Datasets:

Jarmac

/

llama2_bhc_dataset_train_prompt

like 0

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o M with PMhx of CAD s/p CABG in ___, NSTEMI, systolic CHF (EF 35-40%), PVD s/p bypass, CKD stage III, history of LLE DVT s/p IVC filter, chronic SDH, dementia and frequent falls transferred from ___ after a fall. This morning, he had witness fall in the bathroom at his nursing facility and hit his head. Of note, his grandchildren reports that he ___ been doing ___ and ___ been able to walk around. He was then transported to ___ where a head CT revealed an acute on chronic subdural hematoma. A cath was re inserted also. According to his grandchildren, he also had a foley taken out a few days ago because he had had urinary retention which was present on his last admission to ___. In the ___, initial vitals: 97.7 111/52 81 17 99Ra - Exam notable for: nonfocal, alert, confused, right periorbital ecchymsosis - Labs notable for: Hazy urine, +Leuk, + Bld, Tr protein, WBC 50-100, + Bact Hgb 10.9 Hct 34.0, PTT 26.3, Trop neg - Imaging notable for: CTA acute on chronic subdural hematoma - EKG: NSR, prolonged PR interval and RBBB - Patient was given: CefTRIAXone 1 gm IV Q24H @ 11am (___) and haloperidol 5mg x2 for agitation In the ___ ___, initial vitals: 97.6 144/68 92 18 98Ra - Exam notable for: nonfocal, alert, confused, right periorbital ecchymsosis - Labs notable for: Hazy urine, +Leuk, + Bld, Tr Protein, >182, + Bact, Hgb 11 Hct 35.0, PTT 26.3 - Imaging notable for: US ___ 1. No evidence of deep venous thrombosis in the left lower extremity veins. 2. Mild to moderate subcutaneous edema in the left lower extremity. CXR PA and LAT ___ Opacity in the left chest, particularly in the left mid to lower chest - Neurosurgery was consulted who recommended: CT head stable with left subacute on chronic SDH, no new hemorrhage, no midline shift. Exam is nonfocal, alert, following commands briskly. Recommend follow up in clinic with repeat head CT in 8 weeks as he is on ASA 81mg. On the floor, he is with his grandkids who confirms the fall. They report that this is his baseline mental state. He is able to eat by himself but continues to attempt to take out his catheter. Per grandchildren, he ___ not had any fevers, chills, dysuria, shortness of breath, chest pain. He ___ chronic asymmetric b/l lower extremity edema related to a prior LLE bypass surgery. Patient is living at ___ with 24hr supervision. He is uncooperative and does not respond to questions clearly. Though he was able to report that he does have a cough and does not have any CP/SOB/n/v. Of note, patient was recently admitted for sepsis for UTI and LLL parapneumonic effusion. See previous discharge summary dated ___ for more information. UNILAT LOWER EXT VEINS LEFT showed 1. No evidence of deep venous thrombosis in the left lower extremity veins. 2. Subcutaneous edema. Chest: Frontal and lateral views showed Interval increase in opacity in the left chest, particularly in the left mid to lower chest; differential diagnosis includes pneumonia, but in the setting of trauma, pulmonary contusion is not excluded. There is a probable small left pleural effusion and some of the opacity may relate to overlying atelectasis. The patient was diagnosed with Urinary tract infection, site not specified, Traum subdr hem w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had Primary: Chronic stable Subdural hematoma, urinary tract infection Secondary: CAD s/p CABG in ___, NSTEMI, systolic CHF (EF 35-40%), PVD s/p bypass, CKD stage III, history of LLE DVT s/p IVC filter, chronic SDH, 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>___ y/o M with PMhx of CAD s/p CABG in ___, NSTEMI, systolic CHF (EF 35-40%), PVD s/p bypass, CKD stage III, history of LLE DVT s/p IVC filter, chronic SDH, dementia and frequent falls transferred from ___ after a fall with subacute on chronic SDH and UTI. #Subacute on chronic SDH Patient presented with fall. Per neurosurgery who reviewed the CT head: CT head stable with left subacute on chronic SDH, no new hemorrhage, no midline shift. They did not feel that he had an indication for surgery. The neurosurgery team recommended follow up in clinic with repeat head CT in ___ weeks with Dr. ___ (___). His aspirin is being held until he follows up with neurosurgery. #UTI #Urinary Retention Patient with admission in ___ for UTI, and was on CTX until ___ for parapneumonic effusion. He had urinary retention and had catheter in place on admission. UTI may be catheter associated though may have had urinary frequency. Given fall and ?change in mental status causing fall decision was made to treat his UTI with Ceftriaxone. Unfortunately, micro data from ___ ___ grew Proteus with ESBL profile, sensitive to Zosyn, Ceftazadime, and Ertapenem, so decision was made to switch to Ertapenem 1 g daily IM (IV access unavailable because patient continues to rip out IV's) for total of ___ days (___). His Foley was discontinued on admission but in the setting of likely catheter-associated UTI it was discontinued on admission. He failed multiple voiding trials and a new Foley was replaced on ___ prior to discharge. We also continued his home Finasteride and tamsulosin #Fall He ___ had multiple falls recently with most recent fall witnessed. Unclear if fall was syncope related or not per history. ___ be vasovagal in setting of bathroom use. Other ddx includes orthostasis and cardiogenic causes though very low likelihood. Will discharge back to his long term rehab facility. #Toxic metabolic encephalopathy #Dementia/delirium Patient uncooperative and agitated requiring Haldol at ___. Per grandchildren, he is known to sundown and ___ difficulty adjusting to new environments. His agitation was an issue during last admission and psych was consulted who recommended 2.5mg Haldol BID. He ___ not required this back at his SNF. His current encephalopathy is likely delirium related provoked by his UTI. Required 1 dose of IV Haldol overnight ___ but stable without any issues on ___. He required no other antipsychotics for agitation. We suspect he will return to baseline after treatment for UTI. AOx3 on discharge. #LLL opacity Likely related to his previous parapnemonic effusion. There was no indication to intervene on this radiographic finding as patient was afebrile without dyspnea, cough, and leukocytosis and imaging findings can lag clinical resolution. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx of parkinsons disease, HTN, DM, dementia who presents from ___ with lethargy and dehydration. CHEST (AP AND LAT) showed No acute findings. Limited due to low lung volumes. The patient was diagnosed with Altered mental status, unspecified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old lady with history of Parkinsons disease and diabetes, who presented with fatigue, somnolence, poor oral intake, failure to thrive found to have hypernatremia. Now with plan to transition to comfort oriented care given advanced dementia. # Failure to thrive # Weight loss # Goals of care Per review of notes, there has been outpatient discussion with regard to goals of care "team at ___ has recently been discussing pt's decline. There was a family meeting and pt's 5 daughters decided together to make her DNR/DNI, ok for NIV and ok to hospitalize. They would not want a PEG placed. There is a MOLST that ___ provides that is signed by HCP (pt's other daughter is HCP), though not signed by an MD.... ___ states family recognizes that pt is in decline but this has been a difficult process." During her hospitalization with us, discussed advanced dementia, patient's failure to thrive/weight loss. Ultimately, decision was made by family to focus on patient's comfort, and in particular reiterated that they would not want a feeding tube placed. We discussed that that was consistent with geriatric society recommendations: "feeding tubes are not recommended for older adults with advanced dementia. Careful hand feeding should be offered because hand feeding has been shown to be as good as tube feeding for the outcomes of death, aspiration pneumonia, functional status, and comfort. Moreover, tube feeding is associated with agitation, greater use of physical and chemical restraints, healthcare use due to tube-related complications, and development of new pressure ulcers." Family met with ___, and will be discharged on hospice for advanced dementia. # Hypernatremia Na peaked at 160. Likely secondary to poor PO intake. Resolved with D5W. Oral intake was continued to be encouraged in the hospital. After goals of care discussion with family, it was decided that tube feeding was not within her goals; please see above. # Atrial fibrillation: New diagnosis. CHADS-Vasc of 5. Rate controlled in 50-70s without medications. Anticoagulation was not started due to transition to comfort oriented care. # Hypertension Home valsartan was held. Home amlodipine was continued; SBP 120-140s on this medication. Please have ongoing discussion with family with regard to this medication given transition to hospice care. # Parkinsons Home Sinamet was continued.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a pleasant ___ y/o borderline DM female who presents to the ED from the ___ for a 5 day history of pain,swelling and redness. She states on ___ she dropped a frozen chicken onto her bare right foot. Since then she has been soaking her foot daily, and states that since ___ she is no longer able to bear weight. Her foot has had an increase of erythema/ edema and pain over the last couple days and she now states that she feels warm. been getting She states she is a borderline diabetic,but does not take any medications. Today her glucose is 300, and her WBC is 18. She had malodor and no other complaints at this time. FOOT AP,LAT AND OBL RIGHT showed No fracture or dislocation. The patient was diagnosed with CELLULITIS OF FOOT, OPEN WOUND FOOT-COMPL, STRUCK BY FALLING OBJECT. The patient was treated with Right foot incision and drainage: ___ Right foot debridement vac application: ___. At the time of discharge, the patient had right foot 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>The patient presented to Emergency Room on ___. After thorough evaluation, it was deemed necessary to admit the patient to the podiatric surgery service and bring her to the OR for a right foot I&D. For operative details, please see the op note ___ OMR. Three days later, she was taken back to the OR for a debridement, partial closure, and VAC placement. Afterward each procedure, pt was taken to the PACU ___ stable condition, then transferred to the ward for observation. Post-operatively, the patient remained afebrile with stable vital signs; pain was well controlled with IV pain medication that was then transitioned into an entirly oral pain medication regimen on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. The patient received subcutaneous heparin throughout admission; early and frequent ambulation were strongly encouraged while remaining nonweightbearin to her right foot. The patient was subsequently discharged to home on HD5. She was sent home on clindamycin and ciprofloxacin for 10 days. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo man with HIV, HCV cirrhosis, s/p OLTx2, latent TB with recent hospitalization for suspected graft infection (LUE AVgraft placement ___ and fevers, found to have b/l psoas fluid collections concerning for abcesses, treated with vancomycin/zosyn terporarily, admitted to medicine service per request of hepatologist in setting of hyperkalemia and worsening left arm pain. . Pt. notes that over the past week, he has had intermitent nausea, preventing him from taking his antiretrovirals and immunosuppresants. Concominantly he has had chills but no objective fevers. These have resolved by ___ and he resumed his medication rregimen. Over the past week, he in addition has been more withdrawn and fatigued. He also noted increasing redness on the L arm fistula site. Although endorsed during prior interview, he denied SOB, CP, diaphoresis. He notes unchanged ___ edema. Also notes dry cough over the past month. . He was seen by Dr. ___ ___ and after a routine lab check, noted to have potassium >10 in a hemolyzed specimen, thus was called in to the ED. Please see NF note for ED course. In summary, received 1g of Vancomycin. This AM was taken to HD, however, did not undergo HD due to suspected cellulitis over the L graft. Radiology showed Two similar-appearing, but separate collections, is seen in the left upper arm. Each of these could represent a hematoma or seroma; however, infection/superinfection cannot be excluded. Radiology showed New right lower lobe opacification compatible with pneumonia. Recommend followup to resolution. Findings were discussed with Dr. ___ at 2:00 p.m. on ___ by Dr. ___ telephone. CT of the chest without intravenous contrast. COMPARISONS: Radiographs from ___ and CT from ___, dating back to ___. TECHNIQUE: MDCT of the chest was performed without intravenous contrast as per departmental protocol. Axial images are provided at 1.25- and 5-mm collimation. Coronal and sagittal reformations are provided for review. FINDINGS: A small nonhemorrhagic layering right pleural effusion can account for opacification demonstrated on concurrent radiographs. There is no evidence pneumonia. Chain sutures reflect prior resection in the right lower and middle lobes. Centrilobular emphysema is moderately severe in the upper lobes. There is no left effusion. There is no evidence of pneumothorax. Sub-4-mm nodules in the right upper lobe (4:67; 4:77) are of unlikely clinical significance. Stellate scarring within the left upper lobe (4:67) is stable since at least ___. The airways are patent to the subsegmental levels. This is no axillary, hilar, or mediastinal lymphadenopathy. Mild atherosclerotic calcification is demonstrated in the aortic arch and origins of the great vessels. There is mild aortic and mitral valvular calcification. Incidentally noted is bilateral gynecomastia. This examination is not tailored for subdiaphragmatic evaluation. The patient is status post liver transplantation. A splenule in the left upper quadrant survived splenectomy. BONE WINDOWS: There are no findings suspicious for malignancy or infection. IMPRESSION: 1. Small nonhemorrhagic layering right pleural effusion. No pneumonia. 2. Moderately severe centrilobular emphysema, predominantly upper lobe. showed 1. Small nonhemorrhagic layering right pleural effusion. No pneumonia. 2. Moderately severe centrilobular emphysema, predominantly upper lobe. This is a ___ man with history of left AV graft infection with fluid collection in the left antecubital fossa and fluid collection in the left upper arm. The initial request was to aspirate both collections; however, during the procedure, the request was changed to aspirate only the left upper arm collection. COMPARISON: Previous ultrasound examination from ___. PROCEDURE: The risks and benefits of the procedure were explained to the patient and written informed consent was obtained. A preprocedure timeout was performed verifying patient identity using three patient identifiers and the procedure to be performed. The aspiration site was selected using ultrasound. The skin of the left upper arm was prepared and draped in standard sterile fashion. Local anesthesia was achieved via subcutaneous injection of 1% lidocaine buffered with bicarbonate. Under ultrasound guidance a 25-gauge needle was advanced into the small liquefied portion of this lesion. Less than 1 mL clear fluid was aspirated. The sample was sent for gram stain and culture. The patient tolerated the procedure well with no complication evident at the time of the procedure. The attending radiologist, Dr. ___, was present throughout the procedure. IMPRESSION: Technically successful aspiration of fluid from a left upper arm collection. showed Technically successful aspiration of fluid from a left upper arm collection. The patient was diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, PAIN IN LIMB, SWELLING OF LIMB, ABN REACT-RENAL DIALYSIS, END STAGE RENAL DISEASE, LIVER TRANSPLANT STATUS. The patient was treated with Aspiration of fluid collection in the axial aspect of the graft. At the time of discharge, the patient had Primary: Graft cellulitis AND seroma of graft Secondary: End stage renal disease, HIV, liver transplatation.. The patient was given written instructions concerning 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 man with HIV, HCV cirrhosis, s/p OLTx2, latent TB with recent hospitalization for suspected graft infection (LUE AVgraft placement ___ and fevers, found to have b/l psoas fluid collections concerning for abcesses, treated with vancomycin/zosyn terporarily, admitted to medicine service per request of hepatologist in setting of hyperkalemia and worsening left arm pain. Hyperkalemia was a spurious findging. # LUE AV cellulitis at site of Left axilla. Site was erythematous and TTP with thrill. Patient was started on vancomycin 1g with HD for suspected cellulitis. Repeat US of both AV sites in ___ showed shrunken fluid collections at AC fossa, but increased in size in the axilla. Tenderness progressed throughout hospitalization requiring increased pain regimen. Patient had a difficult cannulation episode in the AC graft with clot removal and successful subsequent HD session. BCx remained negative and patient was afebrile while on vancomycin IV. Throughout his stay, he was monitored by Transplant Surgery Service, who felt his graft was not infected. In agreement with infectious dsiease, there was significant concern for endovascular infection given increasing fluid collections as well as cellulitis over the graft. Patient's proximal fluid collection was aspirated per discussion with ID and Renal. This revealed 2+ PMNs, serous fluid w/ negative cultures consistent with a seroma. Patient's pain was felt to be due to expansion of the seroma and improved with drainage (self drainage occured prior to aspiration). Patient was discharged home after completion of vancomycin IV with HD. Pain improved at time of discharge. Given episodes of clot aspiration from graft, patient was arranged for outpatient evaluation of AV fistulogram per discussion with renal. # Cough, chest pressure, chronic. Was found to have an incidental finding of RLL infiltrate on ED CXR. Started empirically on cefepime for HCAP, CT chest revealed near resolution of prior infiltrate and a small effusion. Cefepime was discontinued. # Hyponatremia/volume overload. While awaiting HD session over the weekend, patient developed worsening hyponatremia (119) and was found to be whole body volume overloaded (scrotal edema) with mild encephalopathy. Infectious w/up was unrevealing. It was felt, that patient had took in a grossly larger amount of free water. As HD was performed, volume status normalized and hyponatremia improved to baseline (high 120s). On day of d/c Na was 125 prior to HD. Patient's scrotal edema resolved, ___ trace edema was present bilaterally and encephalopathy had resolved. He was discharged on 1.5L fluid restriction. # ESRD on HD: ___. Maintained on home regimen, sevelamer an low P diet was started for hyperphosphatemia and he was started on Sevelamer. No other changes were made. # HCV cirrhosis s/p OLT x2: HCV VL > ___. At this point no evidence of cirrhosis clinically. Sirolimus level was 4.1 on admission and 6.6 at discharge. He was maintained on current dose, however timing had to be changed to ___ given changes in HD schedule due to hyponatremia. Continued on other immunosuppressants w/o changes in dose. # HIV. Neg. VL and last CD4 count > 1000. Continued on home ARV regimen. </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 MM s/p auto transplant ___, more recently on Revlimid with a recent admission ___ for S. Pneumo pneumonia on Ceftriaxone/doxycycline, then transitioned to levofloxacin on discharge to complete 10 days of antibiotics (last day was to be tomorrow), also extensive workup for PE given his hemopytsis with V/Q scan and MRA/V chest, bilateral LENIs, all negative for clots. He reports a new chest pain which started the day of discharge, "knife-like" per patient, which is worse with cough and inspiration. This is the same pain he had experienced prior to his first admission but it had resolved. The pain initially was waxing and waning. This pain has been present for the past 2 days. It is not worsening. It is currently a ___ but worsens significantly with deep inspiration or coughing. It is worse with lying down and he had to sleep sitting up one night. He denies worsening shortness of breath or DOE, fevers, chills, night sweats, nausea, vomiting, abdominal pain, leg swelling. He has no hemoptysis. In the emergency department, initial vitals: 97.4 58 123/74 20 99%. CXR was unremarkable. ECG showed sinus bradycardia with a RBBB, unchanged from baseline. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Radiology showed Mild bibasilar atelectasis, relatively unchanged compared to the prior study. Radiology showed 1. Small right pleural effusion with adjacent right lower lobe atelectasis and/or pneumonia. The effusion has decreased since ___. 2. Other scattered foci of atelectasis, particularly at the left lung base and in the inferior lingula. 3. Multiple osseous lucencies in keeping with myeloma are unchanged from ___. No new dominant lesion. No acute rib fracture or compression deformity. 4. Coronary artery calcifications. Right-sided pleuritic chest pain in a patient with history of multiple myeloma. PA and lateral upright chest radiograph was reviewed in comparison to chest CT from ___. Right basal consolidation and pleural effusion appear to be present on the current study, improved since ___, but more conspicuous as compared to ___. Only small amount of pleural fluid currently seen. There is no pneumothorax. Left cardiophrenic angle is unremarkable. Those findings are most likely in consitency with developing rounded atelectasis at right lung base, but of note that this study neither confirm no exclude the diagnosis of pulmonary embolism. was done. The patient was diagnosed with PLEURISY W/O EFFUS OR TB. At the time of discharge, the patient had Primary: pneumonia Secondary: multiple myeloma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ gentleman with a history of multiple myeloma s/p auto transplant in ___, most recently on Revlimid, who presents with ongoing pleuritic right sided chest pain in setting of recent treatment for bacterial pneumonia. # Chest pain: nonexertional, right sided, EKG was not suggestive of cardiac ischemia. Patient underwent extensive workup for PE during prior hospitalization (V/Q scan, MRA, LENIs) which were negative. ECHO was done this hospitalization, negative for right sided valve vegetations. Rib films were negative for fracture. CT thorax showed persistent but resolving right sided pleural effusion, likely due to recent pneumonia. Patient was placed back on ceftriaxone/levofloxacin. His pain gradually improved over hospital day ___. He did require nightly doses of oxycodone for pain control. Given his ongoing pain, pulmonology service was consulted who recommended pain control and incentive spirometry. He completed 5d of ceftriaxone and will be discharged with an additional 5d course of levofloxacin. His pain was largely resolved by day of discharge, will go home with small supply of oxycodone to take as needed. # Multiple myeloma s/p transplant: currently treated with revlimid and dexamethasone as an outpatient. Patient did not continue revlimid while in house, further management as per outpatient oncologist. # CKD: Patient presented with Cr of 2.4, slightly increased from his recent baseline of 2.0-2.2. His lisinopril was held on discharge as his creatinine was still elevated to 2.5. This can be restarted based on further assessment of kidney function. # Hx. aflutter: patient was sinus on admission, continued metoprolol and diltiazem # HTN: lisinopril was held as above TRANSITIONAL ISSUES - patient has f/u with ___ clinic to address resolution of pleuritic chest pain - patient will complete 5d course of levofloxacin - patient's lisinopril is on hold pending improvement in kidney function - patient remained full code</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ who tripped over a quilt and fell onto her left hip. She noticed immediate pain and called ___. She was brought here by ambulance. She denies numbess, paresthesias or weakness in her left leg, but it is quite painful when it is moved. She denies LOC, hitting head, other areas of pain. She has a history of osteoporosis and has taken bisphosphonates in the past - though she is not taking any now. Currently taking Vit D and calcium supplements. She is followed by endocrinology at ___. Radiology showed 1. Minimally displaced fracture of the superior portion of the greater trochanter of the left hip. 2. Calcification inferior to the greater trochanter is consistent with calcific tendinosis. These findings were communicated by Dr. ___ to Dr. ___ telephone immediately after discovery on ___ at 3:25 p.m. Radiology showed 1. Comminuted fracture of the left proximal femur greater trochanter, likely involving the gluteus tendon insertion sites. 2. No evidence of fracture traversing the femoral neck or intertrochanteric portion of the left femur. 3. Only mild right hip degenerative changes. 4. Findings are concordant with the wet reading provided on PACS which reads as follows "comminuted fracture of the left greater trochanter without apparent extension into the femoral neck. No additional left hip fracture. No dislocation of the left hip, a joint effusion, or evidence of lipohemarthrosis. No underlying lesion is suspected. Wet read in RISweb." The patient was diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left greater troch fracture and was admitted to the orthopedic surgery service. The injury was determined to be non operative on initial imaging and assessment. The patient worked with ___ and was able to bear weight and mobilize on the left lower extremity so ___ determined that discharge to home with home ___ was appropriate. The patients home medications were continued throughout this hospitalization. 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, and the patient was voiding/moving bowels spontaneously. The patient is weight bearing as tolerated in the left lower extremity with recommendations of minimal abduction of the leg until follow up due to having the greater troch fractured. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ Stroke Scale (performed within 6 hours of presentation)- Total [20] Date: ___ Time: 1735 CHEST (PORTABLE AP) showed 1. An endotracheal tube terminates approximately 4.5 cm above the carina. 2. Left upper lobe opacity better seen on CTA head and neck performed earlier on same day, concerning for pneumonia or aspiration. CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK showed 1. No evidence of acute infarction, hemorrhage or intracranial mass. 2. Most likely artifactual symmetric perfusion mismatch involving the bilateral occipital lobes. 3. Saccular 3 mm left ophthalmic artery versus carotid cave aneurysm. 4. Short-segment caliber change in the distal V2 segment of the right vertebral artery, most likely related to a noncalcified atherosclerotic plaque, however, a small focal dissection is not entirely excluded. 5. Atherosclerotic plaque at the origin of the right vertebral artery, resulting in at least mild stenosis. 6. Otherwise patent cervical intracranial vasculature without evidence of stenosis or occlusion. RECOMMENDATION(S): Saccular 3 mm left ophthalmic artery versus carotid cave aneurysm, neurosurgical consultation is suggested. MRI ROUTINE SEIZURE PROTOCOL WANDW/O CONTRAST ___ MR HEAD. showed 1. Moderate motion degradation, limiting assessment. Within these confines: 2. Possible small focus of T2 hyperintense signal in the right hippocampal head, which is nonspecific but could represent a small focus of right hippocampal gliosis. No definite left hippocampal signal abnormality, within confines of motion degradation. 3. Bilateral grade 3 or 4 medial temporal lobe atrophy, including marked hippocampal height loss. 4. No acute infarct, hemorrhage, or extra-axial collection. 5. Global parenchymal volume loss. 6. Mild changes of chronic white matter microangiopathy. CHEST (PORTABLE AP) showed Heart size is normal. Mediastinum is normal. Lungs overall clear. There is no appreciable pleural effusion. There is no pneumothorax. No definitive consolidation demonstrated. The patient was diagnosed with Altered mental status, unspecified. The patient was treated with LP. At the time of discharge, the patient had 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>___ is a ___ year old woman with PMH of frontal dementia, HTN, HLD, and depression who was admitted to the neuro ICU due to concern for seizure s/p intubation. CT/CTA/CTP only revealing for potential PNA. MRI wuthout stroke. Per discussion with daughter and review of EMS records, patient's presentation could be consistent with a secondary generalized seizure, but this is questionable as other "drop attacks" reportedly may have been worked-up to be syncopal in nature. LP reassuringly bland. She is now at neurological baseline. Impression is seizure vs rigors provoked by community acquired pneumonia vs progression of frontotemporal dementia. Given the fact that she is certainly at risk for seizures, opt to continue treatment with keppra indefinitely. # Neuro: - EEG IMPRESSION: Occasional rhythmic delta activity in the left temporal region, consistent with LRDA. Intermittent polymorphic delta slowing over the left temporal region, indicative of left temporal focal cerebral dysfunction. Diffuse background slowing and disorganization, indicative of mild diffuse cerebral dysfunction. No electrographic seizures or epileptiform discharges. - Continue Keppra 1g PO BID - She was continued on home Donepezil - Memantine was held and in conjunction with OP neurologist, plan to discontinue this medication as it has not been hepful. # CV/Pulm: - Continued on home ASA and statin # ID: - treated with CTX and azithromycin for community acquired PNA. - She completed 5d of azithromycin in the hospital - CTX was transitioned to cefpodoxime while inpatient, she has 2 days left to complete 7 day course. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F with hx reflux re-presenting ___ to ED with the worst headache of her life on a history of known L MCA aneurysm detected 2 days prior. On ___, patient initially presented with sudden onset headache. She was with her father who was getting admitted for a medical issue, when she suddenly developed an acute sharp occipital headache associated with nausea. She has never had migraines before and never had headaches like this in the past. Normal CT, but concern for possible reversible cerebral vasoconstriction syndrome in setting of beading seen on CTA of L MCA (in addition to aneurysmal sac). CTA showed no hemorrhage but did show a L MCA aneurysmal sac. LP was deferred. MRI w/o contrast was performed and showed subtle hyperintense signal in Right superior frontal sulcus possibly representing subarachnoid hemorrhage; it also showed cortical gyriform hyperintensity of Left medial parietal occipital lobe with no evidence of hemorrhage on GRE nor restricted diffusion on DWI, therefore likely representing subacute infarct. She was discharged home on ___ after observation with follow-up with neurosurgery for the incidental L MCA aneurysm. Since that time she had continuous dull bioccipital headache without associated symptoms. Then on day of admission ___ at 1500 she again developed severe sudden onset bioccipital throbbing headache which progressed to involve her entire head. It is associated w nausea and vomiting but no photophobia or phonophobia. At onset she denied neck pain/discomfort, vision changes, weakness, tingling/numbness, speech difficulty, or confusion. On arrival to the ED she was reportedly neurologically intact. She had another NCHCT which did not show any hypodenstity or hemorrhage. She was again evaluated by neurosurgery in the ED who recommended a LP for ruling out SAH. CSF with WBC 57, RBC 11,451 in tube 1 and WBC 90, RBC 11,947 in tube 4. There was reportedly no xanthochromia. At time of neurology evaluation around ___, patient was still having nausea and vomiting, but overall reported feeling somewhat better (headache more dull and less severe). She notes loss of right visual field around 6P but otherwise no weakness, tingling or numbness. CT/CTA was done which showed a new left parietal-occipital intraparenchymal hemorrhage measuring approximately 3.8 x 2.7cm with a 1 cm rightward midline shift. Patient admitted to neuro ICU for close neurological monitoring and blood pressure management. CT HEAD W/O CONTRAST showed 1. No evidence of acute infarction or intra-axial hemorrhage. No CT correlate for findings seen on recent MRI. 2. Moderate paranasal sinus disease. CT ANGIOGRAPHY HEAD AND NECK showed 1. New intraparenchymal hemorrhage in the left parieto-occipital region measuring 3.8 x 2.7 cm with midline shift and early uncal herniation. Subarachnoid blood is also identified. 2. No significant change since the previous CT angiography examination. Previously noted left MCA aneurysm is again noted. No new vascular occlusion is seen. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Findings concerning for enlargement of the left parietal and occipital hematoma. 2. Several areas of peripheral enhancement that raise concern for possible mycotic aneurysm. Alternatively, this may reflect enhancement or engorged veins associated with the hematoma itself. 3. Subarachnoid hemorrhage, superficial cirrhosis or both in both hemispheres. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No significant change in the known, left parieto-occipital hematoma, with subsequent mass effect, including stable rightward shift of normally midline structures, effacement of the left lateral ventricle, sulci of the left cerebral hemisphere, and basilar cisterns. Stable probable left uncal herniation. No evidence of new hemorrhage. 2. Stable left subdural hematoma, with subdural blood tracking along the falx and tentorium. 3. Stable subarachnoid blood interdigitating between sulci of the left cerebral hemisphere. 4. Redemonstrated paranasal sinus disease. Radiology showed Lungs are clear. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen. The aorta is unfolded and tortuous. Diagnostic cerebral angiogram The following vessels were catheterized Right common femoral artery Right internal carotid artery Right external carotid artery Left vertebral artery Left internal carotid artery Left external carotid artery showed Fusiform aneurysm of the left MCA bifurcation. No evidence of vascular malformation to explain left occipital intraparenchymal hematoma. RECOMMENDATION(S): 1. Will discuss aneurysm in vascular conference. The patient was diagnosed with Headache. The patient was treated with ___ cerebral angiography. At the time of discharge, the patient had Reversible cerebral vasoconstriction syndrome Intracranial Hemorrhage. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>In brief, Mr. ___ is a ___ right-handed woman with a past medical history of hypothyroidism and GERD who presented with recurrent thunderclap headaches was found to have a new left parietal intracranial hemorrhage and mass-effect on the left ventricle and subarachnoid bleed. She was also noted to have a 6 mm aneurysm of the left M1. Presentation is found to be most consistent with reversible cerebral vasoconstriction syndrome. Reversible cerebral vasoconstriction syndromes (RCVS) are a group of conditions characterized by reversible narrowing and dilatation of the cerebral arteries. The cause of this syndrome is unknown, though the reversible nature of the vasoconstriction suggests an abnormality in the control of cerebrovascular tone. RCVS can cause intraparenchymal hemorrhages, subarachnoid hemorrhages and cerebral edema. Several other differential diagnoses were ruled out. An MRI with MRV did not show any evidence of venous thrombus. A cerebral angiography did not show any vascular spasms or vascular malformation. Inflammatory markers were negative making a vasculitis unlikely. A trans-thoracic echocardiogram was negative for any cardioembolic source or evidence of endocarditis. Ms ___ received supportive therapy directed towards managing her intracranial pressure, blood pressure and headaches. She was started on oral calcium channel blockers to treat vasoconstriction (nimodipine and amlodipine). She will finish a 20-day course of nimodipine on ___ and will continue amlodipine. She was started on a prednisone taper which was completed on ___. She was started on lisinopril with a goal blood pressure in the normotensive range. For symptomatic treatment of headaches and neck pain she received Tylenol, lidocaine patches and Flexeril as needed. Zofran was given scheduled to help mitigate nausea associated with taking nimodipine. +++++++++++++++++++++++++ Transitional issues -Continue nimodipine until ___ -Continue amlodipine -Continue other antihypertensive agents -Consider starting a statin if LDL continues to be elevated (here LDL was 155) -Follow up in our stroke clinic -Please call ___ for a Neurosurgery follow-up appointment with Dr. ___ in 3 months. +++++++++++++++++++++++++++ AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (bleeding risk, hemorrhage, etc.) 3. Smoking cessation counseling given? () Yes - () No [reason (x) non-smoker - () unable to participate] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male with CAD (cardiac catheterization in ___ showing occluded LAD), CHF (normal EF, mild to moderate AR, increased pulmonary artery systolic pressure), last echo ___, atrial fibrillation since ___ (rate controlled and anticoagulated) presents with dyspnea. Portable chest radiograph showed Pulmonary edema with bibasilar atelectasis, pneumonia cannot be excluded. CHEST (PORTABLE AP) showed ___. Low lung volumes. Moderate cardiomegaly with mild pulmonary edema. No larger pleural effusions. Mild retrocardiac atelectasis. No pneumonia. CHEST (PORTABLE AP) showed Comparison to ___. Moderate cardiomegaly persists. Minimal left pleural effusion. Moderate retrocardiac atelectasis. Mild pulmonary edema. No pneumonia. CT CHEST W/O CONTRAST showed 1. Small bilateral pleural effusions left greater than right with associated atelectasis. No evidence of pulmonary edema or aspiration pneumonia. 2. Tracheomalacia. 3. Severely dilated main pulmonary arteries suspicious for pulmonary hypertension. 4. Severe Coronary artery calcifications. The patient was diagnosed with Heart failure, unspecified, Chronic obstructive pulmonary disease w (acute) exacerbation, Unspecified atrial fibrillation. At the time of discharge, the patient had Primary Diagnosis: Dyspnea Secondary Diagnoses: Atrial Fibrillation Hypertension Coronary Artery Disease Dysphagia Urinary Retention. The patient was given written instructions concerning 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 CAD (cardiac catheterization in ___ showing occluded LAD), CHF (normal EF, mild to moderate AR, increased pulmonary artery systolic pressure), last echo ___, atrial fibrillation since ___ (rate controlled and anticoagulated) presents with dyspnea. ACUTE ISSUES: ============= #Goals of Care: Patient's family expressed desire to transition to hospice care. Patient was discharged to hospice care. #Rash: New rash noted on L buttocks on day of discharge. Papular with rare vesicles concerning for zoster (slight dermatomal distribution, initial report of pain) versus contact dermatitis versus satellite lesions from candidate dermatitis. VZV swab and culture were performed. Patient was discharged with empiric treatment of acyclovir. After uninterpretable test results resulted for VZV direct antigen test, patient was called to discontinue treatment given absence of pain and thus lowered suspicion for shingles, in light of potential renal adverse effects of valacyclovir. #Dyspnea: Patient reported to have increased dyspnea and wheezing since ___. Had been evaluated at ___ for this on multiple occasions prior to admission at which time diuretics were intermittently increased with variable relief of symptoms. Patient with new oxygen requirement at time of admission. Dyspnea felt to be due to volume overload. Echocardiogram revealed moderate regional left ventricular systolic dysfunction c/w CAD (LAD distribution) with remaining segments contracting vigorously (LVEF = 35-40 %) increased PCWP, and mild to moderate aortic regurgitation. This was a newly depressed EF when compared to ___ echocardiogram noted in ___ records that reported EF of 55-60%. Patient was diuresed with IV diuretics during hospital stay and discharged on bumetadine 1mg daily in addition to carvedilol 12.5mg BID. Hydrazine 25mg TID, imdur 20mg TID, amlodipine, ibesartan were discontinued given palliative goals of care. Discharge weight was 95.2 kg. Patient breathing on room air at time of discharge. #Hypernatremia: Hospital stay was complicated by hypernatremia that improved with slow administration of D5W. #Urinary tract infection: Leukocytosis on admission to 11.7. Patient denied dysuria but found to have coagulase negative staphylococcus on urine culture. Initially was treated with ceftriaxone/vancomycin that was broadened to vanc/cefepime/flagyl after patient spiked temperature on initial therapy. Given goals of care and based on culture sensitivities, patient was transitioned to oral levofloxacin Q48H that patient was to continue on discharge. Leukocytosis stable at 12.0 at time of discharge. Blood cultures were all no growth final read. #Atrial fibrillation: Occurring since ___. Atrial fibrillation was rate controlled on metoprolol 125mg per day and anticoagulated on warfarin. Warfarin was discontinued given goals of care. Aspirin 81 mg was continued. Metoprolol was discontinued and patient was discharged on carvedilol 12.5 BID. #HTN: amlodipine, ibesartan, hydralazine 25mg TID and imdur 20mg TID were discontinued given GOC. Patient was discharged on carvedilol 12.5 BID #CAD: Per atrius notes, cardiac catheterization in ___ showing occluded LAD. Patient with rising troponin during hospital stay, felt to be due to demand ischemia. Given that patient was DNR/DNI and was not a candidate for catheterization, further troponin checks were discontinued. Simvastatin was discontinued at time of discharge. Aspirin 81mg was initially discontinued at time of discharge but patient's wife was called following discharge and told to continue it. #CONCERN FOR DYSPHAGIA: Family and nurse note occasionally coughing/having trouble swallowing salivary secretions. S/S evaluated patient with video swallow ___ year ago at which time had evidence of aspiration to thin liquids and nectar thick as well. Discussion of risks/benefits with wife/HCP ___ was performed with plan to continue feeding during hospital stay. CHRONIC ISSUES: =============== #PSYCH: Donepezil 10 mg PO/NG QHS #URINARY RETENTION: Finasteride 5 mg PO DAILY Transitional Issues: ====================== - needs Q48h levofloxacin until ___ - discharging on 1mg bumex daily. Should increase to 1mg BID if patient noted to have increasing shortness of breath. Can return to 1mg daily as breathing improves - noted to have papulovesicular rash on buttocks. Swab and culture for zoster were pending at time of discharge. Patient was initiated on empiric treatment with valacylovir BID and will be called with results. Treatment will be discontinued if results are negative. - dysphagia: risks of aspiration with po intake including both thin and nectar thick liquids were discussed with patient's wife and son and discussed need to balance this risk with patient's comfort and goals of care at this time. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with a history of severe COPD (on ___ O2 at home) with O2 destaturations with ambulation at baseline, OSA on CPAP, history of panic attacks, insomnia, who presents with several weeks of decreasing exercise tolerance and with increasing agitation at home. CHEST (PA AND LAT) showed 1. Marked bullous emphysema. 2. Patchy left upper lobe opacity, new in the interval, may reflect infection, however underlying neoplasm cannot be excluded. Additional patchy left lower lobe opacity may reflect additional site of infection or atelectasis. Followup radiographs after treatment are recommended, and if the finding in the left upper lobe persists, dedicated chest CT is suggested. 3. Pulmonary arterial hypertension. CTA CHEST WITH CONTRAST showed 1. Somewhat limited exam due to respiratory motion artifact. No evidence of pulmonary embolism to the segmental levels. 2. Left upper lobe opacity, concerning for infection. 3. Prominent hilar lymph nodes, likely reactive. 