text
stringlengths 519
60.4k
|
|---|
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male with HCV cirrhosis c/b HE, hepatocellular carcinoma
with recent etoh relapse presents with abdominal pain and desire
to get sober.
The patient was previously being evaluated for liver transplant
but began drinking again for the last several months and was
lost to follow up. He has been through a difficult time recently
caring for his father with cancer and trying to help his son. He
wife died of hemorrhage with liver cirrhosis in ___. He states
that he was sober for ___ years. He began drinking again around
the end of ___ and states that he has drank for 3
months straight. He has been drinking 1 pint of Schnapps per day
along with several beers. He states that he has not been binging
or getting too drunk but just consistently drinking. For the
last 2 weeks he has had increasing abdominal distension and
three days of sharp intermittent RUQ abdominal pain.
Last drink 20 minutes ago. Has been drinking nonstop for 2
months, experiencing withdrawal symptoms after 6 hours without
alcohol.
In the ED, initial vitals were: T 98.0 HR 94 BP 160/83 RR 18 O2
99% RA
Exam - smells of EtOH, alert, appropriate, no asterixis,
diffuse wheezes, enlarged abdomen with diffuse tenderness but no
guarding or grimace on exam.
LABS: WBC 11.9* H/H 12.8*/37.7* plt 125* ALT 78* AST 179* AP
266* Tbili 2.6* lactate 2.4
IMAGING:
RUQ U/S:
-Coarsened nodular liver consistent with cirrhosis. Moderate
ascites and mild splenomegaly consistent with portal
hypertension.
-2.5 cm hypoechoic lesion within the right lobe is unchanged in
size from the prior ultrasound on ___.
-Minimal sludge in a nondistended gallbladder. No evidence of
gallbladder wall thickening.
CXR: Minimal right base atelectasis. No focal consolidation to
suggest pneumonia.
There was no accessible pocket to tap ascites in the ED so
paracentesis was deferred.
Hepatology was consulted: "appears to have alc hepatitis. No
fevers or abdominal pain to suggest SBP" and recommended:
-CIWA protocol
-no beta blockers
-infectious work up including blood cultures, ua, urine
cultures, cxr
-DF<32 at this time and history of non-adherance, so no
steroids.
-social work for alcohol relapse prevention
On the floor, that patient states that he feels terrible about
the situation that he is in but hopeful to get sober again.
Continues to have intermittent abdominal pain. No nausea or
vomiting. No BRBPR or melena. Last BM this am, constipated. He
does have a cough for the past several weeks occasionally
productive of green sputum. He denies any fevers, chills,
dysuria, shortness of breath. He continues to smoke ___
cigarettes per day. No drug use other than marijuana. Last drink
just prior to presenting to ED LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Coarsened nodular liver consistent with cirrhosis. Moderate ascites and
mild splenomegaly consistent with portal hypertension.
2. 2.5 cm hypoechoic lesion within the right lobe is unchanged in size from
the prior ultrasound on ___.
3. Minimal sludge in a nondistended gallbladder. No evidence of gallbladder
wall thickening. Chest: Frontal and lateral views showed Minimal right base atelectasis. No focal consolidation to suggest pneumonia. Radiology showed 1. Technically successful ultrasound guided diagnostic paracentesis.
2. 20 cc of fluid were removed. The patient was diagnosed with Alcoholic hepatitis without ascites. The patient was treated with Diagnostic paracentesis ___. At the time of discharge, the patient had Primary Diagnosis
Alcoholic hepatitis
Alcoholic cirrhosis
Alcohol intoxication. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo male with HCV cirrhosis c/b HE, hepatocellular carcinoma
with recent etoh relapse presents with abdominal pain and desire
to get sober.
#Alcoholic hepatitis: He presented with abdominal pain and
elevated LFTs consistent with alcoholic hepatitis. His ___
discriminant function was 11 on admission so there was no
indication for steroid use. SBP ruled out based on diagnostic
para. He was given 5 mg oxycodone for his pain as needed and
pain improved. Bilirubin uptrended from 2.6 to 2.9 but remained
stable at 2.9 on day of discharge. Transaminases improved during
admission.
#EtOH abuse: Patient started drinking ___ and
arrived for detox. Received Ativan once for CIWA scale, but
otherwise did not have signs of withdrawal. Social worker was
not available to see the patient over the weekend but he agreed
that he wanted to be discharged and would call the liver
transplant social worker/coordinator to make a follow up
appointment to help him with sobriety.
# HCV cirrhosis: Patient had alcoholic hepatitis in addition to
known cirrhosis as above. LFTs downtrended during admission. He
was restarted on his home medications Lactulose, rifaximin,
Lasix and spironolactone. He was also started on MVI, thiamine,
folate. He did not have signs of HE during admission.
# Leukocytosis: Presented with WBC 11.9 which downtrended
during admission. Had no signs of infection. CXR, BCx, UCx, and
diagnostic paracentesis were negative.
# Anemia: Patient had Hgb 12.8 on admission with high MCV which
was felt to be due to alcohol and liver disease.
# Tobacco use:
- Given 14 mg nicotine patch.
# Thrush:
- Started on nystatin for 2 week course.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PORTABLE AP) showed No acute cardiopulmonary process. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Old left occipital lobe infarct. No acute infarct identified. No evidence
of hemorrhage
2. Occlusion of the left posterior cerebral artery distal to the proximal P2
segment. Otherwise patent circle of ___ without evidence of
stenosis,occlusion,or aneurysm.
3. Patent bilateral cervical carotid and vertebral arteries without evidence
of stenosis, occlusion, or dissection. CTA CHEST WITH CONTRAST showed Atherosclerotic changes are seen at the aortic arch without evidence of
dissection.
Suboptimal assessment of right lower lobe subsegmental pulmonary arterial
branches due to respiratory motion.; No evidence of pulmonary embolism seen
elsewhere. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
2. Normal gallbladder. No biliary ductal dilatation.
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 MR ___, 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 CT ANGIOGRAPHY HEAD AND NECK showed 1. Left occipital encephalomalacia. No acute hemorrhage. Hypodensities in
the white matter could be due to small vessel disease.
2. Diminutive left posterior cerebral artery secondary 20 cephalo malacia and
decreased flow. Otherwise ___ is patent. No large vessel
occlusion.
3. No evidence of high-grade stenosis by NASCET criteria in the neck. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality. Radiology showed No worrisome lytic or blastic lesion. Degenerative changes in the spine as
described. CT ABD AND PELVIS WITH CONTRAST showed 1. No evidence of infectious source in the abdomen or pelvis.
2. New subcentimeter focal cortically based lucencies in the bilateral iliac
wings are nonspecific and would be atypical prostate metastases. Correlation
with SPEP and UPEP recommended to exclude multiple myeloma which could have
this appearance although would be unusual in isolation.
3. CT chest dictated separately.
RECOMMENDATION(S): Correlation with SPEP and UPEP. CT CHEST W/CONTRAST showed 1. No evidence of infectious source in the chest.
2. 3 mm right middle lobe pulmonary nodule. See recommendations.
3. CT of the abdomen and pelvis reported separately.
RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___ ___ DUP EXTEXT BIL (MAP/DVT) showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. The patient was diagnosed with Chest pain, unspecified. The patient was treated with N. At the time of discharge, the patient had PRIMARY DIAGONSIS:
-Chest pain
SECONDARY DIAGNOSIS:
-HTN
-HLD
-Prostate cancer s/p XRT
-CVA. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ male with prostate cancer s/p XRT,
HTN, CVA who initially presented with chest pain and shortness
of breath. In the ED, patient was given lidocaine, morphine, and
LR fluids. Patient had no signs of ST changes on EKG along with
negative troponins. Also, no evidence of dissection, PE, or
pneumonia on CTA chest. Upon admission to cardiology floor,
pMIBI showed uniform perfusion. He denied chest pain.
Mr. ___ then began developing intermittently spiking fevers
___ with sinus tachycardia and concerns for altered mental
status in the form of increasing confusion and episodes of
agitation. Patient was pan cultured and CXR obtained. He showed
no obvious signs of infection. Given low suspicion that original
chest pain was cardiac, along with his fevers of unknown origin,
he was transferred to the General Medicine ward for further
evaluation.
On General Medicine, Mr. ___ was well-appearing and BPs were
stable. No leukocytosis and mostly afebrile with some low grade
temperatures. UA bland and CXR unremarkable. CT torso and bone
scan showed no evidence of infectious source. Neuro consulted
and had low suspicion for any acute neurologic changes. LP
deferred as he had a stable temperature curve and returned to
baseline mental status.
===================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with past medical history of
CAD s/p PTCA, DVTs & PE on lifelong coumadin, Diabetes, history
of esophageal cancer, who presents with loss of vision. BILAT LOWER EXT VEINS showed 1. Acute occlusive thrombus in the left popliteal, posterior tibial, and
soleal veins. Non-occlusive thrombus in the right distal femoral vein and
proximal popliteal ___ be acute though could be subacute or chronic.
2. The remaining deep venous system of bilateral lower extremities is patent.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:18 am, 2 minutes after discovery
of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No evidence of hemorrhage or infarction. The patient was diagnosed with Serous retinal detachment, bilateral. At the time of discharge, the patient had Primary:
Bilateral retinal detachment
Metastatic esophageal cancer
Bilateral DVTs
Secondary:
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>Mr. ___ is a ___ yo man with h/o CAD s/p balloon
angioplasty,
DVTs and PE on lifelong warfarin, DM, and esophageal squamous
cell carcinoma (diagnosed ___ who presents with concern for
bilateral retinal detachment from metastatic lesions, opting to
transition to hospice care.
#Bilateral retinal detachment
Mr. ___ was seen by the oncologic ophthalmology service who
felt that his bilateral retinal detachment could represent
metastatic disease. They opined that chemo/radiation would offer
Mr. ___ the best chance of ocular recovery and deferred
surgical intervention. Given the rarity of esophageal squamous
cell carcinoma metastasizing to the choroid, they also raised
the possibility of a second primary cancer. Neuro-oncology
recommended MRI brain and lumbar puncture, but this was not
pursued as Mr. ___ had firmly decided against further
workup given what he considered a low likelihood of meaningful
recovery. In accordance with his wishes, Mr. ___ was
discharged to home hospice.
#New bilateral ___ DVTs
Mr. ___ has a history of DVTs/PE and was on lifelong
warfarin. In the setting of increased leg swelling, he was found
to have bilateral DVTs on ultrasound. Given that lovenox is
superior to warfarin in treating cancer-associated VTE, plans
were made to transition him to lovenox once his INR dropped
below 2. His INR on discharge was 2.4 in the setting of poor
nutritional intake, and he was discharged with plans to go for
an INR check in ___ days with an outpatient provider. Lovenox
should be started at 1 mg/kg BID dosing once his INR drops below
2.
#Metastatic esophageal cancer
Diagnosed on ___. CT A/P on ___ noted new mets to the
liver in the setting of lower abdominal pain. Mr. ___ was
planning to restart palliative chemotherapy (FOLFOX) but is now
no longer amenable given continued disease progression. His pain
was managed here with oxycodone 10mg q4hr PRN. He was discharged
with home hospice. MOLST form was completed and is in chart.
#CAD
He is s/p balloon angioplasty in the 1990s. TTE on ___
showed preserved EF 65-70%. His home atorvastatin was continued.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female history of Nash cirrhosis, well controlled,
presented to ___ with a chief complaint of
dizziness
leading to fall. Patient was found to have a elevated AST to
1300
and a T bili to 1.7 at the outside hospital. Patient was
transferred here for admission to ___ tray.
She went on a long walk uphill on ___, after which she had
progressively worsening fatigue. She also developed back pain
and
was diagnosed with a kidney infection on ___ for which she was
prescribed Bactrim. She was called by her PCP who told her the
infection was resistant to Bactrim, so would need to be started
in Nitrofurantoin. She took one dose of Nitrofurantoin on ___
and started to feel like her legs were made of "rubber". Her PCP
had asked her to come in for a kidney US on ___, and when she
was trying to go up the stairs at her home she became dizzy,
feeling as if the room was spinning, and her legs gave out. She
fell down one step backwards onto her bottom, with no loss of
consciousness. She was down in that position for ___ minutes,
with her sister at her side trying to help her.
She feels her legs were weak at the time, and also had R sided
back pain radiating down to her legs. Of note, she is recently
started on Rosuvostatin in ___. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic liver, without evidence of focal lesion.
2. Patent portal vein.
3. Splenomegaly. No ascites. CHEST (PA AND LAT) showed Stable mild pulmonary vascular congestion. No focal consolidation or frank
pulmonary edema. Radiology showed 1. No evidence of retroperitoneal hematoma or intraperitoneal/intrapelvic free
fluid.
2. Cirrhosis and severe splenomegaly. No ascites.
3. Interval increased conspicuity of indeterminate left adrenal gland nodule
measuring 2.5 cm. Dedicated nonurgent MRI or CT recommended for further
evaluation. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial hemorrhage or calvarial fracture. CHEST (PORTABLE AP) showed Lungs are clear. Heart size is normal. There is no pleural effusion. No
pneumothorax. The patient was diagnosed with Traumatic ischemia of muscle, initial encounter, Fall same lev from slip/trip w/o strike against object, init. The patient was treated with n/a. At the time of discharge, the patient had rhabdomyolysis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ female history of NASH cirrhosis, DM, HTN, BIPOLAR
2,
PCOS, who presented to OSH after a fall with concern for
rhabdomyolysis, with downtrending CK after IVF. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ PMHx prior EtOH abuse, recent detox with no
EtOH ingestion for almost 1 month who is transferred from ___
___ for RUQ abdominal pain. Radiology showed The MRI examination of your patient was canceled because the implanted
biomedical device ___ InterStim II Model 3058 Neurostimulator), was
deemed to be MRI compatible for MRI Head only, using a RF transmit/receive
coil (ref: ___. No images were obtained. ABDOMEN US (COMPLETE STUDY) showed 1. Cirrhotic appearing liver without focal liver lesions.
2. Mild volume ascites and splenomegaly. No evidence of portal vein
thrombosis.
3. The gallbladder is distended with fluid with a small amount of layering
sludge. Mild gallbladder wall thickening and pericholecystic fluid, which may
be due to third spacing of fluids, or reactive from adjacent chronic liver
disease. There was no sonographic ___ sign. No intra or extrahepatic
biliary dilatation. Overall, this represents an equivocal exam for acute
cholecystitis and HIDA is the next most appropriate examination if clinically
indicated.
4. Multiple gallbladder wall polyps or adherent stones/sludge measuring up to
1.4 cm. Follow-up ultrasound recommended in ___ months. The patient was diagnosed with Obstruction of bile duct, Right upper quadrant pain. At the time of discharge, the patient had Alcoholic hepatitis
Cirrhosis
Abdominal pain
Chronic pain
Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ yo F PMHx prior EtOH abuse, recent detox with
no EtOH ingestion for almost 1 month, gastric bypass, who is
transferred from ___ for RUQ abdominal pain, possible
biliary disease, and findings consistent with cirrhosis and at
this point presumed alcoholic hepatitis
RUQ Abd pain, multifactorial
Presumed alcoholic hepatitis
Her symptoms were initially suspected to be biliary in nature,
but work up did not find a cause/concern for obstruction. Her
bili was indirect favoring against bile obstruction.
Cholecystitis was also excluded from HIDA scan. This pain could
be related to distention, ascites, and possibly MSK component as
well. Gastritis was possible but less likely, pancreatitis is
excluded on imaging/lipase. MRCP could NOT be performed due to
bladder stimulator. Another consideration was resolving
alcoholic hepatitis given pain, mild liver decompensation, and
lack of alternative diagnosis. In discussion with Liver team,
alcoholic hepatitis was the more likely cause given lack of
alternative diagnosis. She remained stable with slow
improvement. She was initiated on empiric PPI as a trial.
Alcohol sensation was discussed in detail with the patient. For
her acute pain she was given dilaudid with instructions to
follow up and communicate with her pain provider.
Cirrhosis
Ascites
Labs, exam, and imaging were consistent with cirrhosis. This
was discussed with the patient. She had ascites as well. EtOH
was the likely cause. Viral hepatitis was negative, iron
studies stable. AMA, ___, smooth muscle, Egg levels sent for
follow up purposes. In review of her imaging, there was not
suitable ascites to sample. She had an EGD at ___ 1
month prior which she will get the report for. She will follow
up closely with hematology as scheduled. For her ascites, she
was continued on Lasix which was increased to 40mg daily
HTN
- Continued home antihypertensives
EtOH use disorder
Sober for several weeks now. She is motivated to remain
abstinent and understands implications for her liver disease
- SW consulted
# Chronic back pain.
S/p MVA c/b multiple spinal surgeries and knee replacement.
- Continued home methadone
- Continue dhome duloxetine
- For acute pain will give a short course of oral dilaudid. PMP
reviewed, she will communicate with pain service provider
# ___
- ___ home Ativan
# Bladder dysfunction
Patient has a bladder stimulator in ___, only MRI compatible
for HEAD MRI
- Urology follow up</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with GERD c/b ___ esophagus, remote prostate cancer
s/p prostatectomy (___), and ulcerative colitis presenting with
4 weeks of diarrhea with bright red blood and development of
fever to ___ yesterday. Reports a distended and uncomfortable
abdomen during this time. States he has hx of central serous
retinopathy thus he cannot receive steroids. Prescribed but has
not been using mesalamine. Also endorses non-exertional chest
pain and shortness of breath. Radiology showed Possible bowel wall thickening in the Left hemiabdomen, could be in keeping
with colitis given the clinical history. If clinically warranted, this may be
better assessed by CT. CHEST PORT. LINE PLACEMENT showed Lungs are clear. Right-sided PICC line projects to the SVC. Heart size is
normal. There is no pleural effusion. No pneumothorax Radiology showed 1. Gas-distended sigmoid colon measuring up to 5.6 cm. If there is high
clinical suspicion for toxic megacolon, serial x-rays or CT are recommended
for further evaluation.
2. No evidence of free intraperitoneal air. The patient was diagnosed with Unspecified abdominal pain. The patient was treated with TEE ___. At the time of discharge, the patient had PRIMARY DIAGNOSES:
=================
Ulcerative Colitis flare
Aortic valve vegetation concerning for infective endocarditis
SECONDARY DIAGNOSES:
====================
Atrial fibrillation (AF)
Urinary tract infection
Central serous chorioretinopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with history of ulcerative
colitis(Proctosigmoiditis), GERD, non-dysplastic ___,
remote prostate cancer s/p prostatectomy (___) and history of
central serous retinopathy presenting with bloody diarrhea and
low grade fevers concerning for UC flare. Patient was found to
have diastolic murmur and discovered to have echodensity on the
LVOT side of the aortic valve c/f vegetation. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of DMT2, ESRD due to ADPKD s/p renal transplant
c/b allograft failure 8 months ago, now on peritoneal dialysis,
on tacrolimus, presenting with 3 day history of left ankle pain. Radiology showed No acute fracture or dislocation The patient was diagnosed with Pain in left ankle and joints of left foot. The patient was treated with Left ankle arthrocentesis. At the time of discharge, the patient had Primary diagnosis:
Monoarthritis/ bursitis
Secondary diagnoses:
CKD stage V on Peritoneal dialysis
s/p kidney transplant c/b Allograft failure
Type 2 Diabetes Mellitus
Hypertension
Anemia
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>Summary:
=======
___ with history of DMT2, ESRD due to ADPKD s/p renal transplant
c/b allograft failure 8 months ago, now on peritoneal dialysis,
on tacrolimus, presented with 3 day history of left ankle pain
and swelling.
Acute Issues:
=========
#L ankle pain/swelling: No overlying erythema or warmth. Denied
trauma, injection, or recent instrumentation to area. No
preceding systemic symptoms. Underwent left ankle arthrocentesis
by orthopedic surgery in ED that revealed 765 WBC, 67 PMN, no
crystals. Patient afebrile and without leukocytosis. Given
immunosuppression (on tacrolimus) was treated with empiric
vancomycin in ED. On medical floor underwent usual overnight
peritoneal dialysis and pain control was achieved with prn
tramadol, standing Tylenol. Left ankle demonstrated clinical
improvement with decreased swelling and improved pain, resulting
in improved ROM. The most likely etiology of her symptoms is a
tendonitis vs bursitis (surrounding the lateral malleolus). She
was advised to rest, ice, and elevate her leg and to avoid
NSAIDs given her kidney function. She is discharged with
crutches. She will follow up with her PCP on ___.
# AMS: AAOX3 on admission but falling asleep during exam. Likely
secondary to IV morphine received in ED for pain control. No
flapping tremor to suggest uremia. VSS and afebrile, arguing
against sepsis. Sedation improved with time. Alert, oriented and
appropriate at time of discharge.
Chronic Issues:
===========
# ESRD on PD: Dialysis nephrology was consulted. Underwent
overnight PD per usual schedule. Bowel regimen ordered to ensure
daily bowel movement. Home sevelemer continued.
# Failed allograft: Home tacrolimus 5mg BID continued and
tacrolimus trough checked with AM labs. Returned at 8.8.
# HTN: No evidence of volume overload on exam. Continued home
amlodipine, losartan, torsemide with holding parameters
# HL: Continued fenofibrate.
# DMT2: Denies checking BS at home and does not take insulin or
oral hypoglycemic. Managed with ISS with QACHS ___.
Transitional Issues:
==============
- Follow up blood cultures and synovial fluid cultures from ___
- Discharged with crutches per ___ recommendations
Code Status: Full </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ old right-handed woman with a
history significant for HIV on HAART, possible CNS toxoplasmosis
(s/p treatment, biopsy non-specific, followed with serial
imaging) and medically-refractory focal-onset epilepsy with
recurrent episodes of status epilepticus who presents with
concern for breakthrough seizures. CHEST (PA AND LAT) showed No acute intrathoracic cardiopulmonary process. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Interval resolution of pneumocephalus with stable appearance of a small
left frontal calcified lesion with adjacent hypodensity, likely related to the
sequelae of prior biopsy.
2. Stable postsurgical changes of a left frontal burr hole.
3. Otherwise no acute intracranial abnormality. MR HEAD W AND W/O CONTRAST ___ MR HEAD showed 1. Examination is moderately degraded by motion.
2. Punctate subtle area of enhancement adjacent to the left frontal biopsy
site is likely unchanged dating back to ___. This may relate to
residual toxoplasmosis lesion versus postsurgical changes.
3. No definite additional areas of abnormal enhancement within limitations.
4. No evidence of infarction or hemorrhage.
5. Nonspecific unchanged signal abnormalities in the periventricular white
matter may relate to chronic small vessel ischemic disease changes with
differential considerations of demyelination and/or prior
infectious/inflammatory process. The patient was diagnosed with Altered mental status, unspecified, Epilepsy, unsp, not intractable, without status epilepticus. At the time of discharge, the patient had Breakthrough seizure
HIV. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ old right-handed woman with a history significant for
HIV, possible CNS toxoplasmosis (biopsy non-specific, followed
with serial imaging) and medically-refractory focal-onset
epilepsy with recurrent episodes of status epilepticus who
represented with concern for breakthrough seizures and
recurrence of NCSE.
#Epilepsy, breakthrough seizure:
EEG once placed did not show ongoing seizures. Exam slowly
improved throughout admission with improvement in perseveration
and expressive aphasia. No evidence of infection on labs, per
family patient has been compliant with all medications. MRI was
negative for any new focal lesions. Overall unclear cause of
breakthrough seizures. Her zonisamide was increased to 500mg
QHS. She was continued on home 1000mg BID keppra, and 200BID
Vimpat. Levels were checked though not on admission
unfortunately, trough of vimpat was 8.3. Levels of keppra and
zonisomide were pending at time of discharge.
#Prior probably CNS toxo s/p treatment: Patient was due for
monitoring MRI which was done during admission and showed stable
enhancement at L frontal biopsy site and nonspecific
periventricular white matter changes.
#HIV: Continued on home HAART
Transitional Issues
==============
[] Zonisamide dose increased to 500mg
[] Zonisamide and Keppra levels pending at discharge
[] Screening MRI done during admission that showed enhancement
at prior L frontal biopsy site and nonspecific periventricular
white matter changes.
[]f/u with neurology appt with Dr. ___
[] f/u with PCP ___ 2 weeks.
[]Repeat EKG at next PCP appointment to check PR interval. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo man w/ CAD ___ CABG ___, Aflutter
___ ablation at ___ ___ (on warfarin), h/o DVT (RUE DVT,
saphenous vein DVT resolved), cardiomyopathy ___ CRT-P ___
(previously removed ___ iso MSSA bacteremia),
hyperthyroidism ___ amiodarone toxicity, R. pleural effusion,
and recent hospitalization for polymorphic VT/cardiac arrest on
___ c/b new diagnosis of ESRD with unclear etiology (HD
initiated ___. He initially presented to ___ for
worsening mid-lower back pain on ___ and was subsequently
admitted to ___ for Neurosurgery Evaluation of suspected
discitis vs.osteomyelitis of T8/T9. MRI THORACIC AND LUMBAR PT6 MR SPINE showed 1. Study is moderately degraded by motion.
2. Acute osteomyelitis/discitis at the level of T8-T9, with associated
epidural phlegmon, with evaluation for abscess limited secondary to motion
degradation as described. Enhancing epidural collections resulting at least
moderate to severe vertebral canal narrowing at T7-8 and T8-9.
3. Congenitally short pedicles at L3 through L5 with superimposed spondylosis
resulting in moderate to severe vertebral canal narrowing at L2-3 through
L4-5, as described.
4. Grossly stable multilevel thoracic spine mild spondylosis compared to 2 day
prior outside exam.
5. Nonspecific probable edema throughout thoracic and lumbar paraspinal
muscles as described.
6. Imaging lungs demonstrate lowered right and small left pleural effusions.
If clinically indicated, consider correlation with dedicated chest imaging. CT-GUIDED BONE BIOPSY showed 1. Technically successful spine biopsy with 1 core sent to pathology.
2. Pulmonary parenchymal opacities, concerning for pneumonia, appears similar
to ___.
3. Moderate right pleural effusion. The patient was diagnosed with Weakness. At the time of discharge, the patient had #T8-T9 Osteomyelitis with phlegmon
#End stage renal disease on dialysis
#Atrial flutter
Secondary Diagnoses:
Chronic heart failure with reduced ejection fraction
Hypertension
Coronary Artery Disease
Hypertension
Non-occlusive Deep Vein Thrombosis
Hyperthyroidism
Myelodysplastic syndrome
Gout. The patient was given written instructions concerning 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 w/ CAD ___ CABG ___, Aflutter
___ ablation at ___ ___ (on warfarin), h/o DVT (RUE DVT,
saphenous vein DVT resolved), cardiomyopathy ___ CRT-P ___
(previously removed ___ iso MSSA bacteremia),
hyperthyroidism
___ amiodarone toxicity, R. pleural effusion, and recent
hospitalization for polymorphic VT/cardiac arrest on ___
c/b new diagnosis of ESRD with unclear etiology (HD initiated
___. He initially presented to ___ for worsening
mid-lower back pain on ___ and was subsequently admitted to
___ for further evaluation of suspected osteomyelitis.
He was evaluated by Spine in the ED, who felt he was clinically
stable. ___ MRI w/wo contrast shows T8-9 osteo/discitis with
associated phlegmon and ___ ___ bx of osteo on ___ that
showed no growth to date. ID was consulted and he was started on
IV Vanc/CTX initially and narrowed to complete a 6 week course
of cefazolin dosed at HD (___) at ___
dialysis</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo AA F with PMH CKD ___ FSGS s/p renal transplant x3 (most
recent in ___ on Prednisone and Rapamune, Afib on Coumadin,
?CVA, DM, NASH, HTN, DLP, squamous cell lung cancer s/p
resection ___ who presented with 1 week of N/V/diarrhea and
inability to tolerate po, found to have ___. Pt says her sx
began 1 week ago, the morning after she went to a baby shower
when she woke up with abd cramping, diarrhea, N/V. appetite
decreased. Trying to tolerate po but has been largely
unsuccessful so came to ED because "it wasn't good for her
kidneys." Diarrhea has been ranging from loose to formed stool
this week. Yesterday BM was black. She has been taking pepto
bismol and iron supplements. No blood in stool. Has been
urinating and noticed urine "watery" past few days until
yesterday when it appeared concentrated. No fevers, chills,
sweats. No one else at shower was sick that she knows of,
including daughter and neighbors. No new med changes except
lasix dose which was increased from 20 to 40mg about 1 month
ago.
.
In the ED initial VS were 98 87 115/57 17 98% RA. CXR
demonstrated similar R sided pleural effusion, coarse reticular
parenchymal opacities both unchanged from prior film in ___.
INR slightly supratherapeutic to 3.4. UA with 14 epis, few
bacteria, and WBCs. Labs concerning for worsening renal failure
with creatinine 7.4 and BUN 73. Pt recieved 1L NS, zofran, 2mg
sirolimus, and lorazepam in the ED. VS prior to transfer were
Temp: 98.9 Pulse: 89, RR: 16, BP: 107/68, O2Sat: 100, O2Flow:
ra. Radiology showed Examination unchanged since ___. A large right pleural
effusion appears stable. Color Doppler and spectral waveform analysis was
performed of the transplanted renal vasculature. The main renal vein is
widely patent. The resistive indices in the upper, mid, and lower polar
regions are 0.78, 0.82, and 0.82 as compared to 0.80, 0.75, and 0.79 on the
most recent prior examination. The waveform of the main renal artery appears
normal.
IMPRESSION:
1. No perinephric fluid collection or hydronephrosis. Stable 1.6 cm simple
cyst in the mid pole of the transplant kidney.
2. Unchanged mildly elevated resistive indices in the intraparenchymal renal
arteries. showed 1. No perinephric fluid collection or hydronephrosis. Stable 1.6 cm simple
cyst in the mid pole of the transplant kidney.
2. Unchanged mildly elevated resistive indices in the intraparenchymal renal
arteries. The patient was diagnosed with NAUSEA WITH VOMITING, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, KIDNEY TRANSPLANT STATUS. At the time of discharge, the patient had Primary:
- Acute on chronic kidney impairment
Secondary
- Dehydration
- Supratherapeutic INR
- Atrial fibrilation
- Status post three renal transplants. The patient was given written instructions concerning 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 a PMHx of FSGS s/p 3
failed transplants with a baseline Cr ~2.8, who presents with
___ (Cr~7) after one week of poor PO intake, nausea, emesis,
diarrhea and continuing ACEI and Lasix.
.
For her acute on chronic renal impairment, the etiology was
presumed to be secondary to poor hydration status and
continuation of nephrotoxic medicines. We started IVF with LR,
held lasix and lisinopril, placed her on a low phos/low k diet.
On day of discharge her Cr was 4.9 from 7.1 on admission. Her
physical exam was significantly improved in regards to hydration
status. On day of discharge her orthostatic blood pressure and
heart rate variation was within normal limits. On day of
discharge her urine output was ~45cc/hr.
.
For her renal transplant Sirolimus was continued and her levels
were checked daily. Prednisone was continued. Nephrocaps were
continued. Bactrim was continued for PCP ___. On day of
discharge the patient was placed on all of her home medications
for per the renal transplant service.
.
To evaluate the etiology of her GI illness we checked her Stool
for CDiff and stool culture. We checked a UA, UCx, and CMV + BK
virus serology. No signs of UTI, and serologies are pending. She
was given, although did not require Zofran for nausea.
On day of discharge the patient tolerated a full PO diet without
n/v/diarrhea.
.
For her chronic afib, we continued her beta blocker and held her
Warfarin as the INR was supra therapeutic. She was given
discrete instructions to follow her INR with the ___
clinic.
.
On day of discharge the patient was able to tolerate a full PO
diet, ambulating with walker, urinating appropriately without
problem, and moving bowels appropriately without problems.</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 Afib on Coumadin, CAD
s/p CABG (___), SSS s/p PPM, HFpEF (EF 55%), and mild aortic
stenosis/moderate tricuspid regurgitation/severe mitral
regurgitation, who is presenting with dyspnea. Chest radiograph showed Stable mild cardiomegaly. No evidence of pulmonary edema.
Focal asymmetrical opacity in left apex, for which further evaluation with
standard PA and lateral chest radiographs is recommended.
RECOMMENDATION(S): Recommend a PA and lateral chest radiograph nonurgently
to assess left apical opacity. Radiology showed Persistent left apical opacity for which two view chest is suggested when
patient is amenable. Left basilar opacity likely due in part to an effusion
and atelectasis. Infection is not excluded. CHEST (PORTABLE AP) showed Compared to chest radiographs dated ___ through ___.
Heterogeneous opacification in the upper lungs has improved. There is less
edema in the left lower lung, although moderate left basal atelectasis
persists. I suspect the upper lobe abnormality was asymmetric edema. Small
to moderate left pleural effusion and mild cardiomegaly are stable. No
pneumothorax. Transvenous right ventricular pacer lead in standard placement. The patient was diagnosed with Heart failure, unspecified. At the time of discharge, the patient had Primary: acute on chronic systolic heart failure, community
acquired pneumonia, acute on chronic kidney disease
Secondary: coronary artery disease, atrial fibrillation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ with PMH of Afib on warfarin, CAD s/p
CABG, SSS s/p PPM, HFpEF (EF55-60%) and mild aortic
stenosis/moderate tricuspid regurgitation/severe mitral
regurgitation, who is presented with dyspnea, found to have CHF
exacerbation. The exacerbation was thought to be secondary to
infection vs. ischemia vs. arrhythmia. Pt was treated with IV
diuretic and 5 day course of antibiotics for community acquired
pneumonia and her symptoms improved. Pt was without troponin
elevation and ECG changes on admission. Further work-up of
ischemia was deferred given pt's age and comorbidities. Pt was
transitioned to oral regimen of torsemide 20mg daily with
stabilization in volume status and renal function.
# Acute on chronic systolic heart failure: Patient presented
with shortness of breath and evidence of volume overload on
exam. This was thought to be secondary to heart failure
exacerbation. The exacerbation was thought to be secondary to
infection (community acquired pneumonia) vs. ischemia (TTE with
worsening EF 40% from 55-60% with regional systolic dysfunction,
moderate AS, MR, and TR, moderate pulmonary hypertension) vs.
arrhythmia (brief episode of AF with RVR on arrival to ED).
Pneumonia was treated as below. Ischemic work-up showed no ECG
changes and no troponin elevation. Further work-up was deferred
given the patient's age and comorbidities. AF with RVR resolved
upon admission and the patient's HR remained stable throughout
admission. She was medically optimized with lisinopril 2.5mg
daily and metoprolol succ 25mg daily. She was diuresed was
intravenous furosemide and eventually transitioned to torsemide
20mg daily with stabilization of her weight and renal function.
Her discharge weight was 44.5kg.
# Sick Sinus Syndrome/Atrial Fibrillation: Pt has an isolated
episode of atrial fibrillation with rapid ventricular response
on arrival to the emergency department which was rate controlled
with metoprolol. Pacemaker was interrogated which showed HR <100
for 90% of beats. Patient was started on metoprolol succ 25mg
daily for CHF and for rate control. Her INR fluctuated during
the hospitalization, likely related to antibiotic treatment for
community acquired pneumonia. Despite CHADS ___, decision made
not to bridge for sub-therapeutic INR given the patients age and
comorbidities. She was treated with higher dose warfarin. INR
will be followed by rehab facility after discharge.
# Community acquired pneumonia: Patient presented with shortness
of breath, neutrophilic leukocytosis, and a chest x ray that
showed a possible infiltrate in the left apex. Blood cultures
and urine legionella antigen were negative. Patient was treated
with 5 day course of ceftriaxone and azithromycin which she
completed in house.
# Left calf wound: Patient has a wound from a basal cell
carcinoma removal that did not heal. Wound is mildly odorous and
has exposed tendon, no evidence of active infection. She was
evaluated by wound care while hospitalized with the following
recommendations:
- Tramadol 25mg prn dressing changes
- Acetaminophen 650mg po Q6 prn pain
- Gabapentin 100mg daily
- Sterile water for dressing changes
- Petrolatum Xeroform gauze
- Normlgel
Transitional Issues:
# Continue to titrate metoprolol and lisinopril for BP control
and for optimization of heart failure regimen
# Continue to titrate torsemide dosing for management of volume
status
# Continue to monitor wound on left anterior calf.
# INR 1.5 on discharge, decision made not to bridge given age
and comorbidities. Patient treated with 2mg warfarin, please
continue to check INR and titrate warfarin to goal ___. Check
next INR ___
# Please check Chem 10 on ___ to ensure stability
# Continue to monitor daily weights on patient, call MD if
weight increases > 3lbs
# Discharge weight: 44.5kg
# Consider repeat CXR PA and lateral in ___ weeks for evaluation
of resolution of heterogeneous opacification in left upper lobe
of lung </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with hx of DMII, ESRD s/p transplant in ___ on
immunosuppresion, HIV on antiretrovirals, HTN, b/l BKA who
presents for R arm swelling that began 5 days ago. Swelling
slightly improved with arm elevation, but progressively worsened
prompting her presentation today. Denies any pain, pruritus,
trauma, strenous activity/exercise in that arm, hx of clots/PE,
bites, open sores, rash, ulcers, fevers, or chills. Has baseline
numbness in hands. She has maintained sensation in the hand and
grip strength. This has never happened to her before in the arms
or legs.
.
In ED, intial VS were 98.0 65 145/66 20 98%. She underwent ___
of the right arm which was negative for DVT by preliminary read
although the brachial and basilic veins were not visualized. She
was given ceftriaxone for possible cellulitis and admitted for
further work-up.
.
ROS:
(+) Per HPI. Negative for headaches, changes in vision,
shortness of breath, chest pain, changes in bowels, dysuria or
increased or decreased urinary freq. Radiology showed 1. No evidence of DVT in the visualized veins of the right upper extremity.
Right brachial and basilic veins not visualized. Slightly decreased
respiratory variability seen in the right subclavian vein compared to the
left; extrinsic compression or thrombus within the proximal right subclavian
vein is not excluded. MR venogram without IV contrast is suggested for further
assessment.
2. Right upper extremity AV fistula patent throughout.
3. Extensive subcutaneous edema. Radiology showed Aborted examination. Lack of documentation and artifact from an SVC stent
precludes MRI imaging in this area. Radiology showed 1. Chronic stenosis or obliteration of the inferior aspect of the right
brachiocephalic vein, as it meets the SVC stent. The inferior aspect of the
left brachiocephalic vein also appears stenotic, but is likely patent. Right
IJ vein have a diffusely narrow luminal caliber before it occludes in it's
inferior margin.
2. Right sided arteriovenous fistula remains patent, with a focal aneurysmal
component.
3. No intravascular clot.
4. Slightly prominent Right supraclavicular/subpectoral lymph node as
described, but is not causing mass effect against nearby vasculature. No
obstructing mass. The patient was diagnosed with IDDM W SPEC MANIFESTATION, CELLULITIS OF ARM. At the time of discharge, the patient had PRIMARY
Right upper extremity swelling
Brachiocephalic stenosis
SECONDARY
ESRD s/p kidney transplant
HIV. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ yo F with h/o ESRD ___ DMT2 now s/p SCD
transplant ___ with good renal function, also with h/o HIV on
HARRT who presents with right upper arm swelling x 5 days.
# Right upper extremity swelling: The arm was not painful, red,
or warm and she denies fevers and no leukocytosis which all
argue that deep tissue infection and cellulitis are unlikely.
DVT was ruled out with US and CTA. Most likely explanation is
lymphatic or venous congestion either from brachiocephalic
stenosis noted on CTA or from patent fistula. Transplant surgery
recommended angioplasty of stenosis; they were hesitant to
ligate fistula at this time in case patient requires dialysis in
the future. Patient will follow-up with AV Care to arrange for
angioplasty as an outpatient. In the meantime, patient was
instructed to continue elevating her arm and performing hand
grips.
CHRONIC ISSUES
# HIV: Stable. Continued truvada + raltegravir
# ESRD s/p transplant ___: Stable creatinine and tacro level.
Continued home dose tacrolimus, mycophenolate mofetil,
prednisone, bactrim, calcium, and vitamin D
# DM2: Poorly controlled with last A1c 8.4 on ___. Continued
lantus and ___.
TRANSITIONAL ISSUES
-Please check a CD4 and HIV VL as an outpatient
-She will follow-up with AV Care in the next two weeks for
angioplasty of her stenosis. If this fails to improve her
symptoms, she will likely require ligation of her patent AV
fistula.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ female with stage IIIB ovarian cancer on
study ___ (Olaparib vs. placebo) admitted from the ED with
leg
pain.
Endorses ___ days of right leg and thigh discomfort which is
now
in the last day progress to one day of erythema warmth and
swelling. Her pain is not severe nor as a rapidly spreading. She
denies any confusion. She has chronic lymphedema this extremity.
She denies prior episodes. She denies any other infectious
symptoms but does report a migraine which started with her fever
and has been decreaseing. She reports the headache is achy and
right sided, mild photophobia, no phonophobia, changes in
vision,
neck stiffness or nausea or vomiting.
In the ED, initial VS were pain 4, T 100.8, HR 98, BP 119/63,
RR
16, O2 97%RA. Labs notable for WBC 17.3 (95%N), HCT 32.9, PLT
248. Na 132, K 3.2, HCO3 26, Cr 0.7. ALT 17, AST 26, ALP 71,
TBili 0.5. Lactate 1.8. Patient was given IV Mg, KCL, IV clinda,
IV vanco, APAP and 1L NS prior to transfer for further
management.
On arrival to the floor, patient was laying comfortable in bed
in NAD.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI. Radiology showed No evidence of deep venous thrombosis in the right lower extremity veins. Radiology showed Cardiomediastinal silhouette is within normal limits. There are no focal
consolidations, pleural effusion, or pulmonary edema. There are no
pneumothoraces. Surgical clips are seen at the base of the neck. US LOWER EXTREMITY, SOFT TISSUE showed Subcutaneous tissue edema without fluid collection. The patient was diagnosed with Cellulitis of right lower limb. At the time of discharge, the patient had Primary diagnosis:
Cellulitis
Secondary diagnosis:
Ovarian cancer
Depression
Hypothyroidism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old female with a stage IIIB ovarian cancer on
study ___ (Olaparib vs. placebo) who presented with
cellulitis. She was started on IV vancomycin originally and this
was transitioned to PO clindamycin upon discharge. She was
febrile (~102) with an elevated WBC count (~17) originally, but
she was afebrile upon discharge and her WBC normalized (7). The
day prior to discharge, she noticed worsening soft-tissue
swelling at the site of her cellulitis. An US was performed and
showed no signs of abscess.
#Cellulitis: Her leg pain and erythema are suspicious for
cellulitis, no purulence and no area of skin break however
patient did recently shave the groin area and there is mild
folliculitis there. Edema is chronic and lower extremity US
(___) was negative for DVT. She had a fever throughout her
first couple days and her WBC was 17.3 on admission. She was
started on IV vancomycin and after 3 days of this, her vanc
level was subtherapeutic (2.8) and her erythema was not notably
improving. Her vancomycin dose was increased and on repeat
check, her level was therapeutic. Given her absence of fevers,
normalized WBC count, and improving erythema, she was
transitioned to PO clindamycin, which she will complete a 7 day
course of. On the day of discharge, she was complaining of a
soft tissue swelling on her medial right thigh in the area of
her cellulitis. She received a lower extremity US which showed
no sign of abscess.
#Headache: She presented with a headache consistent with prior
migraines. She has tried many medications in the past and
finally botox was the only time she got relief. She was given
some IVF, tylenol, and reglan with improvement.
#Ovarian cancer: She was continued on her study drug while
in-house.
#Depression: She was continued on her home fluoxetine 50 mg qd
and ativan.
#Thyroid carcinoma s/p thyroidectomy: She was continued on her
home levothyroxine </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with stage IV NSCLC s/p chemo/XRT, GERD,
macular degeneration s/p recent exploratory laparotomy, small
bowel resection, and
primary anastomosis on ___ for SBO secondary to metastatic
lung cancer on pathology, STEMI s/p BMS to LAD with ischemic
cardiomyopathy with EF of 30% who presents s/p unwitnessed fall
during which she stool up and used a grabber to pick up her
dirty laundry off of the floor with a grabber. She reports LH
with standing. She also reports decreased po intake along with
nausea and vomiting x ___ days. She does not report abdominal
pain. She has a mild dry cough that she cannot tell me how long
she has had it. She also reports fatigue and non-focal weakness.
She does not report fevers or chills or weight loss. She fell
backwards and hit her head. She does not report LOC. She laid
still until she recovered and could crawl onto her bed. From
there she called ___. She has had issues with constipation since
her surgery for which she takes stool softeners. Radiology showed Interval removal of a right internal jugular catheter without
radiographic evidence for acute change. Radiology showed 1. No CT evidence for acute intracranial process.
2. Small right parieto-occipital subgaleal hematoma with overlying
ecchymosis. Radiology showed 1. No CT evidence for acute cervical spine fracture.
2. Left apical lung mass with radiation changes and underlying emphysema,
incompletely imaged. Radiology showed 1. No CT evidence for acute rib fracture.
