 1. Extensive ground-glass and consolidative opacities, most severe in the left
lower lobe, have progressed compared to ___ and are most
compatible with worsened multifocal pneumonia.
2. Near complete opacification of the left lower lobe segmental and
subsegmental bronchi.
3. Prominent mediastinal lymph nodes are slightly increased in size compared
to ___, but are not pathologically enlarged by CT size criteria.
4. Extensive calcifications involving the coronary arteries, celiac axis, and
renal arteries. CHEST PORT. LINE PLACEMENT showed 1. Interval placement of a right IJ central venous catheter with tip
projecting over the upper SVC.
2. Interval increase in bilateral lower lobe patchy opacities consistent with
worsening multifocal pneumonia. DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS showed 1. Interval placement of a Dobhoff feeding tube with tip overlying the left
upper quadrant in the expected location of stomach.
2. Interval improvement in bilateral lower lobe patchy opacities.
3. Increased soft tissue density medial to the right IJ central venous
catheter may simply be projectional. However, hematoma cannot be excluded and
short interval follow-up is recommended.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:39 pm, 2 minutes
after discovery of the findings. CT ABD AND PELVIS WITH CONTRAST showed Exam is slightly limited due to lack of oral contrast and paucity of
intra-abdominal fat. However, within these limitations:
1. New left femoral head lucency with possible cortical destruction may
represent an active infectious process such as osteomyelitis in the setting of
reported bacteremia. Alternatively, this finding may reflect a periprostatic
fracture or avascular necrosis. Orthopedic consultation with possible
subsequent MRI is recommended.
2. Rectal air-fluid level may represent diarrheal disease.
3. Bilateral lower quadrant abdominal wall heterogeneous fatty lesions may
represent complex lipomas. These were likely present on the CT dated ___ however appear more conspicuous on the current study given mild diffuse
anasarca. Malignancy such as a liposarcoma is less likely. Ultrasound and/or
MRI is recommended for further evaluation if clinically warranted.
4. Slight interval improvement of likely multifocal pneumonia which is only
partially imaged.
5. Extensive coronary artery calcifications.
RECOMMENDATION(S): Orthopedic surgery consultation with possible MRI is
recommended for further evaluation of left hip. CHEST (PA AND LAT) showed Bibasilar consolidations are compatible with multifocal pneumonia, better
assessed on the CT scan of the abdomen and pelvis performed a few hours prior. HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT; FEMUR (AP AND LAT)
LEFT showed 1. ORIF for intertrochanteric fracture of the Left femur, with fracture
nonunion, overall similar to appearance to previous. Recent lucencies within
the femoral head, favored to represent subchondral cystic changes, and overall
not progressed to osteonecrosis, or septic arthritis.
2. However, there is diffusely mottled appearance, with permeative
reabsorption of the femoral diaphysis, with periosteal stress reaction,
concerning for osteomyelitis. This process is in close proximity to the gamma
nail with no definite periprosthetic lucency concerning for infection, and
there is attenuation of the articular surfaces of the knee with possible joint
effusion, that ___ be seen with associated septic arthritis.
NOTIFICATION: The findings were placed in the Radiology reporting dashboard
by ___, M.D. on ___ at 8:03 pm, 2 minutes after discovery of the
findings. Radiology showed Successful placement of a 16 ___ gastrojejunostomy tube with its tip in the
proximal jejunum. The gastric port should not be used for 24 hours. Jejunal
port may be used immediately.
Midline okay to use. Radiology showed Aspiration with thin and 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). The patient was diagnosed with Pneumonia, unspecified organism. The patient was treated with CVL ___ (removed)
G-J tube placement. At the time of discharge, the patient had Multifocal Pneumonia
MRSA Bacteremia
Dysphagia
Atrial Fibrillation
History of multiple DVTs. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ man, chronically ill, T1DM, multiple toe
amputations, gastroparesis & prior DKA, ESRD (likely ___ DM, no
biopsy on file) on HD, bilateral ___ DVT s/p IVC filter ___, L
non-occlusive jugular thrombus (___), R thalamic bleed in the
setting of HTN emergency w/ residual L hemiparesis (___), &
L hip fracture s/p fixation ___, who presents w/ lethargy,
found to have multifocal pneumonia, Staph bacteremia and DKA.
# PNA:
# MRSA Bacteremia:
Source of MRSA bacteremia felt to be pulmonary. CT A/P without
evidence of abscess. Of note, CT did mention concern for
possible osteomyelitis; however, ortho evaluated the patient and
did not feel that this was consistent. Central line removed
___. The patient was originally treated with vanc/zosyn. Zosyn
was d/c'ed ___, with plan to continue vancomycin for 6 week
course per ID through ___ with hemodialysis.
# T1DM:
# DKA:
Very brittle, in DKA on admission. He is very sensitive to
insulin and has had hypoglycemic episodes in the past. He was
initially treated with insulin gtt in the ICU. ___ followed
closely and made adjustments to his insulin regimen. Please see
discharge medication list for current insulin regimen. Briefly,
he will continue lantus 7 units daily in AM and insulin sliding
scale. His insulin requirement has slightly increased as he has
been cleared for PO intake along with tube feeds and may require
further adjustment.
# Afib:
Appears to be new in the ICU. Was on amiodarone drip and
eventually transitioned to Metoprolol tartrate q6hrs that is now
transitioned to Metoprolol XL (50mg BID). Coumadin was initially
held in the setting of supratherapeutic INR's, has since been
restarted.
-Rate control: HR's have been in the low 100's on long acting
Metoprolol and the dose can be titrated if felt necessary
however he is asymptomatic
-Anticoagulation: he was bridged in the setting of prior DVT and
new AFib to therapeutic INR. His home dose of warfarin is 4mg
but in the hospital he has received 5mg. Heparin IV was stopped
___ after 2 consecutive therapeutic INR's ___ - ___. INR
today (___) is 2.6.
# Hx VTE:
Complicated coagulation history. He had bilateral ___ DVT s/p IVC
filter ___, L non-occlusive jugular thrombus (___), R
thalamic bleed in the setting of HTN emergency w/ residual L
hemiparesis (___). He has been restarted on Coumadin as
above. Given multiple previous clots, decision was made to
bridge with heparin gtt until INR therapeutic. Notably he has
LLE swelling compared to the right leg; he does have an IVC
filter already and is therapeutic on anticoagulation so an
ultrasound is not likely to change management. He has received 5
days of IV heparin and is now therapeutic on Coumadin.
# Dysphagia
# Aspiration
# Severe Protein Calorie Nutrition
Patient underwent a G-J tube placement ___. After ongoing
discussions with SLP and medical team, pt decided to accept
aspiration risk trial pureed solids with nectar-thick liquids.
His current tube feeding regimen is:
Glucerna 1.5 Cal; Full strength
Tube Type: Percutaneous jejunostomy (PEJ); Placement confirmed.
Starting rate: 50 ml/hr; Do not advance rate Goal rate: 50
ml/hr
Residual Check: Not indicated for tube type
Flush w/ 30 mL water Per standard
Free water amount: 100 mL; Free water frequency: Q6H
Supplements:
Banana flakes: Mix each packet with 120 ml water & stir until
dissolved
Administer by syringe through feeding tube
Flush each packet with 30 ml water; #packets: 1; times/day: 3
-He has had some loose stool in the last 1 week that may be due
to tube feeding. Banana flakes were added ___ but not yet
initiated prior to discharge and can be added if loose stool
persists.
-Sugars have slowly trended up with initiation of PO diet along
with tube feeds, please adjust regimen if needed.
# HTN: Labetalol transitioned to Metoprolol as above. HR's have
been low 90-100s and stable, asymptomatic, in AFib. Can titrate
up on regimen further if needed.
# ESRD: HD MWF. On nephrocaps, sevalamer, low phosphorous diet.
Vancomycin dosed with dialysis (last dose ___, due ___,
dose is given based on vancomycin level per dialysis team).
# Anemia
-H&H noted to drift down slightly. No active signs of bleeding.
Iron studies suggest anemia of inflammation/chronic disease. H&H
8.___.2 at the time of discharge. Suspect also a component of
phlebotomy. Please recheck counts in the next ___ hrs to
ensure stable.
# Incidental Imaging Findings:
- CT A/P showed "Bilateral lower quadrant abdominal wall
heterogeneous fatty lesions may represent complex lipomas.
These were likely present on the CT dated ___ however
appear more conspicuous on the current study given mild diffuse
anasarca. Malignancy such as a liposarcoma is less likely.
Ultrasound and/or MRI is recommended for further evaluation if
clinically warranted."
- CXR ___ showed "Increased soft tissue density medial to the
right IJ central venous catheter may simply be projectional.
However, hematoma cannot be excluded and short interval
follow-up is recommended."
- Continue follow up of anemia/blood counts
#Dispo - discharge to rehab today
#Contact - wife ___ ___ has been updated by case
management
Time spent: 50 minutes </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of CHF, ILD and HLD who is presenting with cough and
fever that started last night. The majority of the history is
collected from the patient's wife, ___, as the patient is very
hard of hearing and not consistently answering questions. Radiology showed Possible mild cardiac decompensation, on a background of mild chronic
interstitial abnormality.