4. Severe emphysematous disease. RECOMMENDATION(S): Recommend further imaging after treatment to assess for underlying lesions. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Allowing for streak artifact from embolization material at the vertex, there is no evidence for acute hemorrhage or other acute intracranial abnormalities. 2. Increased local parenchymal volume loss compared to ___. CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD showed 1. No acute intracranial abnormality. 2. Interval progression of small vessel ischemic disease and age-related into involutional changes. 3. Stable findings related to prior embolization of dural AV fistula with associated streak artifact limiting the evaluation of surrounding brain parenchyma. 4. Intracranial atherosclerosis involving cavernous, supraclinoid ICAs resulting in mild stenosis. 5. Atherosclerosis involving V4 segments of bilateral vertebral arteries resulting in moderate to severe luminal narrowing. 6. No aneurysm or occlusion is seen. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Interval progression of confluent FLAIR hyperintensity in the periventricular, subcortical and deep white matter, nonspecific. This is likely secondary to small vessel ischemic disease. 2. Age-related involutional changes. 3. No acute intracranial abnormality. Unchanged appearance of posterior vertex embolization of dural AVF. The patient was diagnosed with Dyspnea, unspecified. At the time of discharge, the patient had Encephalopathy Central Sleep Apnea Atrial Fibrillation Benign Prostatic Hyperplasia 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 M with history of COPD (On ___ O2 at baseline), OSA on CPAP, CAD who presents with subacute agitation and nighttime hallucinations and acute on chronic dyspnea. #Agitation, anxiety, hallucinations: Has several week history of agitation, particularly at night. During first 24 hours in hospital he required 12 mg IV Haldol. Subseuqently his mental status improved and he was calm/alert/oriented, however subsequent exam was notable for pillrolling tremor, masked facies, cogwheeling raising question of Parkinsonism. This diagnosis was particularly interesting given that it could explain central sleep apnea and autonomic dysfunction (hypotension, changes in urinary fx) as well as intermittent agitation and hallucinations. Neurology was consulted and felt that the symptoms of cog-wheeling and pill-rolling were likely related to heavy Haldol exposure on admission. They were concerned for possible REM behavior sleep disorder. It was also possible that progression of his central sleep apnea was causing agitation/delirium particularly at night. A head CT was obtained that showed no bleed but significant small vessel disease. MRI head with and without contrast to evaluate for stroke revealed no acute changes. B12 and TSH were normal. RPR was nonreactive. Given possibility that polypharmacy (esp recent initiation of benzos) was contributing, home benzos were stopped as was home ambien. On HD2 given parkinsonism on exam he was changed from Haldol to Seroquel for agitation. He had no further episodes of agitation and no further notable Parkinsonian symtoms after transfer to the floor. # Leukocytosis # LUL infiltrate Presented with leukocytosis to 36 concerning for acute infectious process, and with LUL opacity c/f PNA on CTA chest. This LUL infiltrate had previously been noted on a ___t OSH. He had no other localizing s/s of infection aside from dysuria (but only 2 WBC on UA) and diarrhea (c diff negative, started after initiating abx). He was treated with ceftriaxone x7 d and azithromycin x 5 d for CAP. Plan was for PET-CT as an outpatient given possibility that LUL infiltrate represented malignancy in this former cigarette smoker. Discussed with radiology - will have to wait 1 month following resolution of PNA to pursue PET scan. #Atrial fibrillation: New diagnosis during this hospitalization, possibly precipitated by infection. He was started on metoprolol, which was uptitrated to provide adequate rate control. Coreg was discontinued. Given his high CHADS2 score, he was also initiated on Apixaban. Aspirin and Plavix were stopped after discussion with his PCP and cardiologist to decrease risk of bleeding while using Apixaban. TTE was done which was limited study but largely unremarkable. #Aniscoria: Patient noted to have aniscoria with possible mild right sided weakness. He underwent CTA head to evaluate for AVM which revealed none. MRI head with and without contrast showed no acute changes. #Lactatemia: #Hypotension: He was hypotensive overnight ___. This was most likely mild hypovolemia from poor intake while delirious and from GI losses (diarrhea). Hypovolemia was further supported by accompanying rise in BUN/Cr. BPs and lactate improved with gentle IVF bolus. #Acute on Chronic Dyspnea: Presentation was consistent with progression of his COPD rather than exacerbation as no clear worsening in dyspnea, no wheeze on exam or change in VBG, slightly worse cough but no new sputum pdt. He was clinically euvolemic pointing against CHF exacerbation. CT negative for PE. Given leukocytosis and LUL CT findings, he was treated for CAP as above. Suspect that anxiety was also contributing to intermittent sensation of dyspnea. He remained stable on his home O2 ___ L NC) throughout his stay. Pt seen by ___ who noted that he desatted to the 70's with ambulation even with O2. Pt noted that this is not far from his baseline given his significant COPD and is insistent on d/c home. Discussed with patient that our recommendations would be for rehab to build up his strength and optimize his pulmonary status prior to going home. Pt refuses rehab and opted for d/c home. #Central sleep apnea: He had an incomplete sleep study in ___ that was most suggestive of a central (rather than obstructive) etiology for sleep apnea. He was fitted for CPAP but did not tolerate the mask, possibly b/c central OSA can be worsened by CPAP. As above he underwent CT head and neurologic eval to help w/u for neuro cause of central sleep apnea. While inpatient he was put on NC rather than cpap at night. Plan is to follow up with ___ (sleep specialist) who saw him inpatient in the FICU regarding his sleep apnea. #Voiding difficulty: Reports sensation of difficulty voiding (sensation that he frequently needs to void but unable to pass urine). This was of unclear chronicity but worse over past few weeks. UA was negative. ___ represent progressive BPH or from neurologic process as above with autonomic dysfunction. NPH unlikely given CT head findings. Started on tamsulosin. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o seronegative RA admitted with SOB in the setting of pericardial and pleural effusions. Patient was seen by her PCP at ___ on ___ for left sided pleuritic chest pain and dry cough which began on ___. She notes that she never had fever or productive cough, no sick contacts. CXR at that visit showed minimal R basilar infiltrate vs atelectasis, WBC 16.6. Pt was prescribed a Z pack for presumed CAP and returned to ___ ___ ___ for continued dyspnea and left sided rib pain. Repeat CXR showed possible L pleural effusion and associated atelectasis vs PNA. Pt was prescribed doxycycline 100mg BID x 10 days and a CTA chest was obtained which was negative for PE but showed small left pleural effusion with associated atelectasis and/or infiltrate and moderate pericardial effusion. Repeat WBC rose to 17.2 and doxycycline was changed to Augmentin on ___. Pt reported continued cough, SOB and pleuritic pain and was advised to report to ED for further work up. She initially declined to go to ED, but agreed after phone discussion with PCP ___ ___ for worsening SOB. Pt reports that she has had intermittent chest discomfort when laying flat for the last several weeks. MRCP showed Minimal intra and extrahepatic bile duct dilation. Post cholecystectomy could contribute, but cannot exclude additional ampullary stenosis or sphincter of Oddi dysfunction. No obstructing stone or mass lesion is identified. Known complex pericardial effusion. Physiologic effects of this effusion on cardiac function would be best assessed with echocardiography FOOT AP,LAT AND OBL BILATERAL showed No acute bony injury. Medial subluxation of the second toe in relation to the second metatarsal heads bilaterally. Mild degenerative changes of bilateral first MTP joints, left side worse than right. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Mild central intrahepatic biliary dilatation, status post cholecystectomy, which is nonspecific given lack of prior imaging. The patient was diagnosed with SHORTNESS OF BREATH, PERICARDIAL DISEASE NOS, PLEURAL EFFUSION NOS. At the time of discharge, the patient had Primary diagnosis: viral pericarditis Secondary diagnosis: rheumatoid 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>Impression: Ms. ___ is a ___ lady with h/o seronegative RA presenting with DOE and cough in the setting of recently diagnosed pleural and pericardial effusions, most likely due to viral process. # Pericardial effusion: Outpatient CTA showed moderate-sized pericardial effusion and patient presented with pleuritic, positional chest discomfort suggestive of pericarditis. There were no EKG changes c/w pericarditis and patient remained stable with normal BP and pulsus. Echo showed a small pericardial effusion without any tamponade physiology. Given the presence of both a pericardial effusion and pleural effusion, rheumatology was consulted for possibility of serositis complicating an underlying rhematologic disorder. They did not believe her symptoms were consistent with either RA or lupus. Diagnostic tests were sent and pending at discharge, including ___, anti-Sm Ab, anti-dsDNA Ab, RNP Ab, anti-CCP Ab, Ro & La. Patient treated with aspirin 650mg TID and colchicine 0.6 BID and will continue these for 2 weeks and 3 months respectively. # Dyspnea: Outpatient CTA noted a small left-sided pleural effusion and patient had persistent dyspnea for 3 weeks. She completed a course of azithromycin and trial doxycycline and augmentin and was started on levofloxacin in the ED. Antibiotics were held and repeat CXR as well as bedside ultrasound did not show any effusion. Dyspnea most likely multifactorial from body habitus, pericardial effusion, and atelectasis. # LFT abnormalities: Patient presented with mild transaminitis with markedly elevated alkaline phosphatase and GGT on admission. RUQ ultrasound showed mild central intrahepatic biliary dilatation and thus, MRCP was performed. This study showed minimal intra and extrahepatic bile duct dilation without any obstructing stones or mass lesions. ALT/AST/ALP trending down at discharge. # Leukocytosis: Patient with increasing leukocytosis as outpatient to peak of 17.2 and on admission was 13.1. Most likely due to a viral process such as ___ virus, leading to systemic inflammation and pericarditis. CRP also elevated to 250 and ferritin as high as 1100. Leukocytosis downtrending on discharge to 11. # Chronic Normocytic Anemia: HGB on admission noted to be 9.4 on ___ from prior baseline 10.7 as of ___ per ___ records. Iron studies consistent with iron deficiency but patient refused iron supplementation. # Rheumatoid arthritis: Patient with history of seronegative RA followed by ___ Rheumatologist ___. She was previously on methotrexate which is being in the setting of PNA. Rheumatologic evaluation recommended x-rays of the foot to evaluate for bony erosions, but only showed mild degenerative changes. Per our rheumatology colleagues, we would recommend re-evaluation of the diagnosis of RA.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female who had acute abdominal pain today, POD10 from elective laparoscopic cholecystectomy at ___ ___. History of atrial fibrillation, mechanical mitral valve (St. ___ in ___ - she was bridged to enoxaparin perioperatively without any untoward events in that time period. On POD8 she saw her PCP and her INR was in the low 2 range - she was advised to discontinue the enoxaparin. Today, after her pain began, she presented to ___ where a CT abdomen pelvis with IV contrast revealed an enhancing focus / contrast blush adjacent to the surgical clips in the gallbladder fossa. She was given 1u PRBC, 1u FFP, PCC, vitamin K. CTA ABD AND PELVIS showed 1. Laceration of the inferior medial right liver surface extending to the surgical bed. No CTA evidence of active arterial extravasation or pseudoaneurysm formation. 2. Moderate to large volume hyperdense intra-abdominal and intrapelvic fluid, consistent with hemorrhage, appears increased in size compared to recent outside CT abdomen pelvis performed ___. 3. Mild periportal edema. NOTIFICATION: The findings were discussed with Dr. ___. by ___ ___, M.D. on the telephone on ___ at 12:31 pm, 10 minutes after discovery of the findings. Radiology showed Diagnostic angiography as above without evidence of active extravasation or pseudoaneurysm. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Perihepatic hematoma as on recent CT exam, appears similar in overall volume and distribution. 2. Status post cholecystectomy. CTA ABD AND PELVIS showed 1. Right hepatic laceration with no signs of active extravasation. 2. Interval worsening of the hemoperitoneum, now severe. 3. Small linear focus of enhancement adjacent to the cholecystectomy surgical clips, which is concerning for a pseudoaneurysm. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 9:02 pm, 1 minutes after discovery of the findings. CHEST (PORTABLE AP) showed No comparison. The lung volumes are normal. Correct alignment of sternal wires. Status post valvular replacement. Left pectoral single lead pacemaker is in correct position, the lead is in the right ventricle. No pleural effusions. No pulmonary edema. No pneumonia. Mild elongation of the descending aorta. The abnormalities mentioned in the referring note are not visible on the chest x-ray. CHEST (PORTABLE AP) showed New right lateral subcutaneous emphysema likely sequelae of recent procedure. Otherwise, no significant interval change in the appearance of the lungs compared to the exam performed 23 hours prior. NOTIFICATION: The findings were discussed with Dr. ___. by ___ ___, M.D. on the telephone on ___ at 9:03 am, 10 minutes after discovery of the findings. The patient was diagnosed with Aneurysm of other specified arteries. The patient was treated with ___: Laparoscopic reexploration with washout and fulguration of the gallbladder fossa.. At the time of discharge, the patient had Hemoperitoneum status post 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>Ms. ___ is a ___ year old was admitted to ___ ___ post-operative day 10 from a laparoscopic cholecystectomy at ___ ___ with concern for a post-operative bleed. She originally presented to ___ prior to ___ where a CT was performed and showed an enhancing focus/contrast blush adjacent to her surgical clips within the gallbladder fossa and given blood products to stabilize her bleeding. At ___ she underwent an ___ that showed no evidence of pseudoaneurysm or active extravasation. She underwent serial H/H checks while in the ICU that were stable and was subsequently started on a heparin gtt 24 hours after last known administration of blood products. On ___ the patient was hemodynamically stable and transferred to the surgical floor. Her heparin drip was titrated to goal PTT and Coumadin therapy was resumed on ___. On ___ she had sudden onset abdominal pain radiating to her back and repeat hematocrit showed a significant drop in hemoglobin/hematocrit. During this event she also had increased heart rate to 130 in atrial fibrillation and hypotension to the 80's systolic. She was given IV fluid bolus and 1 unit packed red blood cells. The patient was then transferred to the ICU for close hemodynamic monitoring and management of acute bleed. On ___ patient was transferred back to the ___ with RUQ pain, hypotension, A-fib w/ RVR, decreased HCT, and radiologic findings significant for perihepatic hematoma. CTA showed no active extravasation from previously noted hepatic laceration or interval worsening of hemoperitoneum. ___ was notified with concern for venous bleed however ___ decided to take patient to OR ___ for ex-lap/washout where a small arterial bleed was found and controlled. ___ patient HCT has remained stable and was restarted on a clear liquid diet and heparin drip. ___ her HCT was stable and the decision was made to transfer her out of the ICU, begin a regular diet, and transition over to home Warfarin. The patient was hemodynamically stable on continuous telemetry monitoring during the remainder of her hospital course. Her Coumadin was dosed daily while maintaining therapeutic anticoagulation with heparin drip. On POD4 surgical drain was removed. She tolerated a regular diet and had adequate pain control. She was voiding adequate amounts of urine without difficulty. She was encouraged to mobilize out of bed and ambulate as tolerated, which she was able to do independently. At the time of discharge, the patient was doing well, afebrile with stable vital signs. Her INR at discharge was 2.3 and heparin drip was discontinued. The patient was instructed to resume 2.5 mg Coumadin at home and follow-up with PCP ___ 24 hours for ___ monitoring. 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: According to the Emergency Department, the patient is a ___ woman without significant medical history presents with intractable nausea/vomiting. Transfer from ___ ___. Her N/V began ___, around the time she began prozac (though she took prozac before with no effects). She has had constant nausea since that time, vomits bilious fluid. Has also had constant diarrhea. Her workup has included a cholecystectomy for chronic cholecystitis on ___, which relieved N/V for 5 days, a normal EGD, an MRCP which showed a liver hemangioma, multiple normal CT scans of abd, a normal CT head, a normal HIDA scan, neg C.diff, neg ciliac dz w/u. She has been hospitalized two times with an unyielding workup. Scheduled for gastric emptying study soon. Since her cholecystectomy, she has also had pain in varying areas of abd, including RUQ and periumbilical. Today had severe RUQ pain which brought her to ___ again. Pain and nausea has persisted here in the ED. Has never had fever/chills. No travel or sick contacts. Labs only been significant for mildly elevated ast/alt. Radiology showed Normal upper GI and small bowel follow-through. Intestinal transit was approximately 130 minutes. The patient was diagnosed with NAUSEA. At the time of discharge, the patient had Abdominal pain, nausea, vomiting. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient is a ___ woman with a recent history of nausea, vomting, and diarrhea who is presenting for continued work-up of these chronic symptoms after extensive work-up at outside hospital failed to yield diagnosis. #) ABDOMINAL PAIN with NAUSEA, VOMITING, DIARRHEA: Patient has had extensive work-up at ___, which appears to rule out pancreatic, liver, and biliary etiologies, although the transaminases are still elevated (may by sequelae of cholecystectomy). Tissue transglutaminase reportedly performed there as well. Patient has yet to have gastric emptying study, and presentation is suggestive of gastroparesis. Abdominal migraine and cyclic vomiting still on the differential, however. In addition, it is unclear if gynecological causes of abdominal pain, outside of pregnancy, have been worked up. Multiple attempts were made to secure a full copy of her workup from ___ ___, but only a portion of the record was obtained. GI was consulted for their input into remaining components of her workup that could be investigated during this hospital course. Stool studies were sent to rule out occult infectious sources, and were negative. The patient was kept NPO and her opiate analgesia discontinued leading into HD#3 in preparation for obtaining a barium swallow with small bowel follow through on HD#3 and gastric emptying study on HD#4. Both of these studies were reported as normal. Throughout her hospital course, she did not develop any fevers, vomiting, peritoneal signs, or diarrhea. Her nausea was controlled on ondansetron IV with lorazepam IV for breakthrough nausea. Her pain was controlled initially on hydromorphone IV, which was discontinued in preparation for her GI studies. At that time she was controlled on around the clock acetaminophen and toradol. After her studies were completed she was restarted on oxycodone PO with adequate relief of her pain. On HD#4 discussion was had with ___ that there were no further components of her workup requiring hospital admission, and that further testing could be completed as an outpatient. At this time it is unclear what is causing Ms. ___ symptoms, and she will potentially need further workup as an outpatient. She is to follow up this coming week with her gastroenterologist in ___ for ongoing symptomatic management, and our GI service will coordinate follow up for her in clinic with one of the Fellows. At the time of discharge, she was afebrile with stable vital signs, her nausea was controlled with ondansetron and lorazepam as needed, her pain controlled with oxycodone as needed, and she was able to tolerate adequate PO intake. #LEUKOCYTOSIS: The patient had a leukocytosis on admission lab testing. Subsequent testing showed that this resolved. She remained afebrile throughout her hospital course. #DEPRESSION/ANXIETY: The patient was continued on her home dose of Prozac. TRANSITIONAL ISSUES The patient is to follow up this coming week with her gastroenterologist in ___ for ongoing symptomatic management, and our GI service will coordinate follow up for her in clinic with one of the Fellows. She has been instructed to attempt to collect her pertinent records from ___ in order to expedite her future workup and ongoing management.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ began having generalized crampy abdominal pain yesterday. By the evening it localized to right lower abdomen. He woke up during the night with rigors, nausea, diaphoresis, and subjective fever. He endorses anorexia today. US APPENDIX showed Acute, uncomplicated appendicitis. The patient was diagnosed with Unspecified acute appendicitis. The patient was treated with ___: Laparoscopic appendectomy. At the time of discharge, the patient had Acute appendicitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ y/o M who was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal US revealed acute, uncomplicated appendicitis, WBC was elevated at 18.2. 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 on IV fluids, and oxycodone and acetaminophen. for pain control. The patient was hemodynamically stable. 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 ___ year old M w/ PMH diet-controlled DM, HTN, chronic Afib on apixaban, HFrEF (EF 35%), moderate to severe MR, HLD, s/p ischemic CVA, severe mixed sleep-disordered breathing, CKD; and OA who presents with left-sided chest pain, dyspnea, and dizziness. The pain is worse with breathing. He hadn't taken his home medications in 4 days. His daughter also stated that he has been somewhat confused for a few days. CHEST (PA AND LAT) showed Interval increase in, now moderate to severe, pulmonary edema with stable moderate cardiomegaly. CHEST (PA AND LAT) showed In comparison with study of ___, there has been some decrease in the degree of pulmonary edema, which still remains quite prominent. Continued enlargement of the cardiac silhouette. Otherwise, little change. The patient was diagnosed with Heart failure, unspecified, Chest pain, unspecified, Dizziness and giddiness. At the time of discharge, the patient had PRIMARY DIAGNOSIS ================= Acute on chronic heart failure with reduced ejection fraction Exacerbation Dyspnea Atrial Fibrillation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old M w/ PMH diet-controlled DM, HTN, chronic Afib on apixiban, HFrEF (EF 35%), moderate to severe MR, HLD, s/p ischemic CVA, severe mixed sleep-disordered breathing, CKD; and OA who presented with chest pain and dyspnea I/s/o medication non-adherence, who was found to have acute decompensation of his heart failure s/p IV diuresis, now euvolemic.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w IDDM, CAD c/b STEMI (___) s/p BMS to RCA, CHF (EF 30%) p/w syncope in setting recurrent nausea, vomiting, abdominal discomfort x 12H. Patient in usual state of health until yesterday late afternoon when he developed vague abdominal discomfort and associated anorexia. Took in small amount soup for dinner. Approximately 11pm felt light headed and went to bathroom where he had episode of emesis followed by syncopal event witnessed by wife. +Fall without head strike. Came to and had additional episode bilious emesis. Wife called EMS who brought patient to ___ ED for further evaluation. Had self-limited episode bradycardia w hypotension en route. Surgery consult obtained. Chest radiograph showed No acute intrathoracic abnormality. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormality. 2. No evidence of acute intracranial hemorrhage or fracture. 3. Atrophy, probable small vessel ischemic changes, and atherosclerotic vascular disease as described. 4. Paranasal sinus disease concerning for acute sinusitis and polyposis as described. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No evidence of traumatic fracture. 2. Extensive multilevel degenerative changes of the cervical spine as described, with narrowing of the spinal canal from C4-C7 and narrowing of foraminal recesses at multiple levels. 3. Please note MRI of the cervical spine is more sensitive for the evaluation of spinal cord or ligamentous injury. CT Abdomen and Pelvis showed 1. 3 abrupt cut offs in small bowel caliber in the right lower quadrant (Se 601b, Im 39) is consistent with a Closed loop distal small bowel obstruction with transition point in the riqht lower quadrant: Short segment of small bowel in the closed loop is fluid filled. The small bowel proximal to the loop is distended with fluid and has fecalization. No evidence of pneumatosis or free air. The bowel wall in the closed loop and remaining small bowel appear to enhance normally. However, there is edema and free fluid around the short closed loop segment (Se 2, Im 104) and proximal bowel loop (Se 2, Im 123) that may suggest complication such as ischemia. Major vessels appear patent. No portal venous gas or mesenteric gas seen. 2. Left inguinal hernia with interval increased herniation of a large segment of distal large bowel/sigmoid colon into the scrotal sac but no evidence of complication. 3. Unchanged 3.5-cm infrarenal abdominal aortic aneurysm. 4. Multiple hepatic and renal cysts. 5. Prostatomegaly. 6. Persistent pancreatic duct dilation and cystic lesions, unchanged. 7. Small hiatal hernia. The patient was diagnosed with Syncope and collapse. The patient was treated with ___: Exploratory laparotomy, lysis of adhesions.. At the time of discharge, the patient had Closed loop 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. ___ is a ___ year-old male who presented to ___ on ___ with complaints of abdominal pain. He was found on imaging to have a small bowel obstruction. He was admitted to the Acute Care Surgery team for further medical management. On HD1, the patient was taken to the operating room and underwent an exploratory laparotomy with lysis of adhesions. The patient tolerated this procedure well and there were no adverse events (reader, please see operative note for details). The patient was extubated and transferred to the PACU. The patient was noted to have low urine output and was hypotensive with systolic blood pressure in the ___ and he was bloused with 500ml IVF with good effect. Once stabilized in the PACU, was transferred to the surgical floor for pain control and to await return of bowel function. The Medicine team was consulted to evaluate the patient for his syncopal episode prior to his hospital admission. His EKGs were unconcerning and he remained stable from a cardiovascular standpoint. His syncopal episode was most likely vasovagal from an episode of emesis. It was recommended he receive an ECHO with his outpatient cardiologist. The remainder of the ___ hospital stay is summarized by systems below: Neuro: The patient was alert and oriented throughout hospitalization; pain was managed with oral pain medication once tolerating a diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. His home metoprolol was held as he was normotensive. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO. On POD2, the patient had +flatus. On POD3, he had a bowel movement and was advanced to a regular diet which was well tolerated. Patient's intake and output were closely monitored. His foley catheter was removed and he voided independently. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient worked with Physical Therapy who recommended his discharge to rehab. The patient declined a prescription for oxycodone as he stated his pain was well-controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. A follow-up appointment was scheduled with the Acute Care Surgery team. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMHx significant for cirrhosis secondary to hepatitis C infection, schizophrenia, and seizure disorder who presents with 3 days of worsening chest pain and shortness of breath. Three days prior to admission he noted some difficulty breathing, particularly with exertion. He also had right-sided chest pain that was worse with inspirationa and cough. These symptoms progressively worsened. he also reports a non-productive cough, no hemoptysis. No fevers, chills, nausea, vomiting, diarrhea. He had not traveled recently, no recent surgery, no leg swelling or pain. He is rather sedentary at home most days. He has a 35-pack-year history of smoking. Radiology showed Blunting of the right costophrenic angle could relate to a small right pleural effusion. Radiology showed Filling defect in the lobar and segmental portions of the pulmonary artery in the right upper lung c/w pulmonary emboli. The patient was diagnosed with PULM EMBOLISM/INFARCT. At the time of discharge, the patient had Primary: lobar and segmental pulmonary emboli Secondary: hepatitis C, schizophrenia, 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>Mr. ___ was admitted with chest pain and dsypnea and found to have lobar and segmental pulmonary emboli, likely in setting of immobility at home. No ECG changes or evidence of right heart strain, was started on a heparin drip, transitioned to enoxaparin to bridge to warfarin for at least 3 months of anticoagulation. He was discharged without chest pain or dyspnea. ACTIVE ISSUES # Pulmonary Emboli Only risk factor is being completely sedentary while at home - no known malignancy, no weight loss or night sweats, no recent surgery, no history of blood clots. ECG without evidence of right heart strain, TropT negative. Was initially started on a heparin drip, but transitioned to enoxaparin to take while bridging to warfarin. He will continue anticoagulation for at least 3 months. He will be followed at the ___ clinic. # Dyspnea Most consistent with pulmonary emboli. No evidence of PNA on CT, no fevers or elevated WBC either, not typical cardiac chest pain and TropT negative. Does not seem consistent with COPD exacerbation given no productive sputum. Clinically not consistent with heart failure. Not anemic. Treatment for PE as above, discharged without pulmonary sypmtoms. CHRONIC ISSUES # Schizophrenia/TBI/seizure d/o No acute changes in mental status. Is establishing outpatient care with a new psychiatrist. Continued quetiapine, lithium, divalproex, lorazepam, diazepam, doxepin, and lurasidone. # Hepatitis C No stigmata of cirrhosis on exam, no evidence decompensation. Seeing GI/liver as an outpatient. # Hypertension Normotensive. Continued HCTZ, lisinopril. # Diabetes Continued metformin. # PUD Not active, continued PPI. # COPD Not active. Continued tiotropium, fluticasone-salmeterol, albuterol/ipratropium PRN. TRANSITIONAL ISSUES - Patient to have ___ checked at ___ on ___ to take 5mg warfarin from ___ ___s enoxaparin BID - Was supposed to have a tooth extraction on ___ but high risk given initiation of anticoagulation. Told patient to defer this and needs anticoagulation for at least 1 month before we can bridge again to lovenox and hold for extraction - Warfarin/divalproex interaction can potentiate warfarin, but will monitor INR closely during the initiation of warfarin</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ w/ h/o DM2, idiopathic axonal sensorimotor polyneuropathy, SBO, coronary vasospasm who presents with one day of N/V. She began vomiting evening prior to presentation (she says too many to count), accompanied by chills, body aches, lower abdominal pain, and substernal left chest pain immediately after her vomiting episodes without associated symptoms. She took nitro. The pain resolved within 5 minutes. None since. No URI symptoms. Lives in assisted living, several other residents with similar symptoms. Radiology showed No acute cardiopulmonary process. Radiology showed 1. Diverticulosis throughout the colon without signs of diverticulitis. 2. No convincing evidence of small bowel obstruction. Tortuous colon with cecum positioned in the midline, and mild prominence of distal small bowel, but no focal zone of transition. 3. Stable right adrenal nodule dating back to ___. 4. Slight thickening of the distal sigmoid colon may be due to collapsed segment. Suggest followup nonemergent endoscopy. NOTIFICATION: #4 of the impression above was entered by Dr. ___ on ___ at 11:42 into the Department of Radiology critical communications system for direct communication to the referring provider. The patient was diagnosed with CHEST PAIN NOS, NONINF GASTROENTERIT NEC. At the time of discharge, the patient had Primary diagnoses: Viral gastroenteritis Acute kidney injury 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>___ with PMH significant for DM2, idiopathic axonal sensorimotor polyneuropathy, SBO, coronary vasospasm who presents with one day of nausea, vomiting, and loose stools. # VIRAL GASTROENTERITIS: Given sick contacts, chills, body aches, the patient's symptoms were felt to be secondary to viral gastroenteritis. She did not have any URI symptoms or myalgias to suspect influenza. CT ABD/PELVIS showed diverticulosis and slight thickening of the distal sigmoid colon, which may be due to a collapsed segment. Blood cultures with no growth to date. C difficile was negative. The patient was treated with IVF and anti-emetics. Her diet was advanced slowly. Her symptoms improved by day 2 of hospitalization. # ACUTE KIDNEY INJURY: Cr was elevated at 1.8 on day 2 of hospitalization, from baseline of 0.8. FENa was 0.08%, which was consistent with a pre-renal etiology. She did not have any episodes of hypotension. She was not on nephrotoxic medications. She was treated with IVF. # CHEST PAIN: Suspect this may be esophageal irritation in the setting of vomiting given temporality. Troponins were negative x 2. EKG was also reassuring. The patient was given omeprazole. She was continued on medications for CAD/coronary vasospasm. Simvastatin was switched to atorvastatin given drug interaction with amlodipine. # DM2: HbA1c was 5.4% in ___ without therapy. Her glucose with daily chemistries were normal. # CHRONIC PAIN: She was continued on tramadol and gabapentin. # SENSIROMOTOR NEUROPATHY: She will have outpatient follow up with plasmapheresis as planned. # DEPRESSION: She was continued on sertraline. # HOME MEDICATIONS: - Continued eye drops. - Held psyllium. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Neurology at bedside for evaluation after code stroke activation within: 5 minutes Time (and date) the patient was last known well: ___ (24h clock) CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Atherosclerosis of bilateral cavernous, clinoid and supraclinoid ICAs and bilateral V4 segments of the vertebral arteries. 2. No stenosis by NASCET criteria in the neck. 3. Tight stenosis of the left external carotid artery near its origin secondary to atherosclerosis. 4. No acute intracranial abnormality. Chest: Frontal and lateral views showed Persistent left base opacity raises concern for consolidation, underlying pleural effusion with atelectasis may also be present. Pulmonary vascular congestion. The patient was diagnosed with Aphasia, Essential (primary) hypertension. The patient was treated with N/A. At the time of discharge, the patient had Multifactorial hypertensive and toxic/metabolic encephalopathy ESRD on HD. The patient was given written instructions concerning 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 PMH signficant for ESRD on HD ___, HTN, DM, HLD who presented with episode of behavioral/speech arrest during dialysis and a possible facial droop which resolved. Her mental status waxed and waned in the hospital (sometimes speaking in ___ some, other times responding slowly in ___ but language exam showed fluent speech with intact repetition and naming. TIA or stroke appeared to be very unlikely given her presentation so MRI was not obtained. EEG was preformed and showed slowing but no seizures. The patient and was found to have a UTI, which was the most likely etiology of her symptoms. CXR showed a questionable consolidation, but she had no clinical signs or symptoms of PNA. She was initially treated with CTX/Vanc to cover both possible etiologies, but when urine culture returned showing a resistant UTI and she continued to have no respiratory symptoms, she was narrowed to Cipro on ___ for a 10 day course (last day ___. Her BP was very high on admission with SBP > 200. HTNsive encephalopathy was another possible etiology of her symptoms. She had previously been on a clonidine patch but developed a rash so the patch was discontinued prior to this presentation. Thus she likely was having rebound hypertension in response to stopping clonidine abruptly. Her HTN was treated with uptitrating labetalol slowly during admission. Her BPs improved to SBP 160s-180s at the time of discharge. The team was not overly aggressive in treating HTN at this time given concern for continued rebound HTN from clonidine, and the potential to drop lower once this acute period is over. Her BP should be monitored at rehab and adjusted as needed with input from the Renal team. Her Nutritional status appeared to be poor and she was started on supplementation. Swallow felt she required a ground diet with nectar thickened liquids. Her Nutrition and Swallow function should continued to be monitored at rehab.</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 CLL complicated by transformation to DLBCL who underwent allo SCT on ___ who presents with dyspnea and headache. Chest: Frontal and lateral views showed No focal consolidation to suggest pneumonia. Grossly stable cardiomediastinal silhouette. CTA CHEST WITH CONTRAST showed - Right upper and right lower lobe segmental pulmonary emboli. No CT evidence of right heart strain. -Intrinsic substantially occlusive thrombus surrounding the Port-A-Cath in the SVC. Venous return from the head and neck vessels occurs via small mediastinal veins and the azygos system draining to the IVC. A custom, hand injected venogram via the port can be considered to assess whether infusion port catheter is patent. Of note, contrast could not be injected mechanically via the port at the time of study. -Interval increase in axillary and mediastinal lymphadenopathy, resulting in further narrowing of the left brachiocephalic just peripheral to the origin of the SVC. -New sclerotic lesions in the T10 through T12 vertebral bodies, concerning for progression of metastatic disease. -Resolving right lower lobe consolidation. -Minimal interval increase in pericardial effusion. -2 new subcentimeter nodules in the left upper lobe are nonspecific, and may be inflammatory. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 4:57 pm, 5 minutes after discovery of the findings. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed 1. Diffusely enlarged cervical, mediastinal and axillary lymph nodes, increased in size from examination of ___. Associated diffuse surrounding inflammatory stranding is noted. 2. Retropharyngeal edema measuring approximately 5 mm in greatest thickness. This may be reactive in nature or secondary to venous congestion. 3. No focal peripherally enhancing fluid collection to suggest abscess. 4. Additional findings described above. CT HEAD W/O CONTRAST showed No CT evidence of intracranial hemorrhage or acute process. Radiology showed Successful SVC recannulization, mechanical and suction thrombectomy. Right port removal. RECOMMENDATION(S): 1. Restart heparin 2. Monitor for SVC syndrome symptoms. Repeat intervention may be considered if there are any additional symptoms in the short-term 3. ___ to follow in house as well as as an outpatient to assess for need of any further interventions The patient was diagnosed with Other pulmonary embolism without acute cor pulmonale. The patient was treated with ___ venoplasty, thrombectomy, and port removal w/ ___ on ___ Skin biopsy ___. At the time of discharge, the patient had PRIMARY ======= - Superior vena cava syndrome - Pulmonary emboli SECONDARY ========= - DLBCL s/p allogenic SCT - Neutropenia - Erythema nodosum. The patient was given written instructions concerning 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 CLL c/b DLBCL transformation s/p Allo SCT on ___ complicated by mild, cutaneous GVHD who presents from clinic with progressive headache, dizziness and dyspnea who was found to have a port associated DVT, PE and potential SVC syndrome. Course complicated by neutropenia and erythema nodosum. #PULMONARY EMBOLISM #PORT ASSOCIATED DVT #POSSIBLE SVC SYNDROME #ACUTE HYPOXIC RESPIRATORY FAILURE: Worsening dyspnea and CT demonstrating right sided PE and occlusive thrombus by the patient's port-a-cath with findings concerning for SVC occlusion. Reviewed imaging with radiology and appears that her obstruction is from thrombus rather than tumor. After discussion with primary oncologist, ___, and IV access team, patient underwewnt Port removal, Mechanical and suction thrombectomy of SVC thrombus, SVC venoplasty w/ ___ on ___ with improvement in symptoms. Patient started on enoxaparin on admission; transitioned to heparin periprocedurally. Switched back to enoxaparin thereafter. Underwent TTE ___ did not reveal intracardiac thrombus, but did show a subaortic membrane. #DLBCL #S/P ALLO SCT #CUTANEOUS GVHD: Post transplant course complicated by mild, cutaneous GVHD and BK viruria which have resolved with treatment. CT showed new T10-12 sclerotic lesions and mediastinal lymphadenopathy initially concerning for recurrent lymphoma. Continued ACV, atovaquone, and fluconazole ppx. Stopped ursodiol for VOD ppx. Obtained PET on ___, which was unchanged from prior; no new FDG avidity. BM biopsy ___ w/o evidence of lymphoma recurrence or leukemia but did show some megaloblastic features, so increased increased dose of b12/folate. MMA level was pending at time of discharge. Tacrolimus was tapered to 1mg QAM, 0.5 mg QPM. #NEUTROPENIA #THROMBOCYTOPENIA: Previously attributed to Bactrim, which was transitioned to atovaquone. Developed severe neutropenia of unclear etiology during admission. Dosed neupogen while ANC < 500. Counts recovered. Etiology of neutropenia was not clear but though most likely to be secondary to a viral illness though respiratory viral panel without detection of common pathogens. A full infectious workup was sent and pending at time of discharge as below. #ERYTHEMA NODOSUM New erythematous leg lesions noted ___. Biospied ___: c/w erythema nodosum. Broad ddx, including autoimmune/inflammatory, infections (viral, bacterial, fungal), and malignant. Given low suspicion for infection, patient was started on methylprednisolone 1 mg/kf on ___ and tapered to prednisone 60mg daily for discharge. Applied topical steroid with occlusive dressing to EN lesions for symptomatic relief. Infectious disease was consulted and recommended obtaining quant gold, viral panel (negative), endemic mycosis labs, ASO which were pending at time of discharge. #HYPOTENSION (c/f sepsis; resolved) Hypotensive to ___ on ___ with sensation lightheadedness/unsteadiness. Initially started vancomycin and cefepime (___). Stopped vanco ___ and cefepime ___. Was prescribed levofloxacin upon discharge. #DEPRESSION: patient tearful on admission given acute illness. -continued bupropion -continued fluoxetine #H/O GASTRIC BIPASS C/B B12 DEFICIENCY: -continued home B12 #CANCER ASSOCIATED PAIN: Chronic and stable -continued home oxycodone #HCP/CONTACT: Relationship: Husband Phone number: ___ Cell phone: ___ #CODE STATUS: Full, presumed TRANSITIONAL ISSUES: [] Determine prednisone taper, discharged on prednisone 60mg daily [] Skin biopsy sutures should be removed on ___, please ensure follow up for removal [] TTE showed subaortic membrane, should have surveillance TTE [] follow up pending quantiferon gold, endemic mycosis labs, ASO, MMA, B-glucan, galactomannan</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ G0 who presented to ___ ED yesterday after developing persistent n/v/d and abd pain which persisted. Was unable to tolerate any po since ___. Otherwise denies f/c, uri sx, dysuria, joint/muscle pains outside of her usual. PELVIS U.S., TRANSVAGINAL showed 1. Normal-sized bilateral ovaries, with normal flow. Only the right ovary was identified by transvaginal ultrasound. The left ovary was seen by transabdominal approach. 