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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M, w/ hx of mild-moderate vascular dementia, poorly
controlled HTN (hypertensive urgency at several recent
outpatient visits), chronic HA (attributed to cervicalgia)
presenting with headache, found to have hypertensive urgency.
He is followed at ___ by Dr. ___. He was seen for a
transfer of care visit at which time his BP was 195/106. There
was concern for his ability to perform self care and medication
management given his cognitive decline; several attempts were
made to connect him with home services, which were ultimately
successful (seen by ___ now connected with ___
___ Alllian___). Home BP monitoring by ___ has shown that he has
been in the 130-140 systolic range on a regimen of metoprolol
succinate 100 and lisinopril 40 (apparently the patient doses
his own medications at home).
He was seen for follow-up last week ___ this appointment
had been re-scheduled after he had failed to present for a
previously scheduled appointment. Of note, the patient was
unaccompanied at the visit and arrived one hour late, noting he
got lost on the way there. He reported having taken his BP
medications at home, but had a BP of 200/102 at presentation,
which was later found to be 160/90 on manual re-check (HR 62).
In regard to his current presentation, he has been having
worsening of his chronic headache for the past 3 days which he
has been treating at home with tylenol. The headache was so
severe the he finally activated EMS. EMS found him in no
distress, but with a blood pressure of 240/160 (confirmed on run
sheets) en route.
ED COURSE:
VS on presentation (11:15p): 254/106; HR 64; 94% on RA
Subsequent VS - BP within 15 minutes of arrival (i.e. prior to
med administration) 191/83; HR 63
Meds administered - labetalol 10mg IV x 3; labetalol 200mg PO x
1; tylenol/ ketorolac 30mg IV; benadryl IV
VS prior to transfer - 143/65; HR 77; RR 17; 98% on RA
On admission to the floor, he continues to complain of headache
which is slightly improved. He is mildly dizzy denies CP,
shortness of breath, and any other neurologic symptoms
(including blurry vision, focal weakness, sensory deficits).
In regard to his hypertension, he is able to tell me that he
takes metoprolol and lisinopril. He fills his pill box himself
and admits that he sometimes misses doses, including potentially
on the day of presentation. He has been taking some OTC
medications (names unknown) for cold symptoms lately, but
otherwise denies new meds or supplements. Radiology showed No evidence for acute cardiopulmonary process. Radiology showed No evidence of acute intracranial hemorrhage or mass effect.
Correlate clinically to decide on the need for further workup are followup.
NOTE:
Deformity of the left nasal bone at the tip and the left lamina papyracea,
similar to the prior study and can relate to prior trauma. The patient was diagnosed with HYPERTENSION NOS. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Hypertensive urgency
Delirium
Urinary Retention
SECONDARY DIAGNOSIS:
Dementia
Benign prostatic hyperplasia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ year-old man with a past medical history
of mild-moderate vascular dementia, poorly controlled
hypertension (hypertensive urgency at several recent outpatient
visits), chronic headache from cervicalgia who presented with
headache and was found to have hypertensive urgency.
# HYPERTENSIVE URGENCY: Mr. ___ presented to the hospital
with a BP of 254/106 with associated with a headache. There were
no signs of end organ damage except for an elevated lactate,
which was thought to be secondary to metformin. He was given IV
labetalol and his BP improved. He was switched to oral agents
and his blood pressure stabilized in the 140s/70s. Hypertensive
urgency was thought to be due to medication noncompliance in the
setting of worsening dementia and possible pseudoephedrine use.
He was discharged on: amlodipine 5mg daily, lisinopril 40mg
daily, and labetalol 200mg BID.
# DELIRIUM: The patient Patient presented to the hospital at
baseline mental state. He was given IV benadryl in the ED and
subsequently became delirious and developed urinary retention.
He was started on olanzapine 2.5mg QHS as well as tamsulosin
(see below) with improvement in delerium prior to discharge to
rehab.
# TYPE B LACTIC ACIDOSIS: Patient's lactate 2.4 on admission,
peaked at 4.1 then downtrended with IV fluids to 2.7. The
patient remained without signs of infection or hypoperfusion.
As such, etiology was though due to type B lactic acidosis from
metformin and decreased oral intake.
# URINARY RETENTION: The patient had baseline benign prostatic
hypertrophy. In the setting of IV Benadryl administered in the
emergency room, the patient developed urinary retention with
bladder scan as high as 900cc. In this setting, the patient was
started on tamsulosin uptitrated to 0.8QHS. He is being
discharged on this medication, which can be downtitrated as an
outpatient as needed.
# DEMENTIA: Mild-moderate by history and exam worsened by
hospital setting. Concern that cognitive deficits and making him
incapable of taking medications appropriately and caring for
self despite family members are helping. The physical therapy
team saw the patient and recommended that he go to rehab.
# HISTORY OF CEREBROVASCULAR ACCIDENT: The patient's blood
pressure was managed per above. He was continued on his home
aspirin and statin for secondary prevention.
# CHRONIC OBSTRUCTIVE PULMONARY DISEASE: The patient was
continued on his home inhalers without complications.
===============================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with PMH of HTN, T2DM, atrial fibrillation
(on amiodarone), and chronic low back pain who presented with
episode of lightheadedness at home when getting up in the middle
of the night to use the bathroom. She did not have a sensation
of the room spinning. She denied CP, N/V, abd pain, diarrhea,
palpitations, or vision changes. She did have a sensation of SOB
as if she needed to breath fast in order to not lose
consciousness. However, she did not lose consciousness. Radiology showed Possible tiny right pleural effusion and persistent cardiomegaly. The patient was diagnosed with SYNCOPE AND COLLAPSE. At the time of discharge, the patient had Prolonged QT interval
Presyncope
Secondary diagnoses:
Type 2 diabetes
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>___ with PMH of T2DM, HTN, HLD, afib on amiodarone and lovenox,
who presents with presyncopal episode at home, found to have
long QTc, low K, low Mg in ED, now being admitted for concern
for cardiac arrhythmia.
# Presyncopal episode: Symptoms isolate to a single event,
currently resolved. Given presentation, differential includes
orthosasis, hypoglycemia, cardiac arrhythmia, ACS, medication
side effect. Most likely orthostasis given multiple hypertension
medications. Aslo pt, noted to have low FSBG during episode
which likely contributed. Pt appears euvolemic on exam.
Troponins negative x2. Lethal cardiac arrhythmia would have more
likely caused sudden syncope without presyncopal symptoms.
Orthostatics were negative. Fingersticks were well controlled.
No events noted on telemetry. This was most likely a single
isolated event; therefore, no interventions were taken.
# Long QTc: Possibly side effect of amiodarone; however
incidence is extremely low. More likely due to electrolyte
imbalance. Pt was discharged home with K supplementation.
Amiodarone was continued. Her cardiologist was notified of the
incident; adjustment of amiodarone dose left to his or PCP's
discretion. EKG in AM showed improved QTc interval. No events on
telemetry.
# Atrial fibrillation: Continued home amiodarone, BB, CBB,
amiodarone, and lovenox for anticoagulation. NSR on tele.
# T2DM: held home po meds and ISSH while inpatient.
# CAD/CHF: continued home coreg, nifedipine, ASA, and
atorvastatin
# GERD: continued home omeprazole
# Chronic LBP: held home tramadol for potential lightheadedness.
pt has appointment with pain clinic in ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yM transfer from ___ w/ worsening perineal & scrotal
pain & swelling after I&D by PCP 1 day ago. CT showed gas ___
perineum and scrotum. s/p I&D of perineum and scrotum by Gen
Surg. Admit to Urology given scrotal involvement Radiology showed 1. Post right peroneal/hemiscrotum debridement with postoperative changes and
mild subcutaneous edema. No evidence of drainable fluid collections, discrete
abscess or severe inflammatory changes.
2. Similar amount of small volume pelvic ascites. Radiology showed The right PICC line projects to the right atrium. Lungs are low volume with
bibasilar atelectasis. Heart size is normal. There is no pleural effusion.
No pneumothorax is seen. Radiology showed As above The patient was diagnosed with Inflammatory disorders of scrotum, Acute kidney failure, unspecified. The patient was treated with PROCEDURE PERFORMED ___: Incision and drainage of
perineal
abscess and scrotal abscess.
___: Right arm 51cm PICC placed
___: 15 cm left basilic single lumen ___ heparin dependent
power
midline placed. At the time of discharge, the patient had Fournier's Gangrene
Elevated transaminases (liver functions). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to Urology after transfer from OSH to
the ED and taken to the OR for urgent incision and drainage
perineal abscess and scrotal abscess, Fournier's gangrene. No
concerning intraoperative events occurred; please see dictated
operative note for details. The patient received perioperative
antibiotic prophylaxis and was continued on empiric triple
therapy until culture data available. The patient was
transferred to the floor from the PACU ___ stable condition. Pain
was well controlled on PCA and and he was hydrated for urine
output >30cc/hour, and provided with pneumoboots and incentive
spirometry for prophylaxis. The patient ambulated, resumed
appropriate home medications and labs were monitored daily. His
diet was advanced to regular. Our colleagues ___ infectious
disease were consulted for management and he was to discharged
on 1g IV ceftriaxone with Flaggyl 500mg PO TID for a 14-day
course. A PICC line that was placed that was accidently
traumatically pulled out by the patient the day before
discharge, when getting out of bed. A midline was placed ___ the
left arm prior to discharge. He was voiding without difficulty
and discharged ___ stable condition, eating well, ambulating
independently, voiding without difficulty, and with pain control
on oral analgesics.
Wound care specialist evaluated him and he was on veraflo wound
vac for 48hrs before it was removed and a wet-to-dry dressing
applied for discharge home. The date of discharge he was to be
met by ___ for application of a new wound vac device.
On exam, incision was clean, dry, and intact, with no evidence
of hematoma collection or infection. The patient was given
explicit instructions to follow-up ___ clinic ___ approximately 2
weeks time. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o CHF, pacemaker presenting with 3 days of fatigue.
His main caregiver is his wife's sister, who called the
ambulance. His wife recently passed away. His only symptom is
fatigue as he denies any other illness, fevers, cough, cp/sob,
leg swelling. His ___ nurse, ___, (___) called
___ on ___ in the heart failure clinic describing
the pt as visibly more SOB with exertion while she was seeing
the patient. She stated that the lungs had rales @ bases, but no
leg or ankle edema. Therefore, the plan was to increase
Torsemide from 60mg to 80mg daily. and to get Chem 6 within 1
week (last creat 1.9 within
baseline ___.
In the ED, initial VS were: 96.1 66 123/71 28 92% nrb. Labs
notable for Cr 1.6 (baseline mid-upper 1s) and troponin of 0.17.
He was given albuterol/ipratroprium nebs, and clopidogrel 75mg
PO once. He developed CP in the ED which improved without
intervention. Given plavix because states he cannot take ASA. VS
on transfer: 80 119/59 28 98% 3L NC
On the floor, pt states he feels fine, denies sob or any other
symptoms. He states he was never offered aspirin and is ok
taking it now.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Radiology showed No evidence of acute disease. Cardiomegaly. The patient was diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, CHEST PAIN NOS. The patient was treated with ___ - cardiac cath. At the time of discharge, the patient had Primary: NSTEMI
Secondary: diastolic CHF. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx. afib on coumadin, tachy/brady syndrome s/p dual
chamber ___ (___), CHF, HTN, HLD, T2DM, presenting with
complaints of fatigue. Patient received aspirin and plavix in
the ED and was admitted to cardiology service. In light of
positive troponins patient was started on a heparin drip. The
following summarizes the problems during this hospital stay:
#NSTEMI: Patient appears to have had as NSTEMI given his
positive enzymes. As above, patient was started on a heparin
drip. He complainted of intermittent chest pain on the floor,
so a nitro drip was started which provided relief. Patient was
also started on atorvastatin 80 mg. The patient underwent cath
on hospital day 1 which showed 2 vessel CAD, s/p POBA to 65%
lesion ___ diagonal (down to 35%), as well as evidence of
microvascular disease. On return from cath, patient's heparin
drip was discontinued. He was continued on low dose aspirin,
plavix, as well as atorvastatin and coumadin. Plavix duration
will be one month. Patient was started on low dose isosorbide
mononitrate and his metoprolol was uptitrated for heart-rate
control. The patient remained chest pain free but continued to
have fatigue. Patient was found to have significant
deconditioning by physical therapy and will be going to rehab to
continue to work on strength and conditioning.
# Afib: on coumadin/metoprolol for a CHADS of 3. Patient's INR
was ___ on day of cath so he received 2 units of FFP with 40IV
lasix pre-cath. His coumadin was restarted post-procedure. He
remained on his home dose coumadin with therapeutic INR and
metoprolol was uptitrated, as above.
# sick sinus s/p pacer: dual chamber pacemaker placed in ___,
last interrogated ___. Patient remained on tele without
issues.
# chronic diastolic CHF: preserved EF in ECHO of ___, however
had asymmetric LVH c/w hypertrophic CM, also impaired relaxion.
Patient's home torsemide was held in anticipation of cardiac
cath. He continued to appear mildly volume overloaded
post-procedure and was diuresed with 80mg IV lasix boluses with
improvement in his respiratory and volume status. Repeat ECHO
in house showed preserved EF with evidence of moderate LVH. He
is being discharged to rehab on his recent home diuretic regimen
of torsemide 80 mg daily.
# HTN: uptitrated metoprolol as above, blood pressures remained
in the ___ to low 100s systolic. Patient would likely benefit
from an ACE in the future if blood pressures allow given
underlying diabetes.
# DMII: On orals at home, was covered with ISS in house.
TRANSITIONAL ISSUES
1. Patient will go to rehab to continue to work on strength and
conditioning.
2. Patient should remain on plavix for one month and then
discontinue plavix given risk of bleeding with triple therapy in
the elderly.
3. Patient would benefit from monitoring of volume status and
titration of diuretic regimen as needed.
4. Patient remained full code.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant ___ HTN, T2-IDDM, Afib on enoxaparin,
h/o Stage III uterine ca ___ s/p chemo, XRT, TAHBSO, and
recently diagnosed w/ AML s/p 7+3 ___, c/b febrile
neutropenia, delirium w/ hallucinations, now in cytogenetic
remission on BMB ___ and ___, awaiting consolidation therapy
tentatively week of ___, who developed a rash on recent
admission (presumptively DRESS from allopurinol vs Cefepime vs
HHV6), presenting w/ recurrent rash and SOB. CHEST (PA AND LAT) showed No acute cardiopulmonary process seen. Radiology showed No evidence of pulmonary embolism or aortic abnormality. No acute
cardiopulmonary process.
Diffusely heterogeneous appearance of the osseous structures likely related to
patient's underlying leukemia. CT HEAD W/O CONTRAST showed No acute intracranial hemorrhage or fracture. CT C-SPINE W/O CONTRAST showed No acute cervical spinal fracture or traumatic malalignment. KNEE (AP, LAT AND OBLIQUE) RIGHT showed No evidence of right knee fracture or dislocation. Small joint effusion. The patient was diagnosed with JOINT PAIN-L/LEG, UNSPECIFIED FALL, LONG TERM USE ANTIGOAGULANT, HEAD INJURY UNSPECIFIED, ATRIAL FIBRILLATION, ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION. At the time of discharge, the patient had PRIMARY DIAGNOSES:
- Acute myeloid leukemia
- Rash
- Peripheral edema
SECONDARY DIAGNOSES:
- Fungal Pneumonia
- Type 2 Diabetes Mellitus
- 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 PMHx of HTN, T2-IDDM, Afib on
enoxaparin, h/o Stage III uterine CA ___ s/p chemo, XRT,
TAHBSO, and recently diagnosed w/ AML s/p 7+3 ___ now in
cytogenetic remission who developed a rash on recent admission
(presumptively DRESS from allopurinol vs Cefepime vs HHV6),
presenting w/ recurrent rash and SOB.
# Rash: Patient presented for recurrance of maculopapular
erythematous rash worse in dependant areas. During last
admission she had this rash that started ___ associated with
fevers, transaminitis, and facial edema. Derm consulted on ___
felt this was DRESS from cefepime or allopurinol. Got 2 doses
solumedrol. HHV6 was also considered as cause of fevers/rash and
simple drug reaction was also in the differential but unclear
which drug caused it. Upon review of medications and rash
started after cefepime, vanco, & vori. Only medication restarted
upon discharge was voriconazole. Only medication changed as OP
was lovenox replaced warfarin. Rash on admission was very
pruritic and widespread. Given history it was decided that it
was unlikely lovenox causing reaction so stopped voriconazole
and switched lasix to torsemide for possible sulfa allergy. HHV6
level was 974 similar to last admission, patient had moderate
peripheral eosinophilia and derm was re-consulted. Decided to
hold off on steroids and rash improved drastically within 72
hours after stopping voriconazole and peripheral eosinophilia
resolved gradually. Voriconazole was added to allergy list.
# Postive BC x1: Patient had one positive blood culture, got
emperic vancomycin from ___ and culture came back as
contaminent bacteria. Vancomycin was stopped and patient
remained well appearing and afebrile.
# Dyspnea on exertion: Patient had lightheadedness and new DOE
at home. CTA ___ ruled out PE and other acute/new pulmonary
process. The patient was not hypoxic and troponins were negative
but her BNP was >1000. She was being diuresed from her last
admission and did not have PND or orthopnea. TTE on ___ was
similar to prior study with EF >55%. Given reassuring evidence
against acute cardiopulmonary process and ambulatory saturation
>98% concern for new pathology was diminished. Patient did not
have recurrence of DOE on admission and thought to possibly be
secondary to over diuresis. . Ambulatory sats 98-100. SOB
resolved on discharge.
#Peripheral Edema / Hypotension: patient presented with mild
hypotension on lasix 40 BID for her residual peripheral edema.
She was switched to torsemide 20mg with continued improvement in
her peripheral edema and resolution of her hypotension after
250cc fluids. She was discharged on 10mg torsemide to be
titrated down and ultimately discontinued once her peripheral
edema resolves.
#Chest Port Erythema: The patient presented with chest erythema
at her previous port site (removed ___ that was flat
confluent and well demarcated likely rash secondary to
bacitracin she applied on the area and exacerbated by the
voriconazole rash. Resolved with discontinuation of both
medications.
#Acute Myeloid leukemia: In hematological CR after 7+3
chemotherapy per bone marrow biopsy from ___. Not eligible for
HSCT due to comorbidities. Planning on consolidation with MiDAC
___ and enrolled in clinical trial ___ Blockade of PD-1
in Conjunction with the Dendritic Cell/AML Vaccine following
chemotherapy induced remission. Planned for readmit on ___
___ for MiDaC consolidation therapy.
#Atrial Fibrillation: CHADS2-VASC of 3. No longer on coumadin
due to difficulty achieving therapeutic INR & contraindicated
for vaccine trial. Home medications continued as prescribed and
discharged on same medications.
#Herpes Simplex Virus 1: continued on acyclovir without acute
event
#Type 2 diabetes Mellitus; home metformin held and continued
home Novolin ___ BID, 9U am 5U pm
#Fungal PNA: Patient with fungal pneumonia on last admission.
Holding anti fungal as above, plan to restart posaconzaole with
next round of chemotherapy.
#Vitamin B12 Deficiency: cont cyanocobalamin </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ right-handed woman with history
notable for Alzheimer's dementia, Grave's disease, HTN, IBS, and
prior right callosal infarct presenting for evaluation of five
days of gait disturbance. MR HEAD W/O CONTRAST showed 1. Acute to subacute infarcts in the pons. No large vascular distribution
infarct.
2. Probable age-related involutional changes
3. Changes of chronic small vessel ischemia in the white matter and chronic
right basal ganglia hemorrhage new since ___. The patient was diagnosed with Ataxia, unspecified, Dizziness and giddiness, Dyspnea, unspecified. At the time of discharge, the patient had Acute Ischemic Stroke. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ right-handed woman with history
notable for Alzheimer's dementia, Grave's disease, HTN, IBS, and
prior right callosal infarct presenting for evaluation of five
days of gait disturbance, found to have acute to subacute
infarct in the pons.
#Pontine Ischemic Infarct: MRI of the brain showed acute to
subacute infarct in the pons. Patient was monitored of
continuous cardiac telemetry and was seen without any
arrhythmia. TTE showed normal EF without any evidence of cardiac
source of embolism or structural abnormalities. A1c was elevated
at 5.9%, indicating pre-diabetes, and LDL was elevated at 135.
