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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/PMHx CAD with prior CABGx4, presents with chest pain x ___
hour. Pt states that he was at the ___ center eating a salty
salami sandwich, when he had sudden onset of left sided achy
chest pain. Pain was non-radiating, deep, and not accompanied by
dyspnea or diaphoresis, but the patient did complain of cold
hands and feet. Received 1 sl ntg at rehab, pain improved, yet
blood pressure dropped to a nadir of 88/49, but quickly
rebounded. He did not receive an aspirin due to a recent GIB
incident 3 weeks ago. Pt was supratherapeutic on coumadin, INR =
9. EGD report on ___ paraphrasing ___
___: Esophageal peptic strictures and small gastric
ulcer without active bleeding, in addition to large erosions in
fundus (secondary to NG tube trauma) were observed. Furthermore,
anterior portion of stomach linear ulceration endoclipped.
Posterior fundus erosions were broad based. No intervention was
performed. Duodenum did not show any marked lesions. Radiology showed No radiographic evidence for mediastinal widening. The patient was diagnosed with CHEST PAIN NOS, ATRIAL FIBRILLATION, DIABETES UNCOMPL ADULT, HYPERTENSION NOS. 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>Mr. ___ is an ___ year old man with a PMHx significant for CAD
(s/p remote CABG), atrial fibrillation, and recent severe upper
GI bleed who presented with an NSTEMI.
# Chest pain: The pt was admitted for concerns of ACS given his
non-exertional substernal chest pain alleviated by nitrate and
history of significant coronary artery disease (CABGx4 in ___
and multiple stents). Aspirin 325 PO daily was initiated. His
markedly elevated serum biomarkers on sets 2 and 3 confirmed the
presence of a moderate sized NSTEMI. It is possible that this
was due to stent thrombosis given that the patient was off
anti-platelet agents at the time.
Heparin drip was initiated after the ___ set of serum biomarker
at midnight of day 1. AM EKG did not show any ST-segment
changes, but did show T wave flattening of precordial leads, a
non-specific sign of ischemia. Cardiac echo showed left
ventricular systolic dysfunction (EF 40-45%), consistent with
left circumflex disease. Moderate mitral regurgitation. Mild
pulmonary hypertension. Heparin drip was stopped after 48 hours
for concerns of GIB. Given pt's advanced age and significant
cardiac surgical history and after weighing the risks and
benefits, decisions were made against PCI at this time, unless
pt experiences another episode of chest pain. Pt is instructed
to continue Aspirin, but at a lower dose, 81 mg PO daily until
the follow-up appointment with Dr. ___ as an outpatient
in 10 days after being discharged to a rehab center.
# Afib - Due to pt's recent GIB incident, all anticoagulation
was discontinued 3 weeks ago. Pt's heart rate has been well
controlled in the 60-70s throughout the hospital course.
Decision has been made to continue holding coumadin for now,
until pt is seen by Dr. ___ 10 days after discharge.
# CKD (creatinine = 2.4, BUN 27 AM on admission) - Precautions
were taken to avoid further renal damage such as avoiding
unnecessary IV contrasts. Upon discharge, creatinine = 2.3, BUN
28. Pt is instructed to follow up with PCP for management of
kidney disease.
# DM2 Pt has a Hx of Dx and was put on insulin sliding scale and
diabetic diet throughout the hospital course.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ mild dementia (lives at home but with 24-hour aides,
completely dependent in iADLs, receives assistance with ADLs
including bathing, cooking, and dressing; feeds self,
incontinent of urine), L hip fracture s/p ORIF in ___
presenting s/p witnessed fall. Radiology showed Decreased small right pleural effusion with mild bibasilar atelectasis. Radiology showed No acute fracture or dislocation. Status post ORIF of a left proximal femoral
intertrochanteric fracture without evidence of hardware complications. CTA CHEST showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Moderate hiatal hernia with a patulous esophagus containing an air-fluid
level which could predispose to aspiration. Thickening of the mid to distal
esophagus is concerning for esophagitis. Correlate with clinical history and
exam.
3. Bilateral right greater than left pleural effusions with associated
compressive atelectasis. Radiology showed 1. Age indeterminate nondisplaced fractures of the left sacral ala and left
inferior pubic ramus which are new from ___.
2. Status post ORIF of the left hip with no evidence of hardware complication.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 12:08 ___, 5 minutes after discovery of the
findings. The patient was diagnosed with Pain in left hip, Hypoxemia, Pleural effusion, not elsewhere classified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ female with history of mild
dementia and left hip fracture s/p ORIF in ___ who presents
after an witnessed fall.
BRIEF HOSPITAL COURSE
=======================
# Fall/Left Hip Fracture: Sounds non-syncopal in nature. Patient
ambulates with walker. Initial hip x-ray was negative for
fracture. Patient continued to report severe left hip pain with
movement and a CT showed age indeterminate nondisplaced
fractures of the left sacral ala and left inferior pubic ramus.
Orthopedics was consulted and recommended non-operative
management and weight bearing as tolerated. Her pain was
controllted with standing tylenol, lidocaine patch, and
oxycodone as needed for pain. She was evaluated by Physical
Therapy who recommended discharge to rehab.
# Hypoxia: Likely secondary known bilateral pleural effusions
with component of compressive atelectasis and possible
aspiration. She had a CTA chest that showed bilateral right
greater than left pleural effusions with associated compressive
atelectasis. No evidence of pneumonia on imaging. She was
encourage to do aggressive incentive spirometry and remain out
of bed as tolerated. Oxygenation improving with diuresis. Would
continue as needed until weaned.
# Leukocytosis, Resolved: Likely reactive in the setting of her
fall. No infectious symptoms. Her white count downtrended and
was normal at time of discharge.
# Dementia: Aides corroborate that currently patient's mental
status is at her baseline.
# Depression: Continued home citalopram.
# Constipation: Continued home bowel regimen; required PR
bisacodyl x 1.
====================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: I have read the nightfloat admission note and agree. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Multiple splenic and hepatic granulomas.
2. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study. No concerning
liver lesions identified.
3. No ascites.
Note: U/S cannot assess for free air Radiology showed Equivocal mild cardiomegaly. No acute pulmonary process identified. No
radiographic evidence of sarcoidosis detected.
Please note that CT could be more sensitive for detection of subtle
lymphadenopathy or pulmonary nodules. The patient was diagnosed with ABDOMINAL PAIN RUQ. At the time of discharge, the patient had PRIMARY DIAGNOSES:
Abdominal pain
Colon polyp
Liver granulomas
ASSOCIATED DIAGNOSES:
Diabetes mellitus
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>___ y/o F with PMHx significant for GERD, asthma, fibromyalgia,
hepatic flexure mass now being transferred from OSH for
evaluation of worsening abdominal pain s/p colonoscopy with
biopsy 3 days prior to presentation. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ no known medical history presents for progressive cough
and dyspnea on exertion. He has not seen a physician ___ ___
years. He has had a productive cough for the past several
months, but has been worse over the past 2 weeks. He has also
had dyspnea on exertion, which has been worsening over the past
1 month. It progressed to the point that he had to leave work
today, which led him to present to the ED. He denies fevers,
chest pain, or hemoptysis. Denies orthopnea, PND, peripheral
edema. He has had a sore throat recently, but that is improving.
He states that his wife has been sick recently with an upper
respiratory illness. He denies myalgias, GI symptoms. He does
feel fatigued.
He reports ~30 lbs. weight loss over the past ___ year. He
attributes this to poor appetite.
On ROS, he denies hematuria and dysuria. He has had increased
urinary frequency for months, which he attributes to incomplete
bladder emptying. He also notes a tremor in bilateral arms,
which has been present for many months.
Vitals in the ED: 99.4 106 116/83 97%
Labs notable for: Cr 1.6; AST 79; Plt 81; +UA
Patient given: albuterol/ipratropium nebs
Vitals prior to transfer: 98.4 88 121/78 18 97% RA
On the floor, patient states that shortness of breath improved
with nebulizers. He otherwise does not have any acute
complaints.
Review of Systems:
(+) per HPI. 10-point ROS conducted and otherwise negative. CT chest without contrast. showed 1. Severe centrilobular emphysema with component of paraseptal emphysema.
2. 0.5 cm solid pulmonary nodule, left lung apex. Follow-up CT in 3 months is
recommended to assess for interval change.
3. Borderline enlarged, ascending aorta, 4.2 cm.
4. Small pericardial effusion.
5. Mild bronchial wall thickening, right greater than left, with focal mucoid
impaction. CTA chest showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. No pneumonia.
3. Redemonstration of a single 5 mm left apical nodule.
4. Severe, predominantly centrilobular and paraseptal emphysema.
5. Diffuse bronchial wall thickening suggestive of bronchiolitis.
RECOMMENDATION(S): On #3 above: Repeat Chest CT in 6 months is advised per
___ society recommendations in this high risk patient with underlying
emphysema. The patient was diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, URIN TRACT INFECTION NOS, FAILURE TO THRIVE,ADULT. At the time of discharge, the patient had Primary:
COPD exacerbation
Secondary:
weight loss
thrombocytopenia
anemia
essential tremor
chronic kidney disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/o known medical history (has not seen MD in ___+ years),
presents with progressive cough and dyspnea, consistent with
COPD.
#COPD exacerbation: History of progressive dyspnea on exertion
worsening in the last days prior to damission. CT scan done on
this admission showed severe centrilobular emphysema. He was
initially treated with duonebs and felt better after these
treatments, reinforcing the diagnosis. He was then started on a
7 day course of levaquin and 3 day course of prednisone 40mg PO
daily. Prednison was discontinued after sugars were 300s and his
respiratory status back to his baseline. He was counseled on
smoking cessation and given a nicotine patch while on the floor.
He was started on tiotropium inhaler daily and albuterol inhaler
as rescue and provided inhaler teaching. He did exhibit
ambulatory desaturation down to 91% as well as tachycardia so
CTA was done after a D-dimer returned elevated. CTA did not show
PE, but did show contrast reflux into hepatic veins, suggesting
right sided hypertension. His ambulatory desaturation may be
related to his COPD with pulmonary hypertension. BNP 250.
- Needs continued counseling on smoking cessation
- Needs outpatient PFTs
- Pulmonology referral made for COPD and possible pulmonary
hypertension
- Will need an AAA screen as an outpatient
- Needs CV risk assessment and likely statin therapy given
extensive smoking history
#Weight loss: Patient has lost 30+ lbs. in the past ___ years
and appears cachectic on exam. TSH normal. ___ be due to
progressive COPD or malignancy. PSA normal and rectal exam
without mass. CT chest shows 5mm nonspecific nodule that will
need follow up. Stool was guiac positive.
- Needs outpatient colonoscopy
- Gastroenterology referral made for chronic weight loss and
colonoscopy given need for colon cancer screening
-0.5 cm solid pulmonary nodule within left lung apex. Follow-up
CT in 3 months is recommended to assess for interval change
#E.coli UTI: Patient with recent increased frequency with +UA.
Started on levaquin for 7 day course. Sensitivities pending at
discharge.
-Would Recommend follow up UA and Culture as outpatient after
completion of abx course
#Hyperglycemia
#CKD stage 2: Cr 1.6 on admission and only improved to 1.5 after
1L NS. UPEP/SPEP pending but no hypercalcemia. Not hypertensive.
Post- prandial glucose elevated so may be diabetic nephropathy,
however may also be due to prednisone administration. Mild
protein in urine. A1C pending on discharge. Provided with Rx for
glucometer for monitoring.
- Fasting glucose < 126, but post meal time sugars 200-300
range; A1c pending on discharge
#Tremor: Exam consistent with essential tremor. Likely
self-medicates with alcohol. Would consider Beta-blocker as
outpatient. TSH normal.
#Alcohol Use: chronic. 1 pint several times a week for years.
Not withdrawal. Given MVI, thiamine, folat in house and on DC.
Encouraged to quit
#Anemia: With guaiac (+) stool and iron deficiency. He need
___ +/- EGD. Will quit ETOH.
#Thrombocytopenia: Mild, borderline macrocytic. Peripheral blood
smear shows thrombocytopenia, macrocytes, and target cells
concerning for liver disease. Alcohol-related steatohepatitis or
cirrhosis likely given alcohol history. Counseled on alcohol
cessation and started thimaine, folate, and multivitamin
repletion.
- Peripheral Blood smear showed macrocytes, target cells, and
thrombocytopenia concerning for liver disease. Consider
outpatient workup for alcoholic liver disease.
#Transitional Issues:
- Needs continued counseling on smoking cessation
- Needs outpatient PFTs
- Needs outpatient colonoscopy +/- EGD (diagnostic)
- Fasting glucose < 126, but post meal time sugars 200-300 range
*ON STEROIDS*; A1c = 5.4%
-Would Recommend follow up UA and Culture as outpatient after
completion of abx course
- Pulmonology referral made for COPD and possible pumonary
hypertension
- Gastroenterology referral made for chronic weight loss and
colonoscopy given need for colon cancer screening
- Needs CV risk assessment and likely statin therapy given
extensive smoking history
-0.5 cm solid pulmonary nodule within left lung apex. Follow-up
CT in 3 months is recommended to assess for interval change.
- Will need an AAA screen as an outpatient
- Peripheral Blood smear showed macrocytes, target cells, and
thrombocytopenia concerning for liver disease. Consider
outpatient workup for cirrhosis.
- Flu VAX and pneumovax protocol ordered here.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a very pleasant ___ w/ a.flutter s/p ablation
___,
CAD s/p stent ___, and stage 2 pancreatic ductal
adenocarcinoma. His oncololgical history is significant for ERSP
on ___ with plastic stenting in CBD, ___ omentectomy and
pancreatic and hepatic LN bs which showed pancreatic CA, and
___ replacement of plastic stent with metal stent. CHEST (PA AND LAT) showed 1. No evidence of acute cardiopulmonary process.
2. Emphysema
3. Increased pulmonary interstitial markings, likely chronic now from
multiple bouts of past pulmonary edema. The patient was diagnosed with OTHER MALAISE AND FATIGUE, URIN TRACT INFECTION NOS, MALIG NEO PANCREAS NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS
Presumptive UTI
SECONDARY DIAGNOSIS
Pancreatic Ca. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ a.flutter s/p ablation ___, CAD s/p stent ___, and
stage 2 pancreatic ductal adenocarcinoma who presents with fever
after recent cycle of chemotherapy.
ACTIVE ISSUES
# Low grade Fever: Patient was afebrile with stable vital signs
throughout hospital stay; with negative urine and blood
cultures, negative chest X-ray, and unremarkable physical exam.
Patient was ultimately discharged on ciprofloxacin for
presumptive UTI (switched initially from bactrim, due to
myelosuppresion risk given co current chemotherapy) in stable
condition, remaining afebrile throughout hospital stay.
Transitional Issues:
[] Patient to continue ciprofloxacin until ___, for 10 day
total course.
[] Pt to resume physical therapy from prior hospital discharge</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ with h/o pancreatitis ___ questionable
pancreatic divisum (only one hospitalization ___ years ago); who
was referred from medicine clinic at ___ for managment of her
epigastric pain. She had an initial episode of epigastric pain 1
week ago, which resolved after adjusting to a clear liquid diet.
Her pain recurred over the last ___ days, which resulted in her
decreasing her po intake. She reports that her episodes of
pancreatitis occur every ___ months. Her PCP wanted her be
evaluated by ERCP given her two episodes in one week, which is
unusual, and since she is planning to fly to ___ in two days.
Currently, her epigastric pain is improved, only hurting when
she presses on her abdomin. She endorses nausea, but denies
vomitting, fevers, chills, cp, sob, dysuria, urinary frequency,
cough, sinus pain. Radiology showed 1. Relatively coarsened echotexture. Correlate with LFTs.
2. Top normal/borderline diameter of the common bile duct without sonographic
evidence of intraluminal stone. If further evaluation is desired, this could
be obtained with MRCP.
3. No gallstone seen. Radiology showed 1. Pancreas divisum anatomy. No findings to suggest acute or chronic
pancreatitis. Please note that imaging is not sensitive for detection of
early noncomplicated pancreatitis.
2. Mildly fatty liver.
3. Renal and splenic cysts. The patient was diagnosed with CHRONIC PANCREATITIS. At the time of discharge, the patient had acute pancreatitis
pancreatic divisum. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo female with history of pancreatitis and pancreatic divisum
admitted with acute pancreatitis. Patient was found to have
acute pancreatitis. She did not have any obvious inciting
factors including no history of alcohol use or
hypertriglyceridemia. She recently completed a course of
augmentin but this was felt to be a less likely cause. She did
have an MRCP which confirmed the previously known pancreatic
divisum, without masses, ductal dilatation or pancreatic
enhancement. Her symptoms improved quickly and she was able to
tolerate a regular low fat diet prior to discharge. She was
discharged to follow up with her PCP and Dr. ___ GI.
___ advanced endoscopy team was consulted during the admission
and elected to defer any intervention until her panreatitis
resolved. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ man with HTN, CKD stage IV, T2DM c/b diabetic foot ulcers,
chronic venous stasis and lymphedema who presents with draining
right ___ wound and cough. CHEST (PA AND LAT) showed Low lung volume. No focal consolidation. Mild pulmonary vascular congestion
without frank pulmonary edema. The patient was diagnosed with Type 2 diabetes mellitus with foot ulcer, Non-prs chronic ulcer oth prt right foot with oth severity, Other encephalopathy, Hypokalemia, Anemia, unspecified. At the time of discharge, the patient had Primary diagnosis:
Chronic kidney disease, stage IV-V
Hyperkalemia
Hyperphosphatemia
Secondary diagnosis:
Hypertension
___ edema. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ M with HTN, CKD stage IV-V, T2DM c/b
diabetic foot ulcers, chronic venous stasis and lymphedema who
presents with draining right foot wound, found to have elevated
BUN/Cr, hyperkalemia and anemia, admitted for concern of
progressive CKD to ESRD. On admission, deemed to not have
capacity to leave AMA as he would not take part in the capacity
assessment. Throughout his course, labs did not have immediate
need for inpatient dialysis. His labs remained stable and he did
not have serious electrolyte abnormalities. At discharge, he was
able to articulate the important of follow-up and the severity
of his renal disease. He was discharged home with medical
therapy and plan for outpatient follow-up.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Radiology showed No focal consolidation. The patient was diagnosed with Orthostatic hypotension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Admission Day 0
Mr. ___ is a ___ gentleman with a history of T2DM,
HFpEF, AV block s/p PPM c/b pacer-induced CMP and metastatic
neuroendocrine tumor who presents with hyperglycemia, polyuria,
polydipsia and presyncope found to have acute kidney failure and
hyponatremia.
#Presyncope: Likely secondary to volume depletion with some
contribution of carvedilol. Symptoms resolved after 1L NS in ED.
-Lower carvedilol dose as below
-Volume repletion as below
-If symptoms were to recur while euvolemic consider PPM
interrogation and autonomic neuropathy work-up
#Volume depletion
#Acute kidney injury
___ is likely pre-renal secondary to renal volume losses in
setting of osmotic diuresis from hyperglycemia. Even though has
mild edema, he is normoxic, remains hyponatremic and with Cr 1.6
after 1L NS in ED so likely still volume down.
-hold losartan and furosemide
-1L LR
-Recheck Cr, Na in AM and decide whether required further
resuscitation
#Uncontrolled Type 2 Diabetes Mellitus: Most likely trigger is
medication non-compliance and dietary indiscretion. But now
infectious work-up perforemed.
-Restart home insulin regime: Glargine 55U bid, Lispro SS ___
starting at 200 (instead of 130).
-UA/UCx
-CXR as limited pulmonary exam
# Pancreatic neuroendocrine tumor: Well-differentiated
pancreatic
neuroendocrine tumor, metastatic to the liver, status post TACE
x
3 and Yttrium-90 x 2 in ___ through ___. He has been off
octreotide. Recent GA 68 scan showed progression off octreotide
injections. Dr. ___ planned to restart octreotide in one
month on his last visit on ___ and repeating scans in about 3
months.
-No acute needs
-Follow as outpatient
# Chronic systolic heart failure, not exacerbated: Normoxic, no
signs of volume overload besides mild ___ edema (likely venous
stasis related).
-Hold furosemide for now
-Carvedilol down to 6.25mg bid while volume depleted, may slowly
re-escalate if orthostatic symptoms do not recur
-Hold losartan until ___ resolved and stable volume status
#Glaucoma
-Combigan NF so timolol and brimonidine ordered separately with
dose adjustment
#FEN: IVF/Encourage PO, Replete Electrolytes PRN, Regular
diabetic
#PPX:
-DVT: UFH 5000U sc bid
#ACCESS: Peripheral IV
#CODE: Full Code presumed
#COMMUNICATION: Patient
#EMERGENCY CONTACT / HCP: Health care proxy chosen: Yes
Name of health care proxy: ___
Relationship: wife
Phone number: ___
Cell phone: ___
Date on form: ___
Proxy form in chart: No
Filed on Date: ___
Comments: alternate: ___ ___ Pt is asked to bring a copy of
proxy form.
Verified on date: ___
Day 1 Hospitalist service
Patient was evaluated in the morning and appeared grossly
asymptomatic. Nutrition met with him, discussed diabetes diet
and glucose control with insulin. Patient walked without issue
or symptoms. Patient had 2 orthostatic testings done, which did
not elicit symptoms. Patient received additional IVF. Patient
tolerated PO. Patient had slightly elevated BP, so coreg will
be restarted at home dose, but due to elevated ___,
___ continue to hold ___ and he should follow up as
outpatient to restart these, however, his creatinine has
improved to upper limit of baseline. Patient was counseled on
diabetes warning signs and appropriate management. Patient was
cleared for dc. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Radiology showed Low lung volumes with secondary bronchovascular crowding. No definite
superimposed acute cardiopulmonary process. CT ABD AND PELVIS WITH CONTRAST showed 1. Jejunostomy tube in place. Partial herniation of jejunal loops into the
J-tube insertion site without evidence of obstruction. The balloon of the
J-tube is not visualized and clinical correlation is advised.
2. Inflammatory changes in the anterior abdominal wall at the site of the
J-tube insertion may represent cellulitis. No fluid collections.
3. Bladder wall thickening is concerning for cystitis. Recommend correlation
with urinalysis.
4. Severe, chronic deformity of the thoracic and lumbar spine as described
above.
NOTIFICATION: Updated findings were communicated with ___, MD by
___, MD via telephone on ___ at 23:42. Radiology showed Successful exchange of a jejunostomy tube for a new 20 ___ MIC jejunostomy
tube. The tube is ready to use. Radiology showed Successful replacement of a 20 ___ MIC jejunostomy tube for a new 22 ___
MIC gastrojejunostomy tube. The tube is ready to use.
RECOMMENDATION(S): Keep the gastric port on intermittent wall suction for 24
hours. Discussed with patient's primary team. CT ABD AND PELVIS WITH CONTRAST showed 1. The bowel is nonobstructed.
2. There is a feeding tube at the jejunostomy site with a balloon in place.
There is mild fat stranding and skin thickening at the site which could
represent cellulitis.
3. A separate tube within the jejunum could represent a migrated
gastrojejunostomy tube. There is no tube within the stomach or duodenum.
Please reassess positioning.
NOTIFICATION: These findings were communicated to Dr. ___ by Dr.
___ at 6:35PM on ___. The patient was diagnosed with Enterostomy infection, Cellulitis of abdominal wall, Form of external stoma cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause. The patient was treated with ___: ___ F Mic J-tube replaced for ___ F MIC GJ tube (using
existing jejunostomy site).
___: J-tube exchange to ___
tub. At the time of discharge, the patient had Primary
---------------
Abdominal Wall Cellulitis
Cystitis
Secondary
---------------
Asthma
Pulmonary embolism
HTN
Epilepsy
Cerebral Palsy
GERD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ year old man with trisomy ___, epilepsy,
and cerebral palsy dependent on J-tube who presented with J-tube
malpositioning and abdominal wall cellulitis. His J-tube was
exchanged by interventional radiology on ___ which was
complicated by recurrent leakage around his tube. Ultimately, he
received a GJ tube on ___ with decreased leakage. He was also
started on a 5 day course of vancomycin and ceftazidime for
abdominal wall cellulitis which ended on ___. Lastly, he was
followed by the wound care team who helped provide
recommendations for his underlying chemical dermatitis. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old woman with history of epilepsy and SLE
who presents as urgent admission from clinic for EEG monitoring
for increased seizure frequency. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. CT HEAD W/O CONTRAST showed 1. No acute intracranial hemorrhage or other acute process.
2. Multiple chronic changes are stable since ___. MRI AND MRA BRAIN PT12 MR HEAD showed 1. Study is mildly degraded by motion.
2. Left frontal probable developmental venous anomaly.
3. Postsurgical changes including bifrontal white matter signal abnormalities
and corpus callosum encephalomalacia are stable.
4. No acute intracranial abnormality, with no evidence of acute infarct.
5. Patent circle of ___ without definite evidence of aneurysm, stenosis or
occlusion. The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus. The patient was treated with Lumbar Puncture. At the time of discharge, the patient had Primary diagnosis:
Refractory epilepsy, focal epilepsy with simple partial, complex
partial, and secondarily generalized tonic-clonic seizures.
Seizure clusters.
Secondary diagnosis:
Lupus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient presented to hospital with increased seizure frequency.
Upon admission, she was continued on her home Felbamate and
Banzel and placed on cvEEG monitoring. On ___, she was seen to
have a cluster of seizures each less than <3 minutes, which
self-resolved. That night, she was started on Briviact 25mg BID
with no reported side effects from medication. Her seizure
frequency markedly improved with initiation of Briviact. LP was
performed to evaluate for possible CNS involvement by lupus,
with routine CSF studies negative. The paraneoplastic CSF
antibody profile was negative. Encephalopathy autoimmune CSF
panel, however, remains pending. Although there were some
abnormal bands on CSF testing, informal oligoclonal band assay
detected 3 or less IgG bands, consistent with a negative result.
On ___ she went for MRI/MRA with no suggestion of lupus
involvement in CNS. Her Felbatol was decreased from home
___ to 900mg TID.
On day of discharge, Epilepsy attending had a discussion with
the patient and her parents about treatment options for her
focal motor seizures, including transcranial magnetic
stimulation or the Neuropace responsive neurostimulator. They
would be interested in learning more about these treatment
options, and will discuss them further with Dr. ___ at
___ next visit.
Patient had a 256 channel EEG for source localization, for which
results are pending.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year-old right-handed woman with HTN, DM,
A fib (off Coumadin since ___ for unclear reason with INR 1.1
today), h/o left BG stroke "with hemorrhage" with residual
right-sided weakness who presents with sudden onset left
face/arm/leg weakness. CTA HEAD AND CTA NECK PQ147 CT HEADNECK showed 1. Atherosclerotic calcification at the carotid bifurcation and of the supra
clinoid internal carotid arteries bilaterally, but no evidence of stenosis or
occlusion by NASCET criteria.
2. Encephalomalacia involving the left frontal lobe, likely representing prior
left ACA territory infarct, but no CT evidence of acute infarct.
3. 1.6 x 1.3 cm hypodense nodule within the right lobe of the thyroid, which
warrants follow-up with ultrasound if not previously performed. Ectopic
thyroid tissue anterior to the hyoid.
4. Multiple enlarged left supraclavicular lymph nodes measuring up to 1.5 cm.
RECOMMENDATION(S): Ultrasound follow-up of the thyroid nodule is recommended.
If clinically indicated, dedicated chest CT is warranted to evaluate
supraclavicular lymphadenopathy. AP chest radiograph showed Right at border is not clearly seen which may be due to prominent mediastinal
soft tissue or consolidation/atelectasis within the right middle lobe. No
pneumothorax or large pleural effusion. MR HEAD W/O CONTRAST T___ MR HEAD showed Right MCA vascular territory infarct, involving the right frontal lobe motor
cortex, right temporal lobe and insular cortex. No evidence of hemorrhagic
transformation or mass effect. CT HEAD W/O CONTRAST Q111 CT HEAD showed Sequela of chronic left frontal infarct. No evidence of other infarct or
hemorrhage. Chest radiograph showed No acute cardiopulmonary process. CT HEAD W/O CONTRAST Q111 CT HEAD showed Hypodensities in the right precentral gyrus extending to the right temporal
lobe and insula, with local mild sulcal effacement, compatible with right MCA
infarct as seen on yesterday's MRI. No evidence of hemorrhagic transformation
or new large territorial infarct. CHEST (PORTABLE AP) showed Compared to prior chest radiographs since ___, most recently ___
and ___.
New pulmonary edema is mild. Moderate cardiomegaly is slightly more
pronounced. No pleural effusion. No consolidation. PORTABLE HEAD CT W/O CONTRAST showed Within the limitations of a study significantly degraded by motion artifact
there is no significant change from yesterday's CT of the head. Right MCA
territory infarct is re- demonstrated. There is no evidence of hemorrhagic
transformation or new large territorial infarct. CHEST (PORTABLE AP) showed Moderate pulmonary edema and moderate cardiomegaly are stable. There is
probably enlargement of the pulmonary arteries. There is no pneumothorax. If
any there is small bilateral effusions CHEST (PORTABLE AP) showed Pulmonary edema has improved. There is no pneumothorax or enlarging pleural
effusion. Cardiomegaly is a stable The patient was diagnosed with Cerebral infarction, unspecified, Unspecified atrial fibrillation, Ataxia, unspecified. The patient was treated with IV tPA. At the time of discharge, the patient had Right MCA Ischemic Stroke. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ ___ year-old right-handed woman with HTN, DM, A fib
(off Coumadin), h/o left BG stroke who presented with sudden
onset left face/arm/leg weakness (NIHSS 9) and was treated with
IV tPA.
# Right MCA Ischemic Stroke: She was admitted to the neuro ICU
for post tPA monitoring. On exam she had left sided neglect,
dysarthria, and a left arm weakness, greatest in the hand. Her
exam worsened gradually and NCHCTs were repeated multiple times,
which were stable apart from expected evolution of her infarcts.
The most likely mechanism is embolic in the setting of rapid A
fib off anticoagulation. The worsening exam was felt to be
related to concurrent active medical issues like infection and
CHF exacerbation. Stroke risk factors were checked and results
included LDL 62, A1c 8.7. TSH was low, but T3 and free T4 were
within normal limits. She was switched from Coumadin to apixaban
for secondary stroke prevention. She was transferred to the
floor when she was stable. Clinically improving significant
throughout hospitalization with close ___ and OT.
# History of idiopathic cardiomyopathy with afib with low EF,
complicated by RVR and acute sCHF exacerbation: She developed a
rapid ventricular rate in the ED and again on the neurology
floor, prompting return to the ICU for a diltiazem gtt. Her home
metoprolol dose had been reduced to allow for permissive HTN,
and was uptitrated for better control. Echo was done and showed
a worsening ejection fraction compared to previous (40-45% from
50-55% in ___. She developed SOB ___ and CXR showed mild
pulmonary edema, likely related to IV fluids, for which she was
diuresed.
# Diabetes, type II: Maintained on an insulin sliding scale. ___
restart home glipizide at rehab, continue to monitor blood
sugars closely.
# SOB: She c/o of shortness of breath early in the hospital
course. Cardiac enzymes negative, EKG showed atrial fibrillation
with mean ventricular rate of 98. Diffuse non-specific
repolarization abnormalities. No significant change from
previous EKG. CXR showed mild pulmonary edema with possible
small bilateral pleural effusions, and was diuresed with
improving pulmonary edema on CXR. Received PRN dosing of Lasix
if clinically fluid overloaded. Did not require Lasix on day of
discharge to rehab.
# UTI: UA was concerning for UTI and she was started on CTX on
___, with plan to treat for 7 days. Switched to Keflex PO
250mg q6H prior to discharge to rehab. Final day of antibiotics
should be ___. Urine culture was negative.
Speech and Swallow recommends: Ground, Diabetic/Consistent
Carbohydrate Consistency: Ground (dysphagia); Nectar
prethickened liquids Pills: crushed or whole in ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ female with a history of polycythemia
___ c/b IJ thrombosis, managed with phlebotomy, migraines, PFO
presented as a transfer from OSH for evaluation of a IVC
thrombus
and PE. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. SECOND OPINION CT ABD/PELVIS showed 1. Thrombus extending from the right renal vein into the IVC. It is unclear
if this thrombus is enhancing.
2. Slightly delayed right nephrogram secondary to underlying venous thrombus.
3. The calices, renal pelvis, and ureters are not well assessed on this single
phase study. No discrete renal lesion detected.
4. No hydroureter or collecting system stone. The patient was diagnosed with Other pulmonary embolism without acute cor pulmonale, Acute embolism and thrombosis of right internal jugular vein. At the time of discharge, the patient had deep vein thrombosis
pulmonary embolism
renal vein thrombosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ YO female with a hx of PV c/b previous
transverse sinus thrombosis managed with therapeutic phlebotomy,
presenting as a transfer from OSH for evaluation and management
of IVC thrombus and PEs. She was placed on a heparin gtt and
converted to warfarin with lovenox bridge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS:
___ with HIV on HAART CD4 513 (___) and history of HBV
presents with falls.
Per report, patient has had "ataxia" for about 4 days with
multiple falls, dry cough, constant hiccups with GERD. Pt with
ETOH abuse, last drink 4 days ago. Diarrhea x 1 today (went all
over himself). Patient asks interview to be brief, but said that
he drank 1.5L to 3L of wine daily until about 2 weeks ago. He
decided to wean himself off over time because of "a bag of bad
stuff." He started to experience nausea, falls, and persistent
burping about 4 days ago. He denies LOC. He reports bumping on
his arms/shoulders and hips, but he denies pain there at this
time. He also states that he started to imagine very vivid
things, such as wars and planet but denied hallucination. These
vivid imagery started also about 4 days ago. He denies ever had
seizure with alcohol withdrawal. He is an ED physician at
___, and was on duty last ___.
In the ED, initial VS were: 99 110 152/73 20 99% RA. On rectal
examination, patient was guaiac positive, black colored (but
reported taking Pepto Bismul). Patient was noted to have narrow
based and shuffling gait, but no dysmetria with FNF. No Romberg
was done b/c his risk of fall. Labs significant for Chem 7 w/ Cl
89. LFTs significant for ALT 205, AST 335. Serum tox
unremarkable. Plts 86K (b/l 200). Coags unremarkable. Blood
cultures sent and pending. EKG is sinus at a rate of 88 w/ nl
axis. CT head demonstrated no acute process. CXR demonstrated no
acute cardiopulmonary process. Pt receive 2L NS, thiamine, folic
acid 1 mg, 10 mg diazepam on CIWA scale, chlorpromazine for
hiccups and GI cocktail (maalox/viscous lidocaine), MVI. VS upon
transfer were 98.3 91 109/70 15 100%. Patient has 2 peripheral
IV. Radiology showed No acute cardiopulmonary process. Radiology showed No acute intracranial process. Radiology showed Echogenic liver consistent with fatty infiltration. Other forms of liver
disease and more advanced liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study. Mild splenomegally. The patient was diagnosed with LACK OF COORDINATION, DIARRHEA, FAILURE TO THRIVE,ADULT, ASYMPTOMATIC HIV INFECTION. At the time of discharge, the patient had Metabolic encephalopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY
___ yo M with HIV (CD4 count 513 and negative VL in ___,
history of HBV, and chronic EtOH abuse presenting with frequent
falls, unsteady gait, nausea, cough, vivid imagery,
thrombocytopenia and transaminitis. Patient underwent a head CT,
RUQ ultrasound, and chest x-ray, all of which were unremarkable.
He was observed overnight. His mental status cleared, his gait
returned to baseline, and he was discharged home.
ACTIVE
# Falls/Mental status changes- Patient with multiple episodes of
falling at home likely ___ unsteady gait. His gross sensory exam
was wnl to light touch and normal propioception. Neurologic
exams were also unremarkable for focal neurologic findings and
with normal cerebellar exam. However, while patient AAOx3, his
affect on admission was not at baseline and his behavior was
somewhat inappropriate/ uninhibited. A head CT was negative for
ICH or mass. Patient reported recent decrease in amount of
alcohol he was drinking prior to episode. There was a report
about a possible fecal incontinence at home but no clear history
of withdrawal seizure. His urine toxicology and serum toxicology
were negative. There were no significant electrolyte
abnormalities that would explain the behavior. It is possible
that there was an element of alcohol related neuropathy.
However, after 24 hours of monitoring the patient's mental
status and gait returned to baseline making a chronic process
less likely. No further diagnostic testing was performed after
discussion with the patient's primary care doctor and the
patient was discharged home with close follow-up.
# EtOH Abuse- Patient has long history of heavy alcohol use
until very recently. EtOH level is negative by tox screen at the
time of admission. There is no report of seizure with alcohol
withdrawal in the past.He was kept on a CIWA scale and given IV
folate, IV thiamine, PO MVI, and home dose of citalopram.
# Transaminitis: Patient has history of HBV and a chronic
transaminitis, but slightly worse with this admission with AST >
ALT and normal bilirubin and coagulation panel. This is likely
___ alcohol related as there are no new meds. A right upper
quadrant ultrasound showed fatty infiltration of the liver.
Hepatitis serologies were repeated and found to be negative for
new or active disease.
# Thrombocytopenia: Patient was found to have thrombocytopenia
at time of admission which was thought to be related to his
alcohol use. A peripheral blood smear was significant for
macrocytosis also consistent with alcohol abuse. His platelets
began to trend up at time of discharge.
# Cough: Symptoms were felt to be related to a viral URI or
allergies. Lung sounds remained clear and his CXR was within
normal limits without evidence of consolidation. He was given an
Albuterol inhaler which improved patient's cough.
INACTIVE
# HIV: Patient's last CD4 count was 513 in ___, HIV 1 RNA not
detected. He was continued on Atripla as an inpatient.
# Physiological tremor: No tremor while inpatient but patient
discharged on home dose of propranolol.
# Guaiac positive stool: Done in the ED, dark brown stool but
took pepto bismul. Hgb stable and unchanged over
hospitalization.
TRANSITIONAL ISSUES
- Will follow-up with his primary care doctor next week. Patient
left prior to receiving discharge paperwork.
- f/u guaiac positive stool, thrombocytopenia, transaminitis,
cough, EtOH dependence and mental status</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old M with PMHx viral myocarditis s/p
orthotopic heart transplant ___ c/b ESRD ___ tacrolimus
toxicity s/p kidney transplant ___ on ASA/sirolimus/prednisone,
cirrhosis ___ HCV (treated harvoni/ribavirin ___ and with SVR),
Type I DM ___ steroid use, partial generalized seizures, H/o
Cdiff (on oral vanco ppx), with recent admission for
folliculitis ___, who presents to the ED BIBA with
multiple complaints including diarrhea fevers and chills cough
and difficulty breathing. Chest: Frontal and lateral views showed No acute cardiopulmonary process. CHEST (PORTABLE AP) showed Comparison to ___. The patient has received a right internal jugular
vein catheter. The course of the catheter is unremarkable, the tip projects
over the mid SVC. No complications, notably no pneumothorax. Stable moderate
cardiomegaly. RENAL TRANSPLANT U.S. showed 1. Normal main renal arterial waveforms with no evidence of stenosis or
occlusion. Patent main renal artery.
2. The renal vein is patent and shows normal waveform.
3. The resistive indices of the intrarenal arteries are within normal range.
4. No hydronephrosis, perinephric fluid collection or renal calculi noted. Radiology showed 1. No diverticulitis or megacolon. Consider mild colitis of the lower
sigmoid, rectum.
2. Cirrhotic morphology of the liver. CHEST (PORTABLE AP) showed Comparison to ___. The cardiac silhouette has increased in size.
There is a new retrocardiac atelectasis and blunting of the left costophrenic
sinus, potentially reflecting a small effusion. Signs of mild pulmonary edema
are present. The right-sided internal jugular vein catheter is in correct
position. The patient was diagnosed with Enterocolitis due to Clostridium difficile. The patient was treated with R IJ line placed in ED on ___. At the time of discharge, the patient had Primary:
Colitis secondary to clostridium difficile infection
Secondary:
Acute kidney injury
ESRD
Hypertension
S/p heart transplant
S/p kidney transplant
Diabetes with insulin pump. The patient was given written instructions concerning 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 with PMHx viral myocarditis s/p
orthotopic heart transplant ___ c/b ESRD ___ tacrolimus
toxicity s/p kidney transplant ___ on ASA/sirolimus/prednisone,
cirrhosis ___ HCV (treated harvoni/ribavirin ___ and with SVR),
Type I DM ___ steroid use, partial generalized seizures, H/o
Cdiff (on oral vanco ppx), with recent admission for
folliculitis ___, who presents to the ___ ED on
___ with abdominal pain, fevers, diarrhea, and vomiting found
to have C difficile colitis.
#C diff colitis
Presented w/ fevers, abdominal pain, nausea, one episode of
watery stools and emesis upon admission. ___ renal MD on ___
prior to admission where work up revealed negative CMV, EBV,
hepatitis C and B, urine culture negative. CXR negative in the
hospital. Flu negative. U/a w/o infection. Respiratory viral X.
Stool studies X. CT a/p with evidence of mild colitis. C diff
testing positive. Pt started on PO vancomycin 125 mg PO q 6
hours. Seen by outpatient ID (Dr. ___ who will follow and
discuss advanced options for C. diff as an outpatient. Bowel
movements improved at the time of discharge.
#Skin abscess
Patient has history of skin abscesses which are recurrent. On
day of discharge he had 2 small groin nodules which he reported
are how the abscesses start. I and D was performed and a wound
culture was sent which was pending at time of discharge. He was
started on doxycycline 100mg BID for 5 days for empiric
treatment. Recommend exam on upcoming PCP to ensure incisions
are healing and no additional abscesses are forming.
___ on ESRD s/p transplant
Cr 2 on admission. Baseline 1.5-2.0. 1.7 on ___. Slight
elevation likely related to dehydration given decreased PO
intake prior to admission. A renal US was without abnormality.
Furosemide and amiloride were held and patient was treated with
IVF. Cr resolved to baseline prior to discharge. Furosemide and
amiloride were restarted at discharge.
#Dyspnea
Upon admission, pt reported SOB and palpitations with activity.
EKG during admission was w/o ischemic changes. Trop negative x2.
proBNP not elevated and pt was w/o overload on exam. Most likely
related to deconditioning. No risk factors for PE. No calf pain
on exam. Etiology likely due to deconditioning and dehydration
given outflow tract obstruction. An echo was performed and
revealed normal cardiac function.
#S/p heart transplant
Hx of viral myocarditis s/p orthotopic heart transplant. No
evidence of volume overload or cardiac ischemia during
admission. Cardiology was consulted as they manage the patient's
immunosuppression. Patient was continued on all
immunosuppressant agents (azathioprine and sirolimus). Dosing of
sirolimus was not changed.
#Diabetes, insulin dependent
Patient has an insulin pump and the inpatient endocrine diabetes
service was consulted. There were no issues related to the
patient's diabetes.
#Seizure disorder - Continued levetiracetam
#Psych, insomnia - Continued ambien and remeron
#Gout - Continued allopurinol
#Cirrhosis
___ HCV s/p treatment with cure. Advanced disease. Had screening
RUQ US on in ___ which was normal. AFP nl. NO decompensation on
this admission. Bilirubin elevated to 2.2 on admission,
downtrended to 1.7 at discharge with all other LFTs within
normal limits.
===================================
TRANSITIONAL ISSUES
===================================
[ ] Discharged on PO vancomycin 125 q6h to be continued until
outpatient ID appointment.
[ ] F/u with Dr. ___ recurrent C. diff. Advanced
options to be discussed as outpatient (such as long vanco taper
to fidaxomycin taper vs consideration of FMT vs long term
suppression).
[ ] He was started on doxycycline for 5 days for possible small
abscesses forming in his groin region. Recommend exam on
upcoming PCP to ensure incisions are healing and no additional
abscesses are forming.
[ ] Wound culture is pending at time of discharge, should be
followed at next ID or PCP ___.
[ ] Was given a script for fluticasone nasal spray for sinus
congestion.
[ ] Sirolimus dosing was unchanged at 1mg daily.
#CODE: full presumed
#CONTACT: ___ Pt would like father called in case of an
emergency; ___ ___ ___ (mother): ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old female with history of MVC in ___
with intraperitoneal hemorrhage and pelvic fracture s/p repair
at
OSH who presented after MVC with grade 3 liver lac. She states
she was the unrestrained passenger in an MVC. +Airbad
deployment.
Denies LOC, +headstrike on the forehead. She presented to
___ and pan scan demonstrated grade 3 liver lac without
other evidence of injury. KNEE (AP, LAT AND OBLIQUE) LEFT showed No evidence of fracture. No joint effusion. The patient was diagnosed with Laceration without foreign body of lip, initial encounter, Car passenger injured in collision w car in traf, init. At the time of discharge, the patient had Grade 3 liver laceration. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to Emergency Department on ___,
transferred from ___, after a motor vehicle collision with
a grade 3 liver laceration. Given findings and hemodynamic
stability, the patient was managed non-operatively and was
admitted to the Acute Care Surgery service for monitoring.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral oxycodone and
acetaminophen.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with IV fluids
given. On HOD1, the diet was advanced to a Regular diet, which
was well tolerated. 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: ___ presents with 2d of abdominal pain, epigastric and RUQ
radiating to back associated with nausea and chills. Patient
reports that the pain began 2 days ago and is sharp and has been
worsening. He has had chills and yesterday began to vomit. He
denies fevers. He has regular BMs and had one yesterday. He has
not been able to eat since yesterday ___. He has had this pain
once before and it resolved with tums. He does have a known
history of gallstones but the pain does not appear to be related
to fatty foods. He denies jaundice, SOB, CP, changes in mental
status, weakness or numbness. Upon initial eval in the ED his
lactate was 4.1 he was given 2L of fluid but lactate remained at
3.9. CHEST (PORTABLE AP) showed No acute intrathoracic process. CT ABD AND PELVIS W/O CONTRAST showed 1. Cholelithiasis without CT findings of acute cholecystitis.