No good evidence for pneumonia. The patient was diagnosed with Pneumonia, unspecified organism, Acute kidney failure, unspecified, Dyspnea, unspecified. The patient was treated with N/A. At the time of discharge, the patient had Community Acquired Pneumonia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year-old man with congestive heart failure (EF
30%), myelodysplastic syndrome, chronic kidney disease, and
possible interstitial lung disease presenting with subacute
onset cough + fever, found to have multifocal
consolidations on CXR and rhonchi on exam concerning for
pneumonia vs. exacerbation of chronic interstitial lung disease.
ACTIVE ISSUES
======================================
#Cough/Fever
#?Pneumonia
He presented with several days of cough with reported history of
T ___ at home, though with no recorded fevers upon
presentation. His CXR showed multifocal opacities with no lobar
consolidation that may represent progression of chronic
interstitial disease as compared to prior radiograph from ___.
However, given his age, poor lung volumes on film, and history,
we could not rule out community acquired pneumonia and he was
started on IV ceftriaxone and azithromycin. He also received
ipratropium/albuterol duonebs as needed. A sputum culture was
sent after starting antibiotics, but this was contaminated. His
oxygen requirement initially ranged from 90 - 97% on 1L NC;
later, he was 92-94% on room air. He was not symptomatic, and
was more interactive/responsive on day of discharge. He was
transitioned to PO cefpodoxime/azithro to complete a course for
CAP.
#CKD
His creatine was 2.2 on admission from baseline 1.7 - 1.9, but
eventually trended down to 1.8 on HD #2 and HD#3.
#Swallowing:
Nursing expressed concern about his aspiration risk, and speech
and language pathology evaluated patient. They recommend
continuing a thin liquid and regular solid diet, with meds
crushed in applesauce. They believed patient requires assistance
with all meals with standard aspiration precautions (sitting
upright, 1:1 assistance with meals). Patient's wife was
educated on monitoring for swallowing difficulty.
#Elevated troponins:
Troponin 0.3 on admission with EKG stable compared to prior.
Repeat troponins were stable at 0.2. We thought troponins
likely elevated in setting of possible mild demand ischemia in
the setting of infection with poor clearance of troponin in th
setting of CKD. The patient has follow up scheduled with his
cardiologist.
CHRONIC ISSUES
======================
#Hypertension: We continued his home carvedilol, and initially
held his home losartan in the setting of decreased renal
function. Losartan was restarted day of discharge.
#Atrial Fibrillation:
Patient noted to have ectopic episodes of atrial fibrillation.
His wife reports that he was on apixaban for three months prior
to an eye surgery, and taken off thereafter. He has not been
taking it at home per her report. As of the most recent note
___, apixaban was to be discussed with cardiology given the
patient's advanced age. Discussed risks/benefits of long-term
anti-coagulation with his wife. She verbalized understanding of
risk of stroke vs. bleeding with decision to anti-coagulate or
not, and wanted to speak further with outpatient cardiologist
before making decision.
# Pancytopenia:
Patient has had anemia with hemoglobin in the ___ range,
leukopenia in the range of ___, and thrombocytopenia between
___ over the past ___ years. Based on a hematology oncology
note from ___ (reporting a bone marrow biopsy from ___, this
was thought to be due to myelodysplastic syndrome. His CBC on
admission was consistent with his baseline.
#Congestive Heart Failure (EF 30%):
Reported per echocardiogram in ___. He did not complain of any
symptoms, he was euvolemic on exam, and CXR showed no signs of
pulmonary edema. We did not diurese him.
TRANSITIONAL ISSUES
===============================
[ ] Antibiotic Course: Cefpodoxime/Azithromycin for 5-day course
(___)
[ ] Consideration of anticoagulation: after initial discussion,
patient's wife would like further discussion of risks and
benefits with cardiologist given history of atrial fibrillation.
[ ] Aspiration risk: will require 1:1 observation with meals,
and medicines crushed in food per speech and swallow evaluation.
[ ] Blood cx x 2 pending at the time of discharge, will need to
be followed up</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo RH male with
hypertension, long standing tobacco and alcohol use who presents
with acute onset severe left sided headache and ataxia. The
patient has been in his normal state of health, other than two
weeks ago when he experiences a few episodes of diplopia that
resolved over about 20 seconds. He also experienced some left
hand clumsiness at the time. Then this past ___ night,
just
over 48 hours ago he was watching football and had a few beers
and experienced a severe headache across the left side of his
head and into the back. He felt like his "head exploded". He
also
heard loud ringing in his ears. He took a couple ibuprofen and
went to bed. ___ morning he woke up and could barely walk. He
was staggering all around. He also was dry heaving and vomiting
through the morning. He walked up to the soup kitchen to visit a
friend and then went upstairs and slept for the afternoon. He
woke up and ate a little dinner and then went back to sleep. He
woke up this morning and was feeling a little bit better, but
still was having trouble walking. He ate a meatball sub and went
to the part and slept on a bench for a while. In the afternoon
he
went to the soup kitchen to visit his friend again and he
insisted that he go to the hospital. He went to ___
where he received a head CT that revealed a large left
cerebellar
stroke. Radiology showed Left cerebellar acute infarction, but without significant mass effect on the
fourth ventricle.
Occlusion of the left vertebral artery from its origin to the mid V2 segment
with distal reconstitution.
Focal atherosclerotic plaque in the proximal ICA causing apparent
mild/moderate stenosis, but this can be better quantified on the CTA The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT. At the time of discharge, the patient had Left cerebellar stroke.
Left vertebral artery occlusion. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Neurologic: Was admitted to Neuro-ICU/Stroke service, Attg, Dr.
___. MRI/MRA brain showed occluded left vertebral artery.
Lipid panel showed mildly elevated TGs, otherwise WNL. HBA1C
WNL. Started ASA on ___. He was transferred to the floor
stroke service later in the day on ___. His headache
resolved and his symptoms slowly improved with respect to his
ataxia and dysmetria. We did not start coumadin given his
current social situation (living in shelter, difficulty getting
to blood draws) and also it's potential interaction with
depakote, so we opted for 3 months of plavix with continued low
dose aspirin. We also started a statin prior to discharge.
Cardiovascular: We allowed BP to autoregulate with goal SBP <
180. TTE w/bubble study was ordered but patient refused to wait
for this study as we could not give him a specific time it could
be done by, so instead of allowing him to leave AMA we
officially discharged him with plans to obtain an echocardiogram
with bubble study as an outpatient. He voiced understanding of
this plan upon discharge and stated he would try to see his PMD
one day after discharge to discuss this. We left a message with
the office of Dr. ___ at ___ about our
recommendations for an outpatient echo with bubble study ASAP.
Resp: We continued home COPD med regimen without changes. His
respiratory status was stable on room air throughout the
hospitalization.
FEN/GI: Bedside swallow study completed while in the ICU and he
was allowed to eat prior to transfer to the floor. Continued to
PO well throughout stay on floor. Colace X1 for constipation.
Chemistry labs stable.
Psych: We continued Depakote ___ mg for bipolar disorder.
Depakote level was stable. Melatonin was given for insomnia. He
did not appear to be at risk for withdrawing and did not require
CIWA scoring. We wrote for a nicotine patch but he refused
this. We do not recommend he start chantix for smoking cessation
due to his risk for further strokes.
Prophylaxis: He recieved DVT boots and subcutaenous heparin
while not ambulating. ___ and OT were consulted and cleared him
for discharge home.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes, confirmed
done - (x) Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 81) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with a remote history left leg length
discrepancy status post LeFort I osteotomy, bone transport at
the
age of ___, who is now recently status post left tibial osteotomy
with intramedullary nailing on ___ by Dr. ___
___
valgus deformity correction and more recently status post left
Achilles tendon lengthening, fifth metatarsal phalangeal joint
capsular release, EDL tenotomy, and pinning of the left fifth
hammertoe by Dr. ___ presents with 48 hours of fevers and
chills. He was seen in clinic yesterday where the fifth
metatarsal phalangeal pin was pulled. Radiographs showed no
evidence of hardware failure or loosening. He was discharged
home with return precautions. However he continued to have
fevers to as high as 101.4. Thus he presents for evaluation.
He
denies any erythema or drainage at the incisions, any cough,
urinary symptoms, abdominal pain, back pain. He states that he
has new increased focal pain at 1 of the proximal incision
sites.
He otherwise feels okay. CHEST (PA AND LAT) showed No pneumonia. CT LEFT TIBIA/FIBULA, NO IV CONTRAST showed 1. No perihardware lucencies suspicious for hardware infection. No osseous
findings suspicious for osteomyelitis. No drainable fluid collections.
2. Nonspecific soft tissue edema over the fifth toe and Left foot, may relate
to recent hardware removal, but overlying infection/cellulitis should be
clinically excluded. ?osteo showed Mild muscle edema is demonstrated surrounding the proximal and distal tibial
metadiaphysis. Mild enhancement of the cortical intramedullary bone is
identified at the lateral femoral diaphysis fracture. The finding may reflect
reactive changes, however osteomyelitis is difficult to exclude. If
clinically indicated, white blood cell nuclear medicine study may be helpful
for further evaluation.