The patient was started on DAPT with aspirin and Plavix, with
plan to continue DAPT for 21 days, after which the patient will
continue only Plavix indefinitely (as she was previously taking
aspirin 81mg daily when this event occurred). Atorvastatin was
also added given elevated LDL. Patient's gait disturbance was
seen to be improving but still not back to baseline prior to
discharge, and ___ recommended further rehab and increased
supervision on discharge. Patient was discharged with neurology
follow up. Given the intermittent arterial calcifications seen
on CTA, the patient's age, and the location of the infarct, the
etiology of the stroke was thought to be due to small vessel
disease.
#Hypertension: home anti-HTN medications were held, as the
patient's blood pressure was allowed to be autoregulated in the
setting of ischemic stroke. Her SBP remained at goal at <180
throughout this hospitalization. She was resumed on amlodipine
10 mg daily and lisinopril 20 mg daily rather than her prior
amlodipine-benzapril in favor of being able to titrate
lisinopril further. This can be further increased as needed.
#Alzheimer's dementia: though she has a prior diagnosis of
dementia, the patient did not experience any agitation during
the hospitalization. She is currently scheduled to follow up
with Dr. ___ in the cognitive neurology department.
=====</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is ___ speaking F with recently diagnosed
___ disease, anorexia, recent UTI, mastectomy of left
breast who presented to the emergency room with increasing
confusion, insomnia, and hallucinations, found to be
hyponatremic. CHEST (AP AND LAT) showed No evidence of pneumonia. CT LIMITED ___ SCANS showed Nondiagnostic study due to the patient's inability to continue the imaging. The patient was diagnosed with Parkinson's disease. At the time of discharge, the patient had Hyponatremia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms ___ is a ___ speaking F with recently
diagnosed ___ disease, anorexia, recent UTI, mastectomy
of left breast (in the ___) who presented to the emergency room
with increasing confusion, insomnia, and hallucinations, found
to
be hyponatremic which improved with fluid restriction now
normalized, started on Carbidopa-Levodopa for ___ also
with deconditioning. She was clinically stablilized and
discharged to rehab. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with a past medical history of
dementia with severe gait disturbances, hyperlipidemia, and
history of multiple falls, who presents from ___ with
behavioral disturbance. CHEST (PORTABLE AP) showed Heart size is normal. Mediastinum is normal. Lungs are clear. There is no
pleural effusion. There is no pneumothorax. CT HEAD W/O CONTRAST Q111 showed 1. Stable appearance of the brain allowing for differences in modality,
including unchanged mild-to-moderate ventricular dilatation. This may reflect
communicating hydrocephalus or chronic small vessel ischemic change.
2. Chronic inflammatory changes including possibility of polyposis involving
the right ethmoid/frontal sinuses. Only change is increased fluid and
aerosolized material within the right maxillary sinus. Acute on chronic
infectious process is not excluded by this study. The patient was diagnosed with Urinary tract infection, site not specified. The patient was given written instructions concerning 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 a past medical history of
dementia with severe gait disturbances, hyperlipidemia, and
history of multiple falls, who presents from ___ with
behavioral disturbance. He has shown less inhibition and more
sexual aggression. Metabolic causes for his aggression were
pursued. CT head was negative for acute pathology. CBC, BMP,
mag, phos, LFTs were all unremarkable. Utox was negative. TSH,
B12, and folate were all normal. Syphilis test is still pending.
UA was borderline positive and pt was started on Cefpodoxime for
five days for possible UTI. I spoke to the pt and his wife. This
type of behavior is not new and has been waxing and waning for
years. Additionally he has not walked for at least ___ years
and has baseline ___ weakness with severe muscle atrophy thought
to be a combination of possible NPH and spinal stenosis. At this
point, his neuro exam is stable for years, so urgent evaluation
would not be helpful. CT head is stable and his symptoms--though
waxing and waning--also sound fairly stable.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male with DMI presents to ED after being seen by Dr
___ in clinic. He has had a L foot plantar ___ metatarsal
ulcer for 4 weeks now. They have tried po antibiotics and total
contact casts, which have failed. This past week, he has felt
ill
and states there is increased pain and swelling in the area.
Patient was schedule for a L ___ met head resection with Dr
___ on ___, but was instructed to go to the ___ ED
after seeing him in clinic today. Patient also states he has a
new onset calf pain and swelling. Patient denies fever, chills,
nausea, vomit in the ED. Left foot and ankle radiographs, three views of each. showed New remodeled appearance to the distal third metatarsal which seems most
likely related to interval trauma and healing rather than infection.
Correlation with interval history is recommended. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. FOOT 2 VIEWS LEFT showed Postop resection of the left fifth metatarsal head with an unremarkable
postoperative appearance. The patient was diagnosed with Type 1 diabetes mellitus with foot ulcer, Long term (current) use of insulin, Cellulitis of left lower limb. The patient was treated with L foot Incision and Drainage with ___ metatarsal head resection. At the time of discharge, the patient had Left foot infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was
evaluated by the podiatric surgery team. The patient was found
to have a left foot abscess and was admitted to the podiatric
surgery service. The patient was taken to the operating room on
___ for L foot incision and drainage with ___ metatarsal
head resection, 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 ___ 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
Heel weightbearing L foot in a post op shoe. 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: ___ yo male with a history of RCC who is admitted with
compression fractures and PEs. The patient states he woke up
early this AM with tachycardia, anxiety, and pain with taking
deep breaths. He states he does get anxiety attacks but this was
different and that the other symptoms were present and the
anxiety was not that severe. The tachycardia did improve some
but
took a few hours and the pleuritic pain persists. He also has
some mid thoracic pain that worsened today. He denies any fevers
or recent illnesses. He was recently at an OSH with
hypercalcemia. Of note he did have PEs diagnosed in the ___
of
this year and was on lovenox but this was stopped due to
hemoptysis. This was diagnosed at ___ and the
records
are not currently available to known the location of the PEs at
that time. CT scan of the abdomen and pelvis showed 1. Mixed response when compared to the prior study. There has been decrease
in size in the large retroperitoneal conglomerate lymphadenopathy, in addition
to decrease in size of the left omental nodule and right iliac crest bony
metastatic lesion.
At the same time, there has been progression in the number and size of many of
the bony lesions. This is most evident in the pelvis and proximal femurs as
detailed above. Significant progression of metastatic bony disease is also
occurred at the level of the sacrum, where there is now all soft tissue
density occupying many of the exiting nerve root foramina at this level.
There is also a new omental lesion noted (5:95) measuring 1.1 x 1.2 cm. In
addition, the patient's bilateral adrenal nodules have also increased in size
as detailed above.
2. There are many lytic lesions involving the vertebral bodies, including a
lytic lesion at the posterior aspect of the L4 vertebral body which abuts and
causes mild destruction of the posterior cortex of the L4 vertebral body. No
definite epidural extension is noted at this time, however close attention on
follow-up is recommended. Radiology showed Partial treatment response with interval decrease in the supraclavicular,
mediastinal and hilar lymphadenopathy. Numerous metastatic pulmonary nodules
and rib/pleural metastases have also decreased.
Osseous metastases have progressed however, with multiple new lytic lesions
involving with the lower thoracic and upper lumbar spine. Mild loss of height
in multiple vertebral bodies has developed and more significant compression
fractures are threatened.
Extensive of pulmonary emboli.
NOTIFICATION: The findings were discussed by Dr. ___ with ___
on the telephone on ___ at 2:30 ___, 10 minutes after discovery of the
findings. MRA CERVICAL, THORACIC, AND LUMBAR PT94 MR SPINE showed 1. Innumerable metastatic osseous disease involving the cervical, thoracic and
lumbar spine.
2. When compared to the prior MRI examination of ___, there is
significant interval worsening in osseous involvement of the thoraco lumbar
spine with new worsened pathologic compression deformity spanning T6 through
L3.
3. Better seen on CT abdomen and pelvis of ___ is soft tissue
expansion into the right S2-S3 neural foramina and portions of the S3-S4
spinal canal level.
4. Minimal soft tissue extension into the epidural space spanning T8 through
T12 without significant spinal canal narrowing.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 6:20 ___, at the time of discovery of
the findings. ELBOW, AP AND LAT VIEWS LEFT showed Vertically-oriented fracture through the lateral epicondyle of the humerus.
Findings are suspicious for pathologic fracture with increased lucency in the
underlying bone. Possible second lesion in the radial neck. This could be
further evaluated with MRI if clinically indicated.
NOTIFICATION: The impression above was entered by Dr. ___
___ on ___ at 13:48 into the Department of Radiology
critical communications system for direct communication to the referring
provider. The patient was diagnosed with TACHYCARDIA NOS. At the time of discharge, the patient had 1. Pulmonary embolism
2. Metastatic renal cell carcinoma
3. Bony metastases
4. Pathalogic elbow fracture
5. Hypercalcemia. The patient was given written instructions concerning 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 male with a history of RCC who was
admitted with spinal compression fractures and PEs.
#PE: Previous imaging, including from OSH, is not able to
exclude that PEs are new. ___ be adverse side effect of
axitinib. Pt did not undergo full anticoagulation course
previously because he developed hemoptysis. As the patient's
pulmonary nodules have shrunk, he is less likely to have
recurrent hemoptysis, so the patient was started on a heparin
gtt then switched to lovenox.
#Compression Fractures: Pt has had progression of bony lesions.
___ be contributing to back pain. The patient's pain was
controlled with home lidocaine patch, fentanyl patch, and
oxycodone. The spine service was consulted and had the following
recommendations: Extensive spinal lesions, no indications for
surgery, no need for brace. Radiation oncology was also
consulted and will review previous records, planning to further
discuss treatment options at an outpatient visit.
#Elbow Fracture: Pt has pathologic fracture of elbow. Ortho was
consulted and recs: sling LUE, (range of motion as tolerated)
ROMAT, (weight bearing as tolerated) WBAT, No lifting >2 pounds.
He will have follow up in ___ clinic in 2 weeks.
#Diarrhea: Likely from CT contrast. Less likely from chemo ASE
given that pt has not had this rx before. C Diff negative.
Resovled with Loperamide
#RCC: Dx in ___, s/p radical nephrectomy now on Axitinib.
Pt has had some response but increase in bony lesions.
#Hyponatremia: Likely ___ hypovolemia given diarrhea. Resolved
with IVF.
#Hypercalcemia: Pt has bone lesions and is getting monthly
zometa (last ___. The Ca2+ remained <12 and was managed with
IVF. The patient has follow up on ___ at an outpatient appt;
he should have lytes repeated for this visit. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ with history of dementia (non-verbal at
baseline) and deep venous thrombosis on Coumadin presenting with
fever of unknown origin. She reportedly has been experiencing
intermittent fevers to 102 in the absence of hemodynamic
instability or hypoxia since the new year and has received
Tamiflu, amoxicillin, and Levaquin for possible influenza versus
aspiration pneumonia in the setting of coarse breath sounds,
without resolution of fevers. Radiology showed Limited, negative. The patient was diagnosed with FEVER, UNSPECIFIED, HYPERTENSION NOS, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE, LONG TERM USE ANTIGOAGULANT, HX VENOUS THROMBOSIS/EMBOLISM. At the time of discharge, the patient had Fever of unknown origin. The patient was given written instructions concerning 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 ___ with history of dementia (non-verbal at
baseline) and deep venous thrombosis on Coumadin who presented
with fever of unknown origin. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Reason for consult: dysphagia s/p cervical fusion The patient was diagnosed with CHEST PAIN NOS, SWELLING IN HEAD & NECK, CAD UNSPEC VESSEL, NATIVE OR GRAFT, HYPERTENSION NOS. At the time of discharge, the patient had Dysphagia following revision anterior cervical spine surgery. The patient was given written instructions concerning 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 for increasing dysphagia and pain. Speech
and swallow evaluated the patient with video swallow and
recommended liquid diet and moist soft diet. GI were consulted
to rule out esophageal injury. They agreed with speech and
swallow recommendations. Their impression was a neurovascular
source
to his persistent dysphagia. As an inpatient the patient was
uncooperative in maintaining the fentanyl patch and removed it
at least once without the nurses knowledge. As the pain
medication are being prescribed by his PCP, he has not been
given any new scripts for narcotic medications. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male with a history of metastatic urothelial cancer s/p
radical cystectomy with ileal conduit s/p XRT, now on
atezolizumab who presents with respiratory distress and
hypotension s/p elective intubation following likely aspiration
event post-EGD in the setting of nausea and guaiac positive
feculent emesis. CHEST (PORTABLE AP) showed In comparison with the study of ___, there again are multifocal areas
of increased opacification bilaterally, consistent with widespread pneumonia.
Obscuration of the left hemidiaphragm and left costophrenic angle are
consistent with volume loss in left lower lobe and pleural fluid. Monitoring
and support devices are stable. CT CHEST W/O CONTRAST showed New multifocal pneumonia. This disease process could be followed with chest
radiographs.
Extensive metastatic disease involving the lungs (please refer to previous CT
report ___ and chest cage.
Hypodense hepatic lesions suggesting hepatic metastasis. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial process, with no definite evidence of acute
intracranial hemorrhage or large territorial infarct. Please note MRI of the
brain is more sensitive for the detection of acute infarct.
2. Within limits of noncontrast examination, no definite evidence of
intracranial mass. Please note contrast enhanced brain MRI is more sensitive
for the evaluation of intracranial metastatic disease.
3. Age-related atrophy and probable small vessel ischemic changes as
described.
4. Paranasal disease as described. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Extensive, multifocal pneumonia, with a suggestion of cavitation is more
pronounced in the right upper lobe, unchanged and less severe on the left.
Pulmonary vasculature is engorged but there is probably no edema. Heart is
mildly enlarged. Pleural effusions are small if any.
Cardiopulmonary support devices are in standard placements. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___ at 04:00.
No appreciable interval change in multifocal pneumonia. Heart size normal.
Pleural effusions small on the left if any. No pneumothorax. Cardiopulmonary
support devices in standard placements. Radiology showed No definite signs of obstruction. NG tube positioned appropriately. Lower
lung opacities better assessed on same-day chest radiograph. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Multifocal pneumonia may be improving. No appreciable pleural effusion. No
pneumothorax. Heart size normal. Lines and tubes in standard placements
unchanged. CHEST (PORTABLE AP) showed Comparison to ___. No relevant change is noted. The extensive
bilateral parenchymal opacities are stable. Borderline size of the cardiac
silhouette. No larger pleural effusions. Stable correct position of the
monitoring and support devices. VENOUS DUP EXT UNI (MAP/DVT) RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. CHEST (PORTABLE AP) showed In comparison to ___ radiograph, the patient has been extubated.
Multifocal bilateral alveolar consolidations have progressed in the interval,
particularly in the lower lungs, left greater than right. Findings may be due
to progressive infectious pneumonia, with or without superimposed acute
aspiration. Portable semi-erect chest x-ray showed Grossly stable multifocal bilateral alveolar consolidations when compared to
___ study. CT CHEST W/O CONTRAST showed Minimal improvement of the known multifocal pneumonia, with decrease of the
ground-glass component. The extensive metastatic disease is stable. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Multifocal pneumonia continues to improve in most areas except for the right
upper lobe where there has been little change since ___ and a
suggestion of cavitation or bronchiectasis. Small left pleural effusion
persists. No pneumothorax. Heart size is normal. There is probably no
pulmonary edema.
Left subclavian infusion port catheter ends in the right atrium. Radiology showed Partial small bowel obstruction versus early ileus . CHEST (PORTABLE AP) showed New pulmonary infiltrates, consider pneumonia, aspiration. CHEST (PORTABLE AP) showed Comparison to ___. New bilateral parenchymal opacities, at the
right lung basis as well as in the left lower lung, in addition to the
pre-existing parenchymal opacities. Overall, the findings are suggestive of
hydrostatic pulmonary edema. The patient has been intubated. The tip of the
endotracheal tube projects 23 mm above the carinal. The presence of a small
left pleural effusion cannot be excluded. Developing left lower lobe
atelectasis. Radiology showed Nonobstructive bowel gas pattern. Moderate to large colonic stool burden. CHEST (PORTABLE AP) showed Comparison to ___. No relevant change is noted. The extent and
severity of the pre-existing parenchymal opacities is stable. No pneumothorax
or other complications. Moderate cardiomegaly persists. Stable monitoring
and support devices. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___, most recently ___.
Lung volumes have increased, but multifocal pulmonary consolidation has not
really improved. Most of this is pneumonia, but some pulmonary edema is
likely. Left pleural effusion is small. Heart is normal size and mediastinal
veins are not engorged. No pneumothorax.
Cardiopulmonary support devices in standard placements respectively. RENAL U.S. showed Normal renal ultrasound. No renal mass nor hydronephrosis. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices
are unchanged. Bilateral pulmonary opacifications may be slightly worsening.
The appearance is consistent with multifocal pneumonia. However, the cardiac
silhouette is also prominent so that some of this could reflect accompanying
pulmonary edema. 6 6 spot CHEST (PORTABLE AP) showed ET tube tip is 4.1 cm above the carina. Port-A-Cath catheter tip is at the
level of cavoatrial junction.
NG tube tip is in the stomach.
Heart size and mediastinum are unchanged. Multifocal consolidations are
unchanged but there is mild interval improvement of pulmonary edema. CHEST (PORTABLE AP) showed Compared to chest radiographs ___ through ___.
Multifocal pneumonia and borderline interstitial edema unchanged since ___. Small left pleural effusion stable. Heart size normal. No mediastinal
venous engorgement. No pneumothorax.
ET tube in standard placement. Nasogastric drainage tube ends in the lower
stomach. Left subclavian infusion port ends close to the superior cavoatrial
junction. The patient was diagnosed with Nausea with vomiting, unspecified. The patient was treated with Intubation ___-line ___. At the time of discharge, the patient had Primary:
Pneumonia
Small bowel obstruction
Gastritis
Secondary:
- Bladder cancer
- History of DVT. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY:
___ with a history of metastatic urothelial cancer s/p radical
cystectomy with ileal conduit s/p XRT, now on atezolizumab who
presented with respiratory distress s/p elective intubation
following aspiration event post-EGD in the setting of nausea and
guaiac positive feculent emesis. After a prolonged ICU course he
was extubated. His respiratory status continued to improve; he
did have a partial SBO that subsequently resolved. He was
discharged in stable condition to acute rehab.
MICU COURSE (___):
=============
#Shock: Patient was admitted to the MICU with a pressor
requirement not responsive to fluid resuscitation. The etiology
was multifactorial from likely sepsis and hemorrhagic from GI
bleed. He was treated with Vancomycin and zosyn for underlying
infection. As his GI bleed and infection began to resolve he was
weaned off of pressors prior to discharge from the MICU.
#Acute respiratory failure: Dr. ___ voluntary
intubation after an aspiration event during GI endoscopy. He
underwent ARDSnet protocol. He was eventually able to be weaned
from volume control to pressure support. He was eventually
weaned from the vent and extubated prior to discharge from the
MICU.
#Aspiration pneumonitis vs pneumonia: The patient required
intubation and underwent ARDSnet protocol after aspiration. He
became febrile and hypotensive. He was empirically treated with
Vancomycin and zosyn. He was extubated for respiratory support
as described above. His pneumonia resolved with treatment and he
was successfully Extubated prior to leaving the MICU.
#Coffee ground emesis: There was ___ clear evidence of active or
recent GI bleeding on EGD. He was maintained on pantoprazole BID
and Zofran for nausea. His H/H remained stable in the MICU.
# Acute on chronic CKD: Patient developed ___ secondary to
hypoperfusion during shock when he was admitted to the MICU. His
creatinine and urinary output improved throughout his stay while
we maintained a MAP of > 65 with pressors and volume support as
needed.
FLOOR COURSE (___)
=============================
# Hypoxemic respiratory failure: Patient initially had a 2L O2
requirement upon arrival on the floor. Based on exam and imaging
he appeared to be volume overloaded secondary to receiving
volume resuscitation in the ICU. He was diuresed over the course
of several days and his respiratory status improved
significantly. Upon discharge he was on room air.
# Cough: Patient had a persistent non-productive cough. He had
___ other signs of infection or pneumonia, and this was thought
to be represent upper airway cough syndrome vs metastatic
disease in lungs. His cough was managed with guaifenisen,
tessalon perles, fluticasone nasal spray, and oral
antihistamines.