2. No CT findings to explain patient's symptoms. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed A mobile 2.5 cm gallstone within the gallbladder which is distended but
without other findings to suggest acute cholecystitis. The patient was diagnosed with CHOLELITH W CHOLECYS NEC. The patient was treated with Laparoscopic cholecystectomy. At the time of discharge, the patient had Acute cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission (abdominal ultra-sound vs abdominal/pelvic CT)
revealed acute 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 oxycodone and Tylenol 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: Patient with substernal chest pain and heaviness since 8pm last
night. Started while she was washing dishes and persisted all
night. It started around ___ and has been unrelenting and
slightly worsening to ___. She tried taking nitro at home
without improvement and received nitro spray from EMS which gave
her a headache without CP relief. The pain is not exertional and
is present at rest. She characterizes it as the same as with her
prior MIs. CHEST (PA AND LAT) showed Mild right basilar atelectasis. Suspected pulmonary hypertension. Otherwise,
no acute cardiopulmonary abnormality. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. Radiology showed No acute fracture or dislocation. Radiology showed No acute fracture or dislocation. Radiology showed No acute fracture or dislocation. The patient was diagnosed with Other chest pain. The patient was treated with ___ transesophageal echocardiogram. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had chest pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your blood pressures were very high, so we gave you
medications through the IV to help lower them.
- You were in the cardiac intensive care unit (CCU) because of
the medications you required.
- We did an transthoracic echocardiogram (TTE) of your heart,
which showed that it is pumping normally.
- We did a transesophageal echocardiogram (TEE) to look at your
larger arteries and confirm there was no tear.
- We did a pharmacological perfusion study of your heart, which
showed no areas concerning for blockage.
- We took xrays of your hip, knee and ankle. The wet read showed
no fractures.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Did the patient have a TIA or stroke (ischemic or hemorrhagic)
diagnosed during this admission?:No
Will this patient be discharged on an opioid pain
medication?:No
Final Diagnosis:PRIMARY:
=========
# HYPERTENSIVE EMERGENCY
# NSTEMI
# ___ ON CKD
# RIGHT HIP PAIN
# HERPES ZOSTER</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ===================================================
MEDICINE NIGHTFLOAT ADMISSION NOTE
===================================================
PCP: ___ MD
CC: ___
HISTORY OF PRESENT ILLNESS:
___ h/o CAD, abdominal/pelvic mass (being worked up), thrombotic
vasculopathy with LLE ulcers, chronic
anemia/leukocytosis/thrombocytosis ___ chronic inflammation, and
chronic hyponatremia who presents with worsening dyspnea, b/l ___
pain and gangrenous R ___ toes. CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS showed 1. Chronic, severe multifocal stenosis/occlusion of the left posterior tibial
artery with distal reconstitution, similar to the examination from ___.
2. Diminutive right peroneal artery.
3. Essentially unchanged 2.5 x 2.2 cm left lower quadrant mesenteric mass in
comparison to most recent prior, with adjacent hematoma.Additional masses
within the lower abdomen/pelvis are also unchanged compared to the prior exam.
4. Prominent main pancreatic duct and common bile duct, progressed since prior
examinations. Consider MRCP for further evaluation.
5. Transverse colocolic intussusception. Colonoscopy is recommended for
further evaluation for possible underlying mass.
RECOMMENDATION(S): 1. Colonoscopy - if not recently performed, is
recommended for further evaluation of possible lead point.
2. Consider possible MRCP for evaluation of enlarging common bile duct.
NOTIFICATION: The findings were discussed with Dr. ___, M.D. by
___, M.D. on the telephone on ___ at 1:59 pm, 60 minutes after
discovery of the findings. Radiology showed No acute fractures or dislocations are seen. There are mild degenerative
changes at the first MTP joint. There is mild overall demineralization.
There is soft tissue swelling of the second through fourth toes. However,
there are no radiographic signs for acute osteomyelitis. There are no
erosions. Radiology showed Cardiomediastinal silhouette is within normal limits. Lung fields are
slightly hyperexpanded. There are no focal consolidations, pleural effusion,
or pulmonary edema. There are no pneumothoraces. There is mild thoracic
scoliosis. SCROTAL U.S. showed 1. No focal masses within or outside the testes on either side. Bilateral
epididymides demonstrate normal echotexture and vascularity.
2. The previously described extratesticular nodule adjacent to the left
testicle, on the ultrasound dated ___ was not visualized on today's
exam. If this prior ultrasound can be scanned into our system an addendum can
be provided following comparison. CHEST (PORTABLE AP) showed Comparison to ___. No relevant change is seen. Moderate scoliosis,
elevation of the left hemidiaphragm. Minimal scarring at the right lung
basis. Mild overinflation. No evidence of pneumonia or pulmonary edema. RENAL U.S. showed 1. No evidence of hydronephrosis.
2. Small amount of debris in the bladder. Please correlate for bladder
infection. MR ___ showed 1. Unremarkable evaluation of the small bowel with no areas to suggest bowel
inflammation.
2. Mesenteric masses in the left hemiabdomen seen on prior CT are not well
evaluated on this study.
3. Bilateral femoral head avascular necrosis. Radiology showed AP and lateral skull: No radiopaque foreign densities are seen. Orbital
contours are preserved. The left frontal sinus is hypoplastic. Bony
structures are intact.
AP cervical spine: No radiopaque foreign densities are seen. The dens and the
lateral masses are intact. Lung apices are grossly clear.
AP chest: Heart size is within normal limits. There is scoliosis of the
thoracic aorta. There is atelectasis at the lung bases. There is no focal
consolidation. No radiopaque foreign densities are seen.
AP abdomen: There are no radiopaque foreign densities. Bowel gas pattern is
within normal limits without obstruction. There is scoliosis of the lumbar
spine with convexity to the left side centered at L2/3. Hip joint spaces are
relatively preserved. CT HEAD W/O CONTRAST Q111 CT HEAD. showed No evidence of hemorrhage, mass, or other acute intracranial abnormality. Radiology showed Severe emphysema.. No acute cardiopulmonary abnormality.
No pneumoperitoneum. The patient was diagnosed with Gangrene, not elsewhere classified, Anemia, unspecified, Melena, Dyspnea, unspecified, Hypertensive heart disease without heart failure. The patient was treated with ___ BONE MARROW BIOPSY. At the time of discharge, the patient had Inflammatory disorder, NOS
Anemia
Leukocytosis
Thrombocytosis
New ___ with persistently elevated Cr
Dry gangrene of R toes
AVN of bilateral femoral heads
IgG MGUS,
HFrEF
Transvere colonic intussusception
Pelvic mass with nondiagnostic biopsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old gentleman with hx of CAD complicated
by anterior STEMI in ___ status post stenting in the LAD artery
and ramus branch, an unrevealing extensive evaluation for pelvic
mass, alpha thalassemia trait, thrombotic vasculopathy with RLE
ulcers, chronic anemia/leukocytosis/thrombocytosis, who
initially presented with dyspnea, weight loss and worsening
gangrenous ___ right toe pain, now stabilized, although
unifying diagnosis remains elusive.
Of note, patient was recently admitted ___ for SOB and found
to have significant drop of Hb 9 to Hb 6. Was transfused and
underwent workup for occult bleeding. EGD showing mild
esophagitis/duodenitis and biopsy of the sigmoid colon was
suggestive of ischemia. Patient also underwent ___ biopsy of a
LLQ abdominal mass, but unfortunately this was nondiagnostic.
Biopsy was complicated by bleeding, and given high risk, repeat
biopsy was not recommended during that admission. Subsequently,
as an outpatient, patient had PET scan which showed smaller soft
tissue lesions in the L hemipelvis and new non FDG avid 2.3 cm
right hemipelvis soft tissue lesion.
#INFLAMMATORY PROCESS, UNDIFFERENTIATED:
OVerall, it appears that Mr. ___ has an underlying
inflammatory process as evidenced by his leukocytosis,
thrombocytosis, and elevated ESR, CRP. Markers likely represent
reactive changes to a systemic inflammatory process for which an
exact
diagnosis has not yet been established. Infection, malignancy,
and rheumatologic processes were all considered as below:
- Patient without any localizing symptoms of infection and
gangrenous toes non-infectious per vascular surgery and
podiatry. ID consulted and extensive infectious workup
unremarkable.
- A primary hematologic malignancy was also a concern given
anemia/leukocytosis/thrombocytosis. However, bone marrow biopsy
performed during this hospitalization (___) was negative.
- Rheumatologic diagnosis was also considered, including medium
vessel vasculitis such as polyarteritis nodosa and less likely
etiologies such as cryoglobulinemia (found to have negative
cortos, elevated complement, negative hepatitis screen), APS
(negative antiphospholipid antibodies). RF and ___ also
negative. There are several findings consistent with possible
PAN: indolent course, chronic gangrenous development, bowel
ischemia and testicular pain/inflammation. However, He does not
have classic findings of PAN or vasculitis on imaging per
rheumatology. PET scan did not show significant uptake along
vessel walls. And dermatopathology from calf biopsy was negative
for evidence of vasculitis or amyloidosis. Will follow up with
rheumatology as an outpatient.
- Amyloidosis was also on differential. Of note, he has
underwent evaluation for this with Dr. ___ as an outpatient.
BCR-ABL PCR and JAK2 V617F/CALR/ MPL testing in peripheral blood
as well as bone marrow biopsy have all been negative.
- Patient expressed his wishes to leave ___ (for rehab), and
will consider getting a second opinion at an outside hospital or
via his PCP (which we support). The discharging team assumed
care for patient on the day of discharge when he insisted on
being discharge to rehab. He was able to demonstrate capacity
to make medical decisions, and acknowledged our recommendation
for him to remain in hospital, a lack of unifying diagnosis and
slowly worsening renal failure. He acknowledged the
consideration by renal team to possibly pursue renal bx if no
improvement. Resident on the team communicated with PCP with an
update.
#Anemia
On admission, patient was found to have severe anemia with
hemoglobin of 4.5 (drop from 8.0 a few weeks earlier). He
received a total of 4U pRBCs, and his HgB has remained
relatively stable. Hemolysis labs were negative, iron studies
consistent with chronic inflammation. Workup for underlying GI
bleed unremarkable, including EGD, colonoscopy, MR enterography,
and capsule endoscopy. Given otherwise negative workup, most
likely anemia of chronic inflammation worsened by frequent blood
draws. Will plan to monitor with qweekly CBCs.
#IgG MGUS
#Leukocytosis
#Thrombocytosis
Patient noted to have concominant leukocytosis and
thrombocytosis which has trended upwards during his hospital
course. Unfortunately, we have not found an etiology for these
abnormalities. Peripheral smear showed atypical large
lymphocytosis with folded nuclei. LDH not markedly elevated,
SPEP with 4% monoclonal IgG Kappa (previously trace), UPEP
negative for ___ protein and monoclonal Ig, elevated
free Kappa and Lamda, but normal ratio. Infectious workup
unremarkable, HIV negative. Cryoglobulin: neg. C3 172, C4 45.
Patient from ___, but HTLV I/II antibodies negative. He
previously had low B12, but now has been taking cyanocobalamin.
Bone marrow biopsy without evidence of heme malignancy with 5%
plasma cells, and a small IgG kappa spike (previously trace, now
4%). As above, will continue to monitor outpatient with weekly
CBC w/ diff and hematology/oncology follow up. Would also
consider tagged WBC scan to further localize inflammation.
#Pelvic Mass
Further workup for left lower quadrant abdominal mass
(incidental finding, ___, was considered given unclear
etiology for leukocytosis, anemia, and elevated inflammatory
markers. Patient had a biopsy of this mass in ___ by
___, which was non-diagnostic and complicated by hematoma. As an
outpatient, patient had a PET CT in ___ which showed
smaller soft tissue lesions in the L hemipelvis and new non FDG
avid 2.3 cm right hemipelvis soft tissue lesion. Per ___, the
other "pelvic masses" are most consistent with low density lymph
nodes. The mass was again present on CTA abdomen on ___.
During the hospital course, we had many lengthy conversations
with ___, ACS, and heme/onc as to whether we should pursue repeat
biopsy. Ultimately, it was decided that the pelvic mass of
interest has not changed in size since ___, was non-FDG
avid, and does not invade any surrounding tissues. Per ___, the
mass appears unlikely to be malignant. Plan for repeat imaging
of pelvic mass in 3 months.
#Chronic, severe multifocal stenosis/occlusion of the left
posterior tibial artery
#Bilateral avascular necrosis of femoral heads
#Gangrenous R toes
Patient had been on Eliquis at home (started in ___ by vascular
surgery for toe ischemia). R toes with dry gangrene and
continuing to demarcate with new
involvement of fifth toe, no e/o infection. CTA without any
acute change, and palpable peripheral pulses on exam, all
pointing to a more microvascular process. There is concern that
this may be related to a systemic inflammatory process (as
below). For anticoagulation, patient was transitioned to
warfarin 2.5mg prior to discharge, given worsening kidney
function. Please trend INR and adjust warfarin dose to INR goal
___. INR at time of discharge 1.2. Follow up as an outpatient
with podiatry.
___ (baseline 0.9)
Still unknown etiology. No sediment in the urine to suggest ATN.
___ have been related to fluid, shifts, diuresis, and poor PO
intake during this month long admission, however Cr continues to
up-trend overall, indicating that this could also be an
intrinsic insult. Could be secondary to his known thrombotic
vasculopathy or an underlying, undiagnosed inflammatory process.
Otherwise, there is no evidence of glomerular bleeding; he has
trace IgG kappa on SPEP, but it is not clear how this is
clinically relevant with regards to his renal function, with
negative UPEP, and subnephrotic proteinuria. His up-trending Cr
at discharge is indeed worrisome, and this was discussed with
the patient prior to discharge. He understands that this could
be life-threatening, and he will follow up with nephrology
within 1 week of discharge for repeat lab-work. Would consider
renal biopsy if his kidney function continues to worsen.
#Newly diagnosed HFpEF (borderline reduced EF, lowest 40-45%
noted on TTE ___
#Non-ischemic cardiomyopathy
There may also be a component of pulmonary edema in setting of
BNP >20,000, severely elevated LA volume and elevated JVP,
although CXR on ___ does not show much evidence of volume
overload. With diuresis proBNP decreased to 9,000. Etiology of
reduced EF is unclear, although amyloid is on the differential.
Plan for cardiac MRI as an outpatient to further evaluate. Will
continue home ASA, increased dose of rosuvastatin, and home
metoprolol on discharge.
#Transverse Colonic Intussusception
Incidentally, CT abdomen pelvis this admission showed
intussusception in the transverse colon. However, patient has
continued to have regular bowel movements, without abdominal
pain or other worrisome clinical features. Likely corrected with
colonoscopy. Plan to follow-up with GI as an outpatient.
#Testicular Pain
Admission to ___ ___ for testicular pain.
Treated with antibiotics with resolution of symptoms. Patient
has a history of during last hospital course and at OSH. Given
initial concern for medium vessel vasculitis, patient had
ultrasound to evaluate for possible biopsy. There was no
inflammation so biopsy was deferred.
#Hypoxia: RESOLVED
Patient intermittently required nasal cannula, usually around
___ O2. Hypoxia seems to be related to poor effort and
atelectatic lungs in setting of deconditioning and underlying
COPD (no PFTs in system, but evidence of emphysema on imaging).
Poor inspiratory strength when MIPs were done with RT (best was
-30 cmH2O). O2 was weaned, and patient was discharged on RA.
Would recommend PFTs as an outpatient.
#Hypoactive delirium: RESOLVED
Patient's mental status much improved compared to severe
somnolence and difficulty staying awake when he was first
admitted. Most likely culprit is gabapentin, as mental status
resolved off medication. NCHCT normal.
#Jaw claudication: RESOLVED
Patient initially presented with jaw claudication/weakness. Jaw
weakness resolved with puréed diet. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old right handed man with past
medical history remarkable for frontal lobe epilepsy and
non-epileptical seizures poorly controlled on Lamictal who was
recently admitted to ___ for tonic-clonic seizure at his
assisted living facility in ___ ___s LTM admission for
characterization of events and AED switch (lamictal -->
clobazam). Radiology showed No acute intrathoracic process. The patient was diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY. At the time of discharge, the patient had Non-electrographic seizures. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># Neurological:
Mr. ___ was noted to have two events in the ED which were
similar to his events which involve the following semiology -
tonic posturing alternating in right and left arms with change
in mental status involving staring left and right reduced
vocalization. Of note these events do not include any loss of
consciousness. No medications were made, as compliance has been
a longstanding issue and after speaking with outpatient
providers determined an appropriate trial on current doses has
not been evaluated. The patient was counseled on absolute need
for medication compliance.
# Transitions of care:
- The patient will undergo two days of EEG monitoring as an
outpatient, and will follow up with ___ his epilepsy
nurse, and ___ for neuropsychiatric evaluation in
the next week.
- Medication changes per ___ will be established via
outpatient management for now.
- We will contact assisted living and ___ upon
discharge for transportation/sign out.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo man with a PMH of prostatitis, AAA, bladder
cancer, and necrotizing cholcystitis s/p cholecystectomy
(___), who presented to the ED with a 1-day history of
chills, rigors, and vomiting. He woke up with these symptoms and
had multiple episodes of non-bloody, non-bilious emesis. He
stated that for the past week he has had some days where he
didn't feel well. No diarrhea/dysuria/dyspnea. Radiology showed No acute findings. Hyperinflated lungs. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. No evidence of fluid collection status post cholecystectomy.
2. Mildly enlarged spleen. Radiology showed 1. Minimal perihepatic fluid and stranding within the gallbladder fossa may be
expected post-operatively. No fluid collections within the abdomen or pelvis
to suggest abscess.
2. Aneurysmal dilitation of the infrarenal abdominal aorta extending to the
level of the iliac bifurcation, without evidence of rupture. Recommend
follow-up ultrasound in 6 months to document stability.
3. Diverticulosis without diverticulitis.
4. Mild prostate hypertrophy.
NOTIFICATIONS: Follow-up recommendations for finding number 2 were discussed
with Dr. ___ by Dr. ___ telephone at 11:39 pm on ___. The patient was diagnosed with FEVER, UNSPECIFIED. At the time of discharge, the patient had Gram negative rod bacteremia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo man with a PMH of prostatitis, AAA, bladder
cancer, and necrotizing cholcystitis s/p cholecystectomy
(___), who presented to the ED with fevers, rigors,
vomiting, found to have GNR sepsis with positive blood and urine
cultures.
========
Active Issues
========
#E. coli septicemia: patient experienced fever/chills, rigors,
and had a RR of 24 upon transfer to the MICU. Blood cx growing
GNR's and patient started on cefepime and flagyl. Urine culture
also positive for GNRs, unclear if patient had primary
bacteremia with subsequent UTI or primary UTI with secondary
bacteremia. Another potential source of infection is
intra-abdominal flora in setting of recent necrotizing
cholecystitis. RUQ US and CT abd/pelvis negative making
cholangitis and acute prostatitis less likely sources of
infection given normal prostate exam. In the MICU patient
received large volume fluid resuscitation and continued on IV
antibiotics. Patient remained hemodynamically stable and was
transferred to the floor on ___. He remained afebrile overnight.
Bacteria came back sensitive to ciprofloxacin, patient was
transitioned to PO ciprofloxacin to take for total ___nd discharged to home with close follow up with his PCP and
recommended follow up with urologist.
-Enterococcus grew in low numbers in the urine, more likely a
colonizer and not true pathogen
=========
Chronic Issues
=========
#AAA: Underwent surgical repair at ___ in ___. His CT abdomen
showed residual dilatation with recommendations for f/u with US
in 6 months to assess stability. Continued home ASA. This
finding was discussed with patient, he expressed understanding
#Gout: stable. Continued home allopurinol.
#Microscopic Hematuria: Noted on urinalysis. Given urologic
history, this could be suspicious for a recurrent malignancy, or
related to infection. Close follow up of this will be needed.
This finding was discussed in detail with the patient, and he
expressed understanding of need of close follow up.
============
Transitional Issues
============
1. Patient had AAA (4.3 cm)noted on his CT that will require f/u
ultrasound in 6 months
2. Followup pending culture speciation
3. Patient had 8 RBC on his urinalysis and with his history
should have urology followup</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo ___ s/p VAVD on ___ complicated by urinary retention
requiring foley catheter placement and 3rd degree laceration
presents to the ED after evaluation in the office today with
continued urinary symptoms as well as anxiety, agitation,
insomnia and 'total body pain',
concerning for postpartum psychosis. Medical records from
her Atrius record that the patient likely had an anxiety attack
in the office today. Dr. ___ her in the office and
recommended admission.BP in office noted to be 140/90 MR HEAD W AND W/O CONTRAST showed Essentially normal MRI of the brain with and without contrast, there is no
evidence of acute or subacute intracranial process The patient was diagnosed with MENTAL DISORDER-POSTPART, TRANSIENT ORG MENTAL NEC. At the time of discharge, the patient had urinary retention
post partum mood 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>On ___ Ms. ___ was admitted for management of
her urinary retention, complaints of pain and psychiatric
changes.PIH labs were negative and bps remained normal during
her hospitalization. She was started on Haldol and Ativan for
her psychiatric symptoms including psychogenic water
drinking.This pt had urinary output of 12,000cc in a day. These
were titrated to her symptoms and the psychiatry service was
following. An EKG was obtained and appeared normal.
The foley catheter had been discontinued one week after
placement and she failed to spontaneously void. The foley
catheter was then replaced and a urogynecology consult was
obtained regarding her peristent urinary retention. She was
instructed in use of the leg bag and was recommended to remain
with indwelling catheter for 2 weeks. Follow up with Dr. ___ in
Urogynecology was recommended.
On hospital day #10 she was stable to be discharged home.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old male with a history of Lyme's disease
presents from ___ with CT imaging concerns for
"diffuse subarachnoid hemorrhage". He explains that he was
shopping at ___ today when suddenly, he began to hear less
from both ears, developed right-sided head pressure and right
posterior eye pain. He became dizzy and fell to his knees. He
had no loss of consciousness, nor any head strike. He rose to
his feet and sat in his car for a while, then drove himself to
___. CTA HEAD AND CTA NECK showed 1. Subarachnoid hemorrhage centered within the right aspect of the suprasellar
cistern with 10mm aneurysm arising from the origin of the right posterior
communicating artery.
2. No new hemorrhage or additional aneurysm.
3. Right-sided thyroid nodule. Radiology showed No evidence of pneumonia. CT HEAD W/O CONTRAST showed Expected postoperative changes from craniotomy and aneurysm clipping. The
subarachnoid hemorrhage is evolving. No new hemorrhage is identified. CTA HEAD WANDW/O C AND RECONS showed 1. Postoperative change of prior right frontotemporal craniotomy and right
posterior communicating artery aneurysm clipping with expected postoperative
pneumocephalus and evolving subarachnoid hemorrhage.
2. Unchanged effacement of cerebral sulci, greater within the right cerebral
hemisphere. No new hemorrhage or mass effect.
3. Interval decrease in caliber proximal intracranial vessels including A1
segments, M1 segments, and P2 segments, the overall findings of which are
compatible with mild non-occlusive vasospasm.
NOTIFICATION:
Wetread findings were discussed with Dr. ___ by Dr. ___ telephone at
10:55am on ___, 5 min after discovery. CTA HEAD WANDW/O C AND RECONS showed 1. Status post clipping of a ruptured right PCOM aneurysm, with resulting
streak artifact in the right temporal lobe.
2. Vessel wall irregularity with areas focal narrowing involving the A1 and M1
segments, right greater than left. These findings are suggestive of mild
vasospasm and grossly unchanged from ___. Posterior cerebral arteries are
unremarkable on the current study, appearing similar in caliber to the
presenting CTA on ___.
3. No acute intracranial hemorrhage. No hydrocephalus. The patient was diagnosed with SUBARACHNOID HEMORRHAGE, NONRUPT CEREBRAL ANEURYM. The patient was treated with ___ Craniotomy for clipping of PCOM aneurysm. At the time of discharge, the patient had SAH
Posterior communicating artery aneurysm
___ nerve palsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year-old man who had sudden right-sided head
and eye pain today, as well as dizziness, nausea and vomiting.
CT and CTA of the head showed a subarachnoid hemorrhage and
PCOMM aneurysm. Patient was admitted to the neurosurgical ICU.
Q1 neuro checks were performed. He was started on Nimodipine,
keppra and pravastatin. SBP goal <130. He was made NPO in
preparation of Right Craniotomy for aneurysm clipping tomorrow.
On ___ Patient went to the OR for clipping of the R PCOM
aneurysm. Intraoperatively, the aneurysm was ruptured in which
there was a 1L blood loss. He received 1 unit of PRBCs and his
h&h was kept above 30. His post operative head CT showed
pneumocephalus, but no acute hemorrhage. On post operative exam,
he was seen to have a ___ nerve palsy on the R, but was
otherwise intact.
On ___, his blood pressure was liberalized to <160. TCDs were
ordered and he was kept on IVF 100cc/hr. Nimodpine was also
continued.
On ___, patient remained stable on exam. TCDs were performed
which showed hyperemia in the R MCA and distal ICA, no
vasospasm. He received 1L fluid bolus to keep his fluid status
even.
From ___, the patient's exam remained stable. He had mild
improvement in right ___ CN function. CTA demonstrated right MCA
spasm, confirmed by elevated velocity in TCDs; he exam remained
stable. His fluid status was kept grossly even.
___, Mr. ___ remained neurologically stable. His TCDs
were unchanged and were consistent wtih R MCA hyperemia versus
mild vasospasm. A CTA was planned for the next day.
___, Exam remained stable and CTA today was unchanged, no acute
intracranial process. Opthalmology consult was requested for
significant Right ___ edema. Intraocular pressures were
normal and cool compresses with f/u in two weeks
was recommended.
Mr. ___ was transferred out of the ICU on ___. He continued
to recover well. His IV fluids were discontinued on ___.
Nimodipine therapy continued. His right eye ptosis was
improving.
On ___, Physical therapy requirs another vist most likely home
with out pt ___- wife will provide 24 hour supervision. The
patients low potassium and magnesium were repleated.
On the day of discharge , the patient was eating well. He and
his wife were looking ___ to discharge from the hospital and
the patient was stable from a hemodynamic and neurologic stand
point. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ year old male with past history of ESRD
___ DM s/p transplant ___ ___ (baseline creatinine 1.8),
diastolic CHF (EF55%), COPD on 3L of home O2, and CAD s/p
multiple stenting, history of lacunar strokes, PVD, and dementia
who is presenting with atrial fibrillation. He speaks primary
___, and limited ___, however is able to
interact with interviewer. He also has a prior history of
dementia.
History quite limited, however patient reports that while he
was at rehab, he was feeling palpitations for the past two days.
He reports no chest pains, shortness of breath, abdominal pains,
nausea/ vomiting. He was then seen yesterday ___ the ___
clinic as detailed below, however notes that his palpitations
increased after he was seen ___ the clinic. Patient has been
having difficulty with urination, and therefore had a foley
catheter manipulated. Patient states that he does not walk any
more.
Patient was then seen ___ the ___ clinic on ___ for a
possible voiding trial after a foley was left during prior
hospital stay. He was seen because of hematuria throught to have
a traumatic foley placement on ___, and then multiple
failed voiding traials, and on ___, had paraphimosis with a
reduction performed. He had previously been treated with
ciprofloxacin for a urinary tract infection while at rehab
starting about ___, and was having erosion at his meatus
where the foley catheter was placed. During this examination, he
was found to have a penis that was quite edematous,
uncircumcised, with apparent paraphimosis, and erosion thought
to be ___ to foley placement. There was exudate and malodorous
discharge, and testicles are surgically absent. A foley exchange
was done, and a paraphimosis reduction was performed and
foreskin was pulled back over penis, partial edema then
resolved, and then a new ___ foley catheter was placed.
Of note, patient was recently discharged on ___, and at
that time his hospital course was complicated with increased
dyspnea and acute on chronic CHF exacerbation. During hospital
stay, patient was initially placed on BIPAP, and was placed on
Lasix gtt and up-titrated to 20 mg / hour. Patient was then
transitioned to 80 mg PO torsemide for home regimen. Further,
patient was found to have new onset atrial fibrillation,
CHADS2Vasc=8, and planned for cardioversion however TEE showed
___ thrombus and therefore was anticoagulated with warfarin and
placed on home labetolol for rate control. Patient was also
found to have urine culture with pseudomonas with repeat
cultures negative, and received a 7 day course of cefepime for
UTI. Patient had urinary retention and a foley catheter was
placed, and was started on finasteride per urology
recommendation. He was therefore discharged with foley ___ place,
and to be scheduled to be removed by Urology. Discharge weight
was 84 kgs. It was noted per discharge summary that the patient
should not be on cyclosporine. ___ discussion with rehab,
tacrolimus was discontinued 1 month ago.
___ the ED initial vitals were: 0 99.4 140 108/58 20 95% RA
EKG: with atrial fibrillation with RVR.
Labs/studies notable for: WBC 16.7, Hgb 7.1, Hct 24.4. INR 2.4.
BUN 63, Creatinine 1.8. Lactate 1.6. U/A with WBC, many
bacteria, 100 protein. Patient underwent a chest x-ray which was
remarkable for volume overload, and also a renal transplant
ultrasound.
Patient was given:
___ 18:00 IV Diltiazem 10 mg
___ 21:40 IV CefePIME 2 g
___ 22:15 PO Diltiazem 30 mg
___ 22:15 IV BOLUS Diltiazem 10 mg
___ 22:25 IV Vancomycin 1000 mg
___ 23:31 IV Furosemide 80 mg
Vitals on transfer: 0 98.1 119 101/53 19 96% Nasal Cannula
On the floor, patient reports no acute complaints.
ROS: On review of systems, denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies recent fevers, chills or rigors.
Denies exertional buttock or calf pain. All of the other review
of systems were negative. Cardiac review of systems is notable
for absence of chest pain, dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope. RENAL U.S. showed 1. No evidence of nephrolithiasis in the native right kidney or right lower
quadrant renal transplant. The native left kidney is not seen likely due to
significant atrophy.
2. Severe hydronephrosis of the native right kidney, similar in comparison to
the prior CT from ___. CHEST (PORTABLE AP) showed Pulmonary edema and small bilateral pleural effusions. CHEST (PORTABLE AP) showed Compared to prior chest radiographs since one ___, most recently ___.
Mild pulmonary edema, right lower lobe atelectasis have worsened. Small
bilateral pleural effusions and moderate cardiomegaly are unchanged.
Esophageal drainage tube ends in the mid esophagus and would need to be
advanced at least 15 cm to move all the side ports into the stomach. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial pathology on noncontrast head CT.
2. Chronic microangiopathic changes and age related global volume loss.
3. Paranasal sinus inflammatory disease. CHEST (PORTABLE AP) showed In comparison to ___ chest radiograph, cardiomegaly and pulmonary
vascular congestion persists, accompanied by improvement in the severity of
pulmonary edema. Small right pleural effusion has also decreased in size in
the interval. Radiology showed 1. Penile edema and edema of the wall of these scrotal sac (status post
bilateral orchiectomy), with a foci of air apparently tracking within the
corpus spongiosum to the right of the Foley catheter, as well as possible 0.9
x 1.0 cm fluid collection along the posterior aspect of the corpus spongiosum
approximately 3cm from the ulcerated urethral meatus. Scattered foci of air
along the surface of the penis, particularly on the left, are indeterminate by
CT since the may be trapped between the penis and adjacent thigh, although
subcutaneous gas cannot be entirely excluded. Further evaluation with
ultrasound is recommended to exclude subcutaneous air (since this would be
concerning for Fournier's gangrene if present), and to assess for a penile
abscess.
2. Severe atherosclerotic disease. Patency of vasculature is not fully
evaluated given noncontrast technique. Occlusive or near occlusive disease as
described above cannot be excluded, although this appearance is unchanged.
3. No evidence of abscess within the pelvis.
RECOMMENDATION(S): Penile US, versus repeat CT or MR with use of gauze to
isolate penis from adjacent soft tissues to allow better assessment for
subcutaneous air.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:48 AM, 2 minutes after discovery
of the findings. PENILE ULTRASOUNDS showed No evidence of abscess or soft tissue gas collections. - CHEST (PORTABLE AP) was done. Radiology showed Successful placement of a right 47 cm brachial approach double lumen PowerPICC
with tip in the cavoatrial junction. The line is ready to use. The patient was diagnosed with Heart failure, unspecified, Unspecified atrial fibrillation. The patient was treated with ___ PICC placement. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is an ___ y/o man with a PMH of HFpEF,
AFib (on warfarin), ESRD ___ T2DM s/p renal transplant (on
pred/MMF), prostate CA s/p XRT/orchiectomy, chronic Foley ___ to
multiple failed voiding trials, COPD on 3L home O2, dementia,
HTN, and PVD, who presented with atrial fibrillation w/ RVR ___
the setting of likely CAUTI with Foley exchange ___ ___ ___
clinic.
# Atrial fibrillation w/ RVR. Prior history of newly onset AFib
___ ___, with CHA2DS2-Vasc score of 8, found to have ___
___ on TEE. Trigger for RVR appears to have been urosepsis.
Rates 140s upon presentation, recovered to ___ on
metoprolol tartrate IV and diltiazem PO, and switched to metop
tartrate 25 mg q6h for rate control. INR remained therapeutic.
He had no subsequent episodes of RVR.
# Acute on chronic diastolic heart failure:
He was hypervolemic on presentation with admission weight
86.7kg, and dry weight approx. 82kg. His last echo from ___
showed LVEF >55%. He was actively diuresed with 200 mg IV Lasix,
5 mg metolazone and Lasix gtt of 15 mg/hr. He was continued on
metoprolol tartrate 25 mg q6h. Once dry weight was achieved at
82kg, he was switched to PO torsemide at 80mg daily.
# Sepsis ___ CAUTI: Patient has a history of chronic urinary
retention with chronic foley catheter ___ place. He was recurrent
UTI's, including positive for pseudomonas ___ the past. He was
admitted on ciprofloxacin, which was switched to
vancomycin/cefepime on admission given decompensated sepsis.
Urine culture grew resistant e. coli sensitive to zosyn,
macrobid, and meropenem. He was switched to meropenem on ___
and will complete a 2 week course.
# Penile ulceration: the patient has two notable ulcerations on
his penis: ___ the proximal base and distal foreskin. He also has
erosion of the uretheral meatus due to chronic foley catheter.
He was seen ___ ___ clinic just prior to admission for
catheter exchange. Urology was consulted during admission and
wounds were felt to be non-operative. CT pelvis was concerning
for air ___ the corpus spongiosum, but penile u/s did not show
any evidence of gas gangrene. Notably he did not have pain ___
the penis. He was seen by wound care nurse and maintained on
daily dressing changes.
# Chronic anemia: This likely represents anemia secondary to
renal disease. Transfused 1u pRBCs on ___ with appropriate
recovery. Baseline Hb ___ and he remained at baseline.
# ESRD s/p transplant: Baseline Cr 1.8. Not HD candidate and
continued on prednisone 5 mg and MMF 360 mg bid. Renal u/s with
hydronephrosis but no abscess. Not treated with cyclosporine
because of recurrent AMS and MDR UTIs. Not on tacrolimus.
Continued on prednisone 5 mg daily and mycophenolate 360 mg BID
and followed by transplant renal during this admission.
Creatinine on discharge was 1.3
# NSTEMI, type II. Hx of CAD s/p PCI to LAD. MIBI most recently
showed inferolateral ischemia. Troponin peaked at 0.17, MB flat,
likely representing type II NSTEMI ___ the setting of sepsis and
a-fib w/ RVR. He was continued on aspirin 81 mg daily,
atorvastatin 80 mg daily, and metoprolol.
# Hypertension: Blood pressures remained well controlled.
Hydralazine was continued at 25mg PO TID and amlodipine was
held.
# Depression: continued on escitalopram 20 mg daily
# Diabetes Mellitus: continued on lantus/Humalog sliding scale
# Urinary Retention: Foley catheter was replaced ___ ___
clinic on ___. He was discharged with foley catheter ___ place,
which was felt to offer better quality of life than intermittent
straight catheterizations. He was resumed on BPH medications.
# COPD: His O2 requirement fluctuated between room air and 2L.
# Glaucoma: He was continued on his eyedrops.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p CT-guided RFA ablation of left apical nodule on ___ p/w
pneumothorax.
She was discharged with a small pneumothorax the day of her
procedure, and had no complaints the following day.
Pt reports onset of L-sided chest pain on ___ with radiation
below bilateral breasts and around to back. No associated
dyspnea, palpitations, dizziness. Presented to OSH today and
found to have L-sided increased PTX. Radiology showed Technically successful CT-guided placement of a ___ pigtail catheter
into the left pleural cavity. Evaluation of the patient after LUL lobectomy due to
lung cancer resection.
PA and lateral upright chest radiographs were reviewed in comparison to ___.
Heart size and mediastinum are stable. A left side pigtail catheter is in
place. Left-sided pneumothorax is moderate, and appears to be similar or
potentially minimally increased as compared to ___ obtained at 07:43
a.m.
There is minimal amount of pleural effusion most likely bilateral, left more
than right. There is evidence of opacity in the left apex, consistent with a
known lesion, better depicted on ___ CT obtained for interventional
purposes. was done. Evaluation of the patient with known pneumothorax
with chest tube on waterseal and increasing pleuritic pain.
PA and lateral upright chest radiographs were reviewed in comparison to ___ obtained at 2:27 p.m.
Since the prior study, there has been interval increase in the left
pneumothorax. The pigtail is in place. The pneumothorax currently is
moderate. Apical thickening is present. A hiatal hernia is redemonstrated,
as well as small amount of pleural effusion. was done. CHEST (PA AND LAT) showed 1. Small, stable left apical pneumothorax.
2. Decreased small left pleural effusion. The patient was diagnosed with OTHER PNEUMOTHORAX, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, HX-BRONCHOGENIC MALIGNAN. The patient was treated with ___
Left pleural pigtail placement. At the time of discharge, the patient had Left pneumothorax. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ was admitted to the Thoracic surgery service after
placement of a left pleural pigtail catheter. Her post placement
chest xray revealed almost full expansion of the left lung. She
had no air leak from her chest tube and minimal discomfort.
The tube remained in place for 36 hours and was removed without
difficulty. Her RA saturations were 95% and her post pull chest
xray revealed a small left apical pneumothorax.
She was up and walking independently, tolerating a regular diet
and without chest pain. She was discharged home on ___ with
___ services for cardiopulmonary assessment and will return to
the Thoracic Clinic in 2 weeks.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ a PMH of ETOH abuse, Hep C, cirrhosis and anxiety p/w
dizziness and presyncope since this morning. Patient reports
that she has had increasing anxiety since this ___ when she
was confronted by a lawyer for her housing complex and was told
that she was being evicted in 30 days. Since then she has
increased her EtOH intake, last night consuming 2 ___ and 5
nips. This morning, she became acutely dizzy when moving around
in bed. She reports her dizziness is worse with sitting upright.
Also reports occasional palpitations, which are not necessarily
associated with dizziness. Denies paresthesias or muscle cramps.
She is additionally reporting diarrhea which began this morning.
She describes it as nonbloody and and not black and says she had
approximately 4 episodes. Denies fevers, chills, nausea,
vomiting. She also reports chest pain which she describes as
being located in her left shoulder and spreading across the top
of her chest above the sternum. Chest pain does not radiate to
the back and is nonpleuritic. This has been occurring for the
past several months and she attributes it to a fall on the black
ice in the ___. Also reports generalized abdominal pain and
bloating since that time. Denies associated dyspnea. Reports
intermittent chronic cough.
In the ED initial vitals were:98.4 89 161/86 18 98% ra. guaiac
negative on rectal exam
- Labs were significant for severe hypomagnesemia to 0.6 and
hypokalemia to 3.2. Also has known abnormal LFT's and
pancytopenia at baseline.
- Patient was given PO magnesium and potassium repletion
- RUQ U/S showed cirrhotic liver but no other acute process.
- Hepatology was consulted regarding her pancytopenia and felt
that her lab results were at baseline and did not require
intervention.
- Orthostatics prior to transfer were: 171/82 standing (HR 73),
159/91 standing (HR 76), and 136/90 standing (HR 89).
Vitals prior to transfer were:72 156/85 20 98% RA
On the floor, patient continued to report intermittent dizziness
with movement.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Nodular, heterogeneous, hyperechoic liver consistent with known cirrhosis. No
focal liver mass is definitely identified. No acute cholecystitis. The patient was diagnosed with OTHER MALAISE AND FATIGUE, ELECTROLYT/FLUID DIS NEC, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA. At the time of discharge, the patient had PRIMARY:
Hypomagnesemia
Hypokalemia
Dizziness
SECONDARY:
Alcoholic Liver Disease
Alcoholic Dependence/Abuse. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ a PMH of ETOH abuse, Hep C, cirrhosis and anxiety
presents with dizziness and presyncope x1 day along with
hypokalemia/hypomagnesemia. Her electrolytes were repleted and
she was given information about EtOH cessation, detox centers,
and housing.
# Dizziness / Presyncope: Felt to be secondary to dehydration
and hypokalemia/hypomagnesemia in the setting of chronic alcohol
abuse. Orthostatics were positive in the ED. On the floor,
orthostatics were negative (supine 141/85 and 75, sitting 148/87
and 67, standing 156/91 and 73), electrolytes were repleted,
patient could walk around the floor unsupported with minimal
difficulty. Neurological examination within normal limits.
# Hypokalemia / Hypomagnesemia: Most likely secondary to EtOH
abuse and recent diarrhea. also with mild hypocalcemia, most
likely related to low Mg. She was aggressively repleted, she
was monitored on telemetry, and her magnesium in ___ AM was
3.0.
# Alcohol Abuse: Patient reports significant chronic and recent
EtOH intake. Patient was monitored on CIWA scale, had a social
work consult for substance abuse, and was maintained on
thiamine/folate/MVI for nutrition.
# Chronic Chest/Abdominal/Neck Pain: Patient has had chest and
abdominal and neck pain for about ___ year. EKG and troponins x2
were unrevealing. Patient had variable tenderness. RUQ
ultrasound showed only old cirrhosis. She was kept on low-dose
APAP and oxycodone for pain control.
# Thrombocytopenia / Anemia: Thrombocytopenia likely secondary
to cirrhosis, somewhat decreased from plt ___ in ___.
Normocytic anemia, but stools guaiac negative, and HCT
relatively stable from 31 in ___. She had an active type and
screen maintained.
# Bibasilar Crackles on Exam: Patient had no dyspnea and no
other signs of volume overload.
# ETOH/HCV Cirrhosis: Followed as outpatient by Dr ___.
Patient reports active ETOH use. MELD 13. She was continued on
nadolol and had an outpatient hepatology appointment scheduled.
Social Work offered substance abuse resources but patient
declined them.
# Hypothyroidism: Chronic stable issue continued on home
levothyroxine.
# Fibromyalgia: Chronic stable issue on home gabapentin.
# Anxiety: Chronic stable issue on home risperidone, trazodone,
and benztropine.
# Housing Situation: Patient was informed by a lawyer that she
would be evicted from her apartment in the ___
___. Social work consult gave relevant materials and
services were offered but declined. She had wanted to stay in
order to avoid a Housing Authority eviction hearing on ___.
# Code Status: Full Code presumed, no Healthcare Proxy
# ___: Home without Services via Cab Voucher
# TRANSITIONAL ISSUES:
___ w/ a PMH of ETOH abuse, chronic hepatitis C, cirrhosis and
anxiety presents with lightheadedness and presyncope x1 day
along with hypokalemia/hypomagnesemia. Had normal cardiac
enzymes, normal ECG, and no evidence of significant alcohol
withdrawal. Her cirrhosis was compensated and a right upper
quadrant US showed no liver lesions or portal vein thrombus. She
had stable pancytopenia, with platelets in the ___ range. She
was not orthostatic. She declined alcohol abuse referral
resources. She was discharged ___ without services no longer
feeling lightheaded and with otherwise stable symptoms. She had
hepatology and PCP follow up.
* Hypomagnesemia/Hypokalemia: Repleted with PO K+ and IV Mg, Mg
3.0 and K 3.5 on discharge
* EtOH Dependence/Liver Disease: Monitored on CIWA which
remained <10, LFTs and blood indices stable, maintained on
cirrhosis meds and folate/thiamine/MVI, Social work evaluated
patient and gave information on detox and housing, will followup
with hepatology
* Dizziness: Orthostatics negative and electrolytes repleted by
time of discharge, dizziness likely secondary to alcoholic
cerebellar dysfunction which can only be improved by EtOH
cessation, consider meclizine for dizziness as outpatient, also
consider reducing doses of medications as outpatient
(gabapentin)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with dementia, diabetes mellitus, anxiety and depression,
presented to her PCP appointment with ___ new PCP at ___ in
___ and complained of chest pressure. Her PCP got an EKG
which showed diffuse T wave inversions, and she was rushed to ___
___. At ___, EKG findings were again confirmed, and
troponin I was 0.07. She was started on a heparin gtt and
transferred to the ___. Radiology showed 1. No evidence of pulmonary embolism or other acute abnormality in the chest.