2. Increased size of left apical lung mass with adjacent radiation fibrosis.
3. New 5-mm left upper lobe lung nodule.
4. Increased size of left adrenal metastasis. Radiology showed 1. No evidence of pulmonary embolism.
2, Left apical lung mass is again noted with encasement of the left common
carotid artery and a left upper lobe pulmonary artery. Radiology showed No dilated loops of bowel or air-fluid levels. Radiology showed 1. No evidence of intracranial metastatic disease.
2. No evidence of acute intracranial abnormalities.
3. Complete opacification of the lateral recess of the right sphenoid sinus,
progressed since ___. The patient was diagnosed with CHEST PAIN NOS, HYPERTENSION NOS. At the time of discharge, the patient had Primary: s/p Fall, Lightheadedness, Nausea, Dehydration
Secondary: Lung Cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with stage IV NSCLC s/p palliative
chemo/radiation, recent SBO s/p ex lap with resection and
primary anastomosis ___, CAD s/p NSTEMI with bare metal
stent to LAD ___ who presents with nausea, vomiting,
delirium s/p fall with sub-galeal hematoma. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Loc is a ___ year old male who presents with low back pain and
bilateral lower extremity pain, numbness, and tingling that has
progressively worsened since ___. There was no clear
antecedent trauma or event. He did explain that he exercised a
normal routine on ___ and felt fine afterwards but
woke up two days later with the low back and leg pain. The pain
begins in his low back and continues down both legs. He states
he does occasionally get shooting pain down both legs. He denies
saddle anesthesia. He denies bowel/bladder incontinence. He
presented to an ED on ___ and was discharged with a
muscle relaxer and IBP. He presents today for further evaluation
and treatment of this pain. L-SPINE (AP AND LAT) IN O.R. showed Images obtained for surgical purposes. The patient was diagnosed with Anesthesia of skin. The patient was treated with ___ Bilateral L4 laminectomy with left microdiscectomy. At the time of discharge, the patient had Herniated Disc L4-5. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo M presents with low back pain and bilateral
lower extremity pain, numbness, and tingling that has
progressively worsened since ___. There was no clear
antecedent trauma or event. On exam at admission, he had no
focal neurologic
deficit. A MRI lumbar spine showed a large disc protrusion at
L4-5 withcentral stenosis.
#Herniated Disc
MRI revealed a large herniated disc L4-5. After admission
patient pain worsened. On repeat examination patient was noted
to have new distal LLE weakness however rectal tone remained
intact, PVR 20. He was added on to the OR schedule for ___. On
___, the patient complained of increased pain and numbness in
his penis and perianal area. He also had decreased rectal tone.
He was taken to the OR for bilateral L4-5 laminectomy and left
microdiscectomy. The procedure was performed without
complication. Please refer to the operative report for full
details regarding the procedure. He recovered in the PACU
post-operatively and was then transferred to the floor. On POD
#1, his pain was much improved. His extensor hallicus longus was
___ bilaterally but otherwise his motor exam was ___. He
continued to have perianal numbness and tingling but he had
pressure sensation. Physical therapy was consulted and
recommended acute rehab. Endorses continue urinary incontinence
with weak stream. Bladder scanned PVR 200. He was discharged
to acute rehab ___ and will follow up in the office.
#Constipation
The patient has not had a bowel movement since ___ so
his bowel regimen was increased. Large BM AM of ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: History obtained through telephone ___ Translator
___ ___ speaking male with PMH sick sinus syndrome, Afib,
CHF (LVEF 45% in ___, asymptomatic RBBB and LAFB, who presents
with worsening dypnea on exertion who was found reclining in a
bathtub at home by a home health aide after a possible fall
although this is not clear. Patient does not really remember how
he ended up lying in the bathtub, he just remembers he was lying
recumbent in the bathtub and did not feel like he had the energy
to get up. This happened a couple of hours prior to his arrival
to the emergency Department, and in the interim, the home health
aide and the patient's daughter discussed whether or not he
needed to go to the emergency department. By the time the son
arrived (who is helping translate with his interview initially
because ___ translator cannot be reached), patient was being
loaded onto a stretcher to be taken to the hospital. The patient
has denied any pain throughout, denying any chest pain,
shortness of breath, or any localizing symptoms of trauma. He is
at his mental baseline per the son. (After discussion with the
translator, the above story is substantially similar).
According to the son, he has a history of falls and was at an
outside hospital several months ago with a fall with head strike
requiring suture.
The patient also complains of productive cough with subjective
fever and chills.
In the ED, initial vitals 98.6 83 120/56 20 97%. There was no
visable sign of trauma. CT head showed no acute process with
evidence of old small vessel disease. CT neck was negative for
fracture of malaignment. CXR showed retrocardiac opacity
(atelectasis vs infection). HCT 38.7 WBC 9.2, PMN 83.6. he was
given Ceftriaxone 1g and azithromycin 500mg for pneumonia.
Vitals on transfer 98.1, hr 84, 113/61, rr 16.
On arrival to the medical floor, vitals were T:98.2 P:86
BP:126/78 RR:20 SaO2: 100% on Room air. Stated his breathing was
comfortable and that he wanted to be left alone. He denies chest
pain, dyspnea. Radiology showed Left lung base consolidation may represent atelectasis or infection in the
appropriate clinical setting. Radiology showed 1. No acute intracranial process.
2. Encephalomalacia involving the left posterior temporo-pariatal lobe with
associated ex vacuo dilatation of the posterior horn of the left lateral
ventricle represents sequela of remote infarction, and appear more conspicuous
in appearance since ___ exam.
3. Prominent sulci and ventricles, likely age-related involutional changes.
4. Chronic small vessel ischemic disease. Radiology showed No evidence of acute fracture or malalignment. Multilevel degenerative
changes, as described above. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, ATRIAL FIBRILLATION. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
1. Community acquired pneumonia
SECONDARY DIAGNOSIS:
1. paroxysmal atrial fibrillation
2. Chronic systolic heart failure (EF 45%)
2. history of deep vein thrombosis
3. chronic kidney disease
4. atrophic gastritis
5. gastroesophageal reflux
6. ___ esophagus
7. osteoporosis
8. osteoarthritis. The patient was given written instructions concerning 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 Atrial fibrillation, CHF, HTN, Sick
Sinus Syndrome presents with possible mechanical fall and found
to have pneumonia.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year-old R-handed woman, pmh of pituitary
microadenoma and hyperprolactinoma who presents with
dysquilibrium and walking to the right. She was in her USOH. At
noon, she went to make her bed. She had a sudden onset of
"rocking on a boat" or "lost balance". This lasted several
seconds and then resolved. MR HEAD W/O CONTRAST showed No significant abnormalities are seen on MRI of the brain without gadolinium. The patient was diagnosed with Ataxia, unspecified. At the time of discharge, the patient had Vestibulopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ year old woman with a history of
pituitary microadenoma who presented after several episodes of
dysequilibirum and veering to right. Exam was notable for slight
R sided dysmetria and veering to the right while walking, which
resolved the morning following admission. Given her symptoms,
she underwent a work up for stroke specifically to rule out
posterior circulation stroke, vertebral dissection. MRI did not
show findings that could explain her symptoms. Her symptom of
dysequilibrium resolved by the following morning. The most
likely cause of her symptoms was felt to be a type of
vestibulopathy. We advised her to follow up with her PCP.
Transitional Issues
#Neurology
[ ] No specific follow up with Neurology set up at this time.
Patient may call ___ to schedule a follow up if
symptoms do not resolve or change in quality
[ ] Pituitary microadenoma: records from ___ showed an
MRI with contrast in ___ to evaluate for progression which
apparently showed regression of the previously suspected
right-sided pituitary microadenoma, per report.
[ ] Follow up lipid panel</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ DM, CKD approaching dialysis, HTN, sarcoid on prednisone
p/w hyperglycemia. Pt c/o weakness x 4 weeks, decreased appetite
x 3 weeks. Had 2 episodes non-bloody emesis 4 days ago, but no
abd pain, no diarrhea. Endorses dysuria at the end of her
stream, urgency, and frequency, but no hematuria. Additionally
has had urinary incontinence for the last few weeks. Felt her
feet have been numb for the last 4 weeks and has been having
difficulty walking. No fevers, but has subjective chills. Radiology showed Right hilar enlargement likely residual lymphadenopathy seen on
CT chest from ___. No acute cardiopulmonary process. The patient was diagnosed with URIN TRACT INFECTION NOS, DIABETES UNCOMPL ADULT. At the time of discharge, the patient had Primary: Hyperglycemia, hyperosmolar ketoacidosis, urinary tract
infection
Secondary: Diabetes mellitus type II, hypertension,
hyperlipidemia, sarcoidosis, stage IV 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/ DM, CKD approaching dialysis, HTN, sarcoid on prednisone
p/w hyperglycemia and UTI.
#Hyperglycemia: likely in the setting of UTI below and patient
also been missing doses of insulin. Also contributing is
prednisone dosing, although patient on less than previously.
Got 20 units Lantus this morning and 12 units of Humalog in the
ED. Sugars are still critically high and anion gap is 17 at
admission. Patient was treated with 32 units of Humalog and 30
units of glargine night of admission and her gap closed to
normal with sugars down to the 100-200 range. We enjoyed
consultation with the ___ team and modified her sliding scale
to their recommendations (increased doses). We continued home
glargine 20U qam and 20U qpm.
- ___ follow up ___
#UTI by Positive UA: patient with dysuria, frequency, and
urgency x1 month. Malodorous urine in room. Urine cultures were
not drawn prior to antibiotics, so we empirically switched her
away from the Cipro treatment in the ED (previous UTI e coli
Cipro resistant) and treated her with ceftriaxone and her
leukocytosis resolved. The following morning her foley catheter
was removed. She reported no more dysuria following a day of IV
ceftriaxone. Patient was given a prescription of cefpodoxime to
complete for 5 more days as an outpatient.
#Hypokalemia and hypertension in setting of steroid use and
ESRD: Patient approaching dialysis, has fistula in place left
side, does not appear matured by my basic exam. Is not volume
overloaded currently. She was however hypokalemic despite
receiving 40meq of potassium twice while in house. She has had
labile potassiums in the past and despite considerations of
hyperaldosteronism as an underlying cause, we did not send off
serum renin levels or add on an aldosterone receptor antagonist.
We did continue furosemide 100mg daily and metolazone 2.5 mg
BID
- consider hyperaldosteronism and aldosterone antagonism therapy
in the future pending initiation of dialysis.
#Sarcoidosis: Residual lymphadenopathy on CXR. Otherwise not
active. We continued prednisone 10 mg DAILY and budesonide 180
mcg/Inhalation Aerosol Powdr Breath Activated Sig: One (1) puff
Inhalation BID (2 times a day) as needed for
cough.
#Prolonged QTc: Avoided Zofran and other QT prolonging meds.
#Hypertension: Patient normotensive, ? hypotensive in ED.
Normotensive during hospitalization. We continued hydralazine
25 mg PO Q6H Diltzac ER 360 qd (dosed as 90 QID) and restarted
furosemide 100mg daily and metolazone 2.5 mg BID day after
admission.
#Primary prevention of coronary artery disease. EKG with NSST
changes likely due to LVH. We continued aspirin 81 mg qd and
pravastatin 80 mg qhs
#Depression: Patient euthymic. We continued citalopram 40 mg qd
#Transitional:
- Patient with prolonged QT interval. Avoid QT prolonging
medications.
- Follow up with ___ day after discharge.
- Patient discharged with ___ and ___ assistance.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx ESRD on HD, DM2, AF not on coumadin, hep C, Left
brachiocephalic AV fistula with steal syndrome s/p banding
presenting with dyspnea and hypotension during dialysis. Pt was
about 3 hours into dialysis when he was transferred over to the
ED for dyspnea. At the time he was noted to be hypotensive to
SBP of ___ and was also complaining of L leg pain. At this time
he denied and chest pain, palpitations, diaphoresis, n/v.
In the ED, initial vitals were: 0 97 92 90/50 20 100% 2L. ___
showed no evidence of DVT in LLE. CXR showed mild pulmonary
edema with small right pleural effusion, overall not
significantly changed from prior exam.
Of note, patient recently hospitalized at ___ ___ for
weakness and tachycardia. Also with two recent hospitalizations
in ___ for AVG steal syndrome.
Vitals prior to transfer were 3 98.1 89 118/69 22 99 3L NC
On the floor, the patient reported chest pressure with
associated palpitations, diaphoresis and nausea but no vomiting.
He also endorsed extreme leg pain that he described as burning,
tingling predominately on the b/l soles of his feet. He reports
that it is similar to the pain he feels on a daily basis but
just worse. CHEST (AP upright AND LAT) showed Mild pulmonary edema with small right pleural effusion, overall not
significantly changed from prior exam. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. The patient was diagnosed with HYPOTENSION NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS
-----------------
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>This a ___ year old gentleman with history of ESRD on
hemodialysis, diabetes mellitus, atrial fibrillation not on
coumadin, hepatitis C, left brachiocephalic AV fistula with
steal syndrome s/p banding who presented with dyspnea and
hypotension during dialysis. He was monitored overnight for
acute coronary syndrome. Workup was negative and his blood
pressure normalized with diet.
BRIEF HOSPITAL COURSE
========================
ACTIVE ISSUES
#Hypotension: After dialysis SBP 70, in ED SBP 90, likely in
context of volume reduction. On admission, SBPs normotensive in
120s. Patient reported chest pressure with associated
palpitations, diaphoresis and nausea. EKG with no ischemic
changed. Troponins cycled thrice with plateau at 0.40 x 3.
Patient was hemodynamcially stable with resolution of cardiac
symptoms, and therefore was transferred back to his skilled
nursing facility. No medication changes were made on transfer
STABLE CHRONIC ISSUES
#Leg pain: As previously described, most likely due to diabetic
neuropathy.
Patient was continued on gabapentin and lidocaine patches.
#Atrial Fibrillation: CHADS-VASc2 = 4. Patient with mild RVR HR
120s. Patient was continued on dilitiazem and digoxin. Heart
rate normalized
#Systolic and diastolic Congestive Heart Failure: Patient was
continued on digoxin and diltiazem. Admission Weight:73.94 kg.
Discharge Weight: 74 kg
#End Stage Renal Diseae on Hemodialysis: baseline Cr ~6. Patient
was continued on midorine, gabapentin, nephrocaps, sevelamer and
Renal caps. Patient did not require hemodialysis this admissio.
Continue dialysis T/R/S schedule
#Obstructive Sleep Apnea: Patient was continued on CPAP and
trazodone.
#Diabetes Mellitus Type II: Patient was continued on glargine 10
U qHS and home insulin sliding scale. Patient should follow up
with ___ continued management of diabetes.
TRANSITIONAL ISSUES
[] Please arrange follow up with ___ continued
diabetes management. ___
[] Please ensure follow up with PCP ___ transplant
surgeon Dr. ___ care of patient's ongoing issues
[] Reconfirmed discontinuation of Imdur with ___
has NOT been updated in the OMR (only under discharge meds)
[] PCP: ___ augmenting patient's antidepressant (his age
and
cardiac risk factors contraindicate increasing celexa) vs
switching to different agent
[] Hip Pain: Pelvic XRay neg. ___ with PCP as outpatient, may
require additional imaging (XRay negative) if does not resolve.
Patient requests orthopedics appointment for management of known
humeral fracture. This appointment was not made on this
admission. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female h/o chronic microcytic anemia, asthma with
chief complaint of allergic reaction to ferumoxytol/iv iron.
Immediately following iron infusion on day of admission, patient
developed chest tightness, SOB, wheezing, throat tightening,
tongue swelling. Oxygenation initially dropped to 90% BP
150s/70s HR 120s. Patient's symptoms improved after
Hydrocortisone 100mg, Benadryl 25mg. She had received
dexamethasone 10mg, Benadryl 25mg, and famotidine 20mg prior to
iron infusion. Patient also has h/o asthma. She received
albuterol neb in clinic. Patient's oncologist recommended
monitoring for minimum of ___ hours as reaction can recur or
admit overnight for monitoring.
.
In the ED, initial vitals 98.7 75 135/73 22 100% 15L. On
admission, patient complained of throat tightness and received
epinephrine x 1, as well as albuterol/ipratropium nebs. Two
hours later, throat tightness recurred and patient received IV
diphenhydramine and epinephrine x 1. CBC was remarkable for
hematocrit of 28, which has been downtrending. Chest X-ray
showed no acute findings. Stable cardiomegaly. At 1:45 in the
morning the patient began to have symptoms again including chest
pressure/tightness some shortness of breath, feeling like she is
having difficulty handling her secretions. Benadryl IV 25 began
was given. ECG was unremarkable. Since this was the third time
the patient had symptoms, it was decided to admit the patient to
Medicine. Vitals upon transfer were 98 72 127/59 20 97%ra.
On arrival to the floor, patient reports ___ chest pain
radiating up to her jaw, no dyspnea, palpitations, or nausea. Radiology showed No acute findings in the chest. Stable cardiomegaly.
NOTIFICATION: The patient was diagnosed with SWELLING IN HEAD & NECK, SHORTNESS OF BREATH, CHEST PAIN NOS, ADV EFF IRON & COMPOUNDS, ANEMIA NOS. At the time of discharge, the patient had Primary diagnosis:
Anaphylaxis to intravenous iron
Iron deficiency anemia of undetermined etiology
Secondary diagnosis:
atypical chest pain, possibly secondary to esophageal spasm
CAD
hypertension
chronic stable asthma
GERD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman with a history of iron deficiency, asthma, atypical
chest pain, and chronic stable asthma, admitted after
anaphylactic reaction to IV iron in ___ clinic.
# Anaphylaxis: Patient with anaphylactic reaction to IV iron
despite premedication with dexamethasone, benedryl, famotidine,
and despite distinct formulation from prior anaphylaxis-inducing
IV iron infusion. Initially patient was transferred from
hematology clinic to emergency room for observation, but given
recurrence of SOB, airway edema after each of two injections of
epinephrine, patient was admitted to medicine. Patient was
closely monitored and treated with famotidine, fexofenadine, and
prednisone as well as prn IV diphenhydramine and albuterol
following discussion with allergy consult service.
-40mg PO prednisone x3 days, then 20mg PO x3 days (last day
___, then taper will be deferred to
outpatient endocrinologist
-Iron supplementation (in any form of administration) noted as
SEVERE allergy for this patient in OMR
# Microcytic anemia: Iron deficiency anemia with positive guaiac
in ___ woman s/p TAH raises concern for occult GI malignancy or
possibly slow GI bleed. Other considerations include
malabsorbtion, hereditary or autoimmune. Has strong family
history of anemia. Past work up has included unrevealing
investigation for hemoglobinopathy and upper and lower endoscopy
in ___. Patient has history of severe anaphylactic reactions to
supplemental iron. She was scheduled for outpatient colonoscopy
which was missed on second day of admission. Given severe
allergy to iron supplementation and labs showing serum iron of
10 and slowly down-trending hematocrit on admission patient was
transfused 1U pRBC with appropriate bump in hematocrit.
-TTG IgA to evaluate for celiac disease as cause of
malabsorption pending at time of discharge
# Atypical chest pain: Angina vs GERD vs anxiety. Patient
presented with chronic epigastric/substernal pressure that had
been stable and ongoing for 2 weeks prior to admission. Inital
cardiac enzymes were negative x2 and EKG showed stable t-wave
abnormalities. During this admission patient had one episode of
left-sided squeezing ___ chest pain radiating to the left arm
that felt subjectively similar to episode in ___ that resulted
cardiac cath and balloon angioplasty back in ___. Pain was
not relieved with 325mg chewed ASA, but was relieved by SL NTG
x1. Cardiac enzymes were again negative and EKG was stable. Pain
may be secondary to esophageal spasm, given response to
nitrates. She underwent exercise MIBI here ___ which was
normal and is followed by Dr. ___ outpatient cardiology.
-Follow up with Dr. ___ as outpatient.
# Asthma - continued home albuterol, fluticasone. Patient
complained of asthma worsening when patient in adjacent room lit
a cigarette just prior to Mrs. ___ discharge. SOB and
subjective wheezing improved with 1x albuterol nebulizer. No
wheezes heard on auscultation following nebulizer, was moving
air well. Patient was given a script to fill for albuterol
inhaler to take with her in the car ride home, knows to return
to an emergency room or call her doctor if her SOB or wheezing
recurs and is not controlled with her rescue inhaler.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CT ABD AND PELVIS WITH CONTRAST showed 1. Large amount of stool throughout the colon.
2. No evidence of malignancy within the abdomen or pelvis. CT CHEST W/CONTRAST showed 1. Fibrosing interstitial lung disease is not significantly changed compared
to prior CT scan from ___.
2. Bilateral pulmonary nodules measuring up to 4 mm are unchanged compared to
prior.
3. Stable bilateral axillary lymphadenopathy.
4. Bilateral breast lesions are better evaluated by recent dedicated breast
MR. CT LOW EXT W/O C LEFT Q61L was done. The patient was diagnosed with Thrombocytopenia, unspecified. At the time of discharge, the patient had MCTD
SLE
myositis
ITP. The patient was given written instructions concerning 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/ASSESSMENT: Ms. ___ is a ___ female with the
past medical history of MCTD w/ SLE/myositis overlap c/b ILD and
b/l hip avascular necrosis and recently diagnosed invasive
ductal
carcinoma (ER+, PR+, Her2 neg) who presented due to concern of
bruising and BRBPR. Labs revealed significant thrombocytopenia
with concern for primary more so than secondary ITP.
#thrombocytopenia
#ITP
She was admitted to ___ on ___ because of mucosal bleeding,
and she was found to have undetectable platelets (<5). She was
evaluated by the hematology team, and was diagnosed with immune
thrombocytopenic purpura (ITP). She was seen by rheumatology,
and it did not seem that this was ___ her MCTD as her bloodwork
did not show active disease (negative dsDNA, normal complement
levels C3 96, C4 13). Rather, this seems to be a separate
autoimmune process. She declined the first line treatment for
ITP, which is steroids, despite multiple conversations, based on
prior experience. Therefore, she then had two days of IVIG (full
dose for ITP), which she did not respond to. She was also
started on N-plate, and had 2 doses of this inhouse, without
improvement so far (though the N-plate can take longer to work).
Several discussions were had with the patient about a possible
splenectomy, which would be the next line of treatment, but she
declined to consider this so far. She was encouraged to have the
vaccines administered that would be needed (pneumococcal,
meningococcal and h. influenzae) prior to a splenectomy, despite
confirming their safety in terms of her MTCD with her
rheumatologist Dr. ___.
Note that rituximab would not be an option in her case because
she had an anaphylactoid reaction to a rituximab infusion in
___ requiring steroids and epinephrine, and she is declining
the use of steroids for pre-medication.
Throughout the hospitalization she continued to have daily
oozing from her mucosae (oral with ulcers; vaginal, in her
stool) but her blood counts stayed stable. She had petechiae and
several small ecchymoses throughout, but no edema/large
hematomas.
The use of Lupron to help decrease her vaginal bleeding was
discussed with the gynecologists, hematology/oncologists, and
rheumatologist Dr. ___ it was determined that it
would be safe for her to get a Lupron injection in the short
term to help with vaginal bleeding. Note that after 12 months of
usage it can cause ___ weakness as it mimics the symptoms of
menopause. She declined this during the hospitalization
The possibility of a tagged platelet indium scan to assess the
success rate for a splenectomy was explored, but this is
unfortunately not a test that we can perform at ___ (or likely
nowhere in the ___ area as the external pharmacy that would
tag the platelets has no experience with this, but this was not
confirmed by calling other hospitals). </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with h/o HTN, HLD, CAD s/p DES, gastric
bypass, gout, DM2 c/b diabetic neuropathy, retinopathy, and
chronic foot ulcerations c/b osteomyelitis s/p multiple
debridements including right ___ met head resection (DOS:
___ with recently healed wound presented to ___ for right foot swelling and was transferred for futher
evaluation concerning for cellulitis and abscess. CT LOWER EXT W/C RIGHT Q62R showed 1. Status post right first metatarsal head resection and sesamoidectomy.
Compared to the ___ radiograph, there is irregularity and
probably small erosions at the resection margin of the ___ metatarsal head
resection, as well as bone spicules at the proximal aspect of the first
proximal phalanx. Bone fragments are seen in the surgical bed, with soft
tissue and fat stranding. The findings are suspicious for osteomyelitis.
2. 1.3 cm linear metallic foreign body adjacent to the fourth toe proximal
phalanx, consistent with retained needle fragment, stable since ___.
3. A foot ulcer is seen at the plantar aspect of the third toe, at the level
of the proximal phalanx, measuring 1.3 cm in depth and 0.6 cm wide. The
underlying bone is unremarkable. The patient was diagnosed with Cutaneous abscess of right foot. The patient was treated with R foot I&D: ___. The patient was given written instructions concerning 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 h/o HTN, HLD, CAD s/p DES, gastric
bypass, gout, DM2 c/b diabetic neuropathy, retinopathy, and
chronic foot ulcerations c/b osteomyelitis s/p multiple
debridements including right ___ met head resection (DOS:
___ with recently healed wound who presented to ___ for right foot swelling and was transferred for further
evaluation concerning for cellulitis and abscess.
ACUTE ISSUES:
=============
#R foot Cellulitis
#R foot abscess
Patient developed pain, erythema and swelling in the R foot
concerning for cellulitis and abscess. Was started on
doxycycline at urgent care without improvement and referred to
ED for I&D with podiatry. Wound culture eventually grew MRSA.
CRP/ESR also very elevated. Initially started on
vanc/cefepime/flagyl then narrowed to vanc/CTX/flagyl. Xray not
concerning for osteomyelitis, and CT scan showed fat stranding
and edema likely from prior surgical changes, though raising
some concern for osteomyelitis. Per ID, given recurrent
infection in the same area, would recommend longer course of
antibiotic. We recommended staying inpatient until an antibiotic
regimen could be established, however patient insisted on
immediate discharge given prior family commitments. Attempted to
discharge on daptomycin 600mg IV daily given prior growth (MRSA
sensitive to Bactrim), but given difficulty with insurance
coverage, he was discharged on Bactrim. Unable to dose
vancomycin given dose required to maintain therapeutic levels
would be >4.5g/day. Will follow up with ID in 2 weeks to follow
up cultures and possibly deescalate antibiotics or switch to IV
antibiotics. Will continue to pack dressing and follow up with
podiatry to close the wound.
#T2DM on insulin
Last A1C was 7.8% per records. Home regimen prior to admission
was NPH 54U and Humalog ___ and HISS. He was on this regimen
given cost of Lantus and had frequent snacking at night which
lead to increased night time blood sugars. Was supposed to be on
NPH in the AM as well but patient preferred to only have one
injection of NPH. He has recently changed his diet and now per
wife, has had episodes of hypoglycemia in the evening. A1C
during admission was 7.3%. At discharge we planned to switch his
NPH to the AM to improve AM coverage and to decrease episodes of
evening hypoglycemia. Discharge regimen was NPH 30U qAM with
Humalog ___ + ISS. Should have endocrine follow up to follow
up blood sugars and possibly switch to Lantus.
CHRONIC ISSUES:
===============
#Diabetic neuropathy:
Continued gabapentin 1200mg TID
#HTN:
Continued lisinopril 40mg daily and metoprolol tartrate 25mg
BID.
#CAD
#ICM
Prior NSTEMI s/p DES with ischemic cardiomyopathy (EF 65% in
___. Appears euvolemic on exam. No chest pain. Continued
home aspirin. Continued rosuvastatin 10mg qPM. Continue
ezetimibe 10mg daily. Continue home metoprolol 25mg tartrate BID
#LEFT EYE RETINAL DETACHMENT:
Chronically dilated pupil on the left without vision. s/p eye
drops per patient. Follows with ophtho here and MEEI in the
past.
#GOUT:
Continued home allopurinol</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS: ___ with lupus on immunosuppressants
presenting with right ankle ulcer with concern for surrounding
cellulitis. History of ulcers treated with vanco. Pt reports she
noted a small skin break in the area of her R lateral leg just
proximal to her ankle approx ___ ago. Within 3 days of
noting it without preceding trauma, she noted that it became a
small ulcer. The ulcer as increased in size and depth over the
past 3 wks. She saw her rheumatologist. She was prescribed
Keflex on ___. She was seen in ___ clinic on ___ and this was
changed to doxy and a biopsy was taken at the lateral border of
the ulcer. She has noted pain in the R ankle area, top of R foot
and pain extending up to mid shin. She reports the pain
increases with wt bearing but she is able to wt bear. She
reports the pain is up to ___ in severity, a burning pain with
associated sensation of pins and needles. She reports spreading
redness at the anterior aspect of the ulcer and some spreading
proximally. She has noted increased swelling of her R foot. She
reports Tmax approx 100.2 at home on day of presentation. She
reports malaise since AM on the day before presentation. +
chills. No n/v. Noted ulcer on L side of tongue on day of
presentation.
Pt with admission ___ with LLE ulcer, treated with Vancomycin
for concern for concurrent infection and biopsies suggestive of
vasculitis at the time. Ulcer were thought related to underlying
SLE. Pt reports the current ulcer on her RLE is different that
this episode ___. She reports the LLE ulcer last year was
typical for her ulcers ___ to SLE starting as a papule and then
transitioning to an ulcer. She reports the current ulcer started
as a small scratch instead. Pt reports ulcers are common
cutaneous manifestation of her SLE; she reports above her waste
they are more pink papules and below her waist will form into
ulcers. Pt reports dose of Benlysta last on ___ (though
cannot find OMR documentation of this).
Referral from Dr. ___: ___ with ___ ulceration for 2wks,
treated for infection with Keflex beginning ___ and doxy added
at derm visit ___ with biopsy done. Leg getting increasingly
swollen. Tmax 100.7. Pt with multiple ABX allergies so will
probably need IV ABX and admission.
In the ED, initial vs were: 97.6 94 134/79 16 96%. Labs were
black with WBC count of 7.6 with normal diff. Patient was given
1g IV ___, 10mg oxycodone, 5mg IV morphine x2. Pt given 1L NS
at 100cc/hr. Bl cx sent. Ankle x-ray done. Pt admitted for IV
ABX and mgmt of cellulitis. Vitals on Transfer: 97.4 85 136/94
16 99%.
On the floor, pt reports ___ pain extending from top of R
foot to ___ way up R shin.
Review of sytems:
(+) Per HPI Radiology showed No evidence of DVT in the right lower extremity. Radiology showed Unchanged position of left-sided Port-A-Cath on this single frontal view. Radiology showed Normal bilateral arterial study at rest. No obvious indication of peripheral
vascular disease. Radiology showed No evidence for bone destruction. The patient was diagnosed with CELLULITIS OF FOOT. At the time of discharge, the patient had Primary Diagnoses:
- Cellulitis
Secondary Diagnoses:
- None. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ SLE (on mycophenolate mofetil, hydroxychloroquine, and
methylprednisolone) presents with RLE ulceration with
?cellulitis and R ankle swelling concerning for tenosynovitis
vs. vasculitis vs. septic arthritis</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMHx of TBM and tracheal stenosis
s/p TBP, cervical tracheoplasty, redo right thoracotomy and
esophagopexy and tracheopexy, soft tissue infection of the
abdomen secondary to malposition of jejunostomy s/p multiple
laparotomies, Addison's disease, and CF presents with n/v and
respiratory distress after recent discharge to rehab. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed 1. Unremarkable neck CT. A tracheal-bronchial Y stent is present, appearing
appropriately positioned and widely patent however the distal extent is not
included on this scan. CHEST (PORTABLE AP) showed No acute radiographic cardiopulmonary abnormality. DX FEMUR AND KNEE showed 1. No acute fracture or dislocation of the left femur or left knee.
2. Small left suprapatellar joint effusion. ANKLE (AP, MORTISE AND LAT) LEFT showed No acute fracture or dislocation. HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT showed 1. Mild degenerative changes of the right hip.
2. No acute fracture or dislocation. CR- RIBS BILATERAL WITH AP CHEST showed 1. No displaced rib fracture is identified.
2. Old healed right fifth, sixth and seventh rib fractures.
3. No pneumonia or acute cardiopulmonary process. CHEST (PORTABLE AP) was done. CHEST (PORTABLE AP) showed Low bilateral lung volumes. Diffuse bilateral airspace opacities could
reflect bronchovascular crowding or mild pulmonary edema. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had PRIMARY
========
Anxiety
Tracheobronchomalacia
Mechanical Fall
SECONDARY
==========
Pancreatic insufficiency
Asymptomatic Bacteruria
Severe adrenal insufficiency
Insomnia
Weight Gain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ PMHx of TBM and tracheal stenosis s/p TBP, cervical
tracheoplasty, redo right thoracotomy and esophagopexy and
tracheopexy, soft tissue infection of the abdomen secondary to
malposition of jejunostomy s/p multiple laparotomies, admitted
with n/v and respiratory distress after recent discharge to
rehab. She was found to have significant pain control
difficulties and anxiety, for which palliative care and
psychiatry modified her medication regiment. On ___, she had
her temporary stent removed due to concerns it was no longer
effective.
ACUTE ISSUES
=============
# Anxiety
Patient with underlying anxiety, however seemed to be
significantly worse this admission concerning her pain control
and disposition. Multiple nights she had episodes of anxiety,
requiring small doses of ativan or increased pain medications to
improve her symptoms. Psychiatry evaluated the patient on ___,
and recommended initiation of Sertraline. Her dose was increased
on ___ to 50mg. They also recommended benefit from continued
work with a therapist outpatient. She was continued on her home
dose of Clonazepam.
[] Continue Sertraline daily, and monitor response. Uptitrate as
appropriate.
[] Patient would benefit from working with a therapist
# TBM; chronic, progressive decline
Patient underwent bronchoscopy with tracheal silicone stent
placement on ___ with Dr. ___. She was discharged to a
rehab, but readmitted after her concerns that the facility could
not meet her level of care. She otherwise appeared to be stable
in terms of her respiratory status. She completed her course of
antibiotics for her PNA from previous hospitalization on ___.
Interventional pulmonology did not feel she needed further acute
intervention, nor that she had developed a new infection. Her
stringent medication regiment was restarted. Through
hospitalization, her respiratory status seemed to mildly
decline, as the patient reported increased mucus plugging and
chest pain. Extensive discussion was had with IP regarding
whether patient's stent could be placed prior to discharge. The
decision was made to remove her stent on ___, and few days
prior she was started on levaquin to treat any possible
underlying lung infection. The stent was removed on ___, with
patient continuing to report significant pain and dyspnea
afterwards. Her pain medications were adjusted as below.
[] Patient will complete 5 additional days of levaquin treatment
for possible respiratory infection (___)
# Pain control/QOL:
Followed by palliative care during prior admission and has a
great deal of chronic chest and musculoskeletal pain. Pain was
well controlled with her regiment initially, however over time
her pain became more significant, raising concerns for failure
of the stent as above. Thus palliative care re-evaluated the
patient and following removal of the stent recommended
concentrated morphine for help with both pain and dyspnea.
[] Reevaluate pain regiment with palliative care
# Asx Bacteruria
Ucx from ___ growing predominantly enterococci, but also has
mixed flora. Patient was no complaining of dysuria. Suspect this
was likely contamination, especially since UA does not appear
inflammatory. Thus, patient was not started on antibiotics.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old male who complains of s/p Fall.
___ male in the emergency department for evaluation
after a fall. Patient states that he was walking around his
block to get exercise and states his leg gave out from under
him. Positive head strike. Denies loss of consciousness.
Suffered a laceration to his left forehead. Bleeding controlled
with pressure. Brought to the ED for evaluation. History of
orthostatic hypotension and has multiple falls. CT ABD AND PELVIS WITH CONTRAST showed 1. Severe compression deformity of T12 is mildly worse from ___,
consistent with acute on chronic compression fracture.
2. No other acute injuries or other acute abnormalities in the abdomen or
pelvis.
3. Additional unchanged chronic findings, as above. MR THORACIC SPINE W/O CONTRAST ___ MR ___ SPINE. showed 1. Compression fracture of the T12 vertebral body with approximately 75%
height loss is overall similar in configuration compared to ___.
The presence of edema signal pattern within the vertebral body and
prevertebral edema suggests possibility of a superimposed injury. There is no
evidence of spinal cord compression or signal abnormality.
2. Mild degenerative changes in the thoracic spine, predominantly related to
ligamentum flavum thickening.
3. Increased anterior-posterior diameter of the thoracic vertebral bodies with
small Schmorl's nodes suggesting the possibility of underlying Scheuermann's
disease.
4. Right upper lobe pulmonary nodule, better characterized on the chest CT
from ___.
PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal, height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
Jarvik, et all. Spine ___ 26(10):1158-1166
Lumbar spinal stenosis prevalence- present in approximately 20% of
asymptomatic adults over ___ years old
___, et al, Spine Journal ___ 9 (7):545-550
These findings are so common in asymptomatic persons that they must be
interpreted with caution and in context of the clinical situation. The patient was diagnosed with Laceration w/o foreign body of oth part of head, init encntr, Other specified injuries of thorax, initial encounter, Fall on same level, unspecified, initial encounter, Weakness, Unspecified abdominal pain. At the time of discharge, the patient had Left anterior ___ rib fractures
Acute on chronic T12 vertebral body compression fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo M with complex medical history including
history of PE/DVT on Eliquis, HIV, anal cancer s/p chemotherapy
and transanal excision of rectal tumor, orthostasic hypotension,
frequent falls, chronic diarrhea, who presented to the emergency
department via EMS after a fall from standing with head strike.
CT head, cervical spine, chest, abdomen pelvis obtained and
showed no acute intracranial process, left sided rib fractures
___, and compression deformity of T12. He underwent MRI that
again showed compression fracture of T12 vertebral body. He was
seen and evaluated by neurosurgery who recommended ___
management and no activity restrictions. The patient was
admitted to the trauma service for pain control and respiratory
monitoring.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with oral Tylenol
and oxycodone.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. The patient
was orthostatic with lightheadedness and recovered with sitting.
He was given a 500 cc bolus with improvement in orthostatic
hypotension.
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 given a regular diet which he
tolerated without difficulty. Patient's intake and output were
closely monitored. He was continued on home antidiarrheals and
bowel movements remained at baseline.
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.
The medicine team was consulted for assistance and managing
orthostatic hypotension and frequent falls in the setting of
systemic anticoagulation. Given the patients extensive work up
of orthostatic hypotension in the past and current management,
no further work up was done inpatient.
The patient's primary care provider ___ was also
notified of the patients admission and recommended discussing
the risk/benefit of Xarelto with the patient and allowing the
patient to decide if he wanted to continue or stop the
medication. These risks/benefits were discusses with the patient
and the patient felt very strongly that he did not want to
experience a blood clot ever again, and chose to continue on
Xarelto despite the risk of bleeding with frequent falls.
The patient was seen and evaluated by physical therapy who
recommended home with home ___. The patient was in agreement with
the plan and recently had home ___ after his last
hospitalization.
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: ___ yo F with h/o ESRD on HD (anuric), DM, CHF, HTN, Dementia,
and multiple PMHx who presents with ___ transferred from
her nursing home (___). Radiology showed 1. Opacification of the left mastoid air cells may suggest mastoiditis of
indeterminate chronicity.
2. No acute intracranial hemorrhage. Radiology showed 1. No evidence of inflammatory process within the abdomen.
2. Diffuse fecal loading with excessively distended rectum due to fecal
contents.
3. Thickening of anterior bladder wall, correlate with clinical exam and
UA/labs.
4. Bilateral small pleural effusions, right > left.
5. Opacification at the right lung base adjacent to pleural effusion likely
atelectasis versus infection in the correct clinical setting. Separate more
rounded area of opacification at right lung base(2:4) is concerning for
consolidation with possible cavitation.
6. Left adnexal cystic lesion, similar to prior exam, may be further evaluated
with US nonemergently if not already performed.
7. Severe atherosclerotic calcification in the abdominal aorta with near
occlusion of the abdominal aorta by atherosclerotic plaque just above the
origin of the ___, unchanged from prior. Distal to this region, the aorta
appears patent. Skin collaterals and underperfused kidneys likely secondary to
severe aortic atherosclerotic calcification.
8. Distened gallbladder without gallastone.
Findings discussed with Dr. ___ at 9:14pm on ___ via telphone. Radiology showed Uncomplicated retrieval of a left-sided internal jugular tunneled hemodialysis
catheter. Radiology showed 1. Near complete occlusion of the left internal jugular with access
eventually obtained via a collateral in the left supraclavicular region.
2. Placement of a tunneled hemodialysis catheter with tip in the right
atrium. The catheter was flushed and is ready for use. Radiology showed 1) Limited exam due to positioning/mobility.
2) Mild degenerative changes.
3) Suspected ligamentous laxity at C3/4.
4) Suspected dense ossification of the ALL in the lower cspine, which may be
contributing to fusion and decreased mobility. However,t his extends beyond
the lower edge of these images and is not fully evaluated.
5) No bone detruction, focal severe disc narrowing or prevertebral soft tissue
swelling to confirm changes related to infection.
6) If clinically indicated, cross-sectional imaging would help for further
assessment of cervical spine alignment, degenerative changes, and soft
tissues.
NOTE: Findings were discussed with Dr. ___ by Dr. ___ at the time
of dictation. Radiology showed 1. Limited study due to motion artifact without CT evidence for acute
intracranial process.
2. Partial opacification of the left mastoid air cells. Clinical correlation
is recommended.
Findings were reported to ___ by ___ by telephone at 9:40
p.m. on ___ at the time of discovery of these findings. The patient was diagnosed with BACTEREMIA NOS, LEUKOCYTOSIS, UNSPECIFIED , OTHER GRAM NEGATIVE INFECTION. The patient was treated with Tunneled line removal
Replacement of tunneled dialysis line. At the time of discharge, the patient had Primary diagnosis:
Pseudomonas aeruginosa sepsis
Neck pain
Secondary diagnoses:
ESRD on dialysis
HTN
T2DM. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F with h/o ESRD on HD (anuric), DM, CHF, HTN, Dementia,
and multiple PMHx who was transferred from her nursing home with
GNR sepsis, found to be pseudomonas sepsis.
# Pseudomonas sepsis: Patient presented with GNR bacteremia by
blood cx ___, hypothermia (T 95.8F) and leukocytosis (WBC
19) consistent with sepsis. Blood culture identified as
Pseudomonas aeruginosa which was also found on the tunneled cath
dialysis tip that was removed per renal consult. She also had a
cavitary lesion on CXR, which could be a source of pseudomonas,
although it was noted that cavitary lesions are usually due to
TB, staph aureus or anaerobes. Patient's antibiotic course was
narrowed to Cefepime for pseudomonal coverage from Vancomycin,
Cefepime and Metronidazole. She was switched to Ceftazidime
after replacement of a tunneled cath line so that she could be
receive it during dialysis. The patient had a transthoracic
echocardiogram on ___ which showed no vegetations and
antibiotic course will be two weeks, should be continued at
dialysis through ___.
Patient also initially had a left mastoid fluid on CT head
concerning for mastoiditis and right mastoid tenderness on
admission. However, there was no erythema or ulceration
consistent with acute otitis externa, confirmed by ENT
consultation.
#Cervical spine ligament laxity: Pt had neck tenderness but no
stiffness on admission. She received a cervical spine x-ray that
showed anterolisthesis and ligament laxity. Neurosurgery
consulted and recommended a cervical collar for 2 weeks and
follow-up with the ___ clinic in 2 weeks, which will
need to be scheduled by rehab.
#ESRD: Last dialysis on ___. Pt is on ___ dialysis schedule
per Nursing home. Her tunneled cath was removed per renal. A
new tunneled cath was placed on ___ after patient was
afebrile and has had no new blood culture growth. Resumed HD on
___ and should continue with ___ schedule after discharge.
She will receive the above described antibiotics at dialysis
after each session.
#Mental status: Patient is lethargic at baseline but arousable
to voice and will answer with head nod. There was briefly some
concern that she was not able to take oral medications or food
and she had a repeat head CT which showed no acute intracranial
process. On the day of discharge, she was at her apparent
baseline mental status and was able to take PO medications
without difficulty.
Chronic Issues
#Chronic constipation: continued home bowel regimen
#Hypothyroidism: continue home Levothyroxine
#Hypertension: Hypertensive on admission because she had only
received labetolol overnight. She started her home meds
Amlodipine, Labetalol, Captopril and her blood pressure became
normotensive/mildly elevated (SBP's 120-160's).
Transitional Issues
-follow-up blood culture results
-will continue to receive ceftazidime for a total 2 week course
with her dialysis sessions, will be continued through ___.
-will need to wear c-collar for 2 weeks until she is seen by
___ clinic
-schedule follow-up in ___ clinic with Dr. ___ in 2
weeks (___)</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M, MVC, unrestrained, + LOC, ___? p/w R ___ anterior
nondisplaced & R ___ ant mild displaced rib fx. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial process.