2. Large predominantly anechoic cystic structure in the mid to left upper abdomen, correlating with findings on the earlier outside hospital CT. It is unclear if this structure originates from the ovaries, but no direct connection to either ovary was identified on this study. Radiology showed Large simple appearing cystic lesions which appears to be arising from the pelvis extending into the abdomen, likely from the left ovary. Its characteristics are most consistent with an ovarian serous cystadenoma. Given the lack of complex features, a serous cystadenocarcinoma is thought to be less likely. The other differential consideration is a benign mesenteric cyst. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPOVOLEMIA, ABDOM/PELV SWELL/MASS UNSP SITE. The patient was treated with Exploratory laparotomy, left salpingo-oophorectomy. At the time of discharge, the patient had Mesosalpinx inclusion cyst Final pathology pending. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with PMH of rheumatoid arthritis on rituximab, bipolar disorder and hypothyroidism admitted to medicine after presenting with 5 days of nausea, vomiting, diarrhea, poor PO intake and crampy lower abdominal pain found to have large pelvic cystic mass. Patient transferred to Gyn-Onc for exploratory laparotomy and left salpingoo-phorectomy for mesosalpinx inclusion cyst. Please see operative note for details. Pre-operative: *) Pelvic mass/nausea/vomiting: 22 cm abdominopelvic mass. ACS general surgery and Gyn consulted. Abd/Pelvic MRI and PUS - likely peritoneal inclusion cyst or a large left ovarian cyst with plan for removal given patients symptoms. Nausea and pain improved with IVF, pain meds and anti-emetics. *) ___: Pre-renal acute kidney injury due to dehydration. Had very limited PO intake over 4 days prior to presenting with slightly elevated lithium level potentially contributing to ___. No evidence of obstruction on CT. Creatinine 2.9 on admission, improved to 0.9 on day of discharge after IV fluid resuscitation. *) RA: Currently asymptomatic, last received rituximab on ___. Patient discharged with instructions to f/u with rheumatology. Post-operative: Her post-operative course is detailed as follows. Immediately postoperatively, her pain was controlled with IV dilaudid and toradol. Her diet was advanced without difficulty and she was transitioned to oxycodone, acetaminophen, and ibuprofen. On post-operative day #1, her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post-operative day #1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Chest radiograph, AP upright and lateral views. showed Finding suggest mild-to-moderate congestive heart failure. Left lateral basilar opacity, possible pneumonia. The site is also typical for atelectasis, however. RECOMMENDATION(S): Follow-up radiographs are recommended to show clearance of the left base and exclude any other alternative underlying process such as a mass lesion. CT HEAD W/O CONTRAST Q111 showed 1. No evidence of acute intracranial process. 2. Inflammatory changes in the ethmoid and sphenoid sinuses including a small air-fluid level in the sphenoid sinus. These findings are nonspecific but acute or chronic sinus disease is not excluded. CTA CHEST AND CT ABDOMEN AND PELVIS PQ45 showed 1. Multifocal opacities in the left lung suggesting bronchopneumonia. 2. No evidence of pulmonary embolism. 3. Finding suggesting a mild inflammatory process involving the jejunum, perhaps an infectious form of enteritis. IMPRESSION: 1. Multifocal opacities in the left lung suggesting bronchopneumonia. 2. No evidence of pulmonary embolism. 3. Finding suggesting a mild inflammatory process involving the jejunum, perhaps an infectious form of enteritis. CHEST (PORTABLE AP) showed In comparison with the study of ___, there are slightly improved lung volumes. Continued enlargement of the cardiac silhouette with engorgement of ill defined pulmonary vessels consistent with pulmonary vascular congestion. Retrocardiac opacification with obscuration of the hemidiaphragm is consistent with volume loss in left lower lobe and pleural fluid.. Single lead pacer again extends to the right ventricle. There is an area of increased opacification in the left mid zone that would be worrisome for developing aspiration/pneumonia in the appropriate clinical setting The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had #Pneumonia #Influenza #Hypoxia #Diarrhea #Nausea #HFrEF #Elevated Troponin #Elevated Pro-BNP #Acute kidney injury #Insomnia #DMII #Microscopic Hematuria. The patient was given written instructions concerning 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 statement for admission: ========================================= ___ year old male with PMHx of HFrEF (EF ___ w/ ICD/AID, HLD, HTN, CAD s/p CABG, T2DM, obesity, depression/anxiety, GERD, psoriasis presenting with dyspnea, malaise in the setting of influenza with superimposed bacterial pneumonia. Patient clinically improved with treatment of above infections and was able to be discharged with plan to complete a PO antibiotic course. Hospital course complicated by insomnia and long qtc interval. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of HTN, HLD, polyvalvular disease, and anemia who presents with one week of shortness of breath. She was in her usual state of health until one week ago when she started developing nausea and shortness of breath with acute worsening on the morning of admission. She has noticed difficulty walking up stairs and around the block, activities she was able to do without getting short of breath prior to last week. She endorses PND and orthopnea (using 2 pillows in past week compared to 1 pillow prior to that). Furthermore, she has noticed increased swelling in her legs and has felt fatigued. She did have a cough this prior ___ but it resolved the same day. She denies any fever, chills, vomiting, diarrhea, chest pain, lightheadedness, or diaphoresis. CHEST RADIOGRAPHS showed 1. Findings consistent with moderate congestive heart failure including pleural effusions with suspected left basilar atelectasis. Pneumonia is not excluded, however. 2. Possible developing opacity at the right lung base versus regional edema. In addition to that, right hilum appears enlarged. Although these findings may be congestive in nature, re-evaluation in follow-up radiographs is recommended after treatment. CHEST (PA AND LAT) showed No relevant change as compared to the previous image. Known left postoperative changes with missing left rib. Elevation of the left hemidiaphragm with small left pleural effusion. Mild pulmonary edema. Mild cardiomegaly. Atelectasis at both the left and the right lung bases. CHEST (PORTABLE AP) showed As compared to the previous image, there is evidence of increasing radiodensity in the right lung apex. Part of this observation might be caused by rotation of the patient. However, coexisting developing pneumonia might also be present. Short term radiographic followup is recommended. Otherwise, the radiograph is unchanged. Mild cardiomegaly and postoperative appearance of the left lung base is constant. Radiology showed 1. No acute fracture or dislocation. 2. Mild degenerative changes of the lateral and patellofemoral compartments, with chondrocalcinosis in the lateral compartment as well as vascular calcifications. RENAL U.S. showed Echogenic kidneys consistent with medical renal disease. No evidence of urinary obstruction. CHEST (PA AND LAT) showed As compared to the previous radiograph, a pre-existing right basal parenchymal opacity has completely cleared. The left hemi thorax is unchanged, the postoperative lesions at the level of the hilus and the costophrenic sinus are constant. No new focal parenchymal opacities suggesting pneumonia. The patient was diagnosed with ANEMIA NOS, SHORTNESS OF BREATH. The patient was treated with Foley catheter (___). At the time of discharge, the patient had PRIMARY DIAGNOSES: Congestive Heart Failure Polyvalvular Heart Disease Acute on Chronic Kidney Disease Chronic Anemia Mechanical Left Knee Pain Neck Muscle Stiffness SECONDARY DIAGNOSES: Hypertension Hyperlipidemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a previously highly functional ___ year old female with history of HTN, HLD, polyvalvular heart disease, and chronic anemia who presented with worsening dyspnea over the past week. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ y/o woman with a history of of TBI (MVA in ___ with right and left frontal encephalomalacia. She had some seizures during that time ( not much known about it, someone documented Ativan withdraw). She was placed on dilantin for 6 months and no seizures after that. Today around 4 am she woke up with a headache and took some ibuprofen and went to sleep. She later woke up feeling ill with a headache. She thought it was the flu. She was with her grandparents and was found with generalized convulsions around 4 pm. Grandparents are not available now so not much known around that time. EMS was called. She was given Ativan (not sure how much) and on arrival at OSH was intubated. There she was given another round of Ativan (not documented how much). No AED's were given and after a head CT she was transferred here. Here she was on a midazolam gtt, intubated. She was not responsive on midaz wean. Radiology showed ET and NG tubes positioned appropriately. Possible left lower lobe mild atelectasis. Radiology showed No acute intrathoracic process. Radiology showed 1. Appropriate positioning of new left subclavian central line terminating in the low SVC, without evidence of complication. All other tubes and lines are well-positioned. 2. New minimal right basilar atelectasis, stable minimal left basilar atelectasis. Otherwise unchanged from this morning. Radiology showed 1. Diffuse enhancement of the leptomeninges and along the margins of the lateral ventricles with fluid-fluid levels in the occipital horns showing slow diffusion. Findings are concerning for leptomeningitis with ventriculitis and intraventricular pus. 2. Encephalomalacic changes in the frontal lobes bilaterally, likely from prior trauma. Findings discussed by Dr ___ with Dr ___ over phone on ___ at 11:50 am. The patient was diagnosed with GRAND MAL STATUS, FEVER, UNSPECIFIED, PERSONAL HISTORY OF TRAUMATIC BRAIN INJURY. The patient was treated with Intubation. At the time of discharge, the patient had 1) Streptococcus pneumoniae bacterial meningitis, 2) Status epilepticus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo woman with a history of TBI from an MVA in ___ with resultant R frontal encephalomalacia and prior seizures (on dilantin for 6 months following TBI, none since then), who presents in status epilepticus in the context of fever and headache. She developed a headache and some flu-like symptoms on the am of ___ but appeared well throughout the day until she was found around 4pm with generalized convulsions. EMS was called and she was given ativan en route to an OSH. She received further ativan there and was intubated. A head CT showed stable R>L encephalomalcia, ethmoidal sinus mucosal thickening, and a frontal skull fracture consistent with her prior TBI. She was transferred to ___ and started on a midazolam drip. Initial exam was significant for fever to 101.6 and nuchal rigidity. Off sedation she did not open her eyes to sternal rub and had roving eye movements when eyelids held open. Corneal, gag, and cough were present. She had some spontaneous movements of all extremities but localized only with LUE. Hyperreflexia L>R, toes downgoing. An LP was performed and she was started on vancomycin, ceftriaxone, and acyclovir for empiric meningitis coverage. She was also placed on decadron 8mg Q6hrs in addition to Rifampin 600mg daily. ID was consulted. She was loaded with Dilantin and admitted to the neuro ICU. She was connected to EEG monitoring, which initially showed burst-suppression pattern. Occasional bifrontal sharp transients but no definitive epileptic discharges. CSF returned with a protein 670, glucose 1, WBC 29 (98% polys), RBC 61, consistent with bacterial meningitis. Gram stain grew out streptococcus pneumoniae, sensitive to ceftriaxone. Her antibiotics were narrowed. Blood cx from the outside hospital also grew strep pneumoniae. She was continued on Dilantin 100mg IV Q8hrs. Levels were monitored with a goal of ___. An MRI brain was performed on ___ and showed diffuse enhancement of the leptomeninges and along the margins of the lateral ventricles with fluid-fluid levels in the occipital horns showing slow diffusion, concerning for intraventricular pus. She was extubated on ___ and did well. She was transferred to the Neurology floor. She was monitored on tele and was initially hypotensive to 80's/50's but improved with IVF. A TTE was performed which was normal without vegetations. The patient did well on the floor and received ___ who deamed her an appropriate rehab candidate. Her AEDs were switched from Dilantin to Keppra as the patient had previously developed a rash while on the Dilantin. She was continued on ceftriaxone to complete a 14 day course. She had some pain associated with meningeal irritation with head and back pain that was treated symptomatically with ibuprofen and muscle relaxants. Her pain was specifically increased in the late afternoon and prophylactic treatment with tizanidine should be considered around that time. Of note her LFTs were mildly elevated, this was attributed to the high doses of tylenol she was receiving as they drifted down when the tylenol was removed. On discarge her AST was 113 (down from 141) and ALT was 47 (down from 75). She is being discharged to ___ for a short rehab stay. She will continue the ceftriaxone through ___, afterwhich her PICC line can be removed. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ with history of AL amyloidosis s/p autologous stem cell transplant ___ years ago, DM2 who presents with left groin pain. He reports that he has had a reducible right inguinal hernia for years which has always been easily reducible and has never been stuck out. He has never had a hernia on the left that he is aware of. Starting yesterday morning he had a sudden left inguinal bulge which increased in discomfort throughout the day with severe pain starting at approximately 3 ___. He left work and went home and tried to take a nap to see if it would get better but it did not, so he came to the emergency department. He reports he had a bowel movement yesterday morning but has not passed any gas or had a bowel movement since. He denies nausea/vomiting. He denies fever/chills, chest pain, dyspnea. CT ABD AND PELVIS WITH CONTRAST showed A left inguinal hernia is noted with a small amount of sigmoid colon herniating into the inguinal canal. Inflammatory changes are noted in the left inguinal canal with fluid present within a patent processes vaginalis with peritoneal enhancement. No evidence of obstruction. The patient was diagnosed with Unil inguinal hernia, w obst, w/o gangr, not spcf as recur. The patient was treated with ___: Left inguinal hernia repair with mesh.. At the time of discharge, the patient had Left incarcerated inguinal hernia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx of AL amyloidosis s/p autologous stem cell transplant, chemotherapy in remission, DM2, presenting with an incarcerated left inguinal hernia, unable to be reduced at bedside. The patient was hemodynamically stable. The patient underwent left inguinal hernia repair with mesh, 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: ___ year old gentleman transferred from OSH after MVC with L1 burst fracture. The patient swered his vehicle to avoid a deer in the road. The patient was able to walk away from the scene but noted immediate low back pain. He presented to an OSH where a CT of the L spine showed an L1 burst fracture. He was transferred to ___ for further neurosurgery evaluation. CHEST (SINGLE VIEW) showed No comparison. Lung volumes are low. Borderline size of the heart. No pneumonia, no pulmonary edema, no pleural effusions. PELVIS (AP ONLY) showed No acute fracture identified. MR ___ SPINE W/O CONTRAST ___ MR SPINE showed 1. Acute compression burst fracture of the L1 vertebral body with prevertebral soft tissue edema and edema in the T12-L1 interspinous ligament. 2. The visualized fibers of the anterior longitudinal ligament appear intact. The posterior longitudinal ligament appears intact intact. 3. There is an apparent defect in the ligamentum flavum. 4. Posterior disc bulge at L5-S1 resulting in mild spinal canal and bilateral neural foraminal narrowing. L-SPINE (AP AND LAT) showed L1 fracture. The patient was diagnosed with Unsp fracture of first lumbar vertebra, init for clos fx, Car driver injured in collision w car in traf, init. The patient was treated with N/A. At the time of discharge, the patient had L1 superior wedge fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ who presented with a L1 superior wedge fracture after an MVC on ___. Neurosurgery was consulted for further recommendations or evaluation. He was admitted to the floor for TLSO brace fitting, but was unable to be fitted for a brace due to his body habitus. Due to holiday, pt was unable to be fitted until ___. Pt was made strict bed rest until brace fitting on ___. He remained neuro intact throughout his hospital stay. He received his brace on the evening of ___ and had AP/Lateral X-rays performed while standing in the brace. Prior to discharge he ambulated independently with the RN. He was cleared for safe discharge to home and instructed to follow up in 6 weeks w/ a CT scan w/o contrast of his lumbar spine prior to his visit.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/prior PE, esophageal cancer, presents w/SOB. Pt reports dyspnea on exertion worsening over the last 3 weeks. Took symbicort, flonase and albuterol w/out relief. Had similar symptoms w/ prior PE ___ years ago. Also with dizziness and left knee/calf pain w/radiation down L leg for 6 weeks of knee calf pain. No falls. MR KNEE W/O CONTRAST LEFT showed 1. Horizontal tear of the body of the lateral meniscus. 2. Intact medial meniscus, cruciate ligaments, and collateral ligaments. 3. Mild degenerative changes of the lateral compartment with partial thickness cartilage loss and probably some areas of full-thickness cartilage loss. CT ABD AND PELVIS WITH CONTRAST showed 1. No evidence of intra-abdominal or intrapelvic malignancy or metastatic disease. Visualized esophagus is unchanged appearance since ___. 2. Please refer to the CTA chest from 2 days prior for intrathoracic findings. The patient was diagnosed with PULM EMBOLISM/INFARCT, HX-ESOPHAGEAL MALIGNANCY. At the time of discharge, the patient had Acute pulmonary embolism Left lateral meniscus tear. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT & PLAN: ___ h/o breast CA on hormone therapy, esophageal CA s/p chemo/XRT, prior PE admitted w/SOB due to acute PE. # SOB/Dyspnea, cough: Ms. ___ was admitted with SOB and chest CTA showed extensive bilateral pulmonary emboli with negative L LENIs. During this stay, there was no O2 requirements: no desaturations with ambulation, no hypotension or concern for RV strain (based on CT scan). This episode represented her ___ PE - as a result there was concern for a hypercoagulable state in setting of adenoCA x2. For this reason, she was treated with lovenox BID and will likely need this medication indefinitely. To evaluate for a possible recurrence of cancer as an etiology, an abd/pelvic CT scan was performed. It showed no evidence of recurrence. She may obtain a PET scan as an outpt to further delineate the need for lovenox (if negative for recurrence then possibly coumadin?). She was seen by ___ and she was mildly orthostatic by pressure (but asymptomatic). She was cleared for home with ___. There was no drop in O2 with ambulation. # L knee pain: Ms. ___ had L knee pain. LLENI and knee x-ray revealed no dislocation, effusion or fracture. The exam was suggestive of possible infrapatellar tenderness possibly ___ ___ disease, infrapatellar bursitis/tendinitis. Ultimatley, L MRI knee was obtained and this showed a tear in lateral meniscus. It was otherwise unremarkable. She was treated with NSAIDs, ice pack, vicodin PRN with good effect. Again, she should continue with home ___ # Esophageal and Breast Cancers: no active treatment - cont exemestane - abd/pelvic CT scan without any signs of recurrence # Chronic Back Pain: cont home meds # OTHER ISSUES AS OUTLINED. #FEN: [] IVF [X] Oral [] NPO [] Tube Feeds [] Parenteral #DVT PROPHYLAXIS: on Lovenox #LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley #PRECAUTIONS: [X] Fall [] Aspiration [] MRSA/VRE/CDiff/ESBL/Droplet /Neutropenic #COMMUNICATION: pt #CONSULTS: ___ #CODE STATUS: [X]full code []DNR/DNI . #DISPOSITION: d/c home with home ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with PMH of COPD, HTN, DM2, and multiple psychiatric comorbidities who presents with several days of dyspnea worse than baseline. Associated with productive cough, rhinorrhea, and pleuritic chest pain. Patient has also had lightheadedness that is worse on standing and some post-tussive N/V. Subjective fever. Does not use oxygen at home. Baseline O2 sats in low ___ per patient. Notably, patient has not been using her inhalers for the last few days and has been smoking more than her usual 1 pack of cigarettes per day. Radiology showed Limited due to patient body habitus. No acute cardiopulmonary process. Radiology showed 1. No evidence of acute pulmonary process nor pulmonary embolism. 2. Ground glass opacities in the lingula along with atelectasis. These may be related to resolved infection. 3. Numerous prominent mediastinal lymph nodes, increased in size and number from prior studies. These may be related to a post infectious process in the lingula but should be followed in ___ months with a CT scan to assure resolution. Updated findings discussed with ___ at 9:19 AM via telephone. -___ The patient was diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSION NOS. At the time of discharge, the patient had Primary: COPD exacerbation Secondary: Diabetes. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F with PMH of COPD, HTN, DM, and multiple psychiatric comorbidities who presents with worsening dyspnea c/w pneumonia vs. COPD exacerbation. Acute Issues # COPD exacerbation: Given tachycardia and hypoxia on admission there was concern for PE for which CTA chest was obtained. It showed no thrombosis or pneumonia making COPD exacerbation most likely diagnosis. Patient was started on prednisone, azithromycin, standing albuterol/ipratropium, and albuterol nebs PRN. Supplementary oxygen was titrated to baseline of 92% on RA. These interventions resulted in rapid improvement in patient's symptoms. By HD#2 she had no SOB. Ambulatory O2 sats were obtained to assess readiness for discharge. O2 sats consistently above 95% with ambulation. Patient was discharged with prescriptions for home inhalers and with instructions to follow-up with ___ pulmonary clinic. # Cocaine abuse: Since recent discharge from psychiatric hospital patient endorsed one use of cocaine. She had no symptoms that were concerning for cardiac ischemia. Troponin on admission was negative and remained negative on cycling. Chronic Issues # Hypertension: Continued home lisinopril. # Hyperlipidemia: Continued home rosuvastatin. # Diabetes, type 2 uncontrolled: Patient hyperglycemic to 417 on transfer to floor for which she was given Humalog 10 units. Continued home Lantus and managed sugars with low dose Humalog sliding scale. Oral hypoglycemics were held. # Bipolar/Depression/PTSD: Continue home psychiatric regimen. # Anemia: Continued home ferrous sulfate. # Glaucoma: Continued home eye care regimen. Transitional Issues # Patient needs follow-up in ___ pulmonary clinic. Given phone number but it is unlikely she will call to make appointment. Is scheduled to see PCP ___ ___ who can help facilitate f/u in pulmonary clinic.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ F with severe dementia and history of a-fib who presents from ___ after witnessed fall, also found to have probable UTI. Radiology showed 1. Intraparenchymal hemorrhage involving the right caudate, lentiform nucleus and anterior limb of the internal capsule. 2. Subcutaneous hematoma in the left periorbital and frontotemporal scalp. Evaluation for fracture is limited by motion artifact. NOTE ADDED AT ATTENDING REVIEW: The density in the right caudate, putamen and anterior limb of the internal capsule reflects calcification, rather than hemorrhage. The density is far too high for hemorrhage, there is no mass effect, and no edema. Given the high density of the calcification, it is not possible to exclude a small amount of hemorrhage, but the findings can be entirely explained by calcification. The ED neurosurgery conslut note recognized this as calcification, so Dr. ___ not enter a follow communication about this revised report. Radiology showed No evidence of fracture. Left periorbital and frontotemporal subcutaneous hematoma. Radiology showed 1. No evidence of acute fracture or subluxation within limitations of motion artifact. 2. A large, heterogeneous thyroid gland containing multiple hypodense nodules. This can be further evaluated with ultrasound if clinically indicated. NOTE ADDED AT ATTENDING REVIEW: Although I agree there is no evidence of a fracture, there is widening of the anterior interspace at C4-5. This is substantially different than the other levels, which demonstrate dramatic ___ if disk height and endplate sclerosis. There is relatively little degenerative change at C4-5, and it is possible that this wide interspace reflects this lack of degenerative disease. However, in the setting of trauma, one must consider the possibility of anterior longitudinal ligament injury. If further evaluation of this is indicated, then an MR examination may be helpful. This finding was noted by Dr. ___ at 10:40 am ___ and discused by telephone with ___ of Neurosurgery at 10:43. The patient was diagnosed with HEAD INJURY UNSPECIFIED, OTHER FALL. At the time of discharge, the patient had Primary: Urinary tract infection Secondary: 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>Ms. ___ is a ___ F with severe dementia and history of a-fib who presents from ___ after witnessed fall, also found to have probable UTI.</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 COPD and recent AVR/MVR and CABG in ___ presents with dyspnea on exertion worse than baseline over the last several days following a recent hospitalization. She was admitted from ___ to ___ for lightheadedness and fall though to be from overdiuresis and orthostasis. Her home lasix dose of 40 mg BID was held on discharge. Following discharge she developed progressively worse DOE, leg swelling, and puffiness around her eyes. She endorses multiple symptoms consistent with heart failure sinc her surgery in ___, including dyspnea on minimal exertion (walking 50 steps or climing 4 stairs), PND usualy twice nightly, she has ___ pillow orthopnea, and nocturia ___ times nightly. She also complains of bilateral lower extremity weakness at baseline. She reports a dry weight of 163 lbs. She called her PCP ___ ___ and described these symptoms and her PCP restarted her home Lasix at 40 mg PO BID and she has continued to take since that time. In the ED, initial vs were 97.4 HR 81 BP 111/74 RR 16. She was complaining of nausea and epigastric discomfort relieved with compazine, but no emesis. Additionally, she notes peristent left sided sharp, intermittent, non-exertional, chest pain radiating into her left arm, which she says has been present since her CABG/AVR/MVR and is entirely stable. EKG was unchanged from prior and CXR showed no acute process. Initial labs were notable for INR of 5.9, Trop<0.01. DRE showed guiac positive brown stool. She does note intermittent epistasix for several years and had a nose bleed this week with large amounts of blood and 5 large clots and noted that she may have swallowed some blood at that time. She received IV dilaudid for pain control and was admitted to medicine for further workup. On arrival to the floor, patient is comfortable appearing. She has been tolerating PO. She denies diarrhea, but feels chronically constipated. She restarted her lasix, which was held on discharge, yesterday. On review of systems she denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. All other 10-system review negative in detail. Radiology showed Stable exam without acute intrathoracic process. The patient was diagnosed with RESPIRATORY ABNORM NEC, DIABETES UNCOMPL ADULT, HYPERLIPIDEMIA NEC/NOS, AORTOCORONARY BYPASS, HEART VALVE REPLAC NEC. The patient was treated with 1.) cardiac catheterization. The patient was given written instructions concerning 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 HISTORY: Ms. ___ is a ___ year old woman with COPD and recent AVR/MVR and CABG (___) who presented with dyspnea on minimal exertion worsening over last several days and sharp, non-exertional, intermittent chest pain. Notably, patient was hospitalized ___ to ___ for lightheadedness and fall, presumed from overdiuresis. Of note, she complains of dyspnea on exertion since CABG/AVR/MVR in ___, but notes acute worsening over last several days following recent discharge. She was re-hydrated during that admission and her lasix was held on discharge. Over the subsequent few days she developed worsening edema and called her PCP who restarted lasix. . []ACTIVE ISSUES: # DOE: During this admission, her DOE was thought to be multifactorial, with COPD and deconditioning also contributing to her acutely worsening CHF, along with known restrictive lung disease. A TTE was done which showed EF of 25% (down from 55% in ___ and severe pressure and volume overload of right heart consistent with symptoms of heart failure. On exam, lungs were diffusely wheezy and rhonchorous with fair air movement, though no rales were appreciated. Given high right heart pressure and volume, V/Q scan was obtained to rule out PE (did not get PE CT due to CKD) which was low to intermediate probability for PE. Diuresis was initiated ___ with 40 mg IV lasix and she proceeded to diurese - 2.7 liters overnight. Ultimately, patient was transferred from medicine to ___ cardiology service for further care. Weight on ___: 156.2 lbs. Once on ___, the patient continued to complain of DOE and SOB despite O2 sats of >95% on RA. The patient underwent a right heart cardiac catheterization which revealed elevated right heart filling pressures that improved significantly with supplemental oxygen. Based on this, the patient qualified for home O2 for symptomatic relief as an outpatient. She was seen by the pulmonary consult service; however, as the patient has restrictive lung disease and was already on optimal therapy, further treatment was deferred to the outpatient setting. . # Chest pain: Patient reports intermittent, sharp, non-exertional chest pain since her sternotomy. She reports it is unchanged in character during this time. EKG unchanged, trop negative x 2. This pain is likely musculoskeletal in origin related to prior sternotomy. This pain is likely musculoskeletal in origin related to prior sternotomy. She was continued on home metoprolol, rosuvastatin, and aspirin 81 mg daily. Given that she is likely ___ class III, she was started on lisinopril 2.5 mg daily. Patient had been complaining of chest pain since sternotomy in ___ (above), but this is unlikely cardiac as it is non-exertional and ECG was stable and troponins were flat. She was started on gabapentin for presumed neuropathic pain with significant improvement in symptomatology. . # Elevated INR: INR was 5.9 on admission (goal of 3.0 to 3.5 given mechanical valves). According to patient, her coumadin dose was increased on last hospitalization. She was previously alternating 1 mg and 2 mg daily, and was discharged on 2 mg daily. She has remained hemodynamically stable without evidence of bleeding. Her coumadin was held until INR entered the therapeutic range then restarted with lovenox bridging to be followed up as an outpatient. . # Hyponatremia: Sodium 130 during this hospitalization, likely secondary to CHF. Hyponatremic to 128 last hospitalization, urine Na<10 and Osm 148 indicative of hypovolemia. Responded to IV hydration, and was 136 on DC. . # CAD s/p CABG and AVR/MRV: She was continued on home metoprolol, rosuvastatin, and aspirin 81 mg daily. Given that she is likely ___ class III, she was started on lisinopril 2.5 mg daily. Patient had been complaining of chest pain since sternotomy in ___ (above), but this is unlikely cardiac as it is non-exertional and ECG was stable and troponis were flat. . # Hypothyroidism: Euthyroid on exam. Synthroid was increased last hospitalization to 100 mcg daily due to TSH of 6 which was continued on this hospitalization. . # DM: Stable. Patient was placed on humalog insulin sliding scale during hospitalization with good blood glucose control. . # Hypertension: Stable in house with BPS 110s-130s/60s-80s. She was continued on home metoprolol as above. . # Asthma/COPD/RLD: Likely contributing to exertional dyspnea (above). Her exam was consistent with obstructive lung disease with diffuse wheezing. V/Q scan also revealed evidence of possible mucous plugging. She was continued on home regimen of Albuterol prn, fluticasone inhaler, montelukast, and salmeterol, salmeterol inhaler. . # GERD: Stable on home regimen of pantoprazole 40 mg PO Q12H and lubiprostone 24 mcg PO BID. . # Depression/psych: Stable on home regimen of sertraline, Seroquel, lamotrigine, and clonazepam. . # Pain: Complaints of diffuse chest and abdominal pain at baseline. This was well controlled on home regimen of oxycodone 5 mg PO Q6H prn. . [] TRANSITIONAL ISSUES: - next INR check is ___, along with routine electrolytes and CBC which will be arranged by ___ services and sent to her PCP. - the patient should have her TSH and FT4 checked by PCP</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ y/o F w h/o several abdominal surgeries who presents to the ED with 24h of crampy abdominal pain in her midline, that is progressively worsening. She has three loose BMs 24h ago, no BM or flatus since. She remembers passing gas 48h ago for the last time. 12 h ago, she started having chills, no fevers. She has had nausea and has vomited bilious fluid three times. She denies any other symptoms including constipation, blood in stool or emesis, burning on urination, weakness. CT abdomen and pelvis with contrast showed 1. Small-bowel obstruction secondary to an abnormal segment of small bowel in the right lower quadrant spanning approximately 20 cm which demonstrates submucosal edema and stratified enhancement with surrounding soft tissue stranding and small amount of mesenteric fluid. Differential considerations include ischemia, infection, or inflammatory bowel disease. There is no pneumatosis. Follow-up imaging is recommended 4 weeks after resolution of obstruction to assess the bowel with MR ___. 2. A 2.2 cm left adrenal nodule is increased in size compared with the ___, and is incompletely characterized. This can have further characterization at the time of the MR ___. RECOMMENDATION(S): Recommend follow-up MR ___ 4 weeks after resolution of obstruction. Attention to adrenal gland lesion as well at that time. The patient was diagnosed with Unspecified intestinal obstruction. The patient was treated with ___: Exploratory laparotomy with lysis of adhesions. 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>The patient presented to the Emergency Department on ___ with progressively worsening abdominal pain and associated nausea and vomiting. Upon arrival, she was placed on bowel rest and given intravenous fluids and pain medication. She underwent an abdominal/pelvic CT scan, which confirmed presence of a small bowel obstruction prompting placement of a ___ tube for decompression. She was subsequently admitted to the Acute Care Surgery service and taken to the operating room where she underwent an exploratory laparotomy with lysis of adhesions; please see operative note for details. The patient was extubated in the operating room and brought to the recovery room in stable condition. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with a PCA and intravenous acetaminophen. Once tolerating a po diet, she was transitioned to oral oxycodone. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. However, on POD3, she did report chest discomfort. An EKG was obtained and troponins were negative x 2. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored and she was weaned from supplemental oxygen on POD4. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO with a ___ tube in place for decompression. On POD4, the patient began passing flatus and tolerated an NGT clamping trial, therefore, the tube was removed and her diet was advanced to sips. Her diet was subsequently advanced as tolerated to regular and well tolerated. She continued to pass flatus and moved her bowels. Additionally, her abdomen be came progressively less distended throughout her hospitalization. Patient's intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. 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: ___ with history of diabetes, ESRD on dialysis, diastolic CHF, who presents with one-week history of worsening cough, body aches and low grade fevers. Symptoms began a week prior to presentation with cough. She was seen by her primary care physician ___ ___, diagnosed with likely viral bronchitis and discharged home with guaifenesin with codeine. She reports that she has not had any improvement since that time and had a low-grade fever to 99.4 at dialysis yesterday. Cough is productive of yellow sputum. Reports nausea, post-tussive emesis (she reports multiple episodes per day), as well as feeling of weakness. Denies shortness of breath. In the ED, initial vitals 98.6 59 164/51 16 98% EKG showed SR 67, NA/NI, biphasic T wave in V3/V4 (new), troponin 0.26 (down from previous baseline). CXR showed small r sided effusion with pulmonary edema decreased from ___ and no evidence of pneumonia. Currently, she complains of diffuse body aches and fatigue, not actively coughing. ROS: Positive for constipation, pruritis worse for the past motnh. per HPI, denies chills, night sweats, headache, vision changes, rhinorrhea, sore throat, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed Mild pulmonary vascular engorgement, slightly improved when compared to the prior exam. Improved aeration of the lung bases with resolution of the previously noted bibasilar airspace opacities. The patient was diagnosed with ACUTE BRONCHITIS, ABNORM ELECTROCARDIOGRAM, FAILURE TO THRIVE,ADULT. At the time of discharge, the patient had Cough Viral bronchitis End stage renal disease 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>Acute issues: # Cough and myalgias: Clinical picture consistent with viral syndrome (including myalgias and possible costochondritis). No signs of pneumonia on CXR, WBC not elevated, patient afebrile throughout admission, so antibiotics were not started. Patient treated symptomatically with guaifenansin, tessalon pearls, tylenol and albuterol and reported symptomatic improvement. # ESRD: Patient on MWF dialysis schedule, received dialysis on ___ as scheduled. # Hypertension: Patient hypertensive to the 170s on admission, likely due to the fact that she missed her morning meds on the day of admission. She had no signs or symptoms of malignant hypertension. She was continued on amlodipine. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of recurrent metastatic ovarian cancer currently undergoing treatment with gemcitabine overseen by oncologist at ___ (most recent treatment this week), history of bowel perforation c/b colectomy with ileostomy who presents with a history of bright red blood per rectum. She has had 4 episodes over the past day of several teaspoons each. She has also had tenderness in the lower abdomen. Of note, she had similar symptoms in ___, for which she was admitted to the OMED service. Flexible sigmoidoscopy at that time was normal, and INR was markedly elevated during that admission (now 1.1). In the ED, initial vitals were T 98, BP 114/75, RR 18, O2 98% on RA. Rectal exam was notable no fisures or hemmorhoids, no active bleeding. CT abdomen pelvis was done, which showed findings concerning for the progression of her metastatic disease but no obvious explanation for the bleeding. Labs were notable for acute on chronic renal failure with creatinine of 3.0 from ___ at time of last discharge, and HCO3 of 13 with AG of 16. She received 4 mg IV Zofran and 5 mg IV morphine. She was admitted to the medicine service for further management. Vitals on transfer to the floor were BP 133/84, T 98.4, RR 16, O2 sat 95-96% ( check on left great toe), HR 92. Radiology showed 1. Interval increase in the small-to-moderate amount of abdominopelvic ascites, concerning for progression of metastatic disease. Known metastatic ovarian cancer, with multiple retroperitoneal, mesenteric, and pelvic metastasis and subcapsular hepatic implants. 2. No evidence of colitis, bowel obstruction or abdominal wall abscess. Radiology showed No acute cardiopulmonary process. Metastatic ovarian cancer with crackles suspected volume overload. PA and lateral upright chest radiographs were reviewed in comparison to ___. There is interval progression of left lower lobe opacity, highly concerning for infectious process. Bilateral pleural effusions are present, small. Right lower lobe linear atelectasis is new as well. There is no pneumothorax. Heart size and mediastinum are stable. IMPRESSION: Interval increase in left pleural effusion as well as left basal opacities that might reflect interval development of infectious process. No evidence of pulmonary edema. Small right pleural effusion is unchanged. New right basal atelectasis is small. showed Interval increase in left pleural effusion as well as left basal opacities that might reflect interval development of infectious process. No evidence of pulmonary edema. Small right pleural effusion is unchanged. New right basal atelectasis is small. Radiology showed No hydronephrosis. A small simple cyst is seen bilaterally in the kidneys. Trace ascites. The patient was diagnosed with ABDOMINAL PAIN UNSPEC SITE, ACUTE KIDNEY FAILURE, UNSPECIFIED, CHRONIC KIDNEY DISEASE, UNSPECIFIED, RECTAL & ANAL HEMORRHAGE, SECOND MALIG NEO LIVER, SEC MAL NEO PERITONEUM, HX OF OVARIAN MALIGNANCY, HX OF COLONIC MALIGNANCY. At the time of discharge, the patient had Clostridium difficile colitis Rectal bleeding Hemorrhoids Acute on chronic renal failure 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>FAX DISCHARGE SUMMARY TO PCP'S OFFICE #Bright Red Blood Per Rectum (BRBPR)--The patient initially noted the bleeding, a few tablespoons over three different instances, the day prior to admission. Throughout the remainder of her hospital course, she noticed passing a couple of small clots. Her hematocrits were trended throughout and slowly declined (possibly related to multiple lab draws), and she received 1U PRBC. The GI team was consulted, and they felt the most likely cause of the bleeding was from hermorrhoids. They felt there was no need for a sigmoidoscopy at this time given her recent scope which showed no correctable anatomic lesions. They recommended steroid suppositories which the patient was started on. Given C.diff infection, they recommended stopping the suppositories especially as her bleeding had improved. #C. diff colitis--the patient showed a marked leukocytosis from admission (WBC on admission 10, peaked at 17), and a C diff PCR assay showed a positive C diff infection. She was initially treated with IV flagyl, but ultimately developed nausea/vomiting. The IV flagyl was discontinued and she was transitioned to PO vancomycin. The GI team was consulted to ensure that the PO vancomycin would provide adequate intestinal coverage given that the patient was in discontinuity, and they commented that the infection was likely in the small bowel (given that the sample was sent from the ostomy) and that PO vancomycin would provide adequate treatment. She was continued on PO vancomycin and ___ need continued therapy through ___. #Abdominal pain/nausea/vomiting--The patient was initially noted to have exquisite tenderness in her LLQ upon admission. This pain ultimately shifted to the LUQ, and the LLQ was no longer painful. Her CT scan showed no acute intraabdominal process such as diverticulitis or obstruction. Notably, the pain was only present upon palpation of the abdomen and not present at rest. On hospital day 3, after starting on IV flagyl, she developed nausea and vomiting. She received a KUB, which showed a normal bowel gas pattern. She was started on an anti-emetic regimen including ondansetron and prochlorperazine, with good effect. Her ostomy output during this time was entirely normal. Upon discharge, she was no longer nauseous or vomiting and was taking a regular diet. #Acute on Chronic Renal Failure--Creatinine upon admission was 3.0, up from a baseline of 2.5 on ___. Urine studies were sent and her FENa was 2.0%, indicating an intrinsic renal cause. She received a renal ultrasound, which was negative. Her renal function ___ need continued follow-up upon discharge, as it appears to be continuing to decline. She was set up with a nephrology follow-up here at the ___. #Skin Ulcers--The patient was suffering from severe skin damage and pain on her distal finger tips with ulcerations on many of her fingers. It was further noted that the patient's hands may also have sclerodactyly. Accordingly, a rheumatology consult was order, and they felt the lesion was more consistent with gemcitabine induced digital ischemia and necrosis. A dermatology consultation was ordered and concurred that the most likely etiology was gemcitabine induced condition as reported in the literature ___ et al, Radiol Oncol ___ ___ et al, Anticancer Drugs, ___. An extensive rheumatologic serological work-up was ordered to rule out any alternative rheumatologic causes, the results were pending up until right before the patient was discharged and ___ was found to be very positive with high titer. Rheumatology recommended the patient follow up as an outpatient with the first available appointment. She was started on nifidipine TID and aspirin 81 mg to relieve the vasospastic component of the skin necrosis. The patient reports significantly improved feeling in her fingers upon discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ ___ F ___ ___ Note History RENAL TRANSPLANT U.S. showed 1. Fullness of the renal collecting system in the upper pole and interpolar region of the transplant kidney is grossly unchanged as compared to renal transplant ultrasound ___. 