# pSBO
# Abdominal pain: Patient initially presented with feculent
emesis concerning for an acute bowel obstructive event. After
his extubation, he was able to eat small amounts of food.
However on ___ he again developed sharp left-sided abdominal
pain. A KUB was performed which was consistent with an ileus vs
a partial SBO. He was given IV fluids and a glycerin suppository
to move his bowels; subsequently the pSBO resolved and his diet
was ddvanced again.
# Goals of care: Dr. ___ is HCP. Daughters are
involved as well. Goals of care discussion held with palliative
care, Dr. ___ oncologist, and family on ___.
Decision was made to remain full code, and to aim for rehab with
the goal of getting stronger. At that time they would
re-evaluate the benefit of additional chemotherapy.
# Back pain
# ___ pain/radiculopathy: Patient has chronic back pain,
attributed to L5-S1 disc herniation with worsening after
radiation therapy. Patient has expressed that he does not want
opioids if avoidable due to a negative experience with his wife.
Per Dr ___ pain is due to edema ___ XRT and has
responded to NSAIDs in the past. His pain was controlled with
standing APAP, gabapentin 300mg TID, PRN ibuoprofen 200-400mg.
# Gastritis:
# Anemia: Patient initially presented with coffee grounds emesis
and an EGD was performed, which showed gastritis. His hematocrit
remained stable throughout the rest of his admission and he was
continued on omeprazole 40mg BID. He did receive 2u of pRBC
transfusion on ___.
# Positive urine culture: Urine culture taken from urostomy was
positive for pan-sensitive pseudomonas on ___. ___ change in
urostomy output to suggest a true urinary tract infection. Per
discussion with outpatient oncologist Dr. ___ antibiotic
treatment was given.
# Altered mental status: Waxing and waning confusion which seems
to worsen at night, most consistent with delirium. Thought
likely due to poor sleep. He was given seroquel 50mg QHS and he
was able to sleep more consistently; thereafter his mental
status returned to baseline. Seroquel was continued for a
limited duration at the time of discharge, with need for ongoing
to be re-assessed at rehab. QT was WNL at the time of
discharge.
# Urothelial carcinoma: Currently on Atezolizumab (atezolizamab
___ Gemzar/Cisplatin D1,D8,q3wks). Followed by Dr. ___.
CT torso on ___ showed progression of disease with hepatic
metastases and increased size of retroperitoneal
lymphadenopathy. Per Dr ___ currently a candidate for
chemotherapy but would discuss further as outpatient if
patient's functional status improved.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of HTN, HL p/w epigastric pain. Pt states that
___ he developed epigastric pain radiating to the back which
became acutely worse after lunch today. He began vomitting with
all PO intake. The pt states he drinks one scotch ___, and
no more than 3 scotches in a day. He recently switch from
claritin to zyrtec and took a course of fluconazole for anal
yeast 10 days ago. Otherwise he denies any changes in lifestyle
habits. In the ED, initial VS were:98.8 128/88 80 92%RA. He was
given morphine 5mg IVx2 and dilaudid 1mg IV x2, zofran x1 as
well as 2L NS. On arrival to the floor, the pt stated his pain
peaked at an ___ but improved with pain medicine. Radiology showed No acute findings, including no radiographic signs of
pneumoperitoneum. Radiology showed Peripancreatic stranding and fluid, consistent with acute
uncomplicated pancreatitis.
Findings reported to ___ by ___ by phone at 8:40 p.m. on
___ at time of discovery of these findings. The patient was diagnosed with ACUTE PANCREATITIS. The patient was treated with Laparoscopic cholecystectomy. At the time of discharge, the patient had 1) gallstone pancreatitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx of HTN, HL p/w epigastric pain found to have
pancreatitis.
# Pancreatitis: Pt presented with significantly elevated lipase
6735 ___s LFTs AST 277 ALT 486 Alk P ___. CT ab/pelvis
prelim showed peripancreatic stranding and free fluid,
consistent with acute pancreatitis. Pt had RUQ u/s showed
Cholelithiasis with multiple small stones and biliary sludge,
but no bile
duct dilatation. On hospital day #1 his lipase, ALT and AST
trended down very quickly making the most likely etiology for
pancreatitis ___ transient obstruction from gallstone. An
increase in ALT is suggestive of pancreatitis (his was 486 on
presentation) per literature a value above 150 strongly suggests
gallstone pancratitis. Patient does drink alcohol (about ___
scotch per night) however he denies excessive drinking and the
fact that the lipase trended down so quickly makes gallstone
pancreatitis from transient obstruction the most likely
etiology. ___ normal. Zyrtec, ibupofen, fluconazole were new meds
that he took over the past few wks and non of them are known to
cause pancreatitis. We calculated pt's ___ score which was 2
(for elevated WBC and AST) which indicated low mortality. He was
given continuous IVF, made NPO and given IV pain meds, zofran
PRN. His vitals remained stable and his lipase and LFTs trended
down. Surgery was consulted and they recommended
cholecystectomy.
.
.
# HTN: initially held PO meds bc he was NPO.
.
# HL: Initially held PO meds bc he was NPO</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ who presents for evaluation of epigastric and
RUQ abdominal pain. Patient reports that she has had atleast 5
similar episodes over the last year, three of which occured this
month. Patient was seen on ___ here in the ED with similar
complaints and was thought to have costochondritis. Surgical
consult was not requested at that time. Patient presents today
with recurrent epigastric and RUQ abdominal pain since 9 am this
morning, now associated with nausea and an episode of emesis
this morning. Pain has improved since arriving in ED, though
still present. She denies fevers, chills, malaise, constipation,
and diarrhea. Radiology showed Cholelithiasis without evidence of cholecystitis. The patient was diagnosed with ABDOMINAL PAIN RUQ, CHOLELITHIASIS NOS. The patient was treated with Laparascopic cholecystectomy. At the time of discharge, the patient had Acute cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was evaluated in the ED by the ___ surgery service.
Her history and examination were concerning for symptomatic
cholelithiasis versus early cholecystitis. She was admitted to
the floor for observation and laparascopic cholecystectomy. Her
LFTs were trended and there was a mild increase in her
bilirbuin, raising concern for obstruction, but this normalized
prior to her surgery.
She was taken to the operating room with the ACS service and
underwent a laparoscopic cholecystectomy, the details of which
are in the operative report. She tolerated the procedure well
and was extubated without incident. Afterward, she was brought
to the PACU for recovery, where she did well and she was
transferred to the surgical floor.
She was hemodynamically stable on the floor. Her vital signs
were monitored routinely and she remained afebrile. She started
a regular diet and tolerated it well. She ambulated and voided
without difficultly. She was transitioned from IV to PO pain
medication. She was discharged in good condition and will call
the ___ clinic to schedule follow up.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male transferred from outside hospital for
evaluation of subdural hematoma. This morning the son noted that
he was garbled in his speech and not acting like himself.
Symptoms resolved prior to arrival at ___. Currently pt denies
headache, nausea, vomiting change in speech altered mental
status
or any complaints. Radiology showed mpression: Right ICA less than 40% stenosis.
Left ICA less than 40% stenosis. Radiology showed Large posterior diverticulum in the upper esophagus consistent
with a Zenker's diverticulum. Regurgitation resulted in trace aspiration of
all consistencies. For full details, please see detailed speech and swallow
note in OMR. The patient was diagnosed with SUBDURAL HEMORRHAGE, HYPERTENSION NOS, PERSONAL HISTORY OF TIA, AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS. At the time of discharge, the patient had subdural 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>Mr. ___ was admitted to the Neurosugery service for
evaluation and surgial planning.
We obtained a medical consult for surgical clearence given his
age and medical history.
He had Carotid dopplers to evaluate his carotid stenosis in the
setting of reported severe stenosis and TIA's. The study showed
less than 40% stenosis, and he was determined to be relatively
safe to undergo a craniotomy for Subdural hematoma evacutation.
We plan to proceed with surgical evacuation of this subdural in
one week given that he has been taking plavix at home.
A physical therapist evaluated the patient and they felt that
the patient needed to be placed in rehab until he returns for
surgery. On ___, pt was stable for discharge to ___
___. He will follow-up accordingly. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: : Mr. ___ is a ___ yrs. male with PMH notable for
CKD s/p renal transplant (___), PVD s/p endarterectomy of
external iliac artery, prostate cancer s/p radiation c/b
radiation proctitis, DM, HLD who who presents with weakness,
lightheaded and pre-syncope. CHEST (PA AND LAT) showed Bibasilar opacities more compatible with atelectasis than pneumonia. RENAL TRANSPLANT U.S. showed Normal appearance of the transplant kidney. Nondependent echogenic focus
along the bladder wall may represent an adherent bladder stone. KNEE (AP, LAT AND OBLIQUE) BILAT showed As above. The patient was diagnosed with Urinary tract infection, site not specified. The patient was treated with Left knee aspiration (___)
Left knee intraarticular steroid injection (___). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ yrs male with CKD s/p transplant in
___ who over the past 10 days, after cystoscopy, felt very
weak, lightheaded and nearly syncopized at an outpatient
appointment presenting with UTI.
# Complicated urinary tract infection: Most likely weakness,
hypotension and fatigue are secondary to urinary tract infection
s/p recent cystoscopy. He presented to the ED with dirty UA and
Cr bump to 3.1 from baseline of 1.4-1.8. UCx from outside PCP's
office showed >100,000 CFU of GNRs that are non-lactose
fermenters. He was started on IVF and CTX and then changed to PO
ciprofloxacin (Day #1 ___ after cultures started
speciating. Species and sensitivities were pending at discharge
in Atrius. Other infectious etiologies were ruled out: CXR
clear, blood cx ngtd, stool cultures, CMV viral load and EBV PCR
all were negative.
#Pre-renal azotemia: Most likely was secondary to hypovolemia in
setting of urinary tract infection. Patient was found to be
orthostatic at his PCP's office and his urine cultures showed as
above. He was given IVF and CTX and then was switched to ___
___ for UTI. Cr decreased to his baseline (1.8) and was stable
for 2 days before discharge.
#Crystal proven gout (left knee): patient has history of gout
and is not on any preventative medications currently. In
addition, patient is immunosuppressed. Pt. had monoarticular
swelling of left knee with warmth posed concern for septic
arthritis. Rheumatology consulted and tapped effusion on ___
which showed 43,500 WBCs, 96% PMNs and monosodium urate
crystals. IV Vancomycin 1gm q12 hr initiated while gram stain
was pending, but discontinued as WBCs most likely ___ to gout
flare and gram stain negative. Patient received colchicine 0.6
on ___ and an intraarticular steroid injection done by
Rheumatology on ___. Pain control with Tylenol and
breakthrough with oxycodone.
#Hyponatremia: most likely was due to hypovolemic hyponatremia
w/UTI + pseuodhyponatremia in setting of hyperglycemia. Resolved
with boluses of NS and better glucose control.
#ESRD s/p left renal transplant ___. Baseline Cr 1.4-1.8.
Patient maintains right lower arm fistula. Cr elevated on
admission to 3.1. Cr improved to baseline after treatment of UTI
and IVF. Tacrolimus 4mg BID, cellcept 500 mg BID continued
#Hyperparathyroidism: Cinacalcet increased slightly on this
admission.
#Uncontrolled Diabetes Mellitus Type II. Patient had glucose
into the 400s on admission. Continued Lantus at an increased
dose from 40 to 53 units daily and d/c'd Humalog 12 with meals
and instead put him on ISS while in house with good control.
Continued gabapentin 300mg capsule daily.
#BPH:
Continued home tamsulosin.
#Coronary artery disease. Continued pravastatin 80 mg daily,
metoprolol tartrate 25 QID, increased amlodipine 5 mg to 10mg
daily, continued aspirin 81 daily and withheld chlorthalidone 25
mg daily (in setting ___ and infection).
#Hypertension
BPs recovered following abx and IVF. Increased amlodipine 5 mg
to 10mg daily. Continued metoprolol at fractionated dosing as
met tartrate 25 QID. Withheld chlorthalidone in setting of
___.
#seasonal allergies
Continued fluticasone nasal spray
#GERD: continued home ranitidine
TRANSITIONAL ISSUES
===================
[] Antibiotics: Cipro for 10 day course (Day #1 ___ thru
___.
[]Labs: Outpatient chemistry 10 within 3 days of discharge to
ensure stability of Cr and good control of Ca with new dose of
Cinacalcet. He should continue with twice weekly chem 10 and
tacrolimus levels at rehab ___ and ___. Please fax
labs to: Nephrology - Transplant Team at ___: ___.
and Dr. ___: ___
[] Tacro Goal: ___. Must be a true tacro trough (drawn within 1
hour prior to AM dose).
[]Rehab Consult: Please have nephrology consulted at rehab and
evaluate patient given complex case.
[]Urine Culture: ___ has a Urine culture from ___
pending. Will need to ensure species is sensitive to cipro once
culture finalizes.
[]HTN: Given ___ and hyponatremia, in place of chlorthalidone,
we increased his amlodipine to 10 mg daily on discharge for
better BP control. If needs improved BP control, consider
restarting chlorthalidone with stable Cr and BP >140.
[]Insulin: Lantus regimen was altered during stay for high
glucose. He is currently at 53 units Lantus AM with NO standing
Humalog and ISS. Please continue to monitor blood sugars 4x
daily and adjust as necessary.
[]Hypercalcemia: Patient will be discharged on cinacalcet at 90
mg daily from 60 mg daily
[]Gout Flare: Patient in middle of gout flare. He received 1
dose of colchicine without good effect, and because of
medication interactions, decided to give intraarticular
injection of left knee.
[]Outpatient F/Up: needs outpatient follow up with urologist,
nephrologist, and primary care provider.
[]Bladder Stone: Patient had cystoscopy on ___ showing
non-obstructive bladder stone. Consider outpatient removal, and
analysis for urate crystals. If + for urate crystals, may need
to be placed on urate lowering medications. Please fax results
to Attn Dr. ___: ___
# CODE: Full Code, confirmed
# CONTACT: ___ (wife, HCP) ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ presents to ED with a two day history of worsening nausea
and vomiting associated with diffuse lower abdominal pain
starting 12 hrs previously localizing to RLQ. She is currently
6 weeks pregnant and has had occassional emesis but worse over
the last two days. She has not experienced any fevers / chills
/shortness of breath / dysuria. Radiology showed Nonvisualization of the appendix. Radiology showed Single live intrauterine pregnancy with size equal to date. Radiology showed 1. Equivocal findings with the appendix appearing very minimally distended
and fluid-filled. Trace free fluid is noted adjacent to the appendix. Early
appendicitis cannot be outruled and correlation with clinical findings is
recommended.
2. Small perigestational bleed.
3. Small amount of free fluid within the pelvic cul-de-sac. 2 cm corpus
luteal cyst within the right ovary.
Verbal report issued to Dr ___ (emergency medicine, ___ or
___ by telephone at 10:00 AM, ___, 5 minutes after discovery. Dr ___
___, Body MRI fellow. Radiology showed Single live intrauterine pregnancy with size equals dates. The patient was diagnosed with ABDOMINAL PAIN RLQ. The patient was treated with ___ laparascopic appendectomy. At the time of discharge, the patient had Acute appendicitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ was admitted on ___ under the acute care
surgery service for management of his acute appendicitis. She
was taken to the operating room and underwent a laparoscopic
appendectomy. Please see operative report for details of this
procedure. She tolerated the procedure well and was extubated
upon completion. He was subsequently taken to the PACU for
recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up in
___ clinic.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old Male with HTN/HL/COPD/HCV and recent diagnosis of
PNA, who was admitted to ___ MC 3 wks prior to admission,
d/ced to rehab ___), where he was found to have
progressively worsening gait abnormality, ? urinary retention
and/or incontienence, who was transferred to ___ for
evaluation of dyspnea from ___. No further history is available,
above obtained from son. Radiology showed 1. Mild bilateral hydronephrosis.
2. Slightly small kidneys, both less than 10 cm in size.
3. No evidence for renal artery stenosis. Radiology showed 1. No evidence for cirrhosis.
2. Moderate bilateral hydronephrosis.
3. Aneurysmal dilatation of abdominal aorta which measures 3.7cm in maximal
diameter.
Findings discussed directly with Dr ___ on ___. Radiology showed No evidence of hemorrhage or infarction. Partial opacification
of bilateral sphenoid sinuses as well as bilateral mastoid air cells Radiology showed Multilevel degenerative changes of the lumbar spine as described above. No
evidence of fracture. Radiology showed 1. No evidence of acute fracture or ligamentous injury.
2. Multilevel severe degenerative changes of the cervical spine, worse at
C3-4 level with severe spinal canal stenosis and abnormal spinal cord signal. Radiology showed 1. No evidence for active extravasation on this examination. High-density
material within bowel loops may represent ingested material versus blood
products from known GI bleed.
2. Moderate atherosclerotic calcification of the aorta and its branching
vessels with an infrarenal aortic aneurysm and aneurysm of the left common
iliac artery.
3. Bilateral small effusions with associated atelectasis. Radiology showed Penetration with thin and nectar-thick liquids and ground solids.
No gross aspiration was seen on today's exam. The patient was diagnosed with HYPERKALEMIA, ACUTE RESPIRATORY FAILURE, GASTROINTEST HEMORR NOS, URINARY OBSTRUCTION, UNSPECIFIED, RENAL FAILURE, UNSPECIFIED. The patient was treated with Hemodialysis. At the time of discharge, the patient had Primary- Respiratory failure
Health Care Associated Pneumonia
Diverticular bleed
Gastritis
Renal failure
Secondary- Coronary artery disease
Hyperlipidemia
Hypertension
COPD
BPH. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M w/ COPD, HTN/HL, CAD, who p/w ___, hypotension tx for
obstructive uropathy w/ foley, urgent HD, with hospital course
complicated by HCA pneumonia and GIB initially ___ gastritis and
subsequently diverticular in nature.
# Hypotension, Adrenal Insufficiency
The patient's hypotension was likely multifactorial and
secondary to a combination of hypovolemia from GI bleed,
infection from pneumonia, and unstable tachycardia. See below
for treatment of each of these problems. The patient also
received stress dose steroids, but was ultimately transitioned
back to his home prednisone as he stabilized. Cardiac enzymes
were not suggestive of MI. The patient was resuscitated fully
and left the MICU slightly hypertensive because he was NPO and
could not take his home nifedipine. While on the medicine
floor, the patient had no episodes of hypotension and did well
on his home metoprolol dose. His home nifedipine was held, but
this can be gradually restarted if his pressures require it.
#Bacterial Pneumonia:
The patient's X-ray on admission showed a RLL opacity. Unclear
if chronic or new, infectious vs. malignant, based on old
records. The patient was treated for HCAP with vancomycin,
cefepime, and levofloxacin, which was tailored back to
vancomycin and levofloxacin as the patient stabilized. He
completed an 8 day course- last day was ___. He continued to
have a 2L oxygen requirement which was attributed to atelectasis
in the setting of deconditioning. He will benefit from continued
physical therapy and incentive spirometry.
# Acute Renal Failure due to Urinary Retention
This was due to obstructive uropathy, given large amount (3L) of
UOP after Foley placement in ED. He was uremic with extensive
electrolyte abnormalities and acidosis. His initial EKG showed
changes consistent w/ his hyperkalemia. The patient's ultrasound
suggested bilateral hydronephrosis. The patient was emergently
hemodialyzed in one two hour session. He did not require further
dialysis. Between the placement of a Foley catheter and the
dialysis, the patient's renal function rapidly improved and his
creatinine was normal by the time he left the ICU. He was
started on finasteride and tamsulosin and foley was kept in
place. Urology recommended foley for at least two weeks with
outpatient follow-up for a voiding trial.
# Etiology of urinary obstruction. Multiple possibilities, the
most concerning of which was cauda equina syndrome. An MRI
showed no cauda equina, so stress dose steroids for possible
cauda equina were stopped. Thought to be caused by benign
prostatic hyperplasia. Urology consult was placed and they
recommended foley for at least two weeks with outpatient
follow-up for a voiding trial. They did not see an indication
for any acute urologic intervention during the hospitalization.
# Acute Blood Loss Anemia due to Diverticulosis with Bleeding:
The patient was was initially given DDAVP 0.4mcg/kg over 10
mins. a PPI drip, and resuscitation with fluids. The patient
underwent endoscopy, which showed gastritis, gastric ulcer,
duodenitis. He was then started on PPI BID. His H pylori
serology was equivocal, stool antigen was ultimately negative.