2. Mild centrilobular emphysema.
3. Vague sclerotic appearance of the bones may correlate with underlying bone
marrow abnormality for which laboratory correlation is suggested. The patient was diagnosed with CHEST PAIN NOS, SENILE DEMENTIA UNCOMP. The patient was given written instructions concerning 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 dementia, diabetes mellitus, anxiety and depression,
presenting with chest pressure, diffuse T wave inversion in
multiple vessel territories with elevated troponin I 0.07 at ___
___ initially concerning for ACS, but gold standard
troponin T assay at ___ negative x2. Nuclear perfusion stress
showed EF 49%, reversible perfusion defect involving LAD
territory most consistent with septal ischemia. Decision made
with daughter ___, ___, to proceed with medical
management. Patient was chest pain free on discharge.
# Unstable Angina: Patient with chest pressure, elevated
troponin-I of 0.07 at ___ (? high sensitivity troponin
assay), T wave inversinos in inferolateral and anterior leads,
nuclear stress test with reversible perfusion defect involving
the septal distribution in the LAD. Troponin T negative x 2 at
___, indicating no myocardial infarction. LV systolic function
normal on echocardiogram, indicating no significant prior MI or
current Takotsubo's syndrome. After discussion with the patients
daughter (also the patient's health care proxy), decision made
not to proceed with cardiac catheterization in favor of medical
management. Patient initially treated with heparin gtt, as
troponin T negative x 2, this was discontinued. Patient
medically managed with high dose aspirin, statin, beta blocker
and discharged home on aspirin 81 mg PO daily, atorvastatin 80
mg PO daily, lisinopril 2.5 mg PO daily, and metoprolol
succinate 12.5 mg PO daily with plan to follow up with
cardiology as outpatient. Home propranolol discontinued as
metoprolol better choice of beta blocker for coronary artery
disease.
# Hypotension: Post nuclear stress test and metoprolol 25 mg PO,
patient hypotensive with SBP ___ which improved to 100s with
1.5L IVF, most consistent with hypovolemic hypotension in
setting of NPO status. Patient's blood pressures normalized with
IV fluid resuscitation. Patient restarted on metoprolol
succinate 12.5 mg PO daily and lisinopril 2.5 mg PO daily.
Patient will need blood pressure monitoring and electrolyte
check at primary care follow up appointment.
# Diffuse erythematous papular rash: Appearance most consistent
with contact dermatitis vs. eczema, possibly due to new laundry
detergent at new ___. Improving with topical
steroids and lubricating lotions. Continue topical steroids x 1
week, sarna for itch, Aquaphor for dry skin. Patient to be
re-evaluated at PCP follow up visit.
# Dementia: Patient appears at baseline per daughter's
assessment. No focal deficits on exam and negative UA/UCx,
therefore acute infection or process unlikely. Patient continued
on home Celexa, Wellbutrin, Donepezil, and Namenda. Discontinued
benzodiazepenes as these medications likely to cause delirium in
this older woman with cognitive impairment. Patient did not
require any haloperidol for agitation; would recommend using
this only on an as needed basis for agitation.
# DM: History of DM2, home metformin held, monitored with
insulin sliding scale while in house. Patient discharged back on
home metformin.
Transitional Issues
Unstable Angina/CAD: Family decided not to proceed with cardiac
catheterization or invasive treatment at this time.
Blood pressure: Patient had episode of hypotension after nuclear
stress and receiving larger dose of metoprolol. Blood pressures
improved with IV fluids. Patient's lisinopril decreased to 2.5
mg PO daily and metoprolol succinate decreased to 12.5 mg daily.
Please continue to monitor BP, repeat electrolytes at PCP ___
Contact Dermatitis: Continue topical steroids x 1 week, Sarna
for itch, Aquaphor for dry skin. Please check rash at PCP follow
up visit and determine if any further evaluation necessary.
Medications: Discontinued patient's benzodiazepenes as well as
oxybutynin as these could be contributing to patient's delirium.
Patient did not have any problem with urinary retention or
further agitation during this hospitalization after these
medications discontinued. Would recommend continuing to monitor
and avoiding benzodiazepenes in this elderly woman with
dementia.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F w hypothyroidism who was transferred from ___
___ after an episode of presumed rectal bleeding.
The patient staes that she awoke at ___ yesterday AM with ___
abdominal pain & urge to defecate. The abdominal pain was
located centrally. She immediately went to the bathroom & had a
watery bowel movement with BRBPR, including clots. The patient
has never had a previous episode of hematochezia. She has also
never had a colonoscopy.
As she got up from the toilet, she felt "whoozy" and had a
witnessed syncopal episode. She states that she had a similar
syncopal episode roughly 3 months ago, when she also experienced
a similar abdominal pain (no hematochezia, however). Her husband
tried to catch her as she fell, but unfortunately she hit her
forehead on the floor.
Of note, she denies fevers, nausea, vomiting, diarrhea prior to
yesterday, recent sick contacts or friends with similar
symptoms. She states that she had one episode of similar pain
(centrally located without radiation) 3 months ago that was not
associated with bleeding.
The patient was transported from ___, but the records
were not transported to the floor. Per the referral form, vitals
& labs at ___ as follows:
sBP: 110-120s HR: 60s RR: 16 96/RA
- Hemoglobin 12.7
- Hematocrit 38
- Troponin (-) x 2
At ___ ___, a CT head was reportedly negative. A CT abdomen &
pelvis revealed colitis & portal vein thrombosis. She felt
slightly nauseated with the CT contrast. She was given a dose of
ciprofloxacin & 3L NS.
At the OSH, the patient had several episodes of BRBPR, but her
most recent BM in ___ ___ was non-bloody.
Vital signs in ___ ___: 97.9 68 137/64 18 98%
In th ___, the pt was given 500 mg flagyl. GI was not consulted. The main, right and left portal veins are patent with
hepatopetal flow. The splenic vein and SMV are visualized in the midline and
are patent with hepatopetal flow. The hepatic veins and IVC are patent.
Appropriate arterial waveforms are seen in the main hepatic artery.
IMPRESSION:
1. Patent hepatic vasculature. No portal vein thrombus is visualized.
2. No focal liver lesion identified.
3. Mildly atherosclerotic aorta with no AAA. showed 1. Patent hepatic vasculature. No portal vein thrombus is visualized.
2. No focal liver lesion identified.
3. Mildly atherosclerotic aorta with no AAA. The patient was diagnosed with PORTAL VEIN THROMBOSIS. The patient was treated with Flexible Sigmoidoscopy on ___. At the time of discharge, the patient had Infectious 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>Ms. ___ ___ yof with hypothyroidism who was transferred from
OSH with several episodes of hematochezia, a syncopal episode
and report of portal vein thrombus seen on OSH CT and found to
have negative RUQ here.
# Hematochezia: The patient's BRBPR with clots is most
consistent with a lower GI process. Per report, her CT showed
colitis (no records transported with patient), but my suspicion
for infectious colitis is low given pt afebrile w/o
leukocytosis. Diverticulosis, internal hemorrhoids & AVMs remain
a strong possibility. Upper GI bleed unlikely given lack of
epigastric discomfort & clinical stability. Ischemic colitis
also unlikely in a relatively young patient who lacks a clear
reason for hypotension, vascular disease, or emboli. The patient
has never had a colonoscopy. She reports having hemorrhoids but
has never had a rectal bleed in the past. Hematocrit at OSH
reportedly 38. Currently HD stable.
-will continue empiric cipro & flagyl for 7 day course (day 1 =
___
-GI Consulted: performed Flexible Sigmoidoscopy on ___
-Flex Sig Report: Overall findings most suggestive of
diverticular or infectious colitis. IBD less likely given normal
rectum and distal sigmoid colon.
No findings to contraindicate anticoagulation
Full colonoscopy in ___ weeks
# ?Portal Vein Thrombus: Reportedly seen on OSH CT abd but RUQ
U/S with doppler at ___ shows patent portal veins. LFTs within
normal limits, no laboratory or exam evidence of cirrhosis.
-due to negative RUQ u/s, decided against anticoagulation
# Syncope: This was a witnessed event. After rising from the
toilet, the pt states she felt unsteady and her family lose
consciousness. Could have been transient hypotension in setting
of GIB vs. vasovagal. Pt now s/p volume expansion with 3L NS at
OSH. Given IVF and had negative orthostatics.
# Hypothyroidism
-continued home levothyroxine
# CODE: Full code-confirmed
### TRANSITIONAL ISSUES:
-will continue cipro & flagyl for 7 day course (day 1 = ___
-will hold off on anticoagulation for reported R portal vein
thrombus, and this was discussed with PCP representative on
afternoon of ___.
-may consider repeat RUQ ultrasound with doppler 2 weeks after
discharge to evaluate continued portal vein patency
-needs screening colonoscopy in ___ weeks.
-will follow up with PCP ___ ___
-if continued diarrhea, stool culture and C Diff assay should be
sent, as she did not have any stools here to send these tests</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with hx. ischemic CM (EF ___, afib on
coumadin, TIA, CAD, colon cancer s/p right hemicolectomy
(___) presenting with back pain, found to have gastric
obstruction and intraperitoneal free air. Radiology showed 1. No free gas in the upper abdomen.
2. Severe outlet obstruction of largely herniated, severely distended
stomach.
3. Some decompression over 6 hours by indwelling esophagogastric tube of the
abdominal portion of the stomach.
4. Cardiomegaly, pulmonary hypertension.
5. No pneumonia or other evidence of aspiration. The patient was diagnosed with ABDOMINAL PAIN UNSPEC SITE, NAUSEA. The patient was treated with NG tube placement and removal. At the time of discharge, the patient had Gastric outlet 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>___ year old female with hx. ischemic CM (EF ___, afib on
coumadin, TIA, CAD, colon cancer s/p right hemicolectomy
(___) presenting with back pain, found to have gastric
obstruction and intraperitoneal free air.
# Gastric outlet obstruction: Patient presented with distended
stomach and signs of bowel perforation/free air on CT scan, s/p
improvement in symptoms with placement of NG tube. Given
patient's hx. colon cancer it is possible a recurrence has
contributed to current presentation. Patient notably refused
surgery in the ED and continued to intimate that she would not
want this. Surgery reviewed the imaging and they are concerned
about biliary dilatation and potential mass near duodenum, but
ultimately, the location of the obstruction is unknown and
surgery does not know hat surgery they could even off.
Additionally, patient is malnourished and at high risk for
complications including anastomatic leak. Any surgery would be
palliative. DDx also includes peptic ulcer disease,
pancreatitis. Given presence of intraperitoneal free air,
covered broadly with antibiotics vanc/zosyn/flagyl while
inpatient. Given comorbidities and surgical morbidity,
palliative care was consulted and transitioned to a comfort
measures focus as below.
# Goals of care: Family decided to transition to comfort
measures only. Patient was comfortable on exam throughout
admission. She removed her NG tube and it was not replaced.
Continued antibiotics to facilitate transition to inpatient
hospice close to home, discontinued at discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ yo female with hx of IDDM, ESRD s/p LRRT (___),
orthostatic hypotension, symptomatic anemia, GERD, who presented
to the ER with a 1 day history of fever, chills, diarrhea, N/V,
dysuria, and reported hypotension at home. She had a recent
admission for enterococcus UTI and was discharged on linezolid
on ___, but was then re-admitted for antibiotic associated
diarrhea and continuing enterococcus UTI, discharged on
augmentin on ___. She finished the course of Augmentin on
___, and had a negative urine culture on ___. Radiology showed No evidence of acute disease. Radiology showed 1. No fluid collection or hydronephrosis in the native or transplanted left
lower quadrant kidney to explain recurrent infections.
2. Normal arterial waveforms to the left lower quadrant transplanted kidney
improved from ___. The patient was diagnosed with PYELONEPHRITIS NOS, KIDNEY TRANSPLANT STATUS, DIABETES UNCOMPL JUVEN. At the time of discharge, the patient had 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>___ female with ESRD s/p LRRT (___), IDDM, h/o recent
enterococcus UTI treated with vancomycin, linezolid, and
Augmentin presented with fever, chills, nausea, vomiting,
diarrhea, and hypotension, and was found to have Enterobacter
cloacea UTI.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ male otherwise healthy s/p fall while
skiing in ___ 3 days ago sustaining a left distal tibia
fracture. He had immediate pain and inability to bear weight.
No head strike or loss of consciousness. He was evaluated at a
hospital and was diagnosed with a left distal tibia fracture and
was placed in a splint. He elected to follow-up here as he is
from the area. He denies any numbness or tingling into the left
foot. TIB/FIB (AP AND LAT) LEFT showed Intraoperative images were obtained during ORIF of the tibia. Please refer to
the operative note for details of the procedure. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins, noting limited visualization of the left popliteal and calf veins due
to pain from fracture and presence of a splint. Radiology showed Comminuted fracture of the distal tibial diaphysis with large butterfly
fragment ventrally and mild lateral and posterior displacement of the distal
fracture fragment. No dislocation. CHEST (PRE-OP AP ONLY) showed No acute cardiopulmonary abnormality. Heart size within normal limits. Radiology showed Interval improvement in alignment of the comminuted left distal tibial
fracture. CT left lower extremity without contrast showed 1. Mildly displaced comminuted fracture of the distal tibial diaphysis. The patient was diagnosed with Oth fracture of lower end of left tibia, init for clos fx, Fall from snow-skis, initial encounter. The patient was treated with Left tibial intra-medullary nail on ___. At the time of discharge, the patient had Left distal tibia 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 left distal tibia fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for intramedullary nailing of the left
tibia fracture, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications. The patient
was given ___ antibiotics and anticoagulation per
routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated to the left lower extremity in air
cast boot, and will be discharged on lovenox 40mg daily for 2
weeks for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ with hx of anxiety and depression here
with several weeks of progressive gait difficulty. CT HEAD W/O CONTRAST showed 1. Age advanced, central predominant involutional changes.
2. No evidence of infarct or hemorrhage.
3. Area of encephalomalacia in the right frontal lobe, possibly related to
prior infarct or insult. CHEST (PA AND LAT) showed No acute intrathoracic process. The patient was diagnosed with Weakness. At the time of discharge, the patient had Serotonin Syndrome. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ man with history of depression and anxiety admitted for
worsening gait difficulty, in the setting of recently starting
bupropion in addition to previous Doxepin (TCA) and fluoxetine
(SSRI). His exam was significant for upper and lower extremity
ataxia, tremor, saccadic intrusions, and diffuse hyperreflexia
including jaw jerk and ___. His labs have been mostly
normal thus far (normal B12 and folate, T3/T4 wnl, pending B1
and B6) with only mild elevation in AST that resolved on day
two, and mild elevation in AP. His symptoms and history were
consistent with serotonin syndrome, triggered by the recent
addition of bupropion, and his outpatient psychiatrist informed
us that he was no longer supposed to be taking Doxepin. His
symptoms clearly began to improve 1 day after discontinuation of
all psychiatric medications (except clonazepam). The treatment
for serotonin syndrome is continued holding of doxepin,
fluoxetine, and bupropion, with close follow-up (from rehab)
with his psychiatrist within the next week to slowly re-initiate
appropriate medications. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ right handed woman with hypertension who presents
to the ED with the above symptoms; she provides her own history.
She reports that for the past month now, she has been
experiencing intermittent ___ times/week) headaches described
as
starting on the back of her neck, and extending forward to the
right side of her head. She notes tight neck muscles and a
"pulling sensation" and her headaches are described as a
constant
pressure. Tylenol at night may sometimes take the edge off.
These
have been getting slightly more frequent, but she hadn't sought
medical attention for the same.
Yesterday evening, she went to the movie theater and noticed
that
her arm went quite heavy. She did not notice any clumsiness or
weakness; she could text and use her hands to eat. At that time,
she noticed the relatively acute onset of 1) numbness and
tingling over the right hemibody (including trunk) as well as 2)
"dizziness", which she clarifies as a sensation of something
"rushing to my head" when she got up from a seated position. Radiology showed No acute intracranial abnormality. Radiology showed No acute cardiopulmonary process. Radiology showed No evidence of infarction or hemorrhage.
Nonspecific white matter abnormalities, of uncertain clinical significance,
could be sequelae of chronic small vessel ischemic disease but some what
atypical give her age. Also, on the differential would be headaches,
vasculitis, demyelinating disease and lyme disease.
No significant stenosis on the head and neck MRA. The patient was diagnosed with OTHER MALAISE AND FATIGUE, HEADACHE. At the time of discharge, the patient had Tension/cerevicogemic headaches
Subjective right hemibody altertation in skin sensations of
undetermined etiology. The patient was given written instructions concerning 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 hypertension presents with one month of
intermittent headaches followed by ~ 1 day of right hemibody
numbness that splits down the midline with + ___ on the
right. CT head unremarkable. MRI/MRA head and neck showed no
acute infarct or intracranial hemorrhage. There was no
significant stenosis on the head and neck MRA. Based on her
history, exam and imaging, it is highly unlikely that patient
had a stroke. Seizure is highly unlikely as her sensory
symptoms persisted for days without spreading or other symptoms
suggestive of seizures. Complex migraine is considered but
there is no clear relationship between the onset of her sensory
symptoms and her headaches. We have given patient aspirin 81mg
daily while she was in the hospital but given that she did not
have a stroke, she will not have to continue with the aspirin.
Her fasting lipid is still pending at this time. Her a1c is
5.9. She was continued to half dose of her home atenolol
initially when stroke was still considered a possible etiology.
She was discharged on her home does of atenolol. For her
chronic daily headaches, she was prescribed nortriptyline 10mg
qhs as a trial. We have set up a follow up appointment for her
to follow up with her PCP.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with recent admission on ___ with MSSA (reported growth at
___ endocarditis, complicated by CNS and spine septic
emboli, multiople procedures (Irrigation and debridement, left
glenohumeral joint on ___ Arthrotomy with washout, right
shoulder on ___. Extraction of carious teeth #5, #18 on
___ transferred here for further evaluation of
endocarditis. Chest radiograph. showed A retrocardiac opacity in the appropriate clinical setting could represent
pneumonia.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
___ at 9:43 AM, 30 minutes after discovery of the findings. CT CHEST W/O CONTRAST showed 1. Interval improvement of known septic emboli, the largest remaining within
the right upper lobe.
2. Focal more consolidative wedge-shaped opacity in the left lower lung.
Although limited examination due to lack of IV contrast, findings raise
concern for pulmonary infarction. Alternatively, these findings could also
reflect focal atelectasis versus an infectious process.
3. Small bilateral non hemorrhagic pleural effusions, significantly improved
on the left as compared to prior CT.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 9:21 AM, 10 minutes after
discovery of the findings. CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD showed 1. Patent circle of ___.
2. Known septic emboli in the right pre and postcentral gyri are better
evaluated on the prior MRI. No acute intracranial abnormality.
3. Unchanged 5 mm left retrobulbar, intraconal mass, which may represent an
orbital cavernous malformation or schwannoma. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Persistent diffusion-weighted hyperintense signal and gradient echo
susceptibility hypointense signal with enhancement in the right medial
precentral gyrus lesion with decrease in associated FLAIR hyperintensity in
keeping with treatment response.
2. New punctate focus of enhancement in the right parietal periventricular
white matter without definitive associated FLAIR abnormality. This likely
represents vascular enhancement although interval lesion is not entirely
excluded. Close attention on followup is recommended.
3. Previously-seen other foci of enhancement have resolved on today's study
with persistent associated FLAIR hyperintensity and susceptibility on gradient
echo imaging in keeping with treatment response.
4. Nonspecific fluid opacification of bilateral mastoid air cells. MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE showed 1. Identified is evolving sequela of L4-L5 discitis osteomyelitis with
residual abscess/phlegmon extending into the anterior right paraspinal space
which appears relatively stable in size as compared to most recent prior
lumbar spine MR. ___ is increased loss of L4-L5 disc space and more
prominent marrow edema pattern. Continued followup is recommended.
2. Interval resolution of the smaller two ventral epidural abscesses at the
L4-L5 level. Near-complete interval resolution of a small abscess at the
junction of the right iliacus and psoas muscles. No new enhancing collections
are identified.
3. Mild degenerative changes in the thoracic spine.
4. Small bilateral pleural effusions, right worse than left, better evaluated
on chest CT without contrast of ___. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Normal appearance of the liver.
2. Gallbladder is decompressed with an unchanged 4mm polyp. Gallbladder wall
thickening and edema may be related to underlying hepatitis C or heart
failure. There is no evidence for cholecystitis
3. Moderate right pleural effusion.
4. No focal fluid collection detected. CTA NECK WANDW/OC AND RECONS Q25 CT NECK. showed 1. No evidence of dissection, occlusion or stenosis on the CTA of the neck.
2. Stable 0.6 cm well-circumscribed lesion posterior to the left globe, within
the intraconal fat, likely representing a small schwannoma or hemangioma.
3. Partially visualized moderate right pleural effusion and cavitary/non
cavitary lung lesions, better seen on the prior dedicated CT of the chest. DX CHEST PORTABLE PICC LINE PLACEMENT showed Comparison to ___. Improved ventilation of the right lung base. The
opacity projecting over the costophrenic sinus on the left is stable. Stable
borderline size of the cardiac silhouette. New right PICC line. The course
of the line is unremarkable, the tip projects over the mid SVC. CLAVICLE LEFT showed 3 frontal views of 3 sternoclavicular regions are submitted. Erosion involves
the upper aspect of the proximal left clavicle and on two of the 3 views it is
elevated by less than a cm relative to the location of the right clavicle.
This intermittent subluxation suggests instability of the left
sternoclavicular joint. The patient was diagnosed with Pneumonia, unspecified organism, Fever, unspecified. The patient was treated with ___ TRANSESOPHAGEAL ECHOCARDIOGRAM. At the time of discharge, the patient had MSSA endocarditis
Gram positive cocci bacteremia (unspeciated at time of
discharge)
Yeast fungemia (unspeciated at time of discharge)
Severe aortic regurgitation
Severe tricuspid regurgitation
Acute heart failure with preserved ejection function
Subluxed left clavicle
L4-L5 epidural abscess/discitis
Left lung infarct. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year-old man with recent ___ admission from
___ for MSSA endocarditis, complicated by CNS septic emobli
and L4-L5 epidural abscess/discitis, bilateral septic shoulders
s/p washout during previous admission, who was discharged to
___ on ___ to continue his remaining two weeks of
intravenous antibiotics. He unfortunately left ___ against
medical advice on ___. On ___, he re-presented to
___ with chest pain and dyspnea in the setting of being
off IV ABx x1 week, and was transferred to ___ on for further
evaluation. He was found to have new severe aortic
insufficiency. He continued intravenous cefazolin, showed no
evidence of recurrent bacteremia or embolic disease, and was to
be scheduled for cardiac surgery next week. Unfortunately, pt
was found to have polymicrobial blood culture from ___ with GPC
in clusters and budding yeast. Source is uncertain, but there is
suspicion patient was tampering with his PICC line. The patient
left against medical advice despite our strong insistence that
he stay for treatment of his bacteremia/fungemia. He expressed
understanding that this infection may be fatal without
treatment. PICC line removed prior to discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with pMHx of RUL nodule with PET/CT (___) c/f metastatic
primary pulmonary malignancy without tissue diagnosis,
emphysema, and significant smoking history presenting
w/gradually worsening dyspnea and ___ edema over the past month. CTA CHEST WITH CONTRAST showed 1. No acute central to segmental PE.
2. Large pericardial effusion, complex attenuation which could be in keeping
with hemorrhagic, cellular or proteinaceous material. Although there is no
constrictive morphology of the cardiac chambers, there is extrinsic narrowing
of the pulmonary veins, with reflux of contrast into the IVC and hepatic
veins, may be seen with passive congestion. This could be better assessed by
cardiac echo if clinically warranted.
3. There is extensive soft tissue within the mediastinum and hilar regions,
some of which likely represents pre-existing adenopathy which was previously
characterized as highly suspicious for underlying lung malignancy, although
given circumferential narrowing of some of the vascular structures,
lymphoproliferative disease and large vessel vasculitis is considered.
4. In addition, there is progressed nodular opacities, overall favoring
mucous plugs, within the right upper lobe, with suggestion of
inflammatory/infectious small airways disease with bronchial narrowing and
thickening. Given the clinical history, and other Findings, atypical
infection including tuberculosis, is raised, and appropriate Respiratory
contact precautions is suggested, and possible endoscopic evaluation.
NOTIFICATION: The findings were discussed with Dr. ___ by ___,
M.D. on ___ at 9:53 pm, 15 minutes after discovery of the findings. CHEST (PORTABLE AP) showed Status post evacuation of pericardial effusion with pericardial drain placed. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Increased visibility of the portal triads relative to the background liver
parenchyma, new compared to abdominal ultrasound ___. While this
could be technical in nature, this appearance can also be seen in the setting
of hepatitis.
2. Trace ascites.
3. Moderate gallbladder wall edema, likely third spacing of fluids. No
gallstones seen.
4. Small right and moderate left pleural effusions.
5. Subtle 1.4 cm echogenic lesion in the right hepatic lobe, unchanged from
prior, likely a hemangioma. CT ABD AND PELVIS WITH CONTRAST showed 1. No definite evidence of metastatic disease or lymphadenopathy in the
abdomen and pelvis.
2. Two nonspecific subcentimeter bony lesions in the left iliac bone.
3. 9 mm hypodense lesion in the dome of the liver is too small to
characterize.
4. Prostatomegaly with median lobe hypertrophy.
5. Partial visualization of moderate pericardial effusion with pericardial
stent in place.
6. Bilateral moderate-sized pleural effusions. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed No evidence of intracranial metastatic disease. CHEST (PORTABLE AP) showed Pericardial drain is in place. Heart size is not enlarged. Right upper lobe
partial atelectasis is re-demonstrated. There is no appreciable pneumothorax.
Small amount of bilateral pleural effusion is present. CHEST (PORTABLE AP) showed Comparison to ___. Stable position of the pericardiac drain. Stable
volume loss in the right upper lobe, with on slightly enlarged right hilus, no
pulmonary edema, no pleural effusions. No pneumonia. CHEST (PORTABLE AP) showed The right upper lobe mass is unchanged. The moderately enlarged cardiac
silhouette has slightly increased in volume since the prior study and could
represent an increasing pericardial effusion. The left-sided pericardial
drain has been removed in the interim. There are trace bilateral effusions.
No pneumothorax. CHEST (PORTABLE AP) showed Status post pericardial window with expected postsurgical changes, including
interval decrease in mildly enlarged cardiac silhouette. No appreciable
pleural effusion or pneumothorax. CHEST (PORTABLE AP) showed In comparison with the study of ___, the pericardial drain is been removed.
Little overall change in the appearance of the heart and lungs. The patient was diagnosed with Cough, Other specified soft tissue disorders. The patient was treated with ___: Emergent Pericardiocentesis
___: Pericardial Window. At the time of discharge, the patient had Primary Diagnosis:
- Stage IV Lung Adenocarcinoma (___)
Secondary Diagnoses:
- Pericardial Effusion with cardiac tamponade
- New Atrial Fibrillation (transient)
- Tachyarrythmia, atrial ectopy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with pMHx notable RUL nodule with PET/CT (___) c/f
metastatic primary pulmonary malignancy without tissue
diagnosis, emphysema, and significant smoking history presenting
w/gradually worsening dyspnea and ___ edema over the past month
found to have pericardial effusion with tamponade and new
diagnosis of NSCLC.
ACTIVE ISSUES
=============
# Pericardial effusion with cardiac tamponade
Patient presented with increasing dyspnea and ___ edema,
tachycardic and hypotensive in the ED, found on CTA to have a
pericardial effusion with tamponade. He had a pericardiocentesis
done upon admission ___, with total of > 1.5L of bloody output.
The etiology of the effusion was discovered to be malignant;
negative cultures were sent on evaluation for infectious
etiologies. Does have history of latent TB (ruled out for
pulmonary TB this admission). AFB studies on the pericardial
fluid were negative. Given malignant etiology, he underwent
scheduled pericardial window on ___ and was closely monitored
in the CCU after his procedure. He was transferred back to the
floor on ___. He had some residual ___ edema, for which he
was discharged with compression stockings and 10 mg PO Lasix
PRN. Stable for discharge from hospital weekend of ___. Last
TTE on ___ with small circumferential effusion, no tamponade or
constrictive physiology.
# New Afib/aflutter
# Tachyarrhythmia
Pt found to be in new Afib/flutter upon initial transfer to CCU
likely iso tamponade. Given metoprolol 6.25mg q6h, which was
discontinued ___. Given paroxysmal nature with resolution
following pericardial window, anticoagulation was not initiated
as this was felt to be secondary to his effusion. On ___,
Mr. ___ was noted to have tachycardia to 130s with activity and
110-120 at rest, with some irregular rates on telemetry. He had
EKG ___ which showed sinus tachycardia. Cardiology was
consulted. They reviewed telemetry and were reassured against
atrial fibrillation. Tachyarrhythmia c/w MAT per consult. He had
TTE which showed small effusion but no constrictive or tamponade
physiology. Cardiology recommended rate control with verapamil
120mg daily and Ziopatch evaluation outpatient. He had Ziopatch
placed ___, with plans for outpatient cardiology follow-up (to
be scheduled).
# Dyspnea
# Possible COPD
Mr. ___ was noted to have likely COPD based on wheezes on exam
responsive to duonebs, some dyspnea, iso long smoking history.
He was given advair during hospitalization, with good effect,
however this required prior auth and was not prescribed at
discharge. He was discharged with albuterol inhaler PRN and had
no dyspnea at discharge.
# Post-op Hypotension
On ___ (POD2 pericardial window), pt was hypotensive with MAPs
50-60s. He was asymptomatic, lactate was 2.4. He received 3L IVF
on ___ with improvement in pressures. Bedside v-scan on ___
showed no e/o recurrent effusion. Hypotension was thought to be
___ poor po intake and being NPO over previous days while
waiting for pericardial window procedure. Neg orthostatics by
admission. Asx.
# Stage IV Lung adenocarcinoma
# PETCT ___
CT lung cancer screen on ___ showed: a dominant 7mm right
upper lobe pulmonary nodule concerning for malignancy. Tiny
2-3mm pulm nodules in RML. Pt cancelled bronchoscopy on ___
(due to snowstorm). Then on admission here, found to have
malignant pericardial effusion. IP was involved and deferred
bronchoscopy as cultures and cytology were pending. Heme-onc was
consulted and recommended CT scan Torso, MRI brain and bone scan
which were negative for metastatic disease. He was ultimately
diagnosed with stage IV lung adenocarcinoma, and oncology will
explained the plan for palliative, not curative, treatment. They
will follow him outpatient. This was scheduled for ___.
# Latent TB
Patient with positive quant gold checked in the context of the
suspicious pulmonary nodule last year, with no symptoms and now
s/p 3 negative sputum AFB and one negative sputum NAAT this
admission. Based on these findings he has latent TB. ID has
scheduled him for follow-up to discuss treatment of this in
___.
# Transaminitis
Pt noted to have slightly elevated transaminases as an
outpatient for unclear reasons. Recently noted to have interval
increase in the AST/ALT, PCP ordered ___ ___ that showed
"Normal hepatic parenchyma with a well-circumscribed hyperechoic
lesion, which likely represents a cavernous hemangioma, is seen
in the left lobe of the liver." Concern now for metastatic
disease as well. LFTs ___ have been congestive hepatopathy iso
effusion. Continue to monitor.
CHRONIC ISSUES
==============
# Dilated ascending aorta 4.9cm
Noted on CTA. Stable.
TRANSITIONAL ISSUES
===================
[] Pt was not given AC for transient afib given high bleeding
risk. To discuss further if afib recurrs on ziopatch monitoring.
[] Had Ziopatch placed on ___ - should wear for two weeks and
cardiology should be scheduling an appointment within ___ weeks
from discharge to evaluate rhythm. No cardiology appt scheduled
at ___ at time of discharge. Please help ensure pt has this appt
made.
[] Pt prescribed verapamil for rate control for his
tachyarrythmia.
[] Follow up with ID as outpatient (scheduled) - latent TB and
hep B core positive, also Hep A/B non immune.
[] Follow up with heme/onc as an outpatient on ___ (Dr.
___ to discuss tx for ___.
[] Thoracic surgery recommended dry gauze for wound care, no
need for thoracics follow up. Area is dermabonded.
[] Dilated ascending aorta 4.9cm on CTA
[] Previous ___ ___ showed "Normal hepatic parenchyma
with a well-circumscribed hyperechoic lesion, which likely
represents a cavernous hemangioma, is seen in the left lobe of
the liver." CTM in setting of known lung malignancy. Repeat LFTs
outpt.
[] Pt likely requires Advair, needs prior auth..
[] Foundation one testing pending at time of discharge.
[] F/u pending blood cultures & final AFB cultures.
#LANGUAGE: ___
#CODE: FULL CODE
#CONTACT/HCP: ___ (son) ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is an ___ year old with dementia, CAD, HTN and stroke
who presents from nursing home with right ___ toe wound. The
patient is unable to give a coherent history so the history is
from chart review. Nursing home staff recently noted a worsening
wound on right ___ toe that was rapidly spreading. They do not
know how long the wound has been there. At the time he denied
fever/chills. Facility documentation shows he has been on Keflex
BID since ___, and it is unclear if he was still receiving it
at time of transfer to ___. Radiology showed No radiographic evidence for osteomyelitis. VENOUS MAPPING of lower extremity superficial veins showed The right greater saphenous vein is not visualized distal to the proximal
thigh.
Patent right small saphenous vein with measurements as above.
Left greater saphenous vein with measurements as above with small diameter
from the knee distally.
Left small saphenous vein thrombosed from the mid calf distally. ART EXT (REST ONLY) showed Right lower extremity: Undetectable posterior tibial and dorsalis pedis
arteries., pulse volume recordings and Doppler waveforms suggest significant
infrapopliteal disease.
Left lower extremity: Noncompressible posterior tibial consistent with
arterial calcification artifact; additionally obstructive arterial disease
present with severly abnormal TBI and pulse volume and Doppler waveforms
distal to popliteal artery. ART DUP EXT LO UNI;F/U RIGHT showed Occlusion of the right posterior tibial and dorsalis pedis arteries, anterior
tibial and peroneal arteries are not identified.
Atherosclerosis of the proximal arteries with no hemodynamically significant
stenosis identified. CR - CHEST PORTABLE AP showed 1. Unchanged right upper lobe volume loss and scarring.
2. Unchanged small left pleural effusion.
3. Unchanged linear opacities in the bilateral lung bases which may represent
atelectasis or focal scarring. The patient was diagnosed with Cellulitis of right lower limb, Non-prs chronic ulcer oth prt right foot with oth severity. The patient was treated with Right foot open fifth digit amputation at MPJ ___
Abdominal aortogram and RLE Angiogram ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ year old man with dementia, CAD, HTN,
on hospice after multiple CVAs, who presents with necrotic right
___ toe wound, s/p ___ digit amputation by podiatry ___,
found to have significant PAD without means for
revascularization, offered R BKA but family declined, returning
to nursing home to resume hospice care.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: A ___ year old male with PMH HTN, HLD, Gout presents to the ___
ED after a positive stress test. Radiology showed No acute intrathoracic process. The patient was diagnosed with INTERMED CORONARY SYND. The patient was treated with Cardiac Catheterization ___. At the time of discharge, the patient had Primary: ST Elevation Myocardial Infarction
Secondary: 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>___ year old male with PMH HTN HLD 40 pack year smoking history
and family history of premature cardiac death presenting with
left shoulder pain concerning for unstable angina who
subsequently developed STEMI and was treated with DES to the
RCA.
ACTIVE ISSUES
=============
# STEMI: patient admitted with stuttering left shoulder pain.
The pain had been chronic over the past ___ years and previously
attributed to calcific tendonitis. The pain had changed in
quality prompting an exercise stress which showed STE in the
inferior leads and reciprocal changes in the precordium. EKG was
remarkable for STD in II, III and aVF and cardiac biomarkers
were indeterminate. TIMI score was 5 on admission (Age, CAD risk
factors, Aspirin use, Angina and ST changes). The pain was
responsive to nitroglycerine on admission. He was staretd on
heparin gtt given ASA 325mg and clopidogrel 300mg, betablockade
and angiontensin receptor blockade were optimized. He was chest
pain free after evaluation by the medical team. The morning
after admission he complained of shoulder pain and EKG was
remarkable for ST elevations in II III and aVF. CODE STEMI was
called. Right sided leads do not show any findings concerning
for RV involvement. He was taken emergently to the cardiac
catheterization laboratory where a DES was placed in the RCA. He
had LAD disease as well however this was thought unlikely to be
the culprit lesion. He was initially treated with prasugrel
however this proved prohibitively expensive and he was changed
to clopidogrel after discussion with Dr. ___. Since he had
already received prasugrel 10mg in the AM, he was discharged
with instructions to take clopidogrel 75mg x4 tablets the
morning after discharge and 75 mg daily thereafter for one year.
He was contacted the day after discharge and it was confirmed
that he had understood and followed these instructions. He will
follow up with Drs. ___ and for consideration of
further stress testing to evaluate the LAD stenosis.
# Hypertension: Patient was hypertensive to SBP: ~150 on
admission, he was changed from valsartan to losartan given
active metabolites and longer duration of action. Chlorthaladone
was continued. Dr. ___ PCP, ___ check Cr and K one week
after discharge.
# GERD: Changed omeprazole to pantoprazole given CYP interaction
between clopidogrel and omeprazole.
# ETOH abuse: Patient drinks ___ alcoholic beverages per day.
Previously e valuated by Dr ___ some hepatic necrosis
on biopsy with no evidence of cirrhosis however patient is
unwilling to quit drinking. He has no stigmata of chronic liver
disease. He was counseled on harm reduction and abstinence was
advised.
INACTIVE ISSUES
===============
# Gout
-- Allopurinol ___ mg PO/NG DAILY
TRANSITION OF CARE
==================
-- He will need electrolytes checked around ___
-- Consideration of repeat stress with imaging to further
evaluate LAD lesion.
#CODE: Full
#CONTACT: Patient Wife ___ ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female presented to ___ with 6 days of
word finding difficulty. The patient reports that she initially
reached out to her long-time Psychologist report new-onset of
intermittent expressive aphasia, and he recommended that she see
her PCP for further workup. She then called her PCP, who was
booking out until ___, therefore her husband took her to
___ for further evaluation. At ___, she
underwent
a NCHCT that identified left frontal vasogenic edema, likely w
representing an underlying mass. She has not had any further
imaging, however she has a pacemaker (which will complicate
getting an MRI). She has no known primary cancer. She is
neurologically intact other than occasional WFD that she can
overcome when given pause to collect herself. CT HEAD W/O CONTRAST showed Stable appearance of the left frontal lesion with post biopsy changes and no
evidence of remote intracranial hemorrhage or complication. New hyperdensity
of the lesion is likely in part due to post biopsy hemorrhage and retained
contrast from the CT head from earlier today. CT HEAD W/ CONTRAST showed 3.7 cm peripherally enhancing lobulated lesion with central areas of necrosis
in the medial left frontal lobe surrounded by vasogenic edema. The lesion
extends into and perhaps across the corpus callosum. The most likely
diagnosis appears to be a glioblastoma. Metastasis is an alternate
possibility. Other potential diagnoses such as primitive neuroectodermal
tumor or a highly aggressive demyelinating lesion are less likely. CT abdomen and pelvis showed 1. No definite evidence of metastatic disease. A left adrenal nodule is not
well characterized, most commonly representative of an adenoma.
2. Mild diffuse renal cortical thinning bilaterally likely secondary to
medical renal disease. CT CHEST W/CONTRAST showed 1. No evidence of metastatic disease.
2. Heterogeneous 1.4 cm lesion in the right thyroid lobe. Recommend further
evaluation with thyroid ultrasound if not previously worked up.
3. Bullae are noted in the right lung.
4. Dilation of the main pulmonary artery up to 3.5 cm, suggesting pulmonary
arterial hypertension.
5. 9 mm left adrenal nodule statistically likely an adenoma.
6. Notable coronary artery calcifications. Radiology showed No radiographic evidence of acute cardiopulmonary disease. CT HEAD W/ CONTRAST showed Enhancing lobulated mass in the anteromedial left frontal lobe, stable since
prior. Most likely considerations are high-grade glioma or possibly
metastasis. PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD showed 1. Severely limited exam due to delete streak artifact from a metallic
surgical halo.
2. The known left medial frontal lobe mass is not clearly demonstrated on this
exam, but vasogenic edema can be seen in the left frontal lobe. The patient was diagnosed with Other specified disorders of brain. The patient was treated with ___ stereotactic brain biopsy. At the time of discharge, the patient had Left frontal brain lesion. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># Left frontal brain lesion
The patient was admitted on ___ and underwent workup for
a left frontal lesion. CT torso was negative for malignancy. She
was started on Keppra for seizure prophylaxis and Decadron for
cerebral edema. On ___, she underwent a stereotactic
brain biopsy of the lesion. The procedure was uncomplicated. For
further procedure details, please see separately dictated
operative report by Dr. ___. The patient was extubated in
the operating room and transported to the PACU for recovery.
Once stable, she was transferred to the ___ for close
neurological monitoring. Routine post-operative NCHCT showed
expected post-operative changes. On POD#___ontrolled, she was tolerating PO diet, and was transferred to
the floor in stable condition. Radiation and neuro oncology were
consulted. She was cleared for safe discharge to home on POD 2
with home ___ and home ___. She was given prescriptions and
follow up information. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is an ___ year old ___ woman with a history
of headaches presenting with 1 month of L sided weakness and
sensory changes. CHEST (PA AND LAT) showed No acute intrathoracic process. Radiology showed Normal brain MRI. No evidence of intracranial lesion. Radiology showed Normal cervical and thoracic spine MRI. No evidence of spinal mass or
demyelination. THYROID U.S. showed Subcentimeter bilateral thyroid nodules which do not demonstrate any
intrinsically worrisome features. Followup ultrasound in ___ year could be
performed to assess stability. The patient was diagnosed with MUSCSKEL SYMPT LIMB NEC. At the time of discharge, the patient had left sided weakness. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old ___ woman without significant past medical
history presenting with 1 month of L sided weakness and sensory
changes in her L arm and leg, as well as shooting pain in her
neck and down her L arm. Exam was notable for ___ weakness of
the L arm and leg and 60% decreased light touch on the L arm and
leg. She was admitted for expedited work up including MRI brain
and C spine. ___ preformed earlier this month showed no large
mass lesion so it was not repeated during her hospitalization.
In addition, she had some thyroid fullness on exam so thyroid
studies and a thyroid ultrasound was ordered. There was a delay
in obtaining the MRI studies. On the second day of admission,
the team was informed that the patient was in the middle of
finals (she had missed all her exams on ___ and ___. The
decision was made to discharge her per her request after getting
the MRI studies so she could attend the last day of finals on
___. A letter was provided to her to excuse her from finals
during the hospitalization (___). A ride with her
uncle was arranged to help facilitate this late discharge. She
was instructed to follow up with her outpatient neurologist, Dr
___ Office: ___ on ___ to get
the results of the MRI and to arrange the appropriate follow up.
An appointment was not scheduled as her discharge was after
office hours. The patient's uncle was contacted on ___ and
informed that the MRI was normal and showed no evidence of
masses, lesions, hemorrhages, or any other acute process. Her
left side had mild persistent weakness but otherwise she was
doing well and was able to complete her finals. He was again
instructed to contact the Neurology Office to arrange follow up
and the rest of the workup for her weakness as an outpatient. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ right-handed man presenting with on
the above in the context of hypertension and dyslipidemia. Radiology showed Large metastatic tumor centered in the frontal bone with
increased vasogenic edema in the left frontal lobe. Radiology showed Stable right hilar lung mass ,with post-obstructive consolidation
and mediastinal lymphadenopathy. Radiology showed 1. Lytic lesion in the frontal region with vasogenic edema is unchanged
compared to the prior CT of ___.
2. Although the superior sagittal sinus is not visualized in the anterior
most portion, this could be due to small size of the sinus or involvement of
the anterior most portion. Most of the portion of the superior sagittal sinus
is visualized and does not demonstrate any filling defect. The transverse
sinuses are patent. The deep venous system is also patent. Arterial
structures are normal. The patient was diagnosed with HEADACHE, SEC MAL NEO BRAIN/SPINE, MAL NEO BRONCH/LUNG NOS, HYPERTENSION NOS. The patient was treated with lumbar puncture. At the time of discharge, the patient had headache
frontal sinus neoplasm. The patient was given written instructions concerning 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 neurology service on ___.
Initial neurologic exam was intact throughout with no signs of
elevated ICP (venous pulsations visualized on fundoscopy, no
worsening of headache with pressure to jugular veins). CT head
showed stable appearance of largy lytic 3x6cm frontal sinus
mass. There was also increase in vasogenic edema in the L
frontal lobe with mass effect on the adjacent frontal horn of
the left lateral ventricle.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o ___ speaking only male w/PMH significant for EtOH/HCV
cirrhosis c/b varices, ascites, and HCC and polysubstance abuse,
IDDM, who recently was admitted in ___ for volume
overload/ascities in setting of known cirrosis ___ ___,
complicated by HCC. Of note patient left AMA during ___
admission.