2. Anterior right basal frontal lobe cystic change may be from prior trauma.
3. Expanded sella turcica. Defect along sellar floor, may be postsurgical, or
from meningocele, correlate with surgical history. Correlate with history of
rhinorrhea. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed No acute findings. CT torso with contrast showed 1. Nondisplaced fractures of the right anterior ___ ribs and lateral
___ ribs. No pneumothorax.
2. No acute organ injury in the chest, abdomen, or pelvis.
NOTIFICATION: The updated findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 2:18 pm, 2 minutes after
discovery of the findings. CHEST (PORTABLE AP) showed No comparison. The lung volumes are normal. The patient shows moderate
cardiomegaly and signs of mild pulmonary edema. There is no evidence of
pathologic parenchymal processes, notably no evidence of pleural effusions or
pneumonia. No pneumothorax. The patient was diagnosed with Multiple fractures of ribs, right side, init for clos fx, Car driver injured in collision w car in traf, init. The patient was given written instructions concerning 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 pmh significant for seizure disorder presented
following a high speed motor vehicle collision with positive
loss of consciousness. He was evaluated in the trauma bay and
pan scanned and found to have R ___ anterior nondisplaced rib
fx, R ___ anterior mild displaced rib fx. He was admitted to
the floor for pain control and pulmonary toilet.
On hospital day 1 the patient's diet was advanced to a regular
diet and he was tolerating oral pain medication. He worked with
___ and OT who recommended that he follow up with cognitive
neuroscience as an outpatient for his loss of consciousness
after the incident. The patient was also instructed to follow up
with his primary neurologist after discharge to discuss his
medications and possible seizure as a cause of his motor vehicle
accident.
Prior to discharge the patient was tolerating a regular diet, he
was ambulating independently. His pain was well controlled on
oral pain medications. He was instructed to follow up with the
___ surgery clinic, as well as the cognitive neurology clinic
for his loss of consciousness. He was also instructed that under
no circumstance should he drive or operate a motor vehicle until
his is cleared to do so by his primary neurologist. He was
instructed to follow up with his neurologist within the next
week. The patient was in agreement with this plan and was
discharged home in good condition. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o woman with type 2 diabetes mellitus, hypertension,
hyperlipidemia, CAD, and atrial fibrillation on warfarin who
presents with bradycardia and hypotension. She was scheduled for
cardiac catheterization on the day of admission to evaluate new
echocardiographic inferior wall hypokinesis. However, on the way
to the procedure, she had 1 episode of non-bloody, non-bilious
emesis. The procedure was cancelled given her symptoms on
presentation and low blood pressures. She was sent home and was
initially doing OK. Her son checked her BP and heart rate and
noted them to be in the ___ systolic and ___ respectively, so he
brought her to the ED. Radiology showed No acute cardiopulmonary process. Radiology showed No pneumothorax The patient was diagnosed with HYPOTENSION NOS, CARDIAC DYSRHYTHMIAS NEC, NAUSEA WITH VOMITING. The patient was treated with Coronary and renal angiography ___ with deployment of a
drug-eluting stent in the mid LAD. The patient was given written instructions concerning 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 woman with type 2 diabetes mellitus hypertension,
hyperlipidemia, CAD, atrial fibrillation on warfarin who
presents with bradycardia and hypotension in the setting of
emesis. After stabilization, she underwent elective coronary
angiography (as previously intended to evaluate new focal
hypokinesis at rest) and was found to have 90% a mid-LAD
stenosis which was stented with DES.
ACUTE ISSUES
------------
# Bradycardia - Unclear etiology. ___ have had increased vagal
tone in the setting of her nausea and vomiting. She is also on
large doses of carvedilol (25 mg bid) but has been on this for a
while. By the time she arrived to the ICU, her bradycardia had
resolved. She had negative cardiac biomarkers. She remained in
sinus rhythm for the rest of her admission and her carvedilol
dose was actually increased to 50 mg BID for better BP control.
# Hypotension - Placed on norepinephrine briefly on admission
for SBPs in ___ (nadir), which was weaned soon after arrival to
the MICU. No clear source of infection, and she was not
continued on antibiotics after her initial dose of ceftriaxone
in the ER. She was likely hypotensive secondary to a combination
of junctional bradycardia and hypovolemia from vomiting and poor
PO intake (including npo for her outpatient procedure). Her home
antihypertensive were reintroduced when she became hypertensive
again.
# CAD+hypertension - The patient was scheduled for coronary
angiography for symptoms of angina and evidence left ventricular
systolic dysfunction with hypokinesis of the basal inferior wall
(EF 60%) on ___ TTE. Her outpatient procedure was cancelled
for vomiting and at home later she developed bradycardia and
hypotension that prompted representation to the ER. She was
managed medically over the weekend until her procedure on ___,
which showed 90% mid LAD stenosis, now s/p DES. Renal arteries
were notably free of disease. Her statin dose was raised and her
home carvedilol dose was increased to 50 mg BID for uncontrolled
BPs while in house. Her blood pressures on all of her home meds
were better controlled but still slightly hypertensive 140-150s
on the day of discharge.
# Atrial fibrillation: CHADS2 score is 3 (HFpEF, HTN, DM). INR
goal ___. She takes warfarin at home. This was held for her
invasive cardiac procedure and she was treated with subcutaneous
heparin. Warfarin was started post-procedure, but she was
subtherapeutic at discharge. She will need follow up of her INR
as an outpatient to ensure that she becomes therapeutic again.
Notably, she is now on dual antiplatelet medications as well as
systemic anticoagulation. Patient counseled on increased risks
of bleeding on the combination of these 3 agents.
# Elevated anion gap metabolic acidosis - Caused by lactic
acidosis with lactate of 5 on admission. This resolved with
volume resuscitation and there was no evidence of toxic
ingestion or impaired tissue perfusion subsequently.
# ___ - The patient presented with sCr of 1.2 from baseline
~0.7. This was thought to be from hypovolemia and this improved
with IV fluids. Cr was at baseline value upon discharge.
# Asymptomatic bacteriuria: The patient grew >100k pan-sensitive
Klebsiella from an admission urine culture obtained in the
setting of her nausea/emesis. She did not have symptoms of a
UTI. However, given that she briefly had a Foley after
admission, it was decided to treat her with 3 days of
nitrofurantoin.
CHRONIC/STABLE ISSUES
# T2DM - Oral agents held on admission, placed on insulin
sliding scale. Discharged on her home medications.
# GERD - Continud on pantoprazole
# Hyperlipidemia - Continued on pravastatin, with dose raised to
80 mg nightly prior to admission.
# Code status this admission - FULL CODE
TRANSITIONAL ISSUES
-------------------
-INR follow up to ensure she returns to therapeutic level
-BP monitoring in clinic to ensure adequate control on higher
dose carvedilol</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male with PMHx of CHF and HTN discharged from the ED 3
days ago for likely CHF exacerbation presents with dyspnea. Pt
was brought in on ___ from psych facility. On initial
assessment, patient with paranoid thinking, telling ED staff
that "people are trying to kill him". He denied chest
pain/f/c/n/v but otherwise was unable to answer many questions.
In the ED initial vitals were: 97.7 88 116/98 26 100% NC. NA
131, K 5.2. Trop x 1 negative.
EKG: QTc 476
Labs/studies notable for: WBC to 10.8, H/H 12.9/40.5, BNP 4545,
INR 1.9. Trop x 1 negative. CXR showed minimal prominence of the
pulmonary interstitial markings suggestive of early pulmonary
edema. There is no focal consolidations, pleural effusion, or
pulmonary edema
Patient was given: IV Zofran 4 mg and IV furosemide 40 mg
Vitals on transfer: 98.6 82 117/81 22 100%RA Radiology showed Mediastinal wires are seen, unchanged. Heart size is enlarged and appears
slightly larger than previous. There is minimal prominence of the pulmonary
interstitial markings suggestive of early pulmonary edema. There is no focal
consolidations, pleural effusion, or pulmonary edema. There are no
pneumothoraces. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Mild gallbladder distention with cholelithiasis and mild gallbladder wall
thickening which is nonspecific, and may be due to third spacing. In the
appropriate clinical setting, however, acute cholecystitis cannot be excluded.
If there is continued clinical suspicion, a HIDA scan or MRI with
hepatobiliary agent could be performed for further evaluation.
2. Gallbladder adenomyomatosis.
3. Small volume ascites.
4. Prominence of the intrahepatic veins and pulsatile flow in the main portal
vein may represent right heart failure or tricuspid regurgitation. Clinical
correlation is recommended.
RECOMMENDATION(S): Mild gallbladder distention with cholelithiasis and mild
gallbladder wall thickening. In the appropriate clinical setting, acute
cholecystitis cannot be excluded. If there is continued clinical suspicion, a
HIDA scan or MRI with hepatobiliary agent could be performed for further
evaluation. Radiology showed Normal bowel gas pattern. The patient was diagnosed with Heart failure, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Acute on chronic systolic heart failure
Coronary artery disease
Psychosis
SECONDARY DIAGNOSIS:
Hypertension
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>SUMMARY: ___ y/o male with psychotic disorder (one previous
hospitalization)m HTN, CAD s/p CABG in early ___ and stenting
in ___, CHF who presented with dyspnea on exertion. He was
thought to have an acute decompensation of his heart failure,
most likely in the setting of medication noncompliance. He was
diuresed with boluses of IV furosemide with good response and
transitioned to PO torsemide 20 mg, on which he maintained a
stable volume status for several days. He had an echo that
showed reduced EF of ___ consistent with ischemic
cardiomyopathy. His medications were optimized for systolic
heart failure; further cardiac ischemic evaluation was deferred
at this time. He was followed by our psychiatry team for his
psychosis, and his quetiapine uptitrated from 25mg BID to ___
BID.
# CAD s/p CABG and stents:
# Acute on chronic systolic heart failure: Presented with acute
decompensation of heart failure with dyspnea on exertion and
elevated BNP. Diuresed over the course of several days with
boluses of 80mg IV furosemide. When he reached euvolemia he was
transitioned to PO torsemide 20mg daily with stable I/O. He was
found on echo to have EF ___ with changes c/w ischemic
cardiomyopathy. For medication optimization, his carvedilol and
lisinopril were uptitrated and he was started on spironolactone.
He will require further ischemic evaluation for stress test as
well as consideration of ICD in the future; this was deferred
during this admission due to psychiatric decompensation and low
likelihood of sufficient followup, ie compliance with DAPT if
ultimately stented.
# Psychotic disorder, NOS: Patient was transferred from ___
psych facility to ___. During this admission, he was followed
by our psychiatry team. He continued to have agitation and
paranoia intermittently. His quetiapine was uptitrated from 25mg
BID to ___ BID. He was kept with a 1:1 sitter but did not
endorse any suicidal or harmful ideation. He was discharged to
psych facility.
# Transaminitis: On admission ALT/AST elevated in 300s
consistent with hepatocellular pattern of injury. Hepatitis, HIV
serologies checked and negative. Likely congestive hepatopathy,
and improved during diuresis. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of afib on flecainide and apixaban, s/p Roux-en-Y
gastric bypass, s/p CCY, htn, thyroid nodule presenting with
weakness and feeling cold x1 day. Patient states that she in her
usual state of health until the afternoon of ___, when she
began to feel weak. Her sister noted that she was diffusely red.
She describes feeling bilateral ___ weakness, cold, shivers, and
palpitations. Denies cough, chest pain, abdominal pain,
constipation, diarrhea, although she does report an episode of
loose stools after arrival to the ED. Denies dysuria, hematuria,
hematochezia, melena. Denies rhinorrhea, sore throat, sick
contacts. She recalls one prior episode of feeling weak in the
setting of hyponatremia during a prior admission in ___. CT abdomen/pelvis with oral and IV contrast. showed 1. Minimal peripancreatic stranding which may reflect acute pancreatitis in
the proper clinical context. The pancreas enhances homogeneously.
2. Anasarca. The patient was diagnosed with Weakness. At the time of discharge, the patient had acute pancreatitis
hypothermia
diarrhea. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with h/o afib on flecainide and
apixaban, s/p Roux-en-Y gastric bypass, s/p CCY, htn, thyroid
nodule presenting with weakness and chills, found to have mild
hypothermia, course c/b mild acute pancreatitis.
# Hypothermia:
Unclear etiology at admission with large differential. No clear
infectious etiologies were found with negative blood and urine
cultures. Cortisol and TSH were within normal limits. Among her
medications, metoprolol is the most likely to produce or
exacerbate hypothermia but this was continued without any
recurrence of hypothermia. Patient also had intermittent
hypoglycemia (see below), but it is unclear if this is related
at all. Patient was treated with 6L of warmed IVF as well as
Bair Hugger, with improved temperatures. Her temperatures then
remained stable throughout her hospitalization. Ultimately,
initial episode thought to be related to potential hypoglycemic
episode in setting of mild acute pancreatitis.
# Mild acute pancreatitis
Patient with abdominal pain, n/v, and radiographic signs of mild
pancreatitis, likely caused by alcohol. Lipase is not
significantly elevated, though checked on ___ day of
hospitalization. Her diet was advanced successfully and she
tolerated a regular diet at discharge with resolution of
symptoms. Pancreatitis thought to be secondary to alcohol
ingestion. Patient pre-contemplative regarding her alcohol
abuse, though abstinence was encouraged.
# diarrhea
Unclear etiology but may be gastroenteritis, possibly viral.
C.diff and stool cultures were negative.
# Hypoglycemia
Hypoglycemic episodes noted to BG in the ___, mostly in the
early AM and late ___. Patient never symptomatic. Unclear if
associated with hypothermia as unfortunately BG not measured on
arrival. Hypoglycemia resolves with PO intake. Patient
prescribed glucometer at discharge and instructed to measure
FSBG in the AM and at night and if she has any concerning
symptoms.
# Hyponatremia likely ___ SIADH
Extensive work-up in the past, found to have evidence of
underlying SIADH, though cause is not clear. Patient received 6L
IVF on admission with some decrease in sodium, consistent with
SIADH. Sodium at discharge was 128, which is consistent with
known baseline.
# CV-rhythm:
Patient with known history of afib, presented in an accelerated
junctional rhythm. Maintained on flecainide and metoprolol. Home
apixaban continued. She has upcoming appointment with EP.
# EtOH abuse:
Pt endorses significant EtOH intake, denies hx of withdrawal.
Last drink ___, no evidence of active withdrawal this
admission and patient monitored on CIWA. EtOH level on admission
was 24. Continued on MVI, thiamine and folate. SW consulted and
provided support, though patient was repeatedly resistant to
discussions regarding abstinence and appears to be
pre-contemplative regarding quitting alcohol use.
# Leukopenia
# thrombocytopenia:
Present since ___, has been evaluated by hematology for
pancytopenia, thought to be related to nutritional deficiencies
in setting of roux-en-y. Pt has not been taking nutritional
supplements as recommended. ___ also be component of
myelosuppression ___ EtOH use. HIV negative ___. Home
multivitamins were continued. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with a history of Crohns maintained on
Tofacitinib 5mg BID (Jak3 Kinase inhibitor) with an extensive
surgical history who is most recently s/p revision of ileostomy
and debridement and drainage of abscess cavity (___) with Dr.
___. She presented to the ___ ED on ___ with dizziness,
nausea, and black stool. CT and labs were reassuring and she was
felt well enough to d/c home. Patient returned today with
paresthesias in her hands bilaterally, which started 2 days ago.
The sensation is constant and is located throughout her entire
hand. She cannot clearly identify any aggravating factors. She
notes maybe holding her phone in a certain position makes it
worse. She also believes her fingers (not just the joints) are
more swollen, Rt > Lt hand. She also has pain and difficulty
making a fist. She does not report any other joint pain or
weakness in her extremities. Patient has history of cervical
radiculopathy and carpal tunnel. Her current symptoms are not
similar to prior symptoms. Patient denies new medications. She
has been on tofacitinib since ___.
In the ED initial vitals were: 97.2 97 ___ 97%
- Labs were significant for normal CBC with slightly increased
anemia (Hgb 12.1 -> 11.1). Chem7 notable for Cl 109, otherwise
WNL, Ca/Mg/Phos normal. LFTs normal. Lactate normal. UA with
6WBCs, few bacteria, moderate LeukEst. The patient was given
dilaudid and zofran. Surgery was consulted but felt patient
without any acute surgical issues.
On the floor, reports paresthesias in her hands. She also
reports feeling fatigued for the past ___ days. She noted specks
of blood in her ileostomy bag this morning. Her stools are at
baseline. She empties her bag ___ ___ per day. She also
complains of nausea, poor appetite, and ___ weight loss over
2 weeks. The patient also has LUQ pain, which is worse than her
usual abdominal pain.
Review of Systems:
(+) per HPI
(-) fever, chills, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
vomiting, diarrhea, constipation, melena, hematochezia, dysuria,
hematuria, rash. VENOUS DUP UPPER EXT UNILATERAL showed No evidence of a deep vein thrombosis in the right upper extremity. Small
nonocclusive thrombus at the tip of the catheter in a superficial vein.
NOTIFICATION: Results were discussed with Dr. ___ at 11:43 AM on ___ via telephone by Dr. ___ 5 minutes after the findings were discovered. The patient was diagnosed with REGIONAL ENTERITIS NOS. At the time of discharge, the patient had 1. Paresthesias
2. Crohn's Disease
3. Anemia
4. Carpal Tunnel Syndrome
5. Superficial 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>___ year old female with a past medical history significant for
Crohn's disease with extensive surgical history, who presented
with a one day history of bilateral numbness, swelling,
tingling, and pain in her hands.
Active Issues
# Paresthesias: Cause unclear at discharge. Patient also noted
sensation of swollen fingers. No objective neurologic deficits
identified. The patient's bilateral hand pain and paresthesias
may be due to carpal tunnel syndrome given positive Phalen's
test and known prior history. During her hospitalization other
causes for her symptoms including B12 deficiency, diabetic
neuropathy, severe hypocalcemia, folate deficiency, and thyroid
disorder were ruled out. Lyme serologies pending at discharge.
CRPS felt to be unlikely in the acute setting. Plain films of
her bilateral wrists and hands did not show any degenerative or
otherwise arthritic changes. As she has a history of DVT and had
swelling that was more prominent in the right hand and arm, an
ultrasound was done of the right upper extremity. It did not
show any DVT but did show a small thrombosis at the tip of her
peripheral IV in the cephalic vein. The IV was removed and her
arm swelling decreased. Discussed with radiology and no follow
up imaging was warranted at this time. No indication for
anticoagulation. Discussed with pharmacy, this is not a known
side effect of her JAK2 inhibitor. Patient was given wrist
splints to be worn at night and during the day when possible.
Should follow up with primary care physician regarding whether
nerve conduction studies as an outpatient are warranted re
carpal tunnel.
# Crohn's disease: The patient sees Dr. ___ and has
been on a stable regimen since starting tofacitinib in ___. Of note the patient did notice some darkening of her stool
color and it was found to be guiac positive and flecked with
blood on admission, though nonbloody at discharge. Her
hematocrit on was near her recent baseline at discharge. She did
not have any abdominal pain above her baseline and was treated
with her home medication regimen of PO dilaudid and fentanyl
patch for her pain. Her WBC, LFTs,lipase, and CT abdomen from ED
visit on ___ were all normal.
Chronic Issues
# Anemia, Normocytic:
H/H currently near recent baseline. Patient with recent history
of black stools. No current active signs of bleeding. Guiac
positive. Iron studies showed normal iron and ferritin, slightly
decreased TIBC, TRF, c/w anemia of chronic disease. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ y/o male with a past medical history of
CAD s/p CABG ___, HTN, AF on Coumadin, DMII, depression,
chronic small vessel disease and recent ischemic stroke ___
who presents with a near syncopal episode. Patient reports that
he was walking to ___ today and started to feel weak and
dizzy. He did not pass out and there was no LOC. Patient denied
chest pain, palpitations, headache, vision changes, or SOB
during this episode. Also denied slurred speech or facial droop.
Has never had an episode like this in the past. No report of
seizure activity. He sat down and his symptoms improved after he
drank a soda. His son checked his blood sugar and it was in the
200s. He has had no change in appetite and did eat breakfast
this AM. Given the concern for syncope he went to the ED. Radiology showed Subtly increased lung markings in the left lower lobe likely reflect
atelectasis or scarring and are unchanged from the prior exam in ___.
Low lung volumes. No definite pneumonia. The patient was diagnosed with Syncope and collapse, Weakness. At the time of discharge, the patient had Primary diagnosis: ___, bradycardia
Secondary diagnosis: atrial fibrillation, hypertension, diabetes. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ y/o male with a past medical history of
CAD s/p CABG ___, HTN, AF on Coumadin, DMII, depression,
chronic small vessel disease and recent ischemic stroke ___
who presented with a ___ episode.
# ___: patient had an episode of ___ while
walking up stairs at ___. Initially there was concern that
this was related to a hypoglycemic episode, however his blood
glucose around the event was within normal limits. Patient
denied chest pain, palpitations, loss of consciousness, slurred
speech, vision changes or seizure activity. Orthostatic vital
signs were negative on admission. Troponins were negative x2. He
was noted to be bradycardic in the setting of nodal agents. His
nadolol, digoxin and nicardipine were discontinued. He was
monitored on telemetry. He had no syncopal or ___
episodes while admitted. His TTE did not show evidence of
valvular disease. He worked with physical therapy and was
discharged home with ___. He was discharged off of nadolol,
digoxin and nicardipine. He will have ___ of Hearts placed in
the outpatient setting.
# Bradycardia: patient was monitored on telemetry and within the
first 24 hours of admission he was noted to have bradycardic
episodes with HRs ___ while sleeping and while awake. Patient
was asymptomatic during those episodes. Rhythm was slow AF. His
nadolol, digoxin and nicardipine were discontinued. He remained
on telemetry and was only noted to have episodes while sleeping.
Ultimately his bradycardia was attributed to medication effect
and increased vagal tone while sleeping. He was instructed to
notify his PCP or return to the ED should he have palpitations,
syncope or ___. He will have ___ of Hearts monitor
placed the day after discharge. If patient has recurrent
bradycardic episodes will need to consider pacemaker placement.
# CVA: patient was recently hospitalized with a CVA. He was
evaluated by ___ and was noted to have attention deficits and
slow gait. He was discharged home with ___. He was scheduled to
see a neurologist in the outpatient setting.
# DM: continued home lantus 14U qHS. Discontinued oral
repaglinide. His PCP ___ consider alternative oral agents such
as metformin.
# HTN: continued lisinopril 15 mg daily. Discontinued nadolol,
nicardipine and digoxin. Added amlodipine 5 mg daily.
# AF: patient was on digoxin and nadolol. In the setting of
bradycardic episodes these agents were discontinued. He did not
have episodes of RVR. His warfarin was continued with INR goal
___. He will have ___ of Hearts event monitor placed as an
outpatient.
# CAD: continued aspirin 81 mg daily and continued atorvastatin.
His nadolol was discontinued in the setting of bradycardia.
# Chronic CHF: continued Lasix and spironolactone.
TRANSITIONAL ISSUES
=====================
- discharged home with ___
- DISCONTINUED MEDICATIONS: nadolol, digoxin, nicardipine,
Repaglinide
- NEW MEDICATIONS: amlodipine 5 mg daily
- continue adjusting blood pressure medications as an outpatient
- will have follow up in the cardiology clinic
- recommend INR check on ___ at ___ appointment
- scheduled an appointment on ___ for ___ of Hearts</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ left parietal glioblastoma discovered after she developed
episodic right foot numbness who presents from clinic for
heparin and PE workup. MR HEAD W AND W/O CONTRAST showed 1. Postoperative change of prior left parietal craniotomy with subjacent
resection cavity, expected underlying blood products, and minimal peripheral
enhancement which is potentially on a postoperative basis although attention
to this region during followup is recommended.
2. Decreased edema within the resection cavity when compared to prior exam.
3. No new lesions or clearly new areas of abnormal enhancement. Bilateral LOWER EXT VEINS showed Acute deep venous thrombosis involving bilateral lower extremity veins
extending from the calf veins to the femoral vein at the groin level
bilaterally.
NOTIFICATION: The findings were discussed by ___ with Dr. ___
___ on the telephone on ___ at 3:45 ___, 5 minutes after discovery of
the findings. CHEST (PA AND LAT) showed Moderate cardiomegaly and a tortuous aorta are unchanged from ___. No acute intrapulmonary process. CT ABD AND PELVIS W/O CONTRAST showed 1. Large left rectus sheath hematoma with additional hemorrhage within the
left anterolateral abdominopelvic muscular wall.
2. Diverticulosis without diverticulitis.
3. Atrophic right kidney.
NOTIFICATION: The preliminary findings were discussed by Dr. ___
___ with Dr. ___ on the telephone on ___ at 17:10, 10
minutes after discovery of the findings. Radiology showed Successful deployment of Denali IVC filter.
RECOMMENDATION: 1. Will be in touch with the patient's primary care provider
in several months to discuss the continued need for the inferior vena cava
filter and to possibly schedule removal at that time. Radiology showed 1. Successful recannulization of the right lower extremity extending from the
popliteal through the right common iliac vein.
RECOMMENDATION: 1. Patient to contact Interventional Radiology administrator
upon discharge to arrange for follow-up appointment and ultrasound in 2 weeks
to ensure patency. The patient was diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF DISTAL LOWER EXTREMITY, MAL NEO PARIETAL LOBE, HYPERTENSION NOS. The patient was treated with IVC FILTER PLACEMENT ___
INTRAVASCULAR DVT TPA ADMINISTRATION ___. At the time of discharge, the patient had ___ vein thrombus
Pulmonary Embolism
Rectus Sheath Hematoma
Glioblastoma Multiforme. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>HOSPITAL COURSE: ___ w/ GBM s/p resection ___, HTN, DL,
CKDIII who p/w new symptomatic DVT and small PEs; started on
heparin gtt but developed rectus sheath hematoma.
Anticoagulation stopped and patient underwent plcmt of IVC
filter and got DVT thrombolysis via ___ on ___.
# Anemia/Rectus Sheath Hematoma: patient had abdominal pain and
Hct drop on presentation which started after anticoagulation
initiated. She had visible large left flank hematoma also. CT
abdomen pelvis non con showed a rectus sheath hematoma with
intrapelvic muscular bleeding also so anticoagulation stopped.
Hct downtrended
further despite this and she ultimately required 2u RBCs with
appropriate bump on ___. At the time of discharge Hct was
stable.
#DVT/PE: asabove pt was started on heparin gtt but found to have
bleeding so anticoagulation stopped. She is s/p IVC fliter
placed on ___. Lung scan ___
suggested that if PEs present they are small and subsegmental
and if present very low clot burden. She underwent DVT
thrombolysis ___. Given her Hct continued to downtrend slightly
despite discontinuation of anticoagulation it was felt unsafe to
restart anticoagulation and that she was somewhat protected
against further thrombotic events given that it was less likely
she had PEs and if so they were small, she now has the IVCF, and
her DVTs were lysed by ___. Would consider restart
anticoagulation as outpatient, but would proceed cautiously.
Note pt also has thrombocytopenia. ___ will contact her about
scheduling her for an appointment for repeat ultrasound to see
if the DVTs have in fact resolved as an outpatient. Her baseline
CKD also complicates anticoagulation dosing.
#Dyspnea: resolved. V/q showed likely small peripheral PEs, if
any present they are small and subsegmental. Held
anticoagulation as above
# Thrombocytopenia - unclear etiology, slowly downtrending this
admit from low 100s to ___. Ptls much lower in ___ of this
year though unclear why (in mid ___
likely ___ radiation as she also had received TMZ/IMRT earlier
in her course this year). Plts were stable at the time of
discharge.
#Acute Kidney Injury: Improved, back to baseline. Has baseline
CKD III, ___ improved after IVF initially.
#HTN: stable. Contd home amlodipine and valsartan
#Glioblastoma: stable, s/p resection. Pt will follow up with Dr.
___, plan is likely to proceed with temozolomide which had
been planned as an outpatient.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w hx of metastatic small cel lung ca to brain who
presents w/ vertigo for past 4 days. He states that he has
had progressively worsening feeling of room spinning for 4
days. Worse when lying down but always there. Denies HA,
vision changes, vomiting, or abdominal pain. Has also had
nausea and increased urinary frequency over the past 4 days
w/ no dysuria, fever, chest pain, dyspnea. Last chemo tx was
5 days ago for 3 days. No headache. Seen yesterday for L
shoulder pain, and had a CTA chest which showed no PE and a
stable lung mass. Referred here by oncology for evaluation. Chest: Frontal and lateral views showed Large left hilar mass and peripheral left upper lobe pulmonary nodule/mass
seen on CT 1 day prior were better assessed on CT. Chronic interstitial lung
disease. No new opacity identified. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial process. MRI is more sensitive in detecting small
intracranial lesions. MR HEAD W AND W/O CONTRAST showed No evidence of tumor progression or recurrence. The intraparenchymal
enhancing masses noted on ___ are no longer detected. The
right scalp mass appears unchanged. The patient was diagnosed with Dizziness and giddiness. At the time of discharge, the patient had Benign paroxysmal positional vertigo
Metastatic small cell lung carcinoma
Benign prostatic hypertrophy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ man with COPD, 60-pack-year
smoking history and extensive stage small cell lung carcinoma,
currently status post four cycles of
platinum/etoposide, presenting with dizziness/vertigo.
#Vertigo, likely BPPV - new onset vertigo x 4 days. Orthostatics
negative. Head CT negative for acute intracranial abnormality.
most consistent with BPPV given positive ___. No
dysmetria w/ cerebellar testing. Intracranial cause such as CVA
or brain mets appears less likely but brain MRI obtained to r/o
and showed ongoing resolution of prior intracranial mets, only
residual is R temporal scalp lesion.
- pt repeatedly declined repeat Epley attempts by providers or
___
- given script for meclizine prn max 25mg TID
- he prefers to f/u w/ his PCP who has performed maneuvers for
him in past. He was given referral to vestibular therapy
although at this time states he declines to attend.
- pt was independent w/ ambulation, gait steady. he was advised
not to drive until vertigo resolves and had a friend/neighbor
take him home from hospital
# Extensive stage small cell lung carcinoma: extensive stage on
diagnosis inc brain mets. Currently C4D7 cis/etoposide recent
imaging shows overall stable disease in chest. Brain MRI
___ showing resolution of prior brain lesions.
Repeat this admission showed ongoing resolution as above.
# HLD: continued home Simvastatin 40 mg PO QPM and Ezetimibe 10
mg PO DAILY
# GERD: continued home Omeprazole 40 mg PO DAILY
# BPH: on Flomax, reports persistent nocturia, advised to
discuss finasteride w/ his PCP, was given urology appointment
but next available not til ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ woman with a history of alcoholism,
alcoholic withdrawal, and possible seiziure disorder and on
Keppra. The patient reports to her PCP in the setting of recent
increase in alcohol use, although her tox screens have evidently
been negative for alcohol and it is unknown when her last drink
was. The patient had an episode of tremulousness and a staring
episode at her PCP's office, for which she was transferred to
___. At ___, she experienced a
generalized seizure for approximately 20 minutes, for which she
was given Versed, Ativan, magnesium. The patient was intubated
and given some Ativan and midazolam. She has been on propofol
for sedation since. The ___ non-contrast
head CT was negative for acute intracranial process. The patient
received 1g Keppra.
.
In the ED, the patient's initial neurological exam was nonfocal.
Neurology was consulted. An EEG was obtained which showed no
status and changes consistent with her propofol sedation. The
patient spiked a temperature of 102 in the ED and received
acetaminophen. An LP was then obtained, along with a
non-contrast head CT. She was also started on 2g ceftriaxone for
possible meningitis. The patient's potassium, calcium, and
magnesium were all replenished. Her NG tube was advanced. The
patient is currentl sedated with a propofol drip.
.
On arrival to the MICU, the patient is sedated on propofol and
intubated. She appears to be quite cachectic. Her heart rate is
in the ___, blood pressure systolic low 100s, diastolic low ___. Radiology showed 1. Endotracheal tube in appropriate position.
2. Nasogastric tube high in position, terminating in the distal esophagus.
Recommend advancement so that it is well within the stomach.
3. Hyperinflated but clear lungs.
4. Subacute-to-old left ninth rib fracture with opacity projecting over it,
which is felt to more likely be related to osseous change. Recommend
comparison with priors and if the opacity has increased, consider chest CT to
evaluate for underlying pulmonary nodule.
5. Old fracture deformity and severe degenerative change at the right
shoulder with possible loose body.
The above findings and recommendation under #2 were discussed with Dr. ___
___ at 6:12 p.m. on ___ via telephone. Radiology showed 1. No intracranial hemorrhage or acute fracture. Chronic involutional
changes.
2. Moderate paranasal sinus opacification, secondary to intubation. Seizures, intubation.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The ET tube tip is 6 cm above the carina. The NG tube is coiled in the
proximal stomach continuing up towards the esophagus with its tip being at the
level of the distal esophagus and should be readjusted.
The heart size and mediastinum are unremarkable. Lungs are hyperinflated but
essentially clear. Calcified right paratracheal lymph node is unchanged in
appearance. Old rib fractures are noted on the left. Overall, within the
limitations of this study technique, no other abnormalities are demonstrated. was done. The patient was diagnosed with GRAND MAL STATUS, ALCOHOL ABUSE-UNSPEC. The patient was treated with Intubated prior to hospital transfer.. At the time of discharge, the patient had Primary Diagnosis: Alcohol Withdrawal Seizure and C. Diff
diarrheal infection
Secondary Diagnosis:
COPD
EtOH dependence and history of withdrawal seizures
C. diff colitis
CAD
Diverticulitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with a history of heavy
alcohol abuse and withdrawal seizures who was transferred to the
ICU following the experience of a generalized 20-minute seizure
at outside hospital necessitating airway protection and
sedation. Found to be C. diff positive with diarrhea.
.
# Seizure, likely secondary to alcohol withdrawal. Confirmed
with partner that patient had been without alcohol for at least
24 hours prior to admission due to a recent hospital admission
for COPD. Lumbar puncture was traumatic, so WBC counts not
suggestive of infection. CT head not suggestive of seziure
focus; report of MRI from outside hospital also not suggestive
of epileptic focus. EEG showed no clear electrographic seizures
or epileptiform discharges. CSF VDRL negative from OSH. She was
sedated with midazolam and then intubated for airway protection;
she quickly was weaned and then self-extubated. She was given
keppra for seizure prophylaxis, and neurology was consulted. She
was given a "banana bag" for vitamin repletion. During her
course in the hospital she did not experience any additional
seizures. Was monitored on a CIWA scale, but did not score.
Patient has a history of seizure disorder NOS, and has been
maintained on Keppra as an outpatient, which was additionally
continued throughout admission per neurology recs.
.
# History of C. diff. colitis: Patient was on a vancomycin taper
as an outpatient. Per PCP, patient was first diagnosed with
c.diff in ___, treated twice with flagyl (incomplete treatment
in ___ as patient had a seizure given flagyl/etoh use), was
started on vanco course with taper on ___ after unrelated
hopsital admission. Followed up with OSH infectious disease
specialist in mid ___ who recommended continuing taper and
trying fidaxomycin should she have another recurrence. Having
diarrhea here which tested c.diff positive, restarted vancomycin
PO and IV flagyl in the unit (flagyl d/c'd on the floor). Ruled
out other etiologies of diarrhea as the toxin assay can often
stay positive even after effective treatment for c. diff (stool
cultures negative for salmonella, shigella, campylobacter,
cryptosporidium or giardia). However, our suspicion for
non-compliance is high and we feel that she likely never
completed a course for her c. diff and therefore has continuing
infection and not recurrence. Patient is being discharged on
full course of fidaxomycin as it is only BID dosing with less
chance of recurrence. She will have ___ and her boyfriend to
help ensure she takes her medication.
.
# Possible urinary tract infection: UA mildly suggestive of
urinary tract infection. Patient received 2g ceftriaxone in ED
for suspected meningitis. Follow up urine culture negative.
Patient was not continued on antibiotics for UTI.
.
# Alcohol abuse: The patient appears, from both physical
appearance and laboratory values, to have chronic malnutrition
from her alcohol use. Social work met with her many times and
her electrolytes were closely monitored and repleted as
necessary. Patient was monitored on a CIWA scale, but was not
scoring.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx STEMI in ___ with stent to LAD complicated by dissection
who presents from her ___ clinic for evaluation of chest
pressure. She explains that she has had a cough for the past
several days and she developed chest pressure yesterday. Her
chest pressure was substernal and without radiation. It occurred
at rest. This did not fully improve with NTG in the ER today,
though there was modest improvement. She takes NTG approximately
___ annually when she has chest discomfort, but has not
recently been evaluated for CAD (last stress TTE ___. She has
not had rhinorrhea, fevers, chills, sore-throat, wheezing,
orthopnea, diaphoresis. She denies diarrhea, nausea, vomiting.
She does not take GERD medications. CHEST (PA AND LAT) showed No acute intrathoracic process. The patient was diagnosed with CHEST PAIN NOS, FLU W RESP MANIFEST NEC, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms ___ is a ___ year old woman with a history of medically
managed LAD STEMI in ___ with subsequent LAD dissection who
presents with 24 hrs of progressive substernal chest pressure
and found to be positive for influenza A.
#Chest pressure: Likely ___ influenza and coughing given
non-exertional, negative trops x3. Tightness rather than pain
suggests non-MSK. A nuclear stress test showed a fixed perfusion
defect in the LAD territory, which likely represents her prior
ischemic event
--Started Oseltamivir 75 mg Q12H (last day ___
#CAD: history of LAD STEMI treated medically due to complete
occlusion.
--continue ASA, simva 10
--discuss with her rheumatologist/cardiologist higher simva
dose, has been limited in past because of myalgias</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male with h/o COPD, recurrent PNA, oropharyngeal
dysphagia, bronchiectasis, and previous MAC pulmonary infection
who presented to the ED after two days of fatigue and cough. The
pt reported an at-home temp of 101.1 F. He reports feeling
feverish, but denies chills or sweats. His cough has been more
productive, he has not had hemoptysis. He reports that these sx
are reminiscent of PNA for him. He also had R side tenderness,
which he noticed more after playing golf several days ago. The
pain has been constant. He denies CP, abd pain, constipation or
diarrhea or changes in urinary frequency. CHEST (PA AND LAT)
TECHNIQUE: Chest radiograph, PA and lateral views
COMPARISON: Chest radiograph ___
FINDINGS:
There is a focal opacity obscuring right heart border, which appears increased
compared to ___. Multiple other faint focal opacities in the left mid
and lower lobe lung and right lower lung are similar compared to ___. There
is small left pleural effusion or left lung base pleural scarring. There is
no pneumothorax. Cardiomediastinal silhouette is normal size.
IMPRESSION:
Increased right middle lobe opacity could be pneumonia in correct clinical
setting. This is unchanged compared to 1 day prior. showed Increased right middle lobe opacity could be pneumonia in correct clinical
setting. This is unchanged compared to 1 day prior. The patient was diagnosed with FEVER, UNSPECIFIED, ACUTE URI NOS. At the time of discharge, the patient had Primary diagnosis:
Sepsis
Pneumonia
Secondary diagnosis:
COPD
bronchiectasis
HTN
CAD
oropharyngeal dysphagia
recurrent pneumonia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PRIMARY ISSUE
Pt is an ___ yo male with h/o COPD, bronchiectasis, recurrent
pneumonias, pulmonary MAC infection in ___, and oropharyngeal
dysphagia who was admitted for signs of sepsis (101.1 F, WBC
22.2 with left shift) with pneumonia as a likely cause.
ACTIVE ISSUES
- Sepsis and pneumonia: In the ED, he was given one dose of PO
levofloxacin, after which he became afebrile and his WBC
decreased to 14.1, and eventually 9.9. Pt's initial CXR showed
bilateral lung hyperinflation with resolving lower lung
opacities, mild blunting of left costophrenic angle but no acute
focal consolidation concerning for pneumonia. A follow up CXR
showed a RLL opacity that could be consistent with PNA. Pt
continued to be hemodynamically stable and afebrile thereafter
on PO levofloxacin. He had a clear UA and no evidence of
meningitis. There was low suspicion for abdominal pathology
given no symptoms except for mild abd discomfort at his right
side.
CHRONIC ISSUES
- COPD: Continued home tiotropium
- CAD/HYPERTENSION: Continued aspirin, atorvastatin, and
metoprolol 50 mg XL.
- GERD: Continued omeprazole 20 mg BID
TRANSITIONAL ISSUES
- Antibiotics: We discussed the issue of prophylactic
antibiotics with Dr. ___, pt's ID doctor. Based on this
discussion, we made the decision to start pt on prophylactic
azithromycin for pneumonia, and scheduled an appointment with
Dr. ___ on ___.
- Code status: pt is DNR, DNI</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman with h/o ESRD ___ anti-GBM disease s/p DDRT ___
with high risk CMV status (D+/R-) with course c/b CMV viremia
(has UL97 mutation c/w Ganciclovir resistance, treated with
foscarnet for 2 weeks and then transitioned to letermovir at 480
bid dose). Has also had recurrent E. Coli and VRE UTIs. Presents
with one day of malaise and fevers up to 101, without any other
localizing signs or symptoms. Specifically denies any HA, N/V,
diarrhea, urinary sxs, neck pains, or URI sxs. Has baseline
urinary frequency from torsemide. RENAL TRANSPLANT U.S. showed 1. Borderline elevated renal resistive indices, however slightly decreased
compared to ___.
2. Persistent minimal right pelviectasis. No hydronephrosis.
3. No sonographic evidence of pyelonephritis. The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had Primary diagnosis:
Urinary tract infection
Secondary diagnosis:
End-stage renal disease s/p renal transplant
History of CMV 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>TRANSITIONAL ISSUES
=====================
[] Discharged on cefpodoxime 100mg BID for a 14 day course to
treat urinary tract infection.
[] Decreased envarsus from 2mg daily to 1.5 mg daily per renal
transplant
[] Pt will have repeat labs including tacrolimus levels ___
___
BRIEF SUMMARY
==============
___ woman with h/o ESRD ___ anti-GBM disease s/p DDRT ___
with high risk CMV status (D+/R-) with course c/b CMV viremia
(has UL97 mutation c/w Ganciclovir resistance, treated with
foscarnet for 2 weeks and then transitioned to letermovir at 480
bid dose), also with hx of MDR E. Coli and VRE UTIs, presented
with fevers, leukocytosis, dysuria with urine culture growing E.
coli concerning for urosepsis. Initially started on linezolid
and cefepime given previous culture data then to linezolid and
ceftriaxone. Pt was clinically improving and remained HDS
throughout hospital course. She was discharged on an oral course
of cefpodoxime 100mg BID (renally adjusted) for total ___CUTE ISSUES:
=============
# UTI
Patient presenting with fever, malaise and increasing urinary
frequency/urgency. Also noted "hot" feeling with urination c/f
dysuria. Found to have elevated WBC to 15. She was started on
cefepime then ceftriaxone and linezolid due to history of E coli
and VRE UTIs. Urine culture grew E coli and she was transitioned
to cefpodoxime 100mg BID per sensitivities.
# ESRD ___ anti-GBM, s/p DDRT ___
# Immunosuppression
Cr is at baseline (1.5-2.0). Renal US with unchanged pelvic
fullness and resistive indices. Tacro level therapeutic on
admission. She was continued on tacrolimus extended release 2mg
daily with goal level of ___. Continued prednisone 5mg daily
(not on anti-metabolite due to CMV history). She was continued
on Bactrim for PCP ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ yo man with a history of T2DM, BPH, HTN and
cholangiocarcinoma on Cisplatin + Gemcitabine presents on C7D17
for fatigue and poor PO intake for 1 week. He has poor PO intake
secondary to poor apatite but does not describe any dysphagia or
trouble eating. He noticed over this time that his urine is
darker but has not noticed any change in his stool. He otherwise
denies nausea/vomiting/pain/SOB and rash. CHEST (PA AND LAT) showed Patchy right lower lobe opacity is concerning for an area of developing
infection. Radiology showed 1. Short interval increase in intrahepatic biliary ductal dilatation with
decreased pneumobilia. Taken together, these findings are concerning for
obstructed biliary stents. Consider ERCP.
2. Perihepatic fluid at the hepatic flexure with apparent mild colonic wall
thickening may be reactive to the underlying hepatic process, however mild
colitis of the ascending colon is possible.
3. Unchanged cystic pancreatic lesions.
4. Unchanged marked prostatomegaly with bladder wall hypertrophy and a
right-sided bladder diverticulum. Radiology showed 1. Possible new pneumoperitoneum. Distinguish with left lateral decubitus
radiograph of the abdomen.
2. Low lung volumes and bibasilar atelectasis.
RECOMMENDATION(S): Possible new pneumoperitoneum. Distinguish with left
lateral decubitus radiograph of the abdomen.
NOTIFICATION: The findings were discussed by telephone with ___ by
___ at 10:20, ___, 1 min after discovery. Radiology showed No evidence of free air. Nonspecific bowel gas pattern. Radiology showed 1. New large volume of intraperitoneal free air, along with new moderate
volume of ascites. Loculated free air is noted within the pelvis, adjacent to
the sigmoid colon, as described above. Given the clinical history of recent
sigmoidoscopy, findings are most concerning for sigmoid perforation. Surgical
consultation is recommended.
2. Interval decrease in degree of intrahepatic ductal dilatation and new
pneumobilia, indicating stent patency. Known cholangiocarcinoma is not well
delineated on the current study. The patient recently had ERCP, however there
are no new sites of retroperitoneal free air to suggest a duodenal
perforation.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on ___ at 5:48 ___, 15 minutes after discovery of the findings. Radiology showed There is stable free air under the hemidiaphragms as compared to the earlier
study. There is bibasilar atelectasis which is unchanged. There is no
pneumothorax or pneumomediastinum. There is no CHF. CHEST (PORTABLE AP) showed Compared to prior chest radiographs since ___, most recently ___ through ___. Bibasilar consolidation, either pneumonia or
atelectasis and moderate bilateral pleural effusion right greater than left,
all unchanged since ___.