He was called out to the floor but returned to the ICU following
additional episodes of hypotension and bright red blood per
rectum. He required transfusions of red blood cells (4 units).
His CTA abdomen was negative, but his colonoscopy showed
left-sided diverticulosis which was believed to be the etiology
of his bleed. He will require GI follow up (scheduled) with Dr.
___ for repeat EGD given concern for gastric metaplasia
in the setting of his gastritis.
# Severe Malnutrition/aspiration risk:
On second to last day of patient's initial ICU stay, the patient
coughed up a large pill that was stuck in his posterior throat.
He was made NPO, his medications were switched to IV. On ___,
S/S team felt the patient was high risk for aspiration so he
remained NPO, failing multiple trials until ___ when he passed a
video swallow and was started on a nectar thick liquids, pureed
solids diet. After completion of GI studies and resolution of
the bleed, patient was given tube feeds for nutrition. These
will need to be continued while his swallowing mechanism is
still improving and nutritional status poor. We would recommend
nutrition to follow him and perform calorie counts to help
decide when to discontinue tubefeeds. Would recommend monitoring
for refeeding syndrome given severe malnutrition and several
days w/o food in setting of GI bleed.
# LUE weakness:
On ___, the patient was seen not using his left arm.
Neurological exam showed biceps and triceps weakness, with no
obvious sign of shoulder dislocation. Strength in hand was ___,
though patient had some swelling of dorsum of left hand. UE
ultrasound was scheduled, but patient refused that test on ___.
Neurology was called. They recommended soft cervical collar and
MRI spine. MR ___ performed on ___, which showed
degenerative changes, posterior disc bulge throughout w/ severe
spinal stenosis. He may benefit from neurology follow up as an
outpatient.
# Possible air embolism:
Shortly after the patient's HD line was removed, he had
hypotension and destauration. This was thought to be secondary
to an air embolism. The patient was placed on his left lateral
decubitus. An echo was obtained that did not suggest right heart
strain or pulmonary embolism. The patient's condition slowly
improved until he only needed 2L nasal cannula. This can
continue to be weaned as tolerated.
# Intraatrial septal aneurysm:
Incidental finding on echocardiography. Following discussion
with Cardiology and Neurology, the patient may be placed on
aspirin once he is out of the window of his acute GI bleed.
# CAD:
Echo w/ EF 55%, no wall motion abnormality, though notable for
interatrial septal aneurysm. Per cardiology and neurology
recommended aspirin and statin. We have been holding aspirin
given his recent bleed but this can be restarted if hcts remain
stable and no signs of further bleed. He was continued on his
metoprolol and restarted on his statin on discharge.
# Polymyalgia Rheumatica:
He briefly received stress dose steroids as above, but then was
switched tot methylpred 4mg iv daily. On discharge he was
restarted on his home prednisone 5 mg daily.
The patient will need to establish care with a PCP and is
interested in doing so at the ___. He will need to follow up
with urology and GI as detailed in the discharge instructions.
He had extensive code status discussions during this
hospitalization and he decided to be DNR/DNI. His health care
proxy is son ___ ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M no significant PMH presents with the worst HA of
life. Pt was in his usual state of good health at ___ Arts
class when he suddenly developed severe head and neck pain as
well as back pain. He had difficulty concentrating and speaking
according to his wife. He was taken to ___ where head
CT
showed SAH with IVH. He was loaded with Keppra, given dilaudid
IV for pain control and sent to ___ for further care. Pt
endorses HA on arrival but is not reliable historian. Wife is
at
bedside to help with hx. CTA HEAD AND CTA NECK showed 1. Diffuse subarachnoid hemorrhage centered within the suprasellar cistern
extending into the fourth ventricle and foramen magnum with possible mild
cerebral edema.
2. No clear evidence of aneurysm by CTA imaging.
3. No evidence of hemodynamically significant stenosis or pathologic large
vessel occlusion within the vasculature of the head or neck.
4. 0.6 cm hypodense right thyroid nodule. Ultrasound could further evaluate,
as clinically warranted. PORTABLE HEAD CT W/O CONTRAST showed 1. Interval placement of a ventriculostomy catheter, with post-procedure
pneumocephalus. Worsening dilation of the lateral ventricles, although the
ventriculostomy catheter was not present at the time of the prior comparison
study.
2. Re-demonstration of subarachnoid hemorrhage, with new intraventricular
extension since the outside hospital CT.
3. Apparent hypodense focus in the right posterior fossa, most likely related
artifact and patient positioning. Close attention on followup to exclude
ischemia. CHEST (PORTABLE AP) showed 1. New endotracheal tube ends 12.7 cm from the carina and should be advanced
6-7 cm for optimal seating within the trachea.
2. No evidence of acute cardiopulmonary process.
NOTIFICATION: The findings were discussed by Dr. ___ with ___
___ on the telephone on ___ at 2:26 ___, 30 minutes after the
discovery of the findings. Radiology showed ___ underwent cerebral angiography which failed to
show a source of his subarachnoid hemorrhage. He will be brought back for an
angiogram in a week's time. CHEST (PORTABLE AP) showed ET tube tip is 6 cm above the carinal. Heart size and mediastinum are stable.
NG tube tip is in the stomach. Lungs are essentially clear with no new
abnormalities developing in the interim. No pleural effusion or pneumothorax
is seen CHEST (PORTABLE AP) showed Volume loss versus infiltrate left lower lobe CT HEAD W/O CONTRAST showed 1. The right frontal ventriculostomy catheter appears to be slightly withdrawn
with the tip now at the periphery of the frontal horn of the right lateral
ventricle. Please correlate with output.
2. Hydrocephalus has resolved, the lateral ventricles have significantly
decreased in size.
3. Significant clearing of hemorrhage from the basal cisterns, however there
is apparent new subarachnoid hemorrhage in the parietal and occipital lobes
and cerebellum. This may be previous blood which is now made more conspicuous
by nonportable technique or reflect some degree of redistribution, however
close attention on followup is recommended.
NOTIFICATION: The findings were telephoned to ___ by ___ at
09:20, ___, 10 min after discovery. CT HEAD W/O CONTRAST showed 1. New blood within the right lateral ventricle, possibly related to catheter
manipulation.
2. Interval decrease in size of the lateral ventricles.
NOTIFICATION: Findings telephoned to Dr. ___ By Dr. ___ ___
@ 7PM. CT HEAD W/O CONTRAST showed The right frontal approach VP shunt catheter terminates in the frontal horn of
the right lateral ventricle abutting the septum pellucidum. Blood is no longer
present in the third ventricle, and blood in the frontal horn of the right
lateral ventricle has changed position. Blood in the occipital horns of the
lateral ventricles, as well as the size of the ventricles, are stable. No new
abnormalities are seen. CTA HEAD WANDW/O C AND RECONS showed 1. Interval progression of vasospasm. There is new narrowing of the left
distal V4 and bilateral A1 segments segment not seen on prior cerebral
angiogram or CTAs.
2. Previously described vasospasm of the proximal trunk of the basilar artery
and bilateral P1 segments (with slightly beaded appearance from narrowing and
dilation) appear worsened when compared to prior CTA examination, but similar
appearance to cerebral angiogram performed on ___ allowing for
technical differences.
3. Continued decrease in ventricular and subarachnoid hemorrhages. No acute
hemorrhage or infarct. Slightly limited assessment of posterior fossa due to
artifacts from ocular shield.
4. No evidence of vascular malformation or aneurysm more than 3mm within the
resolution.
NOTIFICATION: D/w ___ by Dr. ___ phone at approx.
12.10 ___ on ___ over phone BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the bilateral lower extremity veins. The patient was diagnosed with ALTERED MENTAL STATUS . The patient was treated with ___ R EVD placement
___ Diagnostic cerebral angiogram
___ Diagnostic cerebral angiogram
___ Right frontal VP shunt (Strata Programmable Valve 1.0). At the time of discharge, the patient had SAH
Hydrocephalus
Hyponatremia
UTI. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M sudden onset WHOL and neck pain while at Martial Arts
class. CT reveals SAH. CTA negative for anerysm. R EVD placed
for hydrocephalus. Confirmed placement by CT head. Intubated in
ICU for airway protection. Patient taken to angio suite for a
diagnostic angiogram which was negative. He was transferred back
to the ICU where he was monitored carefully. On ___ he was
extubated and his SBP was liberalized to 180. He maintained in
the ICU and his exam was stable. On ___ his EVD was raised to
20. TCDs were performed and were negative for vasospasm.
On ___, patient was intact on exam, but reported headaches.
Oxycodone was increased. EVD was clamped at 20 and reopened for
increased ICPs. He remained stable on exam. TCDs were performed.
On ___, patient was febrile and a workup was sent. A UA was
positive and started on Cipro. Patient's exam remained stable
with plan for repeat imaging tomorrow.
On ___, ICPs were intermittently in the low 20's and a CT head
was obtaine dwhich showed the catheter was at the tip of the
ventricle. Extra staples were also palced at the catheter site
for bleeding that was noted with good effect.
On ___, he underwent a diagnostic angiogram which showed mild
vasospasm but no aneurysm or vascular malformation. He
subsequently underwent a Right VP shunt without complication.
On ___, he was off the clevidipine gtt and his SBP was
liberalized.
On ___, his exam remained neurologically intact and he was
deemed fit for transfer to the SDU and orders were written.
On ___, the patient remained neurologically intact. His sodium
was 129 this morning. His salt tabs were increased from 1g to 2g
every 8 hours. He was placed on a 1L fluid restriction.
On ___, the patient remained neurologically stable. His
morning Na was 132. His K was 3.2 and he received 20mEq of oral
Potassium repletion. Around 12PM, the patient was unable to
state his location and was lethargic yet arousable. He underwent
a STAT CTA which showed mild-to-moderate ACA vasospasm. He
remained in the Neuroscience Step-down unit with neuro checks
every 2 hours. He also continued on NS at 100cc/hr and his SBP
goal was changed to 130-180. He underwent lower extremity
non-invasive vascular studies which showed no DVT. His repeat K
was 3.5 and his evening serum Na level was 131. His neurologic
examination returned to normal at 3PM.
On ___, his K and NA were stable. Patient remained stable
___. On ___ the patient was medically cleared for discharge
and awaited rehab placement.
On ___ Patient remained neurologically stable. Na remained
stable. Awaiting rehab placement
On ___ Patient was discharged to rehab in stable condition. He
was given instructions for follow up. He was afebrile and
tolerating a PO diet. </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 an LAD stent
placed on ___, as well as a history of metastatic prostate CA
and HTN who presents with chest pain. Chest: Frontal and lateral views showed No acute cardiopulmonary process. The patient was diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Anemia, unspecified, Weakness, Hypertensive heart disease without heart failure. The patient was treated with Left heart cath ___ (no intervention done). At the time of discharge, the patient had PRIMARY:
-NSTEMI
-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 ___ year old man with history of CAD, LAD stent
placed ___, hypertension, newly diagnosed metastatic
prostate cancer who presented with chest pain several days after
discharge from LAD stenting. He underwent cardiac cath on ___
which was unchanged from prior. He was discharged with plan for
outpatient stress test.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old man with a history of polyarteritis
granulomatosis currently on azathioprine maintenance therapy who
developed wheezing and fevers for the past week the progressed
to exertional dysnpnea, fatigue, night sweats, sinus pressure,
headache, nonproductive cough, fever and generalized malaise. He
reported to an urgent care visit today and was referred to the
ED for ambulatory sats 89%.
Since an admission in ___ for influenza, he has weaned off
prednisone, requiring short courses in ___ and most recently
___ when he noted a period of increased wheezing. Short
courses of steroids have modulated symptoms well for him, and he
felt his usual self as recently as two weeks ago.
In the ED: T 99.9 115 150/96 18 98% RA desatting to 90% with
ambulation, spiked to 101.3. Labs notable for anemia HCT 39.3
which is at his baseline, chest xray was negative. He was given
prednisone 60mg and albuterol nebulizer as well as levofloxacin
with marked improvement. Pulm saw in the ED and recommended
admission for monitoring, rheum consult and CT scan.
On arrival to the floor he reports feeling much better with
prednisone, though nebulizer helped as well.
ROS:
+ per HPI, also some nasal stuffiness and post nasal drip. No
hematuria, no hemoptysis or productive cough, no epistaxis, no
abd pain/nausea/diarrhea/bloody stools, no joint pain/swelling CHEST (PA AND LAT) showed No acute cardiopulmonary process. CT CHEST W/O CONTRAST showed 1. Bilateral ground-glass opacities, consistent with active polyarteritis
granulomatosis.
2. Minimal, if any, increase in size of mediastinal lymph nodes, which are
top normal in size.
3. Mild main pulmonary artery enlargement, suggestive but not diagnostic of
pulmonary hypertension and largely unchanged.
4. Redemonstration of cholelithiasis and hepatic steatosis. CT SINUS/MANDIBLE/MAXILLOFACIAL W/ CONTRAST showed 1. Status post bilateral maxillary antrostomies and partial ethmoidectomies
with patent maxillary neo-ostia.
2. Mild mucosal thickening of several ethmoid air cells, with a single right
anterior ethmoid air cell completely opacified.
3. No evidence of osseous erosion to suggest sequela of Wegner's
granulomatosis. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPOXEMIA, POSTINFLAMMATORY PULMONARY FIBROSIS, HYPERTENSION NOS. At the time of discharge, the patient had Polyarteritis granulomatosis 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>___ year old man with longstanding polyarteritis granulomatosis
on azathioprine, recently tapered off prednisone, presenting
with one week of worsening respiratory and constitutional
symptoms.
# Fever, hypoxia and malaise: Most likely a flare of
polyarteritis since it matches prior episodes and responded
rapidly to prednisone. Given the degree of systemic symptoms
(fevers, tachycardia, malaise), he was admitted for observation
and empiric pneumonia coverage awaiting complete workup with
pulmonology and rheumatology. There was no evidence of
extrapulmonary disease- no hematuria, no joint effusions though
he had some hand swelling likely due to prednisone. He was
continued on maintenance azathioprine, covered empirically for
pneumonia trigger with levofloxacin though imaging was
unrevealing (Chest CT with expected ground glass, sinuses within
normal limits). ANCA was negative. Rheum and pulmonary
coordinated discharge prednisone taper 60mg daily for 7 days, to
be adjusted by rheum/pulm as outpatient. He was started on
bactrim ppx given possibly prolonged steroid taper. Discharge
amb sats were 93% room air.
# Social Issues: He described an unsafe home environment,
including ongoing conflict with his wife. Social work met with
him and arranged a plan where he would stay with his daughter
when needed. Counseling provided. He was recommended to stay
home from work for a week due to shortness of breath.
CHRONIC ISSUES
# HTN: Continue lisinopril, amlodipine.
# GERD: Cont omeprazole
# Insomnia: Cont prn zolpidem</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ RH F with h/o cryptogenic R MCA
territory embolic stroke in ___ who presents to the
___ as a code stroke for acute onset dysarthria and possible
aphasia. CTA HEAD WANDW/O C AND RECONS showed Normal Study Radiology showed 1. "Late acute-early subacute" infarction involving the right frontal lobar
precentral gyrus, as well as that insular cortex and subcortical white matter,
in a distribution similar to the punctate acute infarct demonstrated in
___.
2. No hemorrhage.
3. Stigmata of chronic small vessel ischemic disease in a distribution that
may be seen in chronic migraineurs; correlate clinically.
COMMENT: A preliminary interpretation of "Acute infarction affecting only the
right precentral gyrus. No hemorrhage." was communicated to Dr. ___
by Dr. ___ telephone, at 5:35 a.m., ___, 20 minutes after
discovery. The patient was diagnosed with CEREBRAL ART OCCLUS W/INFARCT. At the time of discharge, the patient had cerebral embolism with infarction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to the ___ Stroke Service after
presenting with difficulty speaking. CT/A head and neck was
normal. MRI showed a "late acute-early subacute" infarction
involving the right frontal lobar precentral gyrus, the insular
cortex and adjacent subcortical areas. She was started on
aspirin 325 mg and restarted on atorvastatin. She had an echo
that was unremarkable. ESR and CRP were unremarkable.
Anticardiolipin antibody testing was pending at the time of
discharge. The etiology of her stroke remained unclear. She
will likely undergo further testing when she sees Dr ___ in
follow-up as an outpatient. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ RHF smoker with prediabetes, HTN,
hypothyroidism who was brought to the ED by her sister and son
after she was suddenly confused and having difficulty with
memory
at her job today. Neurology is consulted in the ED for further
managment. CHEST (PA AND LAT) showed Bibasilar subsegmental atelectasis. CTA HEAD AND CTA NECK showed 1. No evidence of acute intracranial hemorrhage or mass effect.
2. No evidence of hemodynamically significant stenosis or pathologic large
vessel occlusion within the vasculature of the head or neck. MR HEAD W AND W/O CONTRAST showed 1. No evidence of acute intracranial hemorrhage, mass effect, or acute
ischemia. The patient was diagnosed with ALTERED MENTAL STATUS . At the time of discharge, the patient had Primary:
- Transient Global Amnesia
Secondary:
- Hypertension
- Pre-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>___ is a ___ year-old right-handed woman with past
medical history including hypertension, nicotine dependence,
prediabetes, anxiety and hypothyroidism who presented to the ED
___ with acute short-term memory loss and confusion. She was
admitted to the neurology general wards service for further
management.
Initially, there was concern for stroke or seizure. For concern
for stroke, pt underwent an MRI and CTA of head and neck which
were unremarkable. She was started on aspirin as well. For
concern for seizure, she underwent an EEG which was also
unremarkable.
Symptoms completely resolved about 12 hours after admission. As
her episode manifested as short-term memory loss and confusion
after an emotional precipitant, she was diagnosed with transiet
global amnesia. On day of discharge, pt was at baseline mental
status and had an unremarkable general and neurologic
examination.
Otherwise, pt had a urine culture and TSH level checked in the
hospital. Urine culture was unremarkable and TSH was WNL. She
was continued on her home HCTZ, levothyroxine, and paxil while
in the hospital. Physical therapy also worked with patient who
determined she had no needs.
At time of discharge, she was feeling well. She will follow-up
with neurology closely as an outpatient.
==========================
TRANSITIONS OF CARE
==========================
- EEG, MRI, and CT/CTA were all unremarkable.
- Symptoms began in setting of stress and over 12 hours
resolved, most consistent with TGA.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ female with complex PMHx
including hx of L ICA stroke in ___ (thought to be
cardiembolic iso low EF c/b persistent R-sided paralysis),
dysphagia on TFs, aphasia, HFrEF (EF 25%), HTN, type 2 DM,
hypothyroidism who presents with nausea, vomiting, and diarrhea. CHEST (PORTABLE AP) showed Lungs continue to be low volume with mild interstitial prominence which is
chronic. Heart size is normal. There is no pleural effusion. No
pneumothorax is seen The patient was diagnosed with Dyspnea, unspecified. At the time of discharge, the patient had NSTEMI. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ female with complex PMHx including hx of L ICA
stroke in ___ (thought to be cardiembolic iso low EF c/b
persistent R-sided paralysis), dysphagia on TFs, aphasia, HFrEF
(EF 25%), HTN, type 2 DM, hypothyroidism who presented to the
emergency department on with nausea, vomiting, and diarrhea, and
a transient episode of hypotension in the emergency department
during an episode vomiting. She was stabilized in the medical
ICU before being transferred to the general medicine floor.
Soon after transfer, a goals of care discussion was held between
the care team and the patient's family. After extensive
discussion with the patient's husband regarding the patient's
wishes for her care, the decision was made to place the patient
on comfort measures only as part of hospice care. All
unnecessary treatment and interventions were stopped except
those that would optimize the patient's comfort. She was
discharged and then re-admitted to inpatient hospice. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yr old female w/ ___ metastatic to brain mets s/p
carboplatin and radiation to L chest/mediastinum completed
___ ___s radiotherapy to R frontal lobe ___ and
cerebellar lesion ___. Also has early stage Br Ca ER/PR+ not
treated and CKD. She presents to ED today with 2 days
intermittent hemoptysis. Reports about tsp size bright red blood
last night. Today after eating ice cream had similar amt but was
mixed with sputum. Denies any worsening of breathing. Denies
coughing fits, has chronic cough may be somewhat increased past
2 days. She recently completed 10 days of 2mg dexamethasone for
"inflammation", stopped about one week ago. States that she
gained weight but now appetite dropping off again. Does report
some chest heaviness for past few days over entire front chest,
comes and goes, is on oxycodone for this. Denies overt chest
pain, pressure or radiation. No other bleeding. Has chronic low
grade HA unchanged. No new numbness, tingling, weakness.