The majority of the history is from ED notes and OMR as patient
is ___ speaking only.
Since ___ admission, patient had been presenting to ED every
___ weeks to get tapped per ed report.
Patient currently p/w increased abd pain and distension, scrotal
swelling. Also reports diff breathing. He comes to the ED weekly
to get tapped, has been leaking out of paracentesis site for 2
weeks.
He was seen by liver fellow who recommened admit to liver
service, diag para, and liver ultrasound, and infectiosu workup.
In the ED, initial vitals were: 8 97.8 82 159/80 18 100% ra
- Labs were significant for H/H 8.7/26.7, T bili 1.7, INR 1.5,
- RUQ U/S without PVT, showed moderate ascites. CXR with small
left pleural effusion.
Vitals prior to transfer were: 3 98.0 87 150/62 20 97% RA
Upon arrival to the floor, patient describes abdominal
distention but was able to walk to the bathroom. Chest: Frontal and lateral views showed Small left pleural effusion. Low lung volumes. Gaseous distention of the
stomach. DUPLEX DOP ABD/PEL LIMITED showed 1. No evidence for portal vein thrombosis.
2. Cirrhotic liver with multiple focal hypoechoic nodules, better assessed on
CT abdomen pelvis from ___.
3. Large volume ascites with splenomegaly. CHEST (PA AND LAT) showed A 5 mm nodular opacity at the right apex is stable dating back to ___ and likely represents a calcified granuloma. Nodular opacities at both
lung bases correspond to nipple shadows. Lungs are without focal airspace
consolidation to suggest pneumonia. No pulmonary edema or pneumothorax.
Blunting of the left costophrenic angle likely reflects small effusion.
Overall cardiac and mediastinal contours are stable. No pneumothorax. The patient was diagnosed with CIRRHOSIS OF LIVER NOS, HYPERTENSION NOS, DIABETES UNCOMPL JUVEN. The patient was treated with Paracentesis. At the time of discharge, the patient had Cirrhosis
Ascites. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo with HCV/EtOH Cirrhosis who has been getting paras in EDs
every ___ weeks here with worsening ascites.
# Ascites: Patient with tense ascites on admission and
complained of leaking from previous paracentesis site. He had
diagnostic paracentesis in ED which was negative for SBP. Also
had therapeutic paracentesis in house ___ with 6L removed. He
received 50 g albumin. Home diuretics were continued in house
but stopped on discharge as patient has very poor followup. He
is recommended to follow up with his hepatologist at ___
regularly if possible.
# Cirrhosis: Patient with alcoholic and HCV cirrhosis, Child C,
MELD 14 on admission. Complicated by ascites, hepatic
encephalopathy, and grade ___ varices on last EGD in ___. He
was continued on diuretics in house but will stop these on
discharge due to lack of follow up. His outpatient nadolol was
held given that this is contraindicated in patients with
ascites. His lactulose was continued. He will need outpatient
EGD as he is overdue.
# Alcohol abuse: Patient is heavy drinker but denied use in past
3 weeks. He was placed on CIWA protocol for withdrawal but did
not exhibit any symptoms. He was given multivitamin, thiamine,
and folate in house.
# IDDM: Continued on usual lantus 24 U qHS and insulin sliding
scale.
# Transitional issues:
[]Patient overdue for EGD and will require this as outpatient.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ yo M w/ PMH of CVA in ___ who
presents s/p fall with possible loss of consciousness at his
___ home. Per patient report he was just walking and
slipped and now its "this big deal". He denies any preceeding
chest pain, palpitations, lightheadedness, vision changes or
focal weakness. His transfer paperwork recorded his BP at the
time as 76/49 with a HR of 53 at 6pm. He was transferred to the
ER per request from his daughter.
On arrival tot he ___ ED initial VS were 97.4, 152/63, 16,
100%RA. His exam was notable for a ___ blowing systolic murmur
at the LUSB and his CXR showed a possible infiltatrate
concerning for pneumonia. CT head no evidence of acute
intracranial injury. encephalomalacia in left parietal lobe at
site of prior hemorrhage. And CT neck showed now fracture. He
was admitted for further workup for possible syncope.
On arrival to the floor he has no complaints and reports he is
"in perfect health". He denies any pain following the fall.
On ROS, denies headaches, vision changes, difficulty chewing or
swallowing. No chest pain, palpitations, dyspena on exertion,
cough, fevers, chills, abdominal pain, nausea, vomiting,.
changes in bowel moevements, hematochezia, melena, difficulty
urianting. He reprots walking on his own with no assistive
devices. Radiology showed 1. No evidence of acute intracranial injury.
2. Encephalomalacia in the left parietal lobe at the site of prior
hemorrhage. No new hemorrhage. Radiology showed 1. No acute fracture or malalignment.
2. Degenerative change. Disc osteophyte complex at C5-C6 mildly narrows the
canal and contacts the ventral cord. This can predispose to cord injury in
the setting of significant trauma. Radiology showed Vague perihilar opacity for which developing pneumonia versus
aspiration is a consideration. Short-term followup radiographs are suggested
to reassess in addition to correlation with clinical presentation. The patient was diagnosed with SYNCOPE AND COLLAPSE. At the time of discharge, the patient had 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>___ male with a history of HTN and CVA ___ who
presented after a fall.
.
# Fall: Reported BP of 76/49 with HR 53 around the time of his
fall. No preceding chest pain, lightheadedness, palpitations, or
any other symptoms. Patient denied LOC. In the ED, vitals were
stable and patient had normal EKG, CT head negative for acute
process, and CT neck showed no fracture. A ___ systolic murmur
was noted at the LUSB (documented previously). EKG did not show
evidence of acute ischemia and TTE was within normal. Although
suspicion was low for seizure, spot EEG was obtained given
history of CVA and was negative. On discharge, patient was
asymptomatic and hemodynamically stable.
# Hypertension - Per transfer log patient was documented as
being very hypotensive at his nursing home. Well-controlled
during admission on home amlodipine and lisinopril.
# Leukocytosis - 11.4 on admission, 7.3 the following morning. ?
pneumonia on admission CXR.
# S/p CVA in ___, pt with residual deficits including word
finding difficulty and right sided neglect. BP was controlled
with home amlodipine and lisinopril. We contacted the patient's
outpatient neurologist (Dr. ___, who will schedule an MRI
as outpatient.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ with history of asthma and
depression/anxiety who came from Ophthalmology clinic to ED with
left eye pain and swelling. The patient noted that her left eye
because increasingly edematous and painful over the course of
this past week with increasing conjunctival injection and
discharge. She was initially seen by her PCP who recommended
erythromycin ointment for conjunctivitis, but her symptoms
progressed. She was without fevers, chills, or GI symptoms. She
returned to ___ who concerned for orbital cellulitis,
so transferred patient to ED. In the ED, patient was afebrile. A
CT was obtained which demonstrated preseptal cellulitis and
concern for preseptal abscess. ENT was consulted given her
history of chronic sinusitis and concern for spread from
sinuses. She was started on vancomycin/ampicillin-sulbactam and
was given a dose of piperacillin-tazobactam. Radiology showed 1. Soft tissue swelling with a discrete fluid collection directly anterior to
the left globe, most consistent with pre-septal cellulitis and a small
pre-septal abscess. There is no evidence of post-septal or retrobulbar
cellulitis.
2. Mild sinus disease with thickening of the ethmoidal air cells and left
maxillary sinus. Radiology showed Stable radiographic appearance of the chest with no evidence of
hilar lymphadenopathy. Radiology showed Bilateral preseptal swelling and enhancement, left greater than right. No
evidence of abscess or other post septal abnormality. Radiology showed 1. No evidence of abscess or other fluid collection.
2. Multiple prominent cervical lymph nodes, greater on the left than right.
Though none of these is frankly enlarged by size criteria, they are increased
in number and likely reactive.
3. Enlarged, heterogeneous thyroid gland. Correlation to non urgent thyroid
function testing and thyroid sonography is recommended. Radiology showed Right PICC with tip at lower SVC. No acute cardiopulmonary process. The patient was diagnosed with CONJUNCTIVAL EDEMA, ORBITAL CELLULITIS. At the time of discharge, the patient had Primary diagnosis: Bilateral pre-septal cellulitis
Secondary diagnosis: asthma, depression, 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>The patient is a ___ with history of asthma and depression who
presented with pre-septal cellulitis treated with broad spectrum
IV antibiotics.
.
ACUTE ISSUE
# Pre-septal cellulitis: Patient with crusting of left eye
beginning ___ prior to admission without improvement with
erythromycin ointment and sent from ophtho's office to ED.
Unclear etiology, patient without history of bites, contact with
animals, allergens, or chemical. She was initially started on
vanc/amp-sulbactam after being seen by Ophthalmology and ENT and
initially her exam worsened so MRI was obtained to rule-out
orbital component. MRI demonstrated pre-septal cellulitis and ID
was consulted, who recommended switch to vanc/pip-tazo. Once
therapeutic on vancomycin clinical improvement was noted,
however due to changes in antibiotics, lack of cultured organism
or etiology of infection in addition to anatomical area of
infection, it was decided to continue with IV
vancomycin/pipercillin-tazobactam for total 10 day course of
pipercillin-tazobactam. She will be unable to administer these
antibiotics at home given neuropsych deficits and so will go to
___ for completion of antibiotic course.
.
CHRONIC ISSUES
# Asthma: History of asthma, well controlled and without issues
on this admission. She was continued on salmeterol-fluticasone,
albuterol.
.
# Depression: Med rec done with the help of PACT team, patient
restarted on buproprion 150mg. No acute issues during this
hospitalization.
.
# Chronic abdominal pain: Patient was continued on home
simethicone.
.
Transitional Issues:
- IMAGING FINDINGS: Enlarged, heterogeneous thyroid gland.
Correlation to non urgent thyroid function testing and thyroid
sonography is recommended.
- follow up with PCP, microcytic anemia and chronic issues
- Aunt ___ ___ ___ ___ and
RN ___
- psych: confirmed to be taking alprazolam daily as needed for
anxiety, she received 0.5 mg x1 with good result, and also
responded well to trazodone 25mg x1 on another occasion. could
consider switching to medication with less addictive potential
if appropriate
- follow up sleep study for positive pressure treatment</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ M with NICM with EF of 15% s/p AICD, CKD, HTN
and
abdominal hernias, discharged ___ from ___ after prolonged
hospitalization for hypotension/hypoxia requiring intubation and
pressors, now presenting with hematemesis. CHEST (PA AND LAT) showed Chronic interstitial abnormality with upper lobe predominance, most pronounced
within the left upper lobe, which on the prior chest CT was suggestive of
either sarcoidosis, chronic hypersensitivity pneumonitis, or NSIP.
Patchy opacities in the lung bases may reflect areas of atelectasis though
infection or aspiration are not excluded. The patient was diagnosed with GASTROINTEST HEMORR NOS. The patient was treated with EGD ___. At the time of discharge, the patient had UGIB, Esophagitis with Stricture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ M with NICM with EF of 15% s/p AICD, CKD, HTN
and abdominal hernias, discharged ___ from ___ after prolonged
hospitalization for hypotension/hypoxia requiring intubation and
pressors, now presenting with hematemesis.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with a history of psoriasis, heavy alcohol abuse ___
pints vodka daily), depression and PTSD, who presents
intoxicated, accompanied by her daughter, due to concern for
multiple fluid collections behind her ear and on her scalp. She
says that over the past several weeks, she has had severe scalp
pruritus. More recently, she has begun to noted fluid
collections
on her scalp and her left neck. She is also complaining of a 3
day history of dark urine, though she denies dysuria or abnormal
vaginal discharge. She complains of recent fluctuating
subjective
fevers/chills and intermittent diaphoresis which improves with
EtOH intake. MR HEAD W AND W/O CONTRAST T9112 MR HEAD. showed Mild involutional changes and nonspecific subcortical periventricular FLAIR
hyperintensities likely representative of chronic small vessel ischemic
changes. Otherwise unremarkable brain MRI. MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE. showed 1. Limited examination due to patient motion, within the limits of this exam,
there is evidence of mild to moderate multilevel, multifactorial degenerative
changes throughout the cervical spine, worse at the C4/C5 level, consistent
with spondylosis and disc bulging, causing moderate spinal canal stenosis, and
moderate right-sided neural foraminal narrowing..
2. No focal or diffuse lesions are visualized throughout the cervical spinal
cord. CHEST (AP AND LAT) showed No acute cardiopulmonary abnormality. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial process. The patient was diagnosed with Headache, Weakness. 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>Ms. ___ is a ___ yo female with a history of alcohol use
disorder who presented for concern of scalp pruritus, memory
issues, and left arm weakness who was admitted for alcohol
withdrawal monitoring.
#Alcohol abuse:
#Alcohol withdrawal:
#Subacute cognitive decline
#Thrombocytopenia
Ms. ___ was intoxicated on presentation to the Emergency
Department, and was noted to have an alcohol use history
concerning for impending withdrawal. Prior to admission, she
drank approximately one pint of vodka
daily and she presented 24 hours after her last drink. During
the admission, the patient was placed on CIWA. There were no
seizures during this admission. She was given folate, thiamine,
and a multivitamin. Social work was consulted, and the patient
was interested in attending AA meetings, for which she was
given information. The patient complained of memory issues on
admission, and neurology was consulted. She was evaluated for
infectious (HIV and syphilis) and metabolic (B12) causes of
cognitive decline, however these were negative. Chronic alcohol
use is likely contributing to subacute cognitive decline, and
changes were seen on CT head consistent with chronic alcohol
use. There was low clinical suspicion for Wernicke-Korsakoff
syndrome as the patient was very lucid and without neurologic
signs of nystagmus, tinnitus, and memory loss during her
hospital stay, which were initially seen on admission. On
discharge, the patient was not scoring on CIWA, and she was
interested in sobriety and pursuing Alcoholics Anonymous
meetings. The patient was provided information and handouts on
resources for alcohol sobriety.
#Scalp/post-auricular lesions
On admission, the exam was consistent with pruritus, and
excoriations with hemorrhagic crust. The patient endorsed
repeatedly picking at the lesions, and they are most likely
secondary to excoriation. The lesion
behind the patient's left ear is most consistent with scar. In
the setting of the patient's known history of psoriasis and
self-reported severe pruritus, these lesions could represent a
psoriasis flare; however, does not have classic psoriatic
appearance. Lack of drainage or tenderness suggests against
infection. The distribution of lesions did not suggest insect
infestation. The patient was given Fluocinolone solution daily
to scalp as needed pruritus, and the patient noted significant
improvement in symptoms. Discharged with plan for outpatient
dermatology followup.
#Left-sided weakness
#Left-sided numbness/tingling
The patient reported left sided numbness and tingling on
admission, present for unknown duration. The patient endorsed
falling on her left side 4 days prior to admission at home,
which was concerning for traumatic cause of symptoms. Neurology
was consulted for causes of left sided weakness and recommended
imaging and an infectious work up. MRI cervical spine was
consistent with spondylosis and disc bulging at the C4/C5
level, causing moderate spinal canal stenosis, and moderate
right-sided neural foraminal narrowing. MRI head with contrast
showed mild involutional changes and nonspecific subcortical
periventricular FLAIR hyperintensities likely representative of
chronic small vessel ischemic changes, but no evidence of upper
motor neuron damage. No focal or diffuse lesions were
visualized throughout the cervical spinal cord. The most likely
cause of this unilateral weakness was nerve palsy given history
of alcohol use with unknown associated downtime.
#Transaminitis:
The patient had elevated liver enzymes on admission. Given her
significant alcohol abuse history, the most likely cause was
component of alcoholic hepatitis, supported by transaminitis
pattern of 2:1 AST to ALT. Hepatitis serologies were negative
for hepatitis B and C, however, the patient does not appear to
be immune to Hepatitis B. Her transaminitis is suggestive of an
alcoholic pattern, though LFTs are not elevated enough to
suggest acute hepatitis. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of IDDM (c/b gastroparesis and neuropathy),
HTN, recurrent UTI ___ urethral diverticulum), gastroparesis,
obesity, and almost weekly admissions for intractable
nausea/vomiting and abdominal pain who presents for a similar
episode. She was just discharged from ___ on ___. She
experienced the onset of abdominal pain, nausea, vomiting and
inability to tolerate PO meds. History taking difficult at
present due to patient's pain. She does report taking her blood
pressure medications this AM. MRCP (MR ABD ___ showed Normal MRI of the abdomen. Specifically, normal examination of the pancreas.
No evidence of SMA syndrome. Radiology showed Successful placement of a double lumen chest power Port-a-cath via the left
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use. The patient was diagnosed with DIAB NEURO MANIF IDDM, GASTROPARESIS. The patient was treated with ___ - Femoral temporary CVL placement
___ - Port placement (double-lumen). At the time of discharge, the patient had Primary Diagnosis:
- Severe gastroparesis
Secondary Diagnosis
- Hypertensive urgency
- Mild Acute kidney injury
- Leukocytosis, stress-induced. The patient was given written instructions concerning 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 IDDM (c/b gastroparesis and neuropathy),
HTN, recurrent UTI ___ urethral diverticulum), and obesity
presented with acute-on-chronic abdominal pain, clinically
consistent with a gastroparesis flare.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ Year Old Female with recently discharged from Neurosurgery
___ for right meningioma resection who is readmitted from
___ rehab due to concerns for DVT and aspiration
pneumonia. During her recent hospitalization she suffered an
intracerebral hemorrhage with resultant left-sided weakness.
She ultimately underwent hematoma evacuation ___. Her remaining
deficit is Left leg paralysis and Left arm paresis; although
sensation is intact. Now can grasp left hand but cannot move
entire left arm or left leg. She also suffered a seizure
post-operatively; she was started on Keppra and Dilantin. No
more episodes since then. Radiology showed 1. Bibasilar airspace opacities, more severe in the retrocardiac region,
which could reflect areas of infection or aspiration.
2. Mild pulmonary vascular congestion. Small left pleural effusion. Radiology showed 1. No pulmonary embolism or acute aortic syndrome.
2. Lingular consolidation and bilateral lower lobe ground-glass opacity and
interstitial thickening consistent with pneumonia and superimposed cardiac
decompensation. There is a small-to-moderate-sized nonhemorrhagic left
pleural effusion. Bilateral hilar lymphadenopathy is likely reactive. Radiology showed No DVT of the bilateral lower extremities. Radiology showed Mild penetration with thin barium, but no aspiration with thin
barium and no penetration or aspiration with any other consistency of barium. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY. At the time of discharge, the patient had Pneumonia
Acute kidney injury
Diabetes mellitus type II
Hypertension
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>Ms. ___ is a ___ lady with recent admission to Neurosurgery
___ for right meningioma resection who is readmitted from
___ rehab with hypoxia, which improved with levo/flagyl
treatment for aspiration pneumonia.
# Aspiration Pneumonia/hypoxia: Identified on CXR and chest CT.
Patient also with cough. This is the most likely cause of her
hypoxia at ___. Aspiration seems likely given her recent
neurosurgery for meningioma removal and eating with a Dobhoff in
place. Legionella assay was negative. VTE was considered, but
chest CTA showed no evidence of PE, and LENIS were negative for
DVT. Given her recent hospitalization, full treatment for HCAP
was considered, but given her overall nontoxic appearance, she
was started on levofloxacin and flagyl and did not receive
vancomycin for MRSA coverage. O2 was successfully weaned off.
Plan 7 day course of levoquin/flagyl (last day ___.
# Acute Kidney Injury, Hyperkalemia: On arrival, Cr 1.3 was
above her baseline of 0.8-1.1 likely due to prerenal causes
given poor PO fluid intake and no tube feeds. K was 5.3 likely
due to ___, and her home lisinopril was held. IVF boluses were
given and hyperkalemia resolved. All medications, especially
levofloxacin and ranitidine, were renally dosed. Cr on
discharge was 1.1
# Recent meningioma resection: c/b ICH and left-sided weakness.
Neurosurgery was consulted and recommended tapering her
dexamethasone from 2MG Q6H to 2MG Q12H for ICP control. They
also recommended continued seizure prophylaxis with Phenytoin
and levetiracetam for seizure ppx given post-operative episode
of LUE shaking.
# Bacterial UTI: Pan-sensitive Proteus mirabilis was diagnosed
on ___, and she was started on Bactrim DS, which was
discontinued in the context of starting levofloxicin for
pneuomonia as described above.
# Type 2 Diabetes: Her blood glucose has been very difficult to
control in the setting of dexamethasone treatment for ICP
control. She was continued on her home doses of Glargine and NPH
and covered with a Humalog sliding scale. Metformin was
temporarily held given her ___ (see above) and recent IV
contrast load for chest CTA. Restarted on discharge.
# Hypertension: Her home doses of Amlodipine, HCTZ, and
Metoprolol tartrate were continued, and her home lisinopril was
held due to hyperkalemia as described above.
# Constipation: Her home doses of colace and senna were
continued, and she was started on miralax and dulcolax as
needed.
Transitional issues
- Full Code
- Follow up: Dr. ___
- Levofloxacin and Flagyl should be continued for a total of 7
days, ending on ___
- Consider restarting lisinopril as needed for BP, but potassium
should be monitored
- Metformin can be restarted given resolution ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with IDDM, CAD s/p CABG, HFrEF(30%), Alzheimer's, HTN, HLD
who presents for sore throat, cough, SOB, and chest pain. CHEST (AP upright AND LAT) showed As above. CT HEAD W/O CONTRAST showed 1. No acute intracranial process.
2. Age related involutional and small vessel ischemic changes are similar to
those seen on ___. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. 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>Mr. ___ is a ___ year old gentleman with IDDM, CAD s/p CABG,
HFrEF(30%), Alzheimer's, HTN, HLD who presented for sore throat,
cough, and chest discomfort. D-dimer was elevated, so VQ scan
was done, which was negative. ___ ultrasounds were negative. CXR
showed no pneumonia or pulmonary edema. Serial troponins and EKG
were negative for ischemia. Pain improved with GI cocktail
(maalox). Sore throat improved with cepacol lozenges.
# Atypical chest discomfort
# Shortness of breath
Likely GI in etiology given that it improved with Maalox.
Initially, unclear etiology and unfortunately, given dimentia,
patient is unable to give good history (occaisionally pleuritic,
not reproducible, "hole in chest," unknown if it feels similar
to prior MI, onset unclear). He has several risk factors that
are concerning for both MI (prior CABG, DM, HTN) as well as PE
(immobile, mild trace RLE edema). Therefore, broad workup was
completed: EKG without any significant change from prior and
troponin at baseline 0.02 x 3 with negative MB. D-dimer elevated
and ___ ultrasound negative. VQ scan was done and negative for
PE. No consolidation or pulmonary edema on CXR. Resolved with
Maalox. If continues to have pain, could consider outpatient
EGD.
# Sore throat/Viral URI
Likely viral pharyngitis/URI given onset over 4 days, associated
congestion, lack of fevers, lymphadenopathy, or exudates.
Cepacol scheduled and resulted in symptomatic improvement.
# Insulin dependent diabetes
# Hypoglycemia in ED
Blood glucose down to ___ before getting amp of D50 in ED.
Did get 32U in AM today of 70/30 and for last week has been on
32U in AM 26U in ___ per wife and perhaps this has contributed to
some of the changes noted. Kept on lower dose glargine and
sliding scale while in house and discharged on home insulin
dosing.
# Concern for atrial fibrillation
Per outpatient clinic note, patient EKG concerning for atrial
fibrillation. During this admission, and upon re-assessment, EKG
did not show atrial fibrillation. Multiple EKGs were done and
revealed sinus bradycardia with PR prolongation and no ischemic
changes. Telemetry was reviewed. There was no evidence of atrial
fibrillation on this admission. Could consider repeat EKG as
outpatient or holter monitor as outpatient if concerned for true
Afib.
# Chronic systolic CHF/HFrEF
No significant decompensation at this time. LVEF ___
TTE. Discharge weight ___ = 116kg(255lbs), admission weight
122kg but 119kg 3 weeks ago.
-- PRELOAD: continued Torsemide 20mg EOD and 10mg EOD
alternating
-- AFTERLOAD: no ___ d/t autonomic dysfunction with
hypotension
-- NEUROHORMONAL: no beta-blocker given autonomic dysfunction
-- continued aspirin and statin
# CAD - Continued aspirin and statin
# Alzheimer/Vascular Dementia c/b behavioral dysregulation and
depression - Continued home memantine and Seroquel qhs and prn
# Constipation - Miralax as needed
# Orthostatic hypotension - Last outpatient cardiology NP note
stopped Midodrine and thus not continued after arrived to the
floor, otherwise wife and our list updated
CHRONIC ISSUES:
# CKD: Cr 1.8 which is at his baseline
# Aortic stenosis: Not severe on dobutamine stress. Continue
monitoring as out-patient.
# OSA: Continued home CPAP ___. No desats on pulse ox
overnight.
# BPH: Continued home finasteride
===========================
TRANSITIONAL ISSUES
===========================
[ ] Pain resolved with Maalox. Could consider outpatient EGD if
persists.
[ ] There was no evidence of atrial fibrillation on this
admission. Could consider repeat EKG as outpatient or holter
monitor as outpatient if concerned.
# CODE: full confirmed, outpatient palliative care involved
# CONTACT: Wife ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx HTN, anxiety s/p jump out of car going ___ after
having a few alcoholic beverages this morning suffering
immediate pain in left ankle and inability to bear weight. No
HS/LOC. On presentation, ankle was found to be fractured and
dislocated. ED attempted reduction, though remains posteriorly
dislocated. Ortho no consulted for assessment and reduction.
Patient denies numbness, tingling in left lower extremity. No
pain in other extremities. TIB/FIB (AP AND LAT) LEFT showed Trimalleolar fracture dislocation. ANKLE (AP, MORTISE AND LAT) LEFT showed Trimalleolar fracture with subluxation of the talus at the tibiotalar joint. ANKLE (AP, MORTISE AND LAT) LEFT showed 1. Status post reduction of the tibiotalar dislocation, now in anatomic
alignment.
2. Distal tibial and fibular fractures. Radiology showed Comminuted fractures of the distal left tibia and fibula, detailed above.
Scattered punctate foci of subcutaneous emphysema. Radiology showed No acute cardiopulmonary process. ANKLE (AP, MORTISE AND LAT) LEFT was done. The patient was diagnosed with Displaced trimalleolar fracture of left lower leg, init, Fall on same level, unspecified, initial encounter. The patient was treated with L ankle ORIF ___. At the time of discharge, the patient had Left trimalleolar ankle fracture dislocation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have Left trimalleolar ankle fracture dislocation and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for ORIF Left ankle,
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 <<>>>>>>>>>>>>>>>> was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the LLE, and will be discharged on Lovenox 40mg QD for 4
weeks for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old gentleman, with a history of
hyperlipidemia, CAD s/p CABG, asthma, BPH, AF s/p successful
electrical cardioversion who presents with symptoms of
respiratory distress. CHEST (PORTABLE AP) showed Left base retrocardiac opacity may be due to atelectasis versus pneumonia.
Dedicated PA and lateral views would be helpful for further evaluation. CHEST (PA AND LAT) showed COMPARED TO PRIOR CHEST RADIOGRAPHS ___.
Small region of new consolidation in the right lung projects over the minor
fissure. There is also a small region of peripheral consolidation or tiny
right pleural effusion. Lateral view shows consolidation at one of the lung
bases, probably the right. All of these findings could be small areas of
pneumonia. Heart size is top- normal. There is no pulmonary edema. CT CHEST W/O CONTRAST showed 1. Severe purulent bronchitis, right lower lobe greater than left, responsible
for large scale consolidative atelectasis, but no pleural effusion.
Concurrent pneumonia is certainly possible.
2. Status post coronary artery bypass. Mild to moderate aortic valvular
calcification, hemodynamic significance indeterminate.
3. Tracheal shape associated with tracheobronchomalacia (not elicited by this
study).
RECOMMENDATION(S): Clinical evaluation for possible tracheal bronchomalacia
which may predispose to current bronchitis.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the ___ ___ at 3:47 ___, 5 minutes after discovery
of the findings. The patient was diagnosed with Flu due to unidentified influenza virus w oth resp manifest, Pneumonia, unspecified organism, Hypoxemia. At the time of discharge, the patient had Influenza
Bacterial pneumonia
Acute bronchitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old gentleman, with a history of hyperlipidemia, CAD s/p
CABG, asthma, BPH, AF s/p successful electrical cardioversion
who presents with symptoms of respiratory distress found to be
flu positive with multifocal pneumonia and bronchitis.
# HYPOXIA,
# INFLUENZA,
# MULTIFOCAL PNEUMONIA,
# PURULENT BRONCHITIS:
Patient's hypoxia likely a combination of having worsening flu
(confirmed at ___'s office) along with super-imposed bacterial
pneumonia and bronchitis. Patient was started on Tamiflu as an
outpatient, however given progression of symptoms he was covered
for strep with vancomycin, cefepime, and azithromycin. Patient
initially satting in high ___ on RA with improvement to mid
nineties on non-rebreather requiring ICU admission. With
antibiotics and cough suppressants he was transitioned to nasal
cannula without dyspnea or hypoxia. After three days of broad
spectrum antibiotics he was transitioned to levofloxacin for a
10 day total antibiotic course and five days of Tamiflu. He was
weaned to room air one day after transfer to the floor. He had
initially been planned for an 8 day course of antibiotics, but
he continued to have extremely rhonchorous breath sounds and had
one episode of hypoxia requiring 2L nasal cannula. His symptoms
always improved with chest ___ and nebulizers. Given slow
improvement, a chest CT was ordered. Preliminary read was
notable for bronchitis, however the final read (I will note that
I, ___, was not contacted regarding the updated
read, but was contacted for the preliminary read) noted findings
concerning for possible tracheobronchomalacia. However,
patient's symptoms dramatically improved over the following 36
hours and he his breath sounds and symptoms were much closer to
his baseline. He was ultimately discharged with nebulizers as
needed. His PCP, ___, was contacted regarding the
new findings of possible tracheobronchomalacia so that he could
consider further evaluation as an outpatient.
# COAGULOPATHY:
Patient admitted with INR of 4.4 in setting of warfarin for
Afib/flutter. Coextisting elevated was PTT also elevated
concerning for non-med effect and contribution from infection.
During initial hospital stay INR uptrended to 8 so he was given
vitamin K (2.5mg IV) which brought INR to 1.4. He was initiated
on a lower dose of warfarin than his typical home dose after
discussion with his outpatient ___ clinic. He is
scheduled to have an INR check on ___.
# ACUTE RENAL FAILURE:
Patient's creatinine elevated to 1.5 initially. Baseline of 1.0
in Atrius records. Likely secondary to pre-renal etiology from
poor PO intake in the setting of viral illness. His creatinine
normalized with gentle IVF and holding lisinopril. His home
lisinopril was restarted prior to discharge and was well
tolerated.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx HTN, kidney stones s/p L lithotripsy & stent removal this
morning ___ AM) transferred from ___ with L neck &
shoulder and abdominal pain w/ CT showing subcapsular hematoma
and hematoma around the spleen. Patient reports that patient
underwent L lithotripsy & stent removal this morning with
urology
at ___. The procedure was uncomplicated and the patient
was discharged home. Patient ate and then started to develop L
neck and shoulder, and chest pain for which 911 was called and
she was taken back to ___. Patient was tachy 160s and
given nitroglycerin. Patient endorses some nausea and a couple
episodes of NBNB emesis. Cardiac workup was conducted and
negative. Patient had CTA Chest which was negative for PE, but
demonstrated a subcapsular hematoma and hematoma around the
spleen. A CT A/P confirmed the subcapsular hematoma and hematoma
around the spleen and patient was transferred to ___ ED for
further management. Radiology showed Although no contrast extravasation was seen from the splenic artery, proximal
splenic embolization was performed with an 8 mm Amplatzer 4 plug because of
the large subcapsular splenic hematoma suggesting that to be the site of
bleed.
Initial right common femoral artery access was complicated by arterial
dissection of the right common femoral and external iliac arteries, therefore
splenic artery embolization was performed via left common femoral artery
access, after which balloon angioplasty of the right common femoral and
external iliac artery dissection flap was performed, resulting in only minimal
residual stenosis.
Bilateral ___ and DP pulses were palpable throughout the procedure, noting
weakening of the Right ___ and DP pulses after dissection was discovered until
soon after the right common femoral sheath was removed after which point
pulses were similar to preprocedure.
RECOMMENDATION(S): Recommend q2 hour pulse checks x 12 hours.
Recommend three-month course of aspirin 81 mg to prevent thrombosis of the
right external iliac and common femoral arteries. The patient was diagnosed with Accidental pnctr & lac of the spleen during oth procedure, 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 ___ splenic embolization. At the time of discharge, the patient had large splenic subcapsular hematoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to the ICU after undergoing ___
embolization due to her subcapsular hematoma on ___. She
received 1u pRBC initially for a hematocrit of 26.9. After the
procedure her hematocrit remained stable and on ___ ___ patient
was transferred to the floor. Patient's diet was advanced, on
___ patient was started on aspiring 81mg which she will take
for 3 months. On ___ patient was tolerating a regular diet,
all her post splenectomy vaccinations were received as well as
instructions of following up with her PCP for the pending
vaccinations in 8 weeks. She will follow with us in clinic in 10
days. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with history of L5
disc herniation, endometrial hyperplasia s/p D&C, migraines,
obesity, presenting with acute on chronic back pain. ANKLE (AP, MORTISE AND LAT) RIGHT showed Unremarkable right ankle radiographs. The patient was diagnosed with Other intervertebral disc displacement, lumbar region. The patient was treated with Lumbar epidural steroid injection ___. The patient was given written instructions concerning 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 history of L5
disc herniation, endometrial hyperplasia s/p D&C, migraines,
presenting with acute on chronic back pain.
#Acute on chronic back pain:
#Spinal stenosis:
#L5 radiculopathy: Chronic back pain has been present since
___, presented with acute worsening of back pain. MRI
___ showed stable L4-5 disc extrusion causing mass effect
on L5 root as well as spinal stenosis. Pain is more severe and
limiting mobility. Neurosurgery evaluated in ED and recommended
no acute surgical intervention. She received lumbar epidural
steroid injection with CPS on ___. Her home pain medications
were titrated to the following regimen:
- Cyclobenzaprine ___ mg TID PRN
- Gralise (gabapentin) 1500 mg qHS
- Ibuprofen 400 mg TID PRN
- Acetaminophen 650 mg QID PRN
- Lidocaine patch PRN
- Oxycodone ___ mg q6h PRN
- Diclofenac gel PRN
# Constipation: likely multifactorial from pain medication and
significant pain with straining. Discharged on aggressive bowel
regimen and discussed with patient importance of adhering to
bowel regimen
# Chronic rhinitis: continued home loratadine, pseudoephedrine
===================
TRANSITIONAL ISSUES
===================
[] Pain regimen as above. Discussed with patient and will
provide short narcotic script during acute flare. Reviewed risk
of gastritis, renal dysfunction with prolonged NSAID use.
Recommended limiting use of diclofenac gel to small body surface
area
[] Patient scheduled to follow up with outpatient pain provider
[] Patient evaluated by ___ and recommended for rehab, although
patient declined. Discharged with home ___, script for walker
#CODE: Full code (confirmed)
#CONTACT: ___ (husband), Phone: ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ lady with history of CVID on IVIG, HTN, R and
partial
L nephrectomies, diverticulitis s/p hemicolectomy, ACDF of C3-C7
w/ chronic myelomalacia ___ compression in ___, and L4-S1
laminectomy/posterior fusion who presented for recent fever and
persistent headache. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality. ART DUP EXT UP BILAT COMP showed Patent bilateral temporal arteries without sonographic evidence of temporal
arteritis. MR ___ WAND W/O CONTRAST T___ MR ___ SPINE. showed 1. Stable postoperative changes following C4-C7 ACDF, with unchanged vertebral
body heights and alignment.
2. Multilevel degenerative changes are most notable at C3-4 level, with
moderate canal narrowing, mild-to-moderate right and moderate left neural
foraminal narrowing.
3. Additional levels of neural foraminal narrowing are detailed above, most
notably at C6-7 with moderate to severe left and severe right neural foraminal
narrowing.
4. No definite areas of abnormal cord signal. Cord morphology is unchanged.
No evidence of abnormal enhancement after contrast administration. CT HEAD W/O CONTRAST Q111 CT HEAD. showed 1. No acute intracranial abnormality to explain left upper extremity weakness.
2. Unchanged subcortical hypodensities suggesting chronic vascular insults and
small vessel disease. Ventricles and sulci are age-appropriate.
RECOMMENDATION(S): If there is clinical concern related with acute or
subacute ischemic changes, correlation with MRI is advised. CHEST (PA AND LAT) showed Compared to chest radiographs since ___ most recently ___.
Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes
and pleural margins are normal.. Stabilization hardware projects over the
midline lower cervical spine The patient was diagnosed with Fever, unspecified, Headache. The patient was treated with Lumbar puncture
Occipital nerve block. At the time of discharge, the patient had PRIMARY DIAGNOSES:
-occipital neuralgia
-Viral upper respiratory illness
SECONDARY DIAGNOSES:
-mild intermittent exotropia
-Acute on chronic kidney disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman with history of CVID on IVIG, HTN, R and
partial L nephrectomies, diverticulitis s/p hemicolectomy, ACDF
of C3-C7 w/ chronic myelomalacia ___ compression in ___, and
L4-S1 laminectomy/posterior fusion who presented with fever and
persistent headache.
ACUTE ISSUES:
=============
#Headache secondary to occipital neuralgia
Patient presenting with a 5-day history of severe headache with
reported fever and fever to 102 on admission. Presented to the
ED on ___ for the same complaint and CTA head and neck at that
time with no abnormalities. CT abdomen on current admission
unremarkable. CSF WNL. CXR without consolidation. CRP normal
though ESR mildly elevated. MRI cervical spine showed stable
postoperative changes with no evidence of hardware infection.
Neurology was consulted and recommended an occipital nerve block
for treatment of presumptive occipital neuralgia.
#Fever secondary to viral illness
Patient presented with fever to 102 on admission. Developed
respiratory symptoms during hospitalization. CXR showed no
evidence of consolidation. No clear infectious symptoms except
headache as above. Patient had no leukocytosis. Blood, urine,
and CSF cultures were negative, and lyme antibody titer was
negative. Received levofloxacin ___ and ___ as only
antibiotics because of lack of localizing findings
(cough/hoarseness developed at end of hospitalization after
fever resolved) and given her history of c diff and numerous
drug allergies, no other antibiotics were given. Treated
supportively for presumptive viral illness.
# Normocytic Anemia
Baseline Hgb ___. Hgb 11.5 -> ___ s/p IVF (along with all other
cell lines) in ED for headache. Improved without intervention to
close to baseline.
# Acute on CKD, Stage II
Baseline Cr 1.0-1.1, received IVF for elevated Cr with
improvement.
CHRONIC ISSUES:
===============
# History of C diff
Patient on ppx abx s/p FMT. No ongoing diarrhea currently.
Continued home Vancomycin 125mg po BID
# Chronic Back Pain
Followed at pain clinic.
Continued tramadol, gabapentin, acetominophen
# Moderate Protein-Calorie Malnutrition
Continued Ensure and MVI w/ minerals
# CVID
On q4 weeks of IVIG, last dose ___.
# HTN
Continued home regimen of diltiazem, carvedilol, lisinopril
# Hyperlipidemia
Continued home rosuvastatin
# Hypothyroidism
Continued home synthroid
# OSA
Continued home BIPAP on home settings
# H/o Recurrent UTI
Continued fosfomycin suppression, 1 packet every 10 days.
>30 minutes spent on patient care and coordination on day of
discharge.
Transitional issues
- No medication changes
- Patient continues to have headaches at discharge, though she
received occipital nerve block very recently. She will follow up
with pain service and with neurology.
- Seen by Ophthalmology for intermittent eye pain and diplopia.
Thought to be ___ intermittent XT. Will follow up as outpatient
with Ophtho. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo female patient presents with acute on chronic back
pain. Her pain is primarily in the mid-thoracic spine and
radiates to the scapula. She presents to OSH today where work
up
and MRIs of thoracic and lumbar spine showed multiple spinal
lesions likely metastasis. There was a large T6/7 lesion with
severe cord compression and no signal change. She was
transferred to ___ for Neurosurgical intervention. She
complains of unsteady gait. She denies any weakness,
radiculopathy, paresthesias, or bladder/bowel incontinence. Of
note after chart review it appears she underwent a breast bx 2
weeks ago. He PCP notes state they were trying to get in touch
with her over the past 48 hours to discuss results that were
positive for breast CA. THORACIC SINGLE VIEW IN OR was done. Radiology showed Osseous metastatic disease, better assessed on recent thoracolumbar spine.
The metastases in the pelvis appear worse as described. No new metastatic
disease in the abdomen or pelvis. CT CHEST W/CONTRAST showed 1. Mediastinal lymph nodes are minimally larger compared to ___,
significance indeterminant.
2. No pulmonary nodules suspicious for metastasis.
3. Multilevel vertebral metastases and spinal contents were evaluated on
recent MR ___.
4. Multiple left breast masses and metastatic left axillary lymph nodes were
better evaluated at recent breast imaging and sampling.
5. Interval growth of multinodular goiter since ___ causes new,
rightward displacement of the trachea, but no appreciable narrowing. The patient was diagnosed with Disease of spinal cord, unspecified. The patient was treated with ___: T4-7 laminectomies for tumor resection. At the time of discharge, the patient had T6/7 lesions/cord compression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ ___ year old deaf female found to have multiple
spinal mets on work up of unsteady gait and back pain.
# Spinal lesions
She was taken to the OR on ___ for thoracic laminectomies and
resection of spinal tumor with Dr. ___. Procedure was
uncomplicated, please see operative report for full details.
Hemovac drain was placed intraoperatively. She was continued on
Decadron 4q6 x 48 hours postop. Drain removed on POD1. On POD3,
her ressing was removed and her incision was clean, dry, and
intact
# Breast cancer/Metastatic Disease
The patient's PCP had been trying to reach her to discuss recent
breast biopsy results that were positive for breast CA. The
patient will follow-up with Oncology after discharge for formal
staging, and ongoing management/treatment plan.
# Diabetes
Home metformin and insulin regimen were restarted.
# Mobility
The patient was seen by ___, who felt should would be appropriate
for discharge to home with a walker and home ___ services. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ hx of right breast cancer s/p taxol on ___ who
presents w/ nausea. Last night had a piece of pizza with a soda.
She susequently developed nausea, vomited x1, and prolonged
lightheadedness. Still feels nauseous/lightheadedness. No chest
pain, shortness of breath, fever/chills, abdominal pain,
diarrhea.
In the ED, VS were found to be 98.9 81 149/76 16 100% RA. She
was found to have an elevated WBC to 45.3, which was thought to
be due to neulasta, but the ED was not certain. Her BMP, U/A and
CXR were all WNL. She initially reported feeling 75% better
after receiving 1L IV NS and ondansetron 2mg IV x1. Blood
cultures x2 were send. She was thought to need additional
supportive care and surveillance as an inpatient. The ED
resident spoke to the Omed fellow, who agreed with admission for
observation.
On the medical floor, she reports having further emesis of
"spit". She reports her nausea is unchanged from when she first
presented. She reports an initial improvement with Zofran. She
denies hematemesis. She reports often having intermittent nausea
a few days following chemotherapy, but she felt her symptoms on
this occasion are more constant. She does report feeling hungry
since she hasn't eaten since yesterday and is amenable to trying
to eat.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Radiology showed No acute intrathoracic process. The patient was diagnosed with VOMITING, VERTIGO/DIZZINESS. At the time of discharge, the patient had Primary diagnosis:
Stage IIIA infiltrating carcinoma of right breast
Chemotherapy related nausea/vomiting
Constipation
Thrush
Hypertension
Secondary diagnoses:
Diabetes
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>___ w/ hx of Stage IIIA (pT1bN2aM0) infiltrating right breast
cancer s/p taxol (C2) on ___ who presents w/ nausea,
vomitting and lightheadedness and found to have leukocytosis,
thought to be ___ neulasta.
# Nausea with vomitting improved with symptomatic control. At
the time of discharge, she was eating full meals.
# Oro-pharyngeal thrush: Likely ___ immunosuppression from
recent chemo. She was started on Nystatin swish and swallow.
# Hypertension: New diagnosis. She has 4 separate high readings
in OMR. She was started on lisinopril 10mg daily. She should
have labs on next outpatient visit to make sure electrolytes and
renal function are stable.
# Leukocytosis: Likely ___ neulasta. U/A & CXR WNL. Blood
cultures no growth x2.
# Breast cancer: Follow - up scheduled.
# H/o DM2: Diet controlled.
# Constipation: Started on bowel regimen.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with history of ankylosing
spondylitis and uveitis presenting with knee pain and swelling. Radiology showed Bilateral joint effusion, much larger on the left than right. No acute
fracture. Small periarticular bony erosion adjacent to the left medial tibial
plateau. Mild osteoarthritis. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins.