RECOMMENDATION(S): If clinically indicated, white blood cell nuclear medicine
study may be helpful for further evaluation.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:56 am, 15 minutes after discovery
of the findings. The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had fevers that 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>The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have fevers and an elevated WBC to 15 and was admitted to the
orthopedic surgery service. The patient was given 48 hours of
vancomycin. An MRI and x-rays showed hardware intact without
evidence of osteomyelitis. His WBC resolved to 9 on ___ and he
was afebrile during his admission. He felt well on day of
discharge. It was determined that he would be discharged home
and return if his fevers persisted.
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
WBAT LLE. The patient will follow up with Drs ___
per 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: ___ PMH pituitary macroadenoma, HCV, fibromyalgia, osteopenia,
COPD, PE with recent admission for gallstone pancreatitis s/p
sphincterotomy on ___ who presents with epigastric abdominal
pain and nausea since 11am. Stated that she was discharged with
minimal pain and and no nausea. She then states her pain began
suddently and is constant but does change in intensity. Located
primarily on the left side, is the same as previous pain for
which she was admitted. Has nausea but no vomiting. Could not
take POs. Did have hard stools this AM. No fevers/chills.
In the ED, initial vitals were: 97 67 137/73 18 100% RA
- Labs were significant for unremarkable CBC except for mild
thrombocytosis, mildly elevated alk phos. Normal chem7, INR, UA LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Similar extrahepatic biliary ductal dilation as compared to the prior
examinations dated ___. Previously noted intrahepatic biliary
ductal dilatation has resolved.
2. Gallbladder sludge without cholelithiasis or acute cholecystitis. The patient was diagnosed with Right upper quadrant pain. The patient was treated with Endoscopic Ultrasound. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Abdominal pain
SECONDARY DIAGNOSIS:
Recent Gallstone Pancreatitis
Recent pulmonary embolism
Hepatitis C. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ PMH pituitary macroadenoma, HCV, PE who presented with
recent abdominal pain consistent with gallstone pancreatitis s/p
sphincterotomy now representing with abdominal pain.
# Abdominal pain: Patient presented with worsening abdominal
pain. She had an EUS that showed Slightly dilated (4mm) but
otherwise normal pancreatic duct. Dilated (12mm) but otherwise
normal common bile duct. The dilation extended to the level of
the ampulla. No cause for the dilation could be identified. Her
diet was advanced and she was discharged home.
# HCV (genotype 1a) on Harvoni - continued Harvoni
# Recent Pulmonary Embolism: Patient with PE diagnosed in
___. She is currently on Lovenox as a bridge to
warfarin. INR on discharge was 1.
# Pituitary macroadenoma: continued cabergoline 1 mg oral
2X/WEEK
# Fibromyalgia: continue home meds
# COPD: continued Fluticasone-Salmeterol Diskus (100/50) 1 INH
IH BID
# Depression: Held citalopram due to prior concern for erratic
behavior
=========================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENTING ILLNESS: ___ hx CAD s/p CABG and POBA,
HTN, HLP who presents from home with chest pain and hypertension
to the 180s. She was recently admitted in early ___ for
sepsis and pyelonephritis c/b NSTEMI; she was supposed to have a
stress test as an outpatient but never followed up. Today she
describes waking up with a headache and took her BP which was
~180; she normally is 120s during the day. She then notes onset
of exertional chest pain radiating up the neck a/w dyspnea and
diaphoresis that relieved with rest throughout the day. She
took a NTG once, and afterwards felt dizzy and lightheaded; her
BP at that time was ~80/40, so she sought ED evaluation.
In the ED, initial vitals were 64 116/58 20 97%. EKG was
unchanged from baseline. Trops were negative. She was admitted
for a stress test.
Cardiac review of systems is notable for absence of chest pain
currently, dyspnea on exertion currently, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with CHEST PAIN NOS. At the time of discharge, the patient had Atypical chest pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ hx CAD s/p CABG and POBA, HTN, HLP and recent admission for
NSTEMI in setting of pyelonephritis with sepsis who presents
from home with exertional angina and labile blood pressures
after not following up for a stress test.
#CAD/angina: sx sound anginal although pt with sx overnight and
trops continue to be flat. No concern for UA/NSTEMI at this
time. However she did suffer NSTEMI 1 mo prior and did not f/u
for outpt stress testing; she has known 3VD s/p CABG. Admitted
for nuclear stress imaging over the weekend. During the
weekend, had occ episodes of her described CP; enzymes flat
throughout. Nuclear stress showed no reversible ischemia and
normal LVEF, however her RPP was ___ and she demonstrated
delayed exaggerated BP response to exercise after cessation (no
BP rise during stress). Due to these findings, it was felt that
her nitrates were exacerbating her preload dependent diastolic
dysfunction and as well not helping her symptoms (which were
probably not anginal), so nitrates were discontinued at
discharge with consideration of CCB if BP not controlled. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male presents with left leg/knee pain, swelling, and fevers
s/p left knee ACI and TTO on ___. Patient had above procedure
at ___ in ___ with Dr. ___
___ and ___ home the same day with instructions to be ___
LLE and CPM ___. Since surgery ___ has had difficulty with pain
control and noticed drainage from the incisions starting POD2.
On POD 2 ___ also developed subjective fevers. On POD3 hetook
his temp and it was 102 so ___ went to an OSH before being
transferred to ___. Febrile to 102 at OSH. Denies LLE
paresthesias. Started on vanco at the OSH. KNEE (AP, LAT AND OBLIQUE) LEFT showed Postop tibial fixation with prepatellar soft tissue swelling and soft tissue
gas may reflect postop status, difficult to exclude superimposed infection. UNILAT LOWER EXT VEINS LEFT showed 1. No evidence of deep venous thrombosis in the left lower extremity veins.
2. Significant subcutaneous edema without discrete fluid collection. Radiology showed No acute cardiopulmonary process. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with Infection following a procedure, initial encounter, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause. 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>Patient was admitted to the orthopaedic service for treatment of
post surgical cellulitis. ___ was initially treated with
vancomycin monotherapy and then subsequently Ancef was added for
better strep and MSSA coverage. ___ did have recession of his
erythema on his leg, but continued to have significant swelling
and erythema around the site of the incision with exquisite pain
and inability to ambulate. During this time, we were in contact
with Dr. ___ at the ___ and plan
to transfer him back to Dr. ___.
___ did work with physical therapy. His DVT ppx was continued per
prior instructions. ___ did have a lower extremity ultrasound
that was negative for DVT. His hospitalization was otherwise
unremarkable.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y/o M with MDS/Leukemia, not
currently on treatment, who presented to ___ w/2 weeks
intermittent fevers to 102. No cough, shortness of breath or
chest pain, no abdominal pain, nausea, vomiting, diarrhea,
urinary symptoms. He noticed right leg swelling and right thigh
pain without any precursor trauma. He was seen at urgent care on
___ where CXR negative, RLE US negative for DVT. ___ the ED,
orthopedics and surgery were consulted after a hematoma was
discovered. They noted that patient should have ___ drainage.
___ the ED, initial vitals were:
100.5 77 131/59 18 98% RA
- Exam notable for: right leg swollen
- Labs notable for:
132 92 22 AGap=19
------------< 126
3.7 25 1.0
8.5 <8.5/28.7> 157
- Imaging was notable for:
CT RLE:
1. 2.8 x 2.9 x 7.7 cm heterogeneous rim enhancing collection
within the right rectus femoris muscle concerning for abscess.
2. Myofascitis involving the anterior and medial compartments
of the right thigh. Diffuse subcutaneous soft tissue edema.
3. Osseous structures are intact.
4. Prominent right pelvic sidewall and inguinal lymph nodes,
possibly reactive.
- Patient was given:
___ 01:19 IV Piperacillin-Tazobactam 4.5 g
___ 03:15 IV Vancomycin 1 mg ___
Upon arrival to the floor, patient reports
right thigh pain and chills, otherwise no SOB, chest pain,
abdominal pain. Ultrasound-guided right thigh abscess drain. showed Successful US-guided placement of ___ pigtail catheter into the
collection, attached 2 a drain bag. Samples was sent for microbiology
evaluation. UNI LEG ___ BIL showed 1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. No significant change, possible decrease in size of the known right-sided
rectus femoris hematoma. No drainable fluid collection or hematoma identified
within the right calf. The patient was diagnosed with Cellulitis of right lower limb. The patient was treated with ___ Drainage and Drain Placement of Right Thigh
Hematoma/Abscess. At the time of discharge, the patient had Primary Diagnoses: Right Thigh Hematoma/Abscess, Coagulopathy-
Unspecified
Secondary Diagnoses: Myelodysplastic Syndrome, Hypertension,
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>Information for Outpatient Providers: ___ with a ___ MDS,
hypothyroidism, hypertension presented to ___ ED with 2 weeks
of intermittent fevers found to have spontaneous right thigh
hematoma and likely abscess. Patient was taken for ___ drainage
and drain placement with removal of 8cc purulent fluid and
report of a multiloculated fluid collection measuring 10x3x6cm.
Patient was treated with empiric vancomycin, ceftriaxone,
clindamycin. Abscess cultures grew staph aureus that was
pan-sensitive. Antibiotics were narrowed to cefazolin for a ___
week course to be determined by ID as an outpatient. A midline
was placed for continued IV abx as an outpatient, which was
complicated by persistent bleeding despite DDAVP x3, topical
thrombin application, and multiple dressing changings. The
midline was removed and hemostasis was achieved. Prior to
discharge, patient was transitioned to linezolid ___ PO BID
for continuation of 4 week course (D1: ___, end date:
___.
# Right Rectus Hematoma/Abscess: Patient presented with 2 weeks
of fevers, right thigh pain found to have spontaneous right
thigh hematoma on CT RLE. He had no hx of trauma/inciting event
for development of hematoma. Given his feers/chills/pain,
hematoma was felt to be infected/developed into an abscess.