Is able to climb stairs, do laundry, activities not limited past
few days. No congestion, sore throat, myalgias, sinus pressure. Chest radiographs. showed No evidence of acute cardiopulmonary disease. Stable left hilar and pulmonary
abnormalities. Radiology showed 1. No evidence of pulmonary embolism.
2. Left perihilar fibrosis and soft tissue thickening is again seen, similar
to prior exam and likely secondary to radiation treatment.
3. Multiple small pulmonary nodules, several are stable from prior exam,
however least 1 of these nodules has increased in size from prior exam. Given
the patient's history, consideration of neoplastic disease is warranted.
Attention on followup is recommended. The patient was diagnosed with HEMOPTYSIS, UNSPECIFIED, CHEST PAIN NOS, SEC MAL NEO BRAIN/SPINE, HX-BRONCHOGENIC MALIGNAN. At the time of discharge, the patient had Primary:
1. Recurrent Hemoptysis ___ to radiation changes
2. Metastatic non-small cell lung cancer
Secondary:
1. Chronic atypical chest pain ___ to metastasis
2. Ductal Carcinoma in situ
3. Peripheral Artery disease
4. 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>___ yr old female with hx of ___ metastatic to brain who is
admitted with recurrent hemoptysis.
# Recurrent hemoptysis - Patient had tea spoon full of
hemoptysis. Did not have remarkable worsening of pulmonary
nodules or PE, may be due to ongoing post-radiation
inflammation/friable mucosa. Recently completed course of
steroids but no significant pneumonitis on CT thus not resumed.
IP saw patient and concluded on outpatient follow up for bronch
scheduled by IP.
# ___ with brain metastases - L hilar soft tissue overall
stable, increase in RUL nodule. Currently on supportive cares
due to side effects from prior treatment
# Chronic atypical chest pain - related to underlying disease,
continued on oxycodone
# Ductal carcinoma of the breast: biopsy proven, ER/PR positive.
Per oncologist does not affect her overall survival from ___,
specific therapy deferred.
# Peripheral artery disease: s/p L common illiac kissing stents
placement in ___, no symptoms of claudication currently. ASA 81
was continued.
# Smoking Cessation: <1 ppd currently. Pt reports that she uses
nicotine patches at home. Encouraged nicotine patch in-house.
# Depression: stable. Continued on home fluoxetine and
mirtazapine.
# Panic attacks: stable. Continued on home lorazepam prn.
# Hyperlipidemia: stable. Continued on lovastatin.
# Insomnia: Stable. Continued on home ambien prn.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: RENAL TRANSPLANT U.S. showed Normal renal transplant ultrasound. CT ABD AND PELVIS W/O CONTRAST showed 1. No acute intraabdominal process, specifically no evidence of renal calculi,
diverticulitis or appendicitis.
2. Moderate stool burden throughout the colon, without evidence of
obstruction.
3. Bibasilar pleural based areas of consolidation which may be due to scarring
or rounded atelectasis. Repeat CT of the chest is recommended in six months to
assess stability unless prior outside imaging can confirm stability.
4. The cardiac blood pool is hypoattenuating respect to the myocardium, likely
representing an anemic state.
RECOMMENDATION(S): Repeat CT of the chest is recommended to assess stability
of a 2.2 cm rounded density in the right lower lobe unless prior outside
imaging can confirm stability. The patient was diagnosed with Unspecified abdominal pain. The patient was treated with N. At the time of discharge, the patient had Primary diagnosis
=================
Abdominal pain likly due to increased stool burden
ESRD ___ hypertensive nephropathy s/p DDRT transplant in ___,
complicated by active Antibody mediated rejection
Hypertension
Polysubstance use
Secondary diagnosis
===================
# seizure disorder. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ man with past medical history of
ESRD ___ hypertensive nephropathy s/p DDRT transplant in ___,
complicated by active ___ with advanced transplant
glomerulopathy
s/p steroid pulse, IVIG, and rituximab, h/o BPD, depression,
PTSD, TBI, and seizure disorder presented with abdominal pain
and
found to have ___ which improved with fluids.
TRANSITION ISSUES
=================
[] CT abdomen with incidental 2.2 cm rounded density in the
right lower lobe - follow-up CT in 3 months recommended, a
PET-CT, or tissue sampling is recommended.
[] Given concern for cocaine use, would benefit from appt with
transplant social worker for substance use disorder.
[] BP Were elevated and home medications were restarted after
inital concern for orthostatic hypotension. Please continue to
monitor BP in the outpatient setting and consider adding
Amlopdine to Anti-hypertensive regimen if BP continues to be
elevated
[] Decreased Tacro from 4mg BID to 3mg BID given elevated Tacro
trough. Please followup as outpatient and adjust as needed
[] Patient reported taking olanzapine however, he had not filled
a script in the past couple of months. Did not refill given
patient reported already having medication at home. Please
clarify as outpatient.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HISTORY OF PRESENT ILLNESS: ___ year old female with past medical
hx transfered from ___ with headache and fever x 4days. The
patient reports daily temps to 103 at home and an unrelenting
headache ___. She denies any associated neck pain or
stiffness; or photophobia. She does some hiking in the woods and
gardening, but denies any tick bites or rahses. The patient also
reports she was also alittle more confused with unsteady gait
for the past few days where she fell to her hands and knees a
couple of times. No recent travel, or URI sx. She endorses
decreased PO intake over the past few days secondary to no
appetitie. CHEST (PORTABLE AP) showed Bilateral lower lobe infiltrates. These could be infectious. Given the overall
increase in lung markings is unclear if a more chronic process is present.
Old films would be helpful for comparison The patient was diagnosed with HYPOTENSION NOS. The patient was treated with Lumbar Puncture ___. At the time of discharge, the patient had Likely rickettsial infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ year old woman with no significant past
medical history who presents with severe headaches, fevers and
confusion.
# Headaches and fevers: On arrival to the ED, patient met SIRS
criteria with leukopenia and fever to ___. Her admission labs
were notable for leukopenia to 1.2, platelets of 50, as well as
potassium of 3.2 which was repleted. Blood cultures, and type &
cross were sent. Monospot test was negative. Urine and Chest
x-ray were unremarkable to suggest UTI or PNA respectively as a
cause of her fevers.
With systolic blood pressures to the ___, she was transferred to
the MICU, where she received 5L of normal saline and maintained
her blood pressure with good urine output throughout the rest of
her course. Suspected source on arrival included meninigitis, or
tick borne illness such as anaplasma or ehrlichiosis. She
received 5L She was started empirically on broad spectrum
meningitis prophylaxis with high dose ceftriaxone, vancomycin,
and acylcovir, and doxycycline given inability to perform a
lumbar puncture in the setting of thrombocytopenia. She was able
to get an LP after receiving platelets. Her rapid improvement in
headache and negative LP makes bacterial meningitis very
unlikely. Her hx of hiking, leukopenia, thrombocytopenia, and
tranasminits, with headache and myalgia, suggest anaplasma or
erhlichosis as a potential etiology or other tick borne illness.
She was empirically treated with doxycycline 100mg PO BID for ___nd improved back to baseline.
# Elevated transaminases: pt with elevated transaminases without
any other stigmata of liver disease, coags were normal
indicating intact synthetic function. Transaminases downtrending
with doxycycline. This is most likely ___ tick-borne illness
(other causes could be DILI or drug induced hepatitis, but
patient not on other medications), no risk factors for HCV, and
mild shock liver (less likely). We did not check a RUQ u/s or
hepatitis serologies given the more likely relation to tick
borne infection.
# Leukopenia/ thrombocytopenia - pt with new leukopenia with
calculated ANC of 1190 and thromboyctopenia. Differential
included bone marrow suppresion in the settting of sepsis as
above, but this was quite soon. Other differential includes
malignancy and DIC, but fibrinogen normal and coags relatively
normal, and smear unremarkable. Hematology was consulted and
felt this was likely ___ tick-borne illness.
# TRALI/TACO- She received 2 units of platelets and 45 minutes
after the second unit became acutely short of breath with
audible wheezing. She received IV furosemide and nebulizers and
improved. This was most likely TACO in the setting of massive
volume resuscitation and platelet infusion. We also notified the
blood bank and sent off the appropriate labs for this, but less
likely acute reaction given time course.
TRANSITIONAL ISSUES
====================
- Code status: Full code.
- Emergency contact: husband ___ ( ___.
- Studies pending on discharge: Blood cultures, Lyme Ab, Babesia
Ab, Anaplasma Ab, HSV PCR, C. difficile toxin assay
- ECHO read became available at discharge; patient will follow
up with PCP for further discussion and evaluation of findings</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is an ___ year old ___ speaking female with
a history of low back pain with L3-L4 radiculopathy status post
cortisone injections x4 and physical therapy who presented to
the
ED on ___ with complaints of bilateral lower extremity
pain and progressive weakness over ___ days. Per her daughter
she
used to walk independently and then was using a cane. Now she
has
been ambulating with a walker as of several weeks ago despite
conservative management and physical therapy. She states that
she
is now unable to walk with her walker. She denies any trauma or
other inciting event. She denies saddle anesthesia. She reports
that she is incontinent of urine at baseline x ___ years, which is
unchanged. She denies fecal incontinence. She denies being on
any
anticoagulants. She denies numbness or tingling in her lower
extremities. LUMBO-SACRAL SPINE (AP AND LAT) showed Interval postsurgical changes of posterior instrumented fusion from L3-L5 for
L4 burst fracture. CHEST (PA AND LAT) showed No previous images. There is enlargement of the cardiac silhouette with
tortuosity of the descending thoracic aorta. Mild elevation of pulmonary
venous pressure without substantial pleural effusion.
No acute focal pneumonia is identified, though the area behind the heart is
somewhat difficult to assess. No appreciable atelectatic changes. LUMBAR SPINE MRI WITH AND WITHOUT CONTRAST showed 1. Acute fractures at L3 and L4. L4 fracture involves the anterior superior
corner and the superior endplate, with edema extending into the right pedicle,
with approximately 70% loss of height and superior corner retropulsion. L3
fracture involves the right inferior endplate and the right inferior posterior
corner, with edema extending into the right pars and right inferior articular
facet. There are bilateral L3-L4 facet joint effusions and grade 1
anterolisthesis of L3 on L4. There is also prevertebral edema centered at L4
and anterior longitudinal ligament injury near the L4 superior endplate.
2. The above findings cause severe spinal canal stenosis at L3-L4 with
compression of the intrathecal nerve roots and traversing L4 nerve roots.
There is also moderate to severe right and moderate left L3-L4 neural
foraminal narrowing.
3. Multilevel degenerative disease causes moderate to severe spinal stenosis
at L4-L5 with crowding of the intrathecal nerve roots, as well as mass effect
on multiple traversing and exiting nerve roots, as detailed above.
4. Unremarkable appearance of the distal spinal cord which terminates at L2.
RECOMMENDATION(S): Lumbar spine CT for complete assessment of fracture lines
at L3 and L4, particularly for better assessment of posterior element
involvement.
NOTIFICATION: The following preliminary report was discussed with ___
___, M.D. by ___, M.D. in person on ___ at 5:39 pm, 5
minutes after discovery of the findings:
Cord or cauda equina compression: yes
Cord signal abnormality: no
Epidural collection: no
1. Compression fracture of L4 superior endplate with marrow edema and
retropulsion are noted. Anterolisthesis of L3 on L4 and disc bulge at L3-4 are
also noted. Constellation of findings cause severe spinal canal stenosis with
compression of the traversing nerve roots. There is also severe narrowing of
the bilateral neural foramina at L3-4, compressing the exiting nerve roots.
2. There is severe spinal canal stenosis at L4-5 with compression of the
traversing nerve root, secondary to disc bulge and ligamentum flavum
thickening. Moderate to severe bilateral neural foraminal narrowing is also
noted at the same level.
The final impression and the recommendation above were discussed with ___
___, M.D. by ___, M.D. on the telephone on ___ at 9:43 am,
5 minutes after discovery of the findings. CT ___ W/O CONTRAST Q331 CT SPINE showed 1. L4 compression fracture.
2. Anterior subluxation of L3 on L4.
3. Severe spinal canal narrowing at L3-L4 due to subluxation and degenerative
disease.
4. Widening of the anterior intervertebral space at L3-L4 suggests anterior
longitudinal ligament disruption at this level which is better characterized
on MR lumbar spine dated ___.
5. A mildly displaced fracture at the superior endplate of L5 is likely acute.
6. The fracture at the vertebral body of L3 is not well demonstrated on
current CT.
7. A 2.6 x 2.5 cm left adrenal lesion may represent a myelolipoma. Multilevel
degenerative changes as described above.
RECOMMENDATION(S): A follow-up adrenal MRI is recommended for further
characterization the left adrenal lesion. LUMBAR SINGLE VIEW IN OR showed Intraoperative images were obtained during L3-L5 fusion. Please refer to the
operative note for details of the procedure. The patient was diagnosed with Low back pain. The patient was treated with ___: L3-L5 laminectomies, posterior instrumentation, fusion. At the time of discharge, the patient had Lumbar Stenosis
L3, L4 fractures. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>#L3, L4 Fractures, lumbar stenosis
___ is an ___ year old female with known L3-L4
radiculopathy who presented to the ED on ___ with worsening
lower extremity pain and weakness for ___ days. Patient had MRI
done in ED, and initially fractures were thought to be chronic
in nature, therefore patient was recommended to follow up in the
clinic. On second review of MRI by radiology, it was determined
that fractures were acute, therefore patient was placed in a LSO
brace and admitted and taken to the OR for L3-5 laminectomy and
fusion on ___. Patient tolerated the procedure well and a
Hemovac drain was left in place, which was removed on POD#3.
Please refer to formal op report in OMR for further intra
operative details. Patient was extubated in the OR and
transferred to the PACU for post op care where she remained
stable and was later transferred to the floor. Her routine
post-op xrays showed stable hardware placement. Her foley was
d/c'd and she mobilized out of bed in her brace. ___ evaluated
her and recommended rehab. She remained stable and was
discharged to rehab on POD#6.
#Anxiety
Patient takes Ativan and trazodone at home for anxiety and
sleep. Her Ativan was held initially while she came out of
anesthesia. On the night of POD0 she experienced a panic attack
with associated shortness of breath, nausea, and abdominal pain.
EKG was normal. She was given ativan and Zofran and her home
medications were resumed. Her nausea, SOB and anxiety improved.
Due to her recent psych admission and acute panic attack psych
was consulted to ensure her symptoms were managed appropriately
post-operatively. It was recommended to continue her home meds
and add PRN Ativan to her standing Ativan for anxiety.
#Anemia
On ___, the patient's H/H was ___ and she felt lightheaded.
She was transfused 1 PRBCs, after which her H/H came up
appropriately to 9.7/31.4. H/H continued to uptrend and was
stable at the time of discharge.
#Disposition
___ evaluated the patient and recommended discharge to rehab.
Rehab Stay expected to be less than 30 days. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ y/o male with prior history of early
localized Lyme disease several years ago s/p doxycycline
therapy, who came to the ED today for evaluation of five days of
fevers and chills, which started one day after hitting his head
on a pole; he did not lose consciousness or seek attention after
the injury but did develop a "golf ball sized" lump on his
scalp. The day after hitting his head, his pain worsened and
developed a ___ diffuse headache. On ___, he had
intermittent difficulty forming sentences and focusing his
vision; those symptoms resolved. He has also felt significantly
fatigued and has had low grade fevers and chills. He started
feeling better after taking an OTC acetaminophen/decongestant
medication. He denies rhinorrhea, dysphagia/odynophagia, or
cough. He has minimal appetite and feels nauseous with any PO
intake. He was able to eat tomato soup earlier today without
vomiting.
In the ED, initial vitals were: 100.5 118 118/75 16 99% RA, but
pt subsequently triggered for the sensation of blacking out and
hypotension to 77/44; pt was given IVF and BP improved. Per ED
signout, the patient's BP cuff was not fitting well and BP was
not rechecked manually after the low reading. Exam was notable
for a supple neck and normal cranial nerve exam. Labs were
notable for WBC 8.5K with lymphocyte predominance and 14%
atypical cells. Chemistry panel and lactate were normal. Pt
underwent LP, and CSF had normal protein, glucose, and WBC ___
with significant lymphocyte predominance. Opening pressure not
noted. CT head was normal. Pt was given acetaminophen, percocet
and 2g of ceftriaxone for empiric bacterial meningitis coverage;
no further antibiotics were given after the CSF studies and head
CT read came back. He was also given one liter of normal saline.
VS prior to transfer were 98.1, 13, 109/58, 66, 97%.
On the floor, he does not have any acute complaints, but does
endorse ongoing headache, fevers, decreased appetite, and
dizziness.
ROS: As per HPI. Also endorses dry, non-productive cough, facial
congestion and watery diarrhea. He ___ have noticed swollen
glands on his neck. He denies sore throat, dysphagia,
odynophagia, visual changes, vertigo, shortness of breath, chest
pain, abdominal pain, constipation, BRBPR, dysuria, hematuria,
arthralgia or myalgia. The ten point review of systems is
otherwise negative. Radiology showed Normal head CT. Radiology showed No acute cardiopulmonary process. Radiology showed 1. Splenomegaly.
2. Otherwise, unremarkable abdominal ultrasound. The patient was diagnosed with MENINGITIS NOS, CONCUSSION W/O COMA, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT. The patient was treated with Lumbar puncture. At the time of discharge, the patient had Viral meningitis
EBV hepatitis. The patient was given written instructions concerning 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 ___ yo healthy M w/ PMH of lyme disease (treated) who
presents with headache and photophobia due to aseptic meningitis
and EBV infection.
#EBV meningitis- patient has no known sick contacts so it is
unclear how he received this infection. He was diagnosed by LP
on ___ which showed a 40 WBC and a lymphocyte predominance. He
was admitted to the hospital for fevers and pain control. He was
started on empiric acylovir to cover for HSV, as that could not
be ruled out. When his HSV PCR came back negative this
treatment was stopped. His headache was controlled with
actemainophen and oxycodone. The patient was informed of the
time course of EBV, and that this ___ not completely resolve for
a few weeks.
-If his headache continues to be worse when sitting up or moving
(1 week from now), ___ need to consider a blood patch for a
post-LP headache
#EBV hepatitis- patient had elevated LFTs, which were stable
around the time of discharge in the 300s. A RUQ U/S performed
during this admission did not show any abnormalities of blood
flow, ascites or evidence of hepatomegaly.
-He will need to have his LFTs checked at his appointment to
ensure they are downtrending
#Thrombocytopenia- the patient was noted to ahve
thrombocytopenia during this stay with Plts in the 90K range,
and stable. He had no petichiae or ecchymosis at the time of
discharge. On exam he had a palpable spleen and RUQ u/s
measured his spleen at 14cm in the longest axis. He was
counseled on the signs of petichiae and to call his PCP if these
are noted. He was also counseled on not engaging in contact
sports while he has splenomegaly as he is at risk for splenic
rupture.
-He will need to have his Plt count checked at this follow-up
appointment
Transitional IssuesPending labs: Blood cultures ___,
CSF Spinal fluid viral culture ___, fluid culture ___. HCV
viral Load; Lyme serology
Medications started:
1. Acetaminophen, do not take more than 2g in 24 hours
2. Oxycodone 5mg- do not take prior to driving or operating
machinery
.</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 poorly controlled
DM1 (last A1C of 10.8), HTN, ESRD s/p living related
donor renal transplant in ___ who presents complaining of
vomiting and diarrhea with chills. Symptoms began 5 days prior
to presentation with chills followed by vomiting (browinish, no
blood). 2 days prior to admission, she developed diarrhea
(watery, ___ BM, no blood, no mucous)and dry heaves. She is
uncomfortable but does not have discrete pain. She continues to
have chills and reports a fever to 101. She denies SOB, CP,
rhinorrhea, congestion, sweats.