Moderate subcutaneous edema throughout the medial right thigh. C-SPINE NON-TRAUMA ___ VIEWS showed Extensive ankylosis of the cervical spine without evidence of acute fracture. The patient was diagnosed with Polyarthritis, unspecified. The patient was treated with R knee aspiration and arthroscopic lavage. At the time of discharge, the patient had Primary:
Ankylosing spondylitis
Reactive 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>Mr. ___ is a ___ man with history of ankylosing
spondylitis and uveitis who presented with knee pain and
swelling likely secondary to reactive arthritis in the setting
of ankylosing spondylitis.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: In brief this is a ___ year old female with a past medical
history of pyelonephritis, chronic kidney disease, hypertension,
DVT now off warfarin due to GI bleeding and hemicolectomy for
diverticulitis/diverticular abscess presenting with 5 days of GI
symptoms. Radiology showed 1. No obstruction, diverticulitis or acute abdominal pathology to explain the
patient's pain.
2. Unchanged mild hydronephrosis in the left kidney. Status post right
nephrectomy.
3. Unchanged pancreatic cystic lesions, better evaluated on the recent MRI. Radiology showed Nonobstructive bowel gas pattern. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. At the time of discharge, the patient had Diagnosis:
Constipation
IBS
Secondary diagnoses:
Diverticulitis s/p recent hemocolectomy
HTN
CKD. The patient was given written instructions concerning 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 past medical history of
pyelonephritis, chronic kidney disease, hypertension, GI bleed
and hemicolectomy for diverticulitis/diverticular abscess
presenting with 5 days of GI symptoms.
ACUTE ISSUES
# Abdominal pain: Patient presented with LUQ pain, nausea and
vomiting, which had been progressively worsening for 5 days
prior to admission. She was not febrile, not tachycardic. No
sick contacts. No diarrhea. Last BM was one day prior to
admission. Colonoscopy during previous admission showed
significant circumferential erosions and ulcerations around
surgical anastomosis site, but this was thought to be unlikely
to explain her current pain, as this would correspond to more
right-sided pain. EGD during her last admission was
unremarkable. CT abdomen was performed in the ED, which revealed
prominent jejunal loops, thought to potentially represent
localized ileus vs early partial bowel obstruction. ACS was
consulted while the patient was in the ED, but they did not feel
that the patient required decompression or any further
intervention other than aggressive bowel regimen. The patient
was started on expansive bowel regimen with some improvement in
her abdominal pain, though her pain did not entirely resolve. As
such, other causes for LUQ pain were considered, including
pancreatitis. Lipase was just over the upper limit of normal,
but likely elevated in the setting of nausea and vomiting. Given
her increase in pain with eating, the patient's CT scan was
reviewed with radiology for evidence of mesenteric ischemia, but
the patient's vessels were widely patent throughout.
Additionally, no evidence of splenic infarct was noted. GI was
consulted, but could not elucidate any clear cause for her pain
other than constipation and/or IBS. Therefore the patient was
continued on her bowel regimen and dicyclomine was added for
treatment of possible IBS. The patient's nausea resolved by
discharge and the patient did not have any episodes of vomiting
while hospitalized. Her abdominal pain improved, but
unfortunately persisted. The patient will have close ___
with both PCP and GI to re-address this as an outpatient. The
patient was able to tolerate a low-residue diet prior to
discharge.
# History of recent LGIB: The patient's hematocrit was stable
during this admission. She denied any melena or BRBPR. On EGD
and colonoscopy on last admission no active bleeding was seen,
however, the patient was noted to have areas of ulceration and
erythema at the surgical anastomosis site in the colon that had
likely bled. Continued omeprazole 40 mg daily.
CHRONIC ISSUES
# History of NSVT: During her most recent admission, patient had
episode of 20 seconds of NSVT. In the presence of a structurally
normal heart, seen on most recent TTE, this was most likely a
benign phenomena. The patient's metoprolol succinate was
continued, but dose was increased to 100 mg PO daily (to
compensate for reduction in her diltiazem dose, discussed
further below). Patient wore her ___ of Hearts monitor
throughout the admission.
# HTN: Stable. The patient's diltiazem ER was reduced from 240
mg PO QD to 120 mg PO QD, given that this can cause
constipation. To compensate for this dose reduction, metoprolol
succinate was increased from 50 mg PO QD to 100 mg PO QD.
# CKD: The patient's creatinine upon admission was at baseline
(1.0). She is s/p right nephrectomy and is s/p partial left
nephrectomy for recurrent pyelonephritis. At the time of
discharge, patient's Cr had increased to 1.2, likely secondary
to her general poor PO intake during much of her stay. She was
encouraged to drink plenty of fluids upon discharge. Cr should
be re-checked at her ___ PCP appointment to ensure that it
is trending down.
# Recurrent UTIs: UA and culture w/o evidence of active
infection. Continued weekly fosfomycin.
# Hypothyroidism: Stable. Continued levothyroxine Sodium 88 mcg
PO QD.
# HLD: Stable. Continued rosuvastatin.
TRANSITIONAL ISSUES
- Creatinine had been uptrending at discharge, likely ___ to ___
in the setting of poor PO intake. Patient was encouraged to eat
and drink, per usual. Please ___ Cr at PCP ___ to
ensure that it down-trends.
- F/u ___ of Hearts monitor results w/ cardiologist
- Pt now on diltiazem ER 120 mg PO QD and metoprolol XL 100 mg
PO QD, change from prior
- Pt started on dicyclomine 20 mg PO QID to take 30 min prior to
meals and before bed</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ ___ y/o F w/ PMHx of CKD from polycystic kidney
disease diabetes, hypertension, and coagulopathy admitted for R
flank and abdominal pain and ___ concerning for recurrent cyst
rupture. Patient blood chemistries indicated a need for
semi-urgent dialysis. Patient was dialyzed on day 3 of
admission. Dialysis access was c/b supratherapeutic INR on
admission requiring initial placement of temp left IJ dialysis
line followed by left tunneled dialysis line on ___ once her INR
<2.0. Radiology showed Successful placement of a left internal jugular approach triple lumen
temporary 20 cm Trialysis catheter. The line is ready to use. Radiology showed Successful placement of a 23 cm tip to cuff tunneled dialysis line. The tip
of the catheter terminates in the right atrium. The catheter is ready for use. CHEST (PA AND LAT) showed No acute intrathoracic process. RENAL U.S. showed Enlarged polycystic kidneys bilaterally with innumerable cysts, which markedly
limits evaluation, though no gross signs of hydronephrosis. The patient was diagnosed with Acute kidney failure, unspecified. The patient was treated with Left IJ dialysis cath (temporary)
Left tunneled dialysis line
Dialysis initiation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ ___ y/o F w/ PMHx of CKD from polycystic kidney
disease diabetes, hypertension, and coagulopathy admitted for R
flank and abdominal pain and ___ concerning for recurrent cyst
rupture. Patient blood chemistries indicated a need for
semi-urgent dialysis. Patient was dialyzed on day 3 of
admission. Dialysis access was c/b supratherapeutic INR on
admission requiring initial placement of temp left IJ dialysis
line followed by left tunneled dialysis line on ___ once her INR
<2.0.
Acute medical issues addressed
___ on CKD V
#Anuric Renal failure
Patient presented to OSH w/ R flank and abd pain. Labs reported
from OSH revealed a Cr of 9.83 and BUN of 87. Renal U/S
unremarkable. Presentation concerning for renal cyst rupture.
Patient transferred to ___ for question of need for RRT.
Patient required access for initiation of dialysis, this was c/b
a supratherapeutic INR of 4.8. At this time, patient sent for
temporary IJ dialysis access ___ and dialysis was initiated the
following day ___. Dialysis initiation planned for ___nd was completed ___. Tunneled line placed on ___.
#Coagulopathy of undetermined etiology
Patient has a history of blood clots when sub-therapeutic.
Required argatroban bridging while in hospital to prevent
recurrent blood clotting. Ultimately, it was decided that since
the history of HIT is so remote, argatroban bridging was not
needed and she could be discharged on her home dose of warfarin.
#Metabolic derangement
Developed typical chemical sequelae of renal failure with
elevated Cr, Phos, K, BUN and a low bicarb. Also developed AGMA,
all of which resolved following HD.
Chronic issues managed
=======================
# Diabetes
Takes 60u of premixed 70/30 qam and qpm. Converted to Lantus and
dose-reducing given poor PO intake.
# Hypertension
- Continued amlodipine 10mg nightly
# Anemia:
-Hb at goal, did not require EPO
# HLD
Reportedly intolerant of statins. Did not start a statin.
# Tobacco use
- Nicotine patch
Transitional issues
#Transplant w/u
- PFTs
- Chest CT to rule out lung cancer
- Hematology evaluation at ___
- MRI head if not done in past ___ years
- Echo and Stress with imaging done at ___
- Smoking cessation
# CODE: full (presumed)
# CONTACT: ___
Relationship: Friend
Phone number: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female, with schizophrenia, who
presented to the ED, after her PCP was alarmed by her
deficiencies in ADLs for several weeks. Chest: Frontal and lateral views showed No acute cardiopulmonary process. Radiology showed As above. THYROID U.S. showed Multinodular gland. FNA is recommended of the dominant nodule in the left
lobefor further characterization.
RECOMMENDATION(S): Recommend FNA for further characterization. The patient was diagnosed with Hypokalemia. At the time of discharge, the patient had =======================
PRIMARY DIAGNOSIS
=======================
Refeeding syndrome
Hyperthyroidism w/ Thyroid Nodules ( Dx to be confirmed)
Hypovolemia
Hypokalemia
Hypomagnesemia
Hypophosphatemia
Lactic acidosis
Sinus Tachycardia
Malnutrition
=======================
SECONDARY DIAGNOSIS
=======================
Type II Diabetes
GERD
Melena
Vaginal Bleeding
Undifferentiated psychosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>============================
BRIEF SUMMARY
============================
Ms ___ is a ___ year old F, with schizophrenia, who presented
to the ED with deficiencies in activities of daily living
(eating , nonadherence to medications, ambulation), attributed
to her psychotic beliefs, and who was admitted for failure to
thrive, tachycardia, and repletion of electrolytes in setting of
risk for refeeding syndrome. While she was persistent in
wanting to see her daughter, she was responsive to verbal
redirection and Social Work letting her know that her daughter
is okay.
Her tachycardia was responsive to fluids and her lactate and
electrolytes responded to repletion, except for phosphate, which
is near normal. Given her persistent intermittent tachycardia,
after adequate hydration, and her history of night sweats,
diarrhea, weight loss, we pursued work-up for hyperthyroidism.
Her TFTs were consistent with this diagnosis, and an U/S
received multiple complex nodules.
Her psychiatric symptoms did not cause interference with her
medical care, and she was not on any psychiatric medication
during this time. She was on ___, and calm with a 1:1
sitter throughout her stay, although she was agitated about
wanting to see her daughter with autism. She was able to respond
to verbal redirection.
============================
PROBLEM-BASED SUMMARY
============================
# TFT derangements.
# Thyroid nodule.
Patient was found to have thyroid nodules on exam, and further
work-up revealed complex nodules. Differential includes toxic
multinodular adenoma, Graves disease, subacute thyroiditis,
thyroid cancer, "hot nodule". Her hyperthyroidism could have
precipated her exacerbation of psychiatric symptoms. A formal
endocrine consult was placed. She was started on pronolol.
Methimazole was deferred given uncertainty about the diagnosis
per endocrine (unclear if thyroiditis versus Graves). TSI and
anti TPO pending at time of discharge. She will follow up with
endocrine as outpatient for further imaging, likely with thyroid
uptake, repeat TFTs, and consideration of FNA.
#Agitation. Patient was persistent in wanting to see daughter
with autism , but was responsive to verbal redirection without
psychiatric medications. She had a 1:1 sitter throughout her
hospital course. Social work could not facilitate contact with
her daughter with autism until Department of Developmental
___ approved it. However, Social work was able to let her
know that her daughter was okay.
# Electrolyte imbalance.
# Concern for Refeeding Syndrome.
# Hypokalemia
# Hypomagnesemia
# Hypophosphatemia
# Lactic acidosis
# Malnutrition
Patient has had poor PO intake for several months, resulting in
hypokalemia and hypomagnesemia, hypophosphatemia. Her lactate
elevations was likely from her severe dehydration, and this
normalized with hydration. Her electrolytes responded to
repletion efforts. An increased anion gap, likely from lactic
acidosis, resolved. She was on a diabetic diet, and given
thiamine, folate, MV. She was placed on a telemetry given
cardiac risk in setting of electrolyte imbalance.
# Sinus Tachycardia.
#Prolonged QTc
The patient's tachycardia persisted after fluid resuscitation
,prompting TFTs which revealed a hyperthyroidism. Her QTc was
originally prolonged but responded to electrolyte repletion. She
was placed on telemetry throughout her hospital stay and she was
in sinus rhythm. Her hyperthyroidism is consistent with her
previous intermittent night sweats and diarrhea.
#Epigastric Pain
She reported epigastric pain that was more consistent with
GERD/gastritis versus hunger pains. She was ruled out for
cardiac ischemia. She was placed on pantoprazole 40mg PO, and
then ranitidine, and was given food, all of which resolved her
pain. She would not let us guiaic test her stool though she
denied any melena during her stay.
#Anemia
The patient had a Hct drop from 40.9 to 31.0 over ___, but
her Hct was stable for the remainder of her stay, and she was
HDS. As such, this drop was likely dilutional, but given her
reports of melena, this was possibly a GI bleed. Could also be
from vaginal bleeding given she said she started vaginal
bleeding around the time of her hospital stay. Her iron studies
did not demonstrate iron deficiency.
# Diabetes. Her most recent HbA1c prior to admission was
___: %HbA1c: 9.7 Repeat HbA1c was 8.3 here. She was
followed previously by the ___ her diabetes,
but an outreach call placed in ___, resulted in the patient
refusing to come in. She was placed on a diabetic diet, ___ and
prescribed metformin for followup.
#Deconditioning.
Patient had prior to admission and in the ED not been able to
ambulate due to deconditioning and possible command
hallucinations. Since arrival to the inpatient floor, the
patient has expressed willingness to ambulate with a walker. She
had good strength on exam and no focal neuro signs on admission.
She regained her strength, and the patient was able to ambulate
independently ___.
#Constipation. The patient reported a history of constipation,
but had good bowel movements on admission with colace/senna. Her
KUB was not significant for copious stool.
# Vaginal bleeding:
She provided clarification later that she was going through
menopause, although she described this as intermittent bleeding
in between her periods for ___ years.She has not previously had
a hysterectomy, but in the context of a history of endometriosis
and uterine fibroids, we recommend followup with GYN as
outpatient.
#Schizophrenia. Patient has not been taking her psychiatric
medications (Risperdal, klonopin) for years, and is experiencing
acute decompensation of her psychiatric condition. She was
placed on Section 12a by Psychiatry and had a 1:1 sitter, and
was seen by Psychiatry almost daily. She had auditory/command
hallucinations throughout her stay. She does not have SI/HI.
Social work was consulted.
#Nausea, history of emesis
Patient endorses nausea, even without eating food. However, did
not had emesis while in the ED/hospital.
============================
TRANSITIONAL ISSUES
============================
[ ] Endocrine appointment (please schedule in ___ weeks with Dr.
___
-Hyperthyroid disease likely Graves vs. subacute thyroiditis
Get a radioactive iodine uptake and scan (with repeated TFTs).
If decreased
uptake, will need FNA.
TSI and TPO antibodies pending
[ ] PCP: needs to follow with PCP for propranolol titration,
uptitration of metformin
[ ] Given abd pain, and report of dark stools, consider work-up
of dark stools if
persistent, including with guaiac testing
[ ] Nutrition recs: MV with minerals, glucerna shakes BID for
nutrition
[ ] ___: Diabetes
[ ] GYN: Recommend follow-up with GYN re intermittent vaginal
bleeding, that may or may not be ___ </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 metastatic
renal cell cancer s/p surgery and radiation therapy but no
systemic therapy, atrial fibrillation, and hypertension who
presents with altered mental status found to have severe
hypercalcemia. CHEST (AP AND LAT) showed No acute intrathoracic process. CT HEAD W/O CONTRAST showed 1. No acute intracranial process.
2. Probable tiny right parafalcine meningioma. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormality.
2. Unchanged, small, probable right parafalcine meningioma. UNILAT UP EXT VEINS US LEFT showed No evidence of deep vein thrombosis in the left upper extremity. MR HEAD W/O CONTRAST T9113 MR HEAD showed 1. Diffusion-weighted image is markedly degraded by motion, within limitations
of this study there is no evidence of acute infarction. Radiology showed Low bilateral lung volumes and bibasilar opacities which likely reflect a
combination of pleural fluid and atelectasis. Superimposed pneumonia however
would be hard to exclude given the provided clinical history. SHOULDER 1 VIEW LEFT showed Lytic lesion within the left mid humeral diaphysis as well as nonvisualization
of parts of the left scapula. These findings are concerning for metastatic
disease. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ and ___.
Left lower lobe is still airless, accompanied by increasing moderate left
pleural effusion. Moderate atelectasis at the right lung base, is unchanged
although lung volumes have improved. Heart size normal. No pneumothorax.
Right pleural effusions small if any. No pulmonary edema. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had Hypercalcemia
Renal Cell carcinoma with bone mets
Concern for brain mets
Sacral decubitus ulceration
Afib with RVR
Hypotension
Hypoalbuminemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w metastatic RCC s/p surgery/XRT without systemic therapy,
pAF on AC, HTN p/w AMS I/s/o hypercalcemia, also with focal
neuro deficits c/f CNS lesion/met.
# toxic metabolic encephalopathy: progressive over a week per
wife on admission, improved somewhat with mgmt of calcium,
associated with constipation and hypovolemia, suggesting
originally that hypocalcemia is the primary driver. However,
focal neuro findings raise c/f CNS lesion (left lower facial
droop) (e.g. RCC met). CT head negative for bleed or obvious
space occupying lesion, MRI attempted but unable to sit still
for MRI. Apixaban held due to concern for possible RCC brain
mets. Exam/UA/CXR/BCx all reassuring against infection as a
cause. Although with fever on ___ with increased respiratory
rate. Labs reassuring and patient had increased somnolence that
day due to starting fentanyl patch trying to treat pain if that
was causing delirium. Concern for aspiration pneumonitis and
then added antibiotics when patient spiked fever overnight -
antibiotics on for 24 hours without improvement (Zosyn) on ___
- pt MRSA negative. Without improvement in mental status or
white count to ensure patient not acutely infected, discussed
with oncology who suggested treatment with dexamethasone
empirically for possible brain mets at this time. Within 6 hours
of dex, mental status clearning, by the AM patient almost 100%
at baseline. At that time Dex was continued 4mg q6h - and today
was transitioned to 4mg PO BID. At this time, unsure exactly
what caused altered status - most likely multifactorial from
calcium and ? Brain mets.
However he remained inattentive and sleepy with poor sleep wake
cycle. He has continued confusional state on discharge
# Hypercalcemia: very likely ___ malignancy with bone mets. PTH
appropriately low, UPEP neg, SPEP positive, but may not be
significant, vit D wnl, ___ D low, and PTrP high, TSH wnl.
Improved with aggressive IVF, received pamidronate and
calcitonin in ED on ___ with abrupt response and at time of
transition still downtrending. Most recently 6.7 with correction
to 8.4. Patient required 1 dose of calcium gluconate ___ prior
to transfer with concern that Ca+ low normal still downtrending.
His ionized calcium was <1 on ___ and he received 2gm IV ca
gluconate and may need additional calcium repletion
# renal cell carcinoma
# bone mets
# chronic pain
S/p surgery/XRT, has not started taking his systemic therapy
yet. Note that family has expressed some thoughts about
considering transitioning goals, but per discussion with
oncology there are still good options and he may derive good
benefit. Particularly since the hypercalcemia is likely an acute
and reversible
problem, trying to treat this acute problem before making any
major decisions seems to make sense. Given weakness/numbness on
L side, concern for CNS met despite negative CT, was not able to
tolerate MRI. At time of transfer, Oncology here is still
recommending head imaging MRI to evaluate for metastases - but
unable to perform due to need for sedation due to
claustrophobia. Also discussion about starting some sort of
therapy for patient in the future to see if he can tolerate side
effects. Discussed with family at bedside on ___. Oncologist
seeing patient here was Dr. ___ and is happy to
discuss patient with other providers.
# Extensive bone metastases - Did not receive radiation therapy
here. Consulted Radiation oncology incase transfer was not able
to be arranged for pain treatment while inpatient.
# AFib: CHADS2VaSC=2 most likely, 2.2% risk of CVA. Given
probability of RCC met, this is very high risk for CNS bleed, so
apixaban was held.
- Continued home dilt (fractionated) until 3 days ago. Has been
held due to hypotension thought to be ___ low albumin (1.8) due
to poor PO intake for the last month + 1 week of Altered status
with us. Patient's family declined NG feeding while inpatient.
Has episodes of RVR with movement, with some intermittent use of
IV diltiazem and transition to fractionaed diltiazem now at 60mg
q6h
# anemia: acute on chronic, responded to PRBC x1. Hgb stable in
Mid-7s.
# BPH: continued home doxazosin
# RBBB: unknown baseline
# Goals of Care: patient is not interested in living his life
with significant side effects from treatment for his RCC. At
this time though has not tried any treatment to determine if the
side effects are worth the benefit. Tried to address code status
with wife prior to patient's mental status improving, but
unfortunately caused quite a bit of distress. Palliative care
involved during inpatient stay here and had a great conversation
with patient once he woke up. Established patient as DNR/DNI -
unfortunately ___ (wife) was not able to be at bedside due to
her being in ___. It may be nice to continue to address
these goals going forward with family to ensure everyone is on
the same page.
=======
TRANSITIONAL ISSUES
- Hypercalcemia - has not reach nadir
- Pain - Will need XRT for multiple lesions
- decubitus Ulcer - Wound care with Mepilex
- Debility - Loss of strength due to 1 week hospitalization.
Will need to be re-evaled by ___ now that awake and more able to
participate in care. Currently slated for Rehab vs. SNF pending
further treatments by them
- Speech - Patient currently on Ground with Thin liquids 1:1
supervision. Patient dislikes this diet and would like to be
advanced as possible.
- Control of Afib with RVR in the future if continue to hold
dilt
- Nutrition status - poor PO intake for about 1 month prior to
admission
- MRI Brain for Metastasis
- plan for o/p TKI inhibitor start once mental status improves,
and then possible immunotherapy
- cont to address goals of care with patient, family, oncology,
social work
- will eventually need iron but hold off for constipation effect
for now
- consider TTE given RBBB
- Contacts: ___ (wife) ___
High risk of adverse outcomes given extensive metastasis,
neurological encephalopathy, rapid afib and continued
tachycardia, and cancer pain.
I discussed case with accepting physician at ___ in
___, Dr. ___ ___ on ___.
Family's priority was to have him return to ___ where he can be
closer to his wife and family supports.
Medically stable for transfer to ___ in ___
>30min on care coordination.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH multiple spine surgeries and history of prior fall with
splenic laceration presents s/p mechanical fall from standing
earlier today. Patient reports +headstrike with +LOC. He is not
on anticoagulation. Only complaint is tenderness over the
mid-thoracic spine and scalp pain. Injuries notable for scalp
laceration, bilateral occipital condyle fractures, and T3
compression fracture with retropulsion. He denies any chest
pain, shortness of breaht, pain with inspiration, weakness,
dizziness, urinary or fecal incontinence. MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE showed Please take note of bilateral occipital condylar fractures which was better
seen on prior CT.
Wedge-type compression fracture of the T3 vertebral body with less than 50%
loss of anterior vertebral body height. There is a small fragment protruding
posteriorly by 2 mm into the spinal canal, but there is no abnormal spinal
cord signal. There is still ample CSF present posterior to the cord at this
level. There is mild irregularity of the anterior longitudinal ligament at
this level which suggests ligamentous disruption. The posterior longitudinal
ligament and ligamentum flavum appears intact.
There is mild linear STIR hyperintense and T1 hypointense signal changes in
the posterior aspect of the superior endplate of C7 which may represent a
trabecular microfracture or in the differential diagnosis consider ___ type
1 degenerative changes.
Moderate degenerative changes of the cervical spine which is difficult to
assess due to motion artifact with no evidence of cord compromise in the
spinal canal. Neural foraminal narrowing as described above. T-SPINE showed The upper thoracic spine is difficult to visualize on the lateral view given
overlap of structures however there is suggestion of mild height loss of the
T3 vertebral body as seen on the prior MR and CT examination. Kyphoplasty
change of L1 is seen. There is no new gross vertebral body height loss or
alignment abnormality. Moderate multilevel degenerative changes are again
seen. The frontal view is degraded by overlapping brace device. The patient was diagnosed with Laceration without foreign body of scalp, initial encounter, Unspecified fall, initial encounter. The patient was treated with ___: galeal defect repaired with 6.0 vicryl x6; scalp lac
repaired with 4.0 ethilon x12. At the time of discharge, the patient had T3 compression fx w/ 2mm retropulsion
Occipital condylar fx. The patient was given written instructions concerning 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 ___ multiple spine surgeries and
history of prior fall with
splenic laceration who presented to ___ this admission s/p
mechanical fall from standing. The patient reported +headstrike
with +LOC. Injuries were notable for a scalp laceration,
bilateral occipital condyle fractures, and a T3 compression
fracture with retropulsion. His head laceration was sutured in
the ED. The Orthopedic Spine service evaluated the patient for
his occipital and T3 compression fracture and recommended
non-operative management with a rigid external orthosis and a
CTO brace was ordered.
On HD2, the patient was noticed by his wife to have a left eye
lid droop, left lip droop, and hoarseness of voice, and
Neurology was consulted to evaluate for TIA or stroke. The
patient's symptoms resolved and were thought to be positional
due to his brace. There was not a high suspicion for TIA or
stroke and CTA head/neck was not deemed necessary unless
symptoms return. This was discussed with the wife who was in
agreement.
The patient worked with Physical Therapy and it was recommended
that he be discharged home with home ___. The patient remained
stable from a cardiovascular standpoint; vital signs were
routinely monitored. Pain was well-controlled with
acetaminophen and tramadol. The patient received subcutaneous
heparin for DVT prophylaxis. At the time of discharge, the
patient was hemodynamically stable, tolerating a diet and pain
was controlled on oral pain medication. The discharge
instructions were reviewed with the patient with understanding
verbalized. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with PMH of ESRD ___ diabetes
on HD (___) and on transplant list who presents with 3 days
of melena and BRBPR. He started to have melena on ___
after his regular dialysis session. Stool was mixed with bright
red blood. He had 3 episodes of melena and bleeding on ___,
about ___ episodes on ___ and ___ episodes today. Patient
also reports associated crampy abdominal pain in the LLQ. After
passing the melena this morning, per the patient's wife, he
became light-headed and appeared to pass-out. He denies any
hematemesis, nausea and vomiting. No fevers or chills. Patient
does not have any ETOH history and no liver disease. He takes
81mg aspirin daily otherwise not anticoagulated. He had an EGD
and colonoscopy in ___ last year for work-up of anemia and
iron deficiency anemia which demonstrated old blood in the
stomach without a focal source of bleeding in association with
gastritis. This was felt to represent hemorrhagic gastritis.
Colonoscopy demonstrated diffuse diverticulosis and small
internal hemorrhoids without active bleeding source. No
h-pylori. Radiology showed 1. Significant sigmoid diverticulosis without evidence of diverticulitis.
2. No evidence of significant blood product within the lumen of the bowel to
suggest significant GI bleed. No evidence of hematoma within the abdomen or
pelvis.
3. Multiple peripheral hypodensities and some contour abnormalities in both
kidneys may represent underlying chronic renal disease. However, underlying
pyelonephritis should be clinically excluded. Incompletely distended urinary
bladder limits evaluation for underlying wall thickening, cystitis should also
be clinically excluded.
4. Mild prominence of the distal common bile duct. Status post
cholecystectomy. Recommend correlation with LFTs. A small duodenal
diverticulum is noted near the distal common bile duct.
5. Marked atherosclerotic disease as noted above, most notably involving the
common iliac artery branches, bilateral renal arteries and ___. The patient was diagnosed with MELENA, SHOCK W/O TRAUMA NEC, END STAGE RENAL DISEASE. The patient was treated with - EGD
- Partial colonoscopy
- Dialysis. At the time of discharge, the patient had Primary Diagnosis:
Gastrointestinal bleeding: Unspecified location
Anemia
Hypotension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ male with PMH of ESRD ___ diabetes on HD (___)
and on transplant list who presented with 3 days of melena and
BRBPR.
# GI Bleeding: Patient presented with blood diarrhea with HCT
drop from 34 to 21. He was hemodynamically stable. He received
total 4 pRBCs in the MICU. He was evaluated by GI who performed
EGD which was normal. Colonoscopy (up to splenic flexure;
aborted due to patient discomfort) was also performed which
showed blood in the sigmoid colon but no active extravasation.
His bloody diarrhea was felt to be possibly secondary to his
diverticulosis. His post EGD/colonoscopy hematocrit remained
stable and he was transferred to the floor where he remained
stable for 40hrs. He was recommended to stay for another day of
observation but strongly preferred leaving. He was told about
warning signs and to immediately seek care if any signs/symptoms
of bleeding. He should have a Hct drawn at dialysis on ___
and faxed to PCP ___. He will receive a follow up
colonoscopy with MAC anesthesia as well as a capsule endoscopy
if no source of bleeding is discovered. He is at higher risk for
small bowel AVMs given he is on dialysis. Small bowel AVM would
more appropriately explain reported melena. Hemorrhoids seem
unlikely for such large amount of bleed. He was hemodynamically
stable upon discharge. ASA was held given bleed and use for
primary prevention. This can be discussed with PCP. Of note, GI
did recommend that the patient undergo colonoscopy +/- capsule
endoscopy while admitted to further identify the potential
source of bleeding. The patient, however, refused any additional
further inpatient evaluation. He was able to articulate
understanding of the ramifications including recurrent bleeding
and death. On discharge, he was scheduled for outpatient GI
follow-up.
# LLQ pain Possibly related to large stool load. CT
abdomen/pelvis without significant pathology. Will monitor for
now and try to avoid narcotics as much as possible as this will
worsen constipation.
# + Blood cx for CONS - ___ bottles with Coag Neg Staph after 48
hrs. Suspect contaminate in afebrile pt without leukocytosis
though he does have numerous access points for introduction of
bacteremia. Repeat blood cultures pending on discharge. Received
Vanco with dialysis on ___ pending ___ neg cx's
# ESRD: Patient is on ___ schedule. Received dialysis on
___, day of discharge. Continued nephrocaps,
calcium carbonate. Vitamin D level 16 (low).
# DM2: Insulin sliding scale and home lantus
# Hyperlipidemia: Continued atorvastatin.
# Chronic pain: Minimized home oxycodone prn given constipation.
.</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 ESRD on
HD, CHF, HTN, gout, prostate cancer and heavy ETOH use, afib on
Coumadin who presents with large volume hematemesis x2. Radiology showed 1. No acute cardiopulmonary process. No evidence of pneumomediastinum.
Stable cardiomegaly.
2. Fractures of indeterminate age are seen involving several lower left
lateral ribs, possibly present on priors but not as well- visualized. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, there has been placement of
an endotracheal tube with its tip approximately 4.5 cm above the carina.
Otherwise no change. The patient was diagnosed with Hematemesis. The patient was treated with EGD. At the time of discharge, the patient had Primary: GI bleeding s/p EGD s/p cauterization, sinus brady
Secondary: 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>Brief Hospital Course:
=======================================
Mr. ___ is a ___ year old gentleman with a history of ESRD on
HD, CHF, HTN, gout, prostate cancer and heavy ETOH use, afib on
Coumadin who presents with large volume hematemesis, admitted to
MICU for EGD with cauterization of duolefoy lesion vs. ulcer.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ yo gentleman with ___'s (planning for
transplant from spouse), HTN, gout, migraine, and ESRD on PD
since ___ presenting with acute onset of nausea and
vomiting. Pt felt ill at work yesterday and when he got home
around 6pm he started vomiting. Vomit was bilious with partially
digested food and occasional twinges of bright red blood. He has
had "constant nausea" accompanying this. No diarrhea - has had 2
BM overnight since coming to hospital at 8pm last night but it
was normal in consistency. No abdominal pain or cramping. At
home he had fever to 100 but it has since risen since coming to
the ED to 101.9. He has also had chills and sweats. No sick
contacts, no new foods. Last meal was a salad for lunch
yesterday. Also admits to achey muscles and joints all over, but
the joint pain is not like his gout pain and he has no swollen
or painful joints at this time. No dysuria but admits to
decreased UOP over the past day. ROS positive for dizziness when
standing, nasal congestion and sinus pressure; negative for
chest pain, shortness of breath. Also admits to HA similar to
his migraines; this began prior to nausea and vomiting and has
been going on all weekend. It began on the crown of his head and
radiated to the right eye, then left, then right again. He has
been taking all of his medications as he usually does, but
missed his evening meds due to vomiting. He has been performing
dialysis nightly, 5 sessions, as per his routine. Per pt he has
been running with SBP in 170s for the past few months. Reports
similar onset of symptoms that progressed to gout flares in the
past. Has had flu shot this year.
.
In the ED, initial VS: 99.6 ___ 24 100%. Exam
significant for fever to 102 with tachycardia to 140s. Received
3LNS. Also received, promethazine 12.5mg IV, hydromorphone 1mg
IV x2, Zosyn was orderd but unasyn was given. Vancomycin 1g was
given. Also received ativan 1mg x 1. VS prior to transfer: 100.9
12 153/93 14 hr112 100RA. CXR and CT A/P were unremarkable.
Peritoneal fluid and blood were sent for culture; obtained u/a. Radiology showed 1. No acute intra-abdominal or pelvic process.
2. Bilateral renal cysts. Radiology showed No acute cardiac or pulmonary process. Radiology showed Possible mild cerebral edema; please correlate clinically. No
evidence of intracranial hemorrhage or infarction. Please note that MR would
be more sensitive for subtle intracranial findings. This was discussed with
Dr. ___ on ___ at 9:10 p.m.
NOTE ADDED IN ATTENDING REVIEW: There is no evidence of an acute intracranial
process, with no finding to specifically suggest cerebral edema. The
relatively hyperattenuating principal vessels of the circle of ___ and
dural venous sinuses likely reflect the intravenous contrast material given
for the CTAP, performed some 17 hours earlier, in the setting of ESRD on
peritoneal dialysis. The patient was diagnosed with NAUSEA WITH VOMITING, ABDOMINAL PAIN OTHER SPECIED, HYPERTENSION NOS. The patient was treated with Lumbar Puncture. At the time of discharge, the patient had Hypertensive Urgency
Viral Gastroenteritis
End Stage Renal 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 ___ alport's, ESRD, HTN, migraine, and gout
presenting with fever, leukocytosis, HA, nausea, and vomiting.
# Headache: initially thought to be ___ migraine, which pt has a
history of. He reported his pain was similar to previous
migraines, just worse. Stated HA had been going on all weekend,
but had improved during work on ___. He received sumatriptan
and ativan in ED; he stated the ativan helped. On the floor,
neuro exam showed no deficits, he was AAOx3, and he was
conversing fluently. he was given fiorecet without relief. When
fiorecet did not help, tried morphine. Patient reported this
also did not help, and HA was worsening. pt appeared more toxic
at this time and was visibly unfomcortable. obtained head CT
which showed mild cerebral edema (wet read by radiology over
phone). this was thought to be most likely ___ uremia, but
broadened abx to include ampicillin and acyclovir (pt has
chronic medical problems and is on peritoneal dialysis so wanted
to cover for listeria and age necessitates HSV coverage) to be
safe. Also switched ceftazidime to ceftriaxone because it is
empiric meningitis coverage and consulted neuro. Neuro saw
patient and noted pain with eye movement, a new finding since
the morning of admission, and suspected meningitis. LP was
performed and was clear, champagne colored, and had 0 RBC, 1
WBC. About 3 hours after receiving ampicillin, ceftriaxone, and
getting LP, pt developed swelling under the tongue, cheeks, and
neck. symptoms progressed rapidly per nightfloat and ENT was
called. scope showed no obstruction and ENT thought sx were
possible angioedema. Final CT read said no cerebral edema. The
patient's CT scan was discussed with neuroradiology re:
possibility of dural vein thrombosis contributing to his
headache. As per rads, the patient's scan was NOT consistent
with this. On transfer out of the MICU, the patient reported
feeling headache free. He remained HA free on the floor and was
discharged within a few days.
# ?angioedema: The patient was transferred to the unit for
airway monitoring. In the unit, ENT scoped him again and saw
swelling of the submandibular glands, without lymphadenopathy.
The patient's swelling improved after being given Benadryl,
steroids, and famotidine. On call out from the unit, he was
breathing comfortably. No antibiotics were given, as it was
thought that this was not related to infection; dental was
consulted. There was some concern that this was due to herpetic
infection in the throat, but there was no evidence of any ulcers
or lesions on exam. Patient rapidly improved on steroids and was
transferred out of the unit within 12 hours. Did not pursue
dental consult because suspicion for infectious process was low.
Steroids were continued for 24 hours total, then stopped. He
had no recurrence of edema. Asthma consult was called and
patient was arranged to be seen in asthma clinic within one week
for penicillin and ceftriaxone testing; wanted to verify allergy
before banning any antibiotics in this transplant candidate.
# fever/leukocytosis: with fevers, chills, myalgias, and white
count in the setting of nausea and vomiting, his fevers and WBC
count were initially thought to be ___ GI illness vs. influenza
vs. peritonitis vs. meningitis. vs rheumatologic. meningitis
seemed unlikely on admission because he had no focal neuro
signs, neg brudzinski and kernig, and his HA had been present
for several days and had had a waxing and waning course.
rheumatologic seemed unlikely because he had no joint erythema,
swelling, or reduced range of motion. u/a negative, CXR
negative, CT A/P unremarkable. obtained nasalpharyngeal
influenza swab and viral screen, plus blood and urine cultures.
fluid was drawn from peritoneal space by ED and sent for culture
and cell count. pt had no abdominal pain or tenderness, making
peritonitis seem unlikely, but 20% of patients may not have
these symptoms, so threshold was low to start antibiotics. cell
count on peritoneal showed 90 WBC, so antibiotics were started
empirically while awaiting culture data due to concern for early
peritonitis and high mortality associated with this. pt's HA
worsened and he developed meningeal signs the evening after
admission. his antibiotics were broadened and he received an LP,
but it was completely negative for infection (see above) and his
sx were thought to be ___ uremia.
# nausea/vomiting: thought to be sequelae of viral illness such
as GI virus or influenza vs secondary to uremia. infectious work
up performed as above and ESRD managed as below.
# ESRD: pt has had elevated BUN in the past, but both BUN and
Creatinine have been progressively worsening since ___, and
measurements on admission were highest on record. there was e/o
uremia on physical exam with asterixis and clonus, but no
friction rub or altered mental status. uremia was thought to be
causing n/v on admission. paged renal the morning of admission
and initiated peritoneal dialysis per their recs. transplant
also saw pt while he was in ED. He will continue to adjust his
PD regimen as an outpatient per renal recs.
# anemia: pt has chronic anemia, likely ___ ESRD and ACD. last
iron studies done in ___ showed ACD. resent these and they
showed ACD again. pt gets epo injections every two weeks, but
states last IJ was 3 weeks ago. baseline Hct has been dropping -
was ranging ___ from ___ to ___, now ___ over past month.
on admission his Hct was 21.3 (normocytic but with large RDW),
which could have been partly ___ dilution from fluids in ED, but
also concerning because it is his lowest value yet. tried to
avoid transfusion due to immune sensitization risk but pt was
below 21 on two separate Hct draws and was symptomatic, so he
got one unit PRBC prior to discharge.
# HTN: pt normally runs SBP 170s at home. was up to 190s in ED
and on initial transfer to floor. may have been secondary to
stress, vomiting, and missing BP meds the evening prior and the
morning of admission. restarted his home dose of clonidine and
amlodipine but held lasix in the setting of likely volume
depletion.
While in the unit, the patient was hypertensive in the 180s and
was started on Labetolol 200 mg BID. He was well-managed on
this regimen of clonidine, amlodipine, and labetalol so he was
discharged on this. He was instructed not to restart lasix
unless directed to by PCP or renal.
# GERD: continued omeprazole
# anxiety: continued alprazolam prn, escitalopram
# gout: continued allopurinol </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M with Parkinsonism who was recently admitted to Neurology
from ___ worsening of long-standing muscle weakness,
previously thought to be inclusion body myositis, but felt more
likely to be inflammatory neuromyopathy with sensory axonal
neuropathy, who now presents with concern for 'confusion' at
rehab facility. CHEST RADIOGRAPHS showed Possible trace pleural effusions, otherwise unremarkable. CHEST (PORTABLE AP) showed As compared to the previous radiograph, there is consistent opacification of
the medial aspect 's of the right lower lung. The opacity is ill-defined and
shows several air bronchograms. In the appropriate clinical setting, the
opacity represents pneumonia.
Moderate cardiomegaly without pulmonary edema. Small retrocardiac atelectasis.
Unchanged position of the left pacemaker.
NOTIFICATION: At the time of dictation and observation, 16:35, on the ___, the referring physician ___ was paged and the findings
were discussed 1 min later over the telephone. CHEST (PORTABLE AP) showed As compared to the prior radiograph of ___, there are no new areas
of consolidation in the lungs to suggest a site of pneumonia. The patient was diagnosed with ALTERED MENTAL STATUS . The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted for 1 week of progressive increased
confusion, visual hallucinations, and periods of memory loss.
Ultimately, on infectious work up, he was found to have a right
middle lobe pneumonia that may have been from aspiration. Blood
cultures showed a contaminant in one bottle (Coagulase negative
staphyloccocus), but were otherwise negative. Urine culture was
negative. Outside hospital head CT had no acute intracranial
process and you could not get an MRI because you have a
pacemaker. 48 hr EEG showed generalized slowing but no seizure
activity. We empirically treated the pneumonia with 7 days of IV
vancomycin and zosyn. Unfortunately, on the ___ day of
antibiotic treatment (___), Mr. ___ developed diarrhea
and wasfound to have C. diff. He was put on a 14 day cource of
oral vancomycin to be completed on ___.
His confusion initially improved with treatment of the
pneumonia, but he then developed sundowning delirium from lack
of sleep in the hospital. Once we moved him to a window-ed room
and decreased monitoring frequency overnight and after
resolution of his C. difficile diarrhea, his mental status
returned to baseline - fully oriented, alert, conversant.
His Coumadin dose required changing due to elevated INR (blood
thinning levels). Ultimately, he was discharged on Warfarin 3.5
mg qDay. He will continue to require frequent INR checks (at
least once weekly) to ensure he remains in therapeutic range for
his INR (___).</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ yo M with a PMHx significant for TIDM and cyclic
vomiting syndrome who was transfered to ___ from an OSH for
management of coffee ground emesis and underlying DKA. Pt
reports that he was in his normal state of health up until the
evening prior to admission at which point he started developing
severe, epigastric abdominal pain and associated nausea and
vomiting. After initial vomiting episodes, pt began having
multiple episodes of bloody emesis. On review of systems pt
noted 1 episode of non-bloody diarrhea as well. Pt denies any
fevers, chills, SOB, cough, or headache. He reports that he has
been taking his normal doses of insulin. Also of note, patient
notes that he had a similar episode of vomiting last year
(during which he was diagnosed with ___.
At the OSH patient's blood sugar was found to be 488; VS were T
99.2, HR 98, RR 18, BP 150/84, and 98% RA. He was started on
humalin IV and received 3L NS. Pt received protonix 40 mg IV,
phernergan, and toradol as well. Tox screen was postive for
opioids and barbituates.
On arrival to the ED pt's VS were T 99.6, HR 103, BP 159/60,
24, 100%RA. Glucose on arrival was 410 with an AG of 32, a
bicarb of 12, and a K of 4.5. Pt continued to report ___ abd
pain. Acutely he was given a bolus of insulin and subsequently
started on a drip. He was concommitantly started on IVF
initially with NS w/K x1L, followed by D5W1/2NS w/K. EKG was
negative for peaked T-waves or ischemia.
Regarding the coffee ground emesis, GI was consulted and
believed that given pt's history pt most likely suffered a
___ tear. CXR was negative for any mediastinal
widening. He for which was started on Protonix 40 mg IV BID. Pt
was also T&C'd.
On arrival to the MICU, pt's VS T99, HR 110, BP102/93, RR 19,
99% RA. On exam pt was in acute distress and continued to vomit
coffee ground emesis. Radiology showed No distended loops of bowel suggestive of a bowel obstruction. The patient was diagnosed with DIAB KETOACIDOSIS IDDM. At the time of discharge, the patient had PRIMARY DIAGNOSES:
1. DKA
2. gastroparesis
3. Type I Diabetes
4. Coffe-ground vomiting
5. Abdominal pain
SECONDARY DIAGNOSES:
1. Hepatitis C 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>Pt is a ___ year old male with TIDM, neuropathy, gastroparesis,
cannabis use and cyclic vomiting syndrome who was transferred
from an OSH for management of coffee ground emesis and
underlying DKA.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMHx alcohol abuse, HTN and asthma although has not
recently been seen by a doctor per patient. Hx is obtained per
both daughter and patient. Apparently patient has been declining
at least since ___. She has been experiencing vomiting,
diarrhea, nausea, and shakes so severe she has had very poor PO
intake over the past couple of months. Her cough worsened over
the past ___ weeks in intensity and roughly a week ago she
states she "blew out her left side" stating that she felt
something buldged or pop on the left side of her chest/upper
abdomen had has to apply pressure to prevent pain each time she
coughs since then. Apparently this occurred during an episode of
intense retching. She endorses fevers and chills but states this
has been on going since ___. Radiology showed No evidence of esophageal perforation. Radiology showed 1. Increased size of a right apical pneumothorax measuring 2.4 cm. No
definite evidence of tension.