2. Interval improvement in arterial flow in the intrarenal arteries of the transplant kidney. Specifically, the intrarenal arteries demonstrate normal waveforms and demonstrate normal diastolic flow, improved from ___, when there was no diastolic flow demonstrated. 3. No perinephric fluid collection. CHEST (AP AND LAT) showed Probable tiny left pleural effusion. Stable mild cardiac enlargement. No signs of pneumonia. The patient was diagnosed with Urinary tract infection, site not specified. At the time of discharge, the patient had Acute Issues: #Diarrhea Chronic Issues: #History of recurrent C. diff #Hypertension #Normocytic anemia #S/P LLRT ___ #Depression #Insomnia #Mineral metabolism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT & PLAN: ___ woman with ESRD s/p living donor renal transplant (___), CKD II, recurrent C. difficile, and history of Ga___'s disease on cerezyme infusion, presenting with one bloody bowel movement, loose BMs, and weakness. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male with a past medical history of dementia, ADHD, depression and anxiety who presented from his ALF with FTT and s/p fall. History is extremely limited as patient is unable to provide a detailed history and ALF was unable to provide a history overnight (called, however person covering did not know the patient and did not provide collateral history). Per the ED, patient has had a rapid decline over the past several months. He currently lives at an assisted living facility ___ ___) and he has been difficult to care for. There is concern that his decompensation could be psychiatric related and in the past he has had issues with polypharmacy. Patient reportedly has had multiple falls and recently had a fall today. In the ED, initial VS were T 97.8, HR 94, BP 154/82, RR 18, 92% RA. Labs were notable for a normal WBC, normal Hb, PLT 134, normal electrolytes and renal function. Lactate 1.2. UA was negative for UTI. BCx obtained. CT C-spine with no fracture but degenerative changes. CT head w/o acute process. CXR showed no acute process. On arrival to the floor, T 97.7, BP 135/94, HR 95, RR 20, 95% RA, weight 67.1 kg. Patient was resting in bed and in no acute distress, but withdrawn and slow to respond. Patient stated he was brought to the hospital but does not know why. Complained of feeling confused for quite some time now. Denied hallucinations. Denied HI. Stated that he "would like to go to sleep and never wake up" and would like to die in a "passive way". Reports that years ago he overdosed on aspirin. CHEST (PA AND LAT) showed No acute intrathoracic process. CT HEAD W/O CONTRAST showed No acute intracranial process. CT C-SPINE W/O CONTRAST showed No fracture or malalignment. Extensive multilevel degenerative disease appears unchanged. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had Primary: Depression, Confusion/Altered Mental Status, s/p mechanical fall. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o male with a past medical history of dementia, ADHD, depression and anxiety who presented from his ALF with confusion, failure to thrive, and s/p fall. # Depression with SI: The patient has a long standing history of depression, requiring inpatient hospitalization and ECT. On presentation, the patient reported sadness and desire to go to sleep and not wake up. The patient was found to have flat affect with psychomotor slowing. The patient was evaluated by psychiatry who recommended 1:1 sitter and placed patient under ___. It was thought that the patient's depression may be contributing to his worsening confusion. The patient's psychiatric medication regimen was adjusted as below. The patient was discharged to an inpatient psychiatric facility and should follow up with these psychiatric providers for further titration of medication regimen and further management. # Confusion: The patient reported progressively worsening confusion, which was corroborated by his sister whom he speaks to on the phone nearly daily. The patient was evaluated with a CT head which showed no acute changes. Similarly, electrolytes, UA, Utox and serum tox were found to be within normal limits. TSH, B12 and urine culture remained pending at the time of discharge. The patient's confusion was thought to be due to his worsening neurocognitive condition (Alzheimer's disease versus vascular dementia versus mixed) vs. worsening depression vs. polypharmacy. The patient was evaluated by psychiatry who recommended discontinuation of buspar, and mirtazapine as well as reduction in duloxetine dosing. They recommended discharge to inpatient psychiatric facility at ___. The patient should f/u with psychiatric providers for further evaluation and management. # s/p fall: The patient reportedly had a fall prior to admission, in which he fell onto his lower back. Though the patient did not recall the exact circumstances of his fall, it was suspected to be mechanical in origin given his history of unsteady gait and possible peripheral neuropathy. The patient's ECG showed sinus arrhythmia and the patient reported no history of chest pain, lightheadedness or dizziness. The patient was evaluated as above and his medications were adjusted as above. CT Head, CT C-Spine and CXR did not show any acute changes or injury. The patient was evaluated by physical therapy who felt that intermittent gait disturbance was likely secondary to his underlying medical and psychiatric conditions. # DM: the patient was restarted on his home metformin and glipizide at discharge (he was managed on ISS while in the hospital) # HLD: continued home statin # CAD: continued aspirin, metoprolol # h/o EtOH use: The patient reported his last drink was years prior. He was continued on thiamine, folate, MVI</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH of metastatic mixed carcinosarcoma/serous endometrial cancer (on supportive care, awaiting hospice initiation), PE (Xarelto), Depression, presented with abdominal pain/distension Radiology showed Nonobstructive bowel gas pattern. Ultrasound-guided paracentesis showed 1. Technically successful ultrasound guided diagnostic and therapeutic paracentesis. 2. 2.1 L of fluid were removed and sent for requested analysis. CT ABD AND PELVIS WITH CONTRAST showed 1. Findings concerning for partial malignant small-bowel obstruction in the setting of peritoneal carcinomatosis and large volume loculated ascites which is increased from prior. 2. Significant mass effect on the liver from loculated peritoneal fluid. 3. Right external iliac lymphadenopathy, new from prior exam. 4. Prominent pancreatic duct and biliary tree unchanged. 5. Similar appearance of omental nodularity in the left upper quadrant. CHEST (PORTABLE AP) showed Enteric tube terminates in the left upper abdomen, presumably within the stomach. Apparent elevation of the right hemidiaphragm may be due to pleural effusion and atelectasis. The patient was diagnosed with Other intestnl obst unsp as to partial versus complete obst, Other ascites, Lower abdominal pain, unspecified, Personal history of pulmonary embolism, Long term (current) use of anticoagulants. The patient was treated with ___ Therapaeutic Paracentesis. At the time of discharge, the patient had Primary: Partial SBO, loculated ascites Secondary: Metastatic mixed carcinosarcoma/serous endometrial cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ PMH of metastatic mixed carcinosarcoma/serous endometrial cancer (on supportive care, awaiting hospice initiation), PE (Xarelto), Depression, presented with abdominal pain/distension, found to have partial SBO and ascites. #Abdominal Pain: #Partial SBO: #Ascites Presented with abdominal pain, nausea, and abdominal distension noted to have partial SBO and worsening ascites on CT abdomen. Initially requiring NGT for decompression but removed shortly after admission. Patient also underwent LVP with improvement of her pain/distension. Per Gyn-onc, not a surgical candidate. Diet was slowly advanced and she was tolerating multiple small meals and having regular BMs prior to discharge. Discussed with patient, the possibility of recurrence and whether a venting g-tube should be placed. The patient elected to defer this palliative intervention on this visit but will consider it again if her symptoms recur. On this admission, patient confirmed her preference for DNR/DNI and MOLST was completed. She is being discharged with home hospice. #PE: On Xarelto at home transitioned to heparin gtt in anticipation of LVP. Given her toleration of diet on discharge, she was resumed on her home Xarelto. #Metastatic mixed carcinosarcoma/serous endometrial cancer: As above, not a surgical candidate. Patient now being discharged on home hospice but will see her oncologist, Dr. ___, in follow up after discharge. #Depression -Continued lexapro. TRANSITIONAL ISSUES: ================== [] If patient develops recurrent obstructive symptoms, would again recommend venting g-tube for palliation. > 30 mins spent on discharge coordination </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old lady with history of HFpEF, mild to moderate pulmonary artery systolic hypertension, chronic hypoxic respiratory failure (multifactorial- COPD, ?old interstitial pneumonitis and WHO Group 2 pulmonary hypertension) on 3L NC at home, DVT on warfarin, who presents for evaluation of dyspnea. CHEST (PORTABLE AP) showed Comparison to ___. New ill-defined parenchymal opacities at the left lung bases, with air bronchograms, could potentially reflect pneumonia in the appropriate clinical setting. Mild cardiomegaly persists. The patient is rotated to the right. No larger pleural effusions. No pulmonary edema. Chest radiographs showed Low lung volumes and modest interval improvement in the previously noted left lower lobe airspace opacities. Radiology showed No focal consolidation or pulmonary edema. The patient was diagnosed with Pneumonia, unspecified organism, Chronic obstructive pulmonary disease w (acute) exacerbation, Acute respiratory failure, unsp w hypoxia or hypercapnia. At the time of discharge, the patient had Pneumonia COPD exacerbation Right heart failure, RV Strain. The patient was given written instructions concerning 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 lady with history of HFpEF, mild to moderate pulmonary artery systolic hypertension, chronic hypoxic respiratory failure (multifactorial- COPD, possible interstitial pneumonitis and WHO Group 2 pulmonary hypertension) on 3L NC at home, DVT on warfarin, who is admitted to the ICU for hypoxemic respiratory failure found to have pneumonia and right heart failure. ================= ACTIVE ISSUES ================= # Hypoxemic respiratory failure/Pneumonia: Pt p/w patchy left basilar opacity in setting of cough and low grade temperatures, concerning for pneumonia. She has resided in nursing home for greater than ___ years, which places her at risk for resistant organisms. She has not improved with levofloxacin in outpatient setting. Antibiotics were broadened to vancomycin/ceftazidime/azithromycin (___), vancomycin was discontinued when MRSA swab returned negative. Likely respiratory distress worsened by baseline pulmonary hypertension, COPD and HFpEF. Pt was gently diuresed out of c/f pulmonary edema and also received a prednisone 40 mg burst (___) out of concern for COPD exacerbation given wheezes on exam. She will require slow prednisone taper 10mg daily to start in AM ___ to complete her taper in addition to indefinite azithromycin. TTE showed RV volume overload, discussed below. # Right Heart Strain. Pt p/w new TWI in inferior leads as well as ___, rightward axis in addition to an elevated BNP, all c/f TV strain iso known pulmonary HTN. TTE showed e/o right heart volume overload, no sign of new ischemic changes and mild admission troponin of 0.05 ___. Etiology of right heart strain is unclear as it is out of proportion for underlying pulmonary hypertension. As discussed, ischemia is unlikely and PE is unlikely given that pt presented supratherapeutic on warfarin. Cardiology was consulted and recommneded starting 10 mg torsemide. The patient has follow up scheduled with cardiology. # ___: Pt presented with ___ likely ___ given sodium avid urine lytes. Improved with IVF. # Supratherapeutic INR: In setting of decreased PO intake d/t esophageal dysmotility, also possible drug interaction as she was recently on levofloxacin. Warfarin was held while patient was supra therapeutic and resumed while hospitalized. INR was 2.1 on discharge. Coumadin will be resumed at 3mg daily. =============== CHRONIC ISSUES =============== # Esophageal dysmotility: Per GI, nonspecific dysmotility and would attempt treatment for spasm, with suggestion for SL nitro prior to meals. After TTE could consider this w/ close monitoring of BP as well as swallow evaluation. # Hypothyroidism: Continue home levothyroxine. # Depression/anxiety: Continue home sertraline and clonazepam # Constipation: Continue home linzess 290 mcg daily, senna 2 tabs every 3 days. ==================== TRANSITIONAL ISSUES ==================== CODE: DNR/DNI HCP: ___ (son)</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a previously healthy ___ presenting with abdominal pain, nausea, and anorexia since ___. He reports that the pain is in his right lower quadrant and suprapubic area. Otherwise, he denies fevers but does report chills. Reports one episode of nonbloody emesis. Denies diarrhea, bloody bowel movements, or urinary symptoms. He is accompanied in the ED today by his father. CT abdomen pelvis showed Acute appendicitis with contained perforation. No drainable abscess. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:33 pm, 3 minutes after discovery of the findings. The patient was diagnosed with Acute appendicitis with generalized peritonitis. At the time of discharge, the patient had acute appendicitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ presented to the ___ ED on ___. CT imaging and physical exam were consistent with acute appendicitis and he was admitted for non-operative management with IV antibiotics (Cipro/Flagyl) and bowel rest. He continued to spike intermittent fevers and white count continued to increase (max 18k) until ___ when WBC decreased, pain improved, and he remained afebrile. Diet was advanced to regular on ___ and he was transitioned to PO medications once tolerating oral intake. IV fluids were discontinued once oral intake was adequate. He was discharged home on ___. At the time of discharge, WBC was normalized, he was ambulating independently, voiding spontaneously, tolerating a regular diet, and abdominal pain had resolved. He was instructed to follow up in ___ clinic on ___ to discuss interval appendectomy in 6 weeks.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p lap hiatal hernia repair with Hill gastropexy on ___ which was complicated by peritonitis for which she underwent a negative ex-lap on ___. She was noted to have cholangitis and then underwent ERCP with stone extraction and placement of a stent in the left hepatic duct. Her course was complicated by Ecoli bacteremia for which she was discharged on ___ with a course of linezolid and ultimately changed to CTX which she has since completed. She presents to the ED today with a one day history of sudden onset diffuse abdominal pain as well as nausea and multiple episodes of NBNB emesis. She denies fevers or chills. She is having bowel movements and has diarrhea at her baseline in the setting of lymphocytic colitis for which she was recently started on a steroid taper by her GI doctor. Her nursing home reportedly checked a c.diff 3 days ago which was negative. Radiology showed 1. Technically successful ultrasound-guided percutaneous cholecystostomy with tube and pigtail catheter likely within the gallbladder lumen. However, as this was a portable technique, we recommend CT examination to definitively visualize the pigtail catheter tip within the lumen of the gallbladder. 2. Pericholecystic edema with distention of the gallbladder consistent with acute cholecystitis. The attending radiologist, Dr. ___, was present for the entire procedure and provided direct supervision. Radiology showed 1. Successful CT-guided percutaneous cholecystostomy with repositioning of catheter and new one placed. Pigtail tip within the lumen of the gallbladder. 2. Distended gallbladder with pericholecystic edema consistent with acute cholecystitis. The original suboptimaly positioned pigtail catheter was removed. Dr. ___ attending radiologist, was present and supervised the entire procedure. Radiology showed 1. Malpositioned PICC line. This finding was discussed over the phone with Peg of IV access at 925 on ___ by Dr. ___. 2. Worsened CHF. 3. Right lower lobe infiltrate. Radiology showed Successful placement of a 42 cm left basilic approach double-lumen PICC line with the tip in the distal SVC. The line is ready to use. The patient was diagnosed with ABDOMINAL PAIN GENERALIZED. The patient was treated with percutaneous cholecystostomy tube placement. At the time of discharge, the patient had 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>Ms. ___ presented to the emergency department on ___ with abdominal pain. Right upper quadrant ultrasound as well as Ct abdomen/pelvis were obtained showing acute cholecystitis. Acute Care Surgery service was consulted for further work up and treatment. Given her extensive medical history she was deemed not to be a surgical candidate therefore percutaneous cholecystostomy was planned. She was admitted to the hospital on ___ under Acute Care Surgery Service. Intervantional radiology was consulted for percutaneous cholecystomtomy placement. She was made NPO and prepared for the procedure. On hospital day 1 she developed atrial fibrillation with rapid ventricular response requiring ICU transfer and treatment with amiodarone drip and digoxin. Once she was stabilized she underwent perc chole tube placement on ___. She tolerated the procedure well without complications. Her diet was advanced to sips to clear liquids on ___. She tolerated it well. On ___ the the foley came out, she voided without issues. Intravenous antiarrhythmics were switched to oral, her heart rate was well controlled. Her diet was advanced to regular. She tolerated it well. The patient received intravenous vancomycin and ceftriaxone. IV Vanc was discontinued on ___, IV ceftriaxone was doscontinued on ___ ___. The patinet was dischagrged with 5 day course of Augmentin. On ___ she reported increased episodes of loose bowel movements, c.diff was sent which came back negative. Her Ins and Outs have been recorded throughout the hospital day which remained adequate. She received subcutaneous heparin three times a day. On ___ she was discharged to a rehab clinic to continue her treatment.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ presenting with 2 days of RLQ abdominal pain. He was in his normal state of health until two days ago when he woke-up with mild RLQ pain. He describes the pain as dull and intermittent. No associated fevers, nausea, vomiting or diarrhea. No loss of appetite. He notes a similar pain 3 months ago that resolved within a few hours. During his overnight shift as a ___ at ___, he had moderately worsening RLQ pain so he presented to the ED for further evaluation. No family or personal history of inflammatory bowel disease. Never had a colonoscopy before. Radiology showed No acute intra-abdominal process. RECOMMENDATION(S): The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 9:52 AM, 2 minutes after discovery of the findings. The updated impression above was discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 1:59 ___, 10 minutes after discovery of the findings. The patient was diagnosed with Unspecified appendicitis. At the time of discharge, the patient had 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 presented to the emergency department and was evaluated by the Acute Care Surgery Team. The patient was found to have possible appendicitis and was admitted to the Acute Care Surgery Service. The patient was given IV cipro/flagyl.On re-read of the CT scan, the patient was deemed to not have an evidence of appendicitis and would not need antibiotics on discharge. The patient will follow up in Acute Care Surgery Clinic in 2 weeks. 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: ___ year old female with history of UC presenting and followed by Dr. ___ in GI clinic presenting with abdominal pain, bloody diarrhea, and nausea for 2 weeks that has progressively worsened. She was in her usual state of health until 2 weeks prior to admission when she developed lower band-like abdominal pain and frequent stools that were often liquid and bloody. She has had decreased PO intake but has intermittently been able to eat meals and still feels hungry from time to time. She initially though she would get better on her own but the pain worsened over time and her bowel though decreasing in volume did not decrease in frequency. She called her GI physician and attempted to get labs and C. diff given her history of C. diff however only completed bloodwork. She was then told to present to ___ to be admitted for possible UC flare and C. diff r/o by on call GI team on the day prior to admission to the ward. GI team recommended preliminarily recommendations to obtain "CRP (124), C. diff (pending), CMV, hepatitis B panel, quant gold, Magnesium and cholesterol levels-for possible need of emergent biologic therapy per outpatient provider (Dr. ___. If C. Diff negative, may need high dose IV steroid therapy. Avoid NSAIDs and treat pain with IV Tylenol. Keep NPO for possible flex sig in AM." Radiology showed Overall paucity of gas-filled bowel loops within the abdomen as well wall thickening with an ahaustral appearance of the colon compatible with the provided history of ulcerative colitis. Radiology showed There are no parenchymal lung opacities. Cardiomediastinal and hilar silhouettes are normal. There is no pleural effusion or pneumothorax. The patient was diagnosed with Ulcerative (chronic) pancolitis without complications, Unspecified abdominal pain. The patient was treated with Flexible signoidoscopy ___. At the time of discharge, the patient had Acute Ulcerative Colitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o F h/o of UC and C. Diff presenting with blood diarrhea from UC flare. #Colitis #UC Flare #Leukocytosis Started Solumedrol 20mg IV q8 on ___. She received her first dose of infliximab 10mg/kg (700mg) on ___ and received a second dose indicated for signs of inflammation w initial elevation in CRP on ___ with another 10mg/kg. She was didscharged with a steroid taper starting with prednisone 40mg daily to be reduced by 10mg every three days. By the time of discharge her stools were less frequent, not bloody and more formed than on admission (described as many pea sized particles) She had no known Tb risk factors though her quant gold was indertimanante and her CXR was clear. Hep serologies show immunity to HBV. TPMT activity is pending at discharge. She did have leukocytosis at time of discharge so repeat CBC as outpatient is indicated. Hyperkalemia likely relates to elevated platelet count. whole blood K 4.5 WHole blood potassium can be checked to monitor actual K level if elev plts persist. - #Positive blood culture ___ - micrococcus, repeat cultures negative. contaminant suspected. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year-old left-handed female with h/o RRMS currently on Tecfidera who presents with 2 weeks of worsening sensory changes, dizziness, and vision changes with MRI suggestive of MS flare vs early PML iso persistently elevated JCV titers. MRI CERVICAL AND THORACIC PT21 MR SPINE showed 1. Interval increase in size of intramedullary lesions in the cervical and thoracic spinal cord. 2. There is no i abnormal enhancement after contrast administration. The patient was diagnosed with Multiple sclerosis, Dizziness and giddiness, Paresthesia of skin, Diplopia. The patient was treated with Lumbar puncture. At the time of discharge, the patient had Relapsing Remitting Multiple sclerosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ woman with a history of relapsing remitting multiple sclerosis currently on Tecfidera who presented with 2 weeks of sensory changes, vertigo, and diplopia. Her exam was notable for a partial right ___ nerve palsy and left hand dysesthesia. Her MRI revealed multiple new and more confluent abnormal flair hyperintensities suggestive of progression of her underlying multiple sclerosis. There were some new ring-enhancing lesions. She had a lumbar puncture that was mostly bland (6 nucleated cells and 44 protein with 77 glucose). Given her history of treatment with natalizumab there was some concern initially that she may have progressive multifocal leukoencephalopathy with immune reconstitution. However, after reviewing these images at neuroradiology conference, these were felt to be more consistent with progression of her underlying multiple sclerosis. Toxo PCR and ___ virus PCR were sent from the CSF (results pending at discharge). She was treated with 2 doses of 1 g IV methylprednisolone. Transitional issues =================== -Patient will complete outpatient course of prednisone as dictated by her multiple sclerosis doctor. -___ virus and toxoplasma gondii PCR pending at discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ with history of CAD s/p NSTEMI (___) - medically managed, HTN, diastolic CHF, hypothyroidism, anemia, and neuropathy who presents from assisted living with dyspnea. Of note patient was recently admitted from ___ with new onset afib and dypspnea and was started on amiodarone and lasix. Anticoagulation was deferred given repeated falls. On day of presentation she was found by her ___ to be dyspneic/wheezy. Her daughter came to evaluate her who felt that her breathing was more labored. Patient reports at that time not feeling SOB or having CP or palpitations. She reports increasing DOE however per daughters she was able to walk outside without any difficulty. She denies fevers, ST or cough but endorsed chills and sore throat. Denies orthopnea and PND however states that she slept in a recliner yesterday night because of urinary frequency and urgency. Denied dysuria, nausea or diarrhea. Given her symptoms she represented to the ED for evaluation. Radiology showed Mild pulmonary edema. Radiology showed No acute intracranial process. The patient was diagnosed with SHORTNESS OF BREATH, URIN TRACT INFECTION NOS, HYPERTENSION NOS. The patient was treated with cardiac cath ___. The patient was given written instructions concerning 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 CAD s/p NSTEMI (___) - medically managed, HTN, diastolic CHF, hypothyroidism, anemia, and neuropathy who presents from assisted living with dyspnea and URI, had episode of hypotension and episode of delirium, both resolved. . # NSTEMI/Dyspnea: Given findings on cardiac cath with 90% lesions, acute symptoms can likely be explained by ischemic cardiac disease. Lung exam on full review of chart and discussion with outpatient provider has been abnormal prior to initiation of amiodarone, and ___ evals have also shown desaturation with ambulation in the past. She was weaned off of O2 without any recurrence of her shortness of breath. She should follow up with pulmonology and further imaging as outpatient. She was started on Plavix after placement of BMS to LAD. She was continued on lisinopril, metoprolol, aspirin was increased to 325mg. Atorvastatin 80mg was initiated but switched to 40mg given interaction with amiodarone. She was started on Imdur as well. - follow up with Dr. ___ in ___ weeks . # Atrial fibrillation: She completed amiodarone load while in the hospital and switched to 200mg daily dose. She is also rate controlled on metoprolol. Per previous discussions with outpatient cardiologist, no acticoagulation will be pursued due to history of falls. She was switched to aspirin 325mg daily. - follow up with Dr. ___ in ___ weeks . # Diastolic CHF: Presented in decompensated heart failure in the setting of ischemia. Initially not on home lasix. She was diuresed and shortness of breath improved, after cath and BMS to LAD it had completely resolved. She was started on lasix PO prior to discharge. . # Delirium: Resolved. Episode of decreased level of arousal though remained AxOx3. Infectious workup negative, CT head unremarkable and within a few hours patient was at baseline. Neurology consult also in agreement that this was likely hospital-induced delirium. Seizure was considered but no evidence of ictal event or post-ictal state, only possible contributing medication was cipro which can cause delirium in the elderly. This was switched to bactrim to complete course of treatment for her UTI. . # UTI: Last UTI was citrobacter sensitive. No recent organisms in the past. This would be ___ UTI in one month, found to be ceftriaxone resistant, so patient was switched to cipro (sensitive), however in the setting of deliriuos episode she was switched to Bactrim to complete full course of treatment. - continue bactrim until ___ (treated ___ . # Hypotension: Resolved. She had episode of hypotension after aggressive diuresis on admission. Resolved with IVF. Lisinopril was initially decreased and returned to home dose prior to discharge. . # Hyponatremia: Resolved. Patient admitted with hyponatremia. Improved with diuresis and euvolemia. . # Anemia: Macrocytic. Baseline Hct mid ___. Hemodynamically stable, no acute issues during this hospitalization. . # HTN: Antihypertensive medications were adjusted: metoprolol, lisinopril were continued. Imdur and lasix were added to her medication regimen. . # HLD: Atorvastatin dose was increased to 40mg PO daily. . # Neuropathy: Continued home gabapentin. . Transitional Issues: - CODE: DNR/DNI - CONTACT: Patient and daughter, ___ (HCP) ___ - patient will require further workup with pulmonology and further imaging as outpatient. - follow up with Dr. ___ in ___ weeks - follow up with PCP</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ was a restrained passenger in 30mph MVC w/ airbag deployment however negative for loss of consciousness. Initially evaluated at outside hospital with CT showing left rib ___ fractures, sternal fractures, T8 vertebral body fracture, and R lateral malleolus fracture. DX KNEE AND TIB/FIB showed No fracture or dislocation. CT abdomen and pelvis showed 1. Partially visualized T8 vertebral body fracture, better assessed on chest CT. No additional sequelae of trauma in the abdomen pelvis. 2. Mild hypodense thickening of the endometrium measure up to 4 mm, correlate clinically and with ultrasound warranted. RECOMMENDATION(S): Recommend clinical correlation for increased hypodensity in the uterine cavity. MR ___ ANDW/O CONTRAST ___ MR SPINE showed 1. Nondisplaced fracture through the ossified anterior longitudinal ligament at T8 and through the anterior superior corner of T8, without loss of height. The posterior longitudinal ligament and the posterior ligamentous complex are intact. 2. While linear fluid signal intensity through the left lamina of T7 and subtle linear lucency through the left transverse process of T7 on the preceding CT raise a question of an nondisplaced fracture, there is no edema in the adjacent soft tissues or left T7-T8 facet joint capsule. The posterior ligamentous complex is intact. 3. No epidural hematoma. ANKLE (AP, MORTISE AND LAT) RIGHT showed Possible fracture the tip of the lateral malleolus. HAND (PA,LAT AND OBLIQUE) RIGHT showed No acute bony injury seen. Degenerative changes as described. The patient was diagnosed with Unsp fracture of T7-T8 vertebra, init for clos fx, Multiple fractures of ribs, left side, init for clos fx, Unsp fracture of sternum, init encntr for closed fracture, Passenger injured in collision w unsp mv in traf, init. At the time of discharge, the patient had L rib fx ___, sternal fx, T8 vertebral body fracture, R lateral malleolus 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 the ___ for monitoring for her traumatic injuries after an MVC.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ year old woman a history of Alzheimers and prior concern for NPH based on ___ head CT who presented to the ED s/p fall with lethargy. Per report, the patient suffered a fall on ___ but HCP (son) refused work up at that time. ___ NP at ___ noted pt to be more lethargic over the past few days. She was found on the ground sleeping today. ___ concentration and gait have been worsening. Per NP, no F/C, CP, dyspnea, abdominal pain, N/V, diarrhea, or dysuria. In the past the patient's son has not wanted further work up for ___ symptoms. The patient was sent to the ED where staff members spoke with HCP who agreed with work up. Per referral note, pt has had mental status changes, states that ___ head hurts, and c/o L back/hip pain. The patient has end stage dementia, is non verbal but but ambulatory. She is dependent for all ___ ADLs. Per NP referral note, pt is DNR/DNI. MR HEAD W AND W/O CONTRAST showed 1. There is ventriculomegaly, which may be disproportionate to the degree of superimposed global cerebral volume loss. In addition, there is periventricular FLAIR hyperintensity, which may represent transependymal CSF flow and underlying changes due to small vessel disease. Clinical correlation with normal-pressure hydrocephalus is recommended. 2. The pattern of global cerebral volume loss is nonspecific. 3. No acute intracranial hemorrhage or infarct. 4. Likely subarachnoid cyst in the right posterior fossa. Otherwise no other intracranial mass. PRE-MRI ABDOMEN, SINGLE VIEW ONLY showed No metallic objects in the abdomen or pelvis. ABDOMEN (SUPINE ONLY) showed No metallic objects are seen in the abdomen or pelvis. SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT was done. CT HEAD W/O CONTRAST showed 1. No significant change in dilated lateral and third ventricles out of proportion to sulci raise the possibility of parenchymal volume loss with or without normal pressure hydrocephalus. Clinical correlation is recommended. Asymmetric enlargement of the right temporal is more in favor of medial temporal atrophy. 2. No intracranial hemorrhage. DX ANKLE AND FOOT showed No evidence of acute fracture of the right ankle or fluid. Osseous demineralization reduces sensitivity for detecting subtle fractures and followup radiographs may be helpful if symptoms persist. . CHEST (PORTABLE AP) showed In comparison with the study of ___, there is an area of increased opacification at the right base. This most likely represents atelectasis, though in the appropriate clinical setting aspiration would have to be seriously considered. Otherwise little change. The patient was diagnosed with ALTERED MENTAL STATUS . At the time of discharge, the patient had Primary: - Alzheimer's dementia - Delirium and lethargy due to acute UTI - Urinary tract infection Secondary: - Carotid artery stenosis NOS - Vertebral compression Fractures - Glaucoma - Vaginal Prolapse. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ year old woman with a history of advanced Alzheimer's Dementia and carotid artery occlusion (unknown side) who initially presented to ___ on ___ with two days of lethargy and a change in mental status. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with a PMHx of metastatic bladder ca, HTN, HLD, Afib and OSA, who presents with fever and tachycardia. For the past 3d, pt has been feeling unwell. He experienced geeralized weakness, non-productive cough, nausea, and chills. Measured temp at home on day of admission was 104. Pt called his Oncologist who advised that pt present to ED. In the ED, initial vitals: T 98.8 Tm 102.4, P ___, BP 159/112 R 18, O2 Sat 98% on RA. Labs were remarkable for lactate 3, K 3.2, Cr 1.4, HCT 36.1. EKG showed Afib with RVR to 152bpm. UA was weakly positive. CXR was unremarkable. Pt received cefepime 2g IV x 1, azithromycin 500mg IV x 1, KCl 40mEq, Zofran 4mg IV x 1, MgSO4 2g IV x 1, tylenol 1g IV x 1, phos 250mg po x 1, 3L NS. On arrival to the MICU, pt reports feeling well. Radiology showed No acute cardiopulmonary process. CHEST (PORTABLE AP)CHEST (PORTABLE AP)i showed Right upper paramediastinal pulmonary consolidation is grown more cough lung, probably acute pneumonia. Pulmonary vasculature is engorged and mediastinal veins are dilated, probably a function of hyper circulation in a febrile patient. There are no other regions upper pneumonia is suspected and no pleural effusion is present. NOTIFICATION: Dr. ___ reported the findings to Dr. ___ by telephone on ___ at 12:10 ___, 2 minutes after discovery of the findings. The patient was diagnosed with URIN TRACT INFECTION NOS, ATRIAL FIBRILLATION, MALIG NEO BLADDER NOS. At the time of discharge, the patient had Primary diagnoses: - Acute complicated cystitis - Sepsis Secondary diagnoses: - Atrial fibrillation with rapid ventricular response - Metastatic bladder carcinoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with a PMHx of metastatic bladder ca, HTN, HLD, Afib and OSA, who presented with fever and tachycardia. # Severe Sepsis/Acute complicated cystitis/HCAP: Pt presented with fever, tachycardia and elevated lactate. Source was not clear but thought possibly UTI given +UA (though from urostomy) vs PNA given rhonchi on left. Initially no evidence of pneumonia on CXR, but on morning of HD one a second x-ray was read as a right paramediastinal consolidation. He had no clinical s/sxs of pneumonia and there was previous note of paramediastinal opacities on CT chest. He was treated empirically with vancomycin/cefepime. His lactate normalized within 24 hours, and his tachycardia improved to 90-100s with IVF and beta blockade. Blood, and urine cultures had not grown by hospital day one, and he was transferred to the oncology medicine floor with continued fevers but in stable condition. His urine cultures grew Vancomycin-sensitive enterococcus. Cefepime was discontinued. His blood cultures were negative. His fever curve down-trended. Vancomycin was eventually changed to Amoxicillin x 10days. He was afebrile at discharge. # AFib. Pt with known history of afib, not anticoagulated. Presented with RVR, likely ___ fever/infection. CHADS2 = 1, though stroke risk potentially higher given severe sepsis. Pt was fluid resuscitated and given metoprolol 25mg po q6h with good response in his heart rate. He was switched to home Metoprolol succinate 100mg daily at discharge. Atenolol was discontinued. # Bladder Ca. no active tx while in-house # CKD: Cr at baseline. Lisinopril initially held in setting of sepsis. Restarted at discharge. # Anemia. Chronic, likely ___ malignancy. At baseline, no evidence of bleeding. # HTN: Held lisinopril and amlodipine in setting of sepsis. Resumed upon discharge. SBP running in the 120's to 150's. # Hyperglycemia. Hyperglycemic during ICU admission. On no orals or insulin at home. Maintained on insulin sliding scale. BS better controlled with infection source control. . # GERD. Continued omeprazole at home dose. # HLD: Held simvastatin during ICU admission. Resumed # Depression. Held citalopram in setting of Afib with rvr and concomitant zofran use, given potential for long QT. Resumed upon discharge </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F with PMHx of DM1, bipolar d/o, presented initially to ___ on ___ with abrupt onset of severe RUQ pain associated with nausea and vomiting. Per patient, her symptoms started on ___ at 1AM with RUQ pain, nausea and non-bilious, non-bloody emesis. No chest pain, dyspnea, fevers, chills, diarrhea, constipation. At ___, she was found to have WBC 15.4, normal chemistries (except glucose 270), and normal LFTs except alk phos 142. RUQ u/s showed large gall stones w/o cholecystitis, but did show multiple liver lesions, largest measuring 7cm, which were concerning for metastatic lesions. CT abdomen w/ contrast showed multiple early-enhancing liver lesions, again no evidence of cholecystitis. She received 2L normal saline, cipro, flagyl, and morphine, and transferred here for furthur management. In the ___ ED intial vitals were: pain 5, T 98.7, HR 106, BP 168/82, RR 20, O2 98% - Exam notable for well appearing but dry MM. Moderate RUQ TTP without rebound, guarding, or ___ - Labs were significant for WBC 23.0 (89.3%PMN). LFT's were unremarkable except ALP 139. Normal Chem7 aside from hyperglycemia to 280. - Patient was given 2g IV Mg, 1g ceftriaxone, 500mg IV metronidazole, IV morphine x3, and 19 units lantus. On the floor, patient reports pain is much improved, now ___. No nausea, last vomited in the ED. Radiology showed 1. Moderate distended gallbladder with wall edema and trace perihepatic fluid, and likely an impacted stone in the neck, worrisome for acute cholecystitis. 2.. Three liver lesions in segments VI/ VII, V and VI, largest measuring 8.4 cm, with imaging features of adenoma. The MR imaging characteristics for ___ of adenomas are not classic, but these are thought to represent inflammatory adenomas. 3. Two liver lesions in the segment VI, ___ are consistent with focal nodular hyperplasia. NOTIFICATION: The critical findings for discussed with ___ on ___ at 10:00 A.M, 5 min after discovery. The patient was diagnosed with CHOLELITHIASIS NOS, LIVER DISORDERS NEC, DIABETES UNCOMPL JUVEN, LONG-TERM (CURRENT) USE OF INSULIN. The patient was treated with Cholecystectomy. At the time of discharge, the patient had Acute cholecystitis 8 cm hepatic adenoma in the right lobe. The patient was given written instructions concerning 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 DMI and bipolar disorder admitted for abdominal pain, found to have cholecystitis and multiple hepatic adenomas and FNH. 1) Cholecystitis: noted on MRI abdomen. Initially started on ceftriaxone and flagyl. Surgery consulted. HIDA scan was also positive. 