Patient was taken for ultrasound-guided ___ of the
abscess with placement of a drain for source control. Given
report of multiloculated collection with purulent fluid, patient
was started on broad spectrum antibiotcs with vancomycin,
ceftriaxone, clindamycin (D1 = ___. Abscess cultures grew
pan-sensitive staph aureus. Right thigh drain drained <10cc
serosanguinous fluid per day. Echo was negative for signs of
endocarditis. ___ drain was d/c'ed on ___. Patient's abx was
narrowed to cefazolin with plan for continued treatment as
outpatient. However, midline placement was complicated by
persistent bleeding despite DDAVP x3, topical thrombin
application, and multiple dressing changes. Midline was removed
and patient was transitioned to PO linezolid to complete 4 week
course of abx (___) with ID follow-up as outpatient.
# Normocytic Anemia: Patient was found to be acutely anemic from
baseline hemoglobin of ___ based on outpatient results. This
was felt most likely ___ spontaneous bleed/hematoma ___ patient's
right thigh. No other clinical evidence of other sources of
bleeding. Patient also has known baseline anemia due to MDS.
DIC/hemolysis was considered, but fibrinogen and other DIC labs
were normal. Patient received 1u pRBCs on ___ for Hb 6.9. Right
thigh drain output was monitored and drained <10cc
serosanguinous fluid per day.
# Unspecified Coagulopathy: Patient presented with spontaneous
hematoma without trauma/injury. He also gave history of
consistent with an unclear bleeding disorder that included
continued oozing from a small incision following cyst removal
and bleeding for days following superficial cuts/abrasions at
home. He also had midline placement complicated by persistent
bleeding. He received DDAVP x3 over three days and multiple
dressing changes with topical thrombin without resolution of
bleeding. Differential diagnosis included a secondary process
to the patient's known MDS vs primary platelet
dysfunction/coagulopathy that had not been diagnosed. Atrius
heme/onc was consulted. Empiric vitamin K repletion was given
for INR of 1.5 with some response. DIC labs (given infectious
presentation) were negative. Platelet mixing studies and factor
levels were normal. ___ studies pending. Patient to
follow up with Hematology as outpatient for further evaluation.
# MDS: Stable. Atrius heme/onc followed. Outpatient oncologist
aware of admission.
# Hypothyroidism: Stable. Continued home levothyroxine.
# Hypertension: Stable. Given infection, held patient's home
chlorthalidone.
# Psoriasis: Stable.
# Hyperlipidemia: Continued statin.
TRANSITIONAL ISSUES
========================
[] Patient on 3 week course of PO linezolid. Please monitor
patient for signs of persistent or recurrent infection and
determine whether patient will need longer course of abx or IV
abx treatment.
[] Patient with MDS and baseline neutropenia. Please monitor
patient's CBC every week while on linezolid.
[] Patient with unspecified coagulopathy. Please follow up
pending coagulation studies and further evaluate. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ female with known cervical myelopathy,
scheduled for surgery with Dr. ___ for C5
corpectomy and C4-6 fusion, who presents to ___ ED with
worsening mid thoracic to low back pain as well as "burning on
the inside" from the low back to the groin on the left. She has
had intermittent leg weakness and numbness for several weeks.
Yesterday, she was walking to the bathroom and her left leg went
numb and "did not do as it was told" and she fell. She was able
to get up immediately afterwards with no increase in pain and
void without difficulty. This morning upon wakening, she felt a
worsening in her baseline back pain and did not feel Tylenol
would help. She has been able to void without difficulty since
that time. She also states she feels hypersensitive in the left
groin with wiping and feels "shocks" when her left leg is
palpated. She denies numbness in her lower extremities. She
denies bowel or bladder incontinence. MRI THORACIC AND LUMBAR PT6 MR SPINE showed 1. Multiple nerve root sleeve diverticula in the thoracic spine. No thoracic
spinal canal or neural foraminal narrowing. Normal appearance of the thoracic
spinal cord.
2. Lower lumbar degenerative disease affecting several traversing and exiting
nerve roots, as detailed above. No significant mass effect on the thecal sac. CERVICAL SINGLE VIEW IN OR showed Fluoroscopic images show steps in a C5-C6 anterior fusion with C5 corpectomy.
Further information can be gathered from the operative study. C-SPINE SGL 1 VIEW showed Interval postoperative changes.
No evidence of retained drain. C-SPINE NON-TRAUMA ___ VIEWS showed In comparison with the study of ___, there is little change in the C4-C6
anterior fusion with C5 corpectomy. No alignment abnormality. Prevertebral
soft tissue prominence is related to the recent surgery. The patient was diagnosed with Low back pain. The patient was treated with ___: C5 corpectomy, C4-6 anterior fusion. At the time of discharge, the patient had Cervical myelopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>On ___, Ms. ___ presented to the ED with worsening
mid-thoracic and low back pain and burning. She was taken to
the OR on ___ with Dr. ___ C5 corpectomy and C4-6
anterior fusion. Her operative course was uncomplicated; please
see separate operative note for full details of procedure.
On POD1, patient reported improved pain. Her incision was
intact and there was no underlying hematoma or swelling. Her
strength was full and symmetric, and she denied any sensory
deficits other than subjective numbness in her hands. She
tolerated a regular diet and had sufficient urine output.
She was evaluated by ___, who felt she needed an additional
session prior to discharge. However, patient was adamant about
going home. She felt strongly that she would be safe at home, as
long she could be provided with a rolling walker for some
assistance with ambulation. She stated that she understands the
risk she is taking by going home without being cleared by
Physical Therapy as she is in fact medical school graduate from
___. Hinging on that, she also expressed clear understanding
of precautions she should take to prevent falling and when to
call for help or seek medical care. After discussing with
attending, it was decided that she could be discharged home.
She was provided with a short course of low-dose Valium for
muscle spasms and Oxycodone for breakthrough pain, in addition
to a bowel regimen (Senna/Colace) while on Oxycodone. She was
also provided with longer (>1 month) course of Gabapentin for
which she was instructed to discontinue when no longer needed.
Each of the medications and their risks--particularly as they
relate to impaired mental/physical function--were explained to
the patient and she expressed understanding. She is to follow-up
in clinic for repeat AP/Lateral XR in 1 month. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with AF (apixaban) c/b recent CVA
after ___ (___) with retrieval of left ICA/MCA clot, living
in facility with severe dysphagia at baseline, multiple prior
MDR
E. Coli UTI who presents to the ER after an episode of
unresponsiveness. CHEST (PORTABLE AP) showed Bibasal opacities, concern for bibasal pneumonia. CT abdomen pelvis with contrast showed 1. Large stool burden throughout the colon and rectum with mild perirectal fat
stranding which may correlate clinically with stercoral colitis.
2. Bilateral indeterminate renal cysts of the right lower and left upper poles
which are indeterminate though unchanged when compared with prior study.
3. Diverticulosis without findings of diverticulitis. The patient was diagnosed with Urinary tract infection, site not specified. At the time of discharge, the patient had Urinary tract infection
Moderate sleep apnea
Constipation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ year old gentleman with atrial fibrillation (on
chronic apixaban) complicated by CVA ___/ severe dysarthria
and aphasia and two recent admissions for MDR E coli UTI
presenting from his facility after an episode of
unresponsiveness.
# Sepsis ___ E. Coli UTI:
# Encephaloopathy
He presented with unresponsiveness and sepsis. UA positive and
urine culture growing MRI E. Coli. He was started on Zosyn. He
completed a 10-day course of Zosyn on ___. He will resume
fosfomycin suppression as an outpatient. He will follow-up with
Infectious Disease and Urology for urodynamic testing to ensure
no structural cause for his recurrent UTI as an outpatient. His
mental status improved to baseline and he did not seem confused,
though it's difficult to assess his mental status as he is
aphasic. He follows commands and seems to understand what is
said to him, but cannot communicate back to providers. He had
some episodes in the afternoons/evenings when he would call out
and seem agitated and upset, but this seemed mostly when his
family was not present and at least in part due to frustration
with inability to communicate.
# Pneumonia:
He is at high risk for aspiration. Bibasilar opacities were
seen on CXR. He was treated initially with zosyn and
vancomycin. Vancomycin was subsequently stopped as suspicion
for MRSA PNA was low. He completed the course of Zosyn
(primarily for UTI) as above. He had negative urine Strep and
Legionella antigens.
# Sleep Apnea
He had observed apneic episodes up to 90 seconds while sleeping
overnight. During these episodes he was found to desaturate to
as low as 60%. These episodes were noted to decrease in
frequency and severity as his sepsis was treated. He was seen
by Sleep Medicine who believed he had moderate obstructive sleep
apnea + REM dominant OSA. Sleep recommended that the patient
lie on his side, avoid sedatives, and trial auto-CPAP PRN while
in the hospital. They will follow-up with the patient for
formal sleep testing as an outpatient. He missed his scheduled
appointment due to still being hospitalized, so request that his
PCP's office make sure he gets follow-up with sleep medicine.