2. Unchanged, severe pneumomediastinum and diffuse subcutaneous emphysema.
3. Left basilar atelectasis versus consolidation.
4. Right middle lobe collapse.
5. Small right pleural effusion.
Findings were conveyed by Dr. ___ to Dr. ___ telephone at 9:25 on
___, 1 min after discovery. Radiology showed Right apical pneumothorax appears minimally increased as compared
to the prior study. No definite signs of tension. These findings were
discussed with Dr. ___ at 4 p.m. on ___ via telephone.
Persistent pneumomediastinum, extensive subcutaneous emphysema. Right middle
lobe opacity most likely relates to right middle lobe collapse, although
underlying infection at that location is not excluded. Radiology showed 1. Persistent tiny right apical pneumothorax.
2. No significant change in pneumomediastinum.
3. Extensive subcutaneous emphysema, similar to prior exam. Radiology showed 1. Interval decrease in right apical pneumothorax.
2. Extensive subcutaneous emphysema and pneumomediastinum, similar to prior
exam.
These findings were communicated to the patient's team at 2:08 a.m. on ___ by phone. Radiology showed 1. Persistent small right apical pneumothorax.
2. Extensive subcutaneous emphysema and pneumomediastinum, similar to prior
studies. Radiology showed The parenchymal organs cannot be visualized due to extensive subcutaneous
emphysema Radiology showed 1. Improved right middle lobe segmental collapse and lingular opacity.
2. Right apical pneumothorax and pneumomediastinum appear stable. Radiology showed 1. Right apical pneumothorax is minimally smaller. Stable pneumomediastinum
and subcutaneous air.
2. New New lingular opacification which may represent atelectasis. Concurrent
infectious process must be excluded in the proper clinical setting.
3. Increased right middle lobe partial collapse. The patient was diagnosed with INTERSTITIAL EMPHYSEMA. At the time of discharge, the patient had Alcoholic cirrhosis
Pneumomediastinum. The patient was given written instructions concerning 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 PMHx alcohol abuse, HTN and asthma who
was transferred from an outside hospital due to dyspnea in the
setting of retching vomiting. Her nausea, vomiting, and diarrhea
has been ongoing at least since ___. A chest x-ray was
preformed at OSH which showed a right pneumo thorax. She had a
CTA performed here which showed extensive pneumomediastinum and
subcutaneous gas involving nearly the entire torso with right
medial lung collapse. There was concern for esophageal tear vs
rupture giving hx of vomiting so a barium swallow was performed
which was negative for a leak. She had serial chest x-rays done
which showed her pneumothorax and pneumomediastinum was stable
over the course of her hospital stay. She was followed by
interventional pulmonology who will perform a brochoscopy for
further evaluation in the next several weeks.
Evidence of liver cirrhosis was seen on both her CT scan as well
as elevations of her LFTs, total bilirubin and INR. She was seen
by the hepatology service and will continue to be followed as an
outpatient. No plan to start steriods at this point given
pneumomediastinum; DF >32. She was appropriately counseled that
alcohol cessation is imperative and has life limiting
complications. In addition, she was educated to consume a 2 gram
sodium limited diet and had met with nutrition. </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 a history of
laparoscopic banding in ___, HTN, and hyperlipidemia presenting
to the ___ ED with 5 days of diarrhea. The diarrhea is "soupy"
in consistency and has been brown/clear. She has had ___ bowel
movements a day since the onset. No blood, mucus, or unusual
colors. No abdominal pain. She has also had some mild nausea and
occasional dry heaving, though the patient reports that these
are very mild, and that her diarrhea is the primary problem. No
fevers, but does report bad chills and marked diaphoresis
requiring a change of clothes 2 days ago, which have both since
resolved. Additionally she has had diffuse muscular and joint
pain. She has had no recent travel history, no unusual
exposures, and no sick contacts. Radiology showed No acute cardiac or pulmonary process. Radiology showed No acute fractures. Mild multilevel degenerative changes. The patient was diagnosed with NEUTROPENIA, UNSPECIFIED . At the time of discharge, the patient had Viral diarrhea
Infectious neutropenia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old woman with a history of gastric lap
banding in ___, hypertension, and hyperlipidemia presenting
with 5 days of diarrhea and an Absolute Neutrophil Count of 540.
Over the course of 2 days here her diarrhea improved
significantly. At the time of discharge, she was still having
loose stool, but of far less frequency. Her ANC initially
downtrended to 375, but rose to 884 on the day of discharge. Her
neutropenia was thought to be most likely due to an infectious
cause. Infectious work up here was negative, though several
studies are still pending and will require outpatient follow up.
She was discharged in stable condition with instructions for
outpatient follow up.
# Diarrhea: Upon admission the patient was reporting ___ daily
BM's of a brown/clear color and soupy consistency. During day 1
of admission her diarrhea improved markedly, with decrease in
frequency to ___ BM's throughout the day. However, her stool was
still loose. On the day of discharge she continued to improve
symptomatically, though her stool was still loose. She continued
to have intermittent nausea that was well controlled with
Zofran. She was able to maintain PO hydration with no need for
IVF throughout her stay, no VS intability, and no evidence of
pre-renal failure. Stool cultures and O&P were negative,
including negative for cryptosporidium, giardia, salmonella, and
shigella. Her diarrhea was most likely viral in etiology. Upon
discharge CMV and EBV serologies are still pending, and will be
followed up with in an outpatient setting.
# Neutropenia: Upon admission the patient had an ANC of 540 and
a WBC of 1.8. This was thought to be most likely infectious or
post-infectious in the setting of diarrhea. Drug reaction to
omeprazole or lisinopril was also considered, though these were
less likely. An infectious panel was sent. HIV, Hep B, and Hep C
were all negative. EBV and CMV were pending upon time of
discharge. Stool studies were negative for any causative
bacterial/parasitic/fungal organism. A peripheral blood smear
was unconcerning, and hematology did not recommend a bone marrow
biopsy. Flow cytometry was performed, with results pending at
time of discharge. An SPEP was sent, with results pending at
time of discharge. On hospital day 2 the pt's ANC decreased to
375. On day of discharge the pt's ANC rose 884. During her
hospital course she remained afebrile with all vital signs
stable and no new signs/symptoms of infection. Upon discharge
she was in stable condition without evidence of new onset
infection. She was instructed to follow up with her PCP for this
issue, with repeat CBC/diff in the outpatient setting and follow
up of pending labs.
# Back pain: The patient presented with mid-thoracic back pain
of 3 days duration. A T-spine film was performed revealing
degenerative changes with no evidence of fracture. It was
presumed that her back pain was due to muscle/ligament sprain or
strain. She was given a lidocaine patch, which helped to
alleviate her pain. She was instructed to follow up with her PCP
for this issue.
# Leg pain/weakness: The patient presented with bilateral leg
pain extending from the lateral thighs to just below the knees.
It was somewhat dermatomal, with the burning pain concerning for
Zoster. However, the absence of a rash made this possibility
less likely. She did not have any focal neurologic findings,
making a lumbar spine etiology unlikely. Though she reported
lower extremity weakness, she had full strength on exam. Her
lateral thigh pain was likely most consistent with meralgia
paresthetica, and improved with Tramadol. She was instructed to
follow up with her PCP for this issue.
# Desaturation: On the day of discharge the pt had an O2 sat of
91% on RA in the AM. Upon ambulation her O2 sat remained 90-93%.
However, she did not have any dyspnea during this time. It is
likely that this may be the result of her longstanding asthma.
She was discharged with instructions to follow up with her PCP
regarding this issue. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male with HIV, HCV, cirrhosis c/b ascites with recurrent
varcieal bleeds s/p TIPS c/b encephalopathy, active
endocarditis, mycotic aneurysm and AS who presents from ___
___ with possible GIB. Patient was seen in ___
clinic where he was told that his hematocrit was 21% and he was
instructed to present to the hospital for a transfusion. Upon
interview by his ID physician he reported that he had noticed
blood on his toilet paper for several days. He stated that his
stool had been normal color. He denied any melena or frank
hematochezia. He denied any associated pain though did report an
intermittent LLQ pain that is unrelated to when he notices blood
on the toilet paper. He further denied any dizziness, chest
pain, or shortness of breath. Of note patient had a recent
endoscopy approximately one month ago that did not show any
varices. At ___, the patient's hematocrit was noted to
be 27%. The patient was started on octreotide and Protonix drips
and transferred to ___ for further evaluation. Vitals signs
prior to transfer were 96.9, 48, 127/52, 97%. Hematocrit at
transfer was noted to be 27 and INR was 1.2.
.
In the ED, initial VS were 97.8, 54, 122/96, 14, 100%. Patient
was noted to have guaiac positive brown stool, no external
hemorrhoids, and no internal hemorrhoids were visible on
anoscopy. His serum potassium was noted to be 6.0. An EKG from
___ revealed sinus rhythm at 56, NA and no STT changes.
EKG here revealed sinus bradycardia with peaked T-waves. He was
subsequently given an Amp of D50, 10 units of Regular insulin,
Calcium gluconate and Kayexalate. Repeat potassium was 5.1.
Vitals signs at transfer were 97.8, 50s, 138/55, 22, 98% on RA. Radiology showed 1. Approximately 5-cm sigmoid mass concerning for malignancy. There is no
evidence for metastatic disease and no lymphadenopathy.
2. Highly ectatic aorta with extensive atherosclerotic calcification and
plaque formation.
3. Status post TIPS which is widely patent.
4. Cholelithiasis without cholecystitis.
5. Unchanged 1-cm left adrenal nodule, statistically representing an adenoma.
6. Collapsed ascending colon which cannot be completely evaluated on this
study. If clinically indicated, a CT colonoscopy can be performed for better
evaluation. Radiology showed 1) Findings are consistent with a postoperative small bowel
ileus. If concern for mechanical small bowel obstruction persists, a CT would
provide better characterization.
2) Intraperitoneal free air compatible with recent surgery. Radiology showed 1. Mildly dilated fluid-filled loops of ascending and descending colon
suggestive of focal ileus. Patent distal colon without clear transition point
to suggest large bowel obstruction.
2. Minimally prominent loops of small bowel measuring up to 2.5 cm, however,
no signs of clear obstruction. Findings may also be secondary to
postoperative ileus.
3. Expected moderate pneumoperitoneum due to recent sigmoid colectomy.
4. Normal appearance of the surgical anastomosis. No evidence of
extraluminal leak or stenosis.
5. No organized fluid collection in the abdomen or pelvis to suggest abscess.
6. Standard position of TIPS shunt which appears grossly patent.
7. Stable bulky appearance of the bilateral adrenal glands, left greater than
right. Radiology showed Non-obstructive bowel gas pattern. Air seen throughout the
non-dilated colon, extending to the rectum, could reflect mild colonic ileus. The patient was diagnosed with RECTAL & ANAL HEMORRHAGE, HYPERKALEMIA, CIRRHOSIS OF LIVER NOS, AORTIC VALVE DISORDER, ASYMPTOMATIC HIV INFECTION. The patient was treated with Colonoscopy ___ by Drs. ___. At the time of discharge, the patient had Colonic adenocarcinoma
Acute blood loss anemia
Aortic stenosis
HIV
Idiopathic 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>Primary Reason for Hospitalization:
___ y/o male with HIV, HCV, cirrhosis c/b ascites with recurrent
varcieal bleeds s/p TIPS c/b encephalopathy, active
endocarditis, mycotic aneurysm and severe AS who presented from
___ with BRBPR and anemia, and found to be hyperkalemic
with EKG changes. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: History of Presenting Illness: ___ year old male with hepatitis
B/C cirrhosis complicated by grade II variceal bleed s/p banding
and portal gastropathy, pulmonary sarcoid with possible liver
involvement, now presenting with a few days of worsening
abdominal pain and distension. He describes a colicky-type pain,
mostly around his umbilical region. He does report dyspnea with
exertion but none at rest. He feels his abdomen is more
distended and more bloated than his baseline. He denies leg
swelling, fevers/chills, or vomiting. He does report full
medication compliance. He also states that he has had a few days
of pink hemoptysis in the AM. Denies any recent increased salt
load.
.
Of note, he has had 5 previous admissions in ___, his last in
___ for hemotypsis secondary to his pulmonary sarcoid
and a hematocrit drop concerning for variceal bleed in the
context of a recent banding procedure. He was also tapped during
this admission and the ascites was negative for SBP. A 1.6cm
hepatic lesion was noted to have grown since first visualized
___ but MRi characteristics not completely conssitent with
HCC.
.
In the ED, initial vitals were: 97.3 95 155/78 20 98%. Initial
exam was remarkable for non-tender, distended abdomen and fine
inspiratory crackles at the right lung base. Labs were notable
for an elevated total bilirubin to 3.6, lactate of 2.3, normal
renal function, normal WBC count, and an elevated INR to 1.5
(MELD = 16). He is being admitted to the ___ service
for a therapeutic tap and further work-up for hemoptysis vs.
upper GI bleed. Vitals on transfer: BP 117/69, HR 80, RR 16, T
98.4, 97% on RA
.
Review of Systems: Denies HA, fever. Endorses "chills," which he
describes as a strange sensation throughout his body with
goosebumps. Stuffy nose, no sore throat. AM cough productive of
pink sputum as noted above. Occassionally has nasal discharge or
cough mixed with small clots. No CP, SOB with exertion that he
attributes to increased abdominal distention. Abdomial pain per
HPI. No bloody stools, but notes Hx of internal hemorrhoids. No
peripheral edema. Notes that occassionally his finger or toes
"freeze" and he is unable to move them actively or passively.
This happens about ___ times/day. He was started on Ca/vit D
supplementation as an outpt for this but it has not improved. No
recent sick contacts. Radiology showed Stable bibasilar and right mid-lung opacities likely reflecting
atelectasis and scarring, though infection is not entirely excluded. The patient was diagnosed with OTHER HEMOPTYSIS, OTHER ASCITES, CIRRHOSIS OF LIVER NOS. The patient was treated with Paracentesis
EGD. At the time of discharge, the patient had Cirrhosis
Ascites
Esophageal varices. The patient was given written instructions concerning 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 history of Hep B and C cirrhosis c/b
grade II varices s/p banding and pulmonary sarcoid with
recurrent hemoptysis, presenting with worsening abdominal pain
and distension due to increasing ascites.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M h/o ESRD on HD MWF, Chagas CM, CAD s/p CABG, DM1, PVD, who
came into the ___ ED with shortness of breath for last three
days. The patient, accompanied by his wife, report that over the
last month the patient has had worsening dyspnea worse with
exertion and worse when lying flat. He reports that he has had
similar respiratory issues in the past and had been treated with
thoracentesis once in the past. The patient has ESRD on HD ___
and has been getting his HD as scheduled, last session 2 days
prior to admission on ___. He reports that he has been
limited to less than one block and has been having trouble
sleeping due to inability to lie flat. CHEST (PA AND LAT) showed Mild pulmonary edema.
Acute fracture of the right distal clavicle. CHEST (PORTABLE AP) showed In comparison with the study of ___, there again is enlargement of the
cardiac silhouette with mild elevation of pulmonary venous pressure.
Suggestion of a more focal area increased opacification at the right base
could represent aspiration/pneumonia in the appropriate clinical setting.
Little change in the appearance of the fracture of the distal clavicle on the
right. Radiology showed Interval placement of a left chest wall dual lead AICD. No pneumothorax.
Definitive lead placement can be confirmed with a PA and lateral chest
radiograph.
Unchanged small right pleural effusion and right basal opacities. Radiology showed Left chest wall dual lead pacing device with lead tips in the right atrium and
right ventricle. No pneumothorax. Right basilar atelectasis and pleural
thickening. Radiology showed Successful venogram and angioplasty of multisegment venous outflow stenosis.
Of note, there is a chronic central occlusion.
RECOMMENDATION(S): Pursestring can be removed within 1 day or at dialysis. The patient was diagnosed with Dyspnea, unspecified. The patient was treated with ___ ICD placement
___ fistulogram and angioplasty. At the time of discharge, the patient had CAD
Tachy-brady s/p ICD placememt
Cardiomyopathy, mixed ischemic/chagas/etoh
Acute on chronic systolic CHF exacerbation
ESRD on HD, c/b persistent hyperkalemia
HTN
DM1. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ M h/o ESRD on HD MWF, Chagas CM, CAD s/p
CABG, DM1, and PVD who presented with acute SOB due to sCHF
decompensation/fluid overload found to have a progressive global
depression in LV function (20%). He symptomatically improved
with fluid removal and was medically optimized for systolic CHF.
S/p ICD placement ___ for sick sinus.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old woman with past medical history
significant for GERD and depression who presented to her primary
care physician with weight loss, diarrhea, nausea and vomiting,
and was found to have an intracranial mass and liver lesions
concerning for metastatic malignancy. She states she was in her
usual state of health until last ___ when she started having
abdominal pain, nausea, vomiting, loss of appetite, and loose
stools. Stools are diffuse and frequent, watery, and greasy.
Abdominal pain is achey and primarily in the lower quadrants.
She had an EGD which was normal in ___. She continued
to have symptoms so a colonoscopy was done in ___ which was
normal as well. She thought her symptoms might be due to
depression so she started Zoloft (she had similar symptoms in
her ___, accompanied by weight loss, which resolved with
treatment with an SSRI). Her symptoms did not improve this time.
She has since tried lexapro which has helped but certainly not
resolved her symptoms. She then reported a "bump" on her head
which has been present for several months but she had not paid
much attention to otherwise, and thought was due to where her
glasses rested on her head. She had a head CT at ___ which
showed an infiltrative intracranial mass with cerebral edema and
concern for early venous sinus thrombosis. A CT abdomen/pelvis
also showed what appeared to be liver mets. She was transferred
to ___.
She has had a 60 pound weight loss since ___. Review of systems
otherwise significant for ringing in right ear and insomnia plus
anxiety since the onset of her symptoms. She also reports a pain
on her left posterior and inferior ribcage which occurs off and
on since the onset of the above symptoms as well. She reports
being up to date on mammograms and pap smears which have been
negative. She also had two vaginal ultrasounds in the recent
past which showed an ovarian cyst that appeared benign per the
patient. Radiology showed 1. Large trans-spatial lesion, which appears centered in the right occipital
bone, perhaps at the right occipital-mastoid suture, with marked bone
destruction and both superficial and deep extension. This involves the
intracranial extra-axial space, including the subjacent subdural and
subarachnoid space. Further subjacent brain involvement is not entirely
excluded.
With the reported suspicious lesions in the liver, this process may certainly
represent a large metastatic lesion, centered in bone. An aggressive primary
intra-osseous meningioma or hemangiopericytoma are more remote considerations.
Alternatively, this may represent a primary destructive bone lesion such as
chondrosarcoma or plasmacytoma.
Given the sparing of the structures of the otic capsule, this is unlikely to
represent an aggressive-variant endolymphatic sac tumor. Given the lack of
distinct hypervascularity and hyperenhancement, a paraganglioma, even
malignant, is also unlikely.
2. Apparent invasion of the ipsilateral sigmoid sinus, with both tumoral and
bland thrombosis, extending into the proximal portion of the internal jugular
vein. There is likely related slow flow in the ipsilateral transverse sinus,
as well as much of the superior sagittal sinus, and the presence of venous
sinus thrombosis may be contributing to the vasogenic edema in the right
temporo-occipital region.
3. No finding to suggest metastatic disease elsewhere in the brain.
4. No evidence of regional lymphadenopathy.
COMMENT: As the most superficial portion of this process lies only
approximately 5 mm deep to the skin of the occipital scalp, this may be
amenable to percutaneous biopsy. Radiology showed At least 3 hypoechoic lesions in left lobe of liver all of which are suitable
for percutaneous ultrasound-guided biopsy. Radiology showed Technically successful ultrasound-guided biopsy of lesion within segment IV of
the liver. Radiology showed 1. No evidence of primary lung malignancy as a potential cause for
extrathoracic metastases.
2. Nonspecific 2-mm and 3-mm right upper lobe nodules, which can be followed
up by CT in three months in order to exclude small foci of metastatic disease.
3. Multiple heterogenous hepatic lesions and trace perihepatic ascites are
similar in appearance to recent dedicated outside imaging CT abdomen study
from ___. Radiology showed No evidence of acute cardiopulmonary process. Radiology showed 1. Unchanged large right occipital and temporal bone lesion,
involving the mastoid area with significant bone destruction, avid and
heterogeneous enhancement including dural thickening and subpial and
subarachnoid enhancement. Given the clinical history the differential
diagnosis includes a metastatic lesion, other entities, however, cannot be
completely excluded such as an aggressive interosseous meningioma and
hemangiopericytoma.
2. Persistent thrombosis along the right sigmoid and proximal segment of the
right jugular vein. Radiology showed Status post right craniectomy and reconstruction with resection of right
temporal extra-axial mass. Expected postoperative changes are present without
large intracranial hemorrhage. Right cerebral edema is slightly increased,
now with a 4 mm leftward shift of midline structures. Radiology showed Expected post-surgical changes identified in the right occipital
and temporal bones, the patient is status post resection of extra-axial mass
lesion in this area. There is persistent vasogenic edema and subarachnoid
enhancement in the right occipital and temporal lobe as described above, with
persistent effacement of the right ventricular atrium and vasogenic edema.
There is a trace of fluid and enhancement in the surgical area, long-term
followup is advised. The patient was diagnosed with SWELLING IN HEAD & NECK, LIVER DISORDERS NEC. The patient was treated with ___ Diagnostic Angiogram
___ R craniectomy. At the time of discharge, the patient had Right extra-axial lesion.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman with past medical history
significant for GERD, depression, anxiety, who presented with
weight loss, diarrhea, nausea and vomiting and found at outside
hospital to have intracranial mass and liver lesions concerning
for metastatic malignancy.
# Brain and liver masses: Lesions on head CT and CT
abdomen-pelvis at outside hospital appearing metastatic vs
primary tumor at skull, and with metastatic appearance at liver.
Head imaging consistent with destructive lesion, right posterior
temporal region, vasogenic edema, right temporal horn trapping
or obstruction and concern for intracranial thrombus. Per
outside hospital reports and discussion with radiology here,
lesion is bone-based rather than brain-based with mixed soft and
calcified tissue components. Liver lesions appear metastatic,
given heterogenous appearance.
No neurological deficits at this time but high risk. Primary is
uncertain, with broad differential. Also unclear if both lesions
are related, as intracranial lesion is not typical appearing.
Colon cancer unlikely given normal colonoscopy in ___, although
repeat scope may be warranted. Pt has liver mets and elevated
lipase so pancreatic CA is possible, but no obvious lesions on
CT. Also with diffuse diarrhea a neuroendocrine tumor or
pancreatic tumor causing pancreatic insufficiency is possible.
Possiblility given met locations with diffuse edema is melanoma.
Given met location and family history, breast cancer possible as
well. Pt denies known skin lesions of concern and endorses
up-to-date mammograms that have been negative. Radiology recs
chest CT to complete w/u and evaluate for lung primary or
metastasis as well.
- q4h neuro checks
- Appreciate Neurosurg recs, Neuro-onc recs: started
Levetiracetam 500 mg PO BID
- F/U MRI w/ and w/o contrast
- Zofran for nausea
- Tylenol for pain for now
- Consider chest CT
- Consider intracranial tissue biopsy, liver biopsy - consider
hem-onc c/s to determine best biopsy site and pursue tissue
diagnosis
- Consider sending tumor markers for liver, pancreatic,
neuroendocrine tumors (AFP - HCC, CA-125, ___ - pancreatic,
Chromogranin - neuroendocrine)
# Diarrhea: Possibly unrelated to metastatic cancer of unknown
origin, given response to antidepressants and pt's description
of knotting in stomach when under stress with alternating
constipation and diarrhea, more consistent with IBS, as
diagnosed by PCP and ___ GI.
- F/U stool studies: CDiff, stool cx, ova and parasites
- DC loperamide for now
# GERD: cont sucralfate
# Allergies: cont fluticasone nasal and sub claritin for
cetirizine
# Depression: cont lexapro and lorazepam
# Migraine: cont amitriptyline 10 mg PO HS
******On ___ the patient's care was transfered to the
Neurosurgery service****
The Patient was neurologicaly and hemodynamically stable. A CT
of the torso was ordered for further work up of metastatic
disease and showed a 2-mm and 3-mm RUL nodules, and liver mets a
previously known.
On ___, the patient remained neurologically stable. It was
determined she would go to the OR on ___ for resection of
the lesion. The risks and benefits of the procedure were
discussed and she consented to the procedure. She underwent a
diagnostic angiogram for operative planning. Results of the
angiogram showed an occluded occluded right transverse sinus.
On ___, Ms. ___ was taken to the operating room and underwent
a right craniectomy. A biopsy from her brain mass was sent to
pathology for evaluation. A titanium mesh was inserted in place
of her temporal bone flap. She tolerated the procedure well and
was extubated in the operating room. She was transferred to the
PACU and then the SICU post-operatively. She underwent a
post-operative non-contrast head CT which showed expected post
operative changes. Her diet as advanced as tolerated.
___, Ms. ___ underwent an MRI of the brain which showed
expected post operative changes with persistent vasogenic edema
and subarachnoid enhancement in the right occipital and temporal
lobe, with persistent effacement of the right ventricular atrium
and vasogenic edema.
___, the patient was evaluated by physical therapy who felt
that she had no acute physical therapy needs and was safe to go
home.
___, Ms. ___ remained medically stable. She was also seen by
neuro-oncology.
At the time of discharge on ___, POD #4, Ms. ___
was doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, stable
neuro exam and pain was well controlled. The patient was given
written instructions concerning precautionary instructions and
the appropriate follow-up care. All questions were answered
prior to discharge and the patient expressed readiness for
discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS:
___ is a ___ yo woman with a history of chronic psychiatric
illness who resides in a group home long term and has an
appointed guardian who presented to the ED after swallow tacks
at her group home. Of note she also has a history of HTN, DM,
obesity and heart transplant though she has been refusing all of
her home medications prior to admission. Chest: Frontal and lateral views showed No acute cardiopulmonary process.
2 linear radiopaque foreign objects project over the medial left mid abdomen,
better seen on concurrent abdominal radiograph. No pneumomediastinum seen. Radiology showed 2 radiopaque foreign bodies in the medial left mid abdomen, as described
above, 1 of which has the appearance of a nail/thumb tack, the other may be a
fragment of such. CHEST (PA AND LAT) showed No acute intrathoracic process. CT chest without contrast showed 1. No pneumoperitoneum or foreign body. Trace pleural effusions noted.
2. Borderline cardiomegaly with prominent main pulmonary artery, measuring up
to 3.1 cm, which in the setting of midline sternotomy wires and given
patient's age suggests repaired congenital anomaly. CT abdomen and pelvis without contrast showed 1. 2 radiopaque foreign bodies (linear, metallic, 9 mm and 10 mm in length)
are seen in the small bowel, compatible with ingested tacks. No definite
intra-abdominal free air is identified.
2. Multiple mesenteric lymph nodes appear prominent, likely reactive. Radiology showed No unexpected radiopaque foreign bodies. Radiology showed 1. Two linear radiopaque objects compatible with ingested tacks projecting
over the bilateral paravertebral soft tissues, likely within small bowel.
2. New radiopaque object projecting over the right lower quadrant shaped like
a snap and may be external or newly ingested foreign body. Radiology showed 1. A rounded radiopaque foreign body has progressed and is now in the right
upper quadrant, in the topography of the hepatic flexure of the colon.
2. Two radiopaque linear foreign bodies have also progressed and are now
located in the left upper quadrant in the topography of the splenic flexure of
the colon. Radiology showed Two rounded radiopaque foreign bodies have progressed and are now in the
topography of the sigmoid colon. Two additional linear foreign bodies have
also progressed and are now in the topography of the rectosigmoid junction. Radiology showed 4 radiopaque foreign bodies in total identified, 1 within the proximal
descending colon and the remaining 3 within the sigmoid colon. Radiology showed Previously seen radiopaque foreign bodies are no longer visualized. The patient was diagnosed with Foreign body in other parts of alimentary tract, init encntr, Exposure to other specified factors, initial encounter, Epigastric pain
Foreign body in stomach, initial encounter, Left upper quadrant pain, Exposure to other specified factors, initial encounter. The patient was treated with EGD X 3. At the time of discharge, the patient had Foreign body ingestion
Borderline personality disorder
Schizophrenia
Bipolar disorder
Prior heart transplant for congenital 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 woman with a history of chronic psychiatric illness who
resides in a group home long term and has an appointed guardian
who presented to the ED after swallow tacks at her group home.
# Swallowed foreign objects
# Psychiatric illness with acute decompensation
# Borderline personality disorder.
She underwent 3 EGDs in the ED with successful foreign body
removal, per report she swallowed additional objects in the ED
but repeat imaging with two persistent tacks.
GI followed her after swallowing the remaining 2 tacks and had
no plans for repeat EGD. She was kept on a 1:1 sitter to prevent
further swallowing of objects, although she was able to remove
and swallow her allergy band on HD #1. She did require chemical
and physical restraints at times. KUB showed two metallic linear
objects still in small intestine; repeat KUB on ___ demonstrated
that all foreign bodies had passed from her GI tract. She was
monitored for abdominal pain and stool was monitored for passage
of objects.
# Psych: She has had significant recent psychiatric
decompensation since she left the structured ___
setting. She has had multiple ED visits, and poor compliance,
as well as behavior that has been difficult to control. This
was discussed with the psychiatrist at ___. She was seen by
the psychiatry service, and inpatient psychiatric stabilization
and then likely determination of appropriate long term care
options for her. She was conitnued on home seroquel and
sertraline.
# Heart Transplant
She had a heart transplant for familial cardiomyopathy, and
until recently has been compliant on her immunosuppressant
medications. In the past three months, she has been non
compliant. Her cardiologist Dr. ___ was contacted, and her
tacrolimus and MMF were continued. Her tacro trough was checked
and was initially at 6 and in consultation with Dr. ___
___, her tacrolimus was increased to 4.5 BID. Her subsequent
level was at 8.6 on ___. She should have a repeat Tacrolimus
level drawn on ___. If she is not at goal of 6.0-8.0, please
contact Dr. ___ team to discuss any further dosing changes
___ Cardiologist (___): ___. Coverage
(___ cardiology fellow): ___.
#CONTACT: Under guardianship of children's and family ___
___ ___. Group home director ___ - ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx HLD, 1+MR ___ 3 weeks of fatigue and lethargy. Reports
that over the past 3 weeks has been stably fatigued without any
energy, worse over the last 1 week. Spends most of the time on
the couch only going to bathroom or kitchen. Has been working
hard on a ___ campaign in ___ (working remotely
from ___) for the past 3 weeks. His candidate lost the race 1
week ago. Appetite is significantly decreased, although no
abdominal pain or other GI symptoms. No dysphagia or
odynophagia. No nausea, no hematemesis. Normally not the type to
see medical staff- has been ___ years since last saw a doctor.
Comes in today not because of any focal or new complaint, but
rather due to duration of his unchanged symptoms. History
obtained through patient and his daughter. They declined
interpreter. Rec'd flu shot this year. Works at ___ in lab with
animals (monkeys/rats). Bowel movements have been normal. No
history of constipation. No BRBPR. Says his stools may have been
darker, but not truly black or tarry. No hematuria. No surgery
or trauma recently. No family history of anemia. Chest rate showed No acute cardiopulmonary process. Radiology showed 1. Large heterogeneously enhancing partly exophytic mass arising from the
fundus of the stomach measuring up to 10.2 cm consistent with malignancy, with
CT evidence for diffuse metastatic disease.
2. Multiple omental/peritoneal and serosal nodules measuring up to 2 cm are
consistent with metastatic deposits.
3. Multiple sub cm ill-defined hypoenhancing nodules at the dome of the liver
as well as within the right kidney are too small to characterize but worrisome
for metastasis.
4. A 1.6 cm hyperenhancing lesion in the spleen is indeterminate.
5. Please refer to separately dictated CT chest report from the same day for
description of intrathoracic findings. Chest CT showed No evidence of intrathoracic metastatic disease. The patient was diagnosed with Anemia, unspecified, Weakness. The patient was treated with EGD/Colonoscopy ___. At the time of discharge, the patient had PRIMARY: Acute blood loss anemia, iron deficiency anemia,
Gastric tumor. The patient was given written instructions concerning 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 with a history of
hyperlipidemia and mitral regurgitation who presented with 3
weeks of fatigue found to have severe iron deficiency anemia and
melena, with endoscopies showing a large gastric mass. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with mental retardation, quadriplegia s/p suprapubic cath
presenting from ___ with concern for sepsis ___ infected
left uretal stone. Patient has long PMH including seizure
disorder, PKU, MR, spinal stenosis, ___, HTN,
Tourette's, urethral stricture with suprapubic cath. He
presented to ___ from his living facility with fever and
dehydration. Patient's group home manager ___ reports that
patient was in usual state of health until ___ when they
noted a low grade temp of 100.1 that was treated with tylenol.
He then had decreased appetite throughout the weekend and only
ate popsicles. He went to PCP on ___ who drew labs and did UA
which showed urinary tract infection and WBC 14.7 so he was sent
to ED. Radiology showed Successful placement of a left 8 ___ percutaneous nephrostomy
tube. Radiology showed Interval placement of a right-sided PICC, with the tip either coiled back on
itself or in the azygos vein. The catheter should be pulled back
approximately 3 cm to place the tip in the mid to lower SVC.
These findings were discussed via telephone by ___, MD, with
___, RN, at 1325 on ___. Radiology showed Right-sided PICC with the tip obscured by spinal hardware, requiring
additional oblique views for better localization. Radiology showed Right-sided PICC with the tip in the low SVC. Radiology showed 1. Subsegmental pulmonary embolus in a left lower lobe pulmonary artery. No
signs of heart strain.
2. Pulmonary vein thrombus in the left lower pulmonary vein.
3. Right middle and lower lobe airspace consolidation as well as left upper
and lower lobe airspace consolidation and left lower lobe near total collapse
consistent with multifocal pneumonia.
4. Small pleural effusions. Radiology showed No acute intracranial process. Radiology showed In order to see the tip of the central line a lateral film would be most
helpful. Radiology showed Compared to the prior exam, the aeration of the upper lobes is slightly
improved Radiology showed Successful placement of a 38.5-cm left basilic approach double-lumen PICC line
with the tip in the mid SVC. The line is ready to use. Radiology showed Penetration with thin and nectar thick liquids. No gross aspiration. The patient was diagnosed with CALCULUS OF URETER, URIN TRACT INFECTION NOS, SEPTICEMIA NOS, SEVERE SEPSIS , ACCIDENT NOS, ATRIAL FIBRILLATION. The patient was treated with Intubation/Extubation
Perc-nephrostomy tube placement (___). At the time of discharge, the patient had Urosepsis
Atrial fibrillation and atrial flutter with rapid ventricular
rate. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with urethral stricture and suprapubic cath presenting from
___ with concern for sepsis ___ infected left uretal
stone, course complicated by hypercarbic respiratory failure and
altered mental status requiring transfer to MICU.
ACTIVE ISSUES
# Hypercarbic respiratory failure: Resolved.
Patient was pending discharge when a caregiver from his group
home noted that he had become hyporesponsive. An ABG was checked
and he was found to be hypercarbic and hypoxic. He was thus
transferred to the MICU and was intubated. The cause of this
acute event was unclear. 20-minute EEG showed generalized
periodic discharges which could potentially be highly associated
with seizure, and EEG was continued for 24 hours. The following
day he was switched to pressure support and did well ventilating
on his own. He was extubated the the day after. He was monitored
with no further apneic episodes, serial blood gasses showed
resolution of his hypercapnia. Patient was transferred to
medical floor with continuous EEG monitoring. Neurology was
consulted who recommended starting patient on keppra in
additional to his home carbamazepine. EEG activity improved
with keppra. Patient was discharged on keppra and carbamazepine
with planned outpatient follow-up with his neurologist, Dr. ___
___, ___.
# Sepsis / UTI:
Patient with positive UA in setting of left ureter stone and
hydronephrosis. Met SIRS criteria with leukocytosis with left
shift and tachycardia. Hypotensive requiring neosynephrine in
the setting of induction for intubation. S/p L percutaneous
nephrostomy tube for source control. Treated empirically with
Zosyn given history of prior cultures from ___
with E.coli and pseudomonas sensitive to Zosyn. Post-procedure
patient was quickly weaned off neosyneprhine and extubated.
Urine culture grew pan-sensitive enterobacter, patient was
started on PO ciprofloxacin on ___. This was changed to
ceftriaxone on ___ given concern for seizures and goal to
decrease seizure threshold as little as possible. Ceftriaxone
was switched to PO cefpodoxime after patient passed his video
swallow examination. Will be discharged with 7 day course of
cefpodoxime, will defer final antibiotic course to outpatient
urologist. Will follow-up with outpatient urologist (Dr.
___ at ___ regarding definitive management of
ureteral stone and nephrostomy tube.
# Seizures: Most likely triggered by his urosepsis,
Ciprofloxacin may also have been an exacerbating factor, so the
patient was switched to Ceftriaxone. His EEG monitoring showed
epilleptiform discharges that were consistent with possible
ongoing seizures. Neurologist was consulted and recommended
loading with Keppra as well as continuing Carbemazipine. The
frequency of his epilleptiform discharges was reduced and he
should be continued on both medications (keppra and
carbamazepine) on discharge.
# Atrial Flutter with RVR
Developed new flutter on admission. It has varied between a
variable counduction and a 3:1 block. He is adequately rate
controlled with Metoprolol. Patient was noted to have
subsegmental PEs, thus was started on warfarin. Echo was done
which was largely normal and did not show any sign of valvular
disease. Patient should continue warfarin as outpatient, and he
will be followed by the ___ clinic at his PCP's
office.
# Acute Kidney Injury
Creatinine increased from 1.2 on admission to a peak of 1.7,
then trended down with IV fluids. Likely related to
hypoperfusion from shock as patient's pressures dropped during
percutaneous nephrostomy tube placement in setting of receiving
sedation. Patient's home lisinopril was initially held in
setting of ___. UOP was monitored and continued to be adequate.
Creatinine and I/Os monitored daily. With improvement in
creatinine, lisinopril was restarted at patient's home dose.
# Pulmonary Emboli
CTA was ordered after he became acutely hypoxemic and altered on
planned day of discharge which showed subsegmental pulmonary
emboli without radiographic evidence of right heart strain. He
was initially started on a heparin drip and bridged to Coumadin.
Of note, patient became supratherapeutic on initial dose of
warfarin, thus dose was held, became subtherapeutic and is now
being bridged with lovenox. Current dose is 4mg daily of
warfarin, lovenox 90mg SC q12 hours. Will be followed by ___
___ anti-coagulation clinic (___) who
will manage his bridging. He should continue warfarin for 6
months, goal INR ___.
# Anemia
Patient's Hgb/Hct trended down from admission:
10.8/35.1-->9.4/30.4. Likely secondary to marrow suppression
from sepsis plus bleeding from procedure. Patient was
hemodynamically stable. H/H stabilized in the ___. Iron
studies were sent, but difficult to interpret in the setting of
sepsis. Would recommend repeat CBC to be done at next PCP
appointment, can do further work-up for causes of chronic anemia
if indicated.
# Quadriplegia/Urethral stricture:
S/p suprapubic cath. Urology consulted, no exchange during this
admission. Per urology note: do not recommending exchanging SPT,
as there is no evidence of effect on infections and may be
encrusted and lead to further bacterial seeding. Patient was
continued on his home doxazosin. Patient will follow up with his
outpatient urologist regarding further management of his
suprapubic cathter (has appointment with Dr. ___ at ___
___ Urology on ___ at 4pm, phone: ___.
# Hypocalcemia
Patient noted to be hypocalcemic. Vitamin D levels were normal.
Albumin was low at 2.6, corrected calcium was only slightly
below normal. PTH was appropriately elevated in the setting of
hypocalcemia. Patient was continued on vitamin d
supplementation.
CHRONIC ISSUES
# Right gluteal pressure ulcer: seen by wound care for dressing
recommendations.
# Hypertension
Home lisinopril was initially held in setting of sepsis, then
continued to be held in the setting of ___. Creatinine began
downtrending on ___, thus lisinopril was restarted.
# GERD
Continued on home omeprazole</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ old man with a history of A. fib not on
aspirin or anticoagulation, right occipital intraparenchymal
hemorrhage with intraventricular extension with residual left
field cut, hypertension and diverticulosis with GI bleed who
presents with right hand clumsiness. CT ANGIOGRAPHY HEAD AND NECK showed No significant abnormalities on CT of the head without contrast. No
significant abnormalities on CT angiography of the head and neck. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Study is mildly degraded by motion, and limited secondary to dental
hardware artifact.
2. Areas of slow diffusion, some with associated enhancement within the left
frontal and parietal lobes as detailed above concerning for acute to subacute
infarcts, with differential considerations of primary neoplasm or metastasis.
If clinically indicated, consider follow-up imaging to resolution.
3. Stable right occipital encephalomalacia.
4. Minimal paranasal sinus disease , as described. The patient was diagnosed with Cerebral infarction, unspecified. The patient was treated with N/A. At the time of discharge, the patient had Acute ischemic stroke. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year-old man with a history of atrial
fibrillation not on aspirin or anticoagulation, right occipital
intraparenchymal hemorrhage with intraventricular extension with
residual left field cut, hypertension, and diverticulosis
complicated by GI bleed who is admitted to the Neurology stroke
service with right hand clumsiness secondary to an acute
ischemic strokes in the left frontal and parietal lobes. His
stroke was most likely secondary to atrial fibrillation. His
deficits improved greatly prior to discharge and, in addition to
his baseline field cut, he had some ataxia of the right upper
extremity. He will be discharged home on atorvastatin 40mg and
Eliquis 5mg BID. His Keppra will be titrated down to 500mg daily
for 3 weeks and then off.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F PMH breast cancer s/p R mastectomy and implant
treated w/ anastrazole ___, w/ R chest wall local
recurrence ___ s/p excision along with regional R chest
radiation and ___ lumbar spinal stenosis, s/p
spinal fusion ___, who presents with acute ___ (1.9 from
baseline 0.8 on ___ in the setting of a recent viral
infection. US RENAL ARTERY DOPPLER showed Echogenic kidneys bilaterally, compatible with medical renal disease. No
evidence of renal artery stenosis. Radiology showed Successful placement of a 19cm tip-to-cuff length tunneled dialysis line.
The tip of the catheter terminates in the right atrium. The catheter is ready
for use. Chest radiograph showed Small effusions and mild atelectasis with no definite pneumonia or edema. CT ABDOMEN AND PELVIS WITHOUT CONTRAST showed 1. No acute findings within limitations of a non contrast examination. No
overt small or large bowel abnormality.
2. Small volume ascites/pelvic free fluid and diffuse anasarca. CT CHEST W/O CONTRAST showed 1. Small right greater than left pleural effusions with associated
atelectasis.
2. Stability of previously biopsied spiculated consolidation at the right lung
apex, felt to represent post radiation change, as per interventional report on
___, 6 month follow-up chest CT is recommended to ensure stability.
3. Short-term stability of 6 mm right upper lobe pulmonary nodule.
4. Stability of ___ opacity most apparent in the right upper lobe
suggestive of infection, possibly sequela of chronic aspiration.
RECOMMENDATION(S): As per prior interventional radiology report dated ___, 6 month follow-up chest CT to evaluate for stability of right apical
consolidation. BILAT LOWER EXT VEINS showed 1. No evidence of deep venous thrombosis in the right or left lower extremity
veins.
2. Aneurysm arising from the right popliteal vein without evidence of
thrombus. BX-NEEDLE KIDNEY BY NEPHROLOGIST showed Ultrasound guidance for percutaneous left kidney biopsy. RENAL U.S. showed -Mild increased cortical echogenicity in the bilateral kidneys, may suggest
medical renal disease.
-Numerous left peripelvic cysts are unchanged. No hydronephrosis.
-Small bilateral pleural effusions. Radiology showed Heart size is upper limits of normal. There are small bilateral pleural
effusions and subsegmental atelectasis at the lung bases. There is mild
prominence of the interstitial markings without overt pulmonary edema. There
are no pneumothoraces. The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had Primary Diagnosis:
Acute Kidney Injury
Hyponatremia
Fever. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ F PMH breast cancer s/p R mastectomy and implant
treated w/ anastrazole ___, w/ R chest wall local
recurrence ___ s/p excision along with regional R chest
radiation; lumbar spinal stenosis, s/p spinal fusion ___ who
presented with acute ___ of unknown etiology. Muddy brown casts
were seen, so the ___ was attributed to ATN from ___
nephropathy. The patient was started on dialysis. She also had
intermittent fevers throughout the hospitalization. A full
infectious ___ was negative. She underwent a kidney biopsy,
which showed ANCA+ ___ Rapidly Progressive
Glomerulonephritis. She was started on steroids,
cyclophosphamide, and plasmapheresis. Her fevers resolved. She
is being discharged to continue plasmapheresis as an outpatient.