Initial vitals in the ED were 99.2 92 151/83 18 100% 2L. Labs
were notable for Na 137, K 4.6, Cr 2.2, ALT 16, AST 29, AP 59,
Tbili 0.3, Alb 3.6, Lip 13, WBC 13.1, HCT 42.4, PLT 495. Patient
received Zofran IV, Tylenol PO, Lorazepam IV and FLagyl 500mg
IV. The decision was made to admit the patient to the medicine
service. Vitals on transfer were 100.4 109 20 126/57 97% RA.
On arrival to the floor, patient reports chills and dry heaves
without vomiting.
REVIEW OF SYSTEMS:
Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail. Radiology showed No acute intrathoracic process. Healing right 3rd rib fracture is
new since ___. Radiology showed No evidence of abscess with normal renal transplant waveforms. Radiology showed 1. Heterogeneous enhancement of the transplanted kidney with loss of
corticomedullary differentiation is concerning for pyelonephritis.
2. Slightly hyperdense lesion in the upper pole of the native left kidney has
increased in size compared to prior study. This lesion likely represents a
proteinaceous cyst, but renal ultrasound for further characterization could be
pursued.
3. Anasarca. The patient was diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, DEHYDRATION, VOMITING, KIDNEY TRANSPLANT STATUS. At the time of discharge, the patient had Primary: Urinary tract infection, bacteremia, pyelonephritis
Secondary: diabetes, s/p renal transplant. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>ASSESSMENT AND PLAN: ___ yo F with ESRD s/p kidney transplant on
immunosuppression presenting with multiple days of N/V, diarrhea
and chills found to have gram negative bacteremia likely urinary
source.
#Pyelonephritis: The patient presented with several days of
fever, nausea and vomiting of unclear etiology. She did not
have any pain, nor did she have any tenderness on exam. Labs on
presentation were notable for a white cell count of 13.1. She
was started on ciprofloxacin and flagyl for presumed
gastrointestinal source. One of two sets of blood cultures from
the day of admission grew gram negative rods which were later
speciated to be eschericia coli. Urine cultures were difficult
to obtain as patient often had liquid stool mixed with urine.
Urine cultures done on ___ had <10,000 microorganisms. She
continued to spike fevers during the first 3 days of admission
and so was switched to meropenem for broader coverage including
pseudomonas. On ___ an ultrasound was performed of the
transplanted kidney which showed no evidence of abscess with
normal renal transplant waveforms. The patient improved
clinically but continued to have a rising white blood cell count
so a CT abdomen with contrast was performed to rule out abscess.
The CT showed heterogeneous enhancement of the transplanted
kidney with loss of corticomedullary differentiation concerning
for pyelonephritis. The patient improved clinically and was
switched to Ciprofloxacin on discharge. She will follow up with
renal and ___ after discharge.
#Diarrhea: Patient complained of diarrhea intermittently during
her hospitalization. A clostridium difficile test was ordered
but canceled by the lab because of the consistency of the stool.
The diarrhea was ultimately atributed to high levels of
mycophenoate.
# Acute kidney injury- Patient presented with creatinine of 2.2
on admission. This was likely prerenal in the setting of 5 days
of nausea, vomiting, diarreha and decreased PO intake. She was
hydrated with IVF during admission and creatinine was trended.
Creatinine on discharge 1.1.
# Renal transplant: Patient is s/p hx LRRT in ___. She was
admitted to the renal service. She was continued on
immunosuppressive medications: prednisone, tacrolimus, and
mycophenolate. Tacrolimus levels were checked daily and
adjusted accordingly. Creatinine was elevated on admission as
described above, but trended down with IV hydration to baseline.
The CT scan showed heterogeneous enhancement of the
transplanted kidney with loss of corticomedullary
differentiation concerning for pyelonephritis. The patient was
treated with antibiotics as above and will follow up with
nephrology on discharge.
Chronic Issues:
# Diabetes Mellitus type 1 - Patient was continued on home
lantus with a sliding scale.
# Hypertension - Patient was continued on metoprolol.
Furosemide was held due to volume depletion secondary to
diarrhea, vomiting and decresaed PO intake. Furosemide was
restarted on discharge.
# Hyperlipidemia: Continued on atorvastatin.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ PMH HTN, HLD, DM, who presents with dizziness
and nausea. Per ED, she reported acute onset of dizziness at
3:30 ___. No falls or head strike. No blood thinners. She denied
chest pain, shortness of breath, rashes. Subsequently per
neurology, she
reported progressive symptoms of feeling light-headed,
lethargic, confusion, nausea, vomiting and rightward drift while
ambulating. CT ANGIOGRAPHY HEAD AND NECK showed No significant abnormalities on CT of the head without contrast. No
significant abnormalities on CT angiography of the head and neck. CHEST (PORTABLE AP) showed No focal consolidation to suggest pneumonia. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. No acute intracranial abnormality. No evidence of an acute infarct,
intracranial mass, or hemorrhage.
2. Changes of chronic microangiopathy in the supratentorial white matter,
unchanged compared to prior. The patient was diagnosed with Dizziness and giddiness. At the time of discharge, the patient had Primary diagnosis:
=============
Dizziness
Secondary diagnosis:
================
HTN
DM
HLD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with a past medical history of HTN, HLD,
DM, who presented with lightheadedness, nausea/vomiting and
question of altered mental status. Imaging studies did not
reveal acute intracranial process. Patient was found to have
positive orthostatic vitals. Lightheadedness improved with IV
fluids.
DISCHARGE Cr 1.4
DISCHARGE K 4.8
DISCHARGE Na 141
DISCHARGE H/H 8.9/30.4
#CODE: presumed full
#CONTACT: ___ number: ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ old Male with PMH significant for anxiety, IBS
who presents with abdominal pain, nausea and vomiting for past 2
days. Patient states that last night he ate some cheesy bread
from Dominos and had abd pain associated with nonbloody vomiting
and nausea. The pain was initially in his lower quadrants and
now is diffuse. Per patient he has been drinking heavily for the
past week, about ___ shots of vodka each day with cranberry. He
concedes that he is a heavy drinker and has been drinking ___
times per week for the past year with ___ shots each night. Radiology showed 1. Limited evaluation of the pancreas due to body habitus and bowel gas.
Within this limitation, no evidence of choledocholithiasis or acute
pancreatitis.
2. Hepatic steatosis. However, more advanced forms of liver disease such as
steatohepatitis, cirrhosis, and fibrosis cannot be definitively excluded. 1.8
x 0.9 cm probable area of fatty sparing within the right hepatic lobe. Radiology showed Successful advancement of the Dobbhoff tube into post pyloric position with
the tube terminating at the level of the ligament of Treitz. The tube is
ready to use. Radiology showed 1. Acute pancreatitis with diffuse inflammatory peripancreatic stranding and
peripancreatic fluid collections extending from the lesser sac along the
anterior pararenal spaces, left worse than right, and along the paracolic
gutters bilaterally into the pelvis.
2. There is adequate enhancement of the pancreatic parenchyma, with no
evidence of pseudocyst formation, splenic artery pseudoaneurysm or portal vein
thrombosis.
3. Bilateral small-to-moderate pleural effusions with associated compressive
atelectasis, left worse than right.
Discussed with Dr. ___ by NSR via telephone on ___ at 10:50 ___.
4. Moderately fatty liver. The patient was diagnosed with ACUTE PANCREATITIS. The patient was treated with ___ - Placement of nasojejunal feeding tube. At the time of discharge, the patient had - Acute alcoholic pancreatitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with PMH significant for anxiety disorder and irritable
bowel syndrome presenting with abdominal pain due to
alcohol-induced acute, uncomplicated pancreatitis.
# Acute uncomplicated pancreatitis - Patient endorseD ___ years of
heavy drinking and within past week prior to admission had been
on ___ break and drinking ___ shots of vodka daily. Lipase
was elevated at 1498 on admission, and he was also found to have
a triglyceride level of 1274. RUQ US showed no cholelithiasis
but the pancreas and biliary system could not be adequately
visualized due to body habitus. GI was consulted and felt likely
alcoholic pancreatitis. Patient was treated with bowel rest and
IVF. Triglycerides downtrended to 667 then 277. No signs or
symptoms of complications. Had some dyspnea thought to be due to
bilateral pleural effusions seen on CXR which resolved over the
course of his admission without need for diuresis. On ___ an
NJT tube was inserted and he was started on tube feeds after it
was advanced to the post-pyloric region (jejunal). He also
underwent an abdominal CT which showed acute pancreatitis with
peripancreatic fluid collections extending to the pararenal
spaces, paracolic gutters, and extending into the pelvis, but no
complications. Over several days his tube feeds were
downtitrated, his diet advanced and he improved. He is
discharged with PCP and GI ___. He is to maintain a low
fat diet, per nutrition. He is to avoid all alcohol.
# Alcohol use - Patient reports ___ years of drinking ___ times a
week, about ___ drinks a week. No history of trouble with the
law due to drinking. CIWA scales were ___ and not concerning for
alcohol withdrawal. He was given MVI, folate and thiamine.
Social work was consulted to address his alcohol use and gave
contact information for SA recovery resources. He should abstain
from alcohol.
# Anxiety disorder - Patient states that he has anxiety and
reported taking clonazepam daily. Clonazepam was held initially
due to his being on a CIWA scale with diazepam written; however
clonazepam was restarted on ___, and the patient did not
experience alcohol withdrawal. During his hospitalization, the
patient continued taking his fluoxetine but refused his
buspirone most of the time. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx cirrhosis, chronic pancreatitis with known pseudocyst and
chronic abdominal pain, s/p selective angiography of bleeding
splenic artery pseudoaneurysm with embolization at OSH earlier
this month, chronic EtOH, presents from OSH for recurrent GIB. Radiology showed 1. Edematous pancreas and peripancreatic inflammation and fluid compatible
with pancreatitis. 4.6 cm peripancreatic fluid collection along the pancreatic
body that abuts the stomach.
2. Hepatic steatosis. PORTABLE ABDOMEN showed Oral contrast now within the large bowel. No contrast outside of the bowel or
collecting system is detected. CHEST (PORTABLE AP) showed The heart remains enlarged. Mediastinal contours appear somewhat widened but
are unchanged since ___ and therefore likely reflect a combination of
prominent vascular structures and patient rotation. There is subtle streaky
opacity in the retrocardiac region which may represent focal atelectasis,
although early pneumonia or aspiration should also be considered. Followup
imaging may be helpful. No pleural effusions, pulmonary edema or pneumothorax. The patient was diagnosed with GASTROINTEST HEMORR NOS, AC POSTHEMORRHAG ANEMIA, URIN TRACT INFECTION NOS, CHRONIC PANCREATITIS. The patient was treated with transfusion with 1 U pRBCs (___)
esophagogastroduodenoscopy (___). At the time of discharge, the patient had Primary Diagnosis:
-acute blood loss anemia
-urinary tract infection
Secondary Diagnosis:
-chronic pancreatitis
-chronic alcoholism
-anxiety/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>___ history chronic pancreatitis with known pseudocyst and
chronic abdominal pain, s/p selective angiography of bleeding
splenic artery pseudoaneurysm with embolization at OSH earlier
this month, chronic EtOH abuse, presents from OSH for recurrent
GI bleed with anemia and Hct drop. Patient required ICU level of
care, received 1U packed red blood cells. Endoscopy did not show
acute signs of bleeding, therefore possible re-bleed into
pancreatic pseudocyst. Patient's hematocrit remained stable
without further bleeding. Patient tolerated full solid diet and
was discharged to home with plan to follow up with Dr. ___
(___) for potential ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ without significant past medical history presents with two
weeks of worsening dyspnea on exertion. He was in his USOH until
LDW at which point he came down with a viral illness. His
symptoms included coughing, sneezing, and congestion. He doesn't
recall any muscle aches, body aches, diarrhea, or rash. He did
have a fever. Around that time, he began to notice difficulty
walking up stairs. He could easily walk up ___ flights without
SOB or needing to take a break. However, he soon found it
difficult to climb one flight without taking a break. He also
found that he had difficulty completing his 10,000 steps per his
usual fitbiting. During this time, he couldn't lay flat and
would awake with SOB. His SOB would resolve with sitting up and
deep breathing. On ___, he first noted leg swelling. During
this entire time, he has had fatigue more than usual. CHEST (PA AND LAT) showed Mild cardiomegaly with hilar congestion and mild pulmonary edema. Right lower
lung opacity concerning for pneumonia with small right pleural effusion UNILAT LOWER EXT VEINS BILATERAL showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. RENAL U.S. showed Normal renal ultrasound. No evidence of renal artery stenosis. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC. The patient was treated with Cardiac catheterization. At the time of discharge, the patient had Primary Diagnosis:
Dilated cardiomyopathy
Congestive heart failure
Hypertensive Emergency
Secondary Diagnosis:
Tachycardia
Transaminitis
Diabetes type 2
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>___ with obesity who presents with progressively worsening
DOE, orthopnea, and leg swelling x 1 month precipitated by
recent URI presenting with new onset heart failure.
# Hypertensive emergency: Patient presented with SBPs in the
160s to 170s on admission with evidence of end organ damage
(CHF, pulmonary edema). We successfully treated the patient with
several antihypertensive medications: isordil, hydralazine,
captopril, carvedilol, and torsemide and his SBPs were
maintained in the 110s-130s. We further evaluated the cause of
his hypertension with renal ultrasound, which did not reveal any
evidence of renal artery stenosis. We also obtained a
renin/aldosterone level which will need to be followed-up as an
outpatient.
# New onset heart failure with reduced ejection fraction, ___
IV: Patient presented with new 3-pillow orthopnea, worsening DOE
x 1 month, and leg swelling with bedside ultrasound showing a
depressed EF ~20% without pericardial effusion. Labs showed
downtrending troponins (0.02 to 0.01) and a proBNP: 5351. We
started him on captopril 50 mg daily and torsemide 40 mg daily
and he tolerated it well. On discharge, we lowered his torsemide
dose to 20mg daily and converted his captopril to lisinopril.
Patient underwent cardiac catheterization which revealed
severely elevated R and L sided filling pressures with
borderline cardiac index 2.27, but no obstructive CAD.
# Dilated cardiomyopathy: TTE revealed a dilated left ventricle
with severe global systolic dysfunction with low cardiac output.
CXR showed mild cardiomegaly with hilar congestion and mild
pulmonary edema. EKG revealed LAE and LVH. Patient with no known
PMH, and therefore no known risk factors associated with
ischemic cause, though patient does have obesity and HTN. Based
on cardiac catheterization results showing no CAD, an ischemic
precipitant is unlikely. On the differential for dilated CM
include infection (previous URI with fevers, now resolved as
trops downtrending), most likely given ___ titers
positive, though no cardiac biopsy performed so unclear if this
is the primary causative agent. Other etiologies may include
toxin-mediated vs hypertensive emergency vs tachycardia-mediated
cardiomyopathy vs ischemia. Other less likely etiologies OSA vs
inflammatory vs autoimmune. Workup was notable for negative HIV,
___ negative, TSH 1.2, CMV IgG positive but IgM negative,
___ titer positive.
# Tachycardia: Patient presented with HRs 110s - 120s with EKG
showing sinus tachycardia. Likely compensatory in the setting of
reduced ejection fraction/fall in cardiac output by increasing
sympathetic outflow. Other less likely causes include infection
vs PE vs hypovolemia vs anxiety. In the event the cause is
ischemia, we treated cautiously with beta blockade.
# Transaminitis: Mildly elevated ALT on admission. Etiology
unclear. Patient reported drinking alcohol occasionally. We
continued to monitor his LFTs, which continued to downtrend over
the course of his hospitalization and therefore no further
workup was pursued.
# DM2: HbA1c: 6.3. Newly diagnosed. Patient will need outpatient
___.
# HPL: HDL: 30, CHOL/HD: 6.5 LDLcalc: 141. We started him on
atorvastatin daily.
===========================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with CAD s/p CABG ___ and ___ BMS D1, HFrEF (EF
35-40%), severe AS s/p redo TAVR ___, CVA, HTN, DM1, recent
VF arrest s/p ICD, discharged from ___ on ___, presents
from rehab with dyspnea and lower extremity edema. Chest: Frontal and lateral views showed Small left pleural effusion with overlying atelectasis. Marked enlargement of
the cardiac silhouette, which may be slightly increased as compared to the
prior study. No overt pulmonary edema is seen. ___ DUP EXTREMITIES BIL (MAP/DVT) showed No evidence of deep venous thrombosis in the left lower extremity veins. The patient was diagnosed with Heart failure, unspecified. The patient was treated with N/A. At the time of discharge, the patient had Primary Diagnosis:
-Acute on Chronic Systolic Heart Failure
-Hypertension
-Diabetes Type 1
-Acute Kidney Injury
Secondary Diagnosis:
-CAD s/p CABG and recent PCI BMS D1 (diagonal) ___ after VT
arrest
-Anemia
-BPH
-Peripheral Neuropathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old man with CAD s/p CABG ___ and ___ BMS D1,
HFrEF (EF 35-40%), severe AS s/p redo TAVR ___, CVA, HTN,
DM1, recent VF arrest s/p ICD, discharged from ___ on
___, presents from rehab with acute on chronic systolic
heart failure exacerbation.
# CORONARIES: recent BMS D1, patent LIMA-LAD SVG-OM1
# PUMP: EF 35-40%
# RHYTHM: Sinus rhythm, atrial paced
# Acute on Chronic Systolic Heart Failure. Patient was
discharged from prior admission on Lasix 20mg PO but was not
given at rehab per patient and his wife for unclear reasons. He
presented this admission with classic CHF findings including
scrotal/leg swelling, PND, orthopnea, and dyspnea. Patient
symptomatically improved with Lasix 20 IV at ___ and his
discharge weight was 79.9 kg. Patient was continued on
increasing doses of IV lasix dosing, and transitioned to oral 80
mg PO Lasix BID. Prior to discharge, he was noted to have
orthostasis, so his AM dose of Lasix was switched to 40mg and
his Losartan was switched back to 25mg daily. His ___ dopplers as
well as urine studies did not show other etiologies of lower
extremity swelling. Repeat Echocardiogram confirmed EF <40%,
with mild ?paravalvular aortic regurgitation now seen. Overall,
the left ventricle was found to be less vigorous with Severe PA
systolic hypertension. Patient adhered to 2 g Na diet and 1.5L
fluid restriction. Patient was continued on home Eplerenone 25
mg daily, Losartan 25 mg daily, with addition of Isosorbide
Mononitrate 30 mg daily.
#Hypertension: Isosorbide Mononitrate (Extended Release) 30 mg
PO DAILY added ___ with continued Losartan Potassium 25 mg
PO/NG DAILY and Eplerenone 25 mg PO DAILY.
# CAD. s/p CABG and recent PCI BMS D1 (diagonal) ___ after
VT arrest: Patient denied any recent chest pain. He had a
troponin elevation peaking at 0.10, likely in setting of CHF
exacerbation and acute kidney injury, rather than type 1 MI. His
recent VF arrest likely due to acute coronary lesion s/p BMS D1.
He was loaded on amiodarone for this with 400mg BID. His
amiodarone was decreased to maintenance 400 mg daily, and then
down to 200 mg daily. He was continued on ASA 81, Plavix 75,
metoprolol XL 100, atorvastatin 80.
# s/p Vfib arrest: Patient was admitted on ___, transferred
from outside hospital s/p CPR and 2 rounds epi, amiodarone,
completed cooling protocol after ROSC. Between his history of
myocardial infarction and subsequent scar, and LV dysfunction,
he carries the substrate for sudden cardiac death without a
clear, reversible cause. It is very unclear whether ischemia
from his diagonal branch precipitated arrest. He had an ICD
placed on prior admission ___ for secondary prevention of
sudden cardiac death
# ___. Cr from 1.2 on discharge to 1.5 on admission. This was
likely due to CHF exacerbation and volume overload leading to
decreased intravascular volume. Discharge Creatinine: 1.4.
# DM1: Patient on home glargine with Humalog ISS (normally
Apidra at home), modified sliding scale to account for likely
lower insulin needs in-house. He was seen by ___ Diabetes
specialists in house for help with managing morning relative
hypoglycemia. He was continued on Lantus 22 units QAM + HISS
started w/ BG >70. Patient had follow up outpatient for diabetes
management.
#Anemia: Noted in prior admission, with stable currently Hgb
8.3-9, normal MCV
# Recent spine surgery: Pain was controlled mainly with tylenol.
Physical therapy recommended home with ___ services to optimize
functional status.