It is very difficult to distinguish colonic interposition in the right upper
abdominal quadrant from multi loculated pneumo peritoneum. That determination
is more reliably made with dedicated abdominal imaging. The right pleural
effusion however is the most likely reflective of the abdominal contents,
whether ascites, infection, or bile leak. Radiology showed There is this a stable or slightly decreased amount of free air visualized in
the subdiaphragmatic region. There has atelectasis in both lung bases. There
is no pneumothorax or CHF. CHEST (PORTABLE AP) showed Compared to prior chest radiographs since ___ most recently ___.
Bilateral pleural effusion, moderate on the right, small on the left has been
increasing slowly since ___. Opacification in the lower lungs is
attributable to atelectasis but pneumonia is not excluded. The upper lungs
are clear. There is no pulmonary edema. Cardiac silhouette is also partially
obscured and could be mildly enlarged. No pneumothorax.
In the absence of volume overload or any evidence of cardiac decompensation
and the explanation for pleural effusions might be related to subdiaphragmatic
pathology, including infection, bleeding, or bile leak, as appropriate. CHEST (PORTABLE AP) showed Known free intra-abdominal air, seen under the right hemidiaphragm. The
extent of air has not substantially changed over the last few chest
radiographs. Bilateral areas of atelectasis and right pleural effusion as
well as calcified granulomas at the left lung apex are stable. The patient was diagnosed with Pneumonia, unspecified organism. The patient was treated with ERCP with pus removal and stent placement ___. At the time of discharge, the patient had PRIMARY DIAGNOSES:
CHOLANGIOCARCINOMA
BILIARY OBSTRUCTION
SECONDARY DIAGNOSES:
POOR APPETITE
PANCYTOPENIA
H/O HYPERTENSION AND HYPERLIPIDEMIA. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ w/ cholangiocarcinoma on Cis/Gem presented
C7D17 for fatigue X 1 week and poor PO intake
# Hepatobiliary obstruction c/b perforation:
Patient is very functional and alert individual at baseline and
presented with poor PO intake and fatigue for 1 week. Initially
thought to have pneumonia, he was found to have biliary
obstruction on CT scan likely the cause of his presenting
symptoms. He as taken for ERCP on ___ and had removal of
puss from biliary tracts with placement of a new stent.
Unfortunately, the procedure was complicated by perforation with
intra-abdominal free air and ascites. He was seen by surgery and
ERCP and was treated with antibiotics and supportive care. His
diet was advanced slowly and he tolerated it well. He completed
a course of cefepime, vanc and ___ and was
narrowed to cipro and flagyl on ___ for a 7 day course upon
discharge. His liver function tests and bilirubin were trending
down / normal on discharge and he was taking good PO and
ambulating independently.
# Pancytopenia:
Patient with new progressive thrombocytopenia and anemia now
also neutropenic. This has never occurred on previous chemo
cycles. DIC & TTP / hemolysis ruled out given normal coags,
elevated fibrinogen and elevated haptoglobin, normal LDH and
absence of rash / abnormal bruising. Initial concern for
gemcitabine induced HUS but renal function normal and no
evidence of hemolysis. Blood observed from rectum on ___, but
on exam found external hemorrhoids likely bleeding in setting of
thrombocytopenia. Otherwise no evidence of blood loss. Likely
chemo induced pancytopenia. This improved daily and was trending
up on discharge.
# Poor PO intake
Patient with poor PO intake since 1 week prior to admission.
Also has been NPO since admission for procedures and
complication of SB perforation. His potassium and phosphorus
were repleted during admission and he was given IVF as needed.
He was started on megastrol 400 QD because of patients continued
concern about his poor apatite and was taking good PO upon
discharge.
# Cholangiocarcinoma: Previously tolerating chemo well. Stable
over the last 3 months until admission on C7D17 of Cisplatin +
Gemcitabine with plan for 8 cycles. His outpatient oncologist
was contacted and his next cycle was held in the setting of
acute illness. He was discharged with close follow up to discuss
continued treatment.
# Diarrhea: Small amount, likely secondary to obstructed biliary
ducts. C-diff negative and resolved upon discharge.
# HTN/HLD: his home aspirin was held given anemia</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx of unresectable cholangiocarcinoma s/p incisional
hernia repair (___) c/b C.diff colitis on PO Vancomycin
presents with abdominal pain. Patient reports intermittent pain
in her upper abdomen, and right side of her back for months. It
last varying lengths of duration. She developed the same pain
today that resolved prior to arriving in the ER. She denies N/V,
fever/chills, diarrhea, melena/hematochezia. She is passing
flatus with soft stools. She is able to tolerate POs but her
appetite has been decreasing the last few weeks. Radiology showed Complex heterogeneous area with solid components and internal
vascularity measuring up to 4.1 cm in the right flank, overall unchanged in
size compared to the CT from ___. This could represent a phlegmon
versus a metastatic deposit of tumor. Ultrasound-guided diagnostic and therapeutic paracentesis.
COMPARISONS: CT abdomen and pelvis ___.
PROCEDURE AND FINDINGS: After the risks, benefits and alternatives to the
procedure were explained to the patient, written informed consent was
obtained. A four quadrant ultrasound was performed to determine the largest
pocket of ascites. The largest pocket of ascites was selected in the left
lower quadrant. The skin was then prepped and draped in usual sterile
fashion. A preprocedure timeout was performed, confirming three patient
identifiers and the procedure to be performed.
Subsequently, 1% lidocaine solution was instilled for local anesthesia. A 5
___ ___ catheter was then advanced into the peritoneal cavity. A total of
1.3 liters of clear yellow ascitic fluid was aspirated. Samples were sent for
cytology as requested. The patient tolerated the procedure well with no
immediate post-procedure complications.
Dr. ___, the attending radiologist, was present and supervised
throughout the critical portions of the procedure.
IMPRESSION: Uncomplicated ultrasound-guided diagnostic and therapeutic
paracentesis yielding 1.3 liters of clear yellow ascitic fluid. Samples were
sent for cytology. showed Uncomplicated ultrasound-guided diagnostic and therapeutic
paracentesis yielding 1.3 liters of clear yellow ascitic fluid. Samples were
sent for cytology. Radiology showed 1. Slightly increasing biliary dilatation as compared to the prior studies.
2. Known cholangiocarcinoma along the hepatic hilum with worsening ascites
and suggestion of erosion into the duodenum as described above. Peritoneal
nodules as well as portal vein compression are stable.
3. Right lower lobe collapse. Small-to-moderate right-sided pleural effusion
and trace left pleural effusion.
These findings were discussed with ___ at 7:45 p.m. by ___. Radiology showed No DVT in either lower extremities. Radiology showed Non-occlusive thrombus surrounding the PICC in the right axillary
and subclavian veins. The above findings were discussed with Dr. ___ at
12:05 p.m. on ___ immediately after the study. Radiology showed Right PICC terminating in the region of the right atrium,
proximal re-positioning by 1 to 2 cm is recommended. No other significant
change compared to recent prior examination.
Dr. ___ communicated the above results to IV RN, ___ at
1715 on ___ by telephone. The patient was diagnosed with ABDOMINAL PAIN UNSPEC SITE, ANOREXIA, MAL NEO INTRAHEPAT DUCTS. The patient was treated with Fluid collection I and D ___
EGD ___
Picc placement and removal. At the time of discharge, the patient had Primary: Superinfected abdominal fluid collection, GI bleed,
Left upper extremity DVT (Axillary and subclavian)
Secondary: Cholangiocarcinoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o female with extensive medical and recent surgical history
who presents with abdominal pain. On admission the patient
underwent CT of the abdomen and pelvis. There are several
notable findings, including a right flank wound (CT reports area
of abnormal enhancement in the right flank along the oblique
muscles previously described as a phlegmon; now shows interval
increase in size of central fluid and gas collection measuring
up to 1.6 cm of longest axis diameter with associated probable
fistulous tract communicating with the skin -- more likely to be
superinfected metastasis than pure phlegmon). The wound drained,
and patient was treated with antibiotics. She was initially on
a surgical service, but was transferred to oncology service.
Hospitalization complicated by hematemesis and hypotension
requiring brief MICU stay.
#. Right flank purulent mass: Pt had rupture of right flank
collection revealing purulence with CT scan demonstrating
fistulous tract from abdominal wall communicating with the skin.
Although initial culture after rupture was negative, repeat
aspiration overnight revealed Pseudomonas. Based on imaging, it
appears that the mass may be a tumor focus, superinfected, as
opposed to an abscess/phlegmon. ID recommended cefepime and
Flagyl, which will be continued until patient sees outpatient ID
physician ___ in follow up.
#. Cholangiocarcinoma with possible peritoneal carcinomatosis:
Not a surgical candidate. Therapeutic and diagnostic
paracentesis (for cytology) done on ___, but without definitive
evidence of cancer in the peritoneum. Normal CEA and AFP and CA
___. Treatment in future depending on staging and resolution of
acute infection. She will have medical oncology and radiation
oncology outpatient follow up.
# Hypotension: Patient became hypotensive in AM of ___ to
SBP in ___. Transferred to MICU. Responded well to 4L of IVF.
Resolved. Unclear event as precipitant but likely some form of
inflammatory response evident given WBC count elevation vs.
bleeding alone. Could have been related to inflammatory
response from tumor invasion and bleed versus transient biliary
obstruction. No clear infectious source found outside of flank
mass, which was already being treated. Volume depletion or HCT
drop alone could explain hypotension, but pt may have had
transient biliary obstruction (alk phos elevation, relative ___
elevation) which then resolved.
# GI bleed: Patient had hematemesis with hypovolemia. EGD shows
esophagitis and gastritis. Unclear if this is fully responsible
for the GI bleed, but given small volume hematemesis, this is
most likely cause, as opposed to duodenal tumor which was not
visualized and thus would be unlikely to cause hematemesis. GI
did not find much on EGD that would suggest tumor eroding into
dudeonum. Per GI, radiology reviewed films, and no clear
evidence of tumor communicating into duodenum. If pt were to
continue to have unexplained melena, then tumor into duodenum
would seem more likely. High-dose PPI and Carafate were
prescribed. No further GI bleeding after the EDG.
# Mixed cholestatic and hepatocellular transaminitis: Transient
obstruction seems likely given interval biliary dilation seen on
CT, combined with elevated alk phos and ___ + hepatocellular
picture. This may have played a role in the transient SIRS
response requiring ICU transfer.
#. C diff: PCR here was negative. Pt however gets recurrent C
diff with abx. Thus, she is being prophylaxed while on cefepime
with oral vanco 125 mg Q8h
# Worsening ascites: Likely from peritoneal carcinomatosis. Pt
was tapped ___. Then restarted on PO Lasix.
# Edema: Pt with anasarca. Likely from low albumin, >4L
repletion in ICU. ECHO nml.
# Right lung opacification: RLL collapse on CT on ___. Not
short of breath. No urgent need for bronch. Unclear etiology:
? mucous plug versus pleural effusion but effusion only small to
moderate. Per ICU, nothing clear to tap. Aggressive physical and
respiratory therapy.
# Rising INR: Most likely from poor nutrition. PO vitamin K 5
mg x 3 days was planned, but this was stopped ___ after only 1
dose due to LUE line-associated DVT as below.
# PICC-associated UE DVT: Patient had LUE swelling and, based on
UE venous US, an UE DVT. We cannot anticoagulate given bleed, so
removed PICC and placed another on the right side.
# Prophylaxis: Boots. Would hold off on heparin given continued
evidence of low grade GI bleed.
# Hypothyroid: stable. Continued home levothyroxine.
# Goals of care: This was readdressed. If pt were to clinically
decompensate, unlikely to do well given host of comorbidities
and recurrent illnesses. However, pt does want to be full code.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This patient is a ___ year old M with unknown PMH who presents
via EMS s/p traumatic fall. Per EMS, the patient had a witnessed
fall from approximately
10 feet from and ladder with +LOC. Per EMS report, neighbors
noted that the
patient was unconscious for ___ minutes. Per report, the patient
reported right
rib pain and difficulty breathing, with suspected tracheal
deviation. He denies
neck pain or HA. EMS endorses notable absent breath sounds on
the right in the
field/en route. EMS performed needle decompression in the field
and received
50 fentanyl and 4 of zofran en route. EMS placed 2 IVs PTA.
Patient's last vitals en route were 140/70, 98% on 2L O2 2 via
NC, and sinus rhythm. The patient endorses ___ right sided pain
currently. Does not endorse CP, SOB, n/v/d. Radiology showed Right pneumothorax and pneumomediastinum better seen on subsequent CT. Right
chest tube terminates in the right upper hemithorax.
Multiple right-sided rib fractures. Extensive right-sided subcutaneous
emphysema.
Comminuted displaced mid to distal right clavicular fracture.
See subsequent CT. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormality.
2. Right parietal scalp subgaleal hematoma and laceration without acute
fracture seen.
3. Inferior-most images demonstrate some subcutaneous emphysema tracking into
the upper right neck. CT C-SPINE W/O CONTRAST showed 1. Extensive subcutaneous emphysema tracking along the right neck. No acute
cervical spine fracture or dislocation..
2. Mildly displaced right rib fracture. Nondisplaced medial left rib fracture
and possibly nondisplaced fracture of the medial left first rib. Partially
imaged right clavicle fracture.
3. Partially imaged right pneumothorax. Very tiny left pneumothorax. Possible
right apical chest wall hematoma. CT CHEST/ABD/PELVIS W/ CONTRAST showed 1. Moderate right pneumothorax with chest tube in place. Likely tiny left
pneumothorax.
2. Mild pneumomediastinum.
3. Small chest wall hematoma adjacent to the right lung apex.
4. Multiple cystic lung lesions in symmetric distribution. While difficult to
exclude traumatic pneumatocele, the symmetric and bilateral distribution favor
chronicity and may represent sequelae of Langerhans cell histiocytosis.
5. Acute fractures of the right clavicle, right first, second, third, fifth,
and sixth ribs as well as the left first and second ribs, with the left first
rib fracture better seen on CT C-spine.
6. Acute fractures of the L1-L3 right transverse processes and right iliac
wing.
7. Large amount of subcutaneous emphysema extending from the right neck
through the chest and abdominal walls. CHEST (PORTABLE AP) showed Right-sided chest tube is unchanged. Displaced right-sided rib fractures.
Stable right apical pneumothorax. Lungs are low volume with mild pulmonary
vascular congestion. Cardiomediastinal silhouette is stable. No large
pleural effusions. CHEST (PORTABLE AP) showed Right-sided chest tube place. There is a small right apical pneumothorax.
Subcutaneous emphysema in the right lateral chest wall has slightly improved.
Lungs are low volume. Cardiomediastinal silhouette is stable. WRIST(3 + VIEWS) RIGHT showed Nondisplaced transverse distal radius fracture
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:30 am, 10 minutes after
discovery of the findings. CHEST (PORTABLE AP) was done. CLAVICLE RIGHT was done. BILAT HIPS (AP, LAT, AND PELVIS) 5 OR MORE VIEWS showed No acute fracture of either hip. A known right iliac wing fracture was better
evaluated on recent prior cross-sectional imaging. CHEST (PORTABLE AP) showed Suspected small right apical pneumothorax. Attention on follow-up imaging is
recommended. WRIST(3 + VIEWS) RIGHT showed Acute distal right radial fracture, in near anatomic alignment following
reduction. CHEST (PORTABLE AP) showed In comparison with the study of ___, there again is a small right
apical pneumothorax. Extensive subcutaneous gas is again seen along the right
lateral chest wall extending into the neck.
Displaced right rib and clavicular fractures are again seen.
No acute pneumonia or appreciable vascular congestion. The patient was diagnosed with Multiple fractures of ribs, right side, init for clos fx, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had Right scalp hematoma/laceration
Comminuted right clavicular fracture
Right pneumothorax
Fracture of right ___ and ___ ribs
Fracture of left ___ rib
Nondisplaced distal radius fracture
Right L1-L3 transverse process fractures
Right iliac wing fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old male with no significant PMH, who is
s/p fall from ladder with positive LOC, who was brought to ___
as a trauma evaluation. He was seen by the Trauma service and
had imaging done which showed that he suffered multiple
fractures, including his right clavicle, right ___ ribs,
left ___ rib fx, L1-L3 right transverse process, right iliac
wing, and right distal radius fracture. He also had a right
pneumothorax and is s/p a chest tube insertion. He was admitted
to the Acute Care Surgery/Trauma service for further management
and pain control.
On HD1, his C-Collar was cleared by the primary team. His chest
tube was placed on water seal and his subsequent CXR showed a
stable right pneumothorax. His tertiary exam revealed a swollen
and painful right wrist and left hip pain. Right wrist xray was
ordered which demonstrated a nondisplaced wrist fracture.
Bilateral hip xrays did not show a new fracture, right iliac
wing fracture was seen on xray but already known. The hand
service was consulted for the patient's wrist facture and they
recommended non-operative management with a splint placement,
and NWB of that extremity. He was also seen by the orthopedic
team for his right clavicle fracture. They suggested
conservative management with a sling for comfort and follow up
in clinic.
His chest tube was pulled on HD2 and post-pull CXR showed stable
right apical pneumothorax. The patient remained stable from a
pulmonary standpoint. He was encouraged to use the incentive
spirometer and encouraged to ambulate early. Physical and
occupational therapy was ordered for evaluation and treatment.
After working with the patient, they cleared him to go home with
outpatient ___ on HD3. However, the patient was still noted to be
in considerable pain especially with movement/activity, so pain
medication was adjusted for better pain control. Teaching was
done regarding the importance of pain management in order for
patient to heal and to prevent complications such as pneumonia
or blood clots.
At the time of discharge, the patient was doing well, afebrile,
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without issue, and pain was well-controlled
on oral pain medication. He was discharged on a pain regimen of
acetaminophen, ibuprofen, oxycodone, and lidocaine patch. The
patient and wife received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. His follow up appointments were scheduled
prior to discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient presents via ___ EMS after being found down. per EMS,
pt was found on scene unresponsive after ingesting GHB earlier
this evening. patient was found in a hotel room with other men
naked on the floor. informed that bystander performed a few
chest
compressions due to concern for cardiac arrest. preparing for
intubation at this time. CHEST (PORTABLE AP) showed Endotracheal tube terminates 5.2 cm proximal to the carina. Clear lungs. CT HEAD W/O CONTRAST Q111 CT HEAD showed No evidence for acute intracranial abnormalities. Chest radiograph, portable AP upright. showed Findings consistent with aspiration pneumonitis and/or pneumonia. The patient was diagnosed with Altered mental status, unspecified. The patient was treated with Required intubation and mechanical ventilation.. At the time of discharge, the patient had Toxic ingestion
Polysubstance abuse
Aspiration pneumonia
Transaminitis (hepatocellular). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ Mwith GHB intoxication and + amphetamine in urine.
Intubated for airway protection upon arrival to the ED.
Extubated in the ICU doing well on RA. He was loaded with
phenobarbitol for withdrawal and
agitation. After extubation patient was not providing many
details regarding history of events. He said that he is
homeless, had gotten a hotel room w/ his boyfriend. Says that
the night of admission, he was watching a movie w/ his SO and
then didn't want to elaborate further. ___ notable for HTN, no
meds. Endorses marijuana, denies other substances.
His hospital course further complicated by fever, rising WBC,
sinus tachycardia. CXR with evidence of new RLL consolidation.
He was started on Unasyn for c/f aspiration pneumonia.
# ENCEPHALOPATHY
# TOXIC INGESTION
The patient endorses GHB and amphetamine use prior to episode of
unresponsiveness. Toxicology has been consulted and feels that
overall presentation is consistent with GHB ingestion. He has
been loaded with phenytoin. Mental status much improved since
presentation. He was monitored on ___ and scored 0 throughout
his hospital stay. Psych was consulted. Psych felt that from a
mental health perspective, his presentation is most consistent
with meth-use disorder and substance-induced mood disorder.
They recommended outpatient addictions program and outpatient
mental health. He was provided information regarding some free
resources in the community as he does not currently have
insurance. Once he gets insurance (patient needs to call the
health connector) he would be a good candidate for the ___
___ for PCP and mental health.
# Transaminitis (hepatocellular)
LFTs were wnl on admission, since initiation of Unasyn/Augmentin
he has a new, mild transaminitis. Suspect this is most likely
drug side effect. Changed abx to levofloxacin for CAP and
trended LFTs. LFTs worsening on ___ AM, AST and ALT up to ~200
each. Repeated LFTs in the afternoon and they may have plateaued
but not totally clear. Viral hepatitis studies were added-on,
and he was advised to stay for work-up of his hepatocellular
transaminitis. He declined and chose to leave AMA on ___.
# PNA:
The patient developed fever and tachycardia ___ with CXR
showing concern for PNA. He was started on unasyn which was
changed to PO Augmentin. As above, Augmentin stopped due to
transaminitis and switched to levofloxacin.
- Continue levofloxacin for 5 day course ___ - ___
# No Primary Care Physician: SW & CM consulted. Has new PCP
___. scheduled at ___ on ___.
# Homelessness: SW consulted
>30 minutes spent on discharge-related activitiese today.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with approximately ___ year h/o lymphoma, with
recent c/f recurrence/transformation of disease, presented to ED
for evaluation of 2 day history of rhinorrhea, itchy throat,
cough non productive of sputum, and fever to 102. Denies recent
travel, or specific sick contacts or eating out, however has
been around a lot of family recently. Denied nausea/vomiting,
chest pain, shortness of breath, abdominal pain, dysuria,
diarrhea, headache, neck stiffness, sinus pain/pressure or
earache. The patient was diagnosed with NEUTROPENIA, UNSPECIFIED , FEVER, UNSPECIFIED. At the time of discharge, the patient had PRIMARY
#Neutropenic Fever
#Influenza 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>ASSESSMENT/PLAN: ___ with history of NHL (follicular type) with
recent transformation, on ___ cycle of ___, now with
neutropenic fever and found to be positive for Influenza A.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___, very poor historian, with COPD, PFO, AF off coumadin, prior
CVA and multiple TIAs, hypothyroidism, who presented with
abdominal pain, distension, nausea with vomiting, and frequent
stools for 1 day. CT ABD AND PELVIS WITH CONTRAST showed 1. No bowel obstruction.
2. Diffuse uncomplicated enteritis involving the distal jejunum/ileum. Given
the severe atherosclerotic disease detailed above, ischemic enteritis should
be considered as an etiology though infectious is also very possible.
3. No other acute process in the abdomen or pelvis. CHEST (PA AND LAT) showed The slight increased lung markings diffusely are improved compared to the
prior exam. The cardiac and mediastinal silhouettes are normal. There is no
effusion. Compared to the prior study the appearance of the chest is
improved. There is no focal infiltrate CHEST (PORTABLE AP) showed Pulmonary edema. The patient was diagnosed with ABDOMINAL PAIN LLQ. At the time of discharge, the patient had Abdominal pain and nausea/vomiting caused by enteritis. The patient was given written instructions concerning 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 w/PMHx CAD s/p MI, afib not on warfarin, PVD,
multiple TIAs, admitted for enteritis NOS (thought likely to be
infectious), improved with conservative therapy, including off
antibiotics. She did develop some mild pulmonary edema from
fluid resuscitation for the enteritis, in the setting of COPD,
both of which improved after diuresis and nebs. She's back to
her baseline and ready for discharge.
On the day of discharge, Ms. ___ was doing well. She had
no issues with shortness of breath or pain or other concerns.
No recent stools or nausea -- appetite is good. She clearly
identifies where she is and the day. She is able to remember
details of our conversation later in the conversation. She
clearly articulates why she was admitted. She does have trouble
remembering yesterday's holiday, but from communicating with her
outpatient provider, it's clear this is baseline. I discuss the
idea of discharge with the patient and physical therapy. I also
spoke with her daughter by phone and we agreed that she will
continue to recover back at her assisted living and that
discharge there today is good.
By PROBLEMS
Enteritis NOS
- unclear etiology but suspect viral etiology
- rapidly improved with IV fluids
- initially was on antibiotics, but these were stopped and she
continued to improve
- no further w/u or tx needed unless it recurs
Shortness of breath due to pulmonary edema in the setting of
recent IVF and possibly undx chronic diastolic heart failure --
in the setting of CAD s/p MI, afib not on warfarin, PVD,
multiple TIAs and COPD
- she does not have a TTE in our system -- this could be
considered as an outpatient if clinically indicated
- here she received furosemide x 1, her home meds and nebs, and
rapidly improved back to her baseline
- continue amiodarone, ASA, lisinopril (restarted on the day of
discharge), metoprolol, simvastatin
Adrenal insufficiency
- continued home prednisone
COPD
- continue home inhalers ___, tiotropium),
received some PRN nebs here, and can get these via MDI as an
outpt
IDDM
- sugars were ok here -- per outpt provider she had ___ fall that
could have been associated with hypoglycemia as an outpt, so
higher sugars are ok -- will use metformin + Humulin ___ as
outpt (no more glipizide)
- she may need titration of this regimen
Hypothyroidism
- levothyroxine
Stable normocytic anemia
- continue ferrous sulfate
- outpatient workup as indicated/guided by outpt providers
GERD
- pantoprazole, sucralfate
Possible dementia, with mild delirium while here
- the patient had intermittent mild confusion early in her
hospital stay, with the daughter reporting some hallucinations
- these cleared, and as noted above, the patient was back to her
baseline on the day of discharge
- her ___ memory problems may be mild dementia -- she
should have a cognitive evaluation done as an outpatient by OT
and then ___ with her PCP
- ___ advised the patient's daughter of this
___
- a very extensive medication list was provided with the patient
- I would recommend that this be scrutinzed carefully when she
is evaluated by her PCP in ___ -- it is likely that many
of the medications can be stopped
- we stopped glipizide while she was here, but I think there are
many other changes that could be made
Goals of care
- the patient arrived with a MOLST that indicated:
A: DNR
B: DNI, but ok to use ___ ventilation (e.g. CPAP)
C. Do transfer to hospital
- no changes were made to this -- her prior MOLST should still
be valid/active
Dispo
- came from assisted living, she worked with ___ and it was
determined she could safely return there
OTHER INACTIVE PMHx
PFO
depression
chronic UTIs
diverticulosis
h/o LGIB
left vertebral artery dissection
s/p distant open appy and cholecystectomy, TAH, sigmoidectomy
for diverticular bleed at ___ ___, bilateral common
iliac stents</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ female with history of depression who
presents to the ED after being found unresponsive. She was last
seen three days ago, at which time she was noted to be less
talkative than normal. She was texting with a coworker the night
prior to admission. She did not show up for work today, and a
coworker called her roommate to check on her. At approximately
2pm, her roommates found her door locked and the patient on the
bed with vomit "everywhere" and breathing shallowly. They called
EMS. She was found with a bottle of trazodone. There was
reportedly a note on the desk saying "I'm really sorry."
Patient's medications were not in their normal drawer; roomates
later found a bag with 6 empty pill bottles with the labels
pulled off. CHEST (PORTABLE AP) showed 1. Satisfactory position of endotracheal and enteric tubes.
2. Increased opacification of the right hemi thorax as compared to the left,
likely reflective of layering pleural effusion though it difficult to exclude
superimposed pneumonia. CT HEAD W/O CONTRAST showed No acute intracranial process. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the shift of the heart and the
mediastinum to the right side has minimally increased. However, the
pre-existing pleural effusion on the right. Has decreased and the right lung
is better expanded than on the previous image. Mild cardiomegaly persists.
All monitoring and support devices are in unchanged correct position. CHEST (PORTABLE AP) showed As compared to the previous image, a right chest tube was placed. The right
lung has decreased in volume, making it of a denser radiographic appearance.
There is currently no evidence for the presence of a right pneumothorax. Mild
cardiomegaly persists. No change in appearance of the normal left lung. The
endotracheal tube and the nasogastric tube are in unchanged position. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the right pleural effusion and right
opacities, part of which are atelectatic, have substantially improved.
Unchanged mild left retrocardiac atelectasis. Unchanged borderline size of the
cardiac silhouette. Unchanged otherwise normal left lung. The monitoring and
support devices are in constant position, including the right-sided chest
tube. CT ABD AND PELVIS WITH CONTRAST showed 1. No evidence of esophageal perforation into the abdomen. No extraluminal
oral contrast identified although the nasoenteric tube terminates in the
stomach and oral contrast administered via the NGT may bypass an esophageal
perforation. No free intra-abdominal air.
2. No other abnormality in the abdomen or pelvis.
3. CT chest reported separately. CT HEAD W/O CONTRAST showed No evidence for acute intracranial abnormalities.
RECOMMENDATION(S): MRI would be more sensitive for global hypoxic ischemic
injury, if clinically warranted. CT CHEST W/CONTRAST showed The endotracheal tube is located 1 cm above the carina and could be retracted.
There is no evidence of tracheal/bronchial discontinuity or rupture.
Dense peribronchovascular nodular consolidation in the right upper, right
middle and left lobes as well as dense confluent consolidation in the right
lower lobe are most consistent with aspiration in this clinical situation.
A right chest tube courses through the right lung. There is no right pleural
effusion.
Pneumomediastinum located predominantly within the anterior mediastinum, away
from the to the esophagus, as small cystic lucencies in the right lung may be
related to the high requiring ventilatory pressures.
Rounded densities in the stomach most likely represent ingested pills.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 3:16 ___, 10 minutes after
discovery of the findings. CHEST (PORTABLE AP) showed As compared to the previous radiograph, all monitoring and support devices,
including the right-sided chest tube, are in unchanged correct position. The
opacities on the right have mildly decreased in extent and severity, causing a
slightly improved. Ventilation of the right lung. A medial portion of the
right upper lobe, however, still appears to be atelectatic. No pneumothorax is
visualized on the current image. The appearance of the heart and of the left
lung is unchanged. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the endotracheal tube has been pulled
back. The tube now projects approximately 5 cm above the carina. The course
and position of the nasogastric tube is unchanged. The right chest tube was
removed. There is a millimetric medial pneumothorax without evidence of
tension. Otherwise the lung parenchyma on the right is unchanged. Unchanged
appearance of the left lung and the cardiac silhouette. CHEST (PORTABLE AP) showed As compared to ___ chest radiograph, multifocal, basilar predominant
pulmonary opacities appear similar except for slight improvement in the left
retrocardiac region. No other relevant changes. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen. The
bilateral predominantly perihilar and basal parenchymal opacities are constant
in appearance. No new opacities. No larger pleural effusions. Overall low
lung volumes and moderate cardiomegaly. Unchanged monitoring and support
devices. CHEST (PORTABLE AP) showed As above.. CHEST (PORTABLE AP) showed ET tube in standard placement. Nasogastric drainage tube passes to the distal
portion of the nondistended stomach. Previous mild pulmonary edema has
improved although heart remains mildly enlarged. Residual cavitary
consolidation in the right lower lung has not changed appreciably over the
past 2 days, accompanied by at least some pleural effusion not appreciably
changed. Small region of consolidation at the left base also stable. CHEST (PORTABLE AP) showed Yesterday's mild to moderate pulmonary edema has improved.
The residual of severe multi focal pneumonia, most pronounced in the right
lower lobe is probably continuing to clear, demonstrating areas of cavitation.
Heart is normal size. Pleural effusions are small if any. Radiology showed No evidence of esophageal leak on this limited study.
NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___
telephone at 12:35 on ___, approximately 25 min after discovery. CT ABD AND PELVIS WITH CONTRAST showed 1. No acute process in the abdomen or pelvis. CT CHEST W/CONTRAST showed Substantial improvement of the pre-existing right upper lobe predominant
parenchymal opacities.
Newly occurred partly cavitary right middle lobe consolidation.
No pleural effusions. Bilateral lower lobe predominant mucous plugs in the
airways. Unchanged extent of a small new more mediastinum. CHEST PORT. LINE PLACEMENT showed PICC line, as above.
NOTIFICATION: The findings were discussed by Dr. ___ with ___, PICC RNon
the telephone on ___ at 10:31 AM, immediately after discovery of the
findings. CT CHEST W/CONTRAST showed Overall improvement of the pre-existing parenchymal opacities. All of these
changes, including the conglomerate of cavitary lesions in the middle lobe,
have decreased in extent and severity. Cavitation in 1 of the left lower lobe
nodules has newly appeared. No pleural effusions. No reactive
lymphadenopathy. The patient was diagnosed with POISON-MEDICINAL AGT NOS, ACUTE RESPIRATORY FAILURE, SUICIDE-ANALGESICS. The patient was treated with central line
intubation
right chest tube placement
PICC line placement
Bronchoscopy. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Overdose
Suicide attempt
Respiratory Failure
Strep Anginosus bacteremia
Aspiration pneumonia
s/p PEA arrest
Pulmonary Embolism
Reactive thrombocytosis
Diarrhea
Depression
Pneumomediastinum
Right pleural effusion. The patient was given written instructions concerning 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 depression presented after intentional
overdose with hypercarbic and hypoxic respiratory failure and
shock with course complicated by PEA arrest in the MICU.
=============</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ woman with a history of TIAs,
hypothyroidism who presented to the ED with weakness and
fatigue.
She was in her USOH until the morning of ___ when her son
found her still in bed at noon (she usually is out of bed in the
morning to make coffee and watch Catholic Mass). She required
assistance from her son to ambulate and get to the bathroom
(usually ambulates independently with a cane) and noted to be
mildly confused. EMS was called and she was brought to ___. Chest radiograph showed 1. No acute cardiopulmonary process.
2. Unchanged moderate hiatal hernia. CT HEAD W/O CONTRAST showed No acute intracranial process. The patient was diagnosed with Urinary tract infection, site not specified. At the time of discharge, the patient had Urinary tract infection
Weakness. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ woman with a history of CVAs s/p
CEA, hypothyroidism who presents with weakness and confusion
found to have urinalysis c/w UTI. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ lady with a PMH significant for stage
IV gastric cancer with bony mets who presents with weakness and
dark stools. CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. At the time of discharge, the patient had stage IV gastric cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ lady with a PMH significant for
stage IV gastric cancer with bony mets who presents with
weakness and dark stools, guaiac positive, but stools do not
appear to be consistent with melena.
# Weakness: Differential includes infection, anemia, chemo. No
obvious s/s of infection, aside from loose stool. Blood and
urine cultures negative. c. diff negative. Did not require
antibiotics. Her blood counts had been slowly downtrending but
were stable throughout admission. Anemia may be due to chemo,
especially where patient does not seem to have GIB. Remained
afebrile, WBC stable throughout admission
# Dark stool: Not frankly melanotic. Dark brown, no blood, not
black, no tarry quality. Guiaic positive in ED but this is in
the setting of known gastric cancer. Daily HCT was stable
throughout admission. Given Pantoprazole daily, held
prophylactic heparin. Tolerated regular diet, no indication for
endoscopy or colonoscopy during this admission.
# Gastric adenocarcinoma: Known bony mets. Currently on
Ramucirumab/Taxol. Treatment complicated by cytopenia,
proteinuria, and peripheral neuropathy. Most recent treatment
may be contributing to her profound weakness. Discharge
treatment plan per outpatient team
# HTN: Continued home lisinopril and amlodipine
# Neuropathy: Continued home gabapentin
# Pernicious anemia: Receives monthly B12 injections
TRANSITIONAL ISSUES
#Patient was guaiac positive, though did not have any evidence
of BRBPR or melena this admission. continue to trend H&H to
monitor for any acute or continued bloodloss
#Patient having diarrhea during this admission, c. diff negative
#no changes in medications, except patient written for
simethicone as needed for gas pain
#EMERGENCY CONTACT HCP:
Husband (___) ___
#CODE: Full (confirmed) </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ s/p lap CCY ___ for chronic
cholecystitis who presented to ED on POD5 for acute onset
SOB, general malaise, and fatigue that started the nihgt before
presentation. She denies any pain, notes that since surgery she
has had poor appetite and nausea, no vomiting. She notes having
a fever to
102. On presentation to the ED, she was AF and her HR was 103,
and her labs were notable for WBC 14.2 and lactate 2.5. She also
notes diarrhea for past several days, and endorses
lightheadedness/dizziness. Denies dysuria, frequency, urgency.
ROS o/w negative except as noted above. CTA CHEST AND CT ABDOMEN AND PELVIS showed 1. No evidence of pulmonary embolism or acute aortic pathology.
2. 8-cm abscess in the gallbladder fossa with surrounding fat stranding.
3. Abnormal, relatively avidly enhancing subcarinal lymph nodes measuring up
to 3.4 cm. Findings could reflect a neoplastic process including metastatic
disease or lymphoma, with Castleman disease also in the differential.
Consider further evaluation with tissue sampling.
4. Hepatic steatosis.
RECOMMENDATION(S): Abnormal subcarinal lymph nodes measuring up to 3.4 cm.
Consider further evaluation with tissue sampling. The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had lymphadenopathy. biliary abscess. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ POD#6 from laparoscopic cholecystectomy who presents with
generalized fatigue and fevers at home. The patient underwent
laparoscopic cholecystectomy on ___ for chronic
cholecystitis; procedure was uncomplicated but notable for
chronic inflammation and numerous gallstones. There was some
oozing from the liver bed after removal of the gallbladder and 4
pieces of surgicel were placed in the gallbladder fossa with
hemostasis achieved. She presented to ___ on ___ with
acute onset shortness of breath and malaise. She was found to be
dehydrated (lactate of 2) with a leukocytosis of 14. CTA torso
showed no acute thoracic processes to explain the subjective
shortness of breath, and patient was breathing comfortably on
room air. However, imaging was concerning for an abscess in the
gallbladder fossa. However, after further review by the surgical
and radiology teams, it was determined that the air-containing
collection was reflective of Surgicel in the gallbladder fossa,
with a small 3x3cm collection, likely seroma or residual
hematoma. The CT also noted an incidental finding of a 3.4cm
subcarinal lymph node that was evaluated by IP who recommend an
interval CT in one month. The patient was admitted to the
surgical service, rehydrated and started on antibiotics. Her
symptoms improved and her leukocytosis was down trending and she
was discharged home on a course of oral antibiotics.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p total thyroidectomy ___ w/ Dr. ___ 10
hrs of worsening neck swelling and voice changes. Pt was
discharged on ___ feeling well, when last night she began
having
worsening throat swelling overnight. She denies any inciting
trauma or event. The pain and swelling worsened overnight and
she
presented to ___ in the morning. CHEST PORT. LINE PLACEMENT showed Mild basilar opacities, likely atelectasis. Probable trace pleural effusions. Radiology showed Endotracheal tube and feeding tube are unchanged position. There has been
worsening of the airspace opacities at the lung bases. This may represent
aspiration or pneumonia or atelectasis. There is no pulmonary edema or
pneumothoraces. AP chest showed Heart is now mildly enlarged, pulmonary vasculature is engorged and small
pleural effusions are likely. No pneumothorax.
Moderately severe bibasilar consolidation has worsened, and could be
atelectasis alone, but pneumonia is not excluded.
ET tube and nasogastric tube are in standard placements. CHEST (PORTABLE AP) showed Comparison to ___. The tracheostomy tube and the feeding tube are
in stable correct position. Minimal increase in severity of a retrocardiac
atelectasis. The presence of a minimal left pleural effusion cannot be
excluded. The mediastinum shows unchanged normal appearance. CT NECK W/O CONTRAST (EG: PAROTIDS) Q21 CT NECK showed Complex fluid collection with foci of air centered in thyroidectomy bed
bilaterally, extending inferiorly to the thoracic inlet and superiorly to the
level of the hyoid bone. This is compatible with postsurgical change, but
superimposed infection cannot be excluded on the basis of CT, particularly in
the absence of intravenous contrast.
Evaluation for airway narrowing at and above the level of the thyroidectomy
bed is not possible due to the endotracheal tube. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices
are unchanged. The left hemidiaphragm is much better seen, consistent with
substantial clearing of the left lower lobe collapse and associated pleural
fluid. Cardiomediastinal silhouette is stable and there is no evidence of
acute focal pneumonia. The patient was diagnosed with Postproc hematoma of skin, subcu following other procedure, Oth surgical procedures cause abn react/compl, w/o misadvnt. The patient was treated with Evacuation of neck hematoma. At the time of discharge, the patient had Post-thyroidectomy neck hematoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was taken to the OR for neck washout on ___. Postop,
she had no cuff leak. ENT was consulted and noted edema in the
airway and recommended steroids. She was given dexamethasone and
diuresed in the ICU. She was extubated on ___ and monitored
in the ICU. She had a sore throat which improved. At time of
discharge she was tolerating a regular diet.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old F with PMH of PVD, DM2, DVT/PE with
right sided heart failure on lifelong warfarin, right foot
osteomyelitis s/p debrided/amputation R ___ metatarsal base on
___, and frequent falls who presents from her PCP office for
evaluation of her right foot/leg wound. Pt reports that since
her last episode of osteomyelitis ___ ___ she initially had
improvement ___ the erythema, swelling, and pain up until 2 weeks
ago when she noticed increased pain. This was associated with
increasing erythema and swelling. FOOT AP,LAT AND OBL RIGHT showed Large soft tissue defect adjacent to the lateral base of the fifth metatarsal
with lucency projecting over the remaining proximal fifth metatarsal, and with
possible involvement of the lateral base of the fourth metatarsal, highly
worrisome for acute osteomyelitis. CHEST (SINGLE VIEW) showed Questionable deformities of several mid left-sided lateral ribs of
indeterminate age, but which may have also been present on prior studies
including ___. Correlate with site of pain and need for additional
imaging. No pleural effusion or pneumothorax. CT HEAD W/O CONTRAST showed No acute intracranial process. Partially imaged left zygomatic arch fracture
and nasal bone fracture are again seen, also on the prior study. Other
previously seen facial fractures are not imaged. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins
through the popliteal artery. Radiology showed The patient is status post recent resection of the base of the right fifth
metatarsal, with expected postoperative changes including soft tissue swelling
and soft tissue gas. CHEST PORT. LINE PLACEMENTCHEST PORT. LINE PLACEMENTi showed Mild to moderate cardiomegaly increased slightly since ___, with no
accompanying increase in caliber of either pulmonary or mediastinal veins, or
the development of any pulmonary edema or indication of pleural effusion.
Lungs are clear of any focal abnormality. Radiology showed Moderate right lower extremity edema with no evidence of focal fluid
collection. Radiology showed Successful placement of a 46 cm right arm approach single lumen PICC with tip
in the low SVC. The line is ready to use. The patient was diagnosed with AC OSTEOMYELITIS-FOOT, DIAB W MANIF NEC ADULT, CELLULITIS OF FOOT. The patient was treated with Debridement of R ___ metatarsal foot ulcer
Placement of peripherally inserted central venous catheter. At the time of discharge, the patient had Primary:
Osteomyelitis
Secondary:
Bacteremia
Autonomic dysfunction. The patient was given written instructions concerning 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 for right foot osteomyelitis that failed
outpatient antibiotic treatment after a previous debridement.
#OSTEOMYELITIS: She was started empirically on Vancomycin,
Ciprofloxacin, and Metronidazole for concern of a polymicrobial
infection. She was taken to the operating room with podiatry for
a debridement. Wound cultures grew out MSSA and mixed bacterial
flora. Vancomycin was discontinued and nafcillin started. Her
___ seemed persistently edematous and erythematous
post-debridement, and she had a ___ soft tissue US which
demonstrated no evidence of abscess or fluid collection. (She
had already had a ___ on presentation, which was negative
for DVT.)
# BACTEREMIA: The patient was found to be bacteremic, with blood
cultures growing MSSA. Given that MSSA was also isolated from
her wound culture, she was transitioned to Nafcillin IV from
Vancomycin. Considering her bacteremia, she also had a TTE which
showed no evidence of endocarditis.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with Type 1 diabetes (A1c 11.7),
homelessness, substance use disorder on methadone, PTSD, and
recurrent C.diff with chronic diarrhea who recently left AMA
from ___ after being hospitalized for DKA and reported UGI
Bleed. He presents today to the ___ ED with abdominal pain and
feeling unwell. CT ABD AND PELVIS WITH CONTRAST showed 1. Wall thickening and edema of the large and small bowel, which could be
related to hypoperfusion/reperfusion verses extensive enterocolitis. Ischemic
bowel cannot be excluded. Vasculature appears patent.
2. Markedly distended bladder. Correlate with ability to voluntarily urinate.
Air within the bladder could be related to recent instrumentation. Correlate
with UA.
3. Left lower lobe consolidation may be consistent with aspiration/pneumonia.
4. Abdominal free fluid, soft tissue anasarca, and periportal edema, most
likely related to third spacing. CHEST (PORTABLE AP) showed Opacities at the left lung base are concerning for left lower lobe pneumonia.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:02 pm, 60 minutes after
discovery of the findings after initial attempts at paging were unsuccessful. CHEST (PORTABLE AP) ___ showed Compared to chest radiographs ___.