She will continue on steroids and cyclophosphamide for at least
three months, and she is on atovaquone daily for PCP
prophylaxis, and ___ continue her vitamin D and calcium pills
for bone health.
#ANCA+ ___ Rapidly Progressive Glomerulonephritis
___
#Fever
___ attributed to ___ nephropathy. Patient
was initiated on dialysis. ID was consulted for fever, and full
infectious workup was negative. Renal biopsy on ___ consistent
with rapidly progressive glomerulonephritis. She was started on
steroids, cyclophosphamide, and plasmapheresis per renal
recommendations. She was also given atovaquone and PPI for
prophylaxis. She should follow up with her PCP ___: osteoporosis
and consideration of restarting a bisphosphonate.
- outpatient follow up with nephrology, rheumatology, her
oncologist, and her PCP
- ___ require CBC, ___ antibody this ___ and next
___ and ___, lab slip written
# Anemia
Fe studies c/w anemia of inflammation. Hemolytic studies
negative on repeat. She was given intermittent blood
transfusions for her anemia.
# Breast cancer in remission
S/p long treatment course with tamoxifen, now stopped since ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH chronic pancreatitis due to ethanol ingestion
(although there was a question of idiosyncratic reaction to
lisinopril), MDD, anxiety, seizure disorder ___ frontal lobe
atrophy(on keppra, followed by Neurology at ___) with recent
admission at ___ for pancreatitis presents with vomiting and
abdominal pain. He states that his abdominal pain never fully
resolved after his discharge from ___ on ___. Abdominal
pain acutely worsened and woke him from sleep 3AM on ___.
Unable to localize further than saying it is throughout his
abdomen. It was associated with nausea and self-induced
non-bloody, non-bilious emesis. Pt reports that he frequently
causes himself to vomit when he has acute on chronic
pancreatitis because it temporarily improves his pain. Describes
pain as diffuse, ___ and "horrible"; unable to characterize it
further. Denies fevers, chills, chest pain, sob, urinary
symptoms, diarrhea, constipation. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with CHRONIC PANCREATITIS. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with PMH pancreatitis, MDD, anxiety, seizure disorder, and
frontal lobe atrophy presented with abdominal pain, nausea,
vomiting and inability to tolerate PO, most consistent with
acute on chronic pancreatitis.
.
# Acute on chronic pancreatitis: The patient's diffuse abdominal
pain, elevated lipase (601), nausea and recent admission to OSH
for acute pancreatitis were all consistent with a new
exacerbation of pancreatitis, likely due to alcohol, although
patient denied excessive alcohol intake (reported 2 glasses of
wine a few days prior to symptom onset). RUQ U/S from ___
showed no evidence of gallstones; tbili and alk phos were normal
and LFTs only mildly elevated. Cholesterol panel from ___
showed: TC 206* ___ 49 HDL 98 LDL 98; had ___ 79 at OSh a few days
prior to admission. Normal calcium, no recent procedures to
suggest post-procedural pancreatitis. While lactate was elevated
on admission, it normalized within 24 hours. Although the
patient complained of diffuse abdominal pain (10+/10 to ___
throughout his hospital stay, he appeared comfortable at rest
and his pain was highly distractable during exams. His wbc was
elevated to 20K on admission but was normal on hospital day 2
after receiving IV fluids. On admission, patient was given
dilaudid IV for pain management, and switched to oxycodone once
he began tolerating liquids. He received Zofran as needed for
nausea. We progressed patient from NPO to clear liquids to a
regular diet over the course of 5 days. Of note, the patient's
vomiting is self-induced in an effort to relieve abdominal pain,
and we recommended that he should seek other ways of addressing
pain. There was concern on the part of the medical team that the
patient may be exaggerating his symptoms in order to fulfill
psychosocial needs. He did endorse significant stress at home,
as well as anxiety and depression. He was seen by ___ who noted
that he has support systems at ___ that he has not followed
up with. The patient was very reluctant to advance his diet and
transition to oral medications. He became highly upset with the
medical team on date of discharge, although the team felt that
he could have been discharged two days prior as he was
tolerating a regular diet and ambulating the halls without
evidence of discomfort. He repeatedly asked for unneccesary labs
to be ordered in what was conceived as an attempt to prolong his
stay. He became very agitated and left before we were able to
formalize his discharge and counsel him on steps moving forward.
.
# EtOH use: Per OSH notes, patient has a history of alcohol
abuse including prolonged ICU stays for alcohol withdrawal.
Serum and urine tox from recent admission to OSH were negative;
patient denied excessive EtOH use at that time, but was placed
on CIWA and required high doses of ativan. He continues to deny
excessive EtOH, but tremulousness, HTN and anxiety on admission
were concerning for possible EtOH withdrawal. After his first 24
hours with us, his CIWA score ranged from ___ (all points due to
anxiety) and the CIWA was discontinued. We treated him with
thiamine and folate. The ___ attending recommended
considering dual diagnosis program, either AD Care or the
___ Program but the patient denied excessive EtOH use and
said he was not interested.
.
# Seizure disorder (followed by ___ Neurology Dr. ___:
Attributed to frontal atrophy. Keppra dose decreased from 500
to 250mg BID during recent admission to ___ as it was thought
to be possibly contributing to delirium. Per ___'s discharge
summary, patient has outpatient Neurology appt. On ___, we
resumed his home dose (500mg BID) because we did not see any
signs of delirium and were concerned about seizure control.
.
# Major depressive disorder/anxiety: Mr. ___ was stable in
this area throughout his hospitalization. He was started on
risperidone for delirium per ___'s psychiatry during most
recent admission there with plan for "short course" although
discontinue date not recorded in discharge summary. Patient
reports that risperidone course was only 2 days, so we
discontinued. We continued his home doses of paxil and
trazodone.
.
# Hepatosteatosis: Seen on RUQ ultrasound ___. Likely ___
EtOH use. HIV negative, Hep C VL negative, Hep B surface antigen
negative on prior admission in ___. Hepatosteatosis is most
likely cause of mild transaminitis with normal tbili, normal alk
phos. Coags and platelets normal, suggesting preserved synthetic
function.
.
# HTN: Per OMR, patient has history of HTN, but not on any
anti-hypertensives currently. ___ records show he was
previously on amlodipine 5mg qd in ___. Given consistent
systolic BP >150, we started him on amlodipine 5mg daily on
___. Further BP management per his PCP.
.
# Constipation: Patient was successfully treated with
senna/colace and Bisacodyl/polyethylene glycol.
.
## Transitional issues:
- started amlodipine 5mg daily on ___ for SBPs to 160s.
Further management of hypertension per Dr. ___.
- patient endorses significant stress at home, as well as
depression and anxiety. He would benefit from outpatient
psychiatry follow-up.
- patient interested in obtaining outpatient nutritionist.
Nutritionist may also be able to offer assistance with
self-induced vomiting.
- please consider evaluating patients for celiac disease given
that patients with pancreatitis have been shown to be at higher
risk (___ Clin Gastroenterol Hepatol. ___.
- please consider evaluating patient for hyperthyroidism given
mild eye proptosis, tachycardia, anxiety, tremors, and sweating.
- ___ physician recommended enrolling patient in dual
diagnosis program such as AdCare or the Triangle Program.
Patient is not interested because he denies alcohol abuse, but
please consider readdressing this in the outpatient setting.
# Code: Full (confirmed)
# Communication: Patient
# Emergency ___ (HCP, former partner, personal
attorney): ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p R THA on ___, admitted via ED on ___ for hip
dislocation. Admitted to Trauma and taken to OR for reduction
and aspiration on ___. Of note, dislocated on ___ and
was reduced in ___ ED. Q61R showed 1. Status post right total hip arthroplasty in normal alignment. No evidence
of a periprosthetic fracture.
2. Up to 2 mm gap along the medial aspect of the acetabular prosthesis, this
is at the upper limits for normal suspicious for early loosening..
3. Large right gluteal hematoma, likely related to recent dislocation and
reduction. HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT showed A right total hip arthroplasty is present. Since the CT scan of the head from
earlier today, there is new posterosuperior dislocation of the femoral head
relative to the acetabular cup. An ossified fragment projects adjacent to the
lesser trochanter, unchanged when compared to the radiograph performed
yesterday. There is no acute periprostatic fracture. HIP NAILING IN OR W/FILMS AND FLUORO RIGHT showed Intraoperative images were obtained during closed reduction of dislocated
right THA. Please refer to the operative note for details of the procedure. INJ/ASP MAJOR JT W/FLUORO showed 1. Technically successful aspiration of right hip.
2. Superior dislocation of the right femoral component out of the acetabular
cup.
I Dr. ___ supervised the Resident/Fellow during the
key components of the above procedure and I have reviewed and agree with the
Resident/Fellow findings/dictation. PELVIS AP ___ VIEWS showed Status post right revision hip prosthesis in overall anatomic alignment. The patient was diagnosed with Dislocation of internal left hip prosthesis, init encntr, Exposure to other specified factors, initial encounter. The patient was treated with Right hip revision (acetabulum only) ___, ___. At the time of discharge, the patient had recurrent hip dislocation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the orthopedic surgery service and
was taken to the operating room with the Trauma team on ___
for right hip closed reduction and aspiration. He was then
transferred from the ___ to the ___ for a right
hip revision (acetabulum only) on ___. Please see
separately dictated operative reports for details. The surgeries
wer uncomplicated and the patient tolerated the procedures well.
Patient received perioperative IV antibiotics.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ female with a history of CVA ×2 without
residual defects, maintained on aspirin, who experienced a fall
from standing height on icy steps, landing on left elbow with
immediate pain and swelling. No numbness or tingling in her
left hand. States fall was due to slip on ice. Denies other
injuries. Radiology showed Comminuted, intra-articular fracture of the proximal ulna, involving the
olecranon, with some anterior angulation of the proximal portion. Significant
associated soft tissue swelling. Radiology showed Re-demonstrated comminuted, intra-articular fracture of the proximal ulna with
anterior angulation of the proximal portion, with associated prominent
overlying soft tissue swelling.
No additional fracture seen.
Subtle lucency in the soft tissue swelling may be artifactual, although soft
tissue gas from laceration or open fracture not excluded. ELBOW (AP, LAT AND OBLIQUE) LEFT PORT showed Intraoperative images were obtained during left elbow fracture ORIF. Please
refer to operative report for further details. The patient was diagnosed with Disp fx of olecran pro w intartic extn left ulna, init, Fall on same level, unspecified, initial encounter. The patient was treated with Open reduction internal fixation of left olecranon fracture. At the time of discharge, the patient had Left olecranon 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 left olecranon fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation of left olecranon, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the left upper extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with an orthopedic surgeon of her preference in
___. 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: The patient is a ___ year old man with past medical history
of thoracic outlet syndrome and right upper extremity DVT
presenting with blurry vision in his left eye for 6 weeks. MRI AND MRA BRAIN showed 1. No evidence of infarct. No focal lesions in the brain. Correlate
clinically and followup as needed for any change
2. No evidence of venous sinus thrombosis.
3. Apparent increase FLAIR hyperintense signal of the proximal left optic
nerve with some suggestion of swelling and possible slow diffusion. This may
represent optic neuritis or potentially ischemia. Further evaluation with MRI
of the orbits is recommended.
At the time of this dictation, MRI of the orbits had already been ordered by
clinical team.
Pl. See report. Radiology showed Increased signal intensity with mild edema and swelling and enhancement in the
left optic nerve as described above. Possibilities include optic neuritis,
demyelinating disease, inflammatory, etc. Ischemic/neoplastic etiologies
cannot be completely excluded.
Minimal asymmetry in the cavernous sinuses and superior ophthalmic veins on
some images only, of questionable significance.
Attention on close followup study can be considered.
Correlate clinically, with neuroophthalmologic consult examination and labs
and consider close followup to assess for interval change.
Please see the report on recent MRI brain study.
D/w ___ by ___ over phone at 4.30pm. soon after review.
NOTIFICATION: The patient was diagnosed with HEADACHE, VISUAL DISTURBANCES NEC. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo man with 6 weeks of blurry vision in his left eye which
reached nadir and is
improving, Headache, and eye pain. Examination with ___
___ with a left RAPD. EOMI, VFFTC but patchy areas of fuzzy
vision in left eye with red desaturation. Left disc is blurred.
Remaining exam is normal.
Labs/Test
MRI brain with no demylination
MRI orbit with left optic nerve slightly swollen, enhances, and
restricted diffusion.
CSF with 0rbc, 0wbc. nl prot/gluc
Impression: ___ with left optic neuritis. No evidence of other
regions of demylination. At 6 weeks out and improving there is
limited benefit of IV methylprednisolone. Risk of developing
MSis about 25%.
Discharged to home after 1d of admission.
Will followup with Neuro-ophthalmology (already scheduled) and
Dr. ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: (Primarily obtained from medical record and guardian as patient
cannot provide full history)
___ with a h/o psychiatric illness (?schizophrenia) with
repeated episodes of catatonia and dementia who presents from
ECT after arriving to her treatment session non verbal.
According to ___, the patient's legal guardian, The
patient was talkative upon leaving her nursing home but by the
time she got to ECT was nonverbal. She had not been taking her
meds for 3 days prior to presentation. She was last admitted for
a similar episode in the summer (___) followed by a
prolonged hospitalization. This episode had an unclear
precipitant. Additionally, on this presentation, the patient was
found to have a large bruise over the right arm. ___ reports
that she learned of this bruise only one day ago. The patient
cannot remember if she fell or hit her arm somehow. Radiology showed Removal of the existing left-sided chest port and placement of a new single
lumen left-sided chest port in the same pocket via the left internal jugular
approach with the tip terminating in the right atrium. The catheter is ready
for use.
COMPARISON:
Chest x-ray from ___ The patient was diagnosed with URIN TRACT INFECTION NOS, CATATONIA-UNSPEC. The patient was treated with Replacement of port. At the time of discharge, the patient had Primary: Catatonia, UTI
Secondary: SChizoaffective disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ h/o schizophrenia with catatonia, afib, presents with
catatonia and possible hypoactive delerium ___ UTI.
#Altered mental status, catatonia: This patient has a history of
prior, prolonged episodes of catatonia with unclear
precipitants. It appears that she is very sensitive to even mild
physiologic changes and thus is predisposed to these episodes.
Even mild UTI could precipitate an episode in this patient. UA
on admission suggestive of UTI although the patient denies any
symptoms. The UTI was treated (see below) and the patient's
medications were adjusted per the psych team--initially IV
Ativan 1 mg Q6H while the patient was refusing PO. This was
transitioned to PO. On discharge, the patient was medically
clear for ECT.
#Complicated UTI: Leukocytosis to 15, temp reportedly 100.4 at
ECT prior to admission, afib with RVR in ED. UA with 8 WBC's and
1 epi. No other obvious source for fever aside from malignant
catatonia. The UTI was also thought to be the trigger for this
episode of catatonia thus prompting the decision to treat
despite very clear evidence of symptoms. Received macrobid in ED
which was changed to PO cefpodoxime on the floor. Urine cultures
were sent.
#Afib with RVR: H/o stroke, not-anticoagulated per prior records
___ frequent falls. Rate to 160's in ED likely after missing
home meds and also in setting of likely UTI. Responded to IV
metoprolol. No further episodes on the floor after home
medications were restarted.
#Bruise/possible elder abuse: Per report from the psych team,
the patient notes that someone may have punched/pushed her at
her nursing home. Also reports going hungry many nights and
being fed leftovers. The ECT nurses also feel that she is
dirtier and may be neglected. Patient is not the most reliable
historian given her baseline cognitive deficits however these
stories were investigated. Social work was involved and spoke to
the patient and the legal guardian. Per the note, the legal
guardian was notl concerned and felt that the patient was
getting good care. She did agree to follow up with the staff at
the ___ home to ensure that she was getting as much
attention as she should be. Ultimately, the social worker
decided not to file a report for abuse/neglect since the
conversation with the guardian was reassuring. Further concerns
about any possible abuse in the future should prompt social work
and psych consultation.
#Access: The patient has very poor peripheral access. She has a
port in place on arrival that was placed at ___ in ___ when
she was there for prolonged hospitalization. This was found to
be in the wrong place and thus was exchanged here at ___ on
this admission. The procedure went well.
___. Patient was hemoconcentrated/hypernatremic on arrival and
per history had very poor PO. Likely pre-renal in etiology.
Received fluids and was given a diet and her lab values
improved.
#Hypernatremia. This has been a chronic problem. Of note, the
patient was on lithium in the past and was even admitted at one
point for lithium toxicity. This is likely causing a nephrogenic
DI which puts her at higher risk for developing hypernatremia.
There was also likely a component of hypovolemia contributing as
mentioned above. She was given free water and her hypernatremia
improved.
Chronic Issues:
#HTN: Stable while admitted. Her home ACE-i was held i/s/o ___.
#HLD: Stable. Continue home statin.
#GERD: stable. Home PPI was continued.
#med rec
-home b12, estradiol, bowel reg were continued
# Communication: The patient's legal guardian
is ___ ___. Second emergency contact
___
(brother) ___.
Transitional Issues:
-Patient is medically clear for ECT
-Patient should follow up with PCP upon discharge
-___ cultures pending at discharge</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a very pleasant ___ YO M with a history of
coronary artery disease status post CABG x4 (LIMA-LAD,
SVG-LCx-OMB(known occluded), SVG-RCA ___, peripheral
vascular disease (___ & RCIA stents) who presents with
complaints of chest discomfort. The patient has had prior
episodes of chest pain for which he has undergone intervention
to his grafts (see below). The last coronary angiography was on
___ where he was found to have SVG-RPDA 99% ISR, which
was treated with POBA and cutting balloon (4*10 mm). BILAT LOWER EXT VEINS showed No evidence of pseudoaneurysm bilaterally. The patient was diagnosed with Chest pain, unspecified. The patient was treated with laser with drug eluting balloon. At the time of discharge, the patient had CAD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ - Unable to add on to stress lab schedule, plan for cath
with Dr. ___
___ - Cath- SVG to RCA found to have ostial restenosis.
Successfully treated with laser and drug eluting balloon
___- stable overnight, no events, discharged on Plavix 75mg
daily indefinitely and aspirin 81mg daily lifelong. Bilateral
groin ultrasound revealed no pseudoaneurysm. He was seen by
Hematology service regarding his low platelets, ranged from
___ while admitted. He will follow up with ___ here
at ___ as an outpatient.</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 DMI, gastroparesis,
CKD V on transplant list with right arm fistula (not on
dialysis), presenting with nausea/vomiting. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality. The patient was diagnosed with Type 1 diabetes mellitus with ketoacidosis without coma, Long term (current) use of insulin. At the time of discharge, the patient had DKA
Gastroparesis
Acute on chronic CKD
Viral Syndrom. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old woman with DMI, gastroparesis,
CKD V on transplant list with right arm fistula (not on
dialysis), presenting with nausea/vomiting and mixed metabolic
alkalosis, respiratory alkalosis, and anion-gap metabolic
acidosis concerning for DKA.
#DKA: Patient with elevated blood glucose, urine ketones, low
bicarbonate and N/V consistent with DKA. Unclear trigger as
patient reports she has been taking her insulin appropriately.
Improved with fluids and insulin, ___
consulted. Insulin regimen adjusted during admission due to
persistent N/V and gastroparesis. By the time of discharge, pt
was tolerating po well without any N/V and the following insulin
regimen was recommended by ___.
Levemir 15units qam and 12units qpm
Humalog 3units with meals, with sliding scale
#Stage V CKD: Cr elevated to 4.6 in ED, increased from baseline
3.6. GFR difference is small from baseline GFR. On transplant
list. Continued to receive calcitriol and sevelamer CARBONATE
800 mg PO TID W/MEALS. Furosemide 20 mg PO daily held in setting
of N/V. Cr improved and pt was restarted on all home meds
including Furosemide and Losartan with stable creatinine. Pt
was noted to have persistent metabolic acidosis from advanced
CKD and was started on sodium bicarb 650mg TID. We recommend
follow up BMP at PCP follow up appointment on ___ as this
may need to be increased.
#Gastroparesis, Nausea and Vomiting: A major barrier to
successful transition to home was nausea/vomiting and lack of
appetite. Pt was trialed on Azithromycin for motility and
Olanzapine for N/V without significant improvement. Ultimately,
symptoms resolved with supportive care including bowel rest and
lorazepam/Zofran antiemetics.
#Respiratory Alkalosis: Most likely due to anxiety and distress
from nausea.
#Apnea on IV Ativan: Brief apneic episodes on admission to ICU
after administration of 1.5mg IV Ativan likely in setting of
acidosis. Pt was able to tolerate lorazepam PO 0.5mg -1 mg
without difficulty throughout the rest of hospitalization and
was continued on Ativan 0.5mg for breakthrough nausea on
discharge.
#Family Concern About Depression: Mother expressed concerned
about depression in the patient, she has issues with her not
eating at home and sometimes she goes an entire day without
eating. Husband in ___ currently and is not a good support.
In the past patient unable to afford psych visits. Psychiatry
was consulted and made recommendations to increase sertraline to
125mg daily. Pt was given a script for Sertaline 25mg to take
with her current prescription of 100mg. Pt would benefit from
ongoing outpt support from SW/counseling as an outpt - please
discuss with PCP at follow up.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Healthy ___ year old male with longstanding left sided hydrocele,
presented with 24 hours of L scrotal swelling and pain. Normal
bowel movements, normal appetite, no abdominal pain, no nausea. SCROTAL U.S. showed Fat containing left inguinal hernia extending into the scrotum. The
heterogeneity of the fat may be due to inflammation or related to
incarceration in the appropriate clinical setting.
NOTIFICATION: The findings were discussed with ___, RN working with
___, M.D. by ___, M.D. on the telephone on
___ at 2:24 pm, 10 minutes after discovery of the findings. SCROTAL U.S. showed 1. Re-demonstrated 7.9 cm heterogeneous elongated structure within the left
scrotum which may represent a large hernia. Equivocal fluid level(s) would be
atypical for fat only containing hernia. Cannot entirely exclude
incarceration, including possibly with bowel. CT scan would help further
assess.
2. No evidence of testicular torsion.
NOTIFICATION: Findings discussed with ___, Dr. ___ in
person on ___ immediately after the conclusion of the study. CT pelvis with contrast showed 6.0 x 2.5 x 4.5 cm left intrascrotal, extratesticular lesion, which borders
upon the epididymis, measuring 57 ___ with associated engorgement of the left
spermatic cord. Taking previous ultrasound findings and this CT into
consideration, these findings may be consistent with hematoma, however, as
this is only postcontrast imaging enhancement and thus an underlying lesion
cannot be excluded. Consideration should be given to MRI.
RECOMMENDATION(S): To exclude a mass, MRI should be considered. The patient was diagnosed with Unil inguinal hernia, w obst, w/o gangr, not spcf as recur. The patient was treated with ___: Left groin exploration. The patient was given written instructions concerning 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 Emergency Department on ___ with
left scrotal pain. Given findings, the patient was taken to the
operating room for inguinal hernia repair. The inguinal
exploration was negative. There were no adverse events in the
operating room; please see the operative note for details.
Patient was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
Given the negative inguinal exploration urology was consulted. A
CT scan was completed which showed a likely hematoma in the
scrotum. Patient was examined by urology and they will be
following the patient as an outpatient (urology team will
arrange follow up)
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV dilaudid and
then transitioned to oral oxycodone.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient diet was advanced sequentially to a
Regular diet, which was well tolerated. 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 a history of depression and anxiety with ongoing
psychosocial stressors, history of pulmonary embolism and
hypercoagulability non-compliant with anticoagulation,
hypertension, migraines and multiple previous ED presentations
with functional neurological symptomatology with recent stroke
admission found to have multiple embolic strokes (bilateral
pontine and cerebellar and left vertebral filling defect on CTA)
while non-compliant on enoxaparin and presents from rehab with
right fronto-parietal headache and right hemibody pain and
hyperaesthesia. Radiology showed 1. No acute intracranial process.
2. Evolving bilateral cerebellar infarcts. Known pontine infarct is not
well demonstrated on current exam. Reduced mass effect on ___ ventricle. Radiology showed No acute cardiothoracic process. Radiology showed 1. Evolving bilateral cerebellar and pontine infarctions with no mass effect
or hydrocephalus.
2. No evidence of dural sinus thrombosis.
3. Diminutive right vertebral artery as noted on CTA of ___. The patient was diagnosed with CHEST PAIN NOS, SKIN SENSATION DISTURB, HYPERTENSION NOS. At the time of discharge, the patient had Migraine Headaches. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ yo RHF with PMHx of depression,
anxiety, ongoing psychosocial stressors, hx of PE and
hypercoagulability with non-compliance with anticogulation, HTN,
migraines and multiple previous ED presentations with functional
exams and presentations with recent stroke admission for
multiple embolic strokes (bilateral pontine and cerebellar
infarcts with L vert filling defect on CTA), who represented
from rehab on this admission with a HA and R hemibody
pain/hyperaesthesia found on MRI to have no new infarcts.
# NEURO: we continued the patient's enoxaparin. Her MRI showed
no new infarcts so she was sent back to rehab. She continued to
c/o blurry vision while here, but no abnormalities seen on
fundoscopic exam, visual fields ___ grid testing.
However, she does have baseline mild R exotropia and did not
have her corrective lenses with her, which we felt was the
likely source of her blurre vision.
# ___: we continued patient's home antihypertensives. We
allowed her BP to autoregulate with a goal of < 180. Her
cardiac enyzymes were negative. She was monitored on telemetry
without events.
# ENDO: we continued patient's levothyroxine while she was here.
We also started her on an insulin sliding scale.
# PSYCH: we continued patient on her home bupropion and
sertraline.
# CODE: FULL confirmed with patient</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male with PMH of HFrEF (EF 20%), Afib on pradaxa, aortic
stenosis s/p bioprosthetic AVR (___), CAD s/p CABG (___),
DM, HTN, HLD, and neurodegenerative disease who p/w hypotension,
fatigue, right elbow pain/swelling for past month, worsened over
the past week. Noted by PCP to be hypotensive today to ___, sent
to ED for eval. Patient denies trauma, although had recent fall
last month in which he might have incurred trauma to the elbow
(per wife). Patient denies paresthesia or weakness of the R arm,
fevers, chills, chest pain, orthopnea, PND, dizziness, n/v/d,
recent URI or dysuria. CHEST (PORTABLE AP) showed Limited due to low lung volumes. Cardiomegaly without signs of pneumonia or
edema. Radiology showed Findings concerning for olecranon bursitis. The patient was diagnosed with HYPOTENSION NOS, SEPTICEMIA NOS, SEPSIS , ACCIDENT NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED. The patient was treated with R bursa drainage. At the time of discharge, the patient had Sepsis/hypotension
R olecranon bursitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT & PLAN: ___ with multiple medical problems including
ischemic CM (EF 25%) s/p CABG, AF on amiodarone and Pradaxa, AS
s/p BPAVR, DM, HTN, CKD, and an indeterminate neurodegenerative
disorder
(unable to walk at baseline), who is here with resolving sepsis,
fluid responsive hypotension, and acute on chronic kidney injury
likely related to septic olecranon bursitis.
# ID: Mr. ___ was admitted with hypotension, sepsis,
Septic olecranon bursitis. He had been admitted to the ICU with
SBP ___. He was given a small IV bolus and started on
vancomycin/zosyn. His BP quickly returned to normal. He was
seen by rheumatology and a small amount (2cc) of bloody drainage
was obtained from the bursa. It showed WBC ___, RBC ___.
Gram stain was negative. No crystals were seen.
The cultures have not returned yet. His WBC on admit was 14
and improved to 11 on day of discharge on IV vancomycin. Mr.
___ recognizes that the cultures have not returned yet,
but insisted on leaving (AMA or with medical advice) to attend
his great-grand nephew's ___. Given mult MRSA screens
which have been negative. Mr. ___ given a prescription for a 10
day course of clindamycin. He should follow up with his primary
care doctor to follow up his progress and the status of his
bursa cultures. There was no clear indication for a bursa
washout.
# ___: Mr. ___ was admitted with a Cr 2.6. It improved to
1.8 closed to baseline after the hydration and IV antibiotics.
His ACEI, metoprolol and diuretics were temporarily held during
this hospitalization. This can be restarted on discharge.
# CV: HTN/HLD, afib (on Pradaxa, amiodarone), chronic s/d CHF,
CAD s/p CABG, s/p BPAVR. As noted above, he was admitted with
hypotension and attributed to sepsis + mild dehydration. His
BNP was 1600 but he has been as high as 6000 in the past. He
appeared euvolemic on the day of dsicharge. He was continued on
pradaxa, amiodarone. He can resume home metoprolol, ACEI, and
diuretics at home.
# DM
- ISS while here
# Indeterminate neurodegen disorder: Seemingly stable.
- Continue home medications as indicated
# PPX: Anticoagulated.
# Consults: Rheum
# Disposition: Inpatient. d/c home (pt insisting)
# Code status: Full code</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old female with past medical history
significant for polysubstance abuse brought in by EMS for
altered mental status in the context of huffing, etoh use and
fall x2. Per report, patient was huffing and drinking etoh with
a friend this evening and was noted to become confused. She fell
and hit her head, without LOC. She was able to stand immediately
after, however fell again and was noted to have altered mental
status after. CT C-SPINE W/O CONTRAST showed No acute cervical spine fracture or malalignment. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, the endotracheal tube and
nasogastric tube have been removed. No evidence of pneumonia or vascular
congestion or pneumothorax. Chest radiograph showed 1. Endotracheal tube is low, right at the origin of the right mainstem
bronchus and should be retracted by 3 cm.
2. No pneumonia. CT HEAD W/O CONTRAST showed 1. No acute intracranial abnormality. Specifically no intracranial
hemorrhage.
2. Left frontal scalp and left periorbital soft tissue hematoma without
underlying fracture.
3. Radiopaque foreign body adjacent to the left globe in the periorbital soft
tissues is noted. The patient was diagnosed with Altered mental status, unspecified, Alcohol abuse with intoxication, unspecified, Other psychoactive substance abuse, uncomplicated, Contusion of other part of head, initial encounter, Abrasion of left eyelid and periocular area, init encntr, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had PRIMARY
======
Facial Laceration
Alcohol Withdrawal
Polysubstance Abuse
SECONDARY
========
Depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is ___ w/hx of polysubstance abuse BIBEMS for
altered mental status in the context of huffing, etoh use and
fall x2. Per report, patient was huffing and drinking etoh with
a friend and was noted to become confused. She fell and hit her
head, without LOC. She was able to stand immediately after,
however fell again and was noted to have altered mental status
afterward. Pt was tachy but otherwise stable in ED, however
became acutely agitated requiring intubation for her imaging,
which was unremarkable. Labs sig for serum ETOH 388, serum/Utox
otherwise neg. She was evaluated by trauma surgery who
determined that she had no injury requiring urgent intervention,
later tertiary survey was cleared by trauma. She was admitted to
the MICU for extubation pending mental status improvement, once
weaned off precedex and extubated, she was transferred to the
inpatient medical service. After transfer she showed signs of
alcohol withdrawal, was placed initially on ativan followed by
valium CIWA. Pt otherwise w/o Sx. After meeting with ___, Pt
agreed to EtOH detox after ___ sobriety, will f/u as
outpatient.
ACTIVE ISSUES
==========
# Polysubstance Abuse: Pt reportedly altered after EtOH
ingestion and huffing dust-off, also with fall and apparent head
strike. CT head/cspine unremarkable for abnormality, and
reported nonfocal neurologic exam prior to intubation (was
required for imaging in ED ___ continued agitation), neuro exam
after extubation wnl. Pt was agitated while weaning precedex.
Serum ETOH 388 in the ED, remainder of serum tox negative, Utox
negative, no serum Osm gap. Patient reportedly with 6x EtOH per
day, found to have elevated LDH, most likely i/s/o EtOH use, all
LFTs have trended down to WNL. Was requiring Ativan for EtOH
withdrawal, was adjusted to diazepam for longer acting effects,
and tapered off by DC. Neuro exam normal once mental status
improved, was cleared by ___ for tertiary survey. SW evaluated
pt, gave her information about ___ in
___ (run by ___, where her PCP and psychiatrist are),
where she can go on ___ at 11am for walk-in intensive
outpatient substance treatment intake/assessment as patient was
agreeable to detox by end of admission. Was DC'd with nicotine
patch, thiamine/folate/MVI.
# Trauma: Evaluated by trauma surgery given history of and
apparent evidence of fall with head strike. CT head negative in
ED, and reported nonfocal neurologic exam prior to intubation.
Given tetanus in ED. s/p dermabond repair to forehead. C-spine
cleared and tertiary survey without additional injuries noted
per ACS. Given wound care recs for laceration. No signs of
infxn.
CHRONIC ISSUES
===========
# Psych: restarted home clonidine, celexa. held gabapentin over
admission ___ concerns of oversedation, to restart at home
TRANSITIONAL ISSUES
==============
[] Follow up with primary care physician
[] Patient should cease alcohol use and substance abuse, will go
to ___ on ___ at 11AM for
intake.
[] Cleanse injury site with wound cleanser, pat dry, apply
triple antibiotic ointment, cover with adaptic and gauze for 3
days and then leave open to air, follow up with your primary
care doctor and monitor for signs of infection.
[] Pt's facial lacerations were dermabonded in MICU, please f/u
with PCP to ensure proper healing
[] Pt DC'd with thiamine, multivitamin, folic acid
# CODE STATUS: FULL CODE
# CONTACT: none</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx of cyclic vomiting syndrome with 3 prior hospitalizations
(2 at childrens and 1 at other OSH) presents with nausea and
vomiting x3. Patient is well aware of symptoms and knows to come
to hospital early in his course so he came early in his
nausea/vomiting. He was in obs in the ED for ___id
not vomit though still unable to take in adequate PO. He will be
admitted for IV hydration and observation. His neurologist is
aware pt is in the hospital. In ED his VS were 97.9 86 113/64 18
100%. He was given IVF, zofran IV, ativan IV prn, reglan IV and
transferred to the medicine floor
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail. Radiology showed Normal bowel gas pattern with no signs of obstruction. Radiology showed Normal non-contrast CT of the abdomen. No evidence of pancreatic
pathology. Radiology showed 1. Borderline low lying cerebellar tonsils.
2. Stable FLAIR signal hyperintensity without associated enhancement in the
left peritrigonal white matter may reflect sequela of prior insult such as
from perinatal ischemia or prematurity, or reflect prior demyelination. The patient was diagnosed with NAUSEA WITH VOMITING. At the time of discharge, the patient had Cyclic Vomiting syndrome. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient is a ___ hx of cyclic vomiting seen by neuro in
outpt setting who believes this is abdominal migraine (on
topamax) p/w nausea and vomiting with extensive GI/Neuro workup
here with refractory symptoms.
Cyclic vomiting syndrome: We started the patient on standing IV
pantoprazole, zofran and reglan with prn Ativan with IV fluids.
We also continued his home dose of topamax. Patient did very
well overnight and in the morning we started to advance a diet.
However, he did not tolerate liquids very well so we made him
NPO once more and increased his ativan. Unfortunately, we had
multiple attempts to advance his diet once we stabilized his
nausea and tried feeding him, his vomiting would return. The
patient and family became very anxious and frustrated at the
lack of progress being made. We consulted GI who initially
recommended to add on famotidine and sucralfate. We tried with
these medications but did not see much clinical improvement.
The final medication we added was hydroxyzine IM which seemed to
calm his anxiety. We discussed with the family that there may
be mutliple etiologies playing into this- that it could be
abdominal migraines, a seizure disorder, or other rarer diseases
that we had not looked for yet. GI took him for an endoscopy
with showed some mild gastritis but was otherwise unrevealing.
Neurology was consulted who recommended a sleep-deprived EEG
which came back negative. Additionally, we consulted psychiatry
who recommended increasing his home dose of citalopram but there
would be a risk of GI side effects so the patient declined. At
the end of the week, we were finally able to transition him to
tolerate PO and the patient was discharged.
THE PATIENT WAS READMITTED TWO DAYS LATER- PLEASE REFER TO THE
FOLLOWING DISCHARGE SUMMARY FOR FURTHER INFORMATION</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old female with a history of
severe LV diastolic dysfunction, difficult to control
hypertension, atrial fibrillation on apixaban, CAD s/p MI, DM,
and PVD who presented to the hospital with respiratory failure
requiring BiPAP. CHEST (PORTABLE AP) showed Simplest explanation for combination of current interstitial edema, chronic
cardiomegaly, bilateral pleural effusions and bibasilar consolidation is heart
failure with lower lobe predominant edema, but concurrent heart failure and
pneumonia should be considered also.
Chronically poor aeration in the left lower lobe needs to be explained.
Perhaps it is due to cardiomegaly and bronchial compromise. UNILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the left lower extremity veins. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___ most recently ___.
Moderate pulmonary edema has worsened, obscuring what may have been
pre-existing pneumonia in either or both lower lobes. Severe cardiomegaly is
stable. Moderate right pleural effusion has increased. No pneumothorax. Radiology showed Nonspecific, nonobstructive bowel gas pattern. Stool and gas are seen
throughout the colon. FOOT AP,LAT AND OBL LEFT showed No radiographic evidence of osteomyelitis in the left foot. If there is
continued clinical concern, further evaluation with MRI is recommended. ART EXT (REST ONLY) showed No evidence of significant arterial insufficiency to the right lower extremity
at rest.
Moderate tibial arterial insufficiency to the left lower extremity at rest The patient was diagnosed with Pneumonia, unspecified organism, Heart failure, 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>Ms. ___ is an ___ yo female with severe
HFpEF, CAD, Afib on apixaban, HTN who presented ___ with
hypoxic respiratory failure in the setting flash pulmonary edema
secondary to likely HTN and an acute exacerbation of known
chronic diastolic heart failure. She initially required ICU for
BiPAP support and IV diuresis. She was diuresed with
intermittent boluses of IV lasix 60-120mg and subsequently
weaned to oxygen via nasal cannula. Once on the medicine service
she was transitioned Torsemide 20mg daily. She also completed a
5 day course of Levaquin for treatment of presumed CAP based on
initial CXR findings. Physical therapy evaluated the patient who
recommended discharge to rehab.
# Acute hypercarbic hypoxic respiratory failure
# Acute on chronic diastolic heart failure:
On presentation ___, she had pulmonary edema with BNP elevated
to 1590, consistent with HFpEF exacerbation. Trigger likely
multifactorial with contributions from inadequate diuresis with
concomitant CAP (see below), possible dietary indiscretion
(Meals on Wheels food delivery), poorly controlled BP, and/or
anemia. Notably her weight was 80kg on admission approximatelly
8kg up from last dry weight in ___. She initially
required BiPap support in the ICU. Oxygen status improved with
IV lasix boluses of 60-120mg lasix. She was transferred to the
medicine service ___. PO torsemide was initiated ___ at 20mg
daily. Additionally she continued her home Carvedilol 25mg BID
and Hydralazine 10mg TID. At time of discharge her weight was
75.3kg and Sr Cr 1.1. She was discharged on room air.
# CAP: Patient SOB also possible triggered or contributed to by
concomitant PNA demonstrated on CXR ___. WBC elevated to 10.4
on presentation and was hypothermic. Notably flu swab was
negative. She was treated with a 5 day course of Levaquin for
CAP which concluded ___.
# Chronic Normocytic Anemia: Newly discovered during prior
hospitalization ___ with BRPBR reported by patient (but
stools guaic neg). On this admission was guaiac positive in ED.
This is most likely due to slow GI bleed. Given likely GI source
of bleeding, colonoscopy would be warranted, but per outpatient
GI and the patient's son, risks outweigh benefits and given
stability of her levels, colonoscopy was deferred. Iron studies
consistent with Fe deficiency, and ferrous sulfate treatment
initiated while inpatient. She continued Omeprazole 20mg daily
and hemoglobin remained stable during admission.
# Altered mental status
# Moderate Dementia: On home donepezil for presumed moderate
dementia, but per son at baseline she is A and Ox3. During
admission was noted to be AOx2 likely a reflection of toxic
metabolic encephalopathy secondary to electrolyte abnormalities
and likely delirium. She continued her home Donepezil 10mg QHS.
# ___: Sr Cr slightly elevated from baseline 1.3 from 1.0 ___
likely in the setting of hypovolemia from overdiuresis. Diuresis
was held ___ and ___ subsequently resolved.
CHRONIC PROBLEMS
========================
# Left foot ulceration
# PAD: Patient diagnosed with chronic venous stasis ulceration
during ___ hospitalization of left lower leg. She was
again evaluated by Vascular surgery and repeat ABIs during
admission demonstrated poor L tibial artery flow. Vascular
surgery deferred acute intervention and recommended supportive
care. Wound care evaluated the patient and provided dressing
recommendations.
# Atrial fibrillation: History of atrial fibrillation, rate
controlled with Carvedilol 25mg BID, CHADsVASc score of 7. She
was continued on home Apixaban 2.5mg BID in setting of stable
hemoglobin. Can consider uptitration to 5mg daily provided H/H
stable as patient qualifies for higher dosing. .
# Diabetes: Metformin was held while inpatient and patient
placed on sliding scale insulin.
# Coronary artery disease, history of MI
# HLD: Continued home Rosuvastatin Calcium 20 mg PO QPM and
Carvedilol 25mg BID. Aspirin has been held since ___
discharge in setting of likely GI ooze. Decision to restart
aspirin will be an ongoing discussion as outpatient.
# Hypothyroidism: Continue home Levothyroxine Sodium 50 mcg PO
DAILY </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ old man BIBA today with a history of EtOH
abuse and HCV, as well as a history of withdrawal seizures, who
was sober for 3.5 months previously, started drinking again 2
weeks ago and ran out of alcohol last night. Today drank
mouthwash, could not keep it down, felt that he was shaking, and
then his building manager witnessed that he had two seizures.
Sent by ambulance for evaluation.
In the ED, initial vitals:
T 97.3 HR 100 BP 152/84 RR 19 97% RA CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial process. No hemorrhage.
2. Status post right mastoidectomy. Unchanged partial bilateral mastoid air
cell opacification.
3. Left frontal sinus mucosal thickening involving the left frontoethmoidal
recess.
4. Stable chronic findings, including minimal age-appropriate global
involutional change and vascular calcifications. CHEST (PORTABLE AP) showed In comparison with the study of ___, the cardiac silhouette is
more prominent and there is indistinctness of pulmonary vessels suggesting
elevation of pulmonary venous pressure. The left hemidiaphragm is more
elevated on the current study. Bibasilar atelectatic changes are seen.
Although no definite consolidation is appreciated, in the appropriate clinical
setting superimposed pneumonia would be difficult to exclude, especially in
the absence of a lateral view. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
2. Cholelithiasis without evidence of cholecystitis. The patient was diagnosed with Alcohol dependence with withdrawal, unspecified, Unspecified convulsions. At the time of discharge, the patient had PRIMARY DIAGNOSES
=================
#withdrawal seizure
#alcohol withdrawal
#alcohol abuse
#Transaminitis
#thrombocytopenia
#Anion-gap metabolic acidosis
#Refeeding syndrome
SECONDARY DIAGNOSES
===================
#hyperlipidemia
#glaucoma. The patient was given written instructions concerning 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 with a history of EtOH abuse and
HCV and a history of withdrawal seizures (last ___ years ago)
who presented to ___ with acute alcohol intoxication s/p two
witnessed seizure-like episodes.
The patient had been sober for 3 ½ months, however two weeks ago
began drinking up to 30 beers per day. He ran out of alcohol the
day before ___, and due to the liquor stores being
closed he drank a bottle and a half of mouthwash. He began
vomiting, and apparently lost consciousness and was found by his
building manager to be having a seizure-like episode. He was
sent to the ED at ___ and was admitted to the ICU. He was
noted to have an anion-gap metabolic acidosis, and was placed on
a phenobarbital taper for withdrawal symptoms. His course was
complicated by hallucinations and likely refeeding syndrome due
to lack of food intake during his alcohol binge. His symptoms
subsided, he was transferred to the medicine floor, and he was
successfully weaned from phenobarbital.
ACUTE ISSUES
============
# Seizure: Likely due to alcohol withdrawal vs toxic effect from
mouthwash ingestion. Pt has hx of prior withdrawal seizure ___
years ago. He was found to be having seizure-like activity prior
to admission by building manager and was sent to the ED. His
EtOH level was 254 on admission, however the patient reports
drinking 30 beers per day for two weeks prior to the seizure so
he could have experienced a relative withdrawal even given a
high BAC. We treated with a phenobarbital taper, and he had no
further seizure activity.
# Alcohol withdrawal: As above, patient experienced vivid
hallucinations during part of his course, however these resolved
with phenobarbital administration. He was given IV thiamine for
three days then PO thiamine thereafter. He was monitored on CIWA
protocol and supplemented with MVI and folate. He should
continue MVI, folate and thiamine after discharge.
# Refeeding syndrome: The patient was noted to hypophosphatemia
after eating, likely secondary to refeeding syndrome. He
reported poor PO intake, particularly over the past week while
drinking large quantities of alcohol. He was treated with
intermittent phosphate administration during his course.
Phosphate was WNL on the day of discharge.
# Alcohol abuse: Complicated by HCV. Pt was sober for 3.5 months
until two weeks PTA. He has been a member of AA for ___ years and
says it works well for him when he is able to stick with it.