# BPH. Home finasteride and tamsulosin continued.
# Peripheral neuropathy: Home gabapentin continued</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx afib on coumadin, bladder cancer, peripheral
neuropathy presenting with abnormal MRI, back pain and left leg
weakness. He has had 5 days of worsening bilateral calf cramping
and worsening left leg weakness. He notes is is having severe
difficulty walking ___s pain, but he believes
the two are independent. He feels his left leg as well as foot
are weak. Chronic peripheral neuropathy in BLE with no
paresthesias or noted sensory changes. No bowel/bladder changes.
He notes he's also had some left sided back paraspinal spasms
which are improved with ice/rest over the past few days. MRI
ordered yesterday by Dr. ___ outpatient neurologist for
left leg weakness showing severe spinal stenosis. He was seen by
his PCP today who referred him to ___ for spine surgery
evaluation. On ROS he's also had 3 nights of nausea/chills and
abdominal pain which resolves by the morning. Chest: Frontal and lateral views showed No acute cardiopulmonary process. LUMBAR SP,SINGLE FILM IN O.R. showed Fluoroscopic image shows posterior probe at what appears to be the L4-L5
level. Further information can be gathered from the operative report. The patient was diagnosed with Intervertebral disc disorders w radiculopathy, lumbar region. The patient was treated with 1. Bilateral L3 and L4 laminectomy with medial facetectomy
and foraminotomy.
2. Bilateral laminectomy, L4, with medial facetectomy and
foraminotomy.
3. Lumbar spinal decompression of exiting L3, L4, and L5
nerve roots bilaterally.. At the time of discharge, the patient had 1. Lumbar spinal stenosis, L3-L5.
2. Lumbar degenerative grade 1 spondylosis at L4-5.
3. Neurogenic claudication.
4. Left lower extremity radiculopathy.. The patient was given written instructions concerning 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 ___ Spine Surgery Service and
taken to the Operating Room for the above procedure.Refer to the
dictated operative note for further details.The surgery was
without complication and the patient was transferred to the PACU
in a stable ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as tolerated.
Mr. ___ refused to d/c his foley and would like to do a void
trial at rehab. Physical therapy and Occupational therapy were
consulted for mobilization OOB to ambulate and ADL's.Hospital
course was otherwise unremarkable.On the day of discharge the
patient was afebrile with stable vital signs, comfortable on
oral pain control and tolerating a regular diet.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o Roux-en-Y surgery (___) c/b JJ stricture s/p revision,
dilation of GJ anastomosis, marginal ulcers, malnutrition, and
most recently afferent loop syndrome presents with blocked NJ
tube. The NJ tube was placed on ___ via EGD. It was then found
to be kinked, and the kind was corrected by ___. She was
discharged on ___ but immediately had issues with slow
infusion. She eventually uptitrated to 59 ml/hr, but had a great
deal of abdominal pain. She would feel a left-sided abdominal
cramps, and then the tube feed infusions would stop. She tried
flushing the tube multiple times but was unsuccessful. Because
of these issues, she presented to the ED. CHEST (PORTABLE AP) showed As above. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. PORTABLE ABDOMEN showed Marked gaseous dilatation of small bowel loops centered in the left upper
quadrant with air-fluid levels, slightly worse compared to the prior CT of ___ where obstruction of the afferent limb of the Roux-en-Y gastric
bypass was evident.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:02 pm, 5 minutes after
discovery of the findings. The patient was diagnosed with Oth complication of other internal prosth dev/grft, init, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause. The patient was treated with EGD with NJ tube placement ___. At the time of discharge, the patient had -clogged feeding tube
-roux-en-Y complicated by jejuno-jejunosotmy anastomotic
stricture, adhesions/SBO, afferent
limb syndrome) likely requiring revision surgery, malnutrition
-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>___ h/o roux-en-Y (___) (complicated by jejuno-jejunosotmy
anastomotic stricture, adhesions/SBO, afferent limb syndrome)
likely requiring revision surgery, malnutrition s/p NJ tube
___, and chronic pain presented with clogged NJ tube.
1. Clogged NJ tube w/ severe malnutrition and malabsorption h/o
roux-en-Y, jejuno-jejunosotmy anastomotic stricture,
adhesions/SBO, afferent limb syndrome
-NJ tube clogged and removed by GI. s/p EGD ___ with
replacement of NJ tube. Continue copper gluconate
(nonformulary), ascorbic acid, folic acid, thiamine, and
multivitamins in setting of malnutrition. Patient will need
surgical revision once her nutritional status is improved. Tube
feeds were advanced and she was discharged on Levity 1.5
@80mL/hour cycled for 15 hours per day with free water flush
100mL Q6 hours. Patient should flush tube Q1-2 hours with warm
water (30mL) during the day when not in use to prevent clogging.
2. Acute on chronic Abdominal pain and distention
-Although she does not have clinical signs of obstruction (no
nausea/vomiting and passing gas/bowel movements) she has
evidence of worse obstruction of the afferent limb. Continue
pain regimen: methadone 40mg BID, oxycodone 20mg BID PRN,
oxycodone 30mg BID PRN (as per home regimen managed by her PCP).
Simethicone and acetaminophen. Also started bowel regimen in
setting of high dose narcotics.
3. Lower extremity edema
-As per previous discharge summary this has been a chronic and
ongoing process that has been, "extensively worked up in the
past and was thought to have chronic lower extremity edema
likely in the setting of malnutrition and hypoalbuminemia."
Right lower extremity venous ultrasound negative for DVT.
Continue compression stockings.
4. Acute on chronic normocytic anemia
-Stable. Continued ferrous sulfate.
CHRONIC MEDICAL PROBLEMS
1. Vitamin D deficiency: continue vitamin D
>30 minutes spent on discharge planning </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with chief complaint of Adult Onset Still's
disease developing Macrophage Activation Syndrome. Sent in for
admission by rheumatology, with consultation of hematology, ID,
rheumatology eval, and high dose steroids. Late last week, they
tried to reduce her prednisone from 50 mg (div BID) to 45 mg and
she started to develop fevers to 102, joint pains, and worsening
rash. Her rheumatologist checked labs and found a falling
platelet count to 104, ESR 1, CRP increased to 6.2 from 0.5 and
ferritin of 1431 from 595, increased AST and ALT of 579 and 184,
respectively. This is consistent with possible MAS. He
recommended admission. She took prednisone 60 mg this morning,
30 mg last night and her usual anakinra injection last night.
The patient was diagnosed with adult onset Still's in ___ of
this year after ___ years of occasional fevers with rash and
knee pain that became acutely worse and prompted an admission.
She is followed by ___ here in rheumatology. She has also had
an ID workup for continued fevers despite prednisone, workup has
been negative.
In the ED, initial vital signs were T96.2 HR106 BP120/82 RR18
96%RA. Patient was admitted directly to the floor. Last set of
vitals prior to transfer were T99.1 HR94 BP120/76 RR16 100%RA.
On the floor, T 98, 107/71, 90, 14, 98% RA. Patient notes fevers
and chills last night and knee pain yesterday that has resolved.
She denies any rash currently. She feels well otherwise, see ROS
below.
Review of sytems:
(-) Denies N/V/D, blurry vision, sore throat, hemoptysis,
heartburn, constipation, bloating, dark colored stool, urinary
changes (frequency, burning), CP, dyspnea, palpitations, cough,
sore throat The patient was diagnosed with JUV RHEUM ARTHRITIS NOS, HYPOTHYROIDISM NOS, THROMBOCYTOPENIA NOS. At the time of discharge, the patient had Primary: macrophage activation syndrome
Secondary: Adult Onset ___. The patient was given written instructions concerning 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 recently diagnosed with Adult Onset Still's now
presenting with likely macrophage activating syndrome.
# Adult Onset Still's complicated by Macrophage Activating
Syndrome (MAS): Patient diagnosed with Adult Onset Still's in
___, she had been unsuccessfully trying to taper her
steroids. She presented from her rheumatologist with concern
for MAS. Typical lab abnormalities in MAS are thrombocytopenia,
elevated AST, low WBC and low fibrinogen. Her labs are
consistent with MAS with thrombocytopenia (PLT 49) and increased
aspartate aminotransferase levels (AST 579). Her white count
was normal on presentation (6.7) but dropped to 2.3 on ___
with 10% neutrophils. Her fibrinogen was also normal at 229
mg/dl but dropped to 125 mg/dl on ___. On physical exam, she
had petechia consistent with low platelet count. She also
developed a reticular rash on her trunk and upper extremities.
The patient was followed by rheumatology and her primary
rheumatologist Dr. ___. She was also seen by
hematology/oncology who performed a bone marrow biopsy, which
was consistent with macrophage activation syndrome. CMV IgG and
IgM and monospot were negative making infection unlikely.
Further, she recently had a complete infectious workup and
tested negative for Hep B, Hep C, mycoplasma, schistosoma,
parasite smear, HIV, anaplasma, lyme, RPR, CMV, EBV and negative
PPD.
She was treated with 5 days of 1000 mg of IV methylprednisolone.
Anakinra was initially held and then restarted at QHS and then
BID per rheumatolgoy. On ___, she was transitioned to 125 mg
IV BID of solumedrol. The patient was monitored with telemetry
and daily tumor lysis labs. There was no evidence of tumor lysis
and she tolerated the treatment well. She was switched to
Atovaquone from Bactrim for prophylaxis after developing a rash;
this is unlikely due to the Bactrim however because of the
timing of rash onset. On the day of discharge, her LFTs
continued to trend down and her WBC count increased to 3.3 with
62% PMNs. She was discharged on prednisone 80mg BID and
Anakinra (Kineret) Kineret 100 mg/0.67 mL BID. She will follow
up with her rheumatologist and have labs drawn every other day
for monitoring.
# Hypothyroid: Chronic.
- continued synthroid ___ mcg daily</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with history significant for diastolic CHF (last echo
___ showing EF 55%, mod LV hypertrophy, and mild pulm
HTN), CKD stage III, AFib (was on apixaban but recently changed
to warfarin given renal function), and DM who presents from home
with somnolence at home. CHEST (PORTABLE AP) showed Low lung volumes with complete silhouetting of the left hemidiaphragm, which
may be due to consolidation or a left lower lobe collapse. CT HEAD W/O CONTRAST showed There is no acute intracranial process. Radiology showed 1. No evidence of acute intra-abdominal or intrapelvic process within
limitations of this nonenhanced study.
2. Borderline diameter appendix without periappendiceal inflammation.
Previously seen fat stranding about the appendiceal tip on prior CT has since
resolved.
3. Partially imaged lung bases show no consolidation. Radiology showed As above. MR HEAD W/O CONTRAST ___ MR HEAD showed 1. Subcentimeter acute to early subacute infarct the left frontal cortex/
subcortical white matter. No mass effect.
2. Stable small chronic infarctions in the left cerebellar hemisphere.
3. Unchanged punctate chronic microhemorrhage in the left superior cerebellar
vermis, which could be secondary to hypertension or amyloid angiopathy. No
new blood products seen.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 8:15 AM, 10 minutes after
discovery of the findings. The patient was diagnosed with Pneumonia, unspecified organism, Fever, unspecified, Disorientation, unspecified. The patient was treated with Intubation ___. At the time of discharge, the patient had 1. Encephalopathy
2. Embolic Stroke due to atrial fibrillation
3. Congestive heart failure
4. Chronic kidney disease
5. Diabetes Mellitus
6. Sleep apnea
7. 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>___ h/o chronic diastolic CHF, DM, Afib on Coumadin, and CKD was
admitted to the ICU ___ for severe agitation and acute
encephalopathy. He was febrile raising concern for meningitis
and started on empiric ceftriaxone, vancomycin, and acyclovir
but LP
___ with WBC 2 and vancomycin and ceftriaxone and ___ HSV
negative and acyclovir stopped. He was intubated ___ for the LP
and unable to extubate until ___ due to persistent agitation and
transferred out of ICU ___.
1. Acute encephalopathy with agitation
He had a complete work up including several infectious workups,
LP, CXR, CT, and EEG. Toxicology did not feel that this was due
to his chronic medications. MRI showed subcentimeter acute to
early subacute infarct of left frontal cortex/subcortex.
OUtpatient notes also comment on alcohol use, but tox screen
negative for ethanol.
It is likely that his encephalopathy is multifactorial in nature
- from sedating medications that are renally cleared
(gabapentin, baclofen) when he has renal impairment, infection
(fevers, but all cx negative, so ? viral syndrome) untreated
sleep apnea, and small stroke. His mental status continued to
improve on the floor and he had no further episodes of
agitation. He was AOx3, but occasionally tangential.
2. ___ h/o CKD III
-Baseline Cr 1.6-2.0 that peaked at 4.0 during this admission.
___ likely due to dehydration/prerenal in setting of bumex with
limited PO intake. Creatinine returned to his baseline of 1.9 on
discharge.
3. Atrial fibrillation on Coumadin: Was previously on apixaban,
but during last admission changed to Coumadin as he has CKD. He
was continued on Coumadin here, and INR on discharge is 2.
Coumadin had been held because of supratherapeutic INR,
restarted on ___ at his home dose of 2.5 mg daily. He should
have INR rechecked on ___ to confirm it is above 2.
4. Subacute stroke
Seen by neurology; felt to be thromboembolic stroke (he had a
period of subtherapeutic anticoagulation when taken off apixaban
and restarted on Coumadin). He should be bridged with IV
heparin prior to any procedure given risk of recurrent stroke.
He also has some chronic microhemorrhages seen on imaging,
unchanged from prior. Per neurology attending note: "His
CHADS2VASC score for risk of recurrent
embolic stroke is 6, with a 9.7% per year stroke rate, CHADS
score is 5, 12.5% risk of stroke per year. HASBLED score is 2,
and if microhemorrhage is considered, it is 3 with a 5.8% bleed
risk per year, or 3.73 major bleeds per 100 patient years.
Overall his stroke risk is considerable and would continue
Coumadin". He should f/u with ___, ___ neurologist,
after discharge.
5. Chronic diastolic heart failure h/o HTN
-ECHO ___ EF >55%. Due to recent admission for acute on chronic
heart failure exacerbation bumex was continued upon admission to
ICU and then stopped due to ___.
His bumex dose at home was 2 mg po bid; he was restarted at 1 mg
a day, and did not complain of PND/orthopnea. No ___ swelling.
Weight on discharge is 119.75 kg and dry weight according to
last discharge summary is 125.7 kg. Would gradually increase
bumex dose to his home dose of 2 mg po bid as his weight
increases.
6. Gout: continue allopurinol and colchicine; dose of
allopurinol decreased to 150 mg po daily given his renal
insufficiency, and colchicine dose decreased to .3 mg po daily
given renal insufficiency.
7. GERD: omeprazole held in the hospital and patient without
complaints; I have restarted this as a PRN agent.
8. BPH: continue tamsulosin
9. DM: He is on bid glargine at home, 10 units in the morning,
32 units at night. He was initially on sliding scale insulin
here, but then glargine restarted - now on glargine 12 units in
the morning, and will start him on glargine 6 units at night. I
suspect he may be better servied with 70/30 insulin bid. A1C
here 9.3 indicating poor control at home. Rehab should
uptitrate glargine or consider 70/30 insulin bid
5. Vitamin D deficiency: continue vitamin D
6. Chronic pain: Had intermittent neck and back pain, but
appeared comfortable for the most part; I stopped baclofen given
that it could worsen his encephalopathy; he will continue on
gabapentin, but this dose also decreasd from prior given his
encephalopathy; continue prn Tylenol, lidocaine patch. Tylenol
#3 held as well; tramadol that he took at home was continued for
pain. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with no significant
past medical history who presents to the hospital for evaluation
of new onset painless jaundice. She reports that she was in her
usual state of health until the prior week. She reports that
she
got her flu shot approximately 1 week ago. She reports that
over
the course of the last week she has had significant epigastric
pain with radiation to the back. She reports that she has had
several episodes of feeling chills with uncontrolled shaking.
She is uncertain if this pain is associated with food. She does
report that has some association with nausea. She reports that
she has had normal bowel movements. She has been taking
Pepto-Bismol so is uncertain if her stool has changed color.
Prior to taking the Pepto-Bismol over the course of the last
several weeks that her stool has stayed the same normal brown
color. She reports that her urine has significantly darkened
over the course of the last ___ days. She specifically denies
any
Tylenol use. She reports no other family history of liver
disease. She reports that she woke up on the day of admission
and noticed that she is yellow and that she was urinating very
dark urine. Given that she presented initially to an outpatient
clinic which then referred her to the ___
emergency
department who then referred her to the ___ emergency department for further evaluation and
management. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Diffusely echogenic hepatic echotexture with heterogeneous appearance and
lobular liver contour involving predominantly the left hepatic lobe, not fully
characterized on this exam. A dedicated CT or MR exam can be obtained for
further evaluation/characterization.
2. No evidence of cholelithiasis or acute cholecystitis.
3. Splenomegaly, measuring up to 18.3 cm MRCP showed 1. Cirrhotic liver morphology with hepatic fibrosis predominantly in the left
lobe and anterior segments of the right lobe and evidence of portal
hypertension.
2. Mild dilatation of the central intrahepatic bile ducts without evidence of
a central obstructive mass.
3. Left-sided gallbladder are noted as an anatomic variant.
4. 4 mm cystic lesion in the body of the pancreas is likely a side branch
IPMN. Follow-up MRCP in ___ year is recommended for reassessment.
RECOMMENDATION(S): Follow-up MRCP in ___ year for reassessment of a 4 mm cystic
lesion in the pancreas. Radiology showed Uncomplicated non-targeted liver biopsy of the left and right hepatic lobes. The patient was diagnosed with Unspecified jaundice. The patient was treated with Liver Biopsy ___
EGD ___. At the time of discharge, the patient had Cirrhosis
Splenomegaly, Hyperbilirubinemia, Abnormal LFTS and concern for
PSC or Autoimmune hepatitis. The patient was given written instructions concerning 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 without significant medical history who
presents with one week of worsening jaundice and prandial
epigastric pain found to have elevated transaminitis with
bilirubin to 13, now improving.
1. Jaundice, Hyperbilirubinemia, abnormal LFTs, Epigastric pain,
Splenomegaly - MRCP with evidence of cirrhosis primarily in the
left lobe, and anterior right lobe, with mild dilatation of
central intrahepatic portal ducts. Also with evidence of portal
hypertension including splenomegaly. Serologic work-up has been
negative for viral etiologies or autoimmune hepatitis. ___ have
a biliary stricture or obstruction leading to more focal atrophy
of her liver. S/p liver biopsy on ___.
[ ] will need f/u with Dr. ___ in 2 weeks (see below)
2. EGD on ___ notable for esophagitis for which she has been
started on omeprazole 20mg bid for 8 weeks.
3. Epigastric pain - had significant pain during liver biopsy
yesterday complicated by severe HTN. ___ will see her in f/u but
they are not concerned about procedural complications at this
time. the pain is in same location as the pain she presented
with. Her epigastric pain worsened significantly after liver
biopsy; discussed with ___ no concern for post procedural
complication given. She was discharged on a limited amount of
oxycodone to help manage her pain at home.
3. Hypertension: No prior h/o HTN but hypertensive to 170's on
admission and was started on captopril which has been titrated
up to 37.5 tid. She was converted to lisinopril on discharge.
Discussed with her at length the need to find a PCP and for her
to have ongoing medication titration. She had an episode of
dizziness when she received her blood pressure medication and
oxycodone at the same time.
Transitional Issues: EGD with grade 1 varices, no need for
treatment at this time. Should have repeat EGD in ___ years. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ man with history of
coronary artery disease not on any medications, hypertension,
hyperlipidemia, with poor physician ___, who presents with
2 week history of left-sided headache, neck pain, and
intermittent word finding difficulties. History provided by
discussion from patient. MRI AND MRA BRAIN AND MRA NECK PT11 MR ___ showed 1. No acute infarct.
2. Long segment caliber change of the mid to distal left ICA with
short-segment severe narrowing/complete occlusion of the distal left cervical
ICA. Thickening of the wall with associated intrinsic T1 hyperintensity of the
distal cervical ICA compatible with intramural hematoma and dissection.
3. Poor flow seen in the petrous segment of the left ICA with reconstituted
flow related enhancement seen in the left MCA. There is decreased flow
related signal of the distal MCA branches relative to the right without
definite occlusion.