Lower lobe pneumonia, severe on the left is unchanged. Moderate right lower
lobe pneumonia has improved. Heart size is normal. Small pleural effusions
are likely. Esophagram with additional hypopharynx views showed 1. There was mild penetration with oral contrast, however no gross
aspiration. If there is continued clinical concern for aspiration, a
dedicated video swallow study with speech pathology is recommended.
2. No esophageal web, ring, or stricture. No esophageal dysmotility. A 13 mm
barium tablet passed easily without holdup.
3. No hiatal hernia. Unable to assess for gastroesophageal reflux secondary
to poor patient compliance. Radiology showed Small-bowel loops with likely pneumatosis and possible free air below the
right hemidiaphragm, concerning for acute bowel ischemia with possible
perforation. Further assessment with CT abdomen pelvis recommended
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 5:25 pm, 2 minutes after discovery of
the findings. CT ABD AND PELVIS WITH CONTRAST showed 1. Extensive pneumatosis involving multiple loops of small bowel. There is
associated small volume pneumoperitoneum.
2. Large volume ascites.
3. Consolidative changes in the lung bases are mildly improved since prior
examination.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:54 pm, 2 minutes after
discovery of the findings. CHEST PORT. LINE PLACEMENT showed 1. The endotracheal tube tip is at the level of the clavicular heads, 6.6 cm
above the carina. This could be advanced 1-2 cm for better positioning.
RECOMMENDATION(S): The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:45 am, 10 minutes after
discovery of the findings. Radiology showed No retained surgical instruments visualized.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 1:25 pm, 1
minutes after discovery of the findings. Chest radiograph, portable AP upright view. showed Nasogastric tube terminating in the stomach. Advancing the tube by 5-10 cm is
suggested for better seating, however. CHEST (PORTABLE AP) was done. CT ABD AND PELVIS WITH CONTRAST showed 1. Status post interval cecectomy and small bowel resection with small volume
free intraperitoneal air. No evidence of pneumatosis or bowel obstruction.
2. Moderate volume intra-abdominal ascites without organized collection.
3. Diffuse body wall anasarca, progressed compared to the prior examination of
___.
4. Thickening of the bladder wall may be exaggerated in setting of
underdistention however correlation with clinical signs of cystitis is
recommended.
5. Small bilateral pleural effusions, new compared to the prior examination. The patient was diagnosed with Type 1 diabetes mellitus with ketoacidosis without coma, Gastrointestinal hemorrhage, unspecified, Long term (current) use of insulin. The patient was treated with ___ Exploratory laparotomy and small bowel resection. At the time of discharge, the patient had DMI
DKA
LLL Pneumonia
Small bowel necrosis and pneumatosis
Substance abuse
Chronic diarrhea. The patient was given written instructions concerning 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 DMI, hepatitis C, homelessness, substance use
disorder on methadone, current IVDU, PTSD, chronic diarrhea and
multiple recent admissions to ___ for DKA with AMA discharges
who presented with abdominal pain and DKA. He was initially
admitted to the ICU requiring and insulin drip, and was
subsequently cared for on the medical floor. Also found to have
pneumonia and possible UTI, treated with course of antibiotics.
The pt's abdominal pain worsened acutely and CT imaging showed
extensive pneumatosis and small bowel necrosis. He was taken to
the OR on ___ for small bowel resection and transferred to
the surgical service for post operative care.
TRANSITIONAL ISSUES
=====================
[] Repeat CXR in ___ wks
[] Hepatology f/u as outpt for hepatitis C
ICU COURSE
=============
The patient was admitted to the ICU initially for DKA requiring
insulin drip. On admission he also complained of abdominal pain
with CT A&P showing wall thickening and edema of the large and
small bowel. Serial abdominal exams did not reveal any
peritoneal signs and his symptoms improved after several days,
so these findings were attributed to trauma from a recent
assault prior to admission. The patient was transferred to the
medicine floor after anion gap closed and he was transitioned to
subcutaneous insulin (see medical floor course below).
However while on the medicine service, the pt developed acute
worsening of abdominal exam on ___ and a repeat abdominal CT
showed extensive pneumatosis and small bowel necrosis. He was
taken emergently to the OR for small bowel resection and
transferred back to the surgical service for post operative
care.
MEDICINE COURSE (BY PROBLEM)
==============================
ACUTE/ACTIVE ISSUES
====================
# DMI
# DKA
The patient presented with DKA, in the setting of reportedly
missing insulin for 16 days due to poor access. The pt did not
report that it was cost prohibitive, however was simply unable
to obtain. The patient was initially stared on insulin drip in
the ICU and was subsequently transitioned to subcutaneous
insulin after gap closed and acidosis resolved. ___ diabetes
team was consulted and titrated long acting, prandial, and
sliding scale insulin accordingly.
# Small bowel necrosis
Acute worsening of abdominal pain on ___ ___hest
revealing for pneumatosis and small bowel necrosis. Underwent
small bowel resection that day and was continued on antibiotics.
# LLL PNA
A CXR from admission showed a LLL consolidation, concerning
aspiration vs PNA. At the time, he also endorsed mild cough with
scant sputum production. Given his recent hospitalizations,
including an admission in the ___ ICU, the patient was deemed to
have multidrug resistant risk factors, so was covered broadly
with vancomycin and zosyn with a 7 day course (___).
# Substance Use
# Chronic pain
The patient has a long history of IV drug use, on methadone. He
reported active IV drug use 1 week prior to admission, via
heroine injection to the antecubital fossa. He previously was
prescribed 60mg methadone daily at ___. ___
clinic, however had not been seen there since ___. More
recently he was receiving methadone at ___,
and then admitted to getting methadone of unknown quantity on
the streets after leaving against medical advice. The addiction
psych team was consulted and assisted in narcotic prescription
management. Due to somnolence, the patient was given a decreased
dose of 30mg methadone daily. He was continue ___ home lyrica,
as well as Tylenol and naproxen for chronic pain.
# Klebsiella UTI vs asymptomatic bacteruria
MDR klebsiella was also found to growing in urine from a sample
taken on admission. The patient denied symptoms, so most likely
represents asymptomatic bacteruria. He was already receiving
antibiotics for a PNA as discussed above.
# Dysphagia
Throughout admission, the patient complained of chest pain and
difficulty swallowing. His EKG was unchanged and a barium
swallow study did not reveal any evidence for aspiration or
obstruction. His symptoms were managed with Maalox and Carafate.
CHRONIC/STABLE PROBLEMS
========================
# Anxiety
# Depression
The patient was continued on home duloxetine and received
hydroxazine as needed.
# Chronic diarrhea
The patient has also had longstanding of diarrhea for > ___ years
due to unknown etiology. A cdiff test was negative on admission.
His chronic diarrhea could have been due to pancreatic
insufficiency as he is prescribed creon as a home medication.
The patient was continued on home loperamide, creon, and
diphenoxylate-atropine while here, in addition to a short course
of zinc supplement.
# HCV
There were no signs of acute decompensated liver failure this
admission.
# Coagulopathy
Likely nutritional given lack of significant underlying liver
dysfunction. The patient was given IV vitamin K for 3 days with
improvement in INR.
# Gram positive rod bacteremia
Blood cultures grew gram positive rods from admission, speciated
as bacillus. Felt to be a skin contaminant. An echo was done
which was negative for vegetations.
CORE
======
# CODE: Full
# CONTACT: None
On ___, the patient was transferred to the surgical floor.
Neuro: The patient remained alert and oriented. He was on a
ketamine drip for pain and this was discontinued. Addiction
Psychiatry was consulted and the patient was started on
methadone and oxycodone which was weaned and ultimately stopped.
He was continued on acetaminophen, ibuprofen and Pregabalin.
CV: The patient remained stable from a cardiac standpoint. Vital
signs were routinely monitored
PULM: The patient remained stable on room air with no acute
respiratory distress.
Good pulmonary toilet, early ambulation and incentive spirometry
were encouraged throughout hospitalization.
GI/GU/FEN: Patient's NGT was removed and diet was advanced from
sips to clears and ultimately to regular which he tolerated
well. The patient had diarrhea and a c.diff was checked which
was negative. The diarrhea was attributed to the patient's
history of chronic diarrhea due to pancreatic insufficiency.
The patient was restarted on creon, loperamide and lomotil.
The patient had urinary retention, required straight
catheterization and Urology was consulted and recommended foley
placement for 7 days. He was started on Flomax, the foley was
removed and the patient voided without issue.
HEME: The patient's blood counts were closely watched for signs
of bleeding. On ___, he received 1U PRBC for hematocrit of
20.7, hemoglobin 6.3 and HCT/HGB increased appropriately.
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.
On ___, the patient was noted to have some drainage from
his midline surgical abdominal wound and wicks and a pravena was
placed. Pravena was removed on ___ and the wound was
healing well w/ no s/s infection.
On ___, the patient left the hospital before discharge
paperwork or prescriptions could be provided. His discharge
paperwork and prescriptions were faxed to his pharmacy. The
patient was doing well, afebrile and hemodynamically stable.
The patient was tolerating a diet, able to ambulate to his
wheelchair, 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: ___ who was a pedestrian struck in R hip by a car while
working (police officer). He was spun around and fell. He had
immediate R hip and buttocks pain. No LOC. He also c/o
Right-sided rib pain. Denies pain anywhere else. Radiology showed No evidence of fracture. Radiology showed No acute cardiopulmonary process. Radiology showed No acute fracture. Diverticulosis. Radiology showed 1. No signs for acute fractures.
2. There is minimal fraying of the right superior labrum.
3. Minimal degenerative changes at L5/S1. The patient was diagnosed with JOINT PAIN-PELVIS, LUMBAGO, MV COLL W PEDEST-PEDEST. At the time of discharge, the patient had Right hip contusion. The patient was given written instructions concerning 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 Orthopaedic Trauma Service for
right hip contusion. Pain was controlled with PO pain meds. The
patient worked with ___ on mobility and steadily improved.
Weight bearing status: weight bearing as tolerated.
The patient was discharged in stable condition with written
instructions concerning precautionary instructions and the
appropriate follow-up care. The patient will not require
chemical DVT prophylaxis and should be out of bed and
ambulatory. 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: ___ is a ___ Hispanic woman with recent
bilateral cataract surgeries, who presents now with eye
inflammation and headache, and was found to have both iritis and
bilateral disc swelling in ophthalmology clinic today. According
to her ophthalmologist's records, Mrs. ___ her the 2 surgeries
performed OD ___, OS ___ but the patient is convinced
that OD was operated on second. She had no problems after the
first surgery but ___ weeks after the second procedure (i.e.,
around ___ pt started developing symptoms.
Although it is difficult for her to establish a consistent
timeline, she thinks that ocular redness came first, followed by
pain around the eyes and photophobia. Since then, she has
developed additional symptoms that have gradually worsened over
several weeks:
- blurry vision OD > OS
- superior & temporal visual field restriction (mostly OD)
- transient visual obscurations that last a few seconds and
occur
with position change
- flickering lights and zig-zag shapes in her vision on the
right
that last < 1 minute
- pulsatile tinnitus AS > AD
- a bifrontal & nuchal headache that is steady and worst at
nights and in the morning but then aggravated by walking around
in the day (and better with recumbency); this is different to
the
pt's usual migraines, which tend to be left-sided, pounding and
associated with photophobia (but no aura) Radiology showed No acute intracranial process. No intracranial hemorrhage. Of note MR is more
sensitive in the detection of subtle abnormalities. MRI HEAD WITHOUT AND WITH INTRAVENOUS CONTRAST
MRI ORBITS WITHOUT AND WITH INTRAVENOUS CONTRAST
MRV HEAD WITHOUT INTRAVENOUS CONTRAST showed 1. No evidence for acute intracranial abnormalities or any source of increased
intracranial pressure.
2. 5 mm extra-axial enhancing focus along the right sphenoid wing on
postcontrast MP RAGE images, projecting into the middle cranial fossa ,
without contrast enhancement on spin echo T1 weighted images, and with low
signal on T2 weighted images, most likely representing a vascular loop, rather
than a meningioma.
3. Normal appearance of the orbits, allowing for prior cataract surgery, and
of the cavernous sinuses.
4. No evidence for major dural venous sinus thrombosis.
5. Prominent flow void in the left suboccipital region appears to correspond
to a large vein, but is in close proximity with the left vertebral artery. The
relationship of this vein to the left vertebral artery, and presence of any
pseudoaneurysm, could be better assessed by CTA, in the first instance, if
clinically warranted, though any fistula would be best detected by
conventional angiography.
RECOMMENDATION(S):
Please see impression item #5. Radiology showed Essentially normal CT CHEST W/O CONTRAST showed No evidence of sarcoidosis or other diffuse lung disease.
Mild thyromegaly. Clinical evaluation may be pertinent.
Mild lower lobe bronchial inflammation. The patient was diagnosed with ACUTE IRIDOCYCLITIS NOS, PANUVEITIS. The patient was treated with Lumbar Puncture ___. At the time of discharge, the patient had Migraine
Uveitis
Retinal Cysts. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was admitted with uveitis, concern for papilledema and
headache with high pressure features. Workup for uveitis
included a variety of screens for autoimmune, autoinflammatory
or infectious conditions. All of these were negative or pending
at the time of discharge. She was continued on Prednisone eye
drops to treat inflammation. Upon repeat evaluation by
Ophthalmology, no papilledema was noted. Instead retinal cysts
were identified and the patient will follow up with a retina
specialist, appointment pending. MRI was unremarkable with the
exception of a large left occipital vein coursing close to the
left vertebral artery. No further workup of this was pursued
during this admission. Lumbar puncture was performed. Opening
pressure was 19cm H2O, which was not consistent with elevated
intracranial pressure. Basic CSF studies were reassuring.
Infectious and inflammatory CSF studies were pending at the time
of discharge. Follow up with Neurology was scheduled. TSH was
elevated at 5.2. TSH, T3/Free T4 were repeated prior to
discharge, but were pending. Adjustment to Levothyroxine may be
indicated on the basis of these results.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ pshx notable for c-sectionx2 with recent unremarkable
colonoscopy presenting with intermittent crampy abdominal pain
over preceding 5 days associated with nausea. Directed to
present
to ___ urgent care where CTAP demonstrated transition
point in the RLQ, prompting transfer for surgical evaluation. Abdomen and pelvis CT. showed 1. Fluid-filled, mildly dilated small bowel with a probable transition point
in the right lower quadrant and collapse of the distal bowel. Findings are
suggestive of an early/partial small obstruction. Although the stomach and
duodenum are not dilated, a secondary transition point is not identified.
There is no discreet associated mass identified.
2. Colonic diverticulosis without evidence for acute diverticulitis.
3. Hepatic steatosis.
NOTIFICATION: Findings were conveyed by Dr. ___ to Dr. ___
telephone at 12:55 on ___. The patient was diagnosed with INTESTINAL OBSTRUCT NOS, ABDOMINAL PAIN OTHER SPECIED. At the time of discharge, the patient had Partial small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was admitted to the hospital on ___ for management of
partial small bowel obstruction. She was made NPO with IV
fluids. NGT was not placed. Urinalysis on admission revealed a
urinary tract infection, and she was started on oral
ciprofloxacin for treatment.
Her diet was advanced to clears on hospital day 2, when she was
having flatus. On hospital day 3 she was advanced to regular
diet with marked improvement of her abdominal exam. She
ambulated without assistance. She was discharged from the
hospital with plan to follow up with outpatient primary care
provider.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Briefly Mrs. ___ is a ___ with hx of epilepsy with two
recent
admissions with vEEG monitoring who presented to the ED last
___ with 2 events that were concerning for seizures. She was
observed in the ED and did not have further events and was
continuing to improve and other than mild gait difficulty that
appear somewhat inconsistent she was close to her baseline and
was therefore discharged to outpatient follow up with Dr.
___. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with MUSCSKEL SYMPT LIMB NEC, OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY. At the time of discharge, the patient had Epilepsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was admitted from outpatient Neurology Clinic for EEG
monitoring in the setting of ataxia/unsteady gait. She was
unsure of exact medication dosing upon admisison and so got less
medication than usual (what we had in our system- only 100mg
Vimpat, and only 50mg of Lamictal). Despite this, there was no
seizure activity and her preliminary EEG read was at her
baseline: "IMPRESSION: This is an abnormal continuous EMU
monitoring study because of sleep related paroxysmal interictal
epileptic activity that appears to be generalized. There were
however no sustained events during this recording session." The
EEG read from the last 12 hours of admission is pending at the
time of discharge. The morning following admission, ___,
she felt completely better and her walking was back to baseline.
She remained neurologically at her baseline and received the
extra dose of medications when her correct dosage was figured
out (Vimpat 200mg BID and Lamictal 100mg qAM and 125mg qPM).
She was discharged on all of her home medications and will touch
base with her outpatient neurologist Dr. ___ thing on
___ morning ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ old woman with history of COPD,
CHF, NIDDM, alcohol and tobacco abuse, presented to ___
___ with shortness of breath with hypercarbic respiratory
failure, intubated and transferred to ___ for management of
hypercarbic respiratory failure. Radiology showed 1. Bibasilar dependent consolidations may represent aspiration or
atelectasis. Infection cannot be entirely ruled out.
2. Severe cardiomegaly. Bronchial wall thickening and some areas of
interlobular septal thickening may indicate mild pulmonary edema.
3. Evidence of pulmonary hypertension.
4. Mildly enlarged mediastinal lymph nodes of unclear etiology, may be
reactive.
5. No evidence of SVC obstruction. CHEST (PORTABLE AP) showed ET tube in standard placement. Upper enteric drainage tube passes into the
nondistended stomach and out of view. Pulmonary vascular engorgement and early
interstitial pulmonary edema have cleared since ___, moderate
cardiomegaly has also improved. Pleural effusions if any are small. No
pneumothorax. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen. The
endotracheal tube and the nasogastric tube are in correct position. Moderate
cardiomegaly with mild to moderate pulmonary edema and areas of atelectasis at
both the left and the right lung bases. No larger pleural effusions. No
pneumothorax. CHEST PORT. LINE PLACEMENT showed Left PIC line passes up into the neck and out of view. ET tube is in standard
placement and an upper enteric drainage tube passes into the nondistended
stomach and out of view. Moderate cardiomegaly has worsened and pulmonary
vascular engorgement increased, but there is as yet no pulmonary edema or
evidence of appreciable pleural effusion. Venous access
NOTIFICATION: Venous access nurse was was paged as requested Radiology showed Successful repositioning of a left arm PICC from the left internal jugular
vein to the distal SVC. The line is ready to use. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen. Moderate
cardiomegaly and with mild fluid overload and areas of atelectasis at both the
left and the right lung bases. No new parenchymal opacities. No pneumothorax.
No larger pleural effusions. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the image now includes the upper
stomach. The course of the nasogastric tube can be followed entirely. The tip
of the tube projects over the distal parts of the stomach.
No other change. The apical parts of the left and right hemithorax are not
included on the image. ___ through showed Slight increase in severe cardiomegaly could be due to differences in cardiac
cycling as well as slight increase in cardiomegaly. Pulmonary vasculature is
slightly more distended, but there is no pulmonary edema or focal
consolidation. Pleural effusions are small if any. No pneumothorax. Focal
thickening of the right lateral costal pleura is due to adjacent chronic rib
fractures, one not unhealed. CTA CHEST W/ AND W/O CONTRAST, NON-CORONARY showed 1. Pulmonary emboli in the left and right upper lobes pulmonary arteries,
possibly chronic. No evidence of right heart strain.
2. Enlargement of the main pulmonary artery suggests underlying pulmonary
arterial hypertension.
3. Nonspecific scattered ground-glass opacities at the lung apices are may be
infectious or inflammatory, new from ___. Interval improvement in
bilateral pleural effusions and bibasilar subsegmental atelectasis. Radiology showed No evidence of intracranial hemorrhage. Evaluation of the patient with fevers, pulmonary
embolism and hypoxia.
AP chest radiograph.
Heart size is enlarged, unchanged. Mediastinum is widened, unchanged as well
as there is evidence of pulmonary artery dilatation consistent with pulmonary
hypertension. There is no pleural effusion. There is no pneumothorax. was done. BILATERAL LOWER EXTREMITY DVT ULTRASOUND showed No evidence of deep vein thrombosis in either lower extremity to the popliteal
level.. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen. Moderate
enlargement of the cardiac silhouette, in particular of the left ventricle.
Signs of mild pulmonary edema with evidence of basilar apical blood flow
redistribution. Areas of small atelectasis at the bases of the right lung. No
larger pleural effusions. Minimal atelectasis in the retrocardiac lung regions
but no evidence of pneumonia. No pneumothorax. Oropharyngeal video swallow. showed Trace sensate aspiration with thin liquids. Spontaneous cough with clearing.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations. Radiology showed 1. ET tube is in satisfactory position.
2. NG tube sidehole is at the level of the diaphragm. Advancing several
centimeters will ensure it is within the stomach.
3. Mild interstitial pulmonary edema. Radiology showed 1. Cardiomegaly and probable background COPD. Enlarged pulmonary arteries,
raise question of background pulmonary hypertension, similar to prior.
2. CHF findings with vascular plethora and mild interstitial edema which
appears worse compared with ___. No gross effusion.
3. Bibasilar atelectasis. No frank consolidation identified at this time.
4. Suspected hiatal hernia. Radiology showed No acute intracranial process. The patient was diagnosed with RESPIRATORY ABNORM NEC. The patient was treated with endotracheal intubation and mechanical ventilation. At the time of discharge, the patient had - Hypercarbic, hypoxemic respiratory failure (multifactorial)
- Health care associated pneumonia
- Acute PE
- Systolic congestive heart failure exacerbation
- COPD exacerbation
- Diabetes
- 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>___ old woman with history of COPD, CHF, NIDDM, alcohol and
tobacco abuse, and schizoaffective disorder who presented with
shortness of breath, was intubated for hypercarbic respiratory
failure, s/p extubation ___, finished HCAP course ___, and
returned to the ICU with hypoxemia, found to have PE and now
back on treatment for HCAP due to fever.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old man with h/o dementia
and failure to thrive, who presented from his nursing home after
being found down. CT HEAD W/O CONTRAST Q111 CT HEAD. showed No acute intracranial hemorrhage or evidence of acute large territorial
infarction. Chest radiograph showed 1. Widened appearance of the upper mediastinum likely due to unfolding of the
thoracic aorta in the setting of patient rotation and positioning although
underlying thoracic aortic aneurysm is possible.
2. No focal consolidation identified. FEMUR (AP AND LAT) BILATERAL showed No evidence of fracture or dislocation of the right or left femur. Small
bilateral suprapatellar effusions.
Sclerosis of the medial proximal left tibial metaphysis, incompletely
visualized on these views. Dedicated knee or tibia fibula films is suggested
to further evaluate. PELVIS (AP ONLY) PORT showed No evidence of fracture or dislocation of the pelvis. CT head without contrast showed This exam was aborted due to patient noncooperation. Only 1 lateral scout
image was able to be obtained. The patient was diagnosed with Altered mental status, unspecified, Adult failure to thrive. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old man with history of prostate
cancer s/p XRT and hormonal therapy in ___, vestibular
neuritis, hyperparathyroidism, Paget's disease, hearing loss,
dementia and cognitive decline over the past ___ months, who
presented after a fall with head strike at his nursing home. He
was monitored without evidence of infection or cardiac etiology
for fall, and was discharged back to his SNF.
#Acute on chronic Encephalopathy:
#Rapidly declining cognitive status:
#Dementia:
From review of ___ records, patient's rapid cognitive decline
began in ___. Before then he was functional, driving and
conversant. Since then he has had trouble walking and expressing
himself, although does appear to comprehend. From ___ chart
review, he had MRI/MRA head, CT head, EEG, and broad autoimmune
workup in two different hospitalizations in ___ that were
unrevealing of the etiology. There was concern that his decline
started after a course of steroids given for vestibular neuritis
in ___, but this has not been well described and patient did
not improve with cessation of steroids. There may be a component
of vascular dementia, as he does seem to have the focal deficit
of expression but can comprehend. We recommend he continue to
see an outpatient neurologist (son is continuing to think about
this decision as unsure if it is helpful) and that occupational,
physical and speech therapy would with him frequently to provide
the best chance of rehabilitation.
#Fall:
Patient presented after a fall from his bed, reportedly in the
setting of agitation. Patient have been experiencing sundowning,
leading him to fall, or could have been presyncope in the
setting of medication side effect (on tamsulosin at home). He
sustained an abrasion to his forehead, but otherwise had no
acute injuries. His CT scan was negative for any acute
intracranial processes or bleed. He had an echocardiogram that
was unrevealing for an etiology of presyncope or syncope that
could have led to a fall. He had no falls while in the hospital,
and as above would encourage OT, ___ and frequent orientation.
#Pancytopenia:
On day 3 of his hospitalization, his CBC was notable for all
three cell lines being decreased from admission and baseline. He
received no medications to trigger this, and did not appear to
be actively infected. His counts remained stable, but would
recommend repeating a CBC ___ to ensure resolution vs further
workup.
#Coag-negative staph positive blood culture, likely contaminant:
Patient had 1 blood culture that grew coag-negative staph. He
was temporarily started on vancomycin. The other blood cultures
had no growth at time of discharge, he was afebrile and well
appearing, and this was determined to be a likely contaminant.
#Elevated lactate:
Patient admitted with a lactate of 5, improved to 2 with IVF. He
had no signs of active infection, and suspect this may have been
due to poor PO intake and any muscle breakdown after his fall.
#Medication reconciliation:
Patient was still on medications started at the ___
hospitalization in ___, that were supposed to be discontinued
in early ___. These medications were discontinued and should
NOT be restarted upon return to his nursing home: fleet enema
(can cause marked electrolyte abnormalities), indomethacin (can
worsen confusion in the elderly), melatonin (not needed),
tamsulosin (can cause presyncope, syncope, hypotension, or
confusion in the elderly), omeprazole (no longer an indication
for this).
#Code status:
The patient's son/HCP expressed very clearly that he is full
code, but would not want to be on "life support" for a prolonged
period of time.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M otherwise healthy presenting with RLQ abdominal pain
that began ___. Patient states that it was first located in
the epigastric region and then subsequently localized to the
RLQ. He denies any associated fevers, chills, nausea, vomiting,
or anorexia. He denies any recent changes in his bowel habits.
He denies any history of prior abdominal surgeries or any recent
sick contacts. Radiology showed 1. Findings consistent with acute appendicitis ; the distal appendix is
dilated to 12 mm, fluid-filled, and with thickened, hyperemic wall. Mild
adjacent periappendiceal fat stranding. No drainable fluid collection or
extraluminal gas.
NOTIFICATION: Findings discussed with Dr. ___ by Dr. ___
at 16:15 on ___ via telephone. The patient was diagnosed with Unspecified acute appendicitis. At the time of discharge, the patient had Acute Appendicitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo M admitted to the Acute Care Surgery
Service on ___ with right lower quadrant/epigastric pain
for 3 days. Denies associated fever, chills, nausea, vomiting,
or change in bowels. CT abdomen pelvis was consistent with acute
appendicitis. Risks and benefits of operative versus medical
management with antibiotics was discussed and the patient opted
for medical mangagment. He was made NPO, given IV antibiotics,
and admitted to the floor for monitoring.
On HD2 he remained afebrile, hemodynamically stable, and
abdominal pain improved. White blood cell count was 10.0 from
7.7. His diet was progressively advanced to regular with good
tolerability with normal bowel function.
He was discharged to home on HD2 to complete a 10 day course of
antibiotics. 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: ___ with h/o CABG (___) c/b ISR s/p multiple PCIs (most
recent ___, chronic angina, complains of chest pain and
shortness of breath. After his last cath, he had a brief period
of relief from chronic angina. Since early ___, he has had
progressive recurrence of symptoms. Describes substernal chest
___ pressure, which radiates to the left arm, and is associated
with shortness of breath. Every ___ minutes, he has a sharp
pain, lasting 1 minute. States this pain is similar to prior
cardiac chest pain. It has continued to worsen, to the point
where it is nearly constant, at rest and with exertion. He has
been taking ___ SL nitros daily for the past 2 weeks. He has
remained active and is able to shovel and climb a flight of
stairs. However, he is becoming increasingly dyspneic with
exertion. He also endorses orthopnea but denies palpitations or
presyncopal symptoms. Radiology showed No acute cardiopulmonary process. No cardiomegaly.
Anterior wedge deformities of a lower thoracic vertebral body, age
indeterminate and clinical correlation suggested regarding possibility of pain
in this region. Radiology showed 1. No acute intrathoracic process.
2. Moderate hiatal hernia.
3. Anterior wedge deformity of T12 vertebral body, age indeterminate.x The patient was diagnosed with INTERMED CORONARY SYND. The patient was treated with Cardiac catheterization ___. At the time of discharge, the patient had -refractory restenosis of LAD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo male with CABG (___) with persistent angina s/p
multiple stents (most recent ___ who persists with
worsening chest pain over the past 2 weeks, accompanied by
non-specific ischemic EKG changes but no elevation of cardiac
enzymes.
# UNSTABLE ANGINA: Patient with extensive coronary history, s/p
CABG complicated by recurrent symptoms s/p multiple PCIs
(___). Appears to have stable EKG changes,
however missing posterior/LCx perfusion areas that could be
suspiscious for ischemia. Has 2 sets of negative cardiac
enzymes, but with persistent pain. Has had chronic angina since
CABG, but symptoms had been gradually worsening over the past 2
weeks prior to admission. Patient reported recent negative
stress test done by cardiologist 3 weeks prior, however this did
not necessaily mean that he is perfusing his heart well; could
be low perfusion globally. Unclear if this is actually cardiac
pain in nature given it's chronic presentation without evidence
of infarct or resolution in the pain. He was continued on a
heparin gtt until cardiac cath. He had evidence of refractory
restenosis of the LAD that will require definitive treatment
with repeat CABG. CT surgery consulted during admission and
reccommended surgical work-up and readmission in a few weeks. He
continued medical management with statin, metoprolol, asa 325
and plavix given recent DES in ___. Started amlodipine,
# H/O GI BLEED: Patient had a history of GI bleeding. No
evidence of any bleeding during admission. Denies melena or
hematochezia. Continued home pantoprazole.
TRANSITIONAL ISSUES
-patient will continue on plavix to prevent thrombosis of
multiple stents
-plan for appointment with Dr. ___ surgery) next
week
-started on amlodipine 2.5mg daily </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ who underwent a Whipple procedure ___
for IPMN at the head of the pancreas and is now scheduled for
completion pancreatectomy and splenectomy on ___. Recent MRCP
was performed on ___ showed a large increase in the size of
the main pancreatic duct, from 0.4 cm in ___ to 1.2 cm
presently. Further workup was concerning for either recurrence
of IPMN or pancreatic adenocarcinoma. He is directly admitted
now, a few days prior to his completion pancreatectomy, because
of elevated glucose levels detected yesterday on a ___
clinic visit at the ___ Pancre___. He is currently
taking metformin 500BID for glucose control since his Whipple.
Blood test at the clinic visit revealed an elevated glucose
level of 460 and he was instructed to go to a nearby ED to have
his blood sugar rechecked. At ___, his blood glucose
was 471, A1C was 9.3%, K was 5.7, and Cr 1.4 (baseline Cr. 1.1).
He was asked to come to ___ that night for further
management of his glucose, fluid resusitation for ___, and
management of hyperkalemia. At ___, his blood glucose was 318,
K was 4.5, Cr was 1.2. He was subsequently discharged home from
the ED with a glucometer and instructions to continually check
blood sugars at home. However, becuase of concerns from the
surgical team and family regarding patient's elevated blood
glucose, the decision was made for the patient to be directly
admitted prior to his surgery to optimize his glucose control
with the assistance ___. CHEST PORT. LINE PLACEMENT showed A COMPARISON STUDY OF ___, THERE IS A PLACEMENT OF A RIGHT IJ
CATHETER THAT EXTENDS TO THE MID TO LOWER PORTION OF THE SVC. NO EVIDENCE OF
PNEUMOTHORAX.
ALLOWING FOR THE AP SUPINE POSITION IN THE LOW LUNG VOLUMES, THERE IS PROBABLY
LITTLE OVERALL CHANGE IN THE APPEARANCE OF THE HEART AND LUNGS. The patient was diagnosed with DIABETES UNCOMPL ADULT. The patient was treated with robotic completion pancreatectomy and splenectomy. At the time of discharge, the patient had Pancreatic body mass. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was admitted to the ___ service 3 days prior to
his completion pancreatectomy for findings of elevated glucose
on pre-admission testing. On admission to the hospital, his
glucose level was 284. ___ was consulted to assist with
preoperative and postoperative management of glucose. He was
started on Lantus 10 and insulin sliding scale preoperatively.
He underwent a robotic completion pancreatectomy and splenectomy
on ___. Please see operative report for further details of
the operation. On POD1, he was started on clears and his foley
was removed. However on POD2, he developed abdominal distention
and diet was reduced to sips. On POD4, his abdominal distention
began to resolve and his diet was readvanced up to a regular
diabetic diet. Dilaudid PCA was discontinued on POD4 and he was
switched to oral pain meds and restarted on his home
medications, except for metformin. Throughout the postoperative
period, ___ continued to follow patient for blood glucose
control. At time of discharge, patient's blood glucose was well
relatively well controlled (FSG: 127-222). He was discharged on
18U of Lantus at bedtime and an insulin sliding scale. The
nutritionalists also worked very closely with the patient
regarding diabetic, post-whipple diets and further diet
education. Patient will be followed in the outpatient setting by
the ___ for glucose control and nutrition adivice. He
will have close follow-up with Dr. ___ as well with Dr.
___ pancreas). At time of discharge, patient was
tolerating a regular diabetic diet, self-administering insulin,
ambulating, and having normal bowel movement. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F with PMHx significant for depression with prior SA, who
is admitted with Tylenol overdose. Pt reports that, on ___
night between 6 and 8 pm, she took unknown amount of tylenol ___
(likely 30+ tabs) in attempt to kill herself. She also consumed
one ativan, 6 to 7 lamictal, and several glasses of wine. She
then slept through the night but awoke with lightheadedness,
visual hallucinations, and feeling lethargic. Friends were
unaware of what she took and thought she was hungover.
Ultimately presented to ___ around noon on ___ for eval.
While she was at ___, it became known that she had overdosed on
tylenol. Tylenol level at that point (18 hours after ingestion)
was 22. She was given mucomyst at 4pm (initial oral dose 10g)
then transferred to ___.
In the ED, initial VS were 98.2 114 119/82 16 100%. Labs were
significnat for AST 1393, ALT 884, TBili 2.6. She was seen by
toxicology, who recommended to reload mucomyst w/ IV dosing (150
mg/kg IV over 60min, then 4 hour infusion 12.5 mg/kg per hour,
then 16 hour infusion 6.25 mg/kg per hour). VS prior to transfer
Temp: 98.4 °F (36.9 °C), Pulse: 94, RR: 20, BP: 103/89, Rhythm:
nsr, O2Sat: 100, O2Flow: ra.
On arrival to the floor, the patient denies any complaints other
than allergy symptoms.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, sore throat, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria. Radiology showed 1. Mildly echogenic liver, consistent with hepatic steatosis. However, other
forms of liver disease cannot be excluded on this study. No focal liver
lesions.
2. Patent hepatic and portal veins. Patent main hepatic artery.
3. No ascites. Radiology showed No acute pulmonary process identified. The patient was diagnosed with POIS-AROM ANALGESICS NEC, POIS-BENZODIAZEPINE TRAN, POIS-ANTICONVUL NEC/NOS, TOXIC EFF ETHYL ALCOHOL, DRUG HALLUCINOSIS, SUICIDE-ANALGESICS, SUICIDE-PSYCHOTROPIC AGT, SUICIDE-DRUG/MEDICIN NEC, SUICIDE-SOLID/LIQUID NEC. At the time of discharge, the patient had PRIMARY:
Tylenol overdose with liver failure
depression. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o F with PMHx significant for depression with prior SA
(with various pills), who was admitted with Tylenol overdose.
.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/COPD, HTN p/w acute mesenteric ischemia. Patient had acute
onset of abdominal pain at 4pm yesterday. Has had one episode of
non-bloody emesis since then. Not tolerating PO. Pain is ___
and has remained unchanged since onset. Also endorses one
episode of nonbloody diarrhea in the AM prior to onset of pain.
No chest pain or SOB. No fevers/chills. No history of chronic
mesenteric ischemia symptoms such as food fear or pain
surrounding PO intake or weight loss. CTA A/P showed complete
occlusion of the proximal segment of the SMA approximately 3.5cm
as well as a more distal segment of the SMA approximately 6cm
with minimal reconstitution of flow in between likely secondary
to collaterals. No gross evidence of bowel ischemia was
visualized. She has no history of afib and EKG in the ED showed
normal sinus rhythm with some PACs/PVCs. Chest radiograph showed Grossly unchanged mild pulmonary edema and small pleural effusions. Radiology showed Endotracheal tube, feeding tube, and right IJ central line are unchanged in
position. There is prominence of the cardiac silhouette. There are unchanged
small bilateral effusions and a left retrocardiac opacity. There is mild
pulmonary edema. There are no pneumothoraces. Radiology showed No unexpected radiopaque foreign body identified.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 9:04 am, 1 minute after discovery of the
findings. Chest radiograph showed Compared to the examination from 2 days prior, the small bilateral pleural
effusions have slightly decreased. Endotracheal tube terminates 5 cm cranial
to the carina, satisfactory. Upper enteric tube tip is in at least the mid
gastric body, outside of field-of-view. Right internal jugular approach
central venous catheter terminates in the low SVC, satisfactory.
Cardiomediastinal silhouette appears more narrow than on prior study. There
is no edema. Lungs are otherwise clear. There is no new consolidation. Portable chest radiograph showed Increased pulmonary vascular congestion compared to prior study. Persistent
small bilateral pleural effusions. Radiology showed The ET tube, NG tube and right IJ line are unchanged in position. Lungs are
low volume. Small loculated right pleural effusion is stable. Trace left
pleural effusions also unchanged. Cardiomediastinal silhouette is stable.
There is stable subsegmental atelectasis in the right middle lobe. No
pneumothorax is seen. Chest AP view showed Lungs are low volume with bibasilar atelectasis. Small bilateral effusions
left greater than right are unchanged. Support lines and tubes unchanged in
position. No pneumothorax is seen. Cardiomediastinal silhouette is stable. Radiology showed Lungs are low volume with bibasilar atelectasis. Small bilateral pleural
effusions are unchanged. Cardiomediastinal silhouette is stable. No
pneumothorax is seen. No new consolidations. Radiology showed The tip of the enteric tube is in the mid to distal stomach. CHEST (PORTABLE AP) showed In comparison with study of ___, the new Dobhoff tube extends at least
to the junction of the body and antrum of the stomach, were crosses the lower
margin of the image. No evidence of pneumothorax. Little overall change in
the appearance of the heart and lungs. Radiology showed ET tube terminates approximately 4.5 cm from the carina. Enteric tube is seen
descending of the inferior aspect of the film. Small moderate-sized left
pleural effusion. Small right pleural effusion. Vascular congestion. Aortic
calcifications. Degenerative changes of the left shoulder. No pneumothorax. Radiology showed The tip of a new right internal jugular central venous catheter projects over
the cavoatrial junction. No pneumothorax. CTA ABD/PEL WANDW/O C W/REONS showed 1. Status post placement of a superior mesenteric artery stent, which appears
patent. However, distally the superior mesenteric artery is thrombosed in the
same location described on prior CT from ___. New today, this
portion of thrombosed vessel appears somewhat more distended with thrombus,
and note is made of new surrounding fat stranding.
2. A focus of gas adjacent to the thrombosed portion of the superior
mesenteric artery is presumed related to recent instrumentation (11:60).
3. Status post partial resection of the small bowel. Remaining loops of small
bowel demonstrate normal caliber and enhancement.
4. Open postsurgical anterior abdominal wall defect.
5. Small bilateral pleural effusions with adjacent atelectasis.
6. Extensive sigmoid diverticulosis.
NOTIFICATION: Wet read findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5pm, 60 minutes after discovery
of the findings. CHEST (PORTABLE AP) showed Compared to a chest radiographs ___.
Mild pulmonary edema is new accompanied by increasing small pleural effusions.
Cardiac silhouette is obscured, but moderate cardiomegaly has increased
slightly since ___. No pneumothorax.
Cardiopulmonary devices in standard placements. The patient was diagnosed with Acute infarction of intestine, part and extent unspecified. The patient was treated with ___:
1. Exploratory laparotomy and evaluation of small and large
bowel.
2. Patch angioplasty and exploration of the superior mesenteric
artery, closure of the ___ arteriotomy with a bovine pericardial
patch.
3. Stenting of the superior mesenteric artery origin with a 6 mm
x 15 mm Gore Viabahn VBX stent.
4. Placement of ABThera temporary abdominal closure device.
5. Visceral angiogram
___:
Resection of the small intestine with the intestine left in
discontinuity.
___:
1. Ultrasound-guided access to the right common femoral artery.
2. Selective catheterization of the superior mesenteric artery
with selective superior mesenteric artery angiogram.
3. Reexploration of superior mesenteric artery patch with
fenestration and tacking of dissection flap.
4. Placement of a 7 x 60 mm Innova stent in the proximal SMA,
post dilated with a 6 mm balloon.
5. Embolectomy of distal superior mesenteric artery.
___:
1. Exploratory laparotomy with abdominal washout.
2. Jejunal resection.
3. Application of open abdominal dressing with ABThera VAC.
___:
1. Exploratory laparotomy with abdominal washout.
2. ___ patch and negative pressure dressing.
___:
1. ___ Patch.
2. Jejunoileal anastomosis.
3. Abdominal wall debridement, skin, fat, fascia.
4. Secondary closure of the abdominal wall and placement of an
incisional VAC sponge 3 x 25 cm.. At the time of discharge, the patient had acute on chronic mesenteric ischemia
malnutrition
delirium. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ arrived to the hospital on ___ after an episode
of acute onset abdominal pain ___. CTA A/P demonstrated
complete occlusion of proximal segment of SMA 3.___s
a more distal segment of SMA of 6 cm w minimal reconstitution of
flow in between likely secondary to collaterals. No gross
evidence of bowel ischemia visualized. Diagnosis of acute
mesenteric ischemia was made. She underwent exploratory
laparotomy and had 15 cm of necrotic jejunum resected. She was
left in discontinuity with an abthera vac placed on the open
abdomen. She was taken back ___ POD#1 and POD#3 from initial
operation for washout, but was unable to be closed. She was
diuresed and taken back on POD#5 but was still unable to be
closed secondary to edema. Diuresis was continued, and she was
transfused with RBCs as needed for low hematocrit. On ___
she was primarily reconnected and her abdomen was closed. She
was extubated but reintubated for failure to clear secretions.
She was extubated a second time on ___ and remained
extubated for the duration of her stay. She had multiple guaiac
positive stools, thus her anticoagulation was discontinued and
will remain off per attending vascular surgeon Dr. ___. A
dobhoff tube was placed for nutrition. She was discharged to
rehab with dobhoff tube in place. Please see below for her
course by system.
Neuro: The patient was sedated while intubation but off sedation
when extubated; pain was initially managed with IV dilaudid and
then transitioned to oral medications once tolerating a diet and
cleared by speech and swallow.
CV: The patient's vital signs were routinely monitored, and she
was treated with blood transfusions and pressors as needed to
keep her hemodynamically stable.
Pulmonary: The patient remained stable from a pulmonary
standpoint; when intubated her vent settings were monitored and
when originally extubated she was closely monitored. When it was
noted that she was failing to clear secretions she was
re-intubated. There were no signs of aspiration. Once
extubated the second time her respiratory status remained
stable. Good pulmonary toilet and incentive spirometry were
encouraged throughout hospitalization when extubated.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On ___, the
NGT was removed, and a speech and swallow eval recommended
puree'd diet with thickened liquids. Due to poor oral intake, a
dobhoff feeding tube was placed. Patient's intake and output
were closely monitored. The dobhoff was pulled by the patient on
___ and not replaced. PO intake has gotten better but still
well below the appropriate.
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, and she was transfused with packed RBCs as needed.
Due to multiple guaiac positive stools, her anticoagulation was
discontinued.
The patient was discharged to a rehab facility that accepts
patients with dobhoff feeding tubes on ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male presents to the emergency room with
intermittent abdominal pain
which is been getting worse. He was having these
pains pre-operatively prior to surgery for bowel obstruction
here around ___ time. He is continued to have
episodes of the pain postoperatively. At triage, he was
noted to have an EKG showing ST segment elevation so was
triggered back rapidly. He has no cardiopulmonary symptoms
whatsoever. Looking through his old EKGs, there are several
EKGs that are similar to the current EKG and he was
diagnosed recently as having silent MI according to him. He
also had an echo that showed possible apical aneurysm.
No fevers or chills. He has had one episode of vomiting
today. No urinary tract symptoms. MR ___ showed 1. Persistent mechanical small-bowel obstruction, with transition point at
focal 4.2 cm segment of strictured small bowel with mild edema and mucosal
hyperenhancement. Stricture cause most likely ischemic, with alternative
differential being inflammation.
2. Stable saccular infrarenal abdominal aortic aneurysm. BILAT LOWER EXT VEINS showed No evidence of acutedeep venous thrombosis in the right or leftlower extremity
veins. ABDOMEN (SUPINE AND ERECT) showed 1. Dense material in the ascending colon may represent administered contrast
contrast.