# History of Urinary Retention. He was continued on home
doxazosin.
# Stercoral colitis: Evidence was seen on CT abdomen/pelvis. It
was unclear if his bowel regimen had been continued as
outpatient. He was restarted on bisacodyl, Colace, miralax. He
had no GI issues clinically during his hospital course.
# Atrial fibrillation:
# Sinus bradycardia:
His CHADS2VAsC is 5. In his history, he suffered a stroke after
DCCV in ___. He is followed by cardiologist (Dr. ___. He
continues sotalol and apixaban.
# CVA:
He has known CVA after ___ (___) with retrieval of left
ICA/MCA clot with residual R-sided weakness, dysarthria, and
dysphagia s/p PEG. During his hospital course he was maintained
on strict NPO diet with tube feeds. ___ came and did teaching
with his son and wife for administering tube feeds. He was
switched from continuous tube feeds to bolus tube feeds, to
simplify administration, and tolerated this well.
# Renal Cysts:
Incidental finding on CT A/P in the ED: "Bilateral indeterminate
renal cysts of the right lower and left upper poles which may
reflect hemorrhagic versus proteinaceous cysts for which
follow-up nonemergent ultrasound could be obtained, as
clinically indicated." Ultrasound was not obtained while
inpatient, but could be done as outpatient.
Disposition: ___ and OT evaluated him and recommended rehab.
However, the patient's wife wanted to have the patient come back
home with her. Though he was medically stable for discharge for
days, he was unable to be discharged home until his wife/son had
undergone teaching with ___ on giving tube feeds and for a
Hoyer lift to be delivered to their home. He will have ___
services (Art of Care) who will be teaching them how to safely
use the ___ lift.
Check if applies: [ X ] Mr. ___ is clinically stable for
discharge
today. The total time spent today on discharge planning,
counseling and coordination of care today was greater than 30
minutes.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with ___ CAD s/p MI, COPD, HTN, DM2, presenting with
abdominal pain and increasing dyspnea. Of note, patient was
hospitalized in ___ for COPD exacerbation which resolved with
steroids and antibiotics. On ___, he was walking to the
bathroom when he became overwhelmed with dyspnea and pushed his
Life-Alert necklace. He denies any recent symptoms other than a
cough which is chronic. He has some clear sputum production. He
states it occasionally hurts to take a deep breath. He also
complains of worsening abdominal pain over the last 12 hours
around the site of his ventral hernia. He has had this pain for
some time, and is waiting on a possible repair surgery. Radiology showed Low lung volumes with bibasilar atelectasis. Small right pleural effusion. The patient was diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, VENTRAL HERNIA NOS. At the time of discharge, the patient had Primary diagnosis
COPD exacerbation
Secondary diagnosis
Chronic kidney disease
Hypertension
Type 2 diabetes mellitis
Anxiety
Chronic pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Summary
================================
___ male history of CAD status post MI, COPD (GOLD stage
III, FEV1 38% predicted in ___, hypertension, diabetes
presenting with abdominal pain and increasing dyspnea. He was
found to be in COPD exacerbation and treated with prednisone and
azithromycin. He quickly recovered and was discharged in good
condition. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with end stage renal disease status post
kidney transplant, prostate cancer, and recent penile prosthesis
insertion on ___ who presents with abdominal distention and
urinary retention. Following recent penile prosthesis insertion,
Foley catheter was inserted and subsequently removed on the
night prior to admission, following which she has experienced
only drips. He also complains of abdominal distension and poor
appetite. He recalls 1 bowel movement on the day of admission
after laxatives. He denies fevers/chills, chest pain, abdominal
pain, cough, or vomiting. Radiology showed Findings suggestive of adynamic ileus though bowel obstruction
cannot be completely excluded. If there is strong concern for bowel
obstruction, a CT is advised. Radiology showed 1. Elevated resistive indices with absence of diastolic flow in the
interpolar renal arteries and main renal artery, which is concerning for
rejection.
2. Mild fullness in the mid pole collecting system; no evidence of
hydronephrosis.
3. Simple renal cyst, which is new from the prior exam.
4. Moderately distended bladder despite the presence of a Foley catheter.
Results were discussed with Dr. ___ at 11:10 ___ on ___ via telephone by
Dr. ___. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPOSMOLALITY/HYPONATREMIA. At the time of discharge, the patient had Primary diagnosis:
Urinary retention
Constipation
Acute on chronic kidney injury in the setting of ESRD s/p
transplant
Hyponatremia. The patient was given written instructions concerning 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 end stage renal disease status post
kidney transplant, prostate cancer, and recent penile prosthesis
insertion on ___ who presented with abdominal distention and
urinary retention.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female with previous history of alcohol abuse transfered
to ___ with alcohol withdrawal and sodium of 106. Radiology showed No acute intracranial process. Radiology showed 1. Bilateral aspiration or multifocal pneumonia.
2. New hepatic steatosis.
3. Stable innumerable hepatic and renal cysts and prominence of the
pancreatic duct.
4. Small bilateral pleural effusions and mild pulmonary edema. Radiology showed AP chest compared to ___:
Nearly all of what was extensive pulmonary consolidation on ___ has
resolved. The small residual on the perihilar left mid lung could be a small
pneumonia. Small pleural effusions are also present. Heart is top normal
size. The patient was diagnosed with HYPOSMOLALITY/HYPONATREMIA, ALCOH DEP NEC/NOS-UNSPEC, HYPERTENSION NOS, HISTORY OF FALL. At the time of discharge, the patient had Hyponatremia, likely from poor nutrition and SIADH
Alcohol withdrawal
Cardiomyopathy, likely alcoholic
Troponin elevation
Community-acquired vs. aspiration pneumonia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ F with hx of alcohol abuse/withdrawal, HTN, PKD who
presents with hyponatremia, alcohol withdrawal, and respiratory
distress.
ACTIVE ISSUES
-------------
# Respiratory distress: likely multifactoral including
multifocal/aspiration pneumonia and asthma exacerbation. Patient
presented with tachypnea, tachycardia, and hypotension, possibly
pointing to sepsis although picture complicated by alcohol
withdrawal and hypovolemia. She was treated for
community-acquired pneumonia with levofloxacin and ceftriaxone,
eventually narrowed to a five day course of levofloxacin. Her
asthma exacerbtaion was treated with 5 day course of prednisone
40 mg daily and nebulizers. Patient was able to wean off oxygen
by discharge. Flu vaccine and pneumovax were administered prior
to discharge.
# Hyponatremia: presented to an outside hospital with Na 106 and
initially improved to 113 after NS boluses as she appeared
significantly hypovolemic on exam. Urine lytes obtained and was
most consistent with a ___ picture with elevated sodium and
urine osmolality. In addition, patient had a very limited diet
suggesting nutritional causes from a 'tea and toast' diet.
Patient was then placed on fluid restrition and sodium improved
to 128 on discharge. Patient had no change in mental status
throughout her hospitalization, thus pointing more to a chronic
rather than acute process. She has been instructed to observe a
2 liter fluid restriction at home and to opitimize her nutrition
through 3 meals per day and Ensure supplementation. She will
follow up with her PCP and have sodium rechecked at that time.
# Alcohol withdrawal: history of withdrawal seizures. Patient
was placed on daily folate and thiamine. She was placed on the
phenobarbital protocol for withdrawal, weaned until the time of
discharge, when she did not have symptoms of withdrawal. Social
work consult was obtained, and patient expressed the desire to
stop drinking after this hospitalization. She will be going to
live with her parents initially after discharge.
# Elevated troponins: troponin 1.07 without any ECG changes. No
previous cardiac history, but has risk factors including
smoking, polycystic kidney disease, and hypertension.
Differential included NSTEMI vs. demand ischemia secondary to
tachycardia and metabolic derangements. Patient had no cardiac
symptoms. Per cardiology, they stated to start aspirin and beta
blocker, as well as lisinopril upon discharge, and she will
likely need a cardiac catheterization on discharge. She will
follow up with Cardiology a month after discharge. TTE was
obtained and showed cardiomyopathy with EF 30%, suggestive of
possible alcoholic cardiomyopathy. She was told of this
diagnosis and that she should cease drinking alcohol. She will
get a follow-up TTE at her Cardiology appointment.
# s/p fall: large ecchymosis post fall. Appears to be vasovagal
as patient felt lightheaded prior to episode. No loss of
consciousness reported. In the ED, CT head and torso and abdomen
negative for acute lesion or bleeding. Pain was treated with
acetaminophen and tramadol. Social work consult was obtained to
determine if there was any abuse, which the patient denied.
# Elevated liver function tests: per CT abdomen, the liver is
diffusely hypoechoic attenuating consistent with hepatic
steatosis which is consistent with her history of alcohol use.
AST was not greater than ALT as would we expect with alcohol
use. Hepatitis panel was negative in ___, and was repeated on
this admission and also negative. Possibly also secondary to
hypovolemia leading to decreased perfusion vs. hepatitis. LFTs
downtrended over her hospitalization. They should be rechecked
at her discharge appointment with her PCP.
# Smoking: smoking cessation was encouraged. Nicotine patch was
offered but patient refused.
# Hypertension: lisinopril was held during most of her
admission, but was restarted at discharge. She will get lab
testing (Chem10) at her PCP ___.