2) Hepatic adenomas: OCP stopped. On ___ the patient was taken to the OR for cholecystectomy by Dr ___. At the time of surgery the gallbladder was noted to be very distended and inflamed. There was also a very large gallstone impacted in the infundibulum. Due to the degree of inflammation and the difficulty in locating the cystic duct, the decision was made to convert to an open procedure. Intra-op cholangiogram was performed assuring no bile duct injury. A subtotal cholecystectomy was then completed, and the gallstone had also been removed. The patient was extubated and transferred to the PACU in stable condition. Please see the operative note for surgical details. Post operatively the patient initially did have pain management issues and was using a dilaudid PCA with only moderate success. Adjustments were made and tylenol scheduled which seemed to improve her pain management. She did have a fever to 102. Blood cultures were sent which have been no growth to date. A chest xray was done showing very low lung volumes. Spirometry was encouraged. She did have a desaturation into the 80's on POD 1 evening. She was encouraged to increase the use of her spirometer and this did not occur again. The JP drain was sero-sanguinous, with no evidence of a bile leak. Her diet was advanced from clears to a regular diet with good tolerance. No nausea or vomiting. And once on a regular diet she was tolerating PO oxycodone with improved pain management such that she was ambulating.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ unrestrained driver, MVC vs pole. Pt said he hit black ice then slammed on brakes, swerved right to avoid people on left and in doing so hit a pole. There was intrusion on driver side, no air bag, likely +LOC. Denied EtOH. Taken to OSH where CT scan head was suspicious for a SAH so after initial stabilization he was transferred to ___ for further management. Radiology showed No fracture. Radiology showed No fracture or dislocation. The patient was diagnosed with SPLEEN PARENCHYMA LACER, MV COLLISION NOS-DRIVER, TETANUS TOXOID INOCULAT. At the time of discharge, the patient had Motor Vehicle Collision. The patient was given written instructions concerning 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 as above to the ED at ___ ON ___. On arrival the patient's vitals were within normal limits. His OSH imaging (CT head/neck/Chest/Abdomen) was reviewed and it was decided that a SAH was unlikely. CT neck was negative. CT chest revealed a small left apical pneumothorax while the CT abdomen demonstrated a Grade 2 splenic laceration, L lobe liver laceration without any ___ fluid and a R adrenal hemorrhage. Subsequently, the patient was admitted to the ICU under the Acute Care Surgery Service. Neuro: The patient was alert and oriented throughout hospitalization. He was kept on Q4H neuro-checks in the ICU which were negative so they were discontinued when the patient was transferred to the floor in the evening of HD1. His pain was initially managed with IV narcotics and then transitioned to oral medication when his diet was resumed. His C-collar was cleared after the CT neck was confirmed to be negative and the patient was transferred to the floor on HD1 when he was deemed to be stable. CV: The patient remained stable from a cardiovascular standpoint; he was kept on telemetry in the ICU which was discontinued when he came to the floor. Pulmonary: The patient remained stable from a pulmonary standpoint; he had a small L apical pneumothorax on admission which remained stable on repeat am CXR. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO. On HD1 his diet was advanced sequentially to a regular diet, which was well tolerated. Patient's intake and output were closely monitored. The patient refused a Foley on admission so his urine output was closely monitored and was adequate. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: We held SQH until intracranial bleeding was definitively ruled out and the patient was encouraged to get up and ambulate as early as possible. MSK: The patient had complained of L shoulder and wrist pain on admission so we obtained X rays which were negative for any fractures or dislocation. At the time of discharge on HD2, 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 cautioned against partaking in any activity that involved contact with his abdomen or heavy weights for at least ___ weeks and was advised bed rest until clinic follow-up in 2 weeks. The patient received discharge teaching and follow-up instructions and verbalized understanding of and agreement with the discharge plan. However he left without his paperwork so efforts were made to fax the paperwork to him.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male w/hx CAD, AAA repair, diverticulitis s/p open sigmoidectomy presents w/ acute onset of bright red bleeding from the rectum. Patient report that he started having dull onset of RLQ and mid lower abdominal pain starting about 1 week ago with no other associated symptoms. Then this morning he started to have some dizziness and headache and at 10am, he had a BM and noticed a large amount of bright red clots which has not stopped since. He presented to ___ where he was noted to be tachycardic and pale with large amount active bright red bleeding through his rectum. He was given 5U RBCs, ___ and 1Plt. underwent a CTA a/p which showed many diverticuli with enhancement in the diverticular lumen which are likey calcified inspissated stool with some regions with questionable contrast blush.. Upon transfer to ___, he continued to large clots of blood from the rectum with associated tachycardia and SBP 90's. Massive transfusion protocol was activated and he got additional 4U RBC, ___ 1Plt. Patient currently reports pain in his RLQ. He denies other symptoms. He reports he had a bright GIB almost ___ years ago and was hospitalized however does not remember the diagnosis or intervention. He had his last colonoscopy ___ at ___ which he reports was normal. He also underwent an EGD a few months ago for reflux symptoms which showed mild gastritis. He has been on Omeprazole. He denies any hx of fevers, chills, weight loss, chest pain, SOB, nausea or emesis. Radiology showed No active extravasation, pseudoaneurysm, angiodysplasia, or source of gastrointestinal bleeding was identified despite thorough angiography. DX CHEST PORT LINE/TUBE PLCMT 3 EXAMS showed Mild pulmonary edema with likely small right-sided pleural effusion and bibasilar atelectasis. Interval placement of right IJ venous catheter, which terminates in the proximal SVC and placement of NG tube, which terminates in the stomach. CHEST (PORTABLE AP) showed Interval intubation with ET tube terminating 5 cm from the carina. Consider desufflating endotracheal balloon. Mild interval worsening of pulmonary edema, otherwise unchanged. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 1:41 pm, 5 minutes after discovery of the findings. CHEST (PORTABLE AP) showed Comparison to ___. The patient has been extubated and all other monitoring and support devices were removed, with the exception of the right internal jugular vein introduction sheet. Pre-existing signs of mild pulmonary edema have resolved. Today's radiograph shows minimal pleural effusions bilaterally with areas of retrocardiac and right basilar atelectasis but no evidence of pneumonia or pneumothorax. CHEST (PORTABLE AP) showed In comparison with the study of ___, the right IJ catheter is been removed. Cardiomediastinal silhouette is stable and there is no evidence vascular congestion. Again there are bilateral pleural effusions with atelectatic changes at the bases. No evidence of acute focal consolidation. CHEST (PORTABLE AP) was done. Radiology showed 1. There is gaseous distension without pathologic dilation of the colon. No evidence of small or large bowel obstruction. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. At the time of discharge, the patient had Gastrointestinal Bleed. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient is a ___ year old male with pmh significant for CAD, AAA repair, and diverticulitis s/p open sigmoidectomy that presented to OSH ER with complaints of acute onset of bright red bleeding from the rectum. At the OSH, he was given 5U RBCs, ___ and 1Plt. Imaging was completed and CTA demonstrated many diverticuli with enhancement in the diverticular lumen. Therefore he was transferred to ___ for definitive care. Once at ___, massive transfusion protocol was activated and he received additional 4U RBC, ___ 1Plt. He was then admitted to ___ for further evaluation and management. Interventional Radiology was consulted for mesenteric angiography, but on ___, ___ could not find active extravasation, therefore, no embolization/intervention completed. The patient continued to bleed via his rectum and his Hct dropped from 28 to 21 which brought total transfusion numbers to 12PRBC, ___, 4plt, 2cryo. EGD was then completed on ___ with no clear source of an upper GI bleed. The surgical team requested for a tagged RBC scan which also came back negative and partially low yield because the patient was not actively bleeding. He was then transferred to the inpatient unit when his hct was noted to be stable. Once on the inpt unit, he developed increased work of breathing for which he received tiotropium and albuterol nebulizer with good effect and one time dose of 10mg labetalol for HTN. Once stable, his diet was advanced as tolerated to regular. During this hospitalization, the patient voided without difficulty, was adherent with respiratory toilet and incentive spirometry and actively participated in the plan of care. Venodyne boots were used during this stay. At the time of discharge, the patient was doing well. He was afebrile and his vital signs were stable. The patient was tolerating a regular diet, ambulating, voiding without assistance, and his pain was well controlled. The patient was discharged home without services. Discharge teaching was completed and follow-up instructions were reviewed with reported understanding and agreement.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of OI, prior L femur periprosthetic fracture s/p ORIF ___, ___ and remote R femur fracture treated with ex-fix, now s/p fall with R midshaft femur fracture. Radiology showed Intraoperative images demonstrate placement of an intramedullary rod with proximal and distal interlocking screws fixating a fracture involving the midshaft of the right femur. There is good anatomic alignment. There are no signs for hardware related complications. Total intra service fluoroscopic time is 253.9 seconds. Please refer to the operative note for additional details. The patient was diagnosed with Oth fracture of shaft of right femur, init for clos fx, Fall on same level, unspecified, initial encounter, Osteogenesis imperfecta. The patient was treated with Right femoral osteotomy and ORIF. At the time of discharge, the patient had Right femoral fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right midshaft femur fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for right femur osteotomy and ORIF, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. During hospitalization the patient was intermittently tachycardic. This was consistent with prior hospital admissions. The patient remained asymptomatic. EKG showed sinus tachycardia. She was treated with IV fluids. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is ___ weightbearing in the right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o bladder and prostate CA s/p cystectomy/prostatectomy presents from ___ w N/V and abdominal pain x 5d. Work-up was notable for acute cholecystitis and choledocholithiasis on CTAP in setting of WBC 24 and normal LFTs. He notes that on ___, he felt very gassy, nauseous, and had three episodes of nonbloody, nonbilious emesis. On ___, he had two more episodes of nonbloody, nonbilious emesis, noticed epigastric and RUQ pain. He has been having trouble drinking and eating due to early satiety and feeling full. His last bowel movement was on ___, which he describes as very small in quantity and "tannish" in color. He denies fever, chills, radiation of pain to the arms, back, or jaw, and changes in pain with eating or position. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Acute cholecystitis. 2. Right hepatic lobe hemangioma. Cholecystostomy. showed 8 ___ cholecystostomy with removal of 120 cc turbid brownish foul-smelling fluid. The patient was diagnosed with Nausea with vomiting, unspecified. The patient was treated with Percutaneous cholecystostomy tube 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>Mr. ___, an ___ w h/o bladder and prostate CA s/p cystectomy/prostatectomy, presented from ___ several days of N/V and nonbloody emesis, with abdominal pain on ___. His labs notable were for 24 WBC, LFT and lipase wnl, and imaging demonstrating acute cholecystitis. He underwent EUS to evaluate CBD stones, of which there were. Therefore, he proceeded with ERCP for sphincterotomy and stone extraction on ___. Subsequently, in order to manage his cholecystitis, patient underwent percutaneous cholecystostomy drain placement. A ___ ___ was placed with 120cc of turbid brown purulent material drained. This was sent for microbiology eval (preliminarily GNR and GPC). After normalizing him to his normal regimen, diet, home medication, and pain control, Mr. ___ was discharged with a course of augmentin for 8 days. He had a foley catheter up until discharge due to his bladder history. He reports self-catheterization at home and we felt comfortable for him to continue to do so. His foley was therefore removed upon discharge. Upon d/c, pt was doing well, afebrile, and hemodynamically stable wnl. pt received discharge instructions and teaching, along with follow up instructions. pt verbalizes agreement and understanding of discharge plans.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ yo with PMH of IDDM who initially presented to ___ on ___ for acutely developed right hip lump she had also subjective fevers. At that time u/s showed 2x2 cm fluid accumulation s/p needle aspiration and was started on bactrim and keflex; culture resutls heavy growth + strep. Today she presents to the ED with fluid reaccumulation. Denies fever, nausea, vomiting or any other symptoms. Minimally tender at this point. Radiology showed 1. 3.2 x 2.7 cm superficial organized phlegmon in the subcutaneous fat of the right lateral hip is not yet encapsulated. 2. Fibroid uterus. 3. Uncomplicated, fat-containing ventral hernia with abdominal defect measuring 1 cm. The patient was diagnosed with CELLULITIS/ABSCESS OF TRUNK, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERCHOLESTEROLEMIA. The patient was treated with ___: I+D of right flank abscess. At the time of discharge, the patient had right flank 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>___ year old female admitted to the acute care service with right hip lump. Initial aspiration was done at an OSH, but reported recurrence of mass size. Incision and drainage done at OSH which grew strept. Upon admission, she was made NPO, given intravenous fluids and started on pippercillin and vancomycin. During her hospital course, she remained afebrile with a white blood cell count of 5. She underwent a cat scan of the pelvis on HD #2 to assess progression of the fluid collection. It was determined that the fluid collection was superficial and and incision and drainage was done. wound was packed with nugauze and she was sent with ___ services for packing wound and will be continued on 7 day course of Augmentin. She was discharged on a 2 week course of augmentin with follow-up appointment in ___ clinic. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx OLT ___ for ___ c/b recurrent HepC cirrhosis s/p Harvoni, recurrent cholangitis requiring multiple drain placements, p/w fevers. History obtained from patient on the floor. He took his temperature on ___ and found it to be 102.1 at 8p. He normally get chills and shakes, but did not with this particular fever. He took 1g of Tylenol and called the ___ instructions; he was directed to the ED. He had no other accompanying symptoms, no sick contacts. In the ED, initial vitals were: 101.0 85 130/69 16 97% RA. Labs were notable for: WBC 12.6, PLT 130, Bicarb 21, BUN 21. Other labs were normal. Imaging was ordered, not yet read. Blood cultures were sent. Liver was consulted, recs as below. Vanc/Cef were given. VS on transfer were: 99 71 112/66 16 97% RA. On the floor, the patient is alert, comfortable, able to contribute to the history above and below. He denies HA, n/v, cp/pressure, cough, congestion, rhinitis, SOB, abdominal pain including RUQ pain, change in bowel habits, urinary frequency or pain with urination, rashes, muscle aches. He has chronic joint pains, unchanged. ROS: See HPI. Chest radiograph. showed No acute cardiopulmonary abnormality. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Patent hepatic vasculature with appropriate waveforms. 2. Stable intrahepatic biliary ductal dilatation status post hepaticojejunostomy. The patient was diagnosed with Fever, unspecified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ hx OLT ___ for ___ c/b recurrent HepC cirrhosis s/p Harvoni, recurrent cholangitis requiring multiple drain placements, p/w fevers without other infectious symptoms concerning for possible biliary source. # Fevers. He was afebrile the entirety of his admission (Tmax 100.1). Given his history of recurrent cholangitis from infected bilomas, the initial concern was for repeat cholangitis. RUQ ultrasound on admission showed stable ductal dilation without evidence of focal liver or splenic lesions. He was started on Cefepime and Daptomycin for empiric GN and Enterococci treatment. Daptomycin was selected given his history of "Red Mans Syndrome" with Vancomycin. Abx were discontinued after 48 hours of no growth on cultures. He was monitored for 24 hours off antibiotics and discharged to home in stable clinical condition. His WBC trended down and he did not endorse any infectious symptoms on discharge. CXR was clear, urine cx was negative and blood cultures were NGTD at the time of discharge. # HCV cirrhosis with h/o OLT in ___: He remained well-compensated without ascites or hepatic encephalopathy. His LFTs, Tbilli, and Albumin were trended and remained within normal limits. Tacrolimus level was 4.2 and he was continued on home tacrolimus dosing without adjustment. Home ursodiol and bactrium were continued. Chronic # Osteopenia: Continued alendronate # Anxiety and depression: Continued citalopram, lorazepam, and zolpidem # Cardiac: Continued ASA Transitional Issues - Tacrolimus level: 4.2 on ___. Continued on home dosing without changes. - Patient will continue with monthly lab draws with results faxed to Dr. ___ office as previously arranged. # CODE: Full # CONTACT: Wife, ___, ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old lady with PMH asthma (one 1.5 L at home), afib, PEs on xarelto, CHF w/ pacemaker p/w dyspnea and hypoxia. Pt was found to be 82% on her usual home O2 and ntoed to have increased O2 requirement. CHEST PORT. LINE PLACEMENT showed In comparison with the study of ___, there has been placement of right subclavian PICC line that extends to the mid portion of the SVC. This was conveyed to the venous access nurse. The area of increased opacification in the right mid zone has decreased. Otherwise, there is little overall change. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. The patient was treated with PICC placement.. At the time of discharge, the patient had Atypical healthcare associated pneumonia Hypoxia acute diastolic CHF exacerbation Contact dermatitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old lady with PMH asthma (one 1.5 L at home), afib, PEs on xarelto, CHF w/ pacemaker p/w dyspnea and hypoxia ___ CHF exacerbation and atypical pneumonia. We treated with an 8 day course of vancomycin and cefepime, augmented by azithromycin. We placed a PICC, and treated with IV diuretics which were bothersome. She explained to us that she would not want to be rehospitalized under any circumstance, be treated with antibiotics, diuretics, get a PICC line, or receive aggressive care. After discussion with her PACT team, palliative care she was sent home with ___, with plan to transition to hospice care as an outpatient. ACTIVE MEDICAL ISSUES ================ # Healthcare associated pneumonia and mild diastolic CHF exacerbation. She presented with dyspnea and hypoxia. HCAP was likely primary cause of hypoxia and dyspnea (dced from rehab ~6 weeks PTA), with some contribution from CHF exacerbation. By imaging pneumonia appears atypical (legionella negative), repeated pneumonias likely related to tracheobronchomalacia. Less likely bronchoalveolar carcinoma given only one episode hemoptysis. PE ruled out by CT-A but hepatic reflux suggestive of R heart dysfunction w/ a primary lung process. - Consider 3 month short term follow for posterior RUL lesion vs biopsy if admitted. She appeared euvolemic with 80 mg PO furosemide daily (avoided BID dosing as patient not compliant with it). She received vancomycin/cefepime/azithromycin x8 days via ___, which was dc'ed. Course ended ___. Per IP, there are no further management strategies for her TBM. Asymptomatic. Bacteriuria: Had this in the past. Notable history of ESBL EColi UCxn included meropenem. Asymptomatic, so did not treat with broader spectrum antibiotics. # Arm rash/ contact dermatitis from ___ site tegaderm. Consider alternative bandage for ___ site in future. Attempted to control discomfort with fluocinolone and low dose diphenhydramine. # DIASTOLIC CHF: TTE ___, LVEF >55%, moderate MR. ___ home beta blockade, initially diuresed with IV furosemide, then switched to PO furosemide as above. She is incontinent, would monitor daily weights and exam. # Goals of care: She repeatedly expressed that she wanted to go home, not a rehab or long term care facility. She has had discussions about hospice in the past, but has been ambivalent about it. She intermittently endorsed wanting to go home with hospice and asking "what is hospice?" after long discussion (patient not confused), re-demonstrating this ambivalence. She initially agreed to go to rehab but then did not want anybody to enter her home to retrieve her checkbook, as such she remained at ___ throughout her antibiotics course. The ___ care team, PACT, and her ___ case manager were all closely involved and after several discussions, she noted that she would consider transitioning to home hospice in the future, would probably want hospital re-admission if dyspneic, but would not want to go to a facility. CHRONIC ISSUES =========== # ATRIAL FIBRILLATION WITH CONTROLLED VENTRICULAR RESPONSE: Stable during admission. She is s/p pacer which intermittently V paces. Anticoagulated with rivaroxaban. CHADS2 score is 3 (CHF,HTN, age). Continued home rivaroxaban 20mg and metoprolol succinate 25mg XL. # Tachy-___ syndrome: s/p pacer which intermittently V paces, monitor on telemetry. # OSA. On 1.5L O2 at night at baseline. Not on CPAP. # Depression: Continued home sertraline. # Hypothyroidism: Continued home levothyroxine. # Chronic hip pain: Continued home tramadol. Consider restarting NSAIDs if patient prefers comfort. # CKD, stage 3: No longer trending as kidney function had been stable. # History of pulmonary embolus- b/l PEs, dx in ___ on therapy for 6 months---> warfarin was d/c'ed due to recurrent falls; recurrent PE in ___ w/ saddle embolus thus restarted warfarin, now on rivaroxaban. Continued rivaroxaban. # Hypertension: Normotensive. TRANSITIONAL ISSUES =================== - Code status: DNR/DNI, do not rehospitalize. Confirmed with patient. - Emergency contact: - Studies pending on discharge: None. - Please consider checking chem-7 at f/u. - Please discuss transition to hospice w/ patient and care team.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with metastatic RCC on votrient, presenting with 2 weeks of worsening weakness and fatigue, with hypotension in clinic prompting ED referral. In clinic SBP was initially 89, attempted direct admit but could not obtain IV access. Patient also have increasing lower extremity edema L > R and decreasing ability to ambulate over the last 2 weeks. She denies any fevers, shortness of breath, nausea, diarrhea, or dysuria. She did fall recently. Of note she was diagnosed with a DVT ___ years ago and was on Coumadin until this was stopped prior to her cyberknife treatment in ___. UNILAT LOWER EXT VEINS LEFT showed 1. Extensive deep venous thrombosis in all imaged lower extremity veins bilaterally. Proximal extent of thrombus is not seen on this study. A CTV of the abdomen/pelvis would be more sensitive in evaluating proximal extent of clot burden. 2. 2.1 x 0.9 cm complex left ___ cyst. Radiology showed New left IJ line ends in the mid superior vena cava. No pneumothorax. CTA chest. showed 1. There is a small pulmonary embolus in the mediobasal segment of the left pulmonary artery. There may also be a tiny pulmonary embolus in a subsegmental pulmonary artery branch of the right lower lobe. 2. Mild interval decrease in size of extensive pulmonary nodules, mediastinal, and hilar lymphadenopathy compared to exam from ___. No new pulmonary nodules are seen. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 12:09 ___, 5 minutes after discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Within the limits of this noncontrast study, there is no definite CT evidence of acute intracranial hemorrhage. 2. Known brain metastasis previously seen on MRI are not well demonstrated on the CT exam. Please note that some of the masses were hemorrhagic on prior MRI. If clinically indicated, consider contrast enhanced brain MRI for further evaluation. 3. Paranasal sinus disease as described. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Numerous enhancing supratentorial enhancing metastatic lesions in the bilateral frontal, right parietal, and left occipital lobes which are grossly unchanged as compared MRI ___. 2. No evidence of new or worsening enhancing lesions or worsening edema. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ ___ on the telephone on ___ at 9:13 AM, 5 minutes after discovery of the findings. CHEST (PORTABLE AP) showed Allowing for technical differences between the exams, there has not been a substantial change in the appearance of the chest since recent study of 2 days earlier. CHEST (PORTABLE AP) showed Allowing for differences in technique, there has not been a relevant change in the appearance of the chest since recent study of 1 day earlier. The patient was diagnosed with Acute embolism and thombos of deep vein of low extrm, bi. At the time of discharge, the patient had Bilateral ___ DVTs, Bilateral PE's. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with a history of metastatic RCC with brain metastasis who is admitted with hypotension and extensive DVTs found to have bilateral PEs started on lovenox. Bilateral PE's, Bilateral DVTs: etiology of hypercoagulability likely malignancy - Discussed with neuro oncology - given brain metastasis, patient is at risk for hemorrhagic masses intracranially. CT head showed no active bleed. - patient was started on hep gtt no bolus; transitioned to lovenox BID. will continue this medication at discharge - considered starting apixaban, but this medication was not fully covered by insurance. Patient will continue lovenox instead. Some consideration of restarting patient on Coumadin, but deferred, chose to continue lovenox instead in setting of ___ brain mets with bleeding risk and Coumadin being higher risk for intracranial bleeding Hypotension - Likely secondary to ___ PE's and poor PO intake. - IV fluids given as needed. - CTA Chest as above; treat PE's as above on lovenox - IJ placed in the ED as no other IV access options were available. Will obtain PICC if needed ___: Cr 1.2 today. continue to monitor with daily lytes. encourage PO intake, IVF PRN. renally dosed medications. #Metastatic RCC - previously on pazopanib; patient was not tolerating it well. consider restarting as appropriate - ___ consult given decreased mobility. TRANSITIONAL ISSUES #started on lovenox BID for PE, DVT treatment #Anticoagulation plan: patient discharged on lovenox BID. considered starting apixaban, but this medication was not fully covered by insurance. Some consideration of restarting patient on Coumadin, but deferred, chose to continue lovenox instead in setting of ___ brain mets with bleeding risk and Coumadin being higher risk for intracranial bleeding #consider restarting on Coumadin with close follow up if patient is not tolerating SQ lovenox #Patient had complaints of dizziness with the sensation of room spinning, which started several days prior to admission. She is unable to say what triggers the dizziness, no focal neurological signs or symptoms. should follow up with PCP for further ___ if necessary #Metoprolol XL decreased from 100mg to 50mg; should be increased back to home dose by PCP as appropriate #EMERGENCY CONTACT HCP: Husband ___ ___ ___ ___ #CODE STATUS: DNR/DNI</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt s/p b/l mastectomy and ___ months ago, with recent fat grafting to right breast and lat flap to left. C/o f/c right breast cellulitis and found to have abscess of right breast. Radiology showed Technically successful aspiration of a right breast fluid collection. The sample was sent for microbiology. US BREAST UNILATERAL LIMITED RIGHT showed Diffuse edema in the reconstructed right breast, with the largest pocket of fluid spanning approximately 3.6 cm, which would be amenable to aspiration. Radiology showed Technically successful aspiration of a right breast fluid collection. The sample was sent to microbiology. The findings paged to Dr. ___ by Dr. ___ on ___ at 13:27. RIGHT BREAST ULTRASOUND showed 4.2 cm simple appearing fluid collection in the lateral aspect of the reconstructed right breast. This would be amenable to aspiration. 4.2 cm right breast fluid collection is amenable to aspiration. The patient was diagnosed with Infection following a procedure, other surgical site, init, Mastitis without abscess, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause. The patient was treated with US-guided drainage of right breast x2 I&D right breast. At the time of discharge, the patient had 1) Right breast cellulitis and abscess 2) Type II diabetes (initiated on insulin this admission). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Pt presented w/ fevers and WBC 14, found to have advancing breast cellulitis and abscess s/p US-guided drainages on ___ and ___. Continued to have fevers with drainage from breast and so on ___ the patient had bedside I&D with copious purulent malodorous fluid drained (about 400cc). Cx have grown staph epidermidis and gram pos rods sent out and awaiting speciation. ID consult recommended broadening abx to linezolid and clinda from initial abx of vanc, cipro, flagyl. Patient will be discharged on PO linezolid and clinda to continue until ___ per ID recommendations. ___ was consulted for hyperglycemia and noncompliance with metformin due to metallic taste. Recommended patient be started on Lantus 10U QAM and insulin sliding scale QID while admitted and sent home with Basaglar Kwikpen 10U QAM and Novolog Kwikpen sliding scale with follow-up at ___ on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Briefly this is a ___ yo female presenting with fevers/chills for 6 days with Tmax 102. She has been feeling unwell for the last ___ days with body aches, fevers. She tried managing it at home with tylenol and ibuprofen. The symptoms started with dysuria, and progressed to include left-sided flank pain over the past 2 days, however she also has a cough. Her cough is nonproductive and she denies any chest pain, dyspnea, diarrhea, sore throat, confusion, neck pain. She does endorse fatigue, headache which has improved with fluid, and diffuse muscle soreness. She also endorses a change in stool coloration notng that they are slightly more black than ususal. She has had poor by mouth intake and feels exhausted. Of note she reports mild epigastric tenderness in the setting of taking Tylenol and Ibuprofen for the last ___ days. In the ED, initial VS: 100.2 80 118/64 16 95%. She recieved Ibuprofen, Tylenol and 1 gram of Ceftriaxone.Given 3LNS. Prior to transfer from the ED her vitals were: 102.8 129/65 118 24 98%6LNC Currently, she feels a little "better." She has less muscle aches, but she still has a persisting headache. She continues to have persisting dysuria with foul smelling urine and persisting left side back pain. REVIEW OF SYSTEMS: Denies vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, hematochezia, and hematuria. Radiology showed No acute cardiopulmonary process. Radiology showed Unremarkable study aside from trace right pleural effusion. The patient was diagnosed with PYELONEPHRITIS NOS, HYPERTENSION NOS. The patient was treated with Upper endoscopy. At the time of discharge, the patient had Pyelonephritis Elevated liver function tests. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ presenting with fevers/chills for 6 days with Tmax 102 concerning for pyleonephritis. #. Pyelonephritis: The patient presented with dysuria, fevers/chills, and suprapubic pain. She was found to have left greater than right CVA tenderness and positive UA which grew pan-sensitive E.Coli, and was started on Zosyn for pyelonephritis. Given her fever, white count, and tachycardia an abdominal ultrasound was obtained to rule out complicated pyelonephritis, which was negative. She was switched to IV Ciprofloxacin following the return of the E. coli sensitivity panel with continued improvement of her signs and symptoms. She was discharged on PO Ciprofloxacin for a 14 day course of antibiotics. #Anemia/Black Stools: The patient was noted to have a hct of 32.5 from a prior baseline of 40. She reports black stool within the last ___ days in the setting of significant NSAID use for the pain secondary to pyelonephritis, raising the concern for NSAID-induced gastritis. She had guiac positive brown stool, and was started on a PPI and underwent an EGD in-house which was negative. The PPI was discontinued. T.bili and LDH were normal on initial presentation, ruling out hemolysis. She will need outpatient follow-up to work up her anemia with a colonoscopy and further blood tests when her acute infection has resolved. H. pylori antigen was negative and EGD was normal without any abnormalities. Her PPI was discontinued and she was discharged with instructions to have an outpatient colonoscopy. #. RUQ Tenderness/Elevated LFTs: The patient does not complain of RUQ tenderness but on exam, exhibited RUQ tenderness to palpation. She was also found to have elevated LFT's on initial presentation with ALT > AST and elevated Alk Phos. She denies nausea/vomitting and denies alcohol use. Abdominal ultrasound was negative for cholelithiasis or cholecystitis or fatty liver, and viral hepatitis studies were sent, which showed positive Hepatitis B core antibody and surface antibody, negative surface antigen consistent with prior exposure. Hepatitis C Ab was negative. LFT's down-trended during her hospital stay. She will follow-up as an outpatient with her PCP for monitoring of LFT's and further workup, if necessary. #. Hypertension: The patient's anti-hypertensives were initially held in the setting of her acute illness. Her blood pressures have been elevated in-house and her home anti-hypertensives were restarted prior to discharge (Triamterene/HCTZ 37.5/25 mg daily). #Neck Pain: The patient has chronic neck pain, unchanged from prior symptoms. No confusion, signs of meningismus, and headache improved. Her neck pain improved in-house. # CONTACT: Daughter ___ ___. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH DMII, COPD, ruptured AAA s/p EVAR c/b failure L fem perclose req patch angioplasty, ex-lap for evac RP ___, PAD s/p L fem-peroneal bypass, presenting now ___/ ___ abdominal and back pain which started overnight. She became concerned given her previous history of ruptured aneurysm, and decided to come to the ___ ED. She was initially found to be hypertensive to a SBP of 220s, and an esmolol gtt was started. A CTA was performed, which showed what appears to be contained rupture without active extravasation of contrast. Vascular surgery was consulted for assessment of surgical repair of ruptured AAA. CTA ABD AND PELVIS showed 1. Acute rupture of an infrarenal abdominal aneurysm. The patient is status post suprarenal aorto bi-iliac stent with the iliac portions of the stent located superiorly to the aortic bifurcation, concerning for endoleak type 1B. High-density material is visualized in the excluded aneurysm sac. 2. There is a very focal high density along the small bowel, just anterior to infrarenal aorta, which is not well seen on pre-contrast images (___). Fistulous connection cannot be excluded. No additional evidence to suggest an aorto-enteric fistula. 3. 1.4 cm left common femoral artery aneurysm, new compared to ___. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 9:24 AM, 1 minutes after discovery of the findings. Right lower extremity arterial ultrasound showed Occlusive thrombus within the right proximal SFA. Flow reconstitutes in the distal SFA however there are very low velocities in the distal SFA and popliteal artery. No flow seen in the right posterior tibial or dorsalis pedis arteries. The peroneal artery is not visualized. NOTIFICATION: After review of OMR notes, the ordering physician was already aware of the findings on ___. VENOUS MAPPING showed The right great saphenous and small saphenous veins are patent with diameters above. The left great saphenous vein has been surgically removed. The small saphenous vein is patent with diameters above. VENOUS MAPPING FOR DIALYSIS ACCESS showed The cephalic vein is not visualized in the left upper arm. In the left forearm, the cephalic vein is patent with diameters above. The left basilic vein is patent with diameters above. Examination of the right arm was not performed as the patient had multiple IVs in the right arm veins. Radiology showed Findings in keeping with pulmonary edema. The patient was diagnosed with Abdominal aortic aneurysm, ruptured. The patient was treated with ___ Surgery #1 1. Ultrasound-guided access to bilateral common femoral arteries. 2. Abdominal aortogram. 4. Coil embolization of the right internal iliac artery. 3. Bilateral extension of previously placed EVAR iliac limbs with 2 additional limbs into the iliac arteries on both sides. ___ Surgery #2 1. Right groin exploration. 2. Right femoral patch angioplasty with Dacron graft. 3. Right femoral endarterectomy. 4. Selective catheterization of right external iliac artery, ___ order vessel. 5. Angiogram of right lower extremity.. At the time of discharge, the patient had Ruptured abdominal aortic aneurysm Right lower leg critical limb ischemia status post ruptured abdominal aortic aneurysm Type II Diabetes Mellitus Chronic Obstructive Pulmonary Disease Hypertension Fibromyalgia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ year old female with history of type 2 diabetes, ruptured AAA s/p EVAR complicated by failure of left femoral perclose requiring patch angioplasty and ex-lap for hematoma evacuation (___), PAD s/p L fem-peroneal bypass, who presented with abdominal and back pain, found to have re-rupture of her AAA. She was initially found to be hypertensive to a SBP of 220s, and an esmolol gtt was started. A CTA was performed, which showed what appeared to be contained rupture without active extravasation of contrast. Vascular surgery was consulted for assessment of surgical repair of ruptured AAA. She was emergently taken to the operating room for re-rupture of her AAA, and type 1B bar graft leak. She underwent coil embolization of the right internal iliac artery, as well as bilateral extension of previously placed EVAR iliac limbs with two additional limbs into the iliac arteries on both sides to reseal her previous EVAR graft. Upon transfer to the PACU, there was some concern initially for right leg ischemia, but the ultrasound showed that there was some flow in the superficial femoral artery distal to the puncture site, and she was transferred to the ICU for recovery. Postoperatively, she had initially been doing well, but was noted to have a cooler right foot over the course of the subsequent hours and loss of her posterior tibial Doppler signal. Arterial duplex confirmed occlusion of the right lower extremity lower leg arteries, prompting concern for proximal occlusion. As such, the patient was prepped for immediate right groin exploration. Intraoperatively it was noted that the Perclose closure appeared to have raised a flap of plaque from the posterior aspect of the common femoral artery. This appeared to be the cause of her occlusion. She then underwent right femoral patch angioplasty with Dacron graft, right femoral endarterectomy, selective catheterization of right external iliac artery, second order vessel, and angiogram of the right lower extremity. It was determined that revascularization had been successful, as her posterior tibial artery signal was noted to be strong again intraoperatively and postoperatively. The patient was transferred to the PACU in stable condition. Post-operatively she continued to experience intermittent pain and anxiety. Her home medications were restarted and she received medications as needed for adequate pain control. She was also seen by social work and spoke with her outpatient psychiatrist, which helped to alleviate her anxiety. She was discharged to rehab. She should continue frequent incentive spirometer use daily. Anticipate rehab stay less to be than 30 days. She should follow up with Dr. ___ at her scheduled outpatient appointment. She should continue taking aspirin 81mg daily as well as her other medications as prescribed. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ woman with a history of left breast IDC s/p lumpectomy ___ f/b XRT, DMI on insulin pump, s/p renal transplant ___ and ___ for diabetic nephropathy, presenting with N/V/D fevers x 1 day. She has experienced a cough for approximately two weeks and a slight runny nose but otherwise felt relatively well until the evening of ___, when she experienced acute nausea/vomiting/diarrhea and some transient LLQ pain that has now improved. Also had subjective fevers and chills. Of note, ate a salade with leftover chicken (several days old) on the afternoon of ___ and her friend who ate the same food now has the same symptoms as she does. She also ate a similar salad several hours prior to the development of her symptoms on ___. Radiology showed No acute intra-abdominal process. Radiology showed 1. Peribronchial thickening and adjacent peribronchial lung opacities, potentially due to multifocal aspiration or an early infection. Since the time of this radiograph, followup chest ___ shows resolution of these opacities favoring an uncomplicated aspiration event. 2. Small bilateral pleural effusions. CHEST (PA AND LAT)CHEST (PA AND LAT)i showed previously visible small lung the opacities have resolved since however small bilateral pleural effusions are new, and increased since ___. Heart size is normal. Mediastinal contour unremarkable. The patient was diagnosed with FEVER, UNSPECIFIED, NAUSEA WITH VOMITING, DIARRHEA. At the time of discharge, the patient had Primary diagnoses: #Gastroenteritis #Pyelonephritis #Acute kidney injury #Hypophosphatemia Secondary diagnoses: # S/p renal transplant. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient is a ___ woman with a history of left breast ___ s/p lumpectomy ___ f/b XRT, DMI on insulin pump, s/p renal transplant ___ and ___ for diabetic nephropathy, presenting with N/V/D fevers x 1 day, found to have pyelonephritis. # Gastroenteritis (N/v/d and cough): Likely viral gastroenteritis given rapid onset and similar symptoms in her lunch companion after eating suspicious meal. Leukocytosis and fever without localizing signs and symptoms supports this diagnosis. Other possibilities included URI or a more serious infection (ie bacteremia) given her immunosuppression. As her symptoms were ongoing for 2 weeks prior to presentation, an acute URI presentation was less likely and respiratory swab not necessary. She also was recently hospitalized for pneumonia but CXR was clear and would not explain her cough. Still spiking fevers on ___ but resolved by ___ on antibiotics. She was found to have Enterobacter cloacae growing in her urine: was initially treated empirically with with vanc/cipro for fevers of unclear origin but suspected GI source, then was switched to ceftriaxone empirically for UTI, and was ultimately discharged to complete a course of ciprofloxacin given sensitivity data. She initially required IVF given poor po intake but fluids were stopped when the patient was taking good po's. Blood cultures negative to date, stool cultures also negative to date. By the time of discharge, her nausea/vomiting/diarrhea had resolved and she was complaining of some constipation. #Pyelonephritis: patient's first UA/UCx initially negative for infection but positive on ___ and growing G+ bacteria. Ucx from ___ grew Enterobacter cloacae per above; patient discharged on ciprofloxacin. # ___: RESOLVED. Cr 1.3 up from baseline of 1.0. Likely prerenal given dehydration from poor po intake/vomiting. Taking better po's by ___. Creatinine back to normal at discharge. # S/p renal transplant: Continued cellcept and cyclosporine. Her cyclosoporine dose was decreased at discharge given high levels. #Hypophosphatemia: patient had low phos during her hospital stay, question renal phosphorous wasting. Vitamin D was within normal limits. Patient was discharged on phos supplementation with close renal f/u. #DMI: patient uses an insulin pump at home. She was followed closely by ___ and was maintained on her basal dose rate from her insulin pump as well as supplemental SS carb counting with humolog. Towards the time of discharge, she was switched back to her pump.