2. No evidence of bowel obstruction.
3. A small amount of free air under the left hemidiaphragm, likely related to
recent surgery. The patient was diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst. The patient was treated with ___ exploratory laparotomy, SBR x 2. At the time of discharge, the patient had small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male admitted to the hospital with abdominal pain.
Upon admission the patient was made NPO, given intravenous
fluids, and underwent a cat scan which showed dilated proximal
small bowel loops with air-fluid levels, compatible with a
small bowel obstruction. This finding showed progression of the
bowel obstruction from the prior imaging. Based on these
findings, the patient was placed on bowel rest. He was placed on
a heparin drip because of his history of LV thrombus.
Coagulation studies were monitored and adjustments in the rate
were made according to protocol. After return of bowel function,
the patient resumed clear liquids and slowly advanced to a
regular diet. He again experienced a recurrence of abdominal
pain and was made NPO. He underwent an MRE which showed a
persistent mechanical small-bowel obstruction. Based on these
findings, the decision was made to take the patient to the
operating room. He underwent cardiac clearance and was taken to
the operating room on HD #7 where he underwent an exploratory
laparotomy, extensive lysis of adhesions, and jejunal resection
x 2. His operative course was stable with a 75cc blood loss.
The patient was extubated after the procedure and monitored in
the recovery room.
The patient did well in the PACU. He was alert and oriented x3.
His pain was well controlled and his urine output was
appropriate. After a brief stay in the PACU he was safely
transferred to the floor where his vital signs remained stable.
On ___, pod 1, a heparin drip was restarted which was
subsequently kept at a therapeutic range by trending ptt's every
6 hours. His wbc was slightly elevated which was attributed to
the normal stress incurred during the procedure. His Cr was 1.5
which was attributed to him being slightly volume down. He
received appropriate Iv fluids and his Cr trending down to his
baseline level. He received metoprolol IV while we were awaiting
return of bowel function. The patients pain remained well
controlled and he was able to ambulate early and often after
surgery. The patient started on a clear liquid diet on ___
as he was passing flatus. The patient reported some difficulty
tolerating the full liquid diet at first but had no episodes of
nausea, vomiting, or change in physical exam of his abdomen.
Some erythema around his wound was noted on ___ and some
staples were removed to express any fluid that had accumulated
in his wound. The wound was probed and cultures were sent. On
the following day, more staples were removed and the track was
further probed to express any remaining fluid. The wound was
packed with a wet to dry gauze dressing that was changed twice a
day. At this point, the patient was starting to tolerate a full
liquid diet better. On ___, the patient was transitioned to
po pain meds, which enabled us to discontinue the heparin drip
and start his home dose of apixaban. Further, he was
transitioned to a regular diet and put on a bowel regimen. He
tolerated this transition well. On ___, a wound vac was
placed in his surgical midline wound to aid in healing. His
wound healed nicely and the wound vac was discontinued on
___ and he was transitioned back to bid dressing changes
prior to his discharge to his rehab facility. At the end of his
hospital course, the patients vital signs were stable, he is
ambulatory independently, his pain is well controlled, he was
tolerating a regular diet, and his surgical site is healing
appropriately. He was provided with the appropriate discharge
instructions and an appointment for follow up. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old man with T1DM complicated by ESRD s/p
DDRT in ___, neuropathy, gastroparesis, HFmrEF, A fib, HTN,
hypothyroidism, cirrhosis (likely EtOH +/- HBV) who presented
with nausea and dark emesis. RENAL TRANSPLANT U.S. showed 1. Stable minimally elevated resistive indices of the superior right kidney
transplant, similar to prior exam.
2. Persistent increase in peak systolic velocity of the left main renal artery
of the inferior right kidney transplant measuring up to 223
centimeters/second, previously 300 centimeters/second.
3. Persistent minimally elevated resistive indices of the inferior renal
transplant, similar to prior exam.
4. Moderate bladder debris compared to prior exam. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Main portal vein is patent.
2. Coarsened hepatic parenchyma, similar to prior exam. Chest radiograph showed No radiographic evidence to suggest pneumomediastinum. Otherwise no acute
intrathoracic process. Radiology showed Nonspecific bowel gas pattern. If there is high concern for bowel
obstruction, recommend CT with intravenous and/or oral contrast for further
assessment. The patient was diagnosed with Nausea with vomiting, unspecified. At the time of discharge, the patient had Primary: Hematemesis, abdominal pain, nausea, urinary retention,
type I diabetes, ESRD s/ DDRT ___
Secondary: Atrial fibrillation, cirrhosis, hepatitis B, EtOH
use, HFmrEF, hypercalcemia, hypertension, thrombocytopenia,
hypothyroidism, hyperlipidemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year-old man with T1DM complicated by ESRD s/p
DDRT in ___, neuropathy, gastroparesis, HFrEF borderline, a
fib, HTN, hypothyroidism, cirrhosis (likely EtOH +/- HBV) who
presented for evaluation of nausea and dark emesis, with ongoing
nausea/abdominal pain but stable hemoglobin and hemodynamics
without any observed hematemesis since presentation, discharged
with plan for GI follow up.
# Vomiting, possible hematemesis
Patient reported dark/red emesis about an hour after drinking
___ glasses of red wine 4 days ago along with nausea and
abdominal pain. He reported that he had stopped drinking for
several weeks prior to that. It is unclear if this was truly
hematemesis, given that the dark emesis may have been the red
wine in the setting of gastroparesis. We also considered ___
___ tear vs. gastritis from ETOH use. He was hemodynamically
stable with stable Hgb since ED presentation on ___, with a
negative stool guiac. He was initially started on ceftriaxone,
octreotide, and IV PPI BID. Octreotide was stopped in the ED per
GI. He was admitted due to not being able to tolerate PO. On the
floor his blood counts remained stable so EGD was deferred. He
was able to tolerate a normal diet so we discharged him to home
with his home resources restarted. His home apixaban, BP meds,
diuretic, and beta blocker were held due to concern for
bleeding, but were resumed on discharge. He was prescribed PO
cipro for 4 days to complete a 7 day abx course for infection
prophylaxis in a cirrhotic patient. He will require a follow up
with the hepatology department to possibly pursue outpatient
endoscopy.
# ABDOMINAL PAIN
# NAUSEA
# INABILITY TO TOLERATE PO
The patient presented with nausea/emesis as above, likely
secondary to gastroparesis and gastritis secondary to EtOH. KUB
showed a non-specific bowel gas pattern, but the patient had a
non-bloody, non-melenic BM on day of presentation so there was
low suspicion for obstruction. Lactate was not significantly
elevated and lipase was normal. RUQUS was unremarkable without
ascites or biliary obstruction. There was a mild elevation in
Tbili to 2.2 but no transaminitis or elevated INR to suggest
alcoholic hepatitis. UA was without evidence of infection. He
was given Compazine prn and his diet was advanced to a full DM
diet before discharge.
# TYPE I DIABETES:
Patient has significant microvascular complications. There was
no evidence of DKA during the admission. He was noted to have
large glucose and some ketones on UA, but he had identical UA on
admission in ___ when he had very similar presentation. He
was continued on his home diabetes regimen.
# URINARY RETENTION
Patient had urinary retention in the ED, initially requiring
foley for 849cc of urine. The etiology is unclear, and it seems
this has been a problem on prior admissions as well. The foley
was pulled in the ED, with pre-void bladder scan of 300cc and
post-void with 100cc. On the floor, patient was able to urinate
without issue throughout the hospitalization.
# ESRD ___ TYPE I DIABETES, s/p DDRT ___:
Cr at baseline on admission. He was continued on mycophenolate
mofetil 500mg BID and tacro 1 mg BID. Tacro level was 16. Per
renal transplant, the level is inaccurately high due to timing
of the trough <12 hrs after last dose. They recommended
rechecking the tacro level as an outpatient within the next
week.
CHRONIC PROBLEMS:
=========================
# ATRIAL FIBRILLATION:
Held apixaban due to c/f GI bleed. Restarted on discharge.
# CIRRHOSIS:
# HEPATITIS B: Patient has Child's class A cirrhosis, cirrhosis
likely ___ HBV + EtOH. No signs of decompensation during this
hospitalization and probability of variceal bleeding is very
low. Held home diuretics overnight given question of GIB and dry
appearing on exam, but was continued on discharge. We also
continued lamivudine for HBV.
# EtOH USE: Reports 3 glasses of red wine on Father's Day.
Otherwise, last drink was several weeks ago prior to last
admission in ___. No evidence of withdrawal during admission.
# HFmrEF: Last LVEF in ___ 40-45%. Restarted diuretics on
discharge.
#HTN: Anti-hypertensives were initially held in setting of
concern for GIB but restarted on discharge.
#THROMBOCYTOPENIA: Chronic, stable. Likely due to cirrhosis,
MMF.
#HYPOTHYROIDISM: Continued levothyroxine 25mcg daily
#HLD: Continued atorvastatin 40mg qHS</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with history of diabetes, wheelchair dependent
as a result of alcohol-induced cerebellar ataxia, presenting
with
increasing weakness and frailty. Son states that he has been
increasingly weak for the last 3 days. Today fell to the floor.
No LOC, no head strike and was just sitting. Also complaining of
chest back pain. Patient denies any dysuria, abdominal pain, or
diarrhea. He has lost 17 lbs in the past month. They were told
it
may be from a UTI. Came to emergency department for evaluation. CT HEAD W/O CONTRAST Q111 CT HEAD showed No fracture or acute intracranial process. CT torso without contrast showed 1. Mildly displaced fractures of the left posterior seventh and eighth ribs,
with a small adjacent left pleural effusion. No pneumothorax.
2. New 7.5 cm soft tissue mass in the body and tail of the pancreas, with
innumerable hepatic lesions, concerning for metastatic disease.
3. A 5 mm perifissural nodule in the right lung may be new compared with
prior, possibly representing an intrapulmonary lymph node, however metastatic
disease cannot be excluded. Additional tiny pulmonary nodules bilaterally do
not appear significantly changed. Chest: Frontal and lateral views showed 1. Small left pleural effusion.
2. Left posterior rib fractures are better evaluated on CT performed on same
day. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Innumerable hepatic lesions, concerning for metastatic disease.
2. No biliary duct dilatation. CT C-SPINE W/O CONTRAST showed Degenerative disease.
No evidence of fracture CHEST (PORTABLE AP) showed Comparison to ___. The lung volumes have decreased. Borderline
size of the cardiac silhouette. Mild elongation of the descending aorta.
Minimal atelectasis at the right lung basis. No evidence of pneumonia,
pulmonary edema or pleural effusions. MRCP showed 1. Mass within the pancreatic body/tail suspicious for primary pancreatic
adenocarcinoma.
2. Innumerable hepatic metastases with obstruction of the left lateral
segmental intrahepatic biliary tree. No specific findings of cholangitis.
3. Occluded or severely attenuated left portal vein with multiple left upper
quadrant collateral vessels.
4. Multiple subcentimeter pancreatic cystic lesions are likely small side
branch IPMNs. ULTRASOUND GUIDED CORE NEEDLE BIOPSY showed Uncomplicated 18-gauge targeted liver biopsy x 2, with specimen sent to
pathology in formalin. No immediate complications. CTA chest with CT abdomen and pelvis with contrast showed 1. Subsegmental nonocclusive pulmonary embolism in bilateral lung bases and
possibly right upper lobe. No imaging evidence of right heart strain.
2. Evaluation of the veins is limited due to timing of contrast however
expanded appearance of the left common femoral vein is concerning for deep
vein thrombosis. A hypodensity in the right common femoral vein is equivocal
for thrombosis.
3. Large hypodense mass in the body/tail of the pancreas resulting in
attenuation of the splenic artery and occlusion of the splenic vein.
4. Innumerable hepatic metastases.
5. Small volume ascites.
6. Mildly displaced left-sided rib fractures, unchanged from prior.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:28 pm, 5 minutes after
discovery of the findings. US lower extremity for DVT showed Acute DVT in the right popliteal and tibial veins.
Extensive acute left leg DVT involving the deep femoral and femoral veins as
well as the popliteal, posterior tibial, and peroneal veins. The left GSV
remains patent and fills the CFV. Radiology showed Lungs are low volume with bibasilar atelectasis. Cardiomediastinal silhouette
is stable. There is a small right pleural effusion. No pneumothorax is seen MR HEAD W AND W/O CONTRAST ___ MR HEAD showed 1. No acute intracranial abnormality. No metastases.
2. Diffuse atrophy of the cerebellum and brainstem raise suspicion for
olivopontocerebellar cerebellar degeneration. Some of the findings can be
seen in the setting of long-standing paraneoplastic syndrome, clinically
correlate.
3. Minimal white matter chronic small vessel ischemic disease. The patient was diagnosed with Weakness. The patient was treated with Liver biopsy ___. At the time of discharge, the patient had Primary: Metastatic pancreatic adenocarcinoma
Secondary: Cholangitis, intrahepatic biliary duct obstruction,
pulmonary embolism, deep 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>ASSESSMENT AND PLAN: ___ yo M with T2DM not on insulin,
presenting with progressive weakness and weight loss, with new
diagnosis of pancreatic adenocarcinoma now with cholangitis that
cannot be intervened upon. Patient transitioned to CMO and
discharged home on hospice.
#Goals of care
Patient with metastatic pancreatic adenocarcinoma, there are no
options for treatment. Patient transitioned to CMO and will be
discharged home on hospice.
#Metastatic pancreatic adenocarcinoma
#Elevated transaminases
#Weight loss
S/p biopsy of metastatic site (liver) with pathology consistent
with adenocarcinoma. CEA and Ca ___ markedly elevated. Heme/onc
consulted, patient not a candidate for chemotherapy in setting
of cholangitis.
#Sepsis secondary to cholangitis
#L intrahepatic duct compression
Patient with fever to 102, leukocytosis, tachycardia and rising
bilirubin. Fevers may be secondary to multiple thrombi, tumor
fever or L intrahepatic duct compression ___ to tumor burden.
Not a candidate for ERCP given location of intrahepatic duct
compression. Initially on Ceftriaxone/Flagyl (___),
antibiotics broadened given sepsis to Vanc/Flagyl/Cefepime
(___). ___ unable to offer drainage of intrahepatic duct
given concern for seeding bacteria into additional ducts and
poor functional reserve of liver. Will discharge with
Cipro/Flagyl for ___an be discontinued at any time
if they are causing patient discomfort.
#Multiple subsegmental PEs
#Tachycardia
Patient with CTA chest on ___ with multiple subsegmental PEs,
splenic vein thrombus and L femoral vein thrombus. Likely
etiology of tachycardia. Trop <.01 and BNP 365,TTE with no e/o
RH strain. Anticoagulation with heparin gtt, transitioned to
lovenox BID. Discontinued prior to discharge.
#Occluded or severely attenuated left portal vein
Patient with occlusion of L portal vein on MRCP with multiple
left upper quadrant collateral vessels. Discussed with radiology
likely secondary to tumor burden not thrombus given no e/o vein
expansion or hypoattenuation.
#Rib fractures: Pain on the left side, with extensive bruising.
Reduced inspiratory capacity. Pain well controlled with Tylenol,
Ibuprofen, Lidocaine patch, Morphine Sulfate Liquid 5mg Q6prn.
#Hypercalcemia: Could be related to malignancy, or dehydration.
PTH is low so unlikely to be primary hyperparathyroidism. PTHrP
within normal limits. 25 Vit D is 22. S/p pamidronate on ___.
#Wt loss
#Aspiration risk
Patient disinterested in eating. Evaluated by speech and
swallow, patient at risk for aspiration, recommended NPO.
Discussed with family, it is within patient's GOC to continue
eating with accepted aspiration risk.
#Elevated INR:
#Anemia and thrombocytopenia
Likely secondary to malignancy/dilution. Likely liver
dysfunction in setting of extensive mets. S/p Vit K x 3 days
with no improvement.
#DM:
Initiated on Lantus 10u QHS. Discontinued at time of discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of congestive heart failure, peripheral artery
disease, atrial fibrillation, hypertension and hyperlipidemia
who is presenting with epigastric pain the evening of admission
that woke her from sleep. The patient reports that she was
napping in the earlier evening when she experienced some sharp
pain across her epigastrium that woke her from sleep. The pain
continued until she was ___ to the Emergency Department; the
pain has since resolved. She denies any diaphoresis, nausea,
vomiting, diarrhea, constipation, heartburn, or dark stools. She
denies any previous pathology of liver, gallbladder, or
pancreas. She had a hysterectomy ___ years ago, but no other
abdominal surgeries.
.
In the ED, initial VS: T97.6| HR 76| BP 124/50| RR 20 | 99% 2L
Nasal Cannula. Patient was without abdominal pain by the time
she was evaluated in the ED. No medical interventions were
provided in the ED. CXR showed no acute process. Laboratory data
showed a normal UA, metabolic panel with Cr of 1.2 (baseline
around 1.1), BUN of 32 (baseline), and the rest WNL. CBC was at
baseline values with WBC of 5.4 and baseline anemia with HCT of
28.1. Lactate was 1.1. Lipase was 102, AP was 127, LDH of 266,
and rest of her LFTs WNL. CE's showed Troponin of 0.06 (baseline
of 0.03) with normal CK-MB values.
Vitals prior to transfer were T97.4| HR 81| BP 144/53| RR 17
100% on RA. Radiology showed 1. Gallbladder sludge.
2. Mildly prominent main pancreatic duct. The patient was diagnosed with CHEST PAIN NOS. At the time of discharge, the patient had Primary Diagnosis:
Atypical Chest and Abdominal Pain
Secondary Diagnosis:
CKD
CAD
___
PAD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Primary Reason for Admission: ___ year old woman with systolic
CHF (EF 40-45% ___, h/o previous pulmonary embolus, PVD,
hypertension, hyperlipidemia presents with self limited
abdominal pain admitted to ___ for sets and a stress test.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMHx of T1DM, ESRD ___ diabetic nephropathy s/p DDRT
(___)
w/ PAK (___) c/b acute pancreas rejection (___), CAD (s/p CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. No evidence of acute infarction, edema, or midline shift. Please note,
contrast enhanced MRI is recommended to exclude underlying infectious process
or PTLD.
2. Stable scattered foci of microhemorrhage, likely a sequela of hypertension
or amyloid angiopathy, with stable bifrontal chronic hemorrhage with
surrounding gliosis, possibly related to prior lobar hemorrhage.
3. Parenchymal volume loss particularly involving the frontal and parietal
lobes, which may be related to frontoparietal dementia in the appropriate
clinical setting.
4. Nonspecific right mastoid air cell opacification unchanged from the prior
study. RENAL TRANSPLANT U.S. showed Persistently mild elevated resistive indices. Otherwise, unremarkable renal
transplant ultrasound. The patient was diagnosed with Diarrhea, unspecified, Dehydration. At the time of discharge, the patient had PRIMARY: UTI, C. difficile colitis, syncope
SECONDARY: diabetic nephropathy complicated by ESRD status post
renal transplant. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY
Ms. ___ is a ___ lady with a PMH notable for type 1
diabetes, ESRD status post DDDRT (___) and PAKT (___)
complicated by acute pancreas rejection (___), CAD s/p CABG
and PCI to RCA, seizure disorder, and hypertension, who
presented with 2 days of watery diarrhea and 3 episodes of
syncope. The etiology of her syncope was thought to be due to
dehydration from diarrhea. She had an unremarkable TTE, which
showed normal EF (53%) with regional wall motion abnormality in
the RCA territory, no significant change from prior. She was
found to have C. difficile colitis which improved with
vancomycin p.o. The patient's CellCept was switched to Myfortic
360 mg p.o. twice daily to help improve diarrhea. She was also
found to have a UTI due to pansensitive Pseudomonas, for which
she was initially treated with meropenem and subsequently
ciprofloxacin for 7 days total, last day ___.
TRANSITIONAL ISSUES
[ ] UTI: complete ciprofloxacin 500 mg BID for 7 day course,
initially treated with meropenem, last day ___.
[ ] C. Difficile Colitis: complete vancomycin 125 mg PO Q6H 2
weeks after stopping ciprofloxacin, last doses ___.
[ ] Follow Up: Transplant ID will arrange follow up with them in
clinic.
[ ] Medication Changes: Switched Cellcept to Myfortic 360 mg PO
BID.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o IVDU p/w R shoulder pain and swelling X 2 months. He
describes spontaneous swelling of his right anterior chest
beginning about 2 months ago. The area is red, warm and
swelling waxes and wanes. The area is tender and the pain
radiates over his anterior chest. He also complains of pain
with right arm movement. He denies fevers, chills,
palpitations, SOB, pleuritic
CP, dysphagia, odynophagia. CHEST (PORTABLE AP) showed CHF. CHEST PORT. LINE PLACEMENT showed IN COMPARISON WITH THE STUDY ___, THE PULMONARY VASCULAR CONGESTION HAS
CLEARED. LEFT SUBCLAVIAN LINE EXTENDS TO THE MID PORTION OF THE SVC. The patient was diagnosed with LOCAL SUPRFICIAL SWELLNG. The patient was treated with ___
Right sternoclavicular joint debridement.
___
Left SL Power PICC. At the time of discharge, the patient had Right sternoclavicular osteomylitis
Opiate 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>Mr. ___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for further
managemnent of his right sternoclavicular osteo. He was hydrated
with IV fluids and also evaluated by the Infectious Disease
service for appropriate antibiotic coverage. Vancomycin was
initiated on ___ after blood cultures from OSH grew GPC in
clusters whih eventually MSSA.
He was taken to the Operating Room on ___ where he
underwent resection of the right sternoclavicular joint. The
wound was eventually VAC'd and began to clean up well. The
tissue cultures were + MSSA. He eventually had a left SL power
PICC line placed on ___ for ___ weeks of antibiotic therapy
with Vancomycin. That was the preferred drug as he developed
neutropenia and a rash after treatment with Ceftriaxone during
his earlier admission. He had a cardiac echo which ruled out any
valvular vegetations.
His Vancomycin dose was adjusted on multiple occasions and his
trough was 19.7 which reflrcted 1500 mg Q 8 hrs. The ID service
recommended decreasing the dose to 1250 mg Q 8 hrs. A trough was
done on ___ AM which was 19.6 with a goal of ___.
The final ID plan is for ___ week course of iv vancomycin 1250mg
q8.
Start date: ___
End date: ___ vs ___
Pt should have cbc+diff, basic, lfts, esr, crp and vanc levels
weekly.
Access: 44cm left SL power picc placed ___.
ID follow up during admission to the ___.
On discharge from the ___, he should have ___ clinic follow
up with ___ on ___ at 3pm to discuss
treatment options for Hepatitis C.
He also had some problems with opiate withdrawal on admission,
eventually becoming tachycardic and having muscle cramps as well
as GI upset. He was placed on ___ protocol and his daily
Methadone dose was increased to 20 mg QD. He was given oral
Dilaudid on a prn basis and his symptoms resolved.
The Plastic surgeons feel that the wound needs to improve prior
to surgery and for that reason he was transferred to rehab on
___ where he can get his antibiotics and continue with VAC
dressing changes. He will follow up in the Plastic Surgery
Clinic on ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Radiology showed Acute left femoral neck fracture with impaction. Radiology showed No acute cardiopulmonary process. L-SPINE (AP AND LAT) showed Degenerative changes, wedge compression deformity of T12. The patient was diagnosed with FX NECK OF FEMUR NOS-CL, OTHER FALL. The patient was treated with left hip hemiarthroplasty on ___ by Dr. ___. At the time of discharge, the patient had Left femoral neck 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 femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left hip hemiarthroplasty 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
WBAT LLE, and will be discharged on lovenox x2 weeks for DVT
prophylaxis. The patient will follow up in two weeks with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a pleasant ___ (real birthday is ___ so his
real age is ___) w/ T2DM w/ high risk MDS now found to have AML. Chest radiograph showed 1. Linear opacity overlying the right lower lobe likely represents
subsegmental atelectasis.
2. Port-A-Cath terminates overlying the superior cavoatrial junction Radiology showed 1. No acute abdominopelvic process. No CT findings correlating to the
reported history of neutropenic fever.
2. 2.1 x 1.2 cm left posterior pelvic sidewall soft tissue nodule is
nonspecific, and could represent an enlarged left internal iliac lymph node
versus a neurogenic tumor such as a schwannoma. This is unchanged since ___. Please correlate with any older outside hospital studies if
available.
3. Please refer to the separate chest CT dictation regarding intrathoracic
findings. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST showed Essentially clear sinuses without significant mucosal thickening or air-fluid
levels. No soft tissue abnormality. CT CHEST W/O CONTRAST showed 1. A new 1.1 x 0.9 x 1.1 cm spiculated, solid mass in the right upper lobe
which is suspicious for opportunistic infection or a possible primary cancer.
2. Moderate atherosclerotic calcification of coronary arteries and
intrathoracic aorta, with mild calcification of the aortic valve.
NOTIFICATION: The findings were discussed with ___, P.A. by
___, M.D. on the telephone on ___ at 3:59 pm, 20 minutes
after discovery of the findings. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Sludge in nondistended gallbladder. Wall edema is likely related to
underlying liver disease or third spacing.
2. No intrahepatic or extrahepatic biliary dilatation. CT CHEST W/O CONTRAST showed 1. Multifocal areas of consolidation throughout the lungs some of which are
cavitated new compared to prior exam concerning for opportunistic infection in
an immunocompromised patient with leading differential considerations
including Nocardia and fungal infection. No significant change in previously
described right upper lobe lesion likely representing a focus of atypical
infection.
2. New trace bilateral pleural effusions. Slightly larger small pericardial
effusion.
3. Multiple sub 3 mm pulmonary nodules as above.
NOTIFICATION: The findings were discussed with ___, P.A. by
___, M.D. on the telephone on ___ at 3:49 pm, 10 minutes
after discovery of the findings. The patient was diagnosed with Other neutropenia, Fever presenting with conditions classified elsewhere, Acute myeloblastic leukemia, not having achieved remission. The patient was treated with broncoscopy ___. At the time of discharge, the patient had AML
FN
plt transfusion reaction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with FLT3+ AML
most recently s/p cycle ___ MiDAC consolidation, presenting
originally with FN now extended stay to work up lung findings on
CT chest.
#pulmonary nodules: originally noted for RUL mass on ___ with
persistent FN work up, never had signs/symptoms of respiratory
distress or symptoms including no hypoxia cough. question
malignancy vs opportunistic infection, initiated treatment dose
antifungal with posaconazole and significant improvement in
fever
trend. repeat CT chest to evaluate mass on ___ noted
persistent
mass of similar size with new disseminated nodules scattered
throughout with some cavitation. reconsulted ID for
recommendations.
-r/o TB with 3 sputum cultures--smear neg, quant gold neg
-send AFB b culture NTD
-resent fungal markers
-f/u toxo studies
-underwent bronch on ___ and tolerated well
-GPC growing on bronch, will treat with cefpodoxime x14d per ID
(___) and f/u with sensitivities outpatient
-patient remains clinically stable with count recovery and no
signs/symptoms of infection, plan to d/c home after bronch if
remains this way and will f/u with results outpatient, ID
scheduled outpatient as well. plan to continue posaconazole for
extended period of time per ID recs.
#Febrile Neutropenia: Neutropenia resolved. afebrile >1 week.
Most likely source of fever was mucositis/esophagitis and
questionably lung opportunistic infection as above. peeled off
___ with count recovery and symptomatic improvement,
remains on antifungal coverage per ID.
#Thrombocytopenia: resolved. Due to chemotherapy. He requires
HLA match platelets. He last received 1 unit of HLA matched
platelets on ___. He was on Promacta *NF* (eltrombopag)
100mg oral DAILY, held since ___ with count recovery, will
resume during nadir of next chemotherapy cycle.
#Anemia and Neutrapenia: Improving, likely secondary to recent
consolidation therapy. Showing signs of counts recovery with
evidence of monocytosis. He has no evidence of circulating
peripheral blasts. In regards to his anemia, he has not required
PRBCS since ___. Transfuse if hgb <7 and/or active bleeding
#AML FLT3+: s/p 7+3 midostaurin, in remission. Admitted for C1
MiDAC consolidation (day 6 - ___ s/p neulasta on ___.
-premedication with Tylenol/Benadryl for plts transfusion
#Hyperbilirubinemia: resolved, continue to monitor and trend
#Electrolyte Imbalances: Improved but ongoing hypophosphatemia,
now on BID repletion's adjust prn.
#Prior PICC associated upper extremity clots: Holding
anticoagulation given thrombocytopenia. Repeat upper extremity
ultrasounds on the right shows unchanged deep vein thrombosis in
the right basilic vein, unclear if need to continue anticoag
treatment or not, will discuss with primary attending when
counts
more robust and post bronch
#POC Hematoma: Improved. Evaluated by venous access, reconsulted
venous access to assess site
#GERD: On an oral PPI
#Iron Overload: Holding deferasirox during chemotherapy
#T2DM: holding metformin, low dose sliding scale
#FEN: IVF/Replete PRN/Regular low-bacteria diet
#ACCESS: Port
#PROPHYLAXIS:
-Pain: discontinued dilaudid
-Bowel: Colace/Senna as needed
-GI: Protonix PO since ___
-DVT: holding lovenox due to bronch
#CODE: Full code
#EMERGENCY CONTACT: ___ ___
#DISPO:home f/u ___ in clinic or sooner if issues arise,
pulm/ID f/u to be set outpatient </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with a past medical history
of hypertension and breast cancer s/p mastectomy, who presented
to the ED with elevated blood pressure and was found to be
hyponatremic. Radiology showed No acute process. The patient was diagnosed with Hypo-osmolality and hyponatremia, Essential (primary) hypertension, Cough. At the time of discharge, the patient had Primary:
Hyponatremia
Cough
Viral bronchitis
Hypertensive urgency
Secondary:
Chronic pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ female with a past medical history of
hypertension and breast cancer s/p mastectomy, who presented to
the ED with elevated blood pressure and was found to be
hyponatremic.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with COPD, HTN, HL presents with cough and dyspnea. She
reports that she had been sick for 3 days with fever to 100,
cough productive of yellow sputum. She reports that she feels
like this is how she feels when she has her COPD exaserbation.
Ussually she reports that she is able to use her albuterol and
not have to be admitted, but she did not have her albuterol
inhaler. She reports that she only uses her spiriva when she
feels sick. She reports that she felt dyspneic so went to see
her PCP who sent her to the ED given exam with decreased breath
sounds and oxygen levels of 85-88 percent. Radiology showed Hyperinflation with regions of consolidation in the right lung.
These are compatible with pneumonia in the proper clinical setting. Recommend
repeat after treatment to document resolution. The patient was diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, HYPERTENSION NOS. At the time of discharge, the patient had Primary: COPD exacerbation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Primary Admitting:
___ yo F with COPD, HTN, HL presented with cough and dyspnea and
was found to have a COPD exacerbation complicated by a potential
early PNA.</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 pmh significant for
hepatitis C and HIV (on HAART) infection with cirrhosis,
complicated be portal hypertension, diuretic refractory ascites,
and gastrointestinal varices in the esophagus (grade 1 in
___ and the rectum (large on sigmoidoscopy in ___, portal vein thrombosis on warfarin, and diabetes type
II complicated by neuropathy who presented to the ED from clinic
with chills, left lower quadrant pain, nausea/vomiting, and
weakness.
He has refractory ascites on high dose diuretics (160mg
furosemide and 200mg of spironolactone) requiring frequent
outpatient paracenteses, most recently ___ - 2L,
___ - 2.7L, ___ - 3.75L, ___ - 2.4L). He was seen in
an urgent visit by Dr. ___ on ___ wiht RUQ pain. At that
time he had a CT of the abdomen which was stable with regards to
his clot (main portal vein, splenic vein, and SMV) without any
new acute process. His ascitic fluid from ___ was negative
for SBP.
Since that time, pt reports having LLQ pain for past three days,
denies having and fever or chills. No diarrhea, reports last BM
yesterday. Reports that he hasnt felt pain like this before. No
nausea, vomiting. Pain is dull and non-radiating. No dysuria.
Reports that he has been taking OTC potassium for muscle cramps.
Reports that he is urinating.
In the ED, triage vitals were 97.8 71 113/66 20 100
RUQ US did not show evidence of clot, but some slowed
hepatorenal flow. Reportedly no tappable ascites seen. His
potassium was 8.1 on presentation with cr of 1.9 (baseline is
1.0). Pt reports taken potassium supplements recently. He was
given IV calcium gluconate, insulin, dextrose, sodium bicarb and
60 kayexelate and potassium initially improved to 7.9 and then
6.7 before transfer. Other labs notable for dirty UA with many
bacteria. INR was 1.8 on admission. No leukocytosis. tbili 4.5,
plt 125.
EKG showed peaked t-waves
Transfer vitals were 98.0 67 116/63 16 98%
On floor, pt is aox3, no asterixis, he reports mild pain.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria. Radiology showed Cirrhosis with massive splenomegaly. Patent portal vein with slow
flow. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, HYPERKALEMIA, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, ASYMPTOMATIC HIV INFECTION. At the time of discharge, the patient had Primary: Abdominal Pain, Hyperkalemia, Acute Kidney Injury
Secondary: Hepatitis C, HIV, Cirrhosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo male with a pmh of HIV and HCV cirrhosis complicated by
refractory ascites, esophageal (grade 1) and rectal varices, who
presented to clinic with positional abdominal pain and malaise.
# Hyperkalemia: Due to exogenous intake in setting of recently
starting spironolactone. On presentation to the ED he was
hyperkalemic to 8.1, with a creatinine of 1.8 from a normal
baseline. He had been having occasional leg cramps at home,
thought that he was low in potassium, so he took OTC potassium
supplements. He drinks a large glass of carrot juice in the
morning, and he was also recently switched to spironolactone. He
was treated with kayexalate, insulin and dextrose, bicarb, and
calcium gluconate. His EKG showed peaked t-waves and slightly
long QRS. His potassium and EKG improved with the above
measures. He was strongly advised against further potassium
supplements, educated on low potassium foods, and advised to
tell Dr. ___ time he is considering other OTC or
homeopathic medications.
***Please check electrolytes at/before next visit
# Position Abdominal pain: Labs and exam unrevealing for source.
He had an US in the ED of his abdomen that showed his known
portal vein thrombosis, but no other acute intra-abdominal
process. His pain is largely positional (sitting up or laying on
his side) and improves with movement. He has never had the pain
while active. IT was felt this was mostly peritoneal/MSK
stretching due to his organomegaly as well as the recent
drainage of his very distended abdomen (now much smaller than
before). He was comfortable and without pain by time of
discharge with outpatient followup.
# Acute Kidney Inury: Likely due to dehydration and
overdiuresis. Patient appeared very dry on exam and FENA 0.8%
consistent with pre-renal etiology. Volume down given recent
paracentesis and diuretic change. Patient improved with fluid
challenge and was advised to STOP furosemide and spironolactone
followup with outpatient hepatology and lab checks this week.
***Please check electrolytes at/before next visit
***Consider restarting furosemide and spironolactone,
potentially at reduced doses.
# Hepatitis C cirrhosis: Complicated by portal hypertension,
diuretic refractory ascites, and gastrointestinal varices in the
esophagus (grade 1 in ___ and the rectum (large on
sigmoidoscopy in ___, and portal vein thrombosis on
warfarin. On the transplant list at ___. Currently requiring a
tap every month. No acute decompensation, and diuretics held as
above. Held Nadolol 40mg
# HIV: Most recent CD4 89 on ___. Continued home HAART
regimen and acyclovir. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o female with PMHx of neurofibromatosis type 1, HTN, HLD,
pseudoseizure, anxiety who presents from outpatient ___
clinic for chest pain, syncope, hypotension.
Patient presented to ___ clinic for initial evaluation for
ecchymosis. There, she was found to be hypotensive with a
systolic blood pressure of 88 and she was symptomatic with
dizziness. She is also reporting left-sided chest pain. She
reports that she has had chest pain intermittently in the past
but did not have extensive workup. Last stress was many years
ago. No associated shortness of breath. No recent travel or leg
swelling. The pain is described as a pressure sensation which
occurs intemittently. She is a non-smoker. CHEST (AP AND LAT) showed No acute intrathoracic process. The patient was diagnosed with Syncope and collapse, Hypotension, unspecified, Bradycardia, unspecified. At the time of discharge, the patient had Primary diagnosis
====================
Orthostatic hypotension
Syncope
Secondary diagnoses
=======================
Neurofibromatosis type 1
Anxiety
Psychogenic nonepileptiform seizures
GERD
HLD
HTN. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Key Information for Outpatient ___ y/o female with
PMHx of neurofibromatosis type 1, HTN, HLD, pseudoseizure,
anxiety who presents from outpatient ___ clinic for chest
pain, syncope, hypotension, found to have orthostatic
hypotension which improved with fluids and also holding
lisinopril.
ACTIVE ISSUES
=================
#Syncope
#Hypotension
Patient with several episodes of syncope in the past couple
weeks coinciding with recent initiation of lisinopril. This had
been started at rehab due to report of symptomatic blood
pressures 200s/100s over 2 days (preceded and followed by
normotension); she had previously been on atenolol and losartan.
Telemetry did not alarm; EKG was normal. Her orthostatic vital
signs were positive on ___ am but improved with PO fluids.
Suspect syncopal episodes from over-medication and dehydration.
Lisinopril was discontinued and she was encouraged to drink
fluids. Prazosin was also held during the hospitalization in
case of contribution. She was not familiar with this medicine.
#Anxiety
#Psychogenic nonepileptiform seizures. Patient had a witness
episode of pseudoseizure overnight ___. Vitals remained
stable and patient was A&Ox3 after the episode. During hand drop
test the patients hand did not fall on her face. She had no aura
or postical phase. She is following up with neurology as an
outpatient. Continued home escitalopram, prazosin, lamotrigine.
Home clonazepam held secondary to presyncope.
#Chest pain. She had reassuring EKG and neg trops x2. ___ be GI
related vs anxiety. Continued on famotidine.
CHRONIC ISSUES
==================
#GERD. Continued famotidine 20mg.
#HLD. Continued home simvastatin.
TRANSITIONAL ISSUES
======================
HELD MEDICATIONS: Lisinopril, clonazepam, prazosin.
[ ] Consider restarting low-dose anti-hypertensive if blood
pressure remain elevated in the outpatient setting.
[ ] Consider restarting prazosin as outpatient. Presumed that
she is taking it for off-label use for PTSD.
#Full code
#Health care proxy/emergency contact: Husband ___.
___, h: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with HCV cirrhosis (Childs A, last MELD 13) presents
with abdominal pain and poor PO intake for two days. She
presumably was infected with HCV from a blood transufsion
decades
ago. Her cirrhosis is complicated by portal gastropathy,
esophageal varices, and hepatic encephalopathy. Is currently
listed for liver transplant at ___. Considered for liver donor
txp at ___ but no suitable donors.
Two days ago, she developed generalized abdominal pain which
then
localized to her umbilicus, the site of a known umbilical
hernia.
She reports this hernia often increases with her ascites, but
never to the current size or firmness. She had nausea with meals
over the weekend, no emesis. Diarrhea x3 two days ago, no BM
since. Unable to tolerate food this afternoon. Now states pain
is
focused at her umbilical hernia. Radiology showed Bibasilar atelectasis with no acute cardiopulmonary process. The patient was diagnosed with UMBILICAL HERNIA W OBSTR. The patient was treated with ___: Repain umbilical henia. At the time of discharge, the patient had Incarcerated umbilical hernia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>She was taken to the OR on ___ for repair of umbilical
hernia for incarcerated umbilical hernia. Surgeon was Dr.
___. Please refer to operative note for details.
Postop, she did well. Vital signs were stable. Sips were started
on postop day 1 and diet was advanced over subsequent days. She
was passing flatus, but did not have a BM. Colace and Senna were
ordered.
Abdominal incision (periumbilical incision)appeared intact
without redness or drainage. Abdomen was soft. She used minimal
pain medication (morphine initially then oxycodone).
___ was consulted and felt that she was safe for home without
assistive devices. Previous ___ services were ok to resume. She
was ambulating independently. ___ services were offered, but she
refused services.
She was discharged to home in stable condition. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p kidney transplant from living related donor
(son) p/w chest pain x 4 hours and intermittent right jaw
numbness for several days. Pt has been recovering well since
surgery and was on telephone w/ transplant coordinator regarding
increasing her Tacro dose as well as worsening vaginal
irritation
when she incidentally mentioned the chest pain. She was
instructed to come to ___ ED for evaluation. Pt describes the
pain as band-like running laterally across the front of her
chest. Has not been increasing in intensity. Not substernal, not
radiating to back. States this is unlike her pain associated
with
reflex or previous episodes of pancreatitis. No associated
nausea, vomiting, shortness of breath, numbness or tingling down
arms, diaphoresis or syncopal symptoms. Radiology showed 1. No acute cardiopulmonary process.
2. A vague opacity is noted in the right upper lung and new compared to prior
study and is likely an osseous deformity of the ___ anterior right rib. A
dedicated Chest CT may be obtained in the non-emergent setting for further
characterization. The patient was diagnosed with CHEST PAIN NOS, MULTIPLE SCLEROSIS, KIDNEY TRANSPLANT STATUS. At the time of discharge, the patient had UTI
h/o kidney transplant ___
chest pain likely from 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>She was admitted to the Transplant Service. EKG was without
acute changes. Serial troponins were all less than 0.01. She was
started on Protonix and Reglan. Chest discomfort was attributed
to GERD symptoms.
UA, urine and blood cultures were sent. UA was positive.
Ceftriaxone was started for UTI. She remained afebrile and
denied dysuria. She felt well enough to go home. Nephrology saw
her as well. Cefpodoxime was recommended for 1 week.
Of note, Prograf level was not a true trough level as she had
taken Prograf late the preceding night.
She was discharged to home. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ healthy ___ speaking woman who presented as a
transfer
w/ L SAH and L SDH ___ fall from assault. Per patient (H&P were
obtained with assistance from interpreter), she was at a night
club and trying to get a picture with the singer. She was
stopped
by security guards, most told her she would not be able to get a
picture, but one said to wait and he would help her. Another
security guard told her that she would not be able to get the
picture and then pushed her. The patient fell, striking the back
of her head, +LOC for approx ___. No nausea, vomiting,
seizure after coming to. Minimal residual headache but no
lightheadedness or blurry vision. Patient was taken to ___, where CT C-spine was negative and CT Head showed L
traumatic SAH and L tentorial SDH and she was transferred to
___ for further evaluation and trauma was consulted. CT ORBITS, SELLA AND IAC W/ CONTRAST Q1215 CT HEADSUB showed 1. Longitudinal fracture of the left temporal bone, with partial with
opacification of the middle ear cavity and minimal disruption of the tegmen
tympani with a single intracranial locule of air.
2. No disruption of the skull base foramina, otic capsule, or semicircular
canals.
3. Overlying subarachnoid hemorrhage is seen interdigitating within the sulci
of the partially visualized left temporal lobe.
4. No right-sided temporal bone abnormality. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Interval decrease in the prominence of subarachnoid blood in the left
temporal lobe.
2. Grossly unchanged appearance of left temporal bone longitudinal fracture
and left mastoid air cell opacification.
3. Normal CTA. The patient was diagnosed with Fracture of vault of skull, init encntr for closed fracture, Traum subrac hem w LOC of unsp duration, init, Fall on same level, unspecified, initial encounter. At the time of discharge, the patient had Left temporal and frontal subarachnoid hemorrhage
Non-displaced fracture of mastoid
Mild Traumatic brain injury
Decreased Hearing Left Side. The patient was given written instructions concerning 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 after sustaining a fall after
reportedly being pushed down by a security guard at a local
event. She was admitted to the Acute Care Surgery service and
was found to have a contusion on the occiput, a left left
temporal bone longitudinal fracture, left mastoid air cell
opacification, and a small subarachnoid hemorrhage around the
left temporal lobe. No other injuries were found. She was
evaluated by the neurosurgery service and non-surgical
management was recommended. Given her injuries and reportedly
decreased hearing on the left side, she was seen by the Ear,
Nose, and Throat specialists who evaluated the decreased hearing
and directed the patient to follow up in the outpatient clinic.
After two days of observation with decreasing size of the
hemorrhage in the cranium and improving hearing in the setting
of stable vitals, the patient was discharged with direction to
follow up with Dr. ___ to schedule a follow up
appointment in approximately 3 weeks with an audiogram.
Active Issues:
================
# Contusion of occiput, Temporal bone fracture, TBI: Patient was
evaluated by the neurosurgery service and was found to have a
normal neurological exam short of hearing loss on the left.
Given the small size of her SAH, her improvement on re-imaging
and improvement of her symptoms, decision was made for patient
to follow up with the concussion clinic as needed.
# Decreased hearing on left side: Patient was evaluated by ENT
and a plan for followup in outpatinet setting was planned. At
time of discharge the patient reported improving hearing on the
left side.
Chronic Issues:
================
NA
Transitional Issues:
======================
# Follow up with your PCP
# ___ up with Dr. ___ to schedule a follow up
appointment in approximately 3 weeks for an audiogram.