# Polycystic kidney disease: with renal and liver cysts on CT
abdomen. Creatinine was normal during her presentation. She
will follow up with her PCP after discharge.
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will follow up with her PCP and with
___. She will need a repeat TTE in one month to evaluate
her valvular function, given her new cardiomyopathy. She will
need a recheck of her Chem10 and LFTs after discharge,
especially her sodium level. Blood cultures pending at
discharge will need to be followed up.
# Communication: brother (___) ___,
mother (___) ___
# Code: Full </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ no significant PMH who presents for evaluation for PE after
presenting to PCP with CC of DP and dyspnea. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. The patient was diagnosed with Other pulmonary embolism without acute cor pulmonale. At the time of discharge, the patient had Primary diagnosis:
Class I pulmonary embolism
Secondary diagnosis:
Normocytic 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>___ no significant PMH who presented with several days of chest
pain and dyspnea, admitted for treatment of bilateral PEs.
ACTIVE ISSUES
=============
#Pulmonary embolism
The patient presented with chest pain and shortness of breath.
CTA chest showed left segmental and right subsegmental pulmonary
emboli, and no CT evidence of right heart strain. Given her low
PESI score (39), this is a Class I, very low risk PE, and
outpatient management is appropriate. No obvious reason based on
history to be hypercoagulable, though she did undergo surgery 2
months ago. Doppler US of LEs negative. She was started on a
heparin gtt. Given that she is not tachycardic, had negative
trop, no evidence of heart strain on CTA, hemodynamically stable
and no oxygen requirement, the heparin gtt was discontinued and
she was started on a loading dose of apixaban (10 mg PO BID).
This was changed to rivaroxaban for insurance coverage reasons.
At time of discharge, she was continued on rivaroxaban 15 mg PO
BID for 21 days, which will be followed by rivaroxaban 20 mg PO
daily afterward.
#Normocytic anemia
She was noted to be anemic during this admission. Her anemia has
unclear etiology and is stable from prior. She was noted to have
no signs/symptoms of bleeding.
CHRONIC ISSUES
==============
None
TRANSITIONAL ISSUES
===================
[] She was started on rivaroxaban on ___. She was instructed
to take rivaroxaban 15 mg PO BID for 21 days, followed by
rivaroxaban 20 mg PO daily afterward. Her outpatient provider
should determine the appropriate duration for anticoagulation.
[] She should receive a hypercoagulability work up as an
outpatient. Protein C and S were sent while inpatient, and were
pending at time of discharge. She could also receive factor V
Leiden, cardiolipin, and beta-2 glycoprotein testing.
[] She was noted to have normocytic anemia during this
hospitalization. Her outpatient providers should consider a
workup for anemia (iron studies, B12, folate) and possible
treatment, such as iron supplementation if indicated.
#CODE: Full presumed
#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-female with mild cognitive
impairment (vs. mild dementia), supraventricular tachycardia vs.
nonsustained VT (unclear history), diet-controlled DM,
spine/hip/knee OA, retinal TIA, remote history of breast cancer
s/p lumpectomy, radiation, and hormonal therapy (in her ___,
prior syncopal episodes and hx SVT on verapamil, cholecystectomy
(___), and bilateral hip replacements (10 and ___ yrs ago
approximately), who presented after a fall with hip fracture and
is being transferred to medicine for thrombocytopenia,
hyponatremia and transaminitis. Q433 showed 1. Comminuted and mild-to-moderate displaced right femoral
intertrochanteric/subtrochanteric periprosthetic fracture.
2. Comminuted, mildly displaced left superior ramus, inferior pubic ramus and
pubic body fractures.
3. Concern for nondisplaced right sacral ala fracture.
4. Given patient's osteopenia additional nondisplaced fracture may be occult.
This can be further evaluated on MRI if warranted.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 9:47 am, 10 minutes after discovery
of the findings. Q61R was done. Fracture showed No evidence of acute fracture or dislocation.
Periprosthetic fracture right upper femur shown by radiographs of the pelvis
performed elsewhere on ___ one. Intraoperative fluoroscopy of right femur. showed Fluoroscopic images depicting on going open reduction internal fixation of the
right femur. ABDOMEN US (COMPLETE STUDY) showed 1. Status post cholecystectomy with normal spleen size. No specific findings
to explain the patient's abnormal laboratories.
2. Trace right pleural effusion. CHEST (PORTABLE AP) showed In comparison with study of ___, there are lower lung volumes.
Cardiomediastinal silhouette is essentially unchanged. Mild blunting of the
left costophrenic angle consistent with pleural fluid with underlying
atelectatic changes.. Indistinctness of pulmonary vessels is consistent with
some elevation in pulmonary venous pressure.
No evidence of acute focal consolidation, though this would be difficult to
unequivocally exclude in the appropriate clinical setting. The patient was diagnosed with Periprosth fracture around internal prosth r hip jt, init, Fall same lev from slip/trip w/o strike against object, init. The patient was treated with ___: Open reduction and internal fixation of left
periprosthetic femur fracture. At the time of discharge, the patient had Primary:
Periprosthetic hip fracture
Secondary:
Pancytopenia
Acute anemia likely secondary to multiple myeloma
Transaminitis
Syncope
History of SVT
Hyponatremia
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>Ms. ___ is a ___ year-old-female with mild cognitive
impairment (vs. mild dementia), supraventricular tachycardia vs.
nonsustained VT (unclear history), diet-controlled DM,
spine/hip/knee OA, retinal TIA, remote history of breast cancer
s/p lumpectomy, radiation, and hormonal therapy (in her ___,
prior syncopal episodes and hx SVT on verapamil, cholecystectomy
(___), and bilateral hip replacements (10 and ___ yrs ago
approximately), who presented after a fall with periprosthetic
hip fracture s/p uncomplicated ORIF on ___, and was transferred
to Medicine for thrombocytopenia, hyponatremia, and
transaminitis.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ presenting to the emergency department with headache,
hypertension, and diaphoresis. Patient has noted not feeling
very well for the last couple of days, noting mild headache
every morning. He was evaluated by his primary doctor 2 days ago
and was noted to have BP of 202/120 at that time so was started
on hctz and ACEI. This AM, headache was worse than prior,
located over entire head and did not resolve on its own. He also
had blurry vision. Was accompanied by diaphoresis, nausea, and
vomiting x2. Called PCP about these ___ and was referred to ER
for further evaluation. He denies any specific chest pain,
shortness of breath, left arm pain, numbness, back pain,
abdominal pain, peripheral edema, hematuria, dyspnea, orthopnea.
Has blurry vision due to not wearing glasses, though reports
previous episode of altered vision x ___ last week. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with HYPERTENSION NOS, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA. At the time of discharge, the patient had Primary:
1. Hypertensive urgency
Secondary:
1. Hypertension
2. Hepatitis C. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with PMH of HTN and hepatitis C presents with SBP >200, HA,
nausea, and diaphoresis.
# Hypertensive urgency:
Pt with SBP >200 at PCP ___ ___, prescribed lisinopril
and HCTZ. Now with refractory HTN to SBP >200 having taken these
new medications. Presented to ED with symtoms and EKG concerning
for ACS. Troponins were negative. He was started on nitro gtt,
and his pressures improved to SBP 150s prior to transfer. His
symtoms resolved as well. He was started on his home meds
overnight in addition to amlodipine 5mg. On the floor, his BP
elevated overnight but resolved with medications again. His
amlodipine was uptitrated to 10mg daily, but he continued to
have refractory HTN overnight. He was then changed to nifedipine
30mg long acting daily. Lisinopril and HCTZ could not be
uptitrated due to elevated Cr. An echo was performed to evaluate
for structural damage secondary to HTN, which showed mild LVH,
normal EF, and mild pulmonary hypertension.
# ___:
Pt with Cr of 1.4, baseline unknown. No known hx of renal
insufficiency per atrius notes, but pt had not been followed by
a PCP ___. Possibly elevated at baseline due to chronic
uncontrolled HTN. UA shows protein in the urine, supporting
chronic renal insufficiency. In addition, could be acutely
elevated in the setting of recently starting HCTZ and
lisinopril. It is also possible that the acute injury is in the
setting of hypertensive emergency, thus reflecting end organ
damage. FeUrea 52%, which is borderline ATN/prerenal territory.
Most likely a mixed picture which will improve with management
of his HTN.
# ACS rule out:
EKG with J point elevations and TWI concerning for ACS first
seen at ___'s office. Pt denies CP or SOB. Not started on
heparin gtt. Trops negative x3. Most likely hypertensive
structural heart changes causing EKG patterns.
# Hep C: stable. s/p interferon-ribavirin therapy with
resolution.
# CAD risk: No family history. Pt risk factors include HTN and
obesity. Last lipid panel ordered in atrius ___, pending. Pt
was started on ___ daily.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old F with hx of HTN, DM, HLD, CKD (Stage III), and
papillary thyroid carcinoma s/p total thyroidectomy on ___
presents for elevated creatinine. She has routine blood work
last week and noted to have elevated Cr (baseline 1.1 in
___ per PCP's records). Repeat Cr on ___ and today
showed continued gradual worsening creatinine (3.5). As a
result, PCP (___) sent to ___ where
Cr was 3.9 and BUN 58.
Patient transferred to ___ because due to have a total body
scan today as part of her thyroid treatment. Creatinine in our
system is 0.9 on ___. Denies dysuria and polyuria.