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old gentleman with a history of ETOH cirrhosis complicated by portal hypertension, hepatic encephalopathy, recurrent variceal bleeds as well as diabetes and hypertension, s/p recent hospitalization at ___ in ___ for variceal bleed who presents with shaking in his extremities and hyperglycemia. He states that his lactulose was increased last week for the shaking. He notes that usually his shaking progresses to altered mental status and he is worried that this is imminent. He also reports generalized fatigue over the past few months as well as 30 pound weight gain since ___. He denies any new BLE edema. He also says that he has been intermittently confused, forgetting the year and his social security number. He has been compliant with his home lactulose and has been having ~ ___ BMs/day. With regards to his hyperglycemia, he reports poor glucose control and that his home FSBGs typically run in the 300s. He has been taking 50 u Lantus qam + HISS at home but was recently switched to U500 100u BID yesterday which he has not started; this was prescribed by his Diabetes doctor at ___. He did take his home Lantus this evening. He denies fevers, chest pain, dyspnea, abdominal pain, distention or dysuria. He called his oncologist who advised him to come to the Emergency Department. In the ED, initial vitals were T 98.4 HR 99 BP 126/72 RR 16 99% RA Labs notable for WBC 2.3 Hct 28.9 Plt 45 INR 1.2. Na 132. Glucose 582, anion gap 7. LFTs wnl, Tbili 1.3, INR 1.2. Urine negative for ketones. UA negative for UTI. CXR negative. CT head negative. No ascites noted on bedside US in the ED. He was given 10 units regular insulin SQ for hyperglycemia, followed by ___s well as 1L NS; FSBG prior to transfer improved to 324. Of note he was discharged in ___ after being transferred from ___ for a variceal bleed. He underwent TIPS procedure during that admission and his portosystemic gradient was lowered to 12mmHG. After the procedure, he exhibited mild asterixis and mild difficulty concentration, but this resolved after increasing his lactulose dose and he was discharged with intact mental capacity. At the time, he was discharged on lactulose TID, rifaximin, omeprazole and nadolol. He reports that he has not been taking the rifaximin and that his PCP stopped his nadolol (unclear why). His ___ course prior to transfer was complicated by hemolytic anemia. Patient received 20u PRBC at outside hospital and hemolysis labs were positive on transfer with his Hgb in the ___. They remained stable on the floor with no further evidence of bleeding and did not require any further transfusions. Hemolysis labs trended down in the Hemolysis workup showed no autoimmune process and therefore prednisone initially started at OSH was stopped. Transfusion medicine evaluated his bloodwork and determined that he is not making antibodies to either his own or others' blood. Therefore it is likley due to something in the environment. Heme/onc was involved but a diagnosis was never given. It was thought to be due to splenomegaly, G6PD, or some other environmental factor. He was scheduled to follow up with heme/onc after discharge. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. CHEST RADIOGRAPHS showed No evidence of acute cardiopulmonary disease. HEAD CT showed No evidence of acute intracranial process. The patient was diagnosed with ABN INVOLUN MOVEMENT NEC, ALCOHOL CIRRHOSIS LIVER, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS. At the time of discharge, the patient had Primary: Hepatic Encephalopathy Secondary: Uncontrolled 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>Patient is a ___ with a h/o ETOH cirrhosis s/p TIPS who presents with mild confusion and shakes consistent with hepatic encephalopathy, also found to have hyperglycemia. His confusion and shakes improved with lactulose administration. Patient also presented with a recent fall (last 10 days ago) that on history appeared consistent with syncope. # Hepatic Encephalopathy: The patients history of TIPS procedure with current symptoms of shakiness and mild confusion consistent hepatic encephalopathy. His symptoms improved with lactulose TID and the addition of rifaximin BID. He had no evidence of infection. # Hyperglycemia: The patient presented with severe hyperglycemia to the 500s without evidence of diabetic ketoacidosis. He is followed by outpatient endocrinologist. He is currently on lantus 50U qAM and was told to switch to U500 BID on ___. Lantus 50U qAM and insulin sliding scale was continued while inpatient and patient was advised to switch to U500 as prescribed by his endocrinologist on discharge. # Shoulder pain: Patient also had bilateral shoulder pain for the last few weeks. Exam revealed pain with both active and passive range of motion, positive empty can test on LUE and restricted active range of motion. Patient has seen ortho as an outpatient for other injuries. # GIB/Varices: Patient has a history of variceal bleed, now s/p TIPS in ___. Last EGD in ___ revealed no evidence of varices. # Ascites: Patient has a h/o TIPS in ___ and had no evidence of ascites on bed side ultrasound in the ED. # ETOD Cirrhosis: Patient is currently followed by Dr. ___ ___ in liver clinic. MELD on admission was 9 and is currently not on the transplant list. Patient will follow up in liver clinic in early ___. # Polysubstance abuse/chronic pain: Patient on methadone which he gets from ___ in ___, ___). Patient was continued on methadone while hospitalized. #Fall: patient presented with fall ___ days ago. CT head negative. Patient endorsed loss of vision prior to fall and buckling of knees. Fall was felt to be consistent with syncope. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CT abdomen pelvis showed 1. Mild bilateral hydronephrosis with bilateral kidney stones and bilateral ureteral stones, 6 mm in the left proximal ureter and 3 mm in the right distal ureter. 2. Diverticulosis without evidence of diverticulitis. 3. Bilateral sacroiliitis. 4. Large fibroid uterus. NOTIFICATION: The findings were discussed with Dr. ___. by ___, M.D. on the telephone on ___ at 4:03 pm, 15 minutes after discovery of the findings. Radiology showed As above. Radiology showed Compared to the recent CT dated ___, no radiopaque densities are seen within the left kidney or expected position of the left ureter. On the right side, an 8 mm radio opaque density is seen projecting just lateral to the vertebral body at the level of L2, which likely represents a partially visualized transverse process as there is no renal stone correlate on recent CT. No other right-sided radiopaque densities are noted. COMPLETE GU U.S. (BLADDER AND RENAL) showed 1. Persistent right lower pole 5-mm stone with mild dilation of the renal pelvis and fullness of the proximal ureter, similar to prior CT. 2. Mild left hydronephrosis, improved from prior CT allowing for difference in technique. 3. Bilateral ureteral jets visualized. 4. Post void residual of 7.5 cc. The patient was diagnosed with Hydronephrosis with renal and ureteral calculous obstruction. The patient was treated with ___: cystoscopy, placement of bilateral ureteral stent. At the time of discharge, the patient had bilateral ureteral stones. The patient was given written instructions concerning 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 found to have bilateral ureteral stones in ER on ___. As patient was making urine, renal function was at baseline, and there were no occult signs of infection, she was observed overnight on ___ to see if she would be able to pass as least one of these stones. Repeat labs on HD2 remained stable. Repeat renal US on HD2 showed persistent mild hydronephrosis on both sides. Patient was additionally still having intermittent flank pain, and was thus taken to OR on ___ for cystoscopy and placement of bilateral ureteral stents. Procedure was uncomplicated and patient was transferred to the recovery area in stable condition. She was observed in the recovery area and was discharged after voiding. At the time of discharge, she was ambulating on her own, tolerating diet, pain was controlled with oral meds, and was voiding on her own.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ female with alcohol-induced cirrhosis, decompensated with ascites, history of celiac disease who presents with 2 days of worsening constant non-radiating RUQ and epigastric pain. She reports her ascites has been well controlled on direutics and she does not have any history of SBP. Other associated symptoms include nausea, 10 episdoes of small amount vomiting (bilious but non-bloody), 10 episodes of loose bowel movements which has been improving since this morning. Patient denies any hematemesis or melena. She reports feeling very dehydrated and has not had much po intake in the past two days. She denies any UTI symptoms. She denies any chest pain, coughing. She denies any recent alcohol intake. She reports being complaint with her celiac diet of no gluten. She reports feeling chills/night sweats but did not measure temperature. Radiology showed 1. Cholelithiasis, no evidence of acute cholecystitis. 2. Patent portal veins with appropriate directionality of flow and waveforms. 3. Moderate ascites. Radiology showed 1. Small partially occlusive thrombus in main portal vein, new since ___. 2. Moderate volume ascites. Although no definite CT findings, SBP cannot be excluded. 3. Cholelithiasis. Radiology showed 1. Cholelithiasis. 2. Non occlusive thrombus within the main portal vein. 3. Cirrhosis with evidence of portal hypertension and ascites. Radiology showed No deep vein thrombosis in the right lower extremity. Small knee joint effusion. The patient was diagnosed with ABDOMINAL PAIN RUQ, PORTAL VEIN THROMBOSIS. The patient was treated with Central line placement A-line. At the time of discharge, the patient had Primary: Klebsiella Bacteremia Secondary: 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>___ female with alcohol-induced cirrhosis, decompensated with ascites, history of celiac disease presented with 2 days of worsening RUQ and epigastric pain and admitted to MICU for hypotension and concern for sepsis. # Severe Sepsis: Patient met ___ SIRS criteria including WBC of 20 with 6% bands which along with ___ and elevated lactate on admission suggested severe sepsis. Her blood culture grew GNR bacteremia. The exact source for infection remained unclear. RUQ ultrasound and CT abdomen did not reveal any sources. However given localized RUQ pain there was increased suspicion for biliary source. Patient also had symptoms of gastroenteritis prior to admission which may suggest gut translocation. She was initially hypotensive in the ED and in the MICU and received total of 6L of IVF and 25 g of albumin with response in her blood pressure. She was started on cefepime and flagyl and showed remarkable improvement in clinical status. Her lactate, ___ and ___ WBC count improved significantly. Blood cultures grew pan-sensitive klebsiella and surveillance cultures were negative. Ultimately continued on IV cefepime while in-house and transitioned to oral cipro on dsicharge to complete a 2 week course. Underwent MRCP and ERCP without clear evidence of billiary pathology. # Portal vein thrombosus - Small, partially occlusive portal vein thrombosis seens on CT and on MRCP. Decision made not to anticoagulate in house as it was thought this may have been related to sepsis/low-flow state and could resovle spontaneously. Will need repeat imaging to ensure resolution as an outpatient. # ___: Most likely pre-renal renal. ATN also in the differential given episodes of hypotension. Her ___ improved with IVF. # Cirrhosis: Alcoholic cirrhosis with history of decompensation with ascites. No hx of SBP, HE. Her diuretics were held in the setting of sepsis but restarted on the floor with good effect. # Depression: Continued mirtazapine</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with autoimmune hepatitis c/b cirrhosis with known grade one varices and portal hypertensive gastropathy, h/o GI bleeding and multifactorial anemia who presents with polyuria found to have UTI and acute on chronic anemia. Reports that she started Lasix in ___ and since then has had progressively increasing frequency of urination, up to 20 times per day over the last month. She reports that she also has had some pain and straining with urination recently and is concerned that she has a UTI. No f/c, back or flank pain. Pt also reports that she has h/o overactive bladder. Over the past ___ days, she noted some dysuria, felt feverish (did not measure temperature) and "felt lousy". She has had similar symptoms in the past especially with dysuria that were not UTIs, so she was hesitant to come in, until she started not feeling like herself. Also reports recent black stools but was told this was due to her iron therapy. She was recently hospitalized from ___, for anemia ___ to portal hypertensive gastropathy. Active bleeding was treated with argon-plasma coagulator at that time. Initial vital signs in the ED were T100.3, HR 102, BP 125/65, RR 16, Spo2 99% RA. Exam was notable for no CVA tenderness, dark brown/black stool that was guaiac positive. Labs showed: WBC 3.4, hemoglobin 6.8, plt 60. INR 1.1, Chem panel WNL. LFTS notable for normal transaminases/bilirubin, AP 143 and Alb 2.9. UA with large leuks, large blood, 24 RBCs, >182 WBCs, many bacteria, but 16 epithelial cells. Hepatology was consulted who recommended octreotide and PPI. She was given 1u pBCs, 1g CTX, 1l NS, pantoprazole 40mg IV and octreotide 50mcg. Vitals prior to transfer: T98.5, HR99, BP125/47, RR18, Spo298% RA. She was admitted to medicine for management of GI bleeding and acute on chronic anemia. On the floor, admits that he has been getting winded with short distances, and intermittent epigastric and LLQ pain with associated abdominal bloating. She is eating and drinking well, denies nausea, vomiting, hematochezia, changes in sleep, episodes of confusion, chest pain, dizziness or lightheadedness. Of note, her husband died recently (___). She states that she is "getting on", and that his death was not unexpected. Funeral arrangements are for some time next week. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematuria. DUPLEX DOPP ABD/PEL showed 1. Liver contains calcified granulomas, but is otherwise unremarkable. 2. Patent hepatic vasculature. 3. Splenomegaly. 4. No ascites. The patient was diagnosed with Urinary tract infection, site not specified, Gastrointestinal hemorrhage, unspecified. The patient was treated with Endoscopy ___. At the time of discharge, the patient had Primary: Complicated urinary tract infection GAVE s/p thermal therapy Secondary: Autoimmune cirrhosis Rheumatoid 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>___ yo F with history of autoimmune hepatitis c/b cirrhosis, Childs A c/b GI bleeding (last EGD ___ pt has known grade I varices and portal hypertensive gastropathy vs GAVE causing significant GI bleed with Hgb dropping to 4 ___ who presents with urinary frequency and dysuria and found to be anemic Hgb 6.8. EGD performed showed GAVE which was treated with APC. Found to have UTI so treated with ciprofloxacin.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with history notable for hypertension, hyperlipidemia, and prostate cancer transferred from ___ after presenting with nausea, vomiting, transient speech disturbance, and hypertension, found to have a small right cerebellar IPH. History obtained with assistance of ___ telephone interpreter no. ___. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Stable 1.2 cm right cerebellar intraparenchymal hemorrhage with no evidence of underlying mass or vascular abnormality. No mass effect or midline shift. No evidence of new hemorrhage. 2. Numerous central and peripheral microhemorrhages affecting the pons and bilateral cerebral and cerebellar hemispheres, compatible with hypertensive microangiopathy. 3. Nonocclusive focal stenosis of the superior division of left MCA with distal reconstitution, better evaluated on recent CTA. 4. 6 mm cystic lesion in the left medial pons, likely a chronic lacunar infarct. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had Intraparenchymal hemorrhage. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ man with history notable for hypertension, hyperlipidemia, and prostate cancer transferred from CHA after presenting with nausea, vomiting, transient speech disturbance, and hypertension, found to have a small right cerebellar IPH. Etiology thought to be related to hypertension. CTH showed left small cerebellar IPH. CTA head and neck showed left M2 focal stenosis. MRI brain again showed the cerebellar IPH as well as evidence of small vessel disease, and hypertensive microbleeds. He was noted to be hypertensive during admission and was started on the following medications: lisinopril 40mg daily, Amlodipine 10mg daily and labetalol 200mg TID. His aspirin was stopped given his intraparenchymal hemorrhage, microbleeds seen on MRI. Of note, he was found to have a UTI on admission for which he completed a 3 day course of ceftriaxone. He was seen by ___ who recommended rehab. He has outpatient stroke follow up scheduled. AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (bleeding risk, hemorrhage, etc.) 3. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No. If no, why not? (I.e. patient at baseline functional status) </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ hx of renal cell CA met to lungs s/p IL-2 p/w atraumatic LBP x 2 weeks. Pain is in lumbar area and radiating down b/l legs to back of thigh. Pain has been worsening, esp last several days and is worsened by movement. It is associated w/ tingling, numbness of b/l feet and decreased sensation over buttocks and posterior thighs. Two days ago, she noticed decreased sensation in perineal area when wiping. She had plain films of lumbar spine earlier this week that did not show any lesions. She had CT abd/pelvis today and had two episodes of stool incontinence which she attributes to PO contrast. No urinary incontinence/retention. No fevers or chills. Radiology showed Patient is status post left nephrectomy and adrenalectomy without evidence of residual or recurrent disease at this time. The patient was diagnosed with LUMBAGO, SKIN SENSATION DISTURB. The patient was treated with Radiation therapy ___. At the time of discharge, the patient had spinal tumor with concern for cord compression metastatic renal cell carcinoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with metastatic RCC s/p left nephrectomy, left VATS resection for pulmonary nodules, and HD IL-2 who presents with LBP and perineal sensory loss, found to have L1 intradural, intramedullary metastatic lesion while staging CT torso on day of admission showed no other evidence of metastatic disease. #) L1 spinal met: Has associated radiculopathy and new perianal sensory loss, fecal incontinence. Pt was seen by neurosurgery and neurology in the ED and started on dexamethasone. Neurosurgery has determined that she would not be an optimal candidate for resection, and so she was started on radiation therapy on ___ and ___. Per her request, the patient was discharged home on ___ and will complete the remainder of her radiation therapy on ___ as an outpatient. She will continue on oral dexamethasone 4mg q6h for now. She also should make appointments to follow up with her primary oncologists Dr. ___ Dr. ___ new neuro-oncologist Dr. ___ ___ ___ weeks. #) Metastatic RCC: She has undergone resection for pulmonary metastases, and high-dose IL-2 systemic therapy, most recently in ___. There was no other evidence of disease on CT torso done the day of admission. To complete staging workup, she will complete an MRI head, C-spine, and T-spine as an outpatient (currently scheduled for ___, since it could not be achieved during her inpatient time due to the restriction preventing her from receiving contrast twice within a 48-hour window given her GFR<60. #) Depression: continued on home medications. Patient has a follow-up appointment scheduled with her psychiatrist.</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 metastatic rectal cancer (KRAS wild type, NRAS mutation, MSS) who is admitted from the ED with right chest/abdomen pain and rising bilirubin. Patient was in his usual state of health until about a week ago when he developed a cough thought due to a cold. He also noted associated RUQ pain that has now moved into his right chest/flank, especially with coughing. ___ the last two days he has noticed increasing shortness of breath while speaking. He was seen in his oncologists office today, where his bilirubin was also noted to have increased from 1.0 on ___ to 2.8. Given concern for possible PE, and concern about his bilirubin, he was directed to the ED for further management. In the ED, initial VS were pain 4, T 98.9, HR 116, BP 127/81, RR 12, O2 98%RA. Initial labs notable for WBC 9.9, HCT 36.6, PLT 433, Na 135, K 3.9, HCO3 22, Cr 0.7, ALT 103, AST 151, ALP 725, TBIli 2.8, Dbili 2.0. INR 1.3. EKG whowed NSR at 103, NA, no concerning ischemic changes. CTA chest showed no evidence of PE but did show increase in numerous pulmonary metastatic disease. RUQ US showed known hepatic metastatic disease without evidence of obstruction. VS prior to transfer were pain 0, HR 99, BP 108/68, RR 22, O2 99%RA. On arrival to the floor, patient reports shortness of breath, cough, and pleuritic RUQ/right chest pain as above. No frank chest pain and no chest pain at rest. He has intermittent subjective fevers at home. No N/V. His appetite is poor. No diarrhea, and has been a bit constipated with small hard BM yesterday. He had a headache today that improved with IVF in the ED. No dysuria. No new joint pains, swelling, or rash. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Multiple hypoechoic hepatic masses, compatible with known metastases. No evidence of biliary dilatation. CTA CHEST showed 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Since ___, numerous pulmonary metastatic nodules are slightly larger in size. The largest of these measures 13 mm in the right lower lobe, previously 12 mm. The patient was diagnosed with Shortness of breath. At the time of discharge, the patient had Rectal Cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old man with metastatic rectal cancer (KRAS wild type, NRAS mutation, MSS) who was admitted from the ED with right chest/abdomen pain and rising bilirubin most consistent with disease progression. Metastatic Rectal Cancer - The likely cause of the patients abdominal pain and elevated liver function tests are due to disease progression. Chest CTA and RUQ ultrasound done in the ED were unremarkable. He had a previous oxaliplatin reaction. His primary oncologist decided to start treatment with FOLFOX. He received oxaliplatin desensitization with pre-medications per protocol while admitted and tolerated it well. He will return to clinic tomorrow to receive the rest of the regimen. His liver function tests will be followed up by his primary oncologist as an outpatient.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with history of non-ischemic dilated cardiomyopathy (EF 25%), insulin-dependent DM, and dementia presents with low O2 saturation to 88% on room air at her nursing home. Per nursing home records, she has also been having worsening dyspnea on exertion and lower extremity edema, along with a poor appetite. She was recently discharged from ___ on ___ after a 5-day hospitalization for an acute change in mental status and bradycardia at her ECF. She was evaluated by Cardiology during this time for her bigeminy and bradycardia, and deemed not a candidate for an AICD due to her lack of symptoms and no significant bradycardia noted on telemetry. She was noted to have dissociation between her heart rate measurements on her bedside vitals sign and telemetry/physical exam. They were not able to identify a cause for her acute change in mental status, but she was alert and oriented to name but no longer oriented to place. Her renal failure was deemed secondary to cardiorenal syndrome and her diuretics and ACE-i were started upon discharge. She was last seen in the Cardiology clinic on ___, noted to be volume overloaded. Her furosemide was changed to torsemide and she was scheduled for follow-up with Dr. ___. In the ED, initial VS were: 97.8 66 118/80 24 98% NRB (weaned to 95% 2L NC). Of note, sats were in the mid ___ on room air at times, but would dip when pt went into prolonged bigeminy rhythm. Exam notable for pt AOx1 w/ lungs clear, minimal pedal edema. CXR notable for increased interstitial markings with labs showing hypernatremia to 148, BNP to 28175, and D-dimer to 2933. Creatinine of 1.4 (baseline 1.3-1.6). She was given furosemide 40mg IV x1, a Foley was placed and she was admitted for CHF exacerbation. VS on transfer were: 98 62 117/81 16 95%2LNC. On arrival to the floor, pt is sleeping but arousable. She denies any complaints but requests that "we do this tomorrow." Radiology showed New moderate CHF since ___. The patient was diagnosed with HYPOXEMIA, DIABETES UNCOMPL ADULT, HYPOTHYROIDISM NOS, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE. At the time of discharge, the patient had Acute on Chronic Systolic Heart Failure exacerbation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF HOSPITAL COURSE AND ACTIVE ISSUES ___ year old female with history of non-ischemic dilated CM (EF 25%), DM type 2, and dementia, presenting with hypoxemia, dyspnea on exertion, and lower extremity edema consistent with a CHF exacerbation with BNP in 20,000s. # Acute on chronic heart failure: Pt w/ non-ischemic CMP w/ EF ___ on last TTE in ___. She had been maintained on furosemide 20 mg daily, but was recently switched to torsemide 10 mg PO daily per outpatient cardiology notes on ___ as she was volume overloaded at that time. She was further diuresed with a net total output of about 4.2L over course of admission. She was continued on her spironolactone and lisinopril. We are discharging her on Furosemide 40mg with plans for chem 7 draw on ___ and ___ to be faxed to Dr. ___ in cardiology. ON DISCHARGE HER WEIGHT IS 136 LBS. # Hypothyroidism: She had an elevated TSH and normal T4 during last admission and her Levothyroxine had been increased to 150 mcg daily. However on this admission TSH remained elevated at 65. It should be confirmed after discharge that she takes her levothyroxine separately from her other medications and on an empty stomach. If TSH remains elevated after these interventions, her dose should be further uptitrated. INACTIVE ISSUES # Asymptomatic Bradycardia: Pt with previous admission for reported bradycardia to ___ recorded at ECF. Stable for now. Not AICD candidate. # Diabetes mellitus: Insulin dependent on home ISS and fairly well controlled w/ last A1c 6.3% in ___. Metformin was discontinued during last hospitalization ___ ___ but was restarted in the nursing home at 250 mg daily. Metformin was held in-house. # Hyperparathyroidism with hypercalcemia: Stable. No further intervention per endocrine. # CKD: stable # Dementia: Pt with relatively advanced dementia that has been progressive. Currently oriented x1 which seems to be new baseline. Continued on quetiapine and remeron. # Gout: Stable. Continued on home allopurinol TRANSITIONAL ISSUES -- DAILY WEIGHTS, adjust Lasix based on volume status and weight. ON DISCHARGE SHE IS 136LBS. If >3lb weight gain, call and let Dr. ___ know at ___. -- O/P chem 7 on ___ and ___ to be faxed to Dr. ___ in cardiology -- Make sure Levothyroxine is taken on empty stomach without other medications -- Changed ASA to enteric coated</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (AP AND LAT) showed Improved aeration in the lower lungs when compared with prior exam with small residual right pleural effusion and mild residual atelectasis at the left lung base. RENAL TRANSPLANT U.S. showed 1. Abnormal waveform within the main renal artery with absence of antegrade flow during diastole. 2. Elevated intrarenal resistive indices though somewhat improved when compared with prior exam. 3. Multiple cysts within the transplant kidney, 1 of which in the midpole region contains thin septations, attention on follow-up advised. CHEST (PORTABLE AP) showed Small bilateral pleural effusions with slightly worse bibasilar airspace opacities, possibly atelectasis with aspiration or infection not excluded. No pulmonary edema. The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSES ================= Acute Kidney Injury ___ hypovolemia CHRONIC DIAGNOSES ================= ESRD ___ HTN and DM s/p DDRT c/b CKD of renal allograft Heart Failure with Preserved Ejection Fraction Type II diabetes 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>TRANSITIONAL ISSUES =================== [ ] Discharge Cr 1.4 [ ] Patient should have repeat BMP at next appointment [ ] Patient's home diuretics were held during admission due to hypovolemia. Restarted at lower dose 40mg PO daily. Likely will need close titration of diuretics as PO intake improves. [ ] Patient was noted to be hypoglycemic prior to admission likely ___ poor PO intake as she was recovering from recent PNA. Intake increased as appetite improved, will be discharged on slightly lower dose of insulin but may need further adjustment as outpatient. BRIEF HOSPITAL COURSE ===================== ___ woman with a history of ESRD ___ HTN and DM s/p kidney transplant (___), rectal cancer (s/p resection and ostomy), HFpEF, COPD, DM2, DVT s/p IVC filter, and multiple MDR UTIs who presented with weakness, found to be orthostatic and with ___ likely ___ hypovolemia. Patient had recent admission for multifocal pneumonia and heart failure exacerbation. She had little PO intake at home and continued to take her home diuretics. Patient was given IV fluids and her renal function as well as orthostatics improved. She was restarted on Furosemide 40mg Once daily down from BID and discharged in stable condition with improving kindey function, Cr. 1.4. ACUTE ISSUES ============= #Weakness #Orthostasis Presenting with lightheadedness after trying to get up, in setting of recent hospitalization and decreased PO intake coupled with diuretic use. No focal weakness on exam. Orthostatic vital signs positive on ___. Received 500cc NS on ___ with improvement in symptoms and repeat orthostatic vital signs negative. Patient discharged on lower dose diuretics. ___ on CKD of renal allograft #ESRD s/p DDRT in ___ Cr 1.8 on admission (baseline 0.9-1.3). Likely elevated in the setting of hypovolemia. Renal function downtrended to baseline after IV fluids and holding diuretics. Seen by transplant nephrology. FeUrea was oddly elevated at 48% with is borderline suggestive of intrinsic renal disease but may be impacted by CKD of renal allograft. Renal U/s also showing "abnormal waveform within the main renal artery with absence of antegrade flow during diastole." UA positive for protein. Continued on mycophenolate 250mg BID and prednisone 5mg daily. She was also continued on prophylactic Bactrim and valacyclovir. Cr on discharge 1.4. CHRONIC/RESOLVED ISSUES ========================= #Multifocal PNA (resolved) Recent admission for multifocal pneumonia, completed levofloxacin course on ___. Still having productive cough but not hypoxemic during admission. CXR looked improved. #HFpEF Mild diastolic dysfunction, EF 65% on last TTE ___. Last discharge weight 115.7 lbs. On admission, proBNP elevated 1796 and trop x2 flat. Home Lasix held in setting of hypovolemia. Euvolemic on discharge exam, discharged on 40 mg once daily diuretic. #HTN Initially held home hydralazine given orthostasis, but restarted as BPs improved and hypertensive to 160-170s systolic. Patient continued on home carvedilol and diltiazem. #DM2 Patient reports hypoglycemic episode to ___ at home on recent 70/30 regimen. Discharged on decreased dose of #COPD Patient continued home tiotropium. Held home Symbicort as non formulary. #Urinary retention Has required Q6Hr catheterization in the past, although patient doesn't describe performing at home. Patient urinating well during admission. #CAD Patient continued on home ASA and statin. #CODE: Full (confirmed) #CONTACT: ___ (daughter) ___ >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: PCP: ___. [Affiliated Physician ___. Radiology showed 1. 2.8 cm centrally cavitating opacity in the periphery of the right upper lobe with adjacent ground-glass. An additional 1.1 cm subpleural nodular opacity is seen in the lateral right upper lobe. Findings likely represent an infectious process. Recommend follow-up imaging with radiographs of ___ weeks after treatment. 2. ___ nodularity in the superior segment of the right lower lobe is compatible with small airways infection. 3. Trace right pleural effusion with adjacent right lower lobe atelectasis. 4. Several prominent mediastinal lymph nodes are likely reactive. 5. Hepatic steatosis. Mild splenomegaly. RECOMMENDATION(S): Recommend follow-up imaging with radiographs of ___ weeks after treatment. Radiology showed Left PICC tip over the mid SVC. NOTIFICATION: IV nurse was notified at 13:20 on ___. The patient was diagnosed with Pneumonia due to methicillin suscep staph. The patient was treated with TEE. At the time of discharge, the patient had MSSA bacteremia with cavitary penumonia Elevated ALT 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 male with h/o HTN who presents with staph aureus bacteremia and a cavitary pneumonia. # PNEUMONIA/FEVERS/CAVITARY LUNG LESION/ S aureus bacteremia: Placed on Vanocmycin and tapered to Cefazolin 2gm q8hr per sensitivities. TEE done with mild MR but no obvious ___. FInal report pending. Has PICC placed. Will go home with home infusion ABX in place. OPAT will follow labs (BUN, Cr, CBC w/diff). If final TEE without ___ likely get 4wk IV ABx (OPAT will determine). Quantiferon gold sent prior to discharge and is pending (annual PPD negative per his report) # Transaminitis: elevated ALT on admission and repeat. Imaging suggested hepatic steatosis and borderlined splenomegaly. No other clinical findings to suggest occult cirrhosis. HAV and HBV immune per serology. No HCV exposure. Drinks ___ ETOH daily which could contribute. Patient will f/u with PCP for further evaluation -- may be ___. # HTN: continue chlorthalidone #Migraines: continue zomeg prn</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS: ___ with history of gastric ulcers, CAD s/p CABG, AVR with bovine valve not on anticoagulation, HTN, DM, recent admission for urosepsis c/b e.coli bactermia and NSTEMI, presents with 4 days of dysuria, increased frequency, rigors and low grade fevers today to 100.0F, per daughter. ___ culture was obtained by ___ yesterday, and processed at ___ ___, reportedly showing a urinary tract infection. No antibiotics given as an outpatient. Patient and family deny cough, congestion, sore throat, nausea, vomiting, or diarrhea. Possibly has some left flank pain. Her last bowel movement was yesterday and was formed. During her previous admission, her NSTEMI sypmtoms consisted of shortness of breath. In the ED intial vitals were: 99.3 75 115/54 20 100%RA. Labs were significant for lactate 2.1, Cr 1.6, BUN 44, hct 32, WBC 10.1 (90%N). Blood cultures x2 sent. Urine not tested, patient's daughter refused straight cath. CXR shows hardware from previous surgery, enlarged heart, no obvious focal area of consolidation. Patient was given tylenol and ceftriaxone. Vitals prior to transfer were: 100.4 104 117/44 18 96% RA. On the floor, patient is comfortable. No chest pain, shortness of breath, lightheadedness, abdominal pain or suprapubic pain. Her last episode of rigors was yesterday afternoon. Review of Systems: (+) as above (-) night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, hematuria. Radiology showed Cholelithiasis without sonographic evidence of cholecystitis. The patient was diagnosed with URIN TRACT INFECTION NOS. At the time of discharge, the patient had ------------------ PRIMARY DIAGNOSES ------------------ Urinary tract infection Sepsis Hypotension Shock liver ------------------ SECONDARY DIAGNOSES ------------------ Chronic systolic congestive heart failure Coronary artery disease Acute renal failure Chronic kidney disease, stage III Diabetes mellitus type II, insulin dependent 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>Ms. ___ is a ___ with history of gastric ulcers, CAD s/p CABG, sCHF (LVEF 35-40%), AVR with bovine valve not on anticoagulation, HTN, DM, recent admission for UTI with resultant e/coli bacteremia, who presented with rigors and dysuria and was admitted for sepsis with urinary tract infection. She was stabilized, narrowed to PO antibiotics, and is now being discharged home on a 10 day course of ciprofloxacin (ending ___ and 14 day course of amoxicillin (ending ___. ---------------</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 on HD TTS, HTN, Prostate cancer, Mechanical heart valve on Coumadin, who presented with chest pain and hematuria. Radiology showed 1. Slightly increased pulmonary vascular congestion with new mild pulmonary edema. 2. Stable mild cardiomegaly. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 8:05 AM, 6 minutes after discovery of the findings. The patient was diagnosed with Hematuria, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSES: Atypical chest pain Hematuria SECONDARY DIAGNOSES: End-stage renal disease Gastritis Anemia 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 man with ESRD on HD TTS, HTN and mechanical heart valve on Coumadin here with chest pain and hematuria. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ PMH diabetes, Factor V leiden on Coumadin, recent laparoscopic colectomy due to polyposis ___ at ___ presenting with redness around surgical incision. She refers feeling fine and home but htat the wound started to look red and have some fluid exudate. She was CT scan in ___ which found no abscess but some evidence of cellulitis. CT scan also shows mesenteric vein thrombosis and possible hepatic infarct. INR subtherapeutic at 1.52. She denies any significant abdominal pain, citing only mild lower abdominal pain on palpation. Denies fevers, chills, vomiting or diarrhea. Was seen at ___ where she underwent a CT scan showing a mesenteric vein thrombosis for which she was started on heparin, and given meropenem to cover for possible pseudomonal infection. CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS showed 1. No evidence ongoing anastomotic leak. 2. 6.1 cm area of phlegmonous changes adjacent to the anastomosis with internal foci of gas. No clear or well circumscribed fluid component is identified. 3. Small volume ascites. CT interventional procedure showed No drainable fluid collection present. Improving phlegmonous changes adjacent to the anastomosis with decreased internal foci of gas. No clear well-circumscribed fluid component is identified for drainage. Overall appearance is significantly improved in comparison to prior CT examinations of ___ and ___. NOTIFICATION: The decision to defer the procedure due to no drainable collection was discussed by Dr. ___ with Dr. ___ at 628pm on ___. CHEST (PORTABLE AP) showed -Mild pulmonary vascular congestion and mild pulmonary edema, progressed compared to the prior exam. -Small bilateral pleural effusions. CHEST (PORTABLE AP) showed Comparison to ___. Stable low lung volumes. Stable moderate cardiomegaly. Mild pulmonary edema is present. No pneumonia, no pleural effusions. No pneumothorax. BILAT LOWER EXT VEINS BILATERAL showed No evidence of deep venous thrombosis in the right or left lower extremity veins. The patient was diagnosed with Unspecified abdominal 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>Patient was admitted after recently being discharged. A CT A/P was performed in the emergency room demonstrating a phelgmon proximal to the anastomosis consistent with a leak. However, the patient appeared very well. She was hemodynamically stable and denied any abdominal pain. Patient was started on Zosyn and a regular diet. ___ was called for potential drainage with no drainable collection. However, patient continue to do well. Patient did not spike fever, did not experience nausea/vomiting. She will be discharged home on a total of 14 days of antibiotics as well as therapeutic lovenox. We recommend that she follow-up with her PCP for bridging from Lovenox to Coumadin.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo woman with a history of multiple punctate strokes in the right hemisphere and a single punctate stroke in the left frontal lobe in ___, s/p right CEA ___, DM, HLD, HTN who presents with left arm shaking and bilateral leg weakness. MR HEAD W/O CONTRAST T9113 MR HEAD showed 1. Study is mildly degraded by motion. 2. No acute infarct. 3. Paranasal sinus disease concerning for acute sinusitis as described. 4. Chronic changes as described. 