4. Additional findings as described above, including moderate paranasal sinus
disease as described above. The patient was diagnosed with Dissection of carotid artery, Transient cerebral ischemic attack, unspecified, Unspecified abdominal pain. At the time of discharge, the patient had Transient Ischemic Attack
Left ICA dissection. The patient was given written instructions concerning 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 hypertension,
hyperlipidemia non-compliant with statin therapy, coronary
artery disease non-compliant with aspirin therapy and poor PCP
follow up who presented with 2 weeks of left sided headache,
neck pain and intermittent word finding difficulties. He had a
non focal examination on presentation with some mild left neck
and head pain and initial word finding difficulty that resolved
on day 1 of admission. He was admitted to the neurology service
and was found to have left ICA narrowing to complete occlusion
on CTA s/p left ICA dissection. Suspect TIA as well given word
finding difficulties. His TIA was likely related to occlusion of
his ICA secondary to dissection. He underwent a brain MRI which
showed no evidence of acute infarct on MRI. He was started on IV
heparin and warfarin was initiated however patient remained
subtherapeutic INR 1 on 5 mg warfarin so he was transitioned to
___ with plan to continue this until follow up with PCP who
could then bridge to warfarin. He complained of left sided
headache, neck pain and tooth pain which was managed with
Tylenol and tramadol. He had no deficits on exam on day of
discharge.
His stroke risk factors include the following:
- Coronary artery disease, prior heart attacks
- Hyperlipidemia (LDL 166); simvastatin 20 mg initiated with
plan to increase if tolerated
- Pre-diabetes (HgA1c 5.8%)
- Hypertension
Transitional issues
[ ] New PCP appointment with nurse practitioner at the office of
Dr. ___ phone number
___, fax number ___, Address ___, scheduled for ___ @ 1pm; office called and
provided with summary of hospitalization on ___
[ ] Patient discharged on ___ with plan for PCP to start
warfarin, INR goal ___, which should be continued until
neurology follow up in 3 months
[ ] continue simvastatin 20 mg, increase if tolerated as
outpatient
for LDL 166
[ ] avoid NSAIDs while on anticoagulation if possible
[ ] avoid heavy lifting (greater than 15 lb), strenuous physical
activity and neck manipulation until ___
[ ] needs outpatient follow up with dentist to evaluate for
primary dental problem as etiology of left sided tooth pain
although may be related to dissection
[ ] Polycythemia noted during hospitalization, continue to
monitor
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? () Yes - (x) No
4. LDL documented? (x) Yes (LDL = 166) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - started low
dose to monitor toleranace() No [if LDL >70, reason not given:
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ male with a past medical
history of frontotemporal dementia who presented with vomiting
and abdominal distention. CT ABD AND PELVIS WITH CONTRAST showed 1. The small bowel is distended and fluid-filled with multiple air-fluid
levels. There is air and stool seen to the level of the colon. Findings are
suggestive of a low-grade obstruction or ileus. Chest: Frontal and lateral views showed Relatively low lung volumes. Hazy bilateral perihilar opacities may relate to
low lung volumes, but underlying mild aspiration or pneumonia is difficult to
entirely exclude in the appropriate clinical setting. Suggest dedicated PA
and lateral views if/when patient able, for further assessment.
Patchy retrocardiac opacity seen on the lateral view, but not substantiated on
the frontal view, may relate overlap of vascular structures. CHEST (PA AND LAT) showed In comparison with the study of ___, there are improved lung volumes.
Cardiac silhouette remains enlarged without definite vascular congestion.
Mild obscuration of the left hemidiaphragm could reflect small effusion with
atelectatic changes.
No definite acute focal consolidation, but this would be difficult to
unequivocally exclude in the appropriate clinical setting. Radiology showed There is a nonobstructive gas pattern with a dilated single loop of bowel
measuring up to 4.7 cm, which may be representative of ileus. The patient was diagnosed with Unspecified abdominal pain. At the time of discharge, the patient had Abdominal pain and nausea, likely due to constipation
Haloperidol induced EPS
Purulent cellulitis of LLE
Leukocytosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with a past medical history of
presumed behavioral variant frontotemporal dementia who
presented with vomiting and abdominal distention during recent
admission to ___ for SI and aggressiveness, also with
LLE purulent cellulitis and leukocytosis, on ___. Course
at ___ notable for initiation of Haloperidol which we suspect
may have caused ___ symptoms leading to decreased
verbal output and recent decline.
# Frontotemporal dementia, suspected behavioral variant
# Recent paucity of speech - likely EPS ___ Haloperidol
Patient carries diagnosis of FTD from ___ neurology, although
records unavailable for us to review, with manifestations
including increased appetite as well as insistence on repeated
ICS. Patient had worsening output of language since starting
haloperidol, with increased somnolence. Exam was notable for
some Parkinsonian features including rigidity and masked facies.
Psychiatry consulted for assistance, who recommended stopping
haloperidol and documenting this as an allergy, given concern
for typical antipsychotic causing EPS. Should he be agitated,
recommendation for seroquel 25 mg TID: PRN, while he was in
house he required minimal doses of this medication. Patient's
recent decline was also discussed with patient's outpatient
cognitive neurologist, who notes that the typical FTD
progression is in the ___ year range and therefore EPS seemed
most likely to be cause 1 week decline. Patient improved with
cessation of Haldol and was noted to have improved mood, and was
increasingly interactive with improved speech in terms of
hypophonia and paucity of words.
# Abdominal pain
# Nausea
# Constipation
He initially presented with vomiting and abdominal distension,
CT A/P with distended and ___ small bowel with multiple
___ levels suggestive of a low grade obstruction or ileus.
ACS evaluated and thought he did not have SBO. Started
aggressive bowel regimen with improvement in symptoms. Had
recurrence of nausea on ___ and was given tap water enema x1
with improvement once again. Started lactulose on ___ for
improved bowel regimen. Please continue bowel regimen with
docusate/senna/Bisacodyl and lactulose to titrate BMs to
distension and symptom improvement.
Of note, per sister- patient noted to have nausea with
fluvoxamine in the past and was tapered off of this and started
on fluoxetine instead with improvement in symptoms. If
persistent nausea in spite of regular BMs and improved abdominal
distension, would consider stopping fluvoxamine again in favor
of fluoxetine.
# Leukocytosis/LLE purulent cellulitis:
Patient with LLE cellulitis previously treated with keflex,
however appeared purulent and was worsening on keflex.
Antibiotics switched to TMP/SMX on ___ with improvement in
appearance. Plan for 4 additional days on discharge to complete
10 day course. Leukocytosis resolved after switching
antibiotics. Otherwise, infectious work up was negative. There
was initial concern for questionable infiltrate on CXR which
resolved on repeat the subsequent day; as patient had no
respiratory symptoms, suspicion for pneumonia low.
# Creatinine elevation:
Patient with Cr 1.0--> 1.3 on ___ after starting Bactrim; also
in setting of patient having multiple bowel movements and being
on furosemide. Appears that patient never had indication for
furosemide hence this medication was stopped. Cr remained stable
around 1.3/1.4 and appeared most consistent with impaired Cr
clearance ___ Bactrim. Recommend BMP check after completion of
abx course to ensure resolution. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ with h/o asthma, DMII, morbid obesity who
presents from ___ for evaluation of hypoxia. The
patient reports sudden onset of SOB when awoke 5 days ago with
gradual worsening up until today. He used oxygen w/o effect. (at
baseline 2LNC). Denies change in baseline non-productive cough,
chest pain, palpitations, leg swelling/pain, orthopnea. Denies
fevers, chills, abd pain, melana, hematochezia, dysuria,
dizziness. Patient presented to ___ for evaluation. Patient
was found to have sats 72% on RA w/ improvement w/ oxygen. CXR
negative, trop negative, BNP WNL, EKG with ST depressions, no
STEMI, but D-dimer in 300s. Given h/o PE in ___ and elevated
D-dimer there was greatest concern for PE patient started on
heparin and transfered to ___ for CTA.
Initial VS in the ED: 0 97.6 80 133/94 16 92% 4L. Exam
unremarkeable. Labs notable for neg trop, D-dimer 1157,
hypokalemia, elevated bicarb. Patient was given 40 KCl,
lamictal, ativan, effexor. CTA was negative for PE and heparin
discontinued.VS prior to transfer: 98.8 102 119/96 18 95%. Radiology showed 1. No central, main, lobar, or segmental pulmonary embolism. Evaluation of
the subsegmental pulmonary arteries is limited due to poor contrast bolus and
patient body habitus.
2. Trace left pleural effusion with adjacent atelectasis. Mediastinal lymph
node enlargement of uncertain etiology.
3. The visualized portion of the thyroid gland is markedly enlarged,
compatible with a thyroid goiter. This could be further evaluated with a
non-emergent ultrasound. Radiology showed Limited study as above. No evidence of deep vein thrombosis.
Peroneal veins not visualized.
4.8 x 3.9 x 2.0-cm ___ cyst. The patient was diagnosed with RESPIRATORY ABNORM NEC. At the time of discharge, the patient had 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>___ yo male with PMH notable for asthma, DMII, morbid obesity who
presents from ___ for evaluation of hypoxia.
Active issues:
# Hypoxia: Likely secondary to COPD exacerbation; may have
component of fluid overload as BNP can be falsely low in
obesity. Pulmonary HTN also possible ___ chronic hypoxia.
Patient was gently diuresed with improvement in O2 sat back to
baseline (88%RA). Patient has O2 at home which he uses
occasionally for symptomatic relief. Additionally, uses
albuterol PRN and flovent. Encouraged to continue with
inhalers/O2 as needed.
Chronic issues:
# OSA: Stable. On CPAP
# DM II: Holding oral meds. Maintained on ISS during admission.
# HTN: On combination meds that are NF. Given individual meds
for BP control
# Depression/Anxiety: Stable. Continued home effexor, lamictal,
clonazepam PRN</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ transferred from ___ after presentation for abdominal
pain. Patient reported with diffuse and constant abdominal pain.
Patient reports two weeks of worsening abd pain and constipation
(no BM x 2 weeks), thought partially ___ opioids for MSK pain.
Patient took 5 senna w/o result. +Flatus and burping. No fevers,
chills, nausea, or vomiting. No urinary symptoms. Radiology showed Pulmonary edema with small right pleural effusion. Radiology showed Gallbladder sludge without sonographic findings to suggest cholecystitis.
Prominence to the IVC and hepatic veins which can be seen in the setting of
right heart dysfunction.
Small amount of perihepatic ascites. Radiology showed 1. A right-sided single-lead pacer remains in place with the tip terminating
over the expected location of the right ventricle. Small bilateral layering
effusions, right greater than left. Coarsening of the interstitium which is
felt to most likely represent underlying chronic changes with interval
resolution of the pulmonary and interstitial edema. Overall cardiac and
mediastinal contours are unchanged. No pneumothorax. Degenerative changes in
the thoracic spine with no acute bony abnormality appreciated. No
pneumothorax. Radiology showed 1. No hydronephrosis in either kidney.
2. Two small right renal cysts are noted. A small amount of gravel is noted
in the urinary bladder. The patient was diagnosed with UNSPECIFIED CONSTIPATION, HYPERTENSION NOS. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ hx of ___ mitral regurgitation, systolic
CHF, history of coronary artery disease, status post PROMUS
stenting of the LAD and RCA, chronic left bundle-branch block,
status post pacemaker implantation in ___, and atrial
fibrillation who presents with abdominal pain and fecal
impaction.
# Abdominal pain:
Patient describes lower abdominal to diffuse cramping sensation,
coming and going. Found to have fecal impaction on CT as well as
note of gallbladder sludge and perinephric fat stranding.
Elevated LFTs, ALP (normal bili) and elevate lipase w/ note of
sludge on CT c/f possible cholecystitis/choledocolithiasis, but
exam not consistent and LFT abnormalities stable from prior.
Considered intermittent obstruction with sludge/microlithiasis,
but no recurrent abdominal pain. Lactate 2.5 c/f possible
ischemia in setting of Afib, but overall course not consistent,
and lactate normalized. Pain resolved after constipation
resolved. Unfortunately, following aggressive bowel regimen,
patient developed diarrhea. CDIFF sent and positive. Started on
PO vancomycin ___, plan for 14 day course. Patient had
persistent poor appetite throughout his inpatient course,
although no recurrent abdominal pain, nausea/vomiting. Repeat
KUB And RUQ ultrasound largely unrevealing. Will follow up
outpatient for ongoing evaluation.
# Constipation:
Likely ___ opioids in setting of shoulder injury. S/p fecal
disimpaction in ___ and having BMs here. TSH, calcium, total
protein, albumin unrevealing for cause of constipation. Later
developed diarrhea, as above, and treated for CDIFF. ___ need
bowel regimen in future.
# Acute Kidney Injury:
Patient with CKD and baseline creat 1.7-2.0. Creatinine at ~2
since prior discharge. Rising creatinine since ___ thought
likely ___ poor PO intake. Volume repleted w/ IVF on admission
as appeared hypovolemic but later developed pulmonary edema so
gently diuresed. Patient then again became hypovolemic in
setting of diarrhea and persistent poor PO intake. FENa from
___ was 0.33% c/w pre-renal azotemia and poor po intake. Renal
ultrasound was negative for obstruction. SPEP/UPEP neg, but
albuminuria noted. 250cc IVF given on ___. Diuretics held and
continued to encourage PO intake. He will need continued
monitoring of I/Os, electrolytes, and creatinine. He would
benefit from outpatient f/u with nephrology.
# CHF:
EF 30%. No e/o decompensated CHF by exam on admission, however,
after IVF repletion on day of admission, he developed SOB
despite starting home dose lasix. Lungs were clear on exam, but
noted to have elevated JVP, pro-BNP elevated (4,533) and CXR
with note of pulmonary edema c/w acute systolic heart failure.
Received add'l 20mg IV Furosemide ___ and 5mg torsemide ___
with improvement. However, in setting of diarrhea and subsequent
poor oral intake, noted to be somewhat hypovolemic. Held
diuretics starting on ___ and not resumed at discharge. He
will need to be monitored closely, as diuretics will need to be
resumed once oral intake normalizes as he will be at high risk
for decompensated heart failure. He was continued on carvedilol,
although dose reduced to 12.5mg BID given SBPs ___. He will
also f/u outpatient with cardiology for consideration of cardiac
resynchronization.
# Transaminitis:
ALT 53 AST 60* ALP 207 TB 0.9 LIPASE 186. Patient w/ note of LFT
abnl during previous admission. Congestive hepatopathy and ETOH
considered on ddx. LFTs not significantly changed from prior.
Viral serologies negative. HIV negative. Congestive hepatopathy
+/- obstructive lesion, although nothing noted on non-con CT and
RUQ ultrasound with sludge but no cholecystitis. Improved to
stable on repeat labs. Rosuvastatin held esp with concomittent
increasing creatinine. Will need continued monitoring at f/u
with PCP.
# Severe MR:
Patient being evaluated for MVR. Follow up outpatient for CT
surgery evaluation.
# CAD:
H/o known CAD s/p Promus stenting of the LAD and RCA in ___,
and stable cardiac cath in ___. Continued ASA. Rosuvastatin
held in setting of elevated LFTs and ___. Should f/u with PCP
with repeat LFTs. Consider resuming statin outpatient with close
monitoring. (Rosuvastatin would need to be renally dosed).
# Atrial fibrillation:
CHADS2 of ___. Not anticoagulated per discussion of risks and
benefits with patient, family and PCP. Paced. On ASA 325mg. Rate
controlled w/ carvedilol. Will need outpatient f/u for device
interrogation.
# Anemia, Thrombocytopenia:
___ ~ HCT 30. Ferritin, folate, B12 WNL. Hep C and HIV neg.
SPEP/UPEP neg. H/o heavy ETOH use in past, concerning for ETOH
related marrow toxicity. Seen by hem/onc inpatient during last
admission, at which point considered outpatient f/u for BM
biopsy. Patient should f/u outpatient for further evaluation.
# Depression:
Patient and family endorsed depressed mood since death of wife ~
one year ago. Concern that insominia, decreased appetite and
anhedonia were possibly related. TSH, B12, calcium WNL.
Apparently had discussed and declined medical management prior.
Started low dose mirtazapine inpatient on ___ with no
subsequent adverse effects. Can be further uptitrated as needed.
Would benefit from outpatient social work. Will f/u with PCP
outpatient for ongoing management.
TRANSITIONAL ISSUES:
#CODE STATUS: Full
#CONTACT: ___, ___ ___, ___
- complete 14 days of treatment for CDIFF, D1: ___.
- Please check I/O and weights daily and report results to Dr
___ at ___
- will need to resume diuretics
- check BMP ___ and fax labs to: Fax:
___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs ___ ia a ___ year old female with a past medical history
significant for AFib, dCHF, advanced renal failure, who
presented to ___ with two days of cough and dyspnea. CHEST (AP AND LAT) showed Moderate pulmonary edema with small pleural effusions and cardiomegaly. CHEST (PA AND LAT) showed As compared to the previous radiograph, there is a minimal improvement in
severity of the pre-existing pulmonary edema, but signs of both intra vascular
and interstitial fluid overload are still present. The lung volumes remain
low. Moderate cardiomegaly. Unchanged position of the left pectoral pacemaker
and its components. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC. The patient was given written instructions concerning 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 past medical history significant for AF,
___, near-ESRD, who presented to ___ with several days of SOB
and new orthopnea, found to be in decompensated CHF.
# Acute Decompensated Diastolic CHF: Patient presented with new
orthopnea, SOB, and oxygen requirement in conjunction with
elevated BNP and radiographic evidence of overload all
consistent with CHF exacerbation. She underwent diuresis with
decrease in weight from 76.2kg at admission to 74.7kg at
discharge. Patient was discharge on Torsemide 40mg PO qday.
# Discharge Disposition: The medical team *strongly* recommended
that the patient be discharged to acute rehabilitation facility,
citing reasons of decreased mobility due to deconditioning and
her acute gout flare, high fall risk, and fluctutating insulin
requirements in the setting of being treated with prednisone for
her gout flare. After a thorough discussion of the risks and
benefits of being discharged home with services instead of to a
rehab facility, the patient and her son opted for discharge home
with services. The patient was deemed to have medical decision
making capacity and was subsequently discharged home.
# Mild Hyperkalemia: Serum potassium noted to peak at 5.8 on
___, most likely secondary to mild ___ on CKD secondary to
diuresis. Her losartan was held and she was placed on a
potassium restricted diet with improvement in her potassium to
5.0 on ___. Her home irbesartan was resumed at discharge.
# Gout: Continued on home allopurinol during her entire hospital
stay. Patient with complaint of bilateral (L > R) foot pain on
___, with tenderness to palpation of dorsum of midfoot
bilaterally as well as the soles of the feet. Initially without
swelling or erythema, however this developed on ___ (affecting
the first MTP on the left foot and lateral aspect of the right
foot). Pain was controlled with tramadol 50mg Q6H PRN.
Prednisone 40mg qday was started on ___ and tapered to 30mg
qday on ___ after improvement in symptoms. She will complete 4
additional days of prednisone 20mg as an outpatient before
stopping this medication.
# T2DM: Last A1c: 8.3. Takes Levamir 20 units at bedtime as well
as an hISS and glipizide. Required uptitration of her insulin
sliding scale and long-acting insulin on ___ after starting
prednisone. Oral hypoglycemic (glipizide) was held while
inpatient and at discharge. This may be resumed at her follow up
appointment with her PCP if clinically indicated. Patient was
given instructions to reduce her insulin sliding scale by 3
units on ___ as she will take her last dose of prednisone on
___. Also instructed to reduce her dose of Levemir from 30
units to 20 units at that time.
# Pyuria vs UTI: Patient with history of asymptomatic
bacteriuria and previous UTI with pan-sensitive Klebsiella. On
this admission, she reported having dysuria for about a week. UA
w/ 116 WBC and few bacteria so she received 3 days of
ceftriaxone, completing this on ___. Urine culture was
ultimately negative.
===== TRANSITIONAL ISSUES =====
# CHF:
- Cardiology follow up within 3 weeks (scheduled for patient)
- Discharged on torsemide 40mg PO qday
- Discharge weight of 74.7kg
# T2DM:
- Held home glipizide at discharge given increased insulin dose
while on prednisone for gout and recent ___ on CKD. Please
resume at follow up appointment if needed.
- PCP follow up on ___: Please ensure patient's insulin
regimen remains appropriate given that