Continues to make same amount of urine and denies foamy urine or
hematuria. Has horseshoe kidney, but never had problems with
obstruction/stones. Several UTIs (less than 1/year) and last one
was many years ago. States that her PO intake has been less
since ___ when she started her low iodine diet and stopped
taking levothyroxine.
Also reports feeling generalized weakness, "crappy" and "I
couldn't get out of bed for a week." Cold intolerance and weight
gain since starting low iodine diet and discontinuing
levothyroxine ___. No constipation, confusion, changes in skin,
fevers, chills, CP, abdominal pain, sob, URI like symptoms. Radiology showed No hydronephrosis. Horseshoe kidney. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS
#Acute on chronic renal failure
SECONDARY DIAGNOSES
#Chronic kidney disease, stage III
#Hypothyroidism
#Papillary thyroid carcinoma
#Gastroesophageal reflux disease
#Obstructive sleep apnea
#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>Ms ___ is a ___ yo woman with DMII, HTN, papillary thyroid
carcinoma s/p resection in ___, and CKDIII who presents as a
transfer from ___ for acute on chronic
kidney injury likely secondary to pre-renal azotemia.
#Acute on chronic kidney failure:
This patient has a baseline Cr of 1.1-1.2 per her PCP's records
(reviewed over phone) back in ___. She was noted to
have a Cr of 3.5 on ___ then 3.9 at ___
___ yesterday (3.9). She has not had any extra fluid losses
(diarrhea, polyuria, profuse sweating) nor has she had poor PO
intake. However, she has not taken any thyroid medication since
___ and her gland is surgically absent. Clinically she is very
hypothyroid. Despite being without thyroid hormone replacement
she was on multiple antihypertensive medications (HCTZ,
amlodipine, lisinopril, metoprolol, and spironolactone). The ACE
would directly impair renal blood flow and the diurectics could
indirectly cause the same effect through hypovolemia. All of
these together likely caused pre-renal azotemia which explains
her responsiveness to IV fluid (Cr 3.9 > 2.1) with 2L saline.
On urine microscopy today there were no casts or dysmorphic
RBCs, and there were moderate WBC w/o white cell casts. This
non-specific urinary sediment did not suggest acute tubular
necrosis or acute interstitial nephritis.
#Hypothyroidism: This is secondary to surgical removal of the
thyroid in ___ for papillary thyroid carcinoma. The patient
has been off levothyroxine since ___ in order to increase her
TSH prior to a iodine-123 uptake scan which she had during this
admission. She was maintained on a low iodine diet in accordance
with the nuclear medicine protocol. She will resume her
levothyroxine in accordance with their protocol after discharge.
#Hypertension: See above. All of her home medications except
metoprolol were discontinued in the setting of her acute kidney
injury. Her blood pressures were on the low side (93-115/50-72)
in the last 24 hours on a single agent after 3L of IV fluids.
She was discharged on only metoprolol and her other home
antihypertensives can be restarted after she resumes her
levothyroxine by her PCP.
#Obstructive sleep apnea: The patient is on CPAP at home. She
tolerated sleeping without CPAP x2 days.
#GERD: On outpatient omeprazole for GERD. Discontinued in the
setting of possible acute interstitial nephritis, but because of
the sudden overnight improvement in creatinine after IV fluids
AIN was considered less likely as a cause of her acute renal
failure. She was discharged on her home omeprazole.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old man
with a history of alcohol use disorder, who presents as a
transfer from ___ with jaundice. MRCP. showed Findings most consistent with acute on chronic hepatic injury including portal
hypertension. No evidence for biliary obstruction or filling defects.
Increased retroperitoneal fluid; query coinciding acute pancreatitis. CHEST (PORTABLE AP) showed In comparison with the study of ___ there are lower lung volumes with
elevation of the right hemidiaphragmatic contour and atelectatic changes just
above it.. Cardiac silhouette is at the upper limits of normal in size and
there is engorgement of pulmonary vessels consistent with elevated pulmonary
venous pressure.
In the appropriate clinical setting, it would be difficult to unequivocally
exclude superimposed pneumonia, especially in the absence of a lateral view. US ABD LIMIT, SINGLE ORGAN showed Minimal ascites, most notable in the right lower quadrant. Radiology showed 1. Diagnostic paracentesis, 400 cc of fluid removed. Samples were sent for
analysis Ultrasound-guided interventional procedure showed 1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 1.1 L of fluid were removed. CR - CHEST PORTABLE AP showed 1. No pneumonia or acute cardiopulmonary process.
2. The stomach is distended with air. CT ABDOMEN AND PELVIS WITHOUT CONTRAST showed 1. No evidence of acute intra-abdominal process within the confines of a
noncontrast study. Specifically, no bowel obstruction, ileus, or gross
perforation.
2. Cirrhotic liver with small to moderate ascites, moderate to severe
splenomegaly, paraumbilical vein recanalization, and intra-abdominal varices. The patient was diagnosed with Acute and subacute hepatic failure without coma, Unspecified abdominal pain. The patient was treated with Paracentesis ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
==================
Alcohol Hepatitis
Alcohol Cirrhosis complicated by:
-Ascites
-Coagulopathy
SECONDARY DIAGNOSIS:
=====================
#Spontaneous Bacterial Peritonitis
#Acute Kidney Injury
#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>Mr. ___ is a ___ year-old man with a history of alcohol use
disorder, who presents as a transfer from ___ with
jaundice. Overall picture most concerning for severe alcoholic
hepatitis, complicated by SBP and found to be steroid non
responder.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH of CAD s/p multiple stents, hx of multiple MIs,
CVA, DMII, Afib (on metoprolol and coumadin) who presents with
progressive chest discomfort and lightheadedness. Radiology showed 1. Right internal jugular central venous catheter tip in the mid SVC. No
large pneumothorax identified.
2. Elevated venous pressures. The patient was diagnosed with ATRIAL FIBRILLATION. At the time of discharge, the patient had Primary diagnosis: Afib with RVR, Lightheadedness
Secondary diagnosis:
CAD
HTN
HLD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ year old male with PMH of CAD s/p multiple
stents, with hx of multiple MIs, CVA, DMII, Afib (on metoprolol
and coumadin) who presented with progressive chest discomfort
and lightheadedness and found to be in Afib/flutter with RVR was
rate controlled with diltiazem, metoprolol with self resolution
to sinus rhythm. Previously scheduled catheterization was
deferred given that symptoms were thought to be more likely
related to progressive Afib vs. coronary disease with plan for
further work up and management of Afib.
.
ACTIVE ISSUES
.
# Chest discomfort: progressive over past few months despite
increase in isosorbide mononitrate. Occurs daily at both rest
and exertion. Patient presented with chest discomfort and
lightheadedness in Afib with RVR. Trops neg x2 and mild ST
depression on EKG v5 and v5. Chest discomfort resolved once
patient was back in normal sinus rhythm. Touched base with
patient's outpatient cardiologist and scheduled catheterization
was deferred given symptoms seemed more consistent with Afib
than ACS. Asymptomatic on discharge.
.
# Parox Afib: CHADS2 6. Rate controlled and anticoagulated.
Presented to ED in Afib with RVR to 150s. Beta blocked with
metoprolol and diltiazem. Was been in sinus since arrival to
floor. Warfarin held prior to cath. Patient was started on
lovenox bridge to coumdadin with follow up in ___
clinic. Strategy for rhythm was discussed with outpatient
cardiologist, Dr. ___ @ ___. Unable to use amiodarone
given iodine allergy, decision was made to send home w/ ___
___ to ensure that the lightheadedness and chest discomfort
episodes were related to his atrial fibrillation. Will f/u w/
Cardiology.
.
# CAD: Extensive. Prior cath ___ showed LAD 100% proximal
occlusion, LCx 30% occlusion, 100% occlusion of OM1. Trops neg
x2. Continued with home aspirin, isosorbide mononitrate,
metoprolol, and atorvastatin.
.
# HTN: pressures were elevated to 140s-150s during
hospitalization. Continued home Losartan 25mg, Metoprolol
Succinate 25mg, and Imdur 120 mg.
.
CHRONIC ISSUES
.
# sHF: Etiology ischemic. EF 30% ___. No shortness of breath,
wt gain, orthopnea. Euvolemic on exam. Continued home
metoprolol, losartan. Consider spironolactone given EF < 35%.
.
# Hyperlipidemia: ___ with HDL 48 and LDL of 89.
.
# Moderate AS: ___ of 1.4 and mean gradient of 13 on echo from
___. Patient is not symptomatic. Home Losartan 25mg as
above.
.
# DM2: HbA1c 6.4% ___ on oral agents. No end organ damage.
Held home orals. Insulin sliding scale.
.
# BPH: continued home tamsulosin.
.
# Hypothyroidism: continued home levothyroxine.
.
### TRANSITIONAL ISSUES
- Patient was discharged on ___ of hearts with plan to see if
the lightheadedness and chest discomfort episodes were related
to his atrial fibrillation, will follow up in cardiology clinic.
- Patient was started on Enoxaparin Sodium 150 mg SC daily on
___ as bridge to warfarin with plan to follow up in
___ clinic
- Consider outpatient anti-arrhythmics pending ___ of hearts.