# Follow up with Concussion Clinic as needed.
# Medication Changes:
NEW Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
NEW Ciprofloxacin 0.3% Ophth Soln 3 DROP LEFT EAR TID</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ year-old female with PMhx significant for
psoriasis, psoriatic arthritis, ehlers-danlos, mast cell
activation syndrome, ICH s/p shunt with multiple revisions,
tracheobronchomalacia s/p trach who presented for evaluation of
worsening full-body rash as well as concern for facial swelling. CHEST (PA AND LAT). showed 1. Increased opacification at the right lung base, findings likely consistent
with pneumonia.
2. Low lung volumes with left basilar atelectasis.
3. Trace bilateral pleural effusions. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Pulmonary vascular congestion has increased, and accompanying increase in
heart size and mediastinal caliber suggests increased intravascular volume.
No definite focal pulmonary abnormality or good evidence for pulmonary edema.
No pneumothorax.
Right central venous infusion port catheter and shunt tubing are unchanged in
their respective locations, but the shunt cannot be traced below the
diaphragm. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, the monitoring and support
devices are unchanged. Continued low lung volumes accentuate the prominence
of the transverse diameter of the heart. There is minimal if any pulmonary
vascular congestion. Blunting of the costophrenic angle is again seen on the
right. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed Unchanged appearance of tracheostomy. No evidence of tracheitis. No drainable
fluid collections. The patient was diagnosed with Rash and other nonspecific skin eruption. The patient was treated with ___: Bedside laryngoscopy
___: Bronchoscopy. At the time of discharge, the patient had Primary:
Psoriasis flare
Secondary:
Community associated pneumonia
Tracheobronchomalacia
Recurrent idiopathic angioedema
___ Syndrome
Mast Cell Activation Syndrome
Insomnia
Adrenal insufficiency
Anxiety
Borderline PD
Chronic Pain
History of Pulmonary Embolism
GERD
Hypothyroidism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with a complex PMH of class III
obesity, Ehlers-Danlos Syndrome, Tracheobronchomalacia s/p
T-tube placement, PE on Lovenox, severe OSA, mast cell
activation syndrome, GERD, psoriasis, eczema, borderline PD, and
anxiety, admitted for new onset rash and facial swelling -
overall felt to be due to a psoriasis flare as well as MCAS
flare.
# Rash
# Psoriasis flare
Dermatology was consutled, who recommended high dose steroids
with a slow taper. There was initial concern for drug reaction
or DRESS, however pathology was most suggestive of psoriasis
(and not SJS/TEN, DRESS, drug reaction, or mast cell
activation). Was treated with Methylprednisolone 150mg daily x3
days and then transitioned to 150mg PO Prednisone daily (with
taper plan of decreased Prednisone by 20mg q3 days). She was
also started on NF Otezla while inpatient, as per Dermatology
recommendations. She was otherwise continued on her outpatient
Dermatology topicals of Triamcinolone and Clomitrazole. Given
pathology could not definitively rule out drug reaction, her
Chantix was discontinued (as this was started ~1 month prior to
the worsening rash) - per Derm, PCP could consider restarting as
an outpatient once her current flare settles out. Finally, she
was started of PCP ___ 1500mg daily x21 days given
prolonged steroid use.
# Dyspnea
# Community Associated Pneumonia
# Tracheobronchomalacia
# Recurrent idiopathic angioedema w/ multiple episodes of acute
respiratory failure requiring intubation
Follows with Dr. ___ in IP, who was already planning for an
outpatient bronchoscopy. As such, had a bronchoscopy on ___ to
consider T-tube adjustment as well as to obtain bronchial
washings. On admission, was noted to have a possible right lung
base pneumonia and as such was treated with IV Ceftriaxone x5
days for CAP. Of note, attempted to provide atypical coverage
however had an anaphylactic reaction to Doxycycline and has been
unable to tolerate Azithromycin or Levaquin - nonetheless, her
urine legionella returned negative. Strep pneumo and MRSA
negative as well. Was otherwise continued on her home
Guaifenesin ER 1200mg q12 hrs, home nebulizers of Albuterol q2
PRN, Acetylcysteine BID PRN, 3% NaCl BID, and 7% NaCl BID.
Finally, patient had a bedside laryngoscopy on ___ that showed
granulation tissue but no obstruction.
# ___ Syndrome
# Facial swelling
# Acute on Chronic Mast Cell Activation Syndrome
Has port in place for home IV benadryl. Was otherwise continued
on her current MCAS regimen: Cetirizine 10 mg QID, Ranitidine
150 mg BID, Famotidine 20mg BID, Omeprazole 20mg BID. She also
received 50mg IV Benadryl PRN (often received ___ doses per day;
at home takes ___ doses per day per Allergy). Allergy was
consulted, who recommended this continued regimen - they are
currently considering continuous Benadryl infusions as an
outpatient.
# Neck pain
Patient noticed new and worsening neck pain and swelling, as
well as new mild yellow discharge around her trach. CT Neck w/
contrast without evidence abscess or gas. Rising leukocytosis
concerning for possible tracheitis, though patient remains
afebrile with minimal sputum production and no new oxygen
requirement. Overall, she received a course of antibiotics for
CAP early in her hospitalization - but given her clinical
stability, was not restarted on antibiotics given upcoming
bronch. Her bronchoscopy on ___ demonstrated granulation tissue
that was subsequently debrided and she had a t-tube revision as
well.
# Anxiety
# Borderline PD
# Chronic Pain
Pt follows previously with Psychiatry at ___, currently on
waiting list to establish with new outpatient psychiatrist. Has
been felt that her anxiety may be contributing to her dyspnea.
As per her hospitalization plan, continued her home Clonazepam
0.5mg BID PRN and Oxycodone 10mg q4 PRN, started Quetiapine
100mg QHS and 50mg BID. Obtained frequent ECGs for QTc
monitoring. Otherwise increased her home Trazodone to 150mg QHS
for insomnia as per below while she is on high dose steroids.
# Insomnia
Patient noted that since admission she was having worsened
insomnia, likely in the setting of high dose steroids. As such,
increased Trazodone to 150mg QHS and added Ramelteon, which was
helpful. She was otherwise continued on Seroquel 100mg QHS as
per her hospitalization plan. At discharge, was continued on an
increased dose of her home Trazodone to 150mg QHS.
# H/o adrenal insufficiency
Has history of adrenal insufficiency. Patient refused to take
steroids as recommended until Cortisol obtained given her fear
for adrenal crisis. As such, obtained a Cortisol which was low
at 1.0 - however this is expected given she was on a steroid
taper since ___. Per Endocrinology, recommend outpatient
Ednocrinology follow up once current Prednisone taper is
completed for further evaluation.
# Pulmonary vascular congestion
Noted on CXR to have new pulmonary vascular congestion (since
___ that was more prominent on ___ CXRs. Last TTE in
___ was extremely limited, and as such obtained repeat TTE
that was without obvious abnormalities. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx HTN, HLD, DM2, MI s/p stenting, Afib s/p ablation
in ___, HFrEF (LVEF 40% ___, COPD, OSA not on CPAP,
prostate ca and possibly schizoaffective disorder presenting
with LLE swelling/redness. He also notes that he's been having
some intermittent chest pains which are left-sided, did not
radiate and feeling something is pushing out his chest. This is
worse with exertion and when he gets excited. He also has some
shortness of breath associated with this as well. No
diaphoresis. He is on torsemide for his CHF which he has been
taking as directed. On Pradaxa for afib. Denies current chest
pain.
Of note patient was recently admitted in ___ for HF
exacerbation but left AMA on hospital day 2. Psychiatry at that
time deemed patient had capacity.
In the ED initial vitals were: 97.5 80 108/62 16 97% RA
EKG: RBBB, afib, HR 115, TWI in V1-V3 consistent with RBBB.
Labs/studies notable for: lactate 1.3, Trop 0.02. BNP 5831. He
had a negative left leg U/S for clot, and CXR that showed mild
pulmonary edema.
Vitals on transfer: 91 126/91 21 96% RA
On the floor patient is perservating on his paranoid delusion.
He does report that he has gained weight and feels more SOB, but
when asked more details about ROS, his social history, or family
history,patient began to ramble about his landlord being a
___ and further history was unable to be obtained; much
of history below is per prior d/c summary in ___.
ROS: unable to obtain. UNILAT LOWER EXT VEINS LEFT showed 1. No evidence of deep venous thrombosis in the left lower extremity veins.
2. Left lower extremity subcutaneous edema. The patient was diagnosed with Acute combined systolic and diastolic (congestive) hrt fail. At the time of discharge, the patient had PRIMARY DIAGNOSIS
Atrial fibrillation
Heart failure with reduced ejection fraction
SECONDARY DIAGNOSIS
Coronary artery disease
Venous stasis dermatitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with h/o HFrEF (LVEF 35% ___, CAD s/p
PCI (___), Afib s/p ablation in ___, COPD, prostate cancer and
possibly schizoaffective disorder or paranoia secondary to
neurocognitive decline who presents for left ___ swelling and
pain, found to have volume overload. Of note he was recently
admitted for volume overload but left AMA before he could become
euvolemic.
# CORONARIES: CABG/PCI: PCI ___
# PUMP: HFrEF (LVEF 35% ___
# RHYTHM: Afib s/p ablation in ___
#HFrEF: Pt presenting with left lower leg pain likely in context
of heart failure. Pt had elevated BNP on admission and CXR
showed mild pulmonary edema. CHF exacerbation ikely ___
medication nonadherence. Other etiologies include arrhythmia,
ischemia unlikely precipitant given negative troponins. Preload:
Pt was diuresed with IV lasix and started on a lasix drip. He
then was transitioned to oral torsemide and is being discharged
on torsemide 20 mg daily. He is also being discharged on 10
lisinopril daily for afterload reduction. NHBK: Metoprolol at
12.5 mg BID, spironolactone 25 mg daily.
#History CAD: Patient s/p PCI in ___. Pt was admitted with a
mild trop elevation and an EKG with no changes. Pt had ECHO last
admission that showed slight decline in EF at 35%. Pt's
atorvastatin was increased to 80 mg QD, he continued with
aspirin. Consider stress test as outpatient as patient refused
as inpatient.
#Atrial fibrillation: Was on diltiazem and digoxin at home. Pt
was transitioned to Metoprolol 12.5 Q12H, continued on digoxin
0.25 QD and rivoraxaban.
#Venous stasis dermatitis. Pt was diuresed as above and received
compression stockings. Pt used sarna lotion.
#Hx prostate cancer. Pt received home bicalutamide 50 mg oral
DAILY on discharge
#Psychiatric History or paranoia. Patient was seen by psychiatry
on his prior hospital admissions, and per their notes, he was
noted to have a primary psychiatric condition such as
schizoaffective vs. paranoia secondary to a neurocognitive
condition. During last admission he had bouts of agitation,
which were accompanied by paranoia, delusions, and auditory
hallucinations. His paranoia and delusions contributed to his
refusal of medications while in the hospital. However, during
this hospitalization he was compliant with medications/and
treatment. His repeated hospitalization due to decompensated CHF
are due to medical non adherence due to paranoia above. Patient
refused home services. Family is very involved including son and
ex-wife. At some point in future, family may need to seek
guardianship but this was not addressed during this
hospitalization as patient was competent. Pt received home ___
Haldol daily.
TRANSITIONAL ISSUES
=====================
[] Consider stress test - pt refused as an inpatient.
[] Please check Chem 10 at primary care appointment when on
torsemide 20 daily to ensure that CrCl >50. If <50, will need to
decrease rivaroxaban to 15 daily
STOPPED MEDICATIONS
Diltiazem
NEW MEDICATIONS
Metoprolol 12.5 BID
Spironolactone 25 mg daily
CHANGED MEDICATIONS
Atorvastatin 80 mg QD
Upon discharge: 70.2kg and Cr 1.2
CODE: Full
CONTACT: ___ ex wife ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ h/o CAD s/p CABG x4, multiple cardiac stents, ESRD on PD,
DM2, and LLE osteo who presents with painful R fingers for past
week. She noticed "pins and needles" sensation in her right ___
digits since last ___. A few days later, she noticed color
changes to her fingers, up to dark purple hue. She saw her PCP
today, who referred her to a vascular surgeon, who recommended
she come to the ED for further evaluation. She has not had any
other symptoms, denies fevers, chills, nausea, vomiting, chest
pain, or shortness of breath. Her left had has not had any
symptoms. She denies specifically a history of atrial
fibrillation, and she is a non-smoker. Radiology showed 1. Patent flow from the aortic arch, right brachiocephalic artery to the
radial and ulnar arteries at the level of the wrist, without occlusion or high
grade stenosis. Multifocal moderate to severe narrowing of the distal ulnar
artery.
2. Assessment of patency of the arteries distal to the wrist within the hand
is markedly limited due to extensive atherosclerotic calcifications and the
small caliber of these arteries. MRA of the hand should be considered for
further assessment. Radiology showed Left lower lobe consolidative opacity may reflect pneumonia or rounded
atelectasis with adjacent small pleural effusion, as seen on the recent chest
CT. There was a suggestion of possible pleural enhancement on the chest CT, a
finding which can be seen with empyema, and clinical correlation is
recommended. Radiology showed 1. Widely patent thoracic aorta. No evidence of thoracic aortic aneurysm or
dissection. The origins of the great vessels arising from the aortic arch are
patent. There are mild aortic arch atherosclerotic calcifications.
2. Left lower lobe consolidative opacity may represent pneumonia or perhaps
rounded atelectasis. Small left pleural effusion with suggestion of split
pleural sign can be seen in empyema and clinical correlation is recommended.
3. Ascites noted in the upper abdomen. The patient was diagnosed with CIRCULATORY DISEASE NEC, CYANOSIS, DIAB RENAL MANIF ADULT, END STAGE RENAL DISEASE, LONG-TERM (CURRENT) USE OF INSULIN. The patient was treated with ___: EGD. At the time of discharge, the patient had Right hand ischemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was admitted to the vascular surgery service on ___
with pain and discoloration of her right ___ digit. A CTA was
obtained which was significant for:
Patent flow from the aortic arch, right brachiocephalic artery
to the
radial and ulnar arteries at the level of the wrist, without
occlusion or high
grade stenosis. Multifocal moderate to severe narrowing of the
distal ulnar
artery. Assessment of patency of the arteries distal to the
wrist within the hand
is markedly limited due to extensive atherosclerotic
calcifications and the
small caliber of these arteries.
Due to concern for arterial embolic disease, she was started on
a heparin drip. Because she had a history of GI bleed ___
dieulafoy's lesion, a GI consult was obtained to determine risk
of anticoagulation. On ___, she was started on coumadin, 5 mg,
and also received 5 mg on ___. She was started on high dose
omeprazole, and on ___, GI performed an EGD. They did not see
any bleeding or nidus for bleed, however, they were unable to
perform a full evaluation ___ food in the stomach. GI
determined that the area of her previous bleed appeared stable,
and she would be safe to anticoagulate with a goal INR of
2.0-3.0 while on omeprazole 40 mg daily. She was deemed
appropriate for discharge on ___, and will follow up with Dr.
___ INR and coumadin dosing.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ y/o M w/ PMHx of recurrent pancreatitis, pancreatic
pseudocyst, CAD, DM2, obesity, as well as recent admission
___ for biliary obstruction treated with ERPC with sphx and
stent placement. Pt reports that he was pain-free at the time of
discharge. However, on the day following discharge, his pain
recurred. He initially tried to monitor the pain at home,
thinking that it was normal to have pain after ERCP. However,
pain progressed over the past week to ___. Pain is RUQ in
location, sharp. Worse with eating. He has had persistent N/V
associated with the pain. He initially had some loose stools at
home; however, he has not had a BM in 4 days. He also reports
that he has not been able to eat much in the past 4 days.
.
Initially went to OSH. Lipase 348 (per their range was normal),
LFTs improving. CT abd deferred as pt had "3 CTs in the past 3
wks". Transferred here.
.
ED Course:
Initial VS: 97.8, 94, 132/68, 16, 100% RA, Pain ___
Labs significant for ALT 58 AST 18 ALP 204 TB 1.8
Imaging: CT with focal ileus (see below for report)
Meds given: Zofran, Dilaudid, Miralax
VS prior to transfer: 98.1, 88, 96/64, 19, 94% RA, Pain ___
.
Surgery saw patient in the ED: no SBO, admit to medicine for
workup of abdominal pain and pain conrol.
.
On arrival to the floor, the patient reports that his pain is
better controlled after getting Dilaudid on arrival, currently
___. No current nausea. He reports that he has not had a BM in
4 days. He also endorses weight loss over the past 6 months
(315->241 lbs).
.
ROS: As above. Denies chest pain, heart palpitations, shortness
of breath, cough, urinary symptoms, muscle or joint pains, skin
rash. The remainder of the ROS was negative. Radiology showed Markedly low lung volumes. Bilateral lower lobe opacities most
likely represent atelectasis; however, infection cannot be excluded. No free
intraperitoneal air. Radiology showed 1. A dilated loop of small bowel in the left lower abdomen contains fecalized
material most likely represents a focal ileus, likely a non-specific ileitis,
could be infectious or inflammatory. There is no pneumatosis, mucosal edema
or free air. Follow-up based on clinical symptoms.
2. Common bile duct stent in appropriate position.
3. Cystic lesions in the pancreatic head are unchanged in size and appearance
compared to the prior CT of ___. Previous FNA of the lesion was
benign.
4. Mild splenomegaly again noted. Radiology showed No evidence of deep vein thrombosis in the left lower extremity. The patient was diagnosed with ABDOMINAL PAIN GENERALIZED. At the time of discharge, the patient had Ileus
Pancreatic pseudocyst
Bacteremia, likely contaminant. The patient was given written instructions concerning 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 ___ y/o M w/ PMHx of recurrent pancreatitis, pancreatic
pseudocyst, CAD, DM, obesity, as well as recent admission
___ for biliary obstruction treated with ERCP with sphx and
stent placement, back with recurrent RUQ abdominal.
# RUQ Abdominal Pain, N/V: Most likely etiology felt to be ileus
seen on imaging. Labs significant for mild bilirubin elevation
and transaminitis; however, these were improved from his recent
discharge labs, making ongoing biliary obstruction less likely.
Surgery, both Acute Surgical and Hepatobiliary, were consulted.
Symptoms improved with aggressive bowel regimen. Of note, pt
will likely have a degree of persistent chronic abdominal pain
given known pancreatic pseudocyst.
# Positive Blood Culture: Felt to likely represent contaminant.
He was initially placed on IV Vancomycin, until 2 out of 4
bottles of blood cultures obtained on ___ returned positive
for CoNS only. He did not have any fevers. He does not have an
indwelling catheter or port. He has additional surveillance
cultures (2 sets ordered prior to initiation of IV Vancomycin, 2
sets ordered after stopping IV Vancomycin) that show no growth
to date.
.
# Recurrent Pancreatitis / Pancreatic Pseudocyst: No e/o acute
pancreatitis on admission lab work. However, pt does have lesion
seen on recent CT pancreas protocol, which could not rule out
malignant cystic lesion. Pt also reports signicificant weight
loss over the past 6 months. CA ___ WNL on recent admission.
Surgery evaluated and plans for surgical removal of pseudocyst
in the near future.
.
# LLE pain: Patient complained of LLE pain in the calf. He did
not have any erythema or swelling. ___ was obtained, with
prelim read negative for DVT. He was able to ambulate
comfortably. He should follow-up with his outpatient providers.
.
# DM2, poorly controlled, with complications: He was continued
on his home regimen of Lantus and Humalog.
.
# CAD: continued home ASA, BB
# OSA: Non-compliant with CPAP. O2 sat's were monitored during
hospitalization.
.
# AMA Discharge
Of note, on the day of discharge, we recommended to the patient
that he continue to remain inpatient due to his complaint of
constipation and persistent abdominal pain, as well as pending
surveillance blood cultures. He reported significant anger and
frustration with his abdominal pain. He felt that his pain was
not being treated and he also felt that the Hepatobiliary
Surgery team did not have a well defined plan in place for
surgical management of his pseudocyst. Patient also reporting
that only IV dilaudid adequately controlled his pain and rated
his pain a "12 out of 10." Despite his subjective complaints,
his physical exam was benign and he appeared comfortable on
exam. He had also had a bowel movement within the past 48
hours. Explained to the patient that given his subjective
complaints, would prefer to keep him inpatient to optimize pain
control and management of his constipation, however, he declined
to stay unless IV dilaudid was provided. Given that he appeared
clinically well, he was discharged to home AMA. He agreed to
accept prescriptions for a bowel regimen. He declined an offer
for additional PO opioids, as he felt that new script for opioid
would violate his outpatient opioid contract with his PCP. I
explained that I could provide a short-term supply of PRN opioid
for breakthrough pain and that I would contact his PCP to
explain, but patient declined this offer. He acknowledged and
accepted the risks of AMA discharge.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ presents with R hip pain for 1 week. On ___, she slipped
on a puddle of water in the kitchen, fell onto her right hip and
felt immediate pain. No preceding dizziness, HS/LOC or other
injuries. She has been unable to ambulate since. Prior to injury
ambulated independently and no antecedent hip pain. Believed she
damaged her quad, so she waited to see if pain would improve
before presenting to the ED today. Denies numbness / tingling.
Endorsed episode of diarrhea yesterday that has since resolved. Radiology showed Comminuted, impacted and angulated right intertrochanteric femoral neck
fracture. Radiology showed No acute cardiopulmonary process. Radiology showed No fracture or dislocation. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. HIP UNILAT MIN 2 VIEWS RIGHT IN O.R. showed Total fluoroscopy time of 74.7 seconds is recorded. Process of open reduction
internal fixation of the right hip was recorded. For pre size details please
review the corresponding report. The patient was diagnosed with Displaced intertrochanteric fracture of right femur, init, Fall on same level, unspecified, initial encounter. The patient was treated with Right TFN. The patient was given written instructions concerning 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 right hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for right TFN, which the patient tolerated well. For
full details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right lower extremity, and
will be discharged on heparin for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ who was restrained driver in rollover MVA going
approximately 40mph. EKG prior to arrival c/f ST elevation. Upon
arrival patient complains of pain "everywhere." CT C-SPINE W/O CONTRAST showed Multilevel degenerative changes without acute fracture or traumatic
malalignment. CT torso ** INCOMPLETE**
IMPRESSION:
Scout images obtained. Study was terminated due to patient intolerance. showed Scout images obtained. Study was terminated due to patient intolerance. Radiology showed No acute fracture or alignment abnormality within the thoracolumbar spine.
Chronic appearing wedge deformity of T12. Pelvis is intact. Radiology showed No fracture or dislocation. Portable chest radiograph showed No acute findings in the chest. CT HEAD W/O CONTRAST showed No acute fracture or hemorrhage. The patient was diagnosed with Abrasion of unspecified part of neck, initial encounter, Car pasngr injured in clsn with statnry object in traf, init. At the time of discharge, the patient had Restrained passenger in ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ who was restrained driver in rollover MVA going
approximately 40mph. EKG prior to arrival c/f ST elevation. Upon
arrival patient complains of pain "everywhere." On arrival to
the ED, the patient was GCS 15, eFAST negative and pan-scan and
CT head showed no acute findings. We admitted the patient
overnight for pain control. We decided to keep the C collar in
place, repeat EKG which was WNL, and manage the patients pain.
On discharge on HD#1, the patient was ambulating without
assistance, out of bed, voiding normally, eating a regular diet
and pain controlled with ibuprofen, Tylenol and discharged home
with a prescription for oxy as needed. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ y/o F with a history of STEMI s/p DES to the LAD
in ___ who was an emergent transfer to the cath lab earlier
today after her stress test was stopped short due to chest pain
and EKG changes. Patient has apparently been becoming
increasingly dyspneic on exterion for the last several months.
She was supposed to have a stress at the end of ___,
however, this was delayed secondary to repeated sinusistis. She
went today for her stress echo, during which she developed 1.___epression early into exercise, ST elevation in AVR, AvL
along with crushing chest pain. She was emergently transferred
to ___ cath lab. On arrival, her chest pain had stopped with
nitroglycerin. Cath showed 40% stenosis within the previously
deployed stent in the mid LAD and no intervention was done.
.
On arrival to the floor, patient is mildly dyspneic but denies
any chest pain or SOB.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative. The patient was diagnosed with INTERMED CORONARY SYND. The patient was treated with cardiac catheterization. At the time of discharge, the patient had Coronary Artery Disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted with chest pain and shortness of
breath. She had received an exercise stress test at the outside
hospital, which showed worrisome findings. The patient was
transferred to our service, where she received a cardiac
catheterization. The findings did not warrant intervention, and
the decision was made to optimize medical management. The
patient was monitored and discharged in stable condition. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ smoker with Crohn's s/p total
colectomy and splenectomy on prednisone and Vedalizumab, history
of c diff, Stage IV COPD, dCHF, OSA on CPAP presenting with
lower abdominal pain, diarrhea and hypotension.
Of note, patient was recently admitted from ___ to ___
for a Crohn's flare complicated by a small bowel obstruction. An
NGT was placed and the patient was treated conservatively. He
was discharged on a steroids taper. In addition to treatment for
a SBO he was diuresed due to significant volume overload from
dHF.
In the ED, initial vital signs were: 96.6 118 108/45 24 92% 3L
Nasal Cannula. Labs were significant for Na 125, K 6.0, Cl 86,
HCO3 23, BUN 30, Cr 1.8, glucose 108, AG 22, WBC 13.7, H/H
8.0/26.3, plt 832, ALT 21, AST 21, AP 85, Tbili 0.2, Alb 3.4,
lip 46, proBNP 187, CRP 63.5, INR 1.5 and lactate 2.9. Repeat
labs showed improvement in sodium, Cr and lactate. A CT
abd/pelvis showed: dilated loops of duodenum and proximal
jejunum with a transition point along the right anterior
abdominal wall near the right lateral edge of the patient's
hernia repair mesh similar in appearance to the prior
examination.
On Transfer Vitals were: 86 ___ 100% Nasal Cannula
On arrival to the floor, patient reports that during the two
days after his last discharge, he had daily ___ episodes
nonbloody stool with crampy left sided abdominal pain consistent
with Crohn's pain. Pain is always worse after eating. Only one
urination today. No CP/ SOB/ nausea/ vomiting/ fevers. No
increased oxygen requirement from 3.5 L at home. CT ABD AND PELVIS WITH CONTRAST showed Dilated loops of duodenum and proximal jejunum with a transition point along
the right anterior abdominal wall near the right lateral edge of the patient's
hernia repair mesh similar in appearance to the prior examination. Of note,
fluid and stool are seen distal to this area of caliber change suggesting a
partial small bowel obstruction.
NOTIFICATION: Findings communicated to Dr. ___ telephone at 03:45 on ___ by Dr. ___. The patient was diagnosed with REGIONAL ENTERITIS NOS, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS, LONG TERM USE ANTIGOAGULANT. At the time of discharge, the patient had Final diagnosis: Chrons flare
Secondary Diagnosis:
COPD
Chrons disease
heart failure, chronic. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ smoker with Crohn's s/p total colectomy and splenectomy on
prednisone and Vedalizumab, history of c diff presenting with
lower abdominal pain concerning for an acute Crohn's flare.
Sigmoidocopy did not reveal signs of acute inflammation.
Patient treated with steroid burst and transitioned to PO
steroid taper. On discharge bowel movements were reduced to his
baseline of ___ BM/day and pain was well controlled.
Chronic issues:
# Hyponatremia: thoought to be related to hypovolemia. Resolved
to 131 on discharge
# Chronic dCHF: ECHO in ___ with hyperdynamic LVEF (EF>75%),
with normal free wall contractility. The patient remains volume
overloaded and bp remains stable. He was continued on home
diuretics and ACEi
# Gold Class IV COPD / Hypoxia: Patient was stable on home O2
requirement of 3.5L NC. He was also treated with home meds
Advair, Tiotroprium and duo nebs PRN
# PE/DVT: Suntheraputic INR on admission. History of DVT in
right popliteal vein ___. provoked DVT in RUE in ___
secondary to a line. Coumadin stopped s/p GI bleeding incident
this ___, with PE in ___ prompting reinitiation of
coumadin. INR goal ___. Patient restarted on home dose of
warfarin daily. Lovenox to bridge for 24 hours until INR is at
goal x 24 hours.
# Depression: Stable. Continued home Duloxetine 60mg daily and
Risperidone qHS
# OSA: Stable. continued home CPAP
TRANSITIONAL ISSUES:
-Patient has hematoma on dorsum of right foot which should be
continued to be monitored. Please compress with ACE wrap per
podiatry recommendations. Podiatry would like to see patient
within 1 week after discharge for further surveillance.
-___ start 20 mg steroids taper by 5 mg every 10 days
-f/u with GI ___. Please schedule patient for next Vedalizumab
infusion.
-Please continue to monitor platlets
-Please schedule patient for next Vedalizumab infusion.
-Please monitor INR daily. INR goal ___. Plan to bridge with
lovenox for 24 hours after achieving theraputic INR. recheck
INR on ___ can stop coumadin once INR therapuetic (___) x 24
hours
-Prednisone taper:
___: 20mg daily
___ 15mg daily
___ 10mg daily
___ 5mg daily </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ year-old lady with a history of AS s/p
TAVR, CAD, RA, DVT/PE on rivaroxaban and metastatic breast
cancer
complicated by loculated pleural effusions s/p R TPC and
lymphangitic involvement who presents with worsening dyspnea. Radiology showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Increased intra lobular septal thickening and right perihilar opacity are
consistent with progression lymphangitic carcinomatosis. There is probable
superimposed mild pulmonary edema.
3. Moderate right and small left pleural effusions are slightly increased than
before. Right chest tube is in place. Small right pneumothorax is similar to
before.
4. Multiple lesions in the right breast, liver, and bones are similar to
before. The patient was diagnosed with Pneumonia, unspecified organism, Dyspnea, unspecified, Hypoxemia. At the time of discharge, the patient had Acute on Chronic HFpEF exacerbation
Loculated Pleural Effusion
AS s/p TAVR, Mitral Stenosis
R-sided ER/PR+ Breast Cancer
VTE. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ is a ___ year-old lady with a history of AS s/p
TAVR, CAD, RA, DVT/PE on rivaroxaban and metastatic breast
cancer complicated by loculated pleural effusions s/p R TPC and
lymphangitic involvement who presents with worsening dyspnea.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old male past medical history of atrial
fibrillation, recurrent UTIs on suppressive bactrim, locally
advanced rectal cancer status status post palliative diverting
colostomy, prior hydronephrosis treated with R ureteral stent
that was complicated by recurrent UTIs necessitating stent
removal, being treated with Keytruda (first dose ___ by
Dr. ___ at ___, presenting with worsening ___. Radiology showed Successful placement of 8 ___ nephrostomy on both sides. The patient was diagnosed with Unspecified hydronephrosis, Unspecified abdominal pain, Unspecified atrial fibrillation, Acute kidney failure, unspecified, Long term (current) use of anticoagulants. The patient was treated with PCN tube placement. At the time of discharge, the patient had #Post-renal obstructive uropathy
#Acute kidney injury
#Hydronephrosis s/p bilateral PCN
#Metabolic acidosis
#Atrial fibrillation with rapid ventricular response
#Hypotension
#History of right apical clot
#Anemia
#Rectal cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male with atrial fibrillation, recurrent UTIs on
suppressive bactrim, locally advanced rectal cancer status
status post palliative diverting colostomy, prior hydronephrosis
treated with R ureteral stent that was complicated by recurrent
UTIs necessitating stent removal, being treated with
pembrolizumab (first dose ___ by Dr. ___ at
___, presenting with worsening ___, now s/p bilateral
PCN tubes with initially persistent renal failure that is now
improving
#Post-renal obstructive ___ - improving
#Hydronephrosis s/p bilateral PCN
#Metabolic acidosis - improved
PCN tubes placed on ___, with initially bloody urine now more
clear. Per urology, right draining considerably less d/t
atrophic collection system, may be able to remove in the future.
___ slowly improving since ___ (4.7 ->2.1, and still
improving). Has ___ follow-up in 12 weeks for tube change, and
has instructions and ___ for tube care. Will have labs next week
with oncology follow-up appointment.
#History of right apical clot.
Had been on edoxaban at home, but stopped in setting of renal
failure. Was on renally dosed lovenox during admission, but due
to improvement in renal failure was able to be restarted on
edoxaban at discharge.
#Afib/RVR, likely tachy-brady
#Baseline hypotension
Upon admission digoxin was held, metoprolol was reduced
significantly due to renal failure and sinus with low-normal and
mildly bradycardic rates. Around ___ he had some periods of
afib/RVR with associated hypotension. this occurred in the
setting of lower PO intake and improved with fluids.
Subsequently the patient's PO intake improved somewhat and the
RVR did not recur. Systolic BPs remained in the ___, which
appears to be his baseline and is asymptomatic. Digoxin was not
restarted prior to discharge.
#Anemia
Chronic multifactorial normocytic anemia that has been
intermittently transfusion dependent as an outpatient, often
worse during acute illness. Suspected to be related to
malignancy, renal failure, chemotherapy, and some acute/chronic
blood loss through ostomy and neph tubes. No evidence of
bleeding in days preceding discharge and hemoglobin relatively
stable. Received 3 units of RBCs while inpatient. Will have
labs in outpatient follow-up
#Rectal cancer with invasion into bladder
#Known colovesicular fistula
Patient will follow-up closely with oncology next week and will
resume pembro. He receives prophylactic Bactrim at baseline,
which was switched to cipro during the admission due to his
renal failure, but switched back to Bactrim at discharge.
# Depression
Continued Mirtazapine
# Chronic severe protein calorie malnutrition
Nutrition provided recommendations. patient restarted on
multivitamin and supplements. His PO intake improved during the
admission with treatment of his obstruction and renal failure.
#Intermittent abdominal pain and hiccups - treated effectively
with dicyclomine and baclofen
====================================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMHx of CAD (s/p PCI, on ASA/plavix) and HTN who is
presenting with one day of acute onset headache. The patient
reports that he was in his USOH until this morning when he was
awakened by a severe, throbbing headache, which has been present
most of the day. Although his symptoms are currently mostly
resolved, he reports some neck stiffness as well as the
sensation of "loss of peripheral vision." The headaches were
throbbing and he felt that he had pulsing blood vessels. He took
his pulse at home, which was 120. His BP was also elevated to
the 160s. He reports some light sensitivity, but denies any
fevers, nausea, vomiting, abdominal pain, diarrhea, or rash. He
denies any weakness or focal sensory deficits. He has no history
of headaches. In the ED, initial vitals were: 97.8 ___
18 100% RA. Labs were significant for WBC 6.9 with lymphocytic
predominance (46%), H/H 11.8/35.7, plt 380. Chem 7 w/ Cr. 0.8,
HCO3 20. Head CT showed no abnormalities. The patient was given
morphine 2 mg IV X 2, labetolol 10 mg IV x1, and a liter of NS,
and sent to the floor for further evaluation and management.
Vitals prior to transfer were: 97.8 85 115/78 20 99% RA. Upon
arrival to the floor, pt reported improved headache, but leg
discomfort starting ___ hours prior, he felt likely ___ lying in
the stretcher for a prolonged period. CTA HEAD WANDW/O C AND RECONS was done. The patient was diagnosed with SUBARACHNOID HEMORRHAGE, TENSION HEADACHE, LONG TERM USE ANTIGOAGULANT. The patient was treated with Lumbar puncture. At the time of discharge, the patient had Primary: Heachache
Secondary: Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old man with history of STEMI s/p DES
and HTN who presented with sudden-onset headache X 1 day, likely
secondary to tension headache after ruled-out for subarachnoid
hemorrhage and CNS infection.
#HEADACHE: Mr. ___ presented with an undifferentiated
sudden-onset ___ headache, most concerning for SAH v. CNS
infection v. a migraine or tension headache. Meningitis seems
less likely given absence of leukocytosis, fever or other
systemic signs of infection. He had a CTA of the Head that was
normal without masses or hemorrhage and an LP without evidence
of SAH or meningitis. His headache was managed with
acetaminophen and home pain medications. His headache improved
and he was discharged with plans to follow-up in the outpatient
setting.
#CAD: STEMI w/ DES placed in LAD on ASA and clopidogrel.
Continued home regime.
#HTN: Mr. ___ remained normotensive throughout admission.
Lisinopril initially given at reduced dose but restarted home
dose prior to discharge.
#DMII: Last AIc 6.8. Diabetic diet, gentle ISS used for
inpatient glycemic control.
***TRANSITIONAL ISSUES***
#HEADACHE: Mr. ___ is being discharged with plans for
outpatient clinic follow-up to ensure headaches are fully
resolved.
#HTN: Mr. ___ blood pressure remained well-controlled on
his home Lisinopril.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ female unrestrained driver presents with R acetabular
fracture and posterior hip dislocation s/p MVC. Pt traveling at
70 mph when she slammed into the back of a semi truck. Pt
reports
+ HS, no LOC. + Airbags deployed. Removed herself from car.
Reportedly GCS 15 at scene. Brought first to ___ then
transferred here. CT head and C spine negative. XRs demonstrated
R acetabular fracture with posterior hip dislocation on R. CT
with mild R SI joint widening and posterior ilium fx at SI
joint. PELVIS W/JUDET VIEWS (3V) showed 1. Interval reduction of the right hip dislocation.
2. Redemonstrated comminuted right acetabular fracture and widening of the
right sacroiliac joint. Please see report from CT pelvis for further
description. KNEE (2 VIEWS) RIGHT showed External fixation without displaced fracture or dislocation as described. Radiology showed 1. Interval reduction of the right hip dislocation.
2. Comminuted predominately transverse right acetabular fracture involving the
anterior and posterior columns with an additional posterior acetabular wall
fracture as described.
3. Surrounding high-density material consistent with hematoma.
4. Mildly distracted right posterior iliac bone fracture extending into the
fibrous portion of the sacroiliac joint. Mild asymmetric widening of the
right sacroiliac joint is consistent with diastasis.
5. Right lower quadrant anterior abdominal wall contusion.
6. Small volume free fluid in the pelvis. Radiology showed 1. No fracture, dislocation, or joint effusion.
2. Soft tissue edema and locules of air are partially visualized in keeping
with recent external fixation placement. PELVIS (AP ONLY) showed Interval reduction of right femoroacetabular joint dislocation.
Redemonstration of pelvic fractures. PELVIS (AP, INLET AND OUTLET) showed Images obtained for surgical purposes. PELVIS W/JUDET VIEWS (3V) was done. Radiology showed 1. Right hip dislocation with comminuted fracture of the right acetabulum
likely involving the anterior and posterior columns.
2. Asymmetric right sacroiliac joint and symphysis pubis.
3. No evidence of traumatic injury in the chest. No pneumothorax.
NOTIFICATION: The findings were discussed with the trauma team, M.D. by
___, M.D. in person on ___ at 11:23 am, at the time of
discovery of the findings. The patient was diagnosed with Displaced transverse fracture of right acetabulum, init, Car driver injured in collision w car in traf, init. The patient was treated with ORIF. At the time of discharge, the patient had acetablular 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 an acetabluar fx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehabilitaion ___ 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
TDWB in the RLE extremity, and will be discharged on lovonox 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: ___ year old female presents with sore throat for five days, and
now with several days of pain on left side of mouth. It is
located especially around left upper wisdom teeth. She was
diagnosed clinically and treated for strep pharyngitis with
pencillin, for four days now. She had fever until yesterday, and
has not had one since. She is not vomiting and can tolerate
small amounts of PO, but having pain on swallowing. She feels
her voice is slightly muffled. She relates that several years
ago while in ___ she became very ill after having a sore
throat. She is unsure of the cause. CT SINUS/MANDIBLE/MAXILLOFACIAL W/ CONTRAST Q1217 CT HEADSINUS showed 1. No focal fluid collection identified.
2. Enlargement of both palatine tonsils and adenoids compatible with
tonsillitis and adenoiditis. Bilateral cervical lymphadenopathy is likely
reactive.
3. Paranasal sinus disease primarily involving both maxillary sinuses. The patient was diagnosed with Acute tonsillitis, unspecified, Other forms of stomatitis. At the time of discharge, the patient had Acute pharyngitis with mucositis. The patient was given written instructions concerning 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 hearing loss s/p cochlear implant presenting with acute
pharyngitis and failed outpatient therapy with ongoing
difficulty tolerating PO.
# Acute pharyngitis: Admitted with bandemia though no overt
leukocytosis. With subjective fevers at home, and sore throat
preceded oral ulcers. Most likely viral process given chronicity
and slow improvement, however given Centour criteria will
complete course of antibiotics. Initially given PCN as
outpatient, transitioned to Unasyn and then to amox-clav
suspension. Tolerating it well upon discharge with improvement
in symptoms. No cough. HIV Ab sent and negative, VL pending at
discharge. GC/C throat pending, RPR pending. Monospot negative.
Primary HSV infection was also considered, however visible ulcer
healing and unlikely to provide good lab sample.
- follow up with PCP within one week
- complete abx
- f/u pending labs - per patient request will contact her via
secure email given difficulty with phone conversations</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with rheumatic heart disease, mild AS ___ cm2), mild
AI, mod MR, severe TR, HTN, HLD, RCC s/p resection who presents
with dyspnea, recently discharged after acute on chronic
congestive heart failure, atrial fibrillation s/p
cardioversion,and rash thought to be secondary to lisinopril.
Course also complicated by bradycardia and hypotension with
large rectus sheath and pelvic hematomas, likely ___ heparin gtt
after cardioversion. Radiology showed 1. New moderate interstitial pulmonary edema.
2. Further evaluation of the previously seen right hilar adenopathy is
necessary after resolution of acute symptoms. Radiology showed No evidence of acute intracranial injury or fracture. Radiology showed 1. No cervical spine fracture or acute malalignment.
2. Unchanged multilevel degenerative disease and mild multilevel
anterolisthesis.
3. Diffuse interstitial septal thickening in the imaged upper lungs,
compatible with but not diagnostic of pulmonary edema, and partially imaged
bilateral pleural effusions. Please correlate with any symptoms of left heart
failure. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC. At the time of discharge, the patient had primary diagnosis: acute on chronic diastolic congestive heart
failure exacerbation, tricuspid regurgitaton, hypertension
secondary diagnosis: atrial fibrillation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with rheumatic heart disease (mild AS, mild AI, mild-mod MR,
TR), dCHF, afib s/p cardioversion on amiodarone, HTN, HLD who
presents with dyspnea likely ___ to acute on chronic diastolic
CHF exacerbation.
# acute on chronic diastolic CHF - Recent echo in ___ with
normal EF. Patient's history and exam consistent with volume
overload. Patient was recently started on a prednisone taper
which may have contributed to fluid retention. Patient reported
being complaint with low sodium diet and taking all her
medications as prescribed. There were no localizing s/s of
infection. Patient was diuresed with 20 mg IV lasix boluses. She
was transitioned to 10 mg of torsemide however diuresed too much
to this dose and developed mild ___. Ultimately she was
transitioned to 10 mg po lasix. She was also switched from
metoprolol to carvedilol for improved blood pressure control.
Patient was euvolemic at time of discharge. Discharge weight was
62.3 kg.
# atrial fibrillation - Patient noted to have new dx of Afib
during previous admission. On that time she was started on an
amiodarone load. She was initially given xarelto given her
CHADS of 3 however given rectus sheath and pelvic hematomas she
was discharged off anticoagulation. On presentation, she was in
SR with frequent ectopy. She was completed her amiodarone load
and was transitioned to amiodarone 200 mg daily at time of
discharge. She will need to discuss further with her PCP and
cardiologist when it is safe to start anticoagulation.
#HTN: Patient had difficult to control HTN on 4 agents at home
prior to last admission. However due to transient hypotension,
she was discharged home on reduced dose of anti-hypertensives.
SBP 160's on admission. Her losartan was increased from 50 to 75
mg daily, and she was switched from metoprolol to carvedilol
12.5 mg BID. She was continued on her home felodipine. Blood
pressures were improved at time of discharge.
#leukocytosis: Pt with wbc 13.5 on presentation with no signs or
symptoms of active infection. She completed her previously
prescribed course of keflex for UTI. It was felt that her
leukocytosis was most likely ___eing treated for UTI with 7-day course of keflex, currently
day 6. Leukocytosis likely secondary to PO prednisone course.
- continue to monitor for signs of infection
- prednisone taper: 20mg daily ___, 10mg daily ___
#Skin rash: Skin bx shows evidence of hypersensitivity reaction.
Has been started on topical clobetasol and hydrocortisone per
___ clinic, with sarna lotion and hydroxyzine prn
pruritis. Patient could not tolerate hydroxyzine due to
oversedation. Rash does not appear to be improving despite
discontinuation of lisinopril and therefore was recently started
on a prednisone taper. She was continued on her previously
prescribed course. She is scheduled to follow up with
dermatology.
# s/p fall: Patient had mechanical fall at home which resulted
in bruising to her face. She had a CT head and Cspine which
showed no acute process. She was evaluated by physical therapy
and discharged home with ___.
#HLD: continued lovastatin
#OA: Continued home acetaminophen 650mg BID prn pain.