5. New probable right frontal punctate microhemorrhage. The patient was diagnosed with Weakness, Oth symptoms and signs involving the circ and resp systems. At the time of discharge, the patient had PRIMARY DIAGNOSIS: left hand weakness SECONDARY DIAGNOSIS: hypertension type 2 diabetes glaucoma 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>Mrs. ___ is a ___ with history of stroke and CAE in ___ who presented with weakness on the left arm and lower limb which resolved spontaneously by the time she reached the ED (<3 hours). She was seen by neurology and was found to have reassuring neurologic exam. A CTA head and neck was obtained which showed no acute pathology. She was noted to be mildly hypertensive and she reported she had not been taking any of her home medications for several months as she was feeling well previously. She was admitted to medicine service for stroke workup and medication counseling. MRI brain was obtained, which showed no acute infarct and she was started on her home medications without issue. CHRONIC ISSUES ================ # T2DM: The patient has T2DM on oral agents. during her admission period we held her glipizide/metformin and started her on ___ while inpatient. # CV risk modification: - Continued Aspirin 81 mg PO DAILY - Continued Atorvastatin 40 mg PO DAILY # Glaucoma: - Continued Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID - Substituted latanoprost for bimatoprost while in house - Continued Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID - Continued Timolol Maleate 0.5% 1 DROP BOTH EYES BID # Hypertension: - Continued lisinopril TRANSITIONAL: ====================== [] please continue patient medication education and encourage taking home medications. [] restarted aspirin 81mg daily which we recommend continuing indefinitely. [] recommend outpatient echocardiogram to evaluate for PFO or valve dysfunction that may lend to embolism. [] follow-up with neurology. # CONTACT: ___ (son) ___ # CODE STATUS: Full presumed</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH afib, ___, HTN, prior CVA x2, presenting from ___ with dizziness/weakness. Dizziness described as feeling "lightheaded" on standing and like she is unsteady on her feet, usually in the morning or after lying in bed for a long time. Admits to poor appetite and po intake at baseline which has been stable. Did have an episode of nausea, vomiting yesterday shortly after eating a muffin. No nausea or vomiting currently. Denies diarrhea. No fevers, chills, sweats. Has not noticed any blood in her urine or stool, though she reports she does not examine her stool. No other bleeding that patient has noticed. She was sent in for dehydration per NH report. Pt fell on ___ and ___, no injuries from the fall. No head injury. Of note, pt was recently seen in ED on ___ also for mechanical fall - head/neck CT negative. INR 2.5 as of ___. No falls since ___. . In the ED, VS 99.7 72 138/78 18 95%. orthostatic BP's ___ on sitting. Lungs CTAB. CV - irregularly irregular. Abdomen benign. No neurologic deficits. AOx3. +Several areas of ecchymosis on R thigh/elbow from fall. Guaiac negative. Labs significant for Hct 33.9 (39.3 on ___, INR 3.7, K 3.5, Mg 1.9. CT head - no acute intracranial process. EKG: a-flutter. Pt given 500cc NS gently at 100cc/hr. Admitted for symptomatic anemia Radiology showed No evidence of acute disease. Radiology showed No acute intracranial process. No change from ___. The patient was diagnosed with HEAD INJURY UNSPECIFIED, CONTUSION OF FACE, SCALP, & NECK EXCEPT EYE(S), VERTIGO/DIZZINESS, OTHER FALL, HYPERTENSION NOS, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE. At the time of discharge, the patient had Primary: Orthostasis secondary Afib and volume depletion. The patient was given written instructions concerning 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 afib, dCHF, HTN, prior CVA x2, presenting from ___ with dizziness/weakness. Dizziness described as feeling "lightheaded" on standing usually in the morning # Orthostasis/dizziness: Patinet came in complaining of lightheadedness and the sensation of the room tilting when she was standing up. This unsteadiness resulted in several falls over the last few days. In the ED, a head CT was negative for any acute intracranial process. An EKG showed atrial fibrillation with rvr (~150bpm) and on orthostatic exam the patients SBP dropped from 135 to 95 upon standing. Pt responded well to 100mg of metoprolol and soon converted back into sinus rhythm. Causes of the patient's orthostasis werer thought to be related to volume depletion as she has had poor PO intake recently and her afib . Anemia was also considered as etiology of symptoms as her admission CBC showed a drop of HCT from 39 to 34 over 3 days. This was felt to be less likelty as patient had no fatigue/weakness and relatively high hct with no signs of bleeding or hemolysis. The patient remained in SR for the duration of the admission and orthostatis removed. She received several liters throughout admission and showed no signs of fluid overload. On discharge, her dizziness is greatly improved. # Polycythemia ___: HCT, while below baseline on ED CBC, trended up on repeat labs to 38. Hemolysis labs were unremarkable and there was no signs of bleeding (guiac neg in ED). Patient's CBC has trended lower over the last year with fluctuance in HCT. Uncertain cause but may be secondary to progressive fibrosis. However, other cell lines appear normal. Hydroxyurea was held throughout admission in setting of low HCT and should be started back as 2x a week medication instead of 3x per Heme. She will follow up with them as an outpt next month. She should have a CBC drawn in 2 weeks prior to appointment. TSH and B12 were wnl. . # Afib with RVR: patient converted back to sinus rhythm soon after admission. She required 100mg metoprolol for RVR to 150bpm. Pt was maintained on daily dose of metroprolol 75mg BID throughout the admission without complication. Pt's ECG shows enlarged P waves making conversion back into afib likely in the future. Pt will follow up with cardiologist as an outpatient. Warfarin was restarted after being held for several days for supratheraputic INR. INR is 2.2 on discharge. # H/o atypical cells on urine cytology: Found ___ hematuria at last hospitalization. N hematuria since then or during this admission. It was believed that with a clean UA, this previous finding was not contributing to current symtoms. Pt was made an appointment with urology to follow up. #Family meeting: Prior to discharge, a family meeting was held with daughter and 2 sons, ___ (___ work), Dr. ___, and Dr. ___. Pts recent falls were discussed and ___ were made in her medication to prevent dizziness and lightheadedness. It was decided to continue pt on warfarin and make changes in living situation and family was informed that an added level of care would be optimal at this time. The pros and cons of wafarin therapy were discussed. Patient's PVC and atypical urine cytology findings were also discussed and a follow up plan was established.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female who presents with worsening right flank pain and nausea. She was seen at ___ 2 days ago with similar symptoms. CT imaging at the OSH did not show any obstructing stones however patient was told that she likely had passed a stone. She has developed worsening flank pain, nausea and chills which prompted her to return to the ___ ED. She was noted to be tachycardic HR 115 and febrile to ___. Lab work significant for white count of 9.8, normal Cr 0.7 and positive UA (nitrite positive, 93 wbc per hpf and few bacteria). CT imaging was performed which confirmed a 3-4mm stone at he right UVJ and associated hydroureteronephrosis. She reports dysuria, urinary urgency and frequency. No gross hematuria. ABDOMEN (SUPINE ONLY) IN O.R. showed Intraoperative cystoscopy images demonstrated a right-sided stent placement. Please see operative note for details. The patient was diagnosed with Hydronephrosis with renal and ureteral calculous obstruction. The patient was treated with Ureteral stent placement. At the time of discharge, the patient had Obstructing ureteral stone. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted from the ED and was taken urgently to the OR for ureteral stent placement. The procedure was uncomplicated. Please see dictate operative report for full details. After the procedure, she was returned to the floor and monitored for signs of sepsis. No complications were encountered and the patient remained afebrile. At the time of discharge, she was tolerating a regular diet, her pain was well-controlled, and she was ambulating without aid. The patient was discharged on a 14 day regimen of antibiotics due to her positive UA and concern for infection. She will follow up with Dr. ___ definitive stone management. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of hiatal hernia and GERD, POD2 from laparoscopic hiatal hernia repair with fundoplication, umbilical hernia repair and gastroscopy who presents with altered mental status. She was discharged yesterday and has been doing well until yesterday evening when she got her oxycodone and became confused. Her sister reports that she was with her the entire time and she had only one tab of oxycodone and she denies possibility of narcotic pain medication overdose at this point. This morning she found her in the bed, confused and difficult to arouse. EMS was called and she was found to be tachycardia to 130s, satting 80% on RA. She was brought to ___ ED. Her discharge summary is not available at this time but reportedly she had a relatively uneventful recovery from her surgery. Her barium swallow study was negative, she was successfully advance in diet and was discharged home on POD1. Currently she denies abdominal pain, nausea or vomiting. She states that she hasn't passed flatus since discharge. Sister reports that she hasn't urinated at least for the past 8 hours. She also denies fever/chills, shortness of breath or chest pain. Radiology showed New small bilateral pleural effusions with probable adjacent atelectasis, although pneumonia critically at the left base cannot be entirely excluded. Clinical correlation is recommended. CT HEAD W/O CONTRAST showed Severely limited study, due to motion artifact. Within this limitation, no large acute intracranial hemorrhage detected. CTA CHEST WITH CONTRAST showed 1. No acute pulmonary embolus or acute aortic abnormality. 2. Bilateral, left greater than right, nonhemorrhagic pleural effusions. 3. Adjacent mild compressive atelectasis, left greater than right, with more moderate collapse in the posterior and medial segments of the left lower lobe. 4. Postsurgical changes from recent hiatal hernia repair with gastric fundoplication, including small locules of air in the anterior mediastinum and in the soft tissues of the left posterolateral chest and abdominal walls. Radiology showed 1. Postoperative changes as described above related to recent hiatal hernia repair with fundoplication including an unchanged small collection of fluid and air adjacent to the esophagus. 2. Left greater than right small pleural effusions NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 7:49PM, 5 minutes after discovery of the findings. Radiology showed Prominence of the right mediastinum is has no concerning correlate on the recent CT examination from ___, and is unchanged from prior radiographs. A small left pleural effusion has slightly enlarged since the radiograph from ___. There is increased density at the left retrocardiac region, likely the result of increased left pleural effusion, but underlying consolidation cannot be excluded. Radiology showed No evidence of leak or obstruction. CHEST (PORTABLE AP) showed Heart size and mediastinum are stable. Left retrocardiac consolidation and left pleural effusion are unchanged. Small amount of right pleural effusion is unchanged. There is no pneumothorax. US ABD LIMIT, SINGLE ORGAN showed 1. Patent hepatic vasculature. 2. No intrahepatic or extrahepatic biliary ductal dilation. 3. Mild perihepatic ascites. 4. Small right pleural effusion. NOTIFICATION: The findings were discussed with ___, M.D., the physician requesting ___ wet read, by ___, M.D. on the telephone on ___ at 5:15 ___, 15 minutes after discovery of the findings. The patient was diagnosed with Unspecified atrial fibrillation, Altered mental status, unspecified. At the time of discharge, the patient had Alcohol 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>Patient was admitted to the ICU from the ED for management of her altered mental status. Her ICU course by systems is the following: Neuro: She was placed on a phenobarbital taper for potential alcohol withdrawal. Toxicology screens were negative, including an ETOH level. Her source of her mental status decline was not fully diagnosed. Her CT head was normal. Her mental status began to improve and by transfer, she was AAOx3 without any deficits CV: She was in rapid afib upon arrival and started on a diltiazem drip with IV metoprolol for breakthrough. Cardiology was consulted who recommended cardioversion with a TEE before-hand. Given her recent surgery, it was decided to forgo the TEE. A TTE was obtained which showed preserved EF with some moderate pulmonary artery hypertension. She converted to sinus on ___ and was transitioned to PO diltiazem and metoprolol. Resp: She was protecting her airway throughout this time. CT scan showed b/ pulmonary effusions but she was stable on nasal cannula. GI: She was initially made NPO. CT A/P just showed post-surgical changes, an UGI was negative for a leak and she was advanced to a mechanical soft diet on ___ and tolerated it well. She presented with a significiant transaminitis of an unknown cause. Her enzymes trended down. A liver duplex was negative for any flow issues. GU: She had adequate urine output. Heme: She was initially started on a heparin drip for afib which was transitioned to pradaxa. ID: On arrival, there was concern for sepsis given her slightly elevated WBC, hemodynamic changes, and altered mental status. She was started on empiric cefepime. Her WBC normalized and her hemodynamics imrpoved without any signs of a septic source. UCx and BCx were negative. Her antibiotics were discontinued and her clinical status was monitored. On ___, she was stable for transfer to the floor for further management. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with h/o hypertrophic cardiomyopathy, severe GERD, HTN p-afib presenting with episode of burning substernal CP lasting 45 minutes, occurring intermittently over the past few weeks. On the night she presented to the ED she had a typical episode of substernal burning with radiation up into her throat that rose to an intensity that was greater than any prior episode, such that she felt "acid was about to come out of my ears" with tremendous pressure diffusely in her head. This improved by the time she called the ambulance and came to the ED. She states that her typical substernal chest burning episodes are worst after eating, worse with laying down, at night, often associated with acid/burning in the back of her throat. She was treated for h. pylori several years ago and was heart burn-free for a couple years before symptoms returned in the last ___ weeks. In the ED she was admitted to observation for 2-day stress test which showed a reversible defect in setting of suboptimal study. Troponins were negative and EKG showed no changes but given abnomal stress she was admitted to cardiology for further work up and monitoring. Radiology showed 1. No acute cardiac or pulmonary findings. 2. Unchanged mild-to-moderate cardiomegaly, including left atrial enlargement. The patient was diagnosed with CHEST PAIN NOS, HYPERTENSION NOS. At the time of discharge, the patient had Acid reflux Esophageal spasm Secondary: Hypertrophic cardiomyopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F with h/o hypertrophic cardiomyopathy, GERD, HTN p-afib presenting with episode of burning substernal CP consistent with severe GERD or esophageal spasm, ruled out for MI but with likely false positive stress test in setting of habitus, discharged shortly after arrival to cardiology service. # Abnormal stress test: Patient presented with symptoms typical for GERD with negative troponins x3 and no EKG changes. Stress test showed reversible defect that was discussed with her outpatient cardiologist as well. It was felt that in light of typical GERD symptoms and negative MI rule out, as well as poor study due to habitus, this was most likely a false positive. Additionally, pt with clean coronaries in ___. # GERD: Patient has severe typical GERD symptoms, was treated in past for H. pylori but symptoms have recurred. ___ also now have element of esophageal spasm. Encourage patient to discuss repeat EGD or referral to GI with her PCP after discharge. Continued pantoprazole 50mg BID # Hypertrophic cardiomyopathy: Continued disopyramide, metoprolol, furosemide, aspirin #Asthma: continued albuterol PRN. Patient states does not take fluticasone or singulair this time of year. TRANSITIONAL ISSUES: - Hgb A1c pending at discharge - Patient instructed to f/u with GI or with EGD referral - Instructed to make cardiology clinic appointment during business hours to ___ this week</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ man with H/O CAD (s/p 3 DES in mid-distal AV groove RCA and in the distal AV groove RCA between the RPDA and RPL1 and DES to mid RPDA ___, chronic back pain, diastolic heart failure/HFpEF (EF >60%), DJD, diabetes mellitus with nephropathy, hyperlipidemia, hypertension, peripheral arterial disease, prostate cancer, sleep apnea, GERD, ___ esophagus and anxiety, presenting with chest and abdominal pain. Radiology showed No acute cardiopulmonary process. CTA chest with contrast showed 1. Right upper lobe subsegmental pulmonary embolus. No imaging evidence of right heart strain. 2. Hepatic Steatosis. The patient was diagnosed with CHEST PAIN NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT. The patient was given written instructions concerning 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 CAD (s/p 3 DES in mid-distal AV groove RCA and in the distal AV groove RCA between the RPDA and RPL1 and DES to mid RPDA in ___ during 2 successive procedures during the same day with significant fluoroscopic radiation exposure) presenting with persistent chest and abdominal pain. # Chest and abdominal pain: This pain is chronic and did not improve after ___ in ___. His ECG remained unchanged and his troponins were negative, arguing against ongoing ischemia which would be expected to result in cardiac myonecrosis. Pharmacological vasodilator nuclear stress test showed small reversible defect that was felt unlikely to be contributing to chest pain and was more likely a false positive result from endothelial dysfunction after his recent ___ MI and from the PCIs themselves. There was no improvement in pain with SL NTG or other long acting anti-anginal agents. Pain, therefore, felt to be less likely from cardiac ischemia. Patient underwent CTA to look for pulmonary embolus or aortic dissection. A small RUL subsegmental pulmonary embolus was noted on CTA; given its size, this was again felt to be unlikely explanation for extent of pain. Highest suspicion is for GI etiology. He was treated with omeprazole, GI cocktail, and sucralfate. Sucralfate was most helpful in resolving symptoms (although not consistently or persistently), so he was given sucralfate to take as an outpt. He will have a GI work up (EGD/Colonoscopy) as outpt to further investigate possible GI etiology of pain. # Pulmonary embolus: RUL subsegmental PE found on CTA. No evidence of right heart strain. Normal hemodynamics. Patient was started on warfarin with an enoxaparin bridge and encouraged to undergo colonoscopy as part of age-appropriate cancer screening.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CC: vomiting CHEST (PA AND LAT) showed No acute cardiopulmonary findings. Radiology showed Nonspecific, nonobstructive bowel gas pattern. No free intraperitoneal air. Small bowel follow through showed Scattered small-bowel polyps as can be seen with patient's known ___ syndrome. No evidence of intussusception or obstruction. The patient was diagnosed with Hematemesis. The patient was treated with Upper endoscopy. At the time of discharge, the patient had Peutz-Jehgers syndrome, nausea and vomiting. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#Nausea and vomiting with streaks of blood Differential includes ___ tear (most likely) vs bleeding polyp or ulcer. Reassuringly her imaging failed to show obstruction and she is passing gas, and her Hgb appears stable. EGD ___ showed multiple polyps without active bleeding or obstruction, due to persistent symptoms small bowel follow through was done and also failed to show obstruction. - PO PPI daily dose - As inpatient scheduled Zofran, promethazine and Ativan were used to control symptoms, weaned off to Zofran before discharge, will continue for 3 days. - Patient tolerated full diet before discharge without issues, but she was still very anxious about having the symptoms again and requested if the polyps could be removed. I discussed with her in length with help of the GI team that decision for surgery can't be taken lightly, especially there is no guarantee it will cure the symptoms. She understood and somewhat accepted the plan to discuss further management with her GI doctor ___ ___ in the clinic. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ F with a h/o migraines, polycythemia ___, fibromylagia who is admitted to the OMED service. She complains of a severe headache which is accompanied by right arm tingling and blurry vision. The patient has migraines at baseline, which she describes as predominantly left sided, though they have occurred on the right, sharp and constant in nature. CT HEAD W/O CONTRAST showed No acute intracranial process. MRI AND MRA BRAIN AND MRA NECK showed 1. No acute intracranial process. 2. Normal MRA and MRV of the head and neck. 3. Nonspecific periventricular and subcortical white matter T2/FLAIR hyperintensities, which are non specific and may be seen in the setting of early small vessel ischemic disease. The patient was diagnosed with HEADACHE, POLYCYTHEMIA VERA. The patient was treated with Phlebotomy (___). At the time of discharge, the patient had Polycythemia ___ ___ Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># Headache: 1-day history of throbbing ___ right-sided headache (different from her migraine headaches in the past) accompanied by blurry vision and right hand tingling. She presented to Dr. ___ office, who told her to go to the ED. After presenting to ___, ___ Head without contrast revealed no acute intracranial process. MRI Head, MRA Brain/Neck, and MRV Head revealed no acute intracranial process. Hematocrit was 57.6, and the patient's symptoms were found to be due to her PV. IV fluids were given and the patient received a 1-unit phlebotomy on ___. Post-phlebotomy hematrocit was 50.9. By ___, patient's right-sided headache have resolved. # Polycythemia ___: In addition to receiving phlebotomy, patient received baby aspirin, but did not receive heparin prophylaxis (declined, stating she preferred to walk and move her legs instead). The patient will likely need another phlebotomy treatment within the next week, and should follow-up with Dr. ___. # Atypical ductal hyperplasia of right breast: Found on core biopsy after mammogram in ___ showed calcification in upper outer quadrant of right breast. Nothing was done for this problem during this hospitalization. Follow-up with Dr. ___. TRANSITIONAL CARE ISSUES; ============================ - Follow-up with Dr. ___ need for further phlebotomy - Follow-up with Dr. ___ atypical ductal hyperplasia of right breast</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old female who complained of left ankle injury at an outside hospital and noted to have complex trimalleolar fracture. She was transferred here for operative management. Left ankle, three views. showed Trimalleolar fracture as above with mortise widening medially. ANKLE (AP, MORTISE AND LAT) LEFT IN O.R. showed Correlation with real-time findings and when appropriate conventional radiographs is recommended for full assessment. The patient was diagnosed with FX TRIMALLEOLAR-CLOSED, FALL FROM SIDEWALK CURB. The patient was treated with ___: Left ankle ORIF (with syndesmotic screw). At the time of discharge, the patient had Left trimalleolar ankle fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was transferred directly from an OSH and was evaluated by the orthopedic surgery team. The patient was found to have left trimal ankle fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for Left ankle ORIF (with syndesmotic screw), which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patient’s home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is non weight-bearing in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ y/o M with hx diabets, Afib on coumadin, HTN, presenting with 3 month hx of worsening left foot infection. Pt states that he was being treated by podiatry at ___ for what started ___ ___ as an ulcer on the dorsal aspect of his left foot. Ulcer became purulent with expanding erythema, swelling, tenderness and malodorous drainage. He was started on augmentin 875mg BID and was seeing his podiatrist weekly with intermittent debridements. He states that he took Augmentin throughout this 2 and a half month course. He has been having some diarrhea with the abx, with ROS otherwise negative. Given none improvement he was sent to the ED from ___ clinic. Radiology showed Findings concerning for osteomyelitis at the fourth toe centered at the head of the fourth metatarsal and proximal aspect of the fourth proximal phalanx. Probable soft tissue ulceration at this level, findings are new from the prior exam from ___. The patient was diagnosed with LOCAL SKIN INFECTION NOS. The patient was treated with left fourth toe ray resection PICC line placement. At the time of discharge, the patient had Primary Osteomyelitis Secondary Diabetes Atrial Fibrillation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF HOSPITAL COURSE: This was a ___ y/o M with DM2, HTN, afib on digoxin, presenting with 3 month hx left foot infection treated with augmentin for three months with x-ray evidence of osteomyeltis involving his fourth left ray.. As he was a diabetic with necrotic ulceration concerning for pseudomonal involvement, he was treated with vancomycin and zosyn initially and underwent fourth left ray resection. He received a picc line for continued outpatient intravenous antibiotics. He developed thrombocytopenia during his hospitalization was seen by hematology who felt that the thrombocytopenia was related to his infection and consequent inflammation. It is likely that the zosyn also contributed to a drug induced thrombocytoepenia. He was switched from vanc/zosyn to vancomycin and cefepime and his platelet count stopped dropping. He will have vancomycin trough drawn on ___ for review by his PCP for dose adjustment, as well as creatinine while on intravenous antibiotics, and CBC to trend his platelet count. Additionally he will have his INR followed by his PCP while being treated with coumadin for his atrial fibrillation with goal INR ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with stage IIIb lung cancer currently undergoing chemotherapy, COPD on home 2L O2, presenting with SOB and hypoxia. CHEST (PORTABLE AP) showed Left mid lung nodule corresponds to known lung cancer. Hyperinflated lungs. No superimposed process. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the bilateral lower extremity veins. CHEST (PA AND LAT) showed NO RELEVANT CHANGE AS COMPARED TO THE PREVIOUS IMAGE. KNOWN LUNG CANCER, KNOWN OVERINFLATION. NO EVIDENCE OF PNEUMONIA, PULMONARY EDEMA OR PLEURAL EFFUSIONS. NORMAL SIZE OF THE CARDIAC SILHOUETTE. UNILAT UP EXT VEINS US showed No vessel wall thickening to suggest thrombophlebitis. The patient was diagnosed with RESPIRATORY ABNORM NEC, HYPOXEMIA. The patient was treated with Radiation therapy. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Enterobacter bacteremia COPD exacerbation SECONDARY DIAGNOSES: ___ CAD GERD Depression Insomnia Neuropathy ___. The patient was given written instructions concerning 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 stage IIIb lung cancer currently undergoing chemotherapy, COPD on home 2L O2, who presented with SOB and hypoxia likely due to a COPD exacerbation, found to have GNR bacteremia.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p MVC,trauma. Multi-car accident, pt rear-ended, car turned, T-boned on passenger side. +LOC. primary and secondary survey notable mainly for left clavicle pain, reports area to same. Pt denies paresthesia or weakness to the LUE. Radiology showed No radiographic evidence for intrathoracic injury. Comminuted fracture of the mid left clavicle. Radiology showed No evidence of acute intracranial process. Findings suggesting a history of bilateral maxillary sinusitis. Radiology showed 1. Small bony fragment the the C6 spinous process, possibly a remote prior avulsion fracture; no evidence of recent injury. 2. Severe degenerative changes at C5/C6 with bridging anterior and posterior osteophytes, including ossification of the posterior longitudinal ligament, and fusion of the vertebral bodies, with associated mild to moderate narrowing the spinal canal at this level. Radiology showed 1. Middle third left clavicle fracture with anterior displaced butterfly fragment. 2. No other acute injury of the chest, abdomen or pelvis. 3. Moderate-to-severely distended stomach filled with fluid. The patient was diagnosed with FX CLAVICLE NOS-CLOSED, MV COLLISION NOS-DRIVER, ALTERED MENTAL STATUS , ABRASION HAND. At the time of discharge, the patient had s/p MVC with +LOC Left distal clavicle fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted on ___ under the Acute Care Surgery service after his accident. Upon review of his films it was determined that his only injury was a distal left clavicle fracture. A spinous process C6 fx was seen but determined to be old from a prior accident. C-collar was cleared. Orthopedics was consulted for the clavicle fracture who recommended nonoperative management with a sling and nonweightbearing X 2 weeks. Outpatient f/u was scheduled for 2 weeks from discharge. Occupational therapy was consulted for cognitive evaluation cognitive + LOC, who recommended that the patient f/u with cognitive neurology after discharge. Information regarding this was given to the patient. On ___ he is afebrile and hemodynamically stable. His pain is well controlled on an oral regimen and he is able to ambulate independently. He is tolerating a regular diet. He is being discharged home with f/u with orthopedics and cognitive neurology.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ lady with a ___ significant for colon cancer with known mets to the liver, bone, and lung who is admitted from the ED with right leg pain. DX FEMUR AND TIB/FIB showed No definite lytic or sclerotic lesion. If there is continued clinical concern for metastatic disease, MRI is recommended. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. Radiology showed Unremarkable examination of the right lower extremity from the distal femur through the toes. No osseous lesion or fracture detected. If there is continued concern for metastatic disease or other occult bone or soft tissue abnormality, then MRI would provide a more sensitive examination. Radiology showed Imaging localized to the patient's maximal site of pain from the distal femoral diaphysis to the distal tibial diaphysis of the right lower extremity reveals no evidence of metastatic disease in the bones or surrounding soft tissues. Lower extremity pain can occasionally be referred from the lumbar spine --clinical correlation is requested in that regard. MR ___ AND W/O CONTRAST. showed 1. Heterogeneous signal throughout the lumbar vertebral bodies, lower thoracic spine, sacrum and iliac bones, consistent with bone marrow infiltration from metastatic disease. There is mild to moderate pattern of enhancement in the lumbar vertebral bodies with patchy areas of low signal also consistent with a combination of the sclerotic changes and metastatic disease. 2. Multilevel multifactorial degenerative changes throughout the lumbar spine as described above, more significant at L4/L5 and L5/S1 levels. The patient was diagnosed with Pain in right leg. At the time of discharge, the patient had Leg Pain Metastatic Colon Cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ lady with a PMH significant for colon cancer with known mets to the liver, bone, and lung who is admitted from the ED with right leg pain. # Right leg pain: Concerning for complication of her known metastatic malignancy. Ultrasound showed no DVT, and plain films of leg showed no fracture or obvious lesion. She has known spinal mets and MRI of the ___ in the last 2 weeks did not show any cause for the right ___ pain. Had CT scan of ___ to eval for pain but CT scan showed no fracture or osseous lesion to explain the pain. MRI of the leg was obtained to evaluate for metastatic disease and was negative. MRI of the back was obtained to see if any interval change had occurred in the last 2 weeks and there is mild progression of disk buldging now touching the thecal sack but there are no unstable process or any operable features for pain control. Aldolase level mildly elevated with normal CK and no muscle enhancement on MRI makes myositis unlikely. She was started on oxycodone ___ PO Q4 hours, Tylenol, ibuprofen, and fentanyl patch with the assistance of the palliative care team who followed the patient while she was in the hospital. She continued to demonstrate improved pain control requiring only minimal oxycodone PRNs while on Fentanyl 72mcg Q72H. She will likely benefit from outpatient palliative care involvement. # Levido Reticularis On day prior to admission the patient was noted to have evidence of levido reticularis of her right thigh which appeared unchanged over a 24 hour period. She has not had new symptoms and all of her imaging including LENIs were recently negative only a few days prior. Given clinical stability, normal labs, negative imaging and lack of new symptoms I believe it is safe for patient to be discharged home to continue her maintenance pain management as directed by oncology and palliative care consultations. I discussed the plan with patient who is in agreement to not pursue additional work up in house and she will discuss with her PCP if she wants to evaluate for underlying pathology such as embolic phenomena, vascular disease, rheumatologic disease etc. I also discussed this with the oncology consultant who is also in agreement. Given her goals of care and focus on quality of life work up for Livedo Reticularis may not be warranted at all. However, will defer that final decision to outpatient providers. # Metastatic colon cancer: Most recently on FOLFIRI. Patient has elected to forgo chemo therapy during last two treatment sessions. Case discussed with Dr. ___ ___ (primary oncologist). # Sickle Cell Trait # Anemia: Stable # Vitamin D Deficiency: Continued home Vitamin D 1000 units daily</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH angioimmunoblastic T cell lymphoma / Burkitt lymphoma, on azacitidine, SIADH, who was admitted from her SNF with hyponatremia CHEST (PA AND LAT) showed No focal consolidations. The patient was diagnosed with Hypo-osmolality and hyponatremia. At the time of discharge, the patient had # Hyponatremia # Urinary Tract Infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PATIENT SUMMARY: ================ ___ with PMH of angioimmunoblastic T cell lymphoma and Burkitt lymphoma (on azacitidine ___ and SIADH, who was admitted from her SNF with reported hyponatremia to 123 from baseline of low 130s. S/p 1L NS with initial improvement of Na to 130, uptrended to 134 on discharge. Also found to have positive UA, started on CTX, with culture and sensitivities resulting following discharge showing citrobacter sensitive to cipro.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with a poorly characterized past medical history who presents from an outside hospital with confusion, cough and fever. Ms. ___ and ___ family report that she had cold-like symptoms which she was managing with ___ cold medications such as Robitussin for the past ___ days. She also had a productive cough. No hemoptysis or chest pain per patient. Yesterday evening, she was found confused at her assisted living community and specifically had entered an apartment that was not her own. CHEST (PORTABLE AP) showed As compared to the previous image, there is improved ventilation of the left and the right lung. No evidence of pneumonia. No pulmonary edema. No pleural effusions. Normal size of the cardiac silhouette. Bilateral shoulder replacement. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old woman with a poorly characterized past medical history who presents for confusion and delirium in the setting of cough and fever most concerning for community-acquired pneumonia and an episode of elevated troponin in the setting of concern for ECG changes at an outside hospital. Her hospital course by problem is summarized below. #COMMUNITY ACQUIRED PNEUMONIA: She had a productive cough with fever to ___ and WBC 11 at ___, exam with diffuse wheezing and ronchi R>L, and CXR without clear evidence of consolidation. Flu swab negative. She was treated with a 5 day course of levofloxacin for presumed CAP with notable clinical improvement. She was also treated with duonebs for persistent wheezing. Early in her stay she required supplemental oxygen but was discharged to rehab stable on RA. #TOXIC METABOLIC ENCEPHALOPATHY: Thought to be likely multifactorial secondary to mild dementia and overlying delirium in the setting of infection, possible overuse of OTC cold medications. We held her home amytriptyline.Her mental status improved over the course of her hospitalization and at the time of discharge was at her baseline. #TROPONINEMIA: Elevated troponin at the OSH to 0.11, repeat at ___ was <0.01. There an EKG was taken that was thought to have lateral ST depressions but this appeared unchanged from prior ECGs (___) when compared to those available here. Repeat ECG in the ___ ED was also stable. Denied chest pain throughout her stay. The troponin leak occurred in the setting of infection, tachycardia and hypertension and thus the leading cause is likely demand ischemia that resolved with treatment of her underlying conditions. #HTN: Systolic BP as high as 170-180 while at ___. She had previously been treated for HTN (lisinopril and HCTZ) but was discontinued in ___ during an episode ___ s/s dehydration. Her previous HCTZ was restarted during this admission. #TRANSITIONAL ISSUES: - Please consider arranging follow-up with a Cardiologist for follow-up of this tropnoninemia.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with no significant PMH who presents with one week history of RUQ pain. Pt was seen at OSH where she was diagnosed with cholelithiasis and mild pancreatitis. Pt was discharged and she was scheduled for a RUQ U/S on ___ and an elective cholecystectomy afterward. Pt, however, keeps having persistent pain in RUQ with radiation to her back, worsening with food, ___ in intensity, +nausea, no vomiting, subjective fever, no chill. Pt also reports being constipated for 1 week, last BM was yesterday and it was normal. Radiology showed Cholelithiasis without specific findings suggestive of cholecystitis. The patient was diagnosed with CHOLELITHIASIS NOS. The patient was treated with Laparoscopic Cholecystectomy. At the time of discharge, the patient had symptomatic cholelithiasis. The patient was given written instructions concerning 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 ultra-sound revealed Cholelithiasis without evidence of cholecystitis. 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 on IV fluids, and IV morphine ___ 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: Mr. ___ is a ___ male with history of poorly differentiated adenocarcinoma of gallbladder on neoadjuvant chemotherapy with gemcitabine and cisplatin (last dose ___ who presents with one day of right arm erythema, swelling, and pain concerning for cellulitis. Radiology showed No acute fracture or dislocation. Degenerative changes. No evidence of acute cortical destruction. VENOUS DUP UPPER EXT UNILATERAL RIGHT showed Completely occlusive thrombus within the right cephalic vein in the region of swelling over the anterior lower forearm. No evidence of a deep venous thrombosis above the level of the elbow. The patient was diagnosed with Vascular comp fol infusn, tranfs and theraputc inject, init, Oth medical procedures cause abn react/compl, w/o misadvnt, Cellulitis of right upper limb. At the time of discharge, the patient had Primary Diagnosis -Superficial thrombophlebitis Secondary Diagnosis -Gallbladder cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with history of poorly differentiated adenocarcinoma of gallbladder on neoadjuvant chemotherapy with gemcitabine and cisplatin (C1D12, last dose ___ who presents with one day of right arm erythema, swelling, and pain, found to have two tender cords on exam with ultrasound confirmin superficial cephalic vein clot. # Superficial Thrombophlebitis: Patient with symptoms predominantly concerning for superficial thrombophlebitis of the right upper extremity given palpable superficial vein tender to palpation. The surrounding erythema is likely related to inflammation from the phlebitis. Tenderness if over the cords, but not over skin. He currently has no systemic signs of infection. Of note, no neutropenia noted on admission. Low suspicion for septic arthritis of the wrist at this time or for cellulitis. Right upper extremity venous ultrasound confirmed superficial cephalic vein thrombus, but no DVT. Erythema demarcated and patient will be followed in clinic in three days. Received Vancomycin for initial concern for cellulitis, but this was discontinued. Will continue warm compresses and will treat with NSAIDs and close follow up. # Poorly Differentiated Adenocarcinoma of Gallbladder: Currently on Gemcitabine/Cisplatin, C1D12. Thrombophlebitis likely related to Gemcitabine and so discussed obtaining a port to prevent further episodes. # Anemia/Thrombocytopenia: Likely secondary to malignancy and chemotherapy. No evidence of active bleeding. # Constipation/hemorrhoids: Likely exacerbated by Zofran. Continued bowel regimen. Patient has hemorrhoidal cream at home. TRANSITIONAL ISSUES ====================== [] Will need a port placed for further Gemcitabine/Cisplatin infusions. [] NSAIDs with food and warm compresses to treat superficial thrombophlebitis. [] F/u FINAL blood cultures. [] EMERGENCY CONTACT HCP: ___ (wife) ___, ___ ___ (son) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Ms. ___ is a ___ woman with L medial parieto-occipital AVM s/p embolization and radiation with residual R sided sensorimotor deficits, seizure disorder, and chronic headaches who presents with altered mental status. She was last normal around noon when she went bowling. Family thinks she likely pushed her life alert button, which brought EMS to the home. A neighbor likely came out and said that her speech was slurred and she was very confused. At baseline, Ms. ___ is very independent. She cooks and cleans for herself, fills her own pillboxes, and does quite a few activities with her friends. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Grossly stable treated left medial occipital lobe of arteriovenous malformation with extensive surrounding white matter signal abnormality, likely representing posttreatment changes. 2. No acute intracranial abnormality including acute infarct or hemorrhage. 3. Previously noted subcentimeter extra-axial right medial occipital enhancing nodule is not well evaluated on this noncontrast examination. The patient was diagnosed with Slurred speech. The patient was treated with n/a. At the time of discharge, the patient had 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>Ms ___ is a ___ woman with L AVM s/p embolization and radiation c/b seizures (on Keppra, phenytoin, and zonisamide); who presents with slurred speech and confusion. Reportedly she had been out bowling and was very thirsty but waited for ___ hours until she got home to drink, where she says she wasn't feeling well and so activated her life alert. Initial exam largely nonfocal other than waxing and waning altered mental status, and perseveration. She was admitted due to concern for seizure (given her history). Her mental status improved by the next morning. MRI was stable from prior. EEG showed multiple electrographic seizures over the L occipital lobe that were without clinical correlate and with normal mental status. She was loaded with additional phenytoin, with reduction in electrographic seizure frequency -- but no change in already normal clinical status. Her home phenytoin was increased to 200/150mg to 200 BID, and zonisamide increased from 100/200mg to 200 BID. She will follow-up with Dr. ___ have her phenytoin levels monitored to ensure she does not become supratherapeutic. She was at her cognitive baseline, per family. Electrographic seizures were discussed with them, and they agreed to return to the ED if there was any change in mental status. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with L breast mass (pending workup) who presented with severe back pain. CT TORSO WITH CONTRAST showed 1. Redemonstration of expansile soft tissue lytic lesions involving the L3 vertebral body and around the left sacroiliac joint. 2. 5.5 cm irregular, multilobulated left breast mass is associated with left axillary lymphadenopathy. 3. Overall, findings may represent metastatic breast cancer, however correlation with results of recent biopsy is recommended for final determination. 4. 3.9 cm area of hypoenhancement in the lower uterine segment and cervix may be related to patient's menstrual cycle, however further evaluation with pelvic ultrasound and clinical exam is recommended. 5. Enlarged 1.3 cm right paratracheal lymph node may represent an additional site of metastatic disease. Close attention on follow-up imaging is recommended. 6. 3 mm right upper lung nodule. Attention on follow-up imaging is recommended. RECOMMENDATION(S): Pelvic ultrasound for impression point 3. Radiology showed Successful L3 bone biopsy CT TORSO WITH CONTRAST showed 1. Redemonstration of expansile soft tissue lytic lesions involving the L3 vertebral body and around the left sacroiliac joint. 2. 5.5 cm irregular, multilobulated left breast mass is associated with left axillary lymphadenopathy. 3. Overall, findings may represent metastatic breast cancer, however correlation with results of recent biopsy is recommended for final determination. 4. 3.9 cm area of hypoenhancement in the lower uterine segment and cervix may be related to patient's menstrual cycle, however further evaluation with pelvic ultrasound and clinical exam is recommended. 5. Enlarged 1.3 cm right paratracheal lymph node may represent an additional site of metastatic disease. Close attention on follow-up imaging is recommended. 6. 3 mm right upper lung nodule. Attention on follow-up imaging is recommended. RECOMMENDATION(S): Pelvic ultrasound for impression point 3. BILATERAL DIGITAL 2D AND 3D TOMOSYNTHESIS DIAGNOSTIC MAMMOGRAM INTERPRETED WITH CAD AND LEFT BREAST ULTRASOUND showed 1. Large mass in the upper central left breast measures 5.8 cm on mammogram and at 11 o'clock 9 cm from nipple on ultrasound. There are associated segmental pleomorphic calcifications spanning a length of 8.8 cm. The mass involves the skin with associated skin thickening. Findings are highly suspicious for malignancy. 