AVOID amiodarone given history of anaphylaxis to iodine. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo woman with h/o sz disorder, asthma, migraine, chronic back
pain, depression, gastric bypass and multiple SBOs, p/w vague
sxs including malaise, lethargy, and urinary incontinence.
Patient is poor historian. Was visiting her daughter who is a
patient on ___ and daughter noted she was having trouble
sitting up in her chair. Per triage note there was an episode of
urinary incontinence but patient does not recall this. She is
not aware of the episode that caused her to be referred to ED.
Does say she has been feeling unwell for past several days
though is unable to articulate why. Felt cold at home but unsure
if febrile. No cough, SOB, CP, palpitations, n/v/d, dysuria,
hematuria. She has chronic tremor. She is not sure if she had a
seizure but last was ___ y ago. Lives independently.
Per daughter: baseline is fully independent, has ___ 2x/week to
help with meds only. Seizures typically presents with tremors,
head falls back, stares
On ___ seemed "lazy" and then was seen by MD who changed
tremor meds. Seemed to get worse and over weekend seemed "off"
again, slow, delayed answers. Last night noticed as she was
getting ready to leave that tremors were extremely bad, asked to
get wheelchair. As standing up, could not hold self up and fell
back onto bed, almost as though passing out. Having trouble
supporting herself to get up, having trouble following
directions. Wasn't really making eye contact. Stayed overnight
and had urinary incontinence. On ___ had diarrhea with
incontinence as well. Does not think she had any seizures
In the ED, initial vitals were: 98.0 96 109/69 16 94% RA
- Exam notable for: AOx3 but appears tired, CNII-XII intact,
+resting and intention tremor (reports at baseline),
finger-to-nose intact, good strength in b/l UEs/LEs, ___ beats
clonus
- Labs notable for: WBC 12.2 (70.9% PMN), AST/ALT 44/18, Tbili
0.5, Alb 2.8, Ca 8.2, Na 140, Cr 0.5, Trop < 0.01, Serum/urine
tox NEG, valproate level 44 (low), ammonia < 10, U/A ___, Nit+,
24 WBC, 3 Epi, Few bact, mod Bld, 79 RBC,
- Imaging: CXR: no acute intrathoracic process. NCHCT: no mass,
left frontal artifact vs. much less likely SAH. MRI: extremely
limited by motion with no obvious hemorrhage
- IV CTX 1gm was given.
-Neurology was consulted who recommended checking lytes, coags,
ammonia, B12, folate, thiamine and dispo per ED.
Upon arrival to the floor, patient reports she is feeling much
better. She feels her confusion and lethargy has improved. She
reports feeling frightened and confused about being in the
hospital. She continues to experience dysuria, which has been
present for the past three days. She denies fevers, chills,
abdominal pain, increased urinary frequency or urinary urgency. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. The previously described hyperdense appearance of a left frontal sulcus
does not appear significantly changed since the prior exam in ___, and
likely is artifactual. No evidence of acute major vascular territory
infarction or concerning focus of hemorrhage. The patient was diagnosed with Disorientation, unspecified. At the time of discharge, the patient had Primary Diagnosis: Urinary tract infection
Secondary Diagnosis: 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>PCP: ___. ___
Neurologist: Dr. ___ ___, Fax
___
___ yo woman with h/o sz disorder, asthma, migraine, chronic back
pain, depression, gastric bypass and multiple SBOs, p/w vague
sxs including malaise, lethargy, and urinary incontinence found
to have urinary tract infection.
#Delirium
Patient was visiting her daughter in the hospital when she
developed confusion and lethargy. Received head imaging with no
evidence of hemorrhage or infarct including CT head and MRI. Has
a history of seizure disorder, but current episode not
consistent with seizure. She was seen by neurology for stroke
rule out as Code stroke was called; given reassuring neuro exam
and no significant abnormalities on CT head and MRI, she was
ruled out for acute stroke. She was found to have a urinary
tract infection. Her confusion improved with antibiotic therapy.
#Klebsiella Urinary Tract Infection
Patient with urine culture positive for pan-sensitive
Klebsiella. Plan to treat with 5 day course of Bactrim DS BID
(end ___.
#Seizure disorder
Her Depakote level was 44 in setting of two days of missed
medication. Continued on her home dose of Depakote 1500 daily
and 1000 qHS with plan to follow up with Neurologist on ___ to
ensure Depakote is at an adequate level.
#Peripheral neuropathy:
Patient with neuropathy of R lower extremity, which is chronic
in nature. Also with decreased vibratory sensation bilaterally.
Patient will follow-up with neurologist Dr. ___ should get
serum polyneuropathy work-up if not already done as outpatient
given poor vibratory sensation in ___. Continued on home
Gabapentin 300mg QHS.
#Depression vs PTSD: Per ___ patient with recent psychiatric
admission at ___ discharged on ___. Current
symptoms may be related to daughter's illness and diagnosis of
leukemia. History of suicidal ideation and self mutilation.
Continued home Aripiprozole 20mg, Risperidone 2mg qHS and
Sertraline 200 mg.
#Back pain: Holding home Tramadol in setting of confusion,
continue Lidocaine patch.
# CODE: Full presumed
# CONTACT: ___, Relationship: father, Phone number:
___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old woman with chronic alcohol use
(sober for ___ year), Stage ___ liver fibrosis, stage I lung
cancer s/p RUL wedge resection, multiple colonoic polyps and
diverticulosis c/b bleed s/p partial colonic resection, who
presents with melena.
The patient shares that this morning she was in her usual state
of health, and noticed she had the urge to stool, which is
unusual for her because she is chronically constipated. She went
to the bathroom and had a large "black tarry loose stool" with
some red blood. At first she ignored it, but it happened again,
and this caused her to come to the ED.
In the ED, initial vitals were: 97.8 86 149/86 18 100. Exam
notable for diffuse abdominal tenderness. Labs notable for H/H
9.6/30, Na 127->132, K 6.3-> 4 with no intervention, Cr 0.8
(baseline). Lactate 3.1 -> 1.7 with 1L NS. She had a CTA AP that
was unrevealing for source of bleed. She was given 1L NS and
Tylenol for pain. While in the ED she had at least 2 additional
melanotic stools.
On the floor, patient gives the above history. She does not
have any lightheadness, chest pain, or dyspnea. She has not
taken any NSAIDs recently and is not on a blood thinner or
aspirin. She shares that she has had multiple episodes of
diverticular bleeds in the past, but they have all been bright
red blood, and she has never had black stools before. CTA ABD AND PELVIS showed 1. No active GI bleeding. Significant diverticular disease without
diverticulitis.
2. Status post partial colectomy, no obstruction.
3. Mildly prominent pancreatic duct, stable since ___, stability
suggestive of benignity such as sphincter of Oddi dysfunction.
4. Prominent left pelvic veins can be seen with pelvic congestion syndrome. DX CHEST PORTABLE PICC LINE PLACEMENT showed Since the prior radiograph of ___, a right PICC has been placed,
terminating at the expected level of the confluence of the brachiocephalic
veins. Cardiomediastinal contours are within normal limits. Lungs are
grossly clear except for focal pleural and parenchymal scarring at the right
base peripherally. Rounded contour adjacent the left hemidiaphragm is likely
due to focal eventration, more fully evaluated on the prior CT of ___. Portable chest radiograph showed 1. Right PICC tip in proximal SVC, similar to the prior exam.
2. Trace right pleural effusion versus pleural thickening.
3. Apparent new nodular opacity in left upper lung is potentially due to a
structure external to the patient. Repeat radiograph following removal or
repositioning of external devices may be helpful in this regard.
NOTIFICATION: The findings were discussed with ___, M.D. requesting a
wet read by ___, M.D. on the telephone on ___ at 1:10 AM, 1
minutes after discovery of the findings. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with ___ line placed ___, removed ___
Colonoscopy: ___. At the time of discharge, the patient had Primary diagnosis:
====================
lower gastrointestinal bleed
Secondary diagnoses:
====================
hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman with chronic alcohol use
disorder (sober for ___ year), Stage ___ liver fibrosis, stage I
lung cancer s/p RUL wedge resection, multiple colonic polyps and
diverticulosis c/b bleed s/p partial colonic resection, who
presents with a GIB.
GI bleed:
Presentation with very dark stool mixed in with frank blood, as
well as right-sided abdominal pain that started around the time
the bowel movements began. A slower-transit lower
gastrointestinal bleed was deemed most likely. After admission,
the patient continued to have bloody bowel movements, requiring
transfusion of a total of 3u PRBC. Due to difficulty obtaining
and maintaining peripheral IV access, a PICC line was placed on
___. Patient underwent a colonoscopy on ___ that was
negative. Given her presentation, BUN was <3 and stable
hemoglobin from ___ to ___, it was deemed that an upper GI
bleed was unlikely and Upper GI endoscopy was deferred. It was
deemed most likely that the patient had a colonic diverticular
bleed that spontaneously resolved. She was discharged home with
close follow-up on ___ for monitoring of CBC. She was instructed
to monitor for further melena or hematochezia and return if
further bleeding. She was also discharged on pantoprazole 40mg
BID.
Abd pain:
For pain during this admission, patient was given a small dose
of oxycodone as needed, with good effect. This was discontinued
on discharge.
HTN:
Amlodipine was held during this admission in the setting of GI
bleed and normotension.</s> |