Transitional Issues:
- follow up volume status. diuretic regimen may need further
adjustment
- repeat electrolytes at follow up appointment on ___
- discuss if and when it is safe to start anticoagulation for
atrial fibrillation
- follow up blood pressure, medications may need further
adjustment
- follow up with dermatology regarding rash
- blood culture pending at time of discharge
- patient full code during this admission
- contact: ___ (husband) ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ woman with longstanding history of
polycythemia ___, status post allogeneic transplant with
development of AML, now 6 weeks following her ___ cycle of
Dacogen. Radiology showed Possible small infection, such as viral pneumonia in left mid lung
on background of chronic interstitial abnormality.
Change from preliminary to final report posted to ED dashboard at 11:20 on
___ and page sent to Dr ___ by Dr ___. Radiology showed 1. No evidence of active infection.
2. Stable left upper lobe peribronchial nodules.
3. Splenomegaly. Radiology showed 1. Small amount of fluid in the left posterior ethmoid air cells and right
sphenoid sinus improved from ___. Radiology showed Successful repair of a right internal jugular Hickman catheter. The hub was
sent for culture. Radiology showed Successful removal of right IJ Hickman with tip sent for culture. Radiology showed No relevant change as compared to ___.
Known left upper lobe ___ opacity. No new parenchymal opacities.
Known scars at the right lung base, calcified in part.
A calcified structure within the superior vena cava and brachiocephalic vein,
likely corresponds to a calcified thrombus. The superior vena cava is not
enlarged.
Heterogeneous and coarse bony structure. Radiology showed 1. Persistent thrombus at the origin of the right jugular vein with a lobular
appearance of the vein at this level, unchanged in size and appearance from
MRV dated ___. Again seen, are streaky calcifications within the
right subclavian and superior vena cava likely representing calcified
thrombus.
2. No abnormal fluid collections or cervical lymphadenopathy. Radiology showed Uncomplicated placement of a right-sided triple lumen temporary pheresis
catheter. Catheter ready to use at this time. Radiology showed No clear findings on noncontrast exam to suggest pyelonephritis or other
etiology of patient's back pain. Radiology showed Subcentimeter hyperechoic lesion within the upper pole of the right kidney,
likely representing either a collapsed cyst or tiny angiomyolipoma. Postvoid
residual of 123 cc. Chest AP portable single view. showed Apparently old interstitial changes observed on previous
examinations. No evidence of new acute infiltrates in this single AP chest
view examination. Evaluation of the patient with polycythemia ___, VRE
bacteremia and aortic valve endocarditis and worsening sore throat. Question
of pneumonia.
COMPARISON: ___ neck CT; CT abdomen from ___
and CT chest from ___ as well as multiple prior chest CTs
dating back to ___.
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen without administration of IV contrast. Axial images were reviewed in
conjunction with coronal and sagittal reformats.
FINDINGS:
Assessment of the mediastinum demonstrates no pathologically enlarged
mediastinal, hilar or axillary lymph nodes. Anterior mediastinal distortion
is related to prior mastectomies with stable appearance as compared to prior
examination. No new pericardial or pleural effusion is demonstrated. The
imaged portion of the abdomen reveals no interval change as well as
re-appearance of splenomegaly.
Airways are patent till the subsegmental level bilaterally. The central
venous line tip terminates in the cavoatrial junction.
The assessment of the bones demonstrates diffuse osteopenia as well as a
mixture of sclerotic and lytic lesions, unchanged since the prior study. No
compression fractures or new bone lesions are demonstrated on the current
examination. Overall, the appearance is similar to ___, although
minimal progression cannot be excluded. Findings might be attributable to
myelofibrosis.
Assessment of the lungs demonstrates unchanged left upper lobe nodular
conglomerate, no new nodules or consolidations to suggest interval development
of infectious process and multiple pulmonary nodules stable since recent prior
examinations. was done. Radiology showed Mucus-retention cysts in the left posterior ethmoid and right
sphenoid air cells with only trace mucosal thickening elsewhere, not
significantly changed since the recent study dated ___. There is no
evidence of acute inflammatory disease or bone destruction. Radiology showed The right IJ could not be evaluated over patient's dressing. The
remainder of the study is normal without evidence of right upper extremity
DVT. These results were telephoned to Dr. ___ by ___ at 1:05 p.m.,
___. Right-sided central venous line placement.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The right internal jugular line tip is at the level of low SVC/cavoatrial
junction. The left subclavian line tip is at the level of low SVC. Heart
size and mediastinum are stable. Bilateral basal areas of scarring are
stable. was done. Radiology showed Interval improvement in lung volumes since ___ with no new
acute process such as pneumonia, pulmonary edema, or pneumothorax. Radiology showed No radiographic evidence for acute cardiopulmonary process. Radiology showed No evidence for septic emboli or embolic infarct. Radiology showed Uncomplicated conversion of a right-sided triple-lumen catheters to a 23 cm
tip to cuff tunneled double lumen catheter via the internal jugular vein. The patient was diagnosed with FEVER, UNSPECIFIED. The patient was treated with Trans-Esophageal Echocardiogram (___).
Right internal jugular triple-lumen temporary non-tunneled
pheresis line (___).
Tunneled double-lumen line (___).
Bone marrow biopsy (___).. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
1. AML with preceding polycythemia ___ and secondary
myelofibrosis
2. VRE Bacteremia
3. VRE Aortic Valve Endocarditis
4. Moderate to Severe Aortic Regurgitation
5. Anemia secondary to GI Bleeding
6. Adrenal Insufficiency
7. UTI
SECONDARY DIAGNOSIS:
1. Chronic GVHD with Cutaneous Manifestation
2. Diabetes Mellitus Type 2
3. Pulmonary MALT Lymphoma
4. Vertigo
5. Retinopathy ___ GVHD/AML. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ACTIVE ISSUES
# AML with preceding polycythemia ___ and secondary
myelofibrosis: Pt is s/p matched unrelated nonmyeloablative stem
cell transplant with pre-conditioning on Flu/Bu/ATG (D0
___. Pt was given Cycle 7 of Decitabine (Day 1, ___
on this admission. She was continued on atovaquone, acyclovir,
and ciprofloxacin for neutropenia prophylaxis. Her counts
remained low throughout the admission, but platelets stabilized
around C7D32. Patient is being discharged with close follow-up
with Dr. ___ transfusions as an outpatient, if necessary.
# VRE bacteremia/endocarditis: Pt has a history of multiple
complicated infections including VRE bacteremia resistant to
daptomycin. BCx on this admission grew VRE sensitive to
linezolid. As such, the pt's initial central line was pulled by
___ on ___. She underwent several initial TTEs w/o evidence of
vegetation. Given repeat positive blood cultures, pt had TEE on
___ which showed aortic valve endocarditis and severe AR.
The pt's case was discussed at length with the patient,
cardiology, cardiac surgery and infectious disease. It was
decided that the pt had a very high ___ mortality at
30%. Pt was without evidence of interval prolongation on EKG
throughout hospitalization. Given that she did not meet valve
replacement criteria on this admission, the pt was medically
optimized. The pt was continued on IV linezolid for 6 weeks from
the first negative culture ___ to ___. A repeat TEE on
___ showed no evidence of abscess or discrete vegetations. Upon
discharge, the patient will have follow-up with Dr. ___
cardiology. At that visit, the possibility of TAVR for
compassionate use should be discussed.
# Aortic regurgitation: ___ VRE endocarditis occurring on this
hospitalization. Lisinopril was initially continued for
afterload reduction in order to best reduce regurgitant flow. Pt
had low normal blood pressures, however, during this
hospitalization. As such, her lisinopril was held. Throughout
the hospitalization, the pt was without signs of CHF. She was
able to ambulate with minimal dyspnea on exertion, which the pt
stated was near her chronic baseline. Her dry weight was
recorded at 210 lbs on this admission. Pts weight upon
discharge was 212.2 lbs.
# GI Bleed: Following administration of decitabine, pt was noted
to have repeated dark melanotic stools in addition to an acute
worsening of her chronic anemia without appropriate increase to
pRBCs or plt products. Pt has a hx of GI bleeding related to
treatments with decitabine. Her most recent EGD was in ___
which was negative for source. She was started on IV protonix
and supportively transfused. GI bleeding resolved with
maintainance of plts > 50. The pt remained hemodynamically
stable throughout her hospital course.
# Lightheadedness: During hospital course, the pt began to
describe new lightheadeness with position changes. Her
orthostatic vital signs were normal and her vital signs remained
within normal limits without signs of hypoperfusion. She was
without visual changes, numbness/tingling or weakness of
extremities, or other neurologic deficit on exam. As the pt's
symptoms were somewhat concerning for centrally caused vertigo
in the setting of new aortic valve endocarditis, and MRI brain
was done, which returned negative for evidence of embolic event
or other neurologic lesion. To rule out a significant cardiac
change, a repeat TTE was obtained on ___, which showed
preserved LVEF, moderate to severe AR, and trivial pericardial
effusion. A steroid taper had been initiated during
hospitalization, which corresponded with pt's new symptoms.
Given that she had been chronically on steroids, it was thought
that her symptoms were ___ adrenal insufficiency. As such, she
was placed on higer dose steroids at 10 mg PO with resolution of
symptoms. Her chronic prednisone was reduced to 9 mg at time of
discharge. The patient should continue to taper her steroids by
1 mg per week, down to 5 mg PO QD.
# Enterobacter UTI: On admission, pt reported urinary
"pressure." Her UA was unremarkable but urine culture grew
nearly pansensitive enterobacter. Repeat urine culture growing
citrobacter sensitive to macrobid. Pt received 5 day course of
macrobid with repeat urine cultures negative x 3. Despite what
was thought to be adequate treatment for her UTI, she continued
to have fevers while also on linezolid for her VRE bacteremia.
It was, therefore, thought that the pt could have possible
ongoing UTI, and she was subsequently started on a course of
meropenem. She completed the course with resolution of symptoms.
Urology was consulted for ongoing urinary pressure and
determined that pt was having residual dysuria in the setting of
recently treated UTI. On ___gain noted similar
urinary pressure. Urine culture again grew out citerobacter
sensitive to meropenem. She was, therefore, started on meropenem
and completed a 5 day course on ___. Her symptoms of urinary
pressure resolved shortly thereafter.
# Vascular access: Pt has limited vasculature access options
given complicated medical co-morbidities and multiple
hospitalizations. The pt had a previous central line removed ___
ongoing bacteremia and a new right internal jugular central line
placed on this admission. A permanent tunneled line was
considered during hospitalization. Once the patient completed a
full 6 week treatment course with linezolid for her
endocarditis, the decision was made to proceed with placement of
a new line. A tunneled line was placed on ___ without
complication.
# Upper extremity DVT: Pt has a history of non-occlusive left
brachial vein thrombus in ___ which resolved with course of
heparin while inpatient. On ___, pt was found to have
thrombus in the R internal jugular vein. Given persistent clot
and increased right upper arm swelling, she was placed on
chronic Lovenox at 60 mg twice per day. On this admission, pt
complained of worsening left arm swelling. Left arm
non-invasive ultrasound revealed no visible thrombus in right
upper extremity, however the R IJ was adequately visualized
given the presence of R IJ line (unable to remove line for study
given high risk of inability to place additional line as stated
above). The pt's Lovenox was temporarily discontinued in the
setting of worsening thrombocytopenia and GI bleed related to
cycle 7 of decitabine. At time of discharge, the pt's Lovenox
continued to be held due to ongoing thrombocytopenia and should
be restarted at the discretion of Dr. ___ as an outpatient.
# EBV infection: EBV Viral load was sent on ___ and returned
elevated. A repeat EBV PCR was sent on ___ and ___
which returned undetectable on assay.
# Diarrhea: Pt noted to have several episodes of diarrhea in
hospital course. Multiple C. diffs tests and stool studies were
sent and returned negative. Likely related to antibiotics and
other ongoing medications.
# Sore throat/cough: Patient developed dry non-productive cough
and sore throat during admission without sinus congestion or
nasal discharge. At that time, pt was already on linezolid and
meropenem for her bacteremia and UTI. Patient refused
respiratory viral swab. CT chest and sinus were unchanged from
prior with no clear active infectious process. She completed a
course of azithromycin for atypical coverage with resolution of
symptoms.
CHRONIC ISSUES
# Pulmonary MALToma: Pt had previously received intermittent
Rituxan infusions, last given on ___. CT Chest on
admission revealed stable nodules with no evidence of MALT
lymphoma progression.
# Chronic GVHD/skin: No evidence of active GVHD during
hospitalization. She was continued on her physiologic prednisone
dosing, given adrenal insufficiency.
# Chronic venous stasis: Pt has hx of chronic lower extremity
edema likely ___ venous insufficiency. Pt without evidence of
edema on admission and as such, her torsemide was discontinued.
# DM type II, on insulin: Pt had several episodes of
hypoglycemia on admission. As such, her insulin regimen was
adjusted appropriately. At discharge, she was sent home on
glargine 10U with breakfast and NPH 10 U with breakfast plus a
humalog ISS.
# Sinus tachycardia: Pt without evidence of ongoing sinus
tachycardia. As such, her diltiazem was discontinued.
# Hearing loss: Stable. Monitor and consider audiogram as
outpatient.
# Vertigo: Stable. Continued on meclizine.
# Insomnia: Stable. Continued trazadone and lorazepam as needed</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with PMH of NASH cirrhosis s/p liver and kidney
transplant (___), post-strep GN, DM, HTN, who presents with
persistent cough in setting of failure of multiple antibiotic
trials for pneumonia, as well as creatinine to 3.7. The patient
reports feeling unwell for several months, with persistent cough
which has been treated with several courses of antibiotics as
per PCP. He also has a current gout flare, which he reports
started three days ago and has been improved with febuxostat
treatment; however, when the pain initially came on he took two
doses of naproxen. Of note, the patient had full set of labs
sent by Dr. ___ renal transplant and his creatinine
was up to 3.7 from a baseline of 1.8-2.5.
He also reports that he has had a productive cough for the last
6 months. He has been treated with various inhalers and three
courses of antibiotics, most recently doxycycline of which he is
on day 5 of 10 currently. He does not remember having a CT scan
recently for this.
In the ED, initial VS were: 98.1 50 119/68 18 95% RA
Exam notable for: not documented
Labs showed: Creatinine 3.3, hgb 11.7, INR 1.2, lactate 2.0, WBC
8.1
Imaging showed: Renal USN: unremarkable with slightly improved
resistive indices since the prior examination. CXR with hazy
right upper lobe opacity oncerning for PNA, patchy left basilar
opacity atelectasis vs. infection.
Received: Tylenol ___ mg, Mycophenolate (ordered, not given), 1
L NS then 75 cc/hr.
Hepatology and renal transplant were consulted and recoemmended
admission under Dr. ___ to a medicine team.
Transfer VS were: 98.7 81 115/96 18 93% Nasal Cannula
On arrival to the floor, patient reports continued productive
cough. He denies any recent fevers/chills, chest pain, shortness
of breath, abdominal pain. Otherwise he corroborated the above
history.
REVIEW OF SYSTEMS:
(+)PER HPI CT chest without contrast showed 1. Multifocal pneumonia with most prominent area of consolidation in the right
upper lobe, as noted on the recent prior chest radiograph.
2. Distal subsegmental bilateral lower lobe bronchiectasis with areas of
mucous inspissation and plugging.
3. Splenomegaly.
4. Bilateral renal atrophy.
5. Fat containing ventral abdominal hernia.
6. Somewhat nodular contour of the liver. Correlate clinically for signs of
cirrhosis. The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Acute Kidney Injury in Setting of Chronic Kidney Injury
Community Acquired Pneumonia
SECONDARY DIAGNOSES:
Chronic Cough
COPD
S/p renal and liver transplant on immunosuppression
Diabetes Mellitus Type 2
Hyperkalemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ retired ___ of ___ with a h/o
liver/kidney transplant ___ on MMF/tacro immunosuppression who
presented with ___ and a 6 month productive cough s/p multiple
outpatient antibiotic courses, found to have ___ iso NSAIDs for
gout flare and radiographic multifocal infiltrates on CT
imaging.
#Cough
#Community Acquired Pneumonia : 6mo cough with poor response to
abx in ___ and again in ___. Presented on day 5 of 10 days of
doxycycline. CXR concerning for RUL opacity and chest CT showing
multifocal pneumonia. Given inadequate response to outpatient
antibiotics possibility of simple recurrence of community
acquired pneumonia in immunosuprressed patient vs silent chronic
recurrent aspiration vs unlikely inflammatory process such as
COP. ID and pulm teams were consulted, full fungal diagnostics
pending at time of discharge. TB was indeterminate with poor
mitogen stimulation result, in this context viewed as
unconcerning. Would recommend completion of aspiration studies
as outpatient. He will complete antibiotic course with
levofloxacin ___ for seven day course of abx (received
ceftriaxone and azithromycin while in hospital ___ given
procalcitionin consistent with bacterial infection. Albuterol
and advair should be continued as well as acappella valve BID.
# Acute Kindey Injury on Chronic Kidney Disease
# Status post kidney and liver transplantation in ___:
Crt 3.3 on admission versus baseline 1.8-2.5. Suspect pre-renal
injury at presentation due to combination of NSAIDs, hemodynamic
changes, diuretics. Review of biopsy from ___ at time of
transplant notes already moderate IFTA and significant donor
vascular disease. DSA screen negative, renal ultrasound was
unremarkable and urine protein/creatinine 0.1, BK virus screen
negative. Patient's mycophenlate was continued, prograf was
decreased to 0.5mg Q12hrs given trough goal of 4.0 He will have
levels checked ___ and faxed to Dr. ___.
CHRONIC ISSUES
# Hyperkalemia: managed with Florinef 0.1 mg once daily, would
be hesitant to resume prior Lasix given recent acute kidney
injury.
#HTN: Continued home carvedilol and amlodipine with holding
parameters.
#BPH: Continued home doxazosin
#HLD: Continued home fenofibrate
#Iron deficiency anemia: may resume repletion as outpatient
#DM2: may resume home regimen as outpatient, insulin regimen was
reduced in hospital initially in setting ___
TRANSITIONAL ISSUES
- Please arrange Pulmonary follow-up (___) with repeat
chest CT in ___ wks (___), if opacities remain would
recommend bronchoscopy
- would obtain video speech and swallow to ensure no silent
aspiration
- would consider Outpatient GERD evaluation, including pH probe
- follow-up pending serum fungal markers
- complete antibiotic course with levofloxacin (last day
- continue flutter valve BID
- patient should avoid NSAIDs at all times, even with gout
flares
- please ensure tacrolimus level and creatinie checked on
___ at ___, Please fax to ___
ATTN: Dr. ___ MEDICATIONS: holding lasix, no known cardiac history
CHANGED MEDICATIONS: Prograf changed to 0.5mg q12hrs</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with severe aortic stenosis presents with shortness of
breath, melena, HCT 18.9 from 37 (___). CTA ABD AND PELVIS showed 1. No evidence of GI bleed.
2. 2.1 cm lesion along the greater curvature of the stomach. Contains
calcifications but also has a soft tissue component. As 2 additional
completely calcified lesions are seen in this location these may represent
calcified, torsed epiploic appendages, however the appearance of the largest
lesion is unusual due to its larger soft tissue component in 3 months followup
with MRI is recommended to exclude a gist tumor.
3. Small hiatal hernia.
4. A small focus of soft tissue at the proximal-most portion of the left
inguinal canal is nonspecific. Correlation with prior surgery is recommended.
5. 3 mm pulmonary nodule at the left lung base.
RECOMMENDATION(S): 1. 3 months followup MRI for evaluation of lesion along
the greater curvature of the stomach
2. The ___ society pulmonary nodule recommendations
are intended as guidelines for follow-up and management of newly incidentally
detected pulmonary nodules smaller than 8 mm, in patients ___ years of age or
older. Low risk patients have minimal or absent history of smoking or other
known risk factors for primary lung neoplasm. High risk patients have a
history of smoking or other known risk factors for primary lung neoplasm.
In the case of nodule size <= 4 mm: No follow-up needed in low-risk patients.
For high risk patients, recommend follow-up at 12 months and if no change, no
further imaging needed.
NOTIFICATION: An email sent to the to ED QA nurses by Dr. ___ at 11:01 Chest radiograph. showed Bibasilar and left upper lobe opacities in the appropriate clinical setting
are concerning for pneumonia.
RECOMMENDATION(S): Followup of the patient 4 weeks after completion of
antibiotic therapy is required, in particular to document the resolution of
left upper lobe perihilar opacity. If findings are unchanged, assessment with
chest CT is required.
Additionally giving the presence of left lower lobe pulmonary nodule, followup
with chest CT in 3 months based on the size of the left lower lobe nodule is
recommended as well. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified, Chest pain, unspecified, Anemia, unspecified. The patient was treated with ___ EGD. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
- Duodenal/peptic ulcer disease
- Type II NSTEMI
- Melena
- Anemia secondary to bleeding
- H. pylori infection
SECONDARY DIAGNOSIS:
-HTN
-HLD
-Carotid Artery Stenosis
-Prostatic Adenocarcinoma s/p brachytherapy
-alcohol use disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ PMH of severe aortic stenosis present with shortness of
breath, melena and significant hemoglobin drop (12.4 on ___ to
6.0 on ___ and developed Type II NSTEMI. He was admitted to
the MICU for monitoring (___).
# GI Bleed: Pt presented with melena and a Hgb drop of
12.4->6.0) in the setting of new and significant NSAID use and
drinking one bottle of wine daily. He received 4 units of PRBCs
and underwent an EGD in the MICU on ___. Unfortunately he
became hypotensive at the onset of sedation and the procedure
was aborted. Later that day he developed T-wave inversion on EKG
with a rise in troponin. Cardiology was consulted and believed
that this was secondary to demand ischemia in the setting of an
acute GI bleed. He was transfused another unit of blood to keep
the Hgb above 9.0. He was maintained on PPI BID per GI on
transfer out of the MICU. ___ ___ he had another melanotic
bowel movment which prompted ___ AM EGD. EGD showed bleeding
ulcer in duodenum, which was cauterized and injected with
epinephrine. He was transferred to medicine for monitoring. On
the medical floor, his hemoglobin was stable, 8.9-9.9 with
discharge hemoglobin 9.3 g/dL. He no longer had melanotic
stools. Per GI recommendations, he received Pantoprazole 40 mg
PO Q12H. He was also instructed to discontinue NSAID and alcohol
use. H. pylori IgG test was positive by ___ ___, for
which he was started on a 14 day course of clarithromycin and
amoxicillin in addition to his BID PPI. Per GI and At___
cardiology recommendations, his aspirin dose was downtitrated
and he was restarted on Aspirin 81 mg daily on ___.
# Community acquired pneumonia: CXR showed bilateral opacities
with a recent 5 day course of levofloxacin. He was treated with
ceftriaxone and azithromycin for 1 day. Since he was clinically
asymptomatic with no cough or fever, did not continue to treat.
He is recommended to have repeat imaging in 4 weeks to confirm
resolution.
# Type II NSTEMI: Active angina with lateral ST depressions,
likely demand ischemia in the setting of anemia vs hypotension
during EGD attempt. Troponin rise on ___ to 0.28 and CK-MB 19.
Trop rose to 0.38 but downtrended ___. CK-MB downtrended ___
to 11.
# Severe aortic stenosis: Patient underwent evaluation by
cardiac surgery on ___ and was deemed a moderate risk for TAVR
surgery. He will have further workup as an outpatient for TAVR
per At___ attending. Medicine spoke with and confirmed that ___
___ will be coordinating his follow up care for the AVR. GI
recs that work up for TAVR that requires anticoagulation be
completed after two weeks (after ___
# Leukocytosis: Initially WBC of 13.3 with predominance of
PMNs, felt to be reactive. CXR showed bilateral opacities with
recent completion of a 5 day course of levofloxacin ending on
___. He was afebrile and without cough, and upon transfer out of
the MICU, his WBC had resolved.
#HTN: He was normo- to hypertensive throughout admission. He was
restarted on amlodipine 10 mg PO daily and carvedilol 6.25 PO
BID with instructions to restart home lisinopril and
chlorthalidone in outpatient setting.
=====================
TRANSITIONAL ISSUES
=====================
# Medication changes. Started on pantoprazole 40 mg PO Q12H.
Downtitrated aspirin 325 mg to 81 mg daily. Atorvastatin
downtitrated to 20 mg daily while on macrolide therapy; please
consider uptitrating after completion of antibiotic course.
Chlorthalidone and lisinopril temporarily halted in the setting
of acute GI bleed; will be restarted individually as outpatient.
# Antibiotic course. Will require amoxicillin 1 g BID and
clarithromycin 500 mg BID x14 days (end ___ for treatment
of H. pylori. Please monitor for signs of rhabdomyolysis while
on concurrent macrolide and statin therapy.
# Repeat EGD. EGD ___ showed irregular Z-line, with concern
for ___, needs EGD follow up
# Repeat imaging (CXR, MRI abdomen, CT chest). Please f/u CXR in
4 weeks after resolution of pneumonia. CT ABD/Pelvis showed
lesion along the greater curveature of the stomach concerning
for possible GIST; please order 3 month followup MRI. Incidental
pulmonary nodule 3 mm at left lung base: High risk patient
(extensive smoking history), please follow-up at 12 months and
if no change, no further imaging needed.
# Severe aortic stenosis. Will be contacted by ___ team for
outpatient work-up.
# Communication/HCP: ___ ___
# Code: Full, confirmed </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ ___ year old male hx of dementia, CLL w
nasopharyngeal mass (SLL) hypogammaglobulinemia without frequent
infections, possible Normal Pressure Hydrocephalus status-post
ventriculoperitoneal shunt w increased agitation. UA negative
but
ARF with cr 2.8, copious stool output and colitis on CT. Patient
is not answering questions here in the ED. No other hx able to
be
obtained. Transferred to ___ per family request. SHUNT SERIES AP AND LAT SKULL, AP CHEST, AP ABDOMEN showed No catheter break or kink. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No Mass, or intracranial hemorrhage.
2. VP shunt in stable position terminates in the right lateral ventricle,
without Findings of over shunting or recurrent hydrocephalus.
3. Left pansinusitis, likely due to chronic obstruction of the drainage
pathways, and possible contribution from odontogenic spread of infection to
the Left maxillary sinus.
4. Asymmetry of the nasopharyngeal soft tissues with effacement of the fossa
Rosenmuller, with chronic Left mastoid effusion, could be clinically
correlated. The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had C difficile 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>___ w/ cognitive impairment, gait instability, HTN, depression,
urinary incontinence, hearing loss, IBS-D, NPH s/p VP shunt, and
CLL (not on therapy) who is presenting from assisted living with
confusion, somnolence, and diarrhea found to have severe C
difficile infection.
#Diarrhea
#C difficile infection
#Leukocytosis
Presents from assisted living with encephalopathy. At baseline
he is sometimes disoriented, but alert and appropriate and very
hard of hearing. CT abdomen in ___ showed mild colitis and
at ___ CDiff PCR and toxin both positive. Of note, he received
ciprofloxacin for UTI in late ___. No prior history of CDI.
He was stated on oral vancomycin and his leukocytosis improved
back to his baseline of ___. He will complete a 10d course of
oral vancomycin (___). His ___ blood culture was NGTD at
discharge and UCx was negative.
#Encephalopathy
#Hearing loss
Presented with confusion most c/w delirium due to infection.
Shunt series and CTH on admission unremarkable. No focal neuro
deficits. His hearing loss contributed to his confusion and also
inability to participate in mental status exam. Once his hearing
aid was put in place his confusion and ability to communicate
with staff improved.
___
Presented with Cr 2.3 from baseline 1.1. Initially improved with
IVF and treatment of diarrhea to 1.0, then increased to 1.3 on
___ (though with downtrending BUN) and then with encouragement
of PO intake Cr went back down to 1.1. His lisinopil was held
and will be resumed on discharge. Cr at discharge 1.1.
#Transaminitis
Mild transaminitis on admission, similar to ___. HCV
negative. HBsAg neg, HBsAb neg, HBcAb neg. Transferrin sat 34%.
Admission CT done at ___ comments on normal appearing liver
in report. Pending at discharge: Hepatitis EBV/CMV serologies.
Workup should be continued as an outpatient.
#CLL
Recently seen by Dr. ___ felt no indication for
therapy
at this time (no B symptoms, no evidence of lymphadenopathy, no
evidence of splenomegaly, no evidence of frequent infections,
and a lymphocyte doubling time on the order of 3 or more years).
Dr. ___ was notified of admission. He was continued on
home acyclovir ppx.
CHRONIC ISSUES
#Depression: Continued venlafaxine, buspirone
#Fecal incontinence: holding home eluxadoline and Imodium given
CDI -- resume once oral vancomycin course is complete
#HTN: held lisinopril, resume on discharge
#CV: ASA 81
>30 minutes spent on discharge planning including face-to-face
patient counseling and coordination of care.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH Dm2,CAD s/p rx stent, ERSD s/p renal transplant ___ p/w
chef complaint of hypoxia. She stated that she has two days of
progressive shortness of breath. She noticed some DOE that
progressively gotten worse to dyspnea at rest. Found to be
hypoxic by EMS in the ___. She notes that she has been
non-complaint with her Lasix regiment (40 PO QDay) because she
was on a cruise. She has stated that was only taking 20 mg PO of
lasix which states for chronic lle. She denies any chest pain or
chest pressure. She noticed some PND last night. +Nausea, +GI
symptom +salt food intake Radiology showed 1. Improved moderate pulmonary edema.
2. Mild cardiomegaly.
3. Unchanged small bilateral pleural effusions. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen with regard
to the bilateral pleural effusions. The moderate cardiomegaly, the moderate
pulmonary edema and the bilateral areas of atelectasis. No new parenchymal
opacity. CHEST (PORTABLE AP)CHEST (PORTABLE AP)i showed Mild pulmonary vascular congestion and mild to moderate cardiomegaly have
improved and pulmonary edema has resolved. Small bilateral pleural effusions,
stable on the left. No pneumothorax. RENAL TRANSPLANT U.S. showed 1. No hydronephrosis. Multiple nonobstructing stones are noted in the
transplant kidney.
2. Patent renal transplant vasculature. The patient was diagnosed with RESPIRATORY ABNORM NEC. At the time of discharge, the patient had Primary
1. Acute Disatolic HF in setting of med non-compliance and
dietary indescretion
2. CKD stage ___ s/p renal transplant
3. new onset pAF : started coumadin. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ PMH CKD s/p renal transplant, DM2, CAD, p/w 3 days onset of
dyspnea in the setting of medication non-compliance and dietary
indiscrestion, transferred to the CCU for presumed CHF
exacerbation.</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 right
breast DCIS s/p right lumpectomy on anastrozole and chronic
abdominal pain followed by GI who presents with chest pain. CTA CHEST WITH CONTRAST showed Left lower lobe subsegmental pulmonary emboli. No pulmonary infarct or CT
evidence of right heart strain. The patient was diagnosed with Other pulmonary embolism without acute cor pulmonale. At the time of discharge, the patient had # LLL Subsegmental Pulmonary Embolus
# Chronic abdominal pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># LLL Subsegmental PE: suspect precipitated by her recent plane
flight of ~4 hours from ___, no other clear inciting factors
- low-risk PE: hemodynamically stable and satting well on RA,
trop negative, BNP wnl, and no evidence of right heart strain on
CTA chest
- initially was started on heparin gtt, discussed with her
primary oncology team (Atrius - Dr. ___ Dr. ___, who
advised DOAC over lovenox
- started ___
--10 mg BID x7 days ___ - ___
--5 mg BID after that ___ - )
--Advised patient to stop taking PRN aspirin (uses for
abdominal pain) in setting of starting systemic anticoagulation
--Dr. ___ treating PE for 6 months, but we would
ultimately defer to Dr. ___ final decision on when to stop
anticoagulation based on patient's cancer status at that time.
# Breast Cancer
- Continued home anastrozole
# Chronic Abdominal Pain: Followed by GI at ___. Here with
multiple chronic abdominal complaints. Overall stable and she
was tolerating PO with benign abdominal exam.
- Continued home remeron, PPI, and miralax
- Follow-up with outpatient GI is already scheduled, has appt on
___ at 0920 w/ Dr. ___
# Chronic blurry vision: stable
- can continue outpatient Ophthalmology f/u if appropriate
# Chronic burning pain in b/l distal LEs (below the knees):
stable
- sounds like a symmetric polyneuropathy
- consider further evaluation and trial of symptomatic treatment
as outpatient
.
.
.
.
================================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Time (and date) the patient was last known well: ___ clock) CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Study is mildly degraded by motion.
2. Grossly stable minimal subarachnoid hemorrhage layering in the left
parietal and right frontal sulci.
3. Within limits of study, no new or increasing hemorrhage.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. In person on ___ at 3:49 am, at the time of discovery of the
findings. CTA HEAD WANDW/O C AND RECONSQ1213CTHEA. D showed 1. Background of moderate atherosclerotic disease affecting intra cranial
vasculature with questionable 2 mm left cavernous segment and right ophthalmic
segment of internal carotid artery could represent small non complicated
aneurysm
2. There is no evidence of vasospasm. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Unchanged trace subarachnoid hemorrhage in the left parietal sulcus and
along the parafalcine right frontoparietal lobe.
2. No new hemorrhagic focus. SECOND OPINION MR NEURO PSO4 MR.
___: ___ year old woman with SAH// Please review outside MRI from ___
for evidence of vascular occlusion, venous vs arterial.
TECHNIQUE: This examination was obtained on an outside institution ___
___) on ___, and submitted for second opinion read
interpretation. Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON None available.
FINDINGS:
There is redemonstration of left parietal sulcal FLAIR hyperintensity
representing known convexal subarachnoid hemorrhage. There is no other
intracranial hemorrhage. Small susceptibility there are foci of high-signal
intensity identified on the DWI sequence, which are difficult to observed on
the corresponding ADC map are suggesting of small areas of acute ischemia
(series 2, image 65, 67, and 70). Multiple cortical based foci of signal void
at susceptibility weighted images representing old microhemorrhages. Although
nonspecific these findings can be seen in patients with cerebral amyloid
angiopathy.
Taking into consideration limitation of the nonenhanced study; no imaging
signs to suggest intracranial vascular malformation or mass lesion. Bilateral
multiple periventricular and deep white matter patchy T2 FLAIR hyperintensity
likely related to mild-to-moderate form of chronic microangiopathy.
Generalized mild parenchymal volume loss with mild enlargement of brain sulci.
There is no evolving hydrocephalus.
It is appear normal, the paranasal sinuses and mastoid air cells are
unremarkable. No aggressive osseous lesions identified.
IMPRESSION:
1. Redemonstration of left parietal convexal subarachnoid hemorrhage with
bilateral cortical old microhemorrhages.
2. Subcentimeter foci of high-signal intensity identified on the DWI images
as described above, suggesting acute ischemic changes, however there are too
small to characterize in the corresponding ADC maps.
3. Multiple cortical foci of magnetic susceptibility suggest chronic micro
hemorrhagic changes. Although nonspecific these findings can be seen in
patients with cerebral amyloid angiopathy.
4. No imaging signs to suggest underlying vascular malformation or mass
lesions. showed 1. Redemonstration of left parietal convexal subarachnoid hemorrhage with
bilateral cortical old microhemorrhages.
2. Subcentimeter foci of high-signal intensity identified on the DWI images
as described above, suggesting acute ischemic changes, however there are too
small to characterize in the corresponding ADC maps.
3. Multiple cortical foci of magnetic susceptibility suggest chronic micro
hemorrhagic changes. Although nonspecific these findings can be seen in
patients with cerebral amyloid angiopathy.
4. No imaging signs to suggest underlying vascular malformation or mass
lesions. The patient was diagnosed with Nontraumatic subarachnoid hemorrhage, unspecified, Unspecified atrial fibrillation, Long term (current) use of anticoagulants. At the time of discharge, the patient had Convexal subarachnoid hemorrhage. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ year old woman with HTN and AFib on
Eliquis/metoprolol/dofetilide who was admitted to the Neurology
stroke service with sudden-onset headache and small convexal
Subarachnoid Hemorrhage. This was most likely secondary to
underlying Cerebral Amyloid Angiopathy, with multiple small
punctate hemorrhages seen on outside hospital imaging GRE
sequences, corroborated by second read at ___. She was also
found to have 2 small aneurysms on CTA. She was evaluated by
Neurosurgery but no intervention was recommended. In the
hospital, she had a headache that improved during her stay, and
her exam was notable for mild left pronation without drift but
was otherwise unrevealing. Workup for a cardioembolic source of
multiple small strokes was unrevealing; a TTE did not show any
evidence of either intracardiac thrombus and blood cultures did
not grow any organisms.
Neurosurgery saw the patient and did not feel surgical
intervention was warranted given the small volume of the bleed.
They also did not think the small aneurysms required clipping or
any further imaging or follow-up. Nimodipine was started but
then held for mild hypotension and since it was a small convexal
bleed.
Her Eliquis was held while she was in the hospital. We will plan
to hold it for 14 days from the date of hemorrhage (___). At
that time, she should have a non-contrast CT scan of her head,
to be arranged by her PCP. At that time, if the blood has
resorbed, she can restart Eliquis 2.5mg BID. This plan has been
discussed with her PCP. She will also require close control of
her HTN. Her blood pressure was elevated in-house, requiring
addition of amlodipine to her existing regimen of Lisinopril and
metoprolol. All antiplatelet agents should be held.
Of note, she has difficult to control AFib on metoprolol and
dofetilide. Her PCP and cardiologist were in discussion about
possible Watchman placement. If successful, this would obviate
the need for future anticoagulation but will need to be pursued
further as an outpatient.
Her deficits improved greatly prior to discharge and were
notable only for mild left pronation on pronator drift testing.
She will not continue rehab at a ___ center as she has no
significant residual deficits.
- STOP taking Eliquis. Follow up with your PCP before
restarting.
- We are starting you on a bowel regimen to prevent you from
straining when you go to the bathroom. This includes senna,
Colace, and MiraLAX. If you are having loose stools stop taking
these medications. You can take the senna and Colace regularly
to keep your stools soft. You can take MiraLAX when you are
still constipated and needs additional support. Please follow-up
with your primary care provider for the optimal bowel regimen.
- start taking Amlodipine 5mg. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male who was helmeted riding a motor bike up a ramp, made
a jump, turned in the air and missed his landing and landed on
his head. Per report GCS 7 at the scene. MR HEAD W/O CONTRAST showed 1. Innumerable gradient echo susceptibility foci at the bihemispheric
gray-white matter junction with right frontal lobe predominance, as well as
involving the corpus callosum, basal ganglia, mid brain and pons, several with
corresponding slow diffusion, compatible with severe diffuse axonal injury.
2. Tiny focus subarachnoid hemorrhage along the right frontal lobe as well as
trace bilateral intraventricular hemorrhage.
NOTIFICATION: The findings were discussed with Ms. ___, NP
Dr. ___ via telephone on at 2:40 ___ on ___. Radiology showed No acute fracture or dislocation. MR CERVICAL SPINE W/O CONTRAST showed 1. No evidence of cervical spinal cord injury.
2. No ligamentous or osseous injury of the cervical spine. MRI of the brachial plexus without contrast showed 1. The brachial plexus is obscured by extensive edema within the region.
While no tear is directly visualized, this is not excluded. No tear or
avulsion of the cervical nerve roots is detected.
2. Tiny susceptibility posterior and superior to the junction of the middle
and lateral thirds of the right clavicle. Correlation with open wound in this
region would be helpful in consideration of a microscopic foreign body, as no
obvious foreign body was seen on the recent CT. Alternatively this could
represent a tiny focus of gas from prior contrast/IV injection. CHEST (PORTABLE AP)CHEST (PORTABLE AP)i showed Lungs clear. Normal cardiomediastinal silhouette and pleural surfaces. ET
tube and nasogastric tube in standard placements respectively. Although no
fracture is seen, conventional chest radiographs are not sensitive for
detection of chest cage trauma. Regions where there are focal findings of
possible trauma should be clearly marked and imaged with bone detail views. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen. Normal
lung volumes. Normal size of the cardiac silhouette. Normal hilar and
mediastinal structures. No pleural effusions. No pulmonary edema. The
monitoring and support devices are constant in position. CHEST (PORTABLE AP) showed Heart size and mediastinum are stable. There is slight interval progression of
right basal opacity concerning for developing aspiration pneumonia giving the
provided history. The patient has been extubated as well as the NG tube has
been removed. There is no pneumothorax or appreciable pleural effusion. Radiology showed ET and enteric tubes in appropriate position. No definite acute
cardiopulmonary process. CT HEAD W/O CONTRAST showed 1. Tiny hyperdensities in the right temporal, left frontal lobes may represent
hemorrhagic contusions. In the appropriate clinical setting these may
represent diffuse axonal injury.
2. Small hyperdensity in the right frontal lobe may be a small subarachnoid
hemorrhage.
NOTIFICATION: Findings were discussed with the trauma surgery team in person
by ___. CT C-SPINE W/O CONTRAST showed No fracture or traumatic malalignment. CT CHEST/ABD/PELVIS W/ CONTRAST showed 1. Incomplete, nondisplaced right posterior rib fracture.
2. No solid organ or other injuries are seen. The patient was diagnosed with SUBARACH HEM-COMA NOS, FALL-1 LEVEL TO OTH NEC. At the time of discharge, the patient had Closed head injury
Left frontal contusion
Altered mental status
Respiratory failure
Diffuse axonal injury
Pneumonia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This patient came in as an EU Critical. He was evaluated by
trauma surgery in the trauma bay and found priliminarly to have
an isolated head injury. Upon evaluation and examination of the
patient off sedation we documented a GCS of five. Patient was
admitted to the Trauma ICU. He remained intubated and throughout
the night, his exam improved. MRI head was performed which
confirmed ___. He had an increase in temperature and he was
cooled. On ___, his exam improved. C-spine imaging and brachial
plexus imaging were normal. Cooling was stopped and he was
started on precedex.
On ___, he continued to move all extremities and follow simple
commands L>R. He was extubated successfully. A speech and
swallow evaluation was ordered. On ___, patient was alert to
self, month, and year. He followed commands well on the L side,
the RUE and RLE had minimal movement. Speech and swallow
evaluated the patient and he was cleared for a ground solid and
nectar thick liquid diet. ___ was also consulted. Transfer orders
to the floor were written.
On ___ and ___, Mr. ___ remained stable on the floor and
___ continued to consult. Rehab was recommended and screening
begun.
Mr. ___ was discharge to a rehabilitation facility on ___.
At the time of discharge, he was afebrile, hemodynamically and
neurologically stable. Per discharge instructions, he should
follow up with Dr. ___ Neurosurgery. Also, he will need
an outpatient EMG for further assessment of a right brachial
plexus injury.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ gentleman with a h/o locally
advanced pancreatic adenocarcinoma (s/p chemo/XRT, currently
C5D28 Gemcitabine), DM, CAD, Afib on dabigatran, acromegaly, DVT
___, and recurrent biliary sepsis. He was recently admitted
on ___ for septic shock due to cholangitis, during which he
required pressor support. ERCP during that admission drained
frank pus with the previous plastic stent removed. Prior metal
stent was also noted to be occluded, so 2 new stents were placed
with good flow. He was discharged on ___ and has continued
Cipro/Flagyl. Radiology showed 1. Unchanged position of the biliary stent with stable moderate-to-severe
left hepatic biliary duct dilation and slight interval increase in the mild
right hepatic biliary duct dilation. No evidence of abnormal ___
enhancement. No evidence of a hepatic abscess.
2. Large amount of intra-abdominal ascites, unchanged from the prior exam.
3. Unchanged appearance of the pancreatic mass.
4. Unchanged appearance of the chronic portal vein thrombosis.
5. Unchanged position of the gastric band with free tubing terminating in the
anterior left mid abdomen; recommend correlation with prior surgical history.
6. Mild thickening of the bladder wall, possibly due to secondary
inflammatory changes, though cystitis is difficult to exclude. Recommend
correlation with UA. Radiology showed Increased right basilar opacity, potentially atelectasis but
infection is not excluded. Small right-sided pleural effusion. Radiology showed Successful crossing of the left hepatic duct stricture and
metallic stent placement. Radiology showed 1. Normal bowel gas pattern without evidence of ileus or obstruction.
2. The diaphragms are never included in the field of view, however there are
no secondary signs of free air.
3. Small amount of expected pneumobilia. Radiology showed 1. Left PICC line terminates in the right atrium. The line may be withdrawn
by 3 cm to place the tip in the lower SVC.
2. Increased opacity at right lung base with obscuration of the right heart
border, likely secondary to a right middle lobe pneumonia.
Findings were communicated with ___, IV nurse, ___ at time of
observation at 2:57 p.m. and with Dr. ___ at 5 p.m. on ___. The patient was diagnosed with SEPTICEMIA NOS, SEVERE SEPSIS , SEPTIC SHOCK, ANEMIA NOS, ACCIDENT NOS. The patient was treated with ___: ERCP
___: ERCP
___: PTC
___: ___ placement. At the time of discharge, the patient had Primary:
1) Biliary sepsis
2) Fungemia
3) Hypotension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with locally advanced pancreatic adenocarcinoma (s/p
chemo/XRT, recently s/p C5 Gemcitabine), DM, CAD, Afib on
dabigatran, acromegaly, DVT ___, and recurrent biliary
sepsis, admitted for abdominal pain and hypotension, found to
have Klebsiella bacteremia, s/p ___ PTC and stent placement, now
with Candidemia.</s> |