2. left breast dermal based mass measures 1.2 cm without definite continuity with the dominant mass, suspicious for skin metastasis. 3. Additional hypoechoic left breast mass at 12 o'clock 4 cm from nipple, adjacent to the dominant mass is suspicious for extent of disease. 4. 3 abnormal left axillary lymph nodes, suspicious for metastatic adenopathy. 5. No specific mammographic evidence of malignancy in the right breast. RECOMMENDATION(S): Findings and recommendations were discussed with the breast surgery attending, ___, MD by telephone by Dr. ___ at the time of imaging with confirmation. Biopsy of the dominant mass in the left breast is recommended. Fine-needle aspiration of the abnormal lymph nodes is not recommended at this time by the referring surgeon given recent vertebral biopsy suspicious for pathologic fracture. Decision for further management of additional left breast mass and left axillary lymph nodes will be determined based upon pathology results and clinical evaluation. NOTIFICATION: Findings and recommendation for biopsy were reviewed with the patient through an interpreter who agrees with this plan. BI-RADS: 5 Highly Suggestive of Malignancy. LEFT BREAST ULTRASOUND GUIDED CORE BIOPSY WITH CLIP PLACEMENT showed Technically successful US-guided core biopsy of the breast lesion. Pathology is pending The patient expects to hear the pathology results from the referring provider ___ ___ business days. Standard post care instructions were provided to the patient. PELVIS U.S., TRANSVAGINAL showed Unremarkable pelvic ultrasound. No sonographic correlate to findings on prior CT abdomen pelvis. The patient was diagnosed with Low back pain. The patient was treated with ___ guided biopsy ___. At the time of discharge, the patient had pathologic L3 vertebral fracture metastatic malignancy to bone breast cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with h/o recent L breast mass (pending workup) who presented with severe back pain and was found to have multiple lytic lesions consistent with metastatic malignancy. #SECONDARY MALIGNANT LESION OF BONE #SEVERE LOW BACK PAIN Pt was found to have metastatic lesions as well lumbar vertebral compression fracture. MRI L spine showed no cord compression. She was seen by NSG in ED who did not recommend surgical intervention. Appearance is most suggestive of a metastatic solid tumor. Metastatic breast cancer was strong consideration given her known L breast mass. CT torso was performed for staging which showed enlarged paratracheal LN and RUL nodule as well. She underwent ___ guided biopsy of L3 vertebral body on ___. Her MRI also shows possible tumor extension vs right psoas muscle reactive myositis however CK was normal and CT showed no abnormal enhancement. She underwent ___ guided L3 bone biopsy on ___. She was started on MS ___ and oxycodone PRN for pain control, as well as APAP and lidocaine patch. She underwent workup for breast mass as below. SPEP/UPEP negative. ___ consulted and the plan was initial to perform kyphoplasty on ___, but because of another technique with ablation technology may cause superior pain control, kyphoplasty was deferred. ___ helped arrange follow up for return to hospital for ablation procedure as this was not available to inpatients. ___ consulted to help patient mobilize more and work on walking up stairs. - ___ pathology from vertebral biopsy #Metastatic Breast Cancer (bone path currently pending): She underwent b/l mammogram and L breast u/s on ___ that showed 2 masses with associated skin thinking, highly suspicious for malignancy. The dermal based nodule was not contiguous with mass, and was suspicious for skin met. She also was found to have 3 abnormal L axillary LNs. She underwent FNA of breast mass on ___. Breast surgery was consulted during hospitalization. Breast path showed: Invasive ductal carcinoma, grade 3, measuring at least 13 mm in this limited sample, see note. ESTROGEN RECEPTOR: POSITIVE (>95%, strong) Internal control: Not present PROGESTERONE RECEPTOR: POSITIVE (approximately 80%, strong) Internal control: Not present HER2/NEU PROTEIN: EQUIVOCAL (2+) She was set up with Medical oncology, Dr. ___ to see her on ___. Radiation oncology consulted and will see patient in ___ and will contact her once they know the bone path result. #SW Also consulted to assist ___ resources. Met w/ Ms. ___/ interpreter and ___ ___ Ms. ___ is worried about being out of work and without pay as well as transportation. Ms. ___ and ___ dtr came to the ___. ___ years ago after her other family members petitioned for their arrival. She lives with her family and has a strong support system. She has given permission to speak with her brother regarding logistics including the ride. Discussed the RIDE 30 day medical necessity and Ms. ___ is agreeable to apply. She thinks that her family will help her with the cost of $6.30 round trip (caregiver rides free). Discussed applying to ___ for grocery cards and for assistance funding the RIDE. Ms. ___ was tearful as it is her ___ y.o. dtr graduation today. Emotional support provided. Will ___ once RIDE approved and re: ___. Will also request pt to pt funding. ___ #constipation: pt had not been moving her bowel prior to presentation due to pain with movement and decreased PO intake. Now likely worsened by narcotics. She was started on aggressive bowel regimen of docusate, senna, miralax, bisacodyl #uterine and cervical lesion: seen on CT torso that was performed for malignancy workup. Recent pap results from PCP office performed ___ were obtained and showed no abnormality other than inflammatory changes. Pt denied any abnormal bleeding or vaginal discharge. Pelvic u/s was performed and showed no abnormality. The nature of hospitalization and pending studies and ___ plans were communicated to RN at the ___ who works with patient's PCP ___ : ___. I provided my phone number and email and received the fax number to fax over copy of this discharge summary. >30min on discharge coordination</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ prior subtotal colectomy for perforated c.diff colitis, SBR, and LOA for pelvic abscess draining succus in ___, coming in for RUQ pain throughout the last few weeks. Her pain has been present typically after food for weeks now. Originally it only occurred intermittently, but now it's occurring every time she has a meal. Throguhotu the last few days it's been worse, with pain lasting for an hour or two after every meal, not radiating, and not associated with any BM changes. She only had some nausea and vomiting yesterday, but otherwise not before. Of note, she's also had a recent flex sig which showed a 7 mm ileorectal anastomosis that has been dilated to 12 mm. CT ABD AND PELVIS WITH CONTRAST showed 1. Unchanged appearance of a dilated segment of short segment of small bowel near left hemiabdomen anastomosis. Contrast passes distal to this site into decompressed loops of bowel. The proximal small bowel loops are not dilated. Overall, findings are not consistent with small bowel obstruction. 2. Status post subtotal colectomy. Unremarkable rectal anastomosis. 3. Suggestion of gallbladder wall edema without other signs of inflammation. Correlate clinically with laboratory data and right upper quadrant pain. 4. Small hiatus hernia. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cholelithiasis. Mild diffuse gallbladder wall thickening. The gallbladder is distended but not hydropic. No sonographic ___. Overall, findings equivocal for acute cholecystitis. 2. CBD evaluation measuring up to 9 mm without obstructing stone or mass visualized, although visualization of the distal CBD is limited. This is unchanged in appearance since CT from ___. RECOMMENDATION(S): Recommend repeat non-urgent/routine abdominal ultrasound to re-assess degree of CBD dilation, in ___ weeks, once acute episode has resolved. MRCP showed 1. Choledocholithiasis resulting in mild common bile duct dilation but no evidence of intrahepatic duct dilation or cholangitis. 2. Cholelithiasis but no evidence of acute cholecystitis. The patient was diagnosed with Hypo-osmolality and hyponatremia, Unspecified abdominal pain. The patient was treated with ERCP.. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Choledocholithiasis SECONDARY DIAGNOSIS: - Afib (not on anticoagulation), - Perforated infectious colitis requiring emergent subtotal colectomy with ileostomy - GERD - HLD - Open subtotal colectomy with ileostomy (___). The patient was given written instructions concerning 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 woman with a PMH of afib (not on anticoagulation), HLD, GERD, Fibromyalgia, perforated diverticulitis in ___ s/p sigmoid resection, bowel perforation from C diff colitis s/p emergent subtotal colectomy with end ileostomy in ___ and ostomy takedown in ___, IBS and chronic diarrhea, presenting with abdominal pain triggered by meals, nausea, vomiting, and elevated LFTs concerning for a hepatobiliary process. # Transaminitis/abdominal pain: Patient initially admitted to ___ for concern of cholecystitis. However HIDA scan was negative. Patient was found to have cholelithiasis and mild CBD dilation of 9mm. Patient was transferred to medicine for further management. MRCP showed choledocholithiasis. Patient underwent ERCP on ___. LFTs continued to downtrend. - GI consulted. - Hep panel negative; also not immune to Hep B. - Pain control w/ Dilaudid, and home gabapentin. - Pt sent home with plan for elective CCY as soon as possible. - 10 day course of Cipro for cholangitis ppx after ERCP. # Lose stools: Patient notes this has been her baseline since her C.diff colitis and complications. She has seen a nutritionist and has improved slightly, but still has lose, watery stools. Rifaximin was started for SIBO. Diarrhea starting to improve slightly. - Continue Opium Tincture (morphine) PO ___ PRN TID-QID. - Continue Diphenoxylate-Atropine 2 tab PO TID. - Continue Rifaximin 550mg PO TID. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ lady with past medical history of hypogammaglobulinemia, depression, anxiety, localized scleroderma, IBS who was referred from OSH for evaluation of pancytopenia. CT HEAD W/O CONTRAST Q111 CT HEAD showed No evidence of an acute intracranial abnormality. Chest radiographs showed No evidence of an acute cardiopulmonary abnormality. SPLEEN ULTRASOUND showed 1. Moderate splenomegaly, measuring up to 18 cm. No focal splenic lesions are identified. 2. Normal Doppler evaluation of the splenic artery and vein. CT-guided bone marrow biopsy and aspiration. showed 1. Technically successful CT-guided right iliac bone marrow biopsy and aspiration. 2. Left adnexal cystic lesion is incompletely visualized on this exam. Non urgent pelvic ultrasound is recommended for further evaluation. 3. Possible uterine fibroid can be further evaluated on recommended pelvic ultrasound. RECOMMENDATION(S): Non-urgent pelvic ultrasound. NOTIFICATION: The findings were discussed with ___ M.D. by ___, M.D. on the telephone on ___ at 5:00 pm, 15 minutes after discovery of the findings. CHEST PORT. LINE PLACEMENT showed In comparison with study of ___, there has been placement of right subclavian PICC line, which extends to the mid SVC. Remainder the study is unchanged and there is no evidence of acute cardiopulmonary disease. CT abdomen pelvis with contrast showed 1. No intra abdominal or pelvic lymphadenopathy or solid organ masses identified. 2. Left ovarian cyst measures 4.9 cm and is simple in appearance. Follow-up ultrasound in ___ year is recommended. RECOMMENDATION(S): Follow-up pelvic ultrasound in ___ year is recommended to document stability and/or resolution of left ovarian cyst. CT CHEST W/CONTRAST showed Small mediastinal lymph nodes. These are not enlarged by size criteria. Splenomegaly. Please refer to dedicated report on abdomen which has been dictated separately. Radiology showed Lungs are clear. Right-sided PICC line projects to the SVC. Cardiomediastinal silhouette is stable. There is no pleural effusion. No pneumothorax is seen. CT HEAD W/O CONTRAST Q111 CT HEAD. showed 1. There is no evidence of acute intracranial process or hemorrhage CHEST (PORTABLE AP) showed Compared to chest radiographs ___ one and ___. Right PIC line ends at the origin of the SVC. Heart size normal. Lungs clear. No pleural abnormality. Radiology showed No significant interval change since the prior chest radiograph. The tip of the right PICC line projects over the upper SVC, unchanged. CT bone marrow biopsy and aspiration showed Technically successful CT-guided right iliac bone marrow biopsy and aspiration. LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE showed 1. Lumbar puncture at L4-5 without complication. I, Dr. ___ supervised the trainee during the key components of the above procedure and I reviewed and agree with the trainee's findings and dictation. The patient was diagnosed with Headache. The patient was treated with Bone marrow biopsy ___ Lumbar puncture ___. At the time of discharge, the patient had Primary diagnoses: Ph+ ALL Pancytopenia Secondary diagnoses: Anxiety Depression 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 ___ female with PMH depression, anxiety, IBS-C, scleroderma, hypogammaglobulinemia and HTN who presented as a transfer and was found to have Pro-B Ph+ ALL. # Pro-B Ph+ ALL: On acmiddion patient had pancytopenia concerning for marrow infiltrative process with circulating cells concerning for blasts. Flow and cytogenetics were consistent with Pro-B ___ chromosome positive ALL (pos CD34, CD19, CD10, C79a, and Tdt and 9;22 translocation). Patient was started on prednisone 60 mg BID and Dasatinib 140 mg daily. Patient was changed to Dasatinib 70 mg PO q12h. On Day ___, patient had repeat bone marrow biopsy and LP with intrathecal methotrexate. Per Dasatinib protocol, prednisone was tapered starting on day 24 and will continue until day 32 (___). She required platelet and pRBC transfusions during admission. Patient received ciprofloxacin, Bactrim, micafungin and acyclovir during her stay. Ciprofloxacin was discontinued when neutropenia resolved. Micafungin was discontinued on day of discharge. Patient will follow-up with Dr. ___ as an outpatient. # Thrombocytopenia: Patient developed thrombocytopenia which did not improve despite multiple platelet transfusions. She received aminocaproic acid while thrombocytopenic until platelets improved greater than 50K. HLA PRA was 73% and required HLA-matched platelets during admission. Her last platelet transfusion was on ___. # Folliculitis: Prior to admission, patient had ___ days of inflamed groin nodule and was started on Bactrim. There was concern for abscess v. leukemia cutis on admission. Dermatology evaluated the nodule and determined it was folliculitis. Patient was started on Bactroban with subsequent improvement in nodule. # HTN: Home metoprolol succinate was held on admission. Patient will re-start home metoprolol succinate 12.5 mg on discharge. # Anxiety/Depression Patient had anxiety regarding diagnosis during admission. She received PRN Ativan for anxiety. She continued home sertraline. # Hyperglycemia: Patient has known history of prediabetes and has never taken medication. She had serum glucose ~250 and was started on an insulin sliding scale. Her hyperglycemia was thought to be due to prednisone. Prednisone will be tapered and discontinued on ___. ======================= TRANSITIONAL ISSUES: ======================= [ ] ___ CT Abdomen/Pelvis w/ & w/o contrast demonstrated left ovarian cyst measuring 4.9 cm and is simple in appearance. Please do follow-up ultrasound in one year. [ ] Fingerstick blood sugars elevated during admission with patient requiring insulin sliding scale. She will have prednisone tapered and stopped on ___. She should have ___ checked as an outpatient after she has been off prednisone for greater than 90 days. She has history of prediabetes. [ ] Aspirin was held upon admission given pancytopenia. Consider restarting once counts recover. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of essential thrombocytosis, myasthenia ___ (on prednisone, last crisis ___ and recent admission for perforated diverticulitis s/p ___ drainage placement on ___ who presents with somnolence, emesis and respiratory distress. CHEST (PORTABLE AP) showed ET and OG tubes positioned appropriately. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed 1. Progressive development of nodular opacities in the right lower lung and retrocardiac subsegmental atelectasis as well as small right pleural effusion is concerning for pneumonia. 2. Newly placed right internal jugular catheter terminates in the mid SVC. 3. Interval retraction of the endotracheal tube, now in standard position. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are stable. The right base opacification has decreased. On the left there is pleural fluid with volume loss in the lower lobe. No evidence of acute focal consolidation. Set CHEST PORT. LINE PLACEMENT showed The tip of a new left internal jugular central venous catheter projects over the distal SVC. No pneumothorax. Continued decreased conspicuity of a right lower lung opacity. CT PELVIS W/CONTRAST showed 1. Interval decrease in size of the known pelvic collection located anterior to the tip of right gluteal approach pigtail drainage catheter in rectouterine space abutting the posterior aspect of uterus. The collection measures up to 2.6 cm and appears more organized than on prior imaging. No evidence of fistulous formation. 2. Interval decrease in extent of inflammatory stranding associated with diverticulitis. 3. Stable compression fracture deformity of the superior endplate of L5. Chest radiograph, portable AP upright view. showed Persistent mild left basilar opacification including a small pleural effusion. CT ABD AND PELVIS WITH CONTRAST showed 1. Interval decrease in extent of inflammatory stranding related to diverticulitis. 2. Interval removal of pelvic drainage catheter with persistent 2.1 x 4.4 cm posterior pelvis collection. 3. New small right and trace left pleural effusions with associated atelectasis. Radiology showed Successful CT-guided placement of an ___ pigtail catheter into the collection. Samples were sent for microbiology evaluation. DX CHEST PORTABLE PICC LINE PLACEMENT showed Small left pleural effusion. CT ABD AND PELVIS WITH CONTRAST showed 1. Administered rectal contrast is seen within the perirectal collection surrounding the pigtail catheter, consistent with an ongoing leak. 2. New 4.2 x 1.7 cm right gluteal intramuscular collection, likely an abscess that has developed as a result of tracking along the pigtail catheter. 3. Small bilateral pleural effusions. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:00 pm, 5 minutes after discovery of the findings. CT-GUIDED CATHETER EXCHANGE; CT-GUIDED ABSCESS ASPIRATION showed 1. Successful CT-guided exchange of an ___ pigtail catheter for a 10 ___ pigtail catheter into the perirectal collection, which has largely collapsed. 2. Successful CT-guided aspiration of a right gluteal intramuscular abscess (patient declined drainage catheter placement into this collection). The patient was diagnosed with Peritoneal abscess, Myasthenia gravis with (acute) exacerbation, Tachycardia, unspecified, Essential (hemorrhagic) thrombocythemia. The patient was treated with plasmapheresis. At the time of discharge, the patient had #Myasthenic crisis #Diverticulitis #Pelvic abscess s/p ___ drain replacement ___ #R gluteal abscess #Leukocytosis #Diarrhea #Hypokalemia #Hypomagnesemia #Hypophosphatemia #Hypernatremia #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>TSICU COURSE ============= She was admitted to the TSICU after being intubated in the ED for respiratory failure, and was put on vancomycin and Zosyn. She initially required pressor support which was thought to be mainly driven by propofol sedation and was quickly weaned as propofol was weaned as well. On hospital day 2 she was extubated and was being to room air. Neurology service was consulted who recommended hydrocortisone 50 mg every 6 hours and started plasma exchange while she was in the TSICU. CT scan done on ___ showed that the abscess has now organized more and is smaller in size with less fat stranding and is now located anterior to the tip of the pigtail catheter. From a GI standpoint she was kept n.p.o. due to failing the bedside speech and swallow which was thought to be in the setting of myasthenic crisis initially. Infectious disease service was consulted and recommended discontinuing vancomycin which was done and continuing Zosyn, with consideration of long-term ertapenem as outpatient. On HD5 the patient was hyperventilating in the Am and was hypercarbic was put on Bipap, neuromuscular service recommended restarting pyridostigmine and watch for increased airway secretions. since the patient did not have any surgical issues and her only remaining problems were neurological issues at that point the neuro-ICU service was contacted who accepted the patient. Neuro ICU course =========================== She was transferred to neuro ICU team ___ due to electrolyte abnormalities, anemia, diarrhea and complex care. Electrolytes were aggressively repleted although she often declined various doses. Her diarrhea decreased. She received IVIG ___ with plan for ___nd tolerated this well. For slowly drifting anemia with Hgb 6.6->6.2 (hemodynamically stable, she received a unit of pRBC on ___. For her perforated diverticulitis her antibiotics were changed back from vanc/cefepime to zosyn. Plan is for 7 day course once drain is pulled. Given stability and improvement, she was transferred back to the general service care on ___. NIMU course ======================= Ms. ___ is a ___ year old woman with myasthenia ___ (AChR+, possibly thymoma +, not resected) initially admitted to ICU ___ for myasthenic crisis beginning within hours of discharge for divericulitis/pelvic abscess drained ___. She received several sessions of PLEX; however, given c/f abdominal abscess/infection, she was then switched over to IVIG, of which she completed a 5 day course (last day ___. Respiratory parameters were been limited by poor effort with NIF testing (patient refuses them often), but she was stable clinically with good strength on neck flexion. She continued on IV zosyn for continued management of her abdominal infection per ID recs. Her course was complicated by diarrhea associated with mestinon (now resolved), leukocytosis, as well as hypokalemia, hypomagnesemia. Medicine and nephrology were consulted regarding the electrolyte abnormalities; it was felt that her low magnesium and diarrhea early on during her hospital stay were contributing to her hypokalemia. They provided recommendations regarding electrolyte repletion. Overall, her MG symptoms have been improving with PLEX and IVIG. She also continued on prednisone 30mg daily with plan to taper down by 5mg weekly starting on ___. - Continue PO potassium chloride replacement 40 mEq daily until follow-up with her PCP. - Continue PO magnesium oxide replacement 200mg daily until follow-up with her PCP. For the abdominal abscess, surgery, ___, and ID have provided recommendations. ID recommended to continue Zosyn 4.5g IV Q8H and once drain is removed, continue Zosyn for another week after drain removal. ACS recommended repeat CT pelvis with rectal contrast prior to discharge, which showed new R gluteal abscess. ACS recommended upsizing of the existing drain and new drain placement in the new R gluteal intramuscular abscess. Ms. ___ was in agreement with drain upsizing, but did not agree to placement of a drain in the new abscess. Thus, she underwent ___ procedure for aspiration of the intamuscular abscess and upsizing of diverticular abscess drain on ___. The surgical team (attending Dr. ___ agrees with the plan for her to be discharged on ___, with the drain in place, continuing antibiotics and with close follow-up in the surgery clinic. TRANSITIONAL ISSUES ------------------- #HypoK, #HypoMag []Patient has a primary care appointment on ___ -please check CBC, chem-10 to ensure that Hgb is above 7 and check electrolyte levels, especially K, Mag. Repletion as necessary. ___ will check electrolyte and CBC twice/week; results will be faxed to PCP ___ #Pelvic abscess #R gluteal abscess []follow up with surgery outpatient - Dr. ___ at the ___ Care Surgery Clinic in ___ weeks. ___ Office Number: ___ ___ service set up for zosyn infusion at home []continue Zosyn 4.5g IV Q8H and once drain is removed, continue Zosyn for another week after drain removal ___ will check electrolyte and CBC twice/week; results will be faxed to PCP office and PCP office has been notified of this []follow up with infectious disease outpatient #Myasthenia ___ []follow up with outpatient neurology []continue Prednisone 30mg daily until ___, then decrease by 5mg per week with plan to remain on Prednisone 10mg daily ongoing or until follow-up with outpatient neurologist, Dr. ___ ___ []25mg prednisone daily ___ []20mg prednisone daily and so on until back to 10mg daily</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is an ___ F w/ PMH of HFpEF, HTN, DM on insulin, and osteoporosis p/w chest pain refractory to nitroglycerin, found to have 3-vessel disease on cath, now s/p stent placement x2. CTA chest with abdomen pelvis showed 1. Moderate pulmonary edema. No focal consolidation. No acute aortic dissection or pulmonary embolism. 2. Healing right tenth and eleventh ribs. 3. Cholelithiasis without evidence of acute cholecystitis. 4. Dense calcification in the midportion of the SMA narrowing the lumen. Due to non angiographic technique, evaluation of the patency is limited. No evidence of acute bowel injury/wall thickening or decreased perfusion. CHEST (PORTABLE AP) showed Mild to moderate pulmonary edema. The patient was diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Essential (primary) hypertension, Type 2 diabetes mellitus without complications. The patient was treated with Coronary catheterization with percutaneous coronary intervention. At the time of discharge, the patient had NSTEMI. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>TRANSITIONAL ISSUES: ==================== - F/u TTE in 3 months for akinetic apex and concern for thrombus - please monitor LFTs on atorvastatin 80mg - Patient would benefit from improved diabetes control. Hb A1c while inpatient is 8.5% - Patient's hydralazine and amlodipine were discontinued due to orthostasis. Please follow-up on antihypertensive regimen as an outpatient. Ensure medication compliance as patient became orthostatic when she was given home antihypertensive medications. - New medications on discharge: Clopidogrel 75 mg and atorvastatin 80 mg - Discharge Cr: 1.1, discharge weight: 133 lb, discharge diuretic: torsemide 20 mg </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with ___ mechanical AVR on Coumadin one month s/p TURP with ___ who presented to the ED with clot retention overnight. The patient reports intermittent hematuria since his procedure that has been gradually improving. He denies fever, chills, N/V, or dysuria. He held his Coumadin without bridge for 5 days perioperatively and then restarted. He reports that he had been holding Coumadin over the last week due to hematuria but restarted 2 days prior to presentation. On the day prior to admission, he noted increasing difficulty urinating with worsening blood and clot passage. He got to the point where he was unable to urinate so presented to the ED. INR 1 and HCT stable since last month. A 3 way Foley was placed and CBI started. Given his INR was subtherapeutic a heparin gtt was started in the ED. COMPLETE GU U.S. (BLADDER AND RENAL) showed 1. Moderate amount of echogenic avascular material surrounding the Foley catheter in the bladder, likely representing clot. No bladder wall thickening. 2. Simple cysts, but otherwise normal kidneys bilaterally. The patient was diagnosed with Hematuria, unspecified. At the time of discharge, the patient had Bleeding and clot retention after TURP. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to the urology service from the ED and kept on CBI with hand irrigation as needed to remove clot. His hematocrit was stable through his admission. By the day of discharge, his urine had cleared and he passed a void trial. He was discharged home with instructions to call in or return to the ED if he was unable to urinate or had further hematuria. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with Down syndrome, recent hx of aspiration PNA presenting from group home with fever. Radiology showed Patchy left base opacity which could be due to atelectasis and vascular structures, but consolidation due to pneumonia may be present. If patient able, dedicated PA and lateral views would help further assess. Radiology showed New posterior right middle lobe consolidation, concerning for new pneumonia versus aspiration. Unchanged left lower lobe opacities, likely due to atelectasis. RECOMMENDATION(S): Repeat chest radiograph in ___ weeks to ensure resolution of right middle lung consolidation and exclude an underlying malignancy. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 3:45 pm, 20 minutes after discovery of the findings. CHEST (PORTABLE AP) showed In comparison with the study of ___ the, the appearance of the opacification at the right base again is worrisome for pneumonia associated with pleural effusion. The cardiomediastinal silhouette is stable and there is indistinctness of pulmonary vessels suggesting some elevation in pulmonary venous pressure. Mild atelectatic changes and possible small effusion are seen on the left. CTA CHEST WITH CONTRAST showed 1. Suspected small pulmonary emboli within subsegmental branches of the left lower lobe (series 301, image 126, 100). 2. Multifocal pneumonia predominantly throughout the right lower lobe, with additional consolidations within the right upper and left lower lobes, with associated small bilateral pleural effusions. 3. Enlarged right subcarinal/subhilar lymph nodes and high right paratracheal/infraclavicular lymph node which may be reactive to patient's multifocal pneumonia. Consider follow-up CT chest in ___ weeks to ensure resolution/improvement. RECOMMENDATION(S): Follow-up chest CT examination in ___ weeks for re-evaluation of the left pulmonary arteries and mediastinal nodes. AP portable chest radiograph showed Increased opacification and pleural effusion at the right lung base raises concern for worsening pneumonia. Video oropharyngeal swallow showed Gross aspiration of thin consistency barium by teaspoon. 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). BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity veins. The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had Primary: Aspiration Pneumonia Acute Hypoxemic Respiratory Failure Hypotension Secondary: Alzheimer's Downs syndrome Constipation Osteoporosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is a ___ with PMH of Down Syndrome (complicated by progressive Alzheimer's dementia) and history of recurrent aspiration PNA, presenting with fever and pulmonary infiltrate consistent with recurrent aspiration PNA. The patient completed a 5 day course of cefepime and metronidazole with improvement in leukocytosis, fever, and oxygen requirement. His hospitalization was complicated by frequent nighttime oxygen desaturations. Goals of care discussions were initiated with the family, and while it was ultimately deemed appropriate that the patient be discharged back to the group home that he is currently living at, hospice applications were placed for additional support there. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ year-old woman with DM, HTN, HLD, CKD who had a chair break from under her one week ago now presenting with RLE swelling and erythmea. Patient reports that she landed on her bottom and felt well initially however ___ the days that followed she had stiffer back and neck and sore right leg, athough she was able to walk. She then noticed RLE swelling two day prior to presentation with redness of her RLE prompting presentation to the ED. Radiology showed No evidence of deep vein thrombosis in the right lower extremity. Radiology showed No radiographic evidence for pneumonia. Radiology showed 1. No acute fractures. Severe multilevel degenerative changes. 2. Chronic bilateral maxillary sinus disease. Radiology showed No definite fracture or subluxation. Radiology showed No fracture or dislocation. Radiology showed No acute fracture or dislocation. Moderate-to-severe osteoarthritis of the first CMC and triscaphe joints. Radiology showed AP chest compared to ___, 3:04 p.m.: Lung volumes are lower and there is a suggestion of small areas of new opacification at both lung bases, either of which could be early pneumonia or atelectasis or even a result of recent aspiration. Followup advised. There is no pulmonary vascular engorgement. Heart size is normal. Ascending thoracic aorta is tortuous or dilated. No pneumothorax or appreciable pleural effusion. Radiology showed Limited examination as above. No definite acute abnormality. Septic knee, now base of the thumb pain and swelling, to exclude trauma or fluid accumulation. COMPARISON: ___. As compared to the prior study, there is no substantial change with diffuse demineralization of the osseous structures that were imaged. There is no evidence of fracture or dislocation seen. Severe degenerative changes of the first carpometacarpal joint and triscaphe joint are noted with joint space narrowing, subchondral sclerosis, and osteophyte formation, unchanged since the prior study. No interval development of soft tissue swelling, or subcutaneous or periarticular gas is noted. was done. Radiology showed There continues to be a left PICC that courses superiorly up the left jugular vein. Otherwise, the cardiopulmonary appearance is unchanged. Findings were discussed with IV nurse over the phone at 17:03 on ___ by ___. The patient was diagnosed with DIAB W MANIF NEC ADULT, CELLULITIS OF LEG, URIN TRACT INFECTION NOS. The patient was treated with ___ I&D, washout, and liner exchange of the right knee. At the time of discharge, the patient had Primary Diagnosis: Septic knee Secondary Diagnosis: Type II diabetes, hypertension, high cholesterol, obesity, mild renal insufficiency, and a previous history of 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>___ year-old woman with DMII, HTN, HLD, obesity and CKD presented one week after a mechanical fall with right knee Group G strep cellulitis, septic joint, and evidence of osteomyelitis of the surrounding bones, as well as a UTI. . # Septic Joint/Osteomyelitis: Joint tap of the right knee showed impressive septic joint, growing group G strep. Patient was admitted to the unit after a run of SVT. Orthopedic surgery took the patient to the OR and performed a right knee washout with replacement of the plastic liner on ___. A JP drain was placed for several day which drained serosanginous fluid. Tissue and bone samples also growing Group G strep, pansensitive. Patient was inititially started on vancomycin and levofloxacin ___ the ED, but was broadened to Vanc/Zosyn ___ the unit, and then switched to ceftriaxone once the cultures returned on ___. ESR (127), CRP (142.8), suggestive of osteomyelitis as well. Bone sample also growing Group G strep. Midline catheter was placed (there was difficulty advancing the PICC further). Infectious disease was consulted and recommended at least 6 weeks of ceftriaxone and weekly blood monitoring. Patient will have OPAT monitoring ___ the outpatient setting (___). TTE study was suboptimal but did not show vegetations on the valves. TEE did not show any valvular vegetations. JP drain was removed 2 days prior to discharge to rehab. Joint was bandaged with dry sterile dressings during admission. Pain was managed initially with dilaudid and transitioned to oxycodone. . #. Point tenderness and erythema over right wrist: Erythema and tenderness is surrounding a previous IV site, which suggests previous infilration by the IV. Xray more consistent with osteoarthritis. Appearance is somewhat suggestive of a cellulitis, however it has been improving since administration of ceftriazone. It has also been treated with warm compresses. . #. UTI: Patient had a grossly positive UA with WBC greater than assay and many bacteria. Initial urine culture was mixed flora and second culture, after antibiotic administration, was negative. Patient remained asymptomatic. Continued ceftriaxone should adequately treat the infection. . #. Hypoxemia: Upon transfer from the MICU, patient was 5L above her normal weight with an oxygen requirement. She was lying flat and breathing comfortably on 2L nasal cannula. Patient was given lasix 20mg IV and put out 4L of urine. Soon after, patient was weaned off supplemental oxygen and breathing comfortably on room air. Echo shows EF>55%. . #. SVT: Patient had a single observed run of SVT to 160s ___ the ED likely secondary to infection. No repeat episode has been observed. Patient was monitored ___ the MICU and transferred to the floor, shortly after without any further events. During her hospitalization, she remained on diltiazem. It was discontinued several days prior to discharge without any further events. . #. DMII: Held oral diabetic medications while inpatient. Continued home lantus therapy and covered with an ISS. Finger sticks remained ___ the mid ___ - mid ___. . #. HTN: Initially held lisinopril for concern of low blood pressure and recurrence of SVT, but we were able to restart it without any issues. Patient was also ___ diltiazem initially on admission. Just prior to discharge, lisinopril with discontinued for a rising creatinine (1.2) and K+ (5.2). Blood pressures were monitored and systolics were below 140. . #. HLD: Continued statin therapy. . #. CKD: Initially held lisinopril for low blood pressure. It was restarted prior to discharge, but again discontinued for rising K+ and Creatinine. Urine Lytes were unrevealing and her creatinine improved on ___. . </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with history of chronic back pain s/p spinal cord stimulator placement in ___ and revision in ___ who was admitted to ___ for several weeks after fall down stairs 2 weeks ago with head strike after losing feeling in her left leg, unclear if related to baseline left foot drop. She initially presented there after seizure at home, was also diagnosed with concussion and intracerebral hemorrhage. She underwent EEG and was noted to have multiple epiosdes of seizure; neurology at ___ recommended an MRI which was could not be performed due to spinal cord stimulator. Seizure medication was adjusted and she was discharged home. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial abnormality. If there is continued concern for acute infarction, MRI is suggested. MYELOGRAM 2 OR MORE REGIONS W/LUMBAR INJECTION ___ N57 XA SPINE showed 1. Technically successful fluoroscopic guided lumbar puncture with installation of intrathecal contrast material. Please see the subsequent CT total spine myelogram for further details. I, Dr. ___ supervised the trainee during the key components of the above procedure and I reviewed and agree with the trainee's findings and dictation. CT C/T/L SPINE W/ CONTRAST PQ316 CT SPINE showed 1. Spinal cord stimulator is identified at T7-8 level with its lead extending to the posterior soft-tissues through the interspinous region of T8-9 level. There is no deformity of the spinal cord seen adjacent to the stimulator. 2. Disc degenerative changes and vacuum at L5-S1 level and mild indentation by disc bulging at L3-4 and L4-5 levels as on the previous CT myelographic study of ___. 3. No evidence of spinal stenosis or high-grade foraminal narrowing in cervical, thoracic or lumbar region. US NECK, SOFT TISSUE showed Focused images of the right lower neck demonstrate patent right IJ vein and common carotid artery without adjacent mass or abnormal fluid collection concerning for hematoma. MR HEAD W AND W/O CONTRAST T9112 MR HEAD. showed 1. There is no evidence of acute intracranial process or hemorrhage. There is no evidence of abnormal enhancement after contrast administration. 2. 2 x 2 mm focus of T2 and FLAIR hyperintensity in the right frontal white matter (06:17) is nonspecific, similar findings can be seen in patients with chronic migraines. The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus. At the time of discharge, the patient had Non-epileptic seizures Pseudoseizure Chronic progressive distal myopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with bilateral lower extremity weakness and pseudoseizures. #Bilateral Lower Extremity Weakness and Pseudoseizures Pt presented to ED with c/o bilateral lower extremity weakness s/p fall. CT of the head was obtained for question of seizures and showed no evidence of acute intracranial process. CT myelogram was ordered due to the patient being status post spinal cord stimulator placement. The patient initially refused CT myelogram when she found out it would not be done under anesthesia. She was admitted to the floor, and CT myelogram was ordered with anesthesia. On ___, patient had multiple seizure-like episodes which consisted of thrashing in the bed, no loss of consciousness, oxygen saturations remain stable and there was no post-ictal state. CT myelogram was completed on ___ and showed no evidence of spinal cord compression. 24 hour video EEG was ordered, which was negative for epileptic seizures. Neurology was consulted for their recommendations related to the patient's bilateral lower extremity weakness and pseudoseizures and recommended a MRI of the brain to rule out any acute intracranial process. MRI of the brain showed no evidence of acute intracranial process and a small area in the right frontal lobe with possible migranous changes. Neurology work-up was negative and they believe that the patient's seizure-like episodes are consistent with pseudoseizures. Neurology recommended outpatient follow-up with the neurologist at ___ who had seen the patient during her previous admissions there. Neurology recommends maintaining the patient's current antiepileptic drug regimen as her medical history is unclear and we have not yet received the medical records from ___. The antiepileptic drug regimen may be addressed and revised as needed during outpatient follow-up with the Neurologist at ___. Psychiatry was consulted for recommendations related to pseudoseizures. Their differential dx includes conversion disorder (functional neurological symptom disorder), which may co-exist with primary seizure disorder, and complex migraines. Per ___, pt continues to have functional impairments that would benefit from ongoing rehabilitation. Treatment for conversion disorder includes ___ to address functional needs and individual psychotherapy. Pt should follow up outpatient with her psychiatry team in home town of ___. On ___, the patient was neurologically stable with the patient actually reporting some subjective improvement in her symptoms. She was afebrile, tolerating a diet, ambulating with assistance, voiding without difficulty, and her pain was well controlled on her home pain medication regimen. #Disposition Physical Therapy and Occupational Therapy were consulted for disposition planning and both recommended discharge to rehab. Psychiatry recommends treatment for conversion disorder includes ___ to address functional needs and individual psychotherapy. Her insurance denied both acute rehab and skilled nursing facility. ___ worked with her during the continued stay, and she was able to develop enough strength to be able to go home in a wheelchair, with visiting home ___. Her boyfriend arrived with the wheelchair, and she was discharged home without complication.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PA AND LAT) showed No active disease. The patient was diagnosed with Non-ST elevation (NSTEMI) myocardial infarction. The patient was treated with Coronary angiogram PCI w/ DES placed in mid-RCA. At the time of discharge, the patient had PRIMARY DIAGNOSIS ================= NSTEMI HLD 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>===================== TRANSITIONAL ISSUES ===================== [] New NSTEMI discharged on aspirin, prasugrel, atorvastatin, metoprolol, lisinopril [] Should be on ASA 81 indefinitely, prasugrel 10 QD for at least 12 months [] Uptitrate metoprolol and lisinopril as tolerated [] Recommend lipid panel in 1 month to assess adequacy of high intensity statin therapy, consider adding ezetimibe or PCSK-9 inhibitor if with continued dyslipidemia [] A1c 5.5% on ___ =====================</s>