This is his main support system. Pt states that he is not
interested in going to a detox program, and just wants to follow
up with his regular AA meetings. The patient was evaluated by
social work to reinforce abstinence. The patient should f/u with
PCP for further support and management.
# Anion-gap metabolic acidosis: Admission AG of ___ with osm gap
of 62. Likely from lactic acidosis (7.8 on admission) vs
mouthwash ingestion. Resolved with fluids.
# Transaminitis: Pt was noted to have hepatocellular pattern of
LFTs on admission, likely secondary to alcoholic hepatitis with
contribution of HCV vs toxic effect of mouthwash (case reports
describing multi-organ failure after mouthwash ingestion). The
patient was evaluated with RUQ US which showed echogenic liver
consistent with steatosis, but could not r/o steatohepatitis or
significant hepatic fibrosis/cirrhosis. LFTs down during his
course by the time of discharge. The patient should f/u with
hepatology for further evaluation and management, for
consideration of repeat RUQ US or additional liver testing for
further characterization of underlying disease, and for
consideration of further treatment of HCV as indicated.
# Thrombocytopenia: Platelets fell from 199 on admission to 111.
This was thought to be secondary to patient's underlying liver
disease vs. acute effect of heparin (non-HIT mechanism). The
platelets at discharge trended up to 118.
# hyperlipidemia: Continued home simvastatin
# Glaucoma: Continued latanoprost eye drops
Transitional Issues
- f/u Healthcare proxy forms, patient stated that he wanted to
designate ___ as HCP, he was provided with the form to
complete this
- f/u with hepatology for further management of hepatitis C and
possible liver disease, consider repeat RUQ US or other imaging
for further evaluation as needed
- f/u with PCP for further management of medical conditions.
- Patient will need repeat CBC, LFT's, chemistry panel as
outpatient.
- Please obtain repeat UA as outpatient given evidence of
hematuria on UA.
- Continue to re-inforce attending AA meetings in future. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ ___ gentleman with a history of iCMP (EF
35%, stable 3VD) and stage IIIb colonic adenocarcinoma with
microsatellite instability s/p C1 FOLFOX not tolerated ___
thrombocytopenia, s/p CK, s/p 3 cycles of palliative intent
pembrolizumab with progression of disease who was found to have
elevated creatinine prior to C4 of pembrolizumab. Radiology showed No pneumonia. RENAL U.S. showed No hydronephrosis or definite stones. RENAL U.S. showed No evidence of renal vein thrombosis or hydronephrosis. The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had Primary Diagnosis:
#Acute on Chronic Kidney Injury
#Acute tubular necrosis
Secondary Diagnoses:
#Ischemic Cardiomyopathy
#Chronic Systolic Heart Failure
___ chronic pain
#Type II Diabetes Mellitus
#Advanced MSI Colonic Adenocarcinoma
#Hx LV thrombus
#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>Mr. ___ is a ___ ___ gentleman with a history of iCMP (EF
35%, stable 3VD) and stage IIIb colonic adenocarcinoma with
microsatellite instability s/p C1 FOLFOX not tolerated ___
thrombocytopenia, s/p CK, s/p 3 cycles of palliative intent
pembrolizumab with progression of disease who was found to have
elevated creatinine prior to C4 of pembrolizumab.
#Acute on Chronic Kidney Injury
#Acute tubular necrosis: Baseline Creatinine ___. Creatinine
upon admission 4.4, which was presumed to be prerenal in setting
of poor PO and taking medications incorrectly (taking extra
Lasix, lisinopril, and metformin). Contrast nephropathy may have
contributed, as well, given staging CT on ___. Renal ultrasound
without evidence of obstruction or thrombus. Urine sediment with
hyaline and granular casts, but no evidence of a
glomerulonephritis (nephritis is a possible pembro toxicity).
Renal function improved with cautious IV fluids and holding
nephrotoxins. Renally cleared meds were held, including
apixaban, oxycodone, oral hypoglycemic.
Nephrology was consulted, who agreed with the above. At the time
of discharge creatinine was 2.0. It was felt that ___ was due to
patient surreptiously taking extra Lasix after his ___ caremark
stopped bubble packing his medications for a few days.
#Ischemic Cardiomyopathy
#Chronic Systolic Heart Failure. Patient with dyspnea/orthopnea
in past after ___ cyberknife session and was treated for HF
exacerbation in past. ___ be etiology of ___. ___ ECHO
showed Normal LV cavity size with EF 32%. TTE here with EF of
25%. Home Lasix and ACEi were held in setting of ___. Continued
home atorvastatin and coreg. Lasix and ___ were held at d/c to
be resumed after ___ if creatinine normalizes.
___ chronic pain: Localized to abdomen at this time.
oxycodone converted to hydromorphone equivalent
#Type II Diabetes Mellitus: Held metformin, repaglinide; Lispro
sliding scale while in house
#Advanced MSI Colonic Adenocarcinoma: Did not tolerate FOLFOX
given cytopenias. s/p CK. Has progressed on pembrolizumab, which
was held during hospitalization. Further plans per outpatient
oncology.
# Hx LV thrombus: Notes document that patient was on apixaban in
past for LV thrombus, but no recent documentation. On review of
___ records, it appears that patient was on
apixaban in past for LV thrombus in setting of reduced EF from
ischemic CM. He then had redemonstrated LV thrombus in ___
during ___ admission, and was restarted on apixaban,
and had ___ ECHO that showed persistent thrombus. While in
house Echo shoed no thrombus (but sensitivity of TTe for LV
thrombus ___ %). However, given patient's difficulty with
proper adherence to medications and reason for admission
(surreptious use of Lasix) decision was made to hold apixaban on
discharge, and follow up with his cardiologist Dr. ___
consideration of resuming anticoagulation. His PCP and
oncologist were made aware of decision to hold anticoagulation. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old man presented to the ___ ED with approximately 1
day of painless gross hematuria associated with clot retention,
admitted to urology for CBI overnight and once urine cleared
discharged to home. Radiology showed 1. Foley balloon is seen within the right prostatectomy fossa. Distended
bladder with layering dependent hyperdense nonenhancing material, likely due
to a clot. Repositioning is recommended given the location of the balloon and
incomplete decompression.
2. Multiple small bladder diverticulum at the dome.
3. No urolithiasis or hydronephrosis. No definite filling defect is seen
within the upper tracts to suggest urothelial lesion.
4. Partially thrombosed focal infrarenal abdominal aortic aneurysm measuring
3.6 x 3.2 cm. Aneurysm of the left common iliac artery up to 2.9 cm.
RECOMMENDATION(S): Repositioning of the Foley catheter.
NOTIFICATION: Finding #1 was discussed with ___ by ___ phone at
5:45pm on ___, 10 minutes following discovery. The patient was diagnosed with Retention of urine, unspecified, Hematuria, unspecified. The patient was treated with Cystoscopic Foley Catheter placement on ___. At the time of discharge, the patient had Gross Hematuria with Clot 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>Mr. ___ was admitted to Dr. ___ service for CBI
after presenting to the ___ ED with painless gross hematuria
with clot retention. In the ED there was some difficulty hand
irrigating and recurrent blockage of CBI therefore urology was
consulted and replaced the catheter and were able to hand
irrigate to clear however there continued to be reports of
intermittent catheter blockage from CBI
CT urogram obtained as part of a routine hematuria workup
revealed that the Foley catheter had been pulled down into the
empty prostatic fossa. Given this the catheter was replaced
cystoscopically on HD1 and following this hand irrigation was
found to be substantially easier than prior. CBI was run
overnight and clamped on HD2.
In the morning of HD2 his urine was clear translucent, red and
without clots. He remained a-febrile throughout his hospital
stay. At discharge, the patient's pain well controlled with
oral pain medications, tolerating regular diet, ambulating
without assistance, and voiding without difficulty. He is given
pyridium and oral pain medications on discharge and a course of
antibiotics. He is given explicit instructions to follow up in
clinic for Foley catheter removal and void trial. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with multiple myeloma s/p auto transplant in ___ w
recurrence(on and off revlimid since ___, diastolic CHF, h/o
AVNRT s/p ablation, AFib, HTN, hyperlipidemia, who is presenting
from outpatient ___ clinic for atrial fibrillation with
RVR. CHEST (PORTABLE AP) showed Mild interstitial edema. The patient was diagnosed with ATRIAL FLUTTER. The patient was treated with ___ Right atrial tachycardia ablation with line from CS
ostium to IVC. At the time of discharge, the patient had PRIMARY DIAGNOSIS
------------------
Right atrial tachycardia (likely reentrant). The patient was given written instructions concerning 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 multiple myeloma s/p auto transplant in ___ w
recurrence(on and off revlimid since ___, diastolic CHF, h/o
AVNRT s/p ablation, AFib, HTN, hyperlipidemia, who is presenting
from outpatient ___ clinic for recurrent SVT.
BRIEF HOSPITAL COURSE
=======================
ACTIVE ISSUES
--------------
SUPRAVENTRICULAR TACHYCARDIA: Patient appears to have e/o atrial
flutter and atrial fibrillation with RVR on admission.
Previously has had an ablation for AVRT. Currently medically
managed with several medications including amiodarone switched
to atenolol switched to metoprolol, with breakthrough of
symptoms and atrial fibrillation. s/p successful cardioversion a
few months ago, but back in atrial fibrillation c/b by recurrent
episodes of RVR. Patient underwent a right atrial tachycardia
ablation with line from CS ostium to IVC. Procedure noted to
have multiple tachycardias during study, however, was
uninducible after ablation. Telemetry noted to have conversion
to sinus after the procedure, intermittently back in SVT, but
without RVR. Patient discharged with Ziopatch monitor,
metoprolol restarted at 50 XL on discharge. Patient is to follow
up with Dr. ___ on ___.
# DIASTOLIC CONGESTIVE HEART FAILURE, no acute exacerbation:
Patient on home dose Lasix and potassium, initially held pending
procedure. Patient noted to have increased congestion, but
otherwise appeared euvolemic. Weight increased slightly from
70.1 kg on admission to 71.0 on day of discharge. Patient given
IV Lasix 20 on day of discharge. PO Lasix 40 with potassium
restarted on discharge
CHRONIC STABL ISSUES
# MULTIPLE MYELOMA: Patient followed by Dr. ___. Revlimid
held during hospitalization ___. This was restarted
on discharge.
# HYPOTHYROIDISM: Continued home levothyroxine
# HYPERTENSION: Beta blocker held on admission as per above.
Beta blocker restarted on admission.
# HYPERLIPIDEMIA: Patient continued on home statin
# VITAMIN D DEFICIENCY: Patient continued on home vitamin D
supplementation
TRANSITIONAL ISSUES
=====================
[] Patient to follow up with Dr. ___ in one month for
post-ablation procedure
[] Patient will need follow up appointment with Dr. ___,
___. This was unable to be scheduled prior to discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female with PMH significant for
HTN, HLD, DMII who presented to ___ with nausea,
vomiting, diarrhea, abdominal pain, hypotensive, found to be
septic ___ cholangitis now transferred for further management of
sepsis and possible ERCP. Radiology showed 1. No fracture or dislocation. Mild degenerative changes.
2. Soft tissue prominence over the dorsal aspect of the foot. The patient was diagnosed with CHOLANGITIS. The patient was treated with ERCP with stent placement. At the time of discharge, the patient had Cholangitis
Choledocholithiasis
Bacteremia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female with PMH significant for
HTN, HLD, DMII who presented to ___ with nausea,
vomiting, diarrhea, abdominal pain, hypotensive, found to be
septic with cholangitis transferred for further management of
sepsis and possible ERCP.
# Sepsis, cholangitis, bacteremia. Pt. with acute onset of
nausea/vomiting. Presented to OSH with elevated LFTs, TBili,
lipase later found to have evidence of cholelithiasis,
choledocholethiasis, and likely cholangitis on abdominal
ultrasound, MRCP, and HIDA scan. Pt. was placed on cefazolin at
the outside hospital and given several liters of IVF. OSH Blood
cultures later pan-sensitive Ecoli. Antibiotics will continue
for a 14 day course(day #1 ___. Patient was on IV
antibiotics (Zosyn) initially, and then transitioned to cipro
last day of antibiotics ___. Patient will need repeat ERCP
in 4 weeks for stent removal. Dr. ___ will contact
the patient with an appointment.
#Pancreatitis: Pt. with acute worsening of chronic back pain
located in middle of back at midline later found to have an
elevated lipase to 2000s at OSH. Likely ___ gallstone
pancreatitis. Pt received upportive treatment with IV fluids,
bowel rest and pain management. The patient was tolerating a
regular diet prior to discharge.
# Left lower lobe infiltrate: Pt. with evidence of LLL
infiltrate at OSH. Pt. without evidence of cough, SOB, or other
symptoms suggestive of pneumonia. She was not given antibiotics
for pneumonia while hospitalized.
# Anemia: Pt. with normocytic anemia. Last hct at PCP office
was in ___ (34). Recommend repeat CBC next week. HCT on
discharge 27.4.
# ___: Pt. with evidence of elevated creatinine and elevated
BUN/Creatinine ratio, likely pre-renal. Improved with IV fluids.
Creatinine on discharge 1.3. Recommend repeat BUN/Cr check next
week.
#Hypertension, benign
Patient with history of hypertension, antihypertensives were
held on admission in the setting of sepsis and cholangitis.
Recommend resuming Amlodipine and Metoprolol. IF blood pressure
tolerates, can resume additonal blood pressure medications.
#B/L foot pain
Patient had complaints of B/L foot pain on the day prior to
discharge. She underwent xrays which were negative for fracture.
It is possible her foot pain represents neuropathy given that it
is bilateral and burning in nature. Could consider trial of
gabapentin if persits.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ year-old male with a history of IVDU, endocarditis,
prior cervical osteomyelitis, Hep B, HCV untreated,
depression/anxiety, recently treated at ___ for one month with
IV
vancomycin, left AMA from rehab last week, presenting with body
aches and chills. US EXTREMITY LIMITED SOFT TISSUE RIGHT; UNILAT UP EXT VEINS US
RIGHT showed 1. There is thrombus within the right basilic (superficial) vein. Other
superficial and deep veins of the right upper limb are patent and demonstrate
normal flow.
2. Fluid collection overlying olecranon measuring 2 x 0.6 x 3 cm, most likely
representing olecranon bursitis.
3. No drainable collection seen around the right ankle or wrist. US EXTREMITY LIMITED SOFT TISSUE RIGHT; UNILAT UP EXT VEINS US
RIGHT showed 1. There is thrombus within the right basilic (superficial) vein. Other
superficial and deep veins of the right upper limb are patent and demonstrate
normal flow.
2. Fluid collection overlying olecranon measuring 2 x 0.6 x 3 cm, most likely
representing olecranon bursitis.
3. No drainable collection seen around the right ankle or wrist. US EXTREMITY LIMITED SOFT TISSUE RIGHT; UNILAT UP EXT VEINS US
RIGHT showed 1. There is thrombus within the right basilic (superficial) vein. Other
superficial and deep veins of the right upper limb are patent and demonstrate
normal flow.
2. Fluid collection overlying olecranon measuring 2 x 0.6 x 3 cm, most likely
representing olecranon bursitis.
3. No drainable collection seen around the right ankle or wrist. CHEST (PA AND LAT) showed 5 mm nodular density in the right upper lobe may correspond to small pulmonary
nodules seen on the prior CT chest dated ___. At that time
recommendations for follow-up were provided.
Bibasilar atelectasis. No focal consolidation. CHEST (PORTABLE AP) showed New diffuse reticulation and ground-glass change throughout the lung
parenchyma, with suspected ___ B-lines at the inferior lung zones,
suggesting at least some vascular congestion or pulmonary edema.
Patchy opacity in the right infrahilar lung may reflect superimposed
consolidation.
Otherwise chronic changes, as above. ANKLE (AP, MORTISE AND LAT) RIGHT showed No acute osseous abnormality of the right ankle. No radiographic evidence of
osteomyelitis. The patient was diagnosed with Acute and subacute infective endocarditis, Oth bacterial agents as the cause of diseases classd elswhr. At the time of discharge, the patient had PRIMARY DIAGNOSIS
===================
Fever, chills. The patient was given written instructions concerning 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:
==================
[] PCP:
- ___ start iron as patient found to be iron deficient, but
iron deferred in setting of concern for infection
- Will need to continue on his rivaroxaban 20MG daily. Given
unclear treatment history (prolonged periods of non-adherence),
full duration of treatment will need to be determined
- Will need repeat echo in ___ months to ensure improvement in
EF (45% at this hospitalization)
- Given smoking history, pt may benefit from f/u of 6mm SPN with
optional CT in 12 months
[] ID:
- Would benefit from treatment for known Hepatitis C
- Should have hepatitis B viral load drawn after continued
therapy with entecavir
#CODE: Full Code, presumed
#CONTACT: none given</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ year old female with a history of EtOH
cirrhosis, IPH in ___ resulting in seizure disorder,
dysarthria, left hemiparesis and ___ nerve palsy, Afib, and
C-diff who presented to the ED with two generalized seizures. Radiology showed Successful exchange of a gastrostomy tube for a new 22 ___ MIC gastrostomy
tube. The tube is ready to use. CHEST (PORTABLE AP) showed In comparison with the study of ___, the diffuse bilateral pulmonary
opacification may have slightly decreased. Nevertheless, there is again
substantial enlargement of the cardiac silhouette with bilateral pleural
effusions an areas of compressive lung volume loss. The mediastinum is not
appreciably shifted on the current study.
The right PICC line again extends to the mid to lower portion of the SVC. The
endotracheal tube and nasogastric tube have been removed. Radiology showed Stable position of gastric feeding tube. CHEST (PORTABLE AP) showed Endotracheal tube terminates 8.2 cm above the carina and would recommend
advancement by approximately 5 cm for more optimal positioning. CHEST (PORTABLE AP) showed Enteric tube now high in position with the side port in the upper to mid
thorax. Recommend advancement by approximately 15 cm so that it is well
within the stomach.
Endotracheal tube now terminates approximately 3 cm above the carina.
Low lung volumes and persistent streaky bibasilar opacities. CT HEAD W/O CONTRAST showed 1. No acute intracranial process.
2. Unchanged large area of temporoparietal encephalomalacia involving the
right basal ganglia and posterior right thalamus, with secondary ex vacuo
dilatation of the right lateral ventricle.
3. Aerosolized secretions in the upper oropharynx, in addition to paranasal
sinus and sphenoid sinus mucosal thickening, likely related to intubation. Radiology showed Nasoenteric tube terminating below the diaphragm likely in the stomach. Radiology showed Severe enlargement of the cardiac silhouette has progressed since ___, due
to worsening cardiomegaly and/or pericardial effusion. Pulmonary vascular
congestion has worsened, but there is no pulmonary edema as yet. New
atelectasis in the right lower lung could be middle or lower lobe. Severe
left lower lobe atelectasis has also worsened, and both are accompanied by at
least small pleural effusion its.
ET tube in standard placement. New right PIC line ends in the right atrium at
a level no less than 8 cm below the carina, and would need to be withdrawn 4
cm to reposition it at the superior cavoatrial junction. Esophageal drainage
tube passes substantially below the diaphragm. Distended hollow viscus in the
left upper abdomen could be stomach, but is more likely large bowel. Radiology showed The tip of the PICC is at the cavoatrial junction. Improved aeration in the
right lung base. Pulmonary vascular congestion persists. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Mild gyriform slow diffusion within the left cingulate, insular, and
anterior aspect of the left frontal superior gyrus. Finding may represent
sequela of reported left cerebral seizure activity versus embolic disease
within the left internal carotid artery distribution. Less likely
differential includes encephalitis, however this pattern is not typical.Follow
up MR could further differentiate these processes by assessing for
characteristic evolution.
2. Encephalomalacia within the right temporal and basal ganglia consistent
with sequelae of prior hemorrhage.
3. Mild sinus disease.
RECOMMENDATION(S): Consider follow up MR of the brain to assess for
evolution. CHEST (PORTABLE AP) showed Worsened fluid status. CHEST (PORTABLE AP) showed As compared to ___ radiograph, left main bronchus now abruptly
terminates approximately 2 cm from its origin with associated partial collapse
of the left lung, with residual partially aeration of the left upper lobe.
This is most likely due to acute mucous plugging. Exam is otherwise similar
to the prior study, with persistent moderate pleural effusions and pulmonary
vascular congestion accompanied by mild perihilar edema.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 11:42 AM, 5 minutes after discovery of the
findings. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep vein thrombosis in the right upper extremity. CHEST (PORTABLE AP) showed In comparison with the study of ___, the mediastinal contours have return
to a more normal position, suggesting removal of an obstructing mucous
plugging to the left lung. Nevertheless, there is still substantial
enlargement of the cardiac silhouette with bilateral pleural effusions,
compressive atelectasis, and pulmonary edema.
Monitoring and support devices are essentially unchanged. Radiology showed 1. NG tube with tip terminating in the stomach.
2. G-tube in place with passage of contrast into the stomach and through the
duodenum without any evidence of obstruction. The G-tube balloon is inflated
but does not appear to overlie the gastric shadow. If there is a Clinical
concern, consider CT to confirm position of the G-tube balloon.
3. Non-obstructive bowel gas pattern.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 5:02 ___. Radiology showed 1. Bibasilar infiltrates in the lungs bilaterally, compatible with pneumonia.
2. NG tube with tip terminating in the stomach.
3. G-tube in place with balloon overlying gastric shadow and residual
contrast now in the ascending and transverse colon.
4. Nonobstructive bowel gas pattern. Radiology showed Improvement in pulmonary edema, now mild, and bilateral pleural effusions, now
mild-to-moderate. Persistent bibasilar consolidations may reflect atelectasis
or pneumonia in the correct clinical setting. CHEST (PORTABLE AP)
TECHNIQUE: Portable chest radiograph cough frontal view
COMPARISON: Chest radiograph ___
FINDINGS:
ET tube terminates 32 mm above the carina. Right PICC terminates mid SVC.
The transesophageal tube terminates in the stomach. Large left pleural
effusion is increased. Left lower lobe is collapsed with left mediastinal
shift. Right base atelectasis is less severe compared to the left. There is
pulmonary vascular congestion. Moderate right pleural effusion is unchanged.
There is pleural fluid collection in the right major fissure. Cardiac
silhouette is obscured by pleural effusions.
IMPRESSION:
1. Left lower lobe is collapsed with left mediastinal shift. Right lung base
atelectasis is less severe compared to left. Superimposed pneumonia is
possible in correct clinical setting.
2. Large left pleural effusions increased. Moderate right pleural effusion
is stable.
3. Pulmonary vascular congestion is reflective of cardiac decompensation. showed 1. Left lower lobe is collapsed with left mediastinal shift. Right lung base
atelectasis is less severe compared to left. Superimposed pneumonia is
possible in correct clinical setting.
2. Large left pleural effusions increased. Moderate right pleural effusion
is stable.
3. Pulmonary vascular congestion is reflective of cardiac decompensation. Radiology showed 1. Malpositioned Gastrostomy tube with the retaining balloon positioned within
the anterior subcutaneous fat. No evidence of leak after injection of
contrast
2. Bilateral small pleural effusions.
3. Cirrhotic appearance of the liver with splenorenal shunt partially
visualized. The patient was diagnosed with ACUTE RESPIRATORY FAILURE, ALTERED MENTAL STATUS , URIN TRACT INFECTION NOS, EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY, ATRIAL FIBRILLATION. The patient was treated with Intubation ___ extubated ___
Bronchoscopy ___ and ___. At the time of discharge, the patient had Primary Diagnosis:
Generalized Tonic Clonic Seizures
Status Epilepticus
Secondary Diagnosis:
Hemorrhagic Stroke
Ischemic Stroke
Dysphagia
Pneumonia
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>SUMMARY
==========================
___ year old female with ETOH cirrhosis, intraparenchymal
hemorrhage resulting in seizure disorder, dysarthria, left
hemiparesis and cranial nerve three palsy, history of atrial
fibrillation, and history of c diff, who presented to the ED
with two generalized seizures and required intubation for airway
protection. She was admitted to the ICU for airway and medical
management. With input from neurology, seizures were eventually
controlled with keppra, phenytoin and lacosamide. Following
control of seizures and extubation she was safely transferred to
the floor, where she completed a course of IV antibiotics for
HCAP, and IV antiepileptic medications were transitioned to PO
and tolerated well.
ACUTE ISSUES
==========================
#) SEIZURE: Patient presented with evidence of seizure activity
on arrival to the FICU. Seizures were thought to be incited by a
UTI or pneumonia. Neurology was consulted due to difficulty in
controlling seizures. As a result, a midazolam drip was started
which finally broke seizure activity. Midazolam drip was slowly
weaned, and patient with patient well-controlled on IV
levatiracetam, phenytoin and lacosamide, all of which were
transitioned to PO on ___ and ___. Transition to PO
anti-epileptic drugs was tolerated well without any further
seizure activity. Neurology follow-up scheduled.
#) RESPIRATORY FAILURE: Suspect respiratory failure secondary to
status epilepticus and inability to maintain airway
patency/protect airway. She was intubated on admission for
airway management in the setting of sedation for status
epilepticus. Patient initially was covered with broad spectrum
antibiotics, which were narrowed to gentamicin to treat ESBL E
coli which grew from bronch samples on ___ and ___. Gentamicin
chosen as it does not affect seizure threshold per neurology.
Patient was successfully extubated on ___, and maintained
adequate oxygen saturation on room air. She completed PNA
therapy as below.
#) PNEUMONIA: Patient was found to have recurrent left lobar
collapse, for which she underwent bronchoscopy on ___ and ___.
Cultures grew ESBL E. coli and she was started on a 7-day
course of extended interval dosing gentamicin Q36hr. Patient's
clinical status improved throughout antibiotic course that was
completed at time of discharge.
#) URINARY TRACT INFECTION: Initial urinary cultures grew VRE
and patient was being treated with zosyn. However per
consultation with ID this was felt to be a contaminant. As a
result, treatment was discontinued with no further evidence
suggestive of infection.
#) ADRENAL INSUFFICIENCY: Patient was hypotensive and
hypoglycemic during ICU admission. Endocrine was consulted and
suggested starting stress dose steroids. After several days of
steroids her blood pressure improved and episodes of
hypoglycemia stopped. Steroids were discontinued prior to
transfer from the ICU, with stable pressures maintained
throughout her admission.
#) DIARRHEA: Unkown etiology; possibly secondary to excess
lactulose for hepatic encephalopathy; C diff testing was
negative. Patient was receiving lactulose which was not held due
to concerns for hepatic encephalopathy in a patient with poorly
controlled seizures. Diarrhea and lactulose use led to repeated
hypoglycemia, magnasemia and phosphatemia which were repleted
aggresively. Rectal tube was placed, and stool output was
closely monitored before being discontinued. Lactulose was
titrated to goal of ___ BMs per day, tolerated well with
improvement in symptoms throughout hospital course.
#) GOALS OF CARE: Currently, patient is full code.
CHRONIC ISSUES:
==========================
#) ALCOHOLIC CIRRHOSIS: No evidence of acute decompensation.
Continue spironolactone, nadalol, rifaximin, and lactulose.
#) ANEMIA: Reportedly iron deficiency. Stable during admission
and did not require transfusion. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ history of depression, etoh who presents after 4x self
inflicted stab wounds to the chest. Patient was hemodynamically
stable evaluated in trauma bay found to have a left hemothorax
so a chest tube was placed she was also found to have a
pericardial effusion on CT scan and FAST exam and was taken to
the OR where a pericardial window revealed bleeding and a median
steronotomy was performed showing a small left ventricle
laceration which was repaired primarily. CHEST (PORTABLE AP) showed Since ___ 17:00 on ___ bilateral basal pleural and
mediastinal drains have been headed and the residual left hemothorax has been
drained. Consolidation in the left lung has also improved. Left apical
pneumothorax is minimal. There is no right pleural effusion or pneumothorax.
Right lung is clear. Cardiomediastinal silhouette following surgery is
unremarkable.
ET tube in standard placement. Esophageal drainage tube ends in the stomach
but would need to be advanced 5 cm to move all side ports beyond the GE
junction. Right jugular introducer ends at the thoracic inlet. CHEST (PORTABLE AP) showed Right chest tube is in place. Heart size and mediastinum are stable. Left
retrocardiac consolidation and small bilateral pleural effusions are
unchanged. No definitive pericardial drainage is present. Post sternotomy
wires are unremarkable. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, the the left chest tube has
been removed and there is no definite pneumothorax. Other monitoring and
support devices are essentially unchanged. Opacification at the left base is
consistent with some volume loss in the left lower lobe and possible small
effusion. CHEST (PORTABLE AP) showed Right chest tube is in place. The patient was extubated with removal of the
NG tube and right internal jugular line. Left retrocardiac opacity is
substantial, slightly progressed since the prior study. Minimal left apical
pneumothorax is noted. Moderate bilateral pleural effusion is present, as
well as bibasal atelectasis. . There is no pulmonary edema. Radiology showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. A moderate left pleural effusion is stable in size compared to the prior
chest CT performed 1 day ago and a small right effusion has increased in size.
3. Tiny left anterior pneumothorax has decreased in size.
4. Partial left lower lobe collapse and moderate atelectasis appear stable. CHEST (PORTABLE AP) showed Allowing for differences in technique, there has not been appreciable change
in the appearance of the chest since the recent study of 1 day earlier. Radiology showed No significant interval change from ___. Unchanged bibasilar atelectasis
with small pleural effusions. Persistent left lower lobe collapse. CHEST (PORTABLE AP) showed As compared to ___, cardiomediastinal contours are within normal
limits, and left lower lobe atelectasis has substantially improved in the
interval. Multifocal linear atelectasis in the right mid and lower lung has
also slightly improved. Interval decrease in small left pleural effusion,
nearly resolved, and no evidence of pneumothorax. The patient was diagnosed with INTRATHORAC INJ NOS-OPEN, TRAUM HEMOTHORAX-OPEN, SUI/SELF-INJ BY CUT INST. The patient was treated with ___: Pericardial window, median sternotomy, and repair of
left ventricular laceration.. At the time of discharge, the patient had Self-stab wound to left chest. The patient was given written instructions concerning 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 brought to the ICU following the OR. She was left
intubated on the morning of POD#1 until an echocardiogram
revealed ___ reaccumulation of the effusion. She was then weaned
to extubate. Her left chest tube which was placed in the trauma
bay was removed. Later on POD#1 her bilateral chest tubes were
removed however her mediastinal tubes were left in place.
Additionally she had her pacer wires which were placed during
the surgery removed on POD#1 as well. She was started on a diet
and was hemodynamically stable. On the evening of POD#1 she did
have some shortness of breath and assymptomatic hypotension. She
went for a CTA which was negative for any PE. She remained
stable. On POD#2 she again had an echo that did not demonstrate
any effusion however it did demonstrate that there was global
right ventricle hypokinesis.
On POD4, the patient had her medisatinal drains removed and
post-pull CXR was stable. The patient was then transfer to
step-down surgical floor.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with a PMH notable for pancreas
divisum, prior pancreatitis, and hypothyroidism who presents
with
acute onset epigastric abdominal pain. CHEST (AP AND LAT) showed As above. CT U without contrast showed 1. Acute pancreatitis.
2. Cross fused renal ectopia. Radiology showed As above. CHEST (PA AND LAT) showed Heart size mediastinum appear to be stable. There is interval improvement in
bibasal consolidations. Small bilateral pleural effusion is demonstrated.
There is no pneumothorax. The patient was diagnosed with Acute pancreatitis without necrosis or infection, unsp, Unspecified abdominal pain. At the time of discharge, the patient had Primary:
Acute pancreatitis
Hypoxia
Secondary:
Pancreas divisum. The patient was given written instructions concerning 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 pancreas divisum and
history of pancreatitis s/p CCY ___ p/w recurrent pancreatitis.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old RN with h/o breast cancer in remission
___ s/p surgery, chemo and radiation), h/o DM type II who
presents with fevers, weakness and anorexia which began 5 days
after returning from a medical mission to ___ where she
was for two weeks.She did not have any other associated sx such
as fevers, cough, sore throat, chest pain, diffuse myalgias,
dysuria, or diarrhea. She Her fevers were as high as 102 then
resolved two days after they began. She still felt weak and
could
not eat. She tried to drink as much as she could. She went to
see her PCP's associate 3 days ago who sent a fever w/u
including
smears for malaria. She went home and the fever returned. She
then developed severe pain in the R leg. She denies trauma to
the
leg. She has not fallen. Her malaise persisted so her husband
brought her to the ED.
In the ED she triggered for hypotension despite 6 L IVF. She was
admitted to the FICU.
On the floor the pain in her R leg is much worse and the
swelling
has also worsened. She feels better since she has received abx.
She is able to drink and does not have any nausea. She had one
loose stool today.
. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Echogenic liver consistent with steatosis. Other forms of liver disease and
more advanced liver disease including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
Mild gallbladder wall thickening likely reactive to underlying chronic liver
disease.
RECOMMENDATION(S):
Radiological evidence of fatty liver does not exclude cirrhosis or significant
liver fibrosis which could be further evaluated by ___. This can be
requested via the ___ (FibroScan) or the Radiology Department with
either MR ___ or US ___, in conjunction with a GI/Hepatology
consultation" *
* Chalasani et al. The diagnosis and management of nonalcoholic fatty liver
disease: Practice guidance from the ___ Association for the Study of
Liver Diseases. Hepatology ___ 67(1):328-357 US MSK SOFT TISSUE showed 1. Superficial thrombophlebitis of a varix/dilated superficial vein along the
calf.
2. Extensive subcutaneous edema of the right calf without fluid collection or
mass.
NOTIFICATION: The findings were discussed with Dr. ___ by ___,
M.D. on the telephone on ___ at 10:49 pm, 2 minutes after discovery of
the findings. CT LOWER EXTREMITY showed 1. Extensive subcutaneous edema, without an organized fluid collection.
2. Prominent superficial varix along the posterior aspect of the gastrocnemius
muscles, likely corresponding to superficial thrombophlebitis seen on the
recent ultrasound. The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had # Group A Strep Sepsis secondary to acute blood stream infection
# R leg cellulitis
# Superficial thrombophlebitis of R leg
# Type 2 diabetes complicated by hyperglycemia
# 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>This is a ___ year old female with past medical history of breast
cancer, type 2 diabetes, recent travel to ___, admitted
___ with sepsis, right leg cellulitis and group A strep
bacteremia, treated with antibiotics and improving, seen by ID
with workup without suggestion of endocarditis, course otherwise
notable for initiation of Lantus insulin, able to be discharged
home on IV penicillin infusion
# Group A Strep Sepsis SECONDARY TO
# Acute blood stream infection AND
# Superficial thrombophlebitis of R leg
Patient presented with sepsis, hypotension, elevated lactate,
initially requiring transfer to MICU for fluid resuscitation and
broad spectrum antibiotics. Workup for source of sepsis was
notable for significant erythema and edema of R lower leg.
Given recent travel, consideration was given to alternate exotic
etiologies: malaria test was negative. Her blood cultures
quickly returned positive at 12 hours for gram positive cocci
that subsequently speciated to strep group A. Patient was seen
by ID consult service, with antibiotics narrowed to CTX, and
then penicillin as sensitivities returned. TTE was reassuring
no signs of cardiac involvement. Source of strep bacteremia was
felt to be right lower extremity cellulitis complicated by a
severe soft tissue infection. CT leg did not demonstrate any
sigs of focal fluid collection, but did show evidence of a
superficial thrombophlebitis, which was felt to be reactive to
her severe infection and not the cause of her severe infection.
She was treated with antibiotics as above, elevation,
compression and warm compresses. Erythema and nonpitting edema
improved slowly over the course of multiple days. She had a
midline placed and per ID consult was able to be discharged on
penicillin G, 3 million units every 4 hours (d1 = ___, last day
= ___. Prior to discharge, took pictures of resolving
cellulitis with patient's cell phone, for use for comparison at
follow-up visit.
# Type 2 diabetes complicated by hyperglycemia
In setting of sepsis, patient developed significant
hyperglycemia to > 500. Patient was seen by ___ diabetes
consult service and was treated with fluid resuscitation and
insulin with improvement in glucose control. Once patient
clinically improving, she indicated that she did not wish to
restart her home metformin given poor GI tolerance. Per ___
consult recommendations, she was discharged on Glipizide,
Canagliflozin + plus Lantus. Patient is a ___ nurse and knew
about administration. She already had a glucometer at home and
agreed to monitor and record her fingersticks. Identified which
pen was covered by her insurance, and patient discussed ___
with patient, who agreed. Would review fingerstick data with
patient at follow-up visit.
# Hypertension
Held home regimen in setting of her sepsis, then restarted
chlorthalidone and valsartan.
# Hyperlipidemia
Held home statin in setting of mild elevation in CK 200-300,
thought to be secondary to her severe soft tissue infection.
Could consider restarting at outpatient follow-up.
# ___
In setting of sepsis patient had Cr peak at 3.0 from baseline
0.9. Thought to be secondary to sepsis and dehydration.
Treated as above. Cr improved to 0.9 prior to discharge.
# Shock Liver
# Steatosis
In setting of sepsis, patient had elevated transaminases (ALT
204, AST 327), prompting RUQ ultrasound while in the ICU.
Incidentally showed "Echogenic liver consistent with steatosis.
Other forms of liver disease and more advanced liver disease
including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study." LFTs
improved with clinical improvement. Prior to discharge ALT 54,
AST 39, AP 107, Tbili 0.4. Could consider outpatient hepatology
referral. Based on hepatitis serologies, patient may benefit
from Hepatitis B vaccination. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year-old lady with history of recently diagnosed biopsy
confirmed LLL NSCLC with recent head MRI concerning for putamen,
C4 and C6 metastatic lesions presents with worsening abdominal
distension and dyspnea.
Over the last week she has rapidly developed abdominal
distension that over the last two days has been tense enough to
cause her dyspnea and palpitations. She's had a dry cough since
___ that has actually improved after antibiotic treatment
during the last 2 weeks. She denies having any nausea, vomiting,
abdominal pain, change in bowel habits, melena, hematochezia,
chest pain.
In the ___ ED, initial vitals were T 99, HR 140, BP 128/85, RR
16, SPO2 96% RA. Labs were notable for leukocytosis at 14.4 with
neutrophilia 74% , Hgb 9.2 with MCV at 77, thrombocytosis with
platelets 838, INR 1.4, hyponatremia with Na 129 (recent
baseline 132), anion gap metabolic acidosis with bicarbonate 18,
glucose 330, anion gap 24, creatinine 0.6, albumin 2.4, calcium
9.5 (corrected to 10.7), unremarkable LFTs. VBG 7.41/33/35.
Lactate normal at 1.3. UA significant for glucose at 1000,
ketones at 80 and 7 WBC.
CXR was without consolidation, pleural effusion, edema, or other
clear explanation for patient's dyspnea.
CTA of the chest demonstrated a large LLL mass compatible with
known history of NSCLC, enlarged mediastinal and hilar
lymphadenopathy, concerning for metastatic disease, large volume
intraabdominal ascites, and multiple arterially enhancing liver
lesions concerning for hepatic metastases.
She underwent 3.1L therapeutic/diagnostic paracentesis.
Peritoneal fluid labs were significant for Alb 1.8, WBC 670 with
55%MPh, 36%L, 8%NPh.
Vitals prior to transfer were T 98.6, HR 135, BP 121/72, RR 24,
SPO2 99 on 2L NC.
On arrival to the unit vitals are 99.5 | 126 | 104/67 | 23 |
96%RA, patient no longer complains of dyspnea or difficulty
taking deep breaths since the paracentesis. She does complain of
recurrence of some left shoulder pain which is ___. Otherwise
she feels very hungry and thirsty. Radiology showed Probable small bilateral pleural effusions. Known left lower lobe mass and
intrathoracic lymphadenopathy are seen to better detail on separately dictated
chest CTA. CTA CHEST showed 1. No evidence of pulmonary embolism.
2. Large heterogeneously enhancing left lower lobe mass compatible with
history of non-small cell lung cancer.
3. Enlarged mediastinal and hilar adenopathy, consistent with nodal
metastases.
4. Multiple arterially enhancing liver lesions, consistent with hepatic
metastases.
5. Large volume ascites.
6. Lytic lesion within the superior endplate of the T11 vertebral body most
likely represents a hemangioma. SHOULDER ___ VIEWS NON TRAUMA LEFT showed Unremarkable left shoulder. Radiology showed 1. Numerous osseous metastases in the cervical, thoracic, and lumbar spine.
2. Left anterior paraspinal mass from C4-5 through C6-7 which encases the left
vertebral artery with mild narrowing, and which severely narrows the left C4-5
and C5-6 neural foramina. No evidence for epidural extension into the spinal
canal.
3. Small soft tissue mass projecting from the large metastasis in the left C7
lamina and spinous process into the left posterior paravertebral soft tissues.
4. 5 x 8 x 12 mm right intradural mass at T8-9 level, which displaces the
spinal cord to the left and compresses the spinal cord. Mild associated cord
edema. This mass demonstrates high signal on T1 weighted images and
hyperdensity on the prior chest CT, compatible with blood products or
mineralization. Diagnostic considerations include a metastasis versus a
meningioma.
5. Possible small soft tissue mass extending posteriorly and inferiorly from a
metastasis in the right C6 lamina.
6. Small right and midline anterior paraspinal mass associated with the L2
vertebral body metastasis. Mild deformity of the L2 inferior endplate with
minimal associated loss of height, compatible with pathologic compression or a
Schmorl's node.
7. Extensive right supraclavicular lymphadenopathy, 9 mm right cervical lymph
nodes between levels 3 and 4, large pulmonary mass in the left lower lobe,
extensive left hilar and subcarinal lymphadenopathy, multiple liver lesions
consistent with metastases, indeterminate lesion in the spleen which may also
represent a metastasis, and large amount of ascites. Possible peritoneal
metastases along small bowel loops in the pelvis.
NOTIFICATION: Results were discussed over the telephone on ___ at
15:42 by Dr. ___ with Dr. ___. The patient was diagnosed with TACHYCARDIA NOS. The patient was treated with Paracentesis ___. At the time of discharge, the patient had Non-small cell lung cancer
Spinal cord involvement
Ascites
Hyperglycemia. The patient was given written instructions concerning 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 recently diagnosed widely metastatic
___ who presented with 1 week of new rapidly evolving ascites
and 2 days of dyspnea with relief after 3.1L fluid paracentesis
on admission. Course complicated by spine met seen on MRI with
cord compression, started on steroids and receiving radiation
with plan for erlotinib once radiation is finished.
==================
ACUTE ISSUES
==================
# Cord compression seen on MRI spine: Evaluated by neurosurgery-
no indication for surgery and instead deferred to rad-onc.
Patient with some weakness of right arm, pain in left shoulder,
otherwise neurologically intact. Radiation initiated with plan
for total fractions. Started on decadron, originally 4 mg q8h
then spaced to 4 mg q12h. Continue this dose until radiation is
finished, then decrease dose by half every ___ days (rad-onc to
outline taper). Also started on protonix for prophylaxis. After
radiation can progress to erlotinib.
# Lung AdenoCa: EGFR positve. Recent diagnosis in young
non-smoker. Now with mets to brain, liver, and ? peritoneal
carcinomatosis. Patient is from area of ___ with heavy air
pollution.
- CT abdomen and pelvis with contrast when possible as
outpatient (transitional issue)
- Erlotinib to be initiated after radiation per above
# Diabetes: On Metformin as an outpatient. Pt with recently more
difficult to control hyperglycemia even prior to steroids,
worsened with steroids. Patient started on lantus and humalog
sliding scale and eventually ___ consulted due to very
difficult to control blood glucose. Patient educated by diabetes
educator and provided supplies for regular blood glucose
measurement and insulin administration. Also counseled on
warning signs and provided contact info as well as outpatient
follow-up.
# Ascites: Differential includes hypoalbuminemia, peritoneal
carcinomatosis, portal hypertension ___ massive liver mets or
portal vein thrombosis. Suspect carcinomatosis with previous
imaging corroborating. S/p 3.1L therapeutic paracentesis on
admission, dyspnea was likely secondary to ascites and has now
resolved. ___ need paracentesis as outpatient as +fluid wave,
however appears stable/slightly improved. SAAG is 0.6, so portal
hypertension highly unlikely. No signs of peritonitis in cell
count. Cytology with positive malignant cells consistent with
lung adenoca and no growth from culture. Future ct abdomen with
contrast per above should show PVT if present.
# Sinus tach: Patient presented with sinus tachycardia to 130s.
PE ruled out via CTA, echo normal. Not responsive to fluid
boluses or albumin. ?Anxiety component vs catecholamine release
from high tumor burden. No CP/SOB. HR in outpatient clinic
120-140 over last month. Improved overall to low 100s, later
___ by discharge.
# Blood count abnormalities: Anemia likely due to chronic
inflammation given elevated ferritin and ESR- stable.
Thrombocytosis and leukocytosis likely ___ malignancy. No s/s of
bleeding throughout stay.
==================
TRANSITIONAL ISSUES
==================
- CT Abd and Pelvis w/contrast to finish staging
- Further steroid taper per rad-onc
- Further titration of insulin for glucose management in setting
of future steroid taper
- Start erlotinib after finishing radiation course
- Patient to call ___ at ___ to
schedule delivery of erlotinib to her home
- Continue to provide support for coping with new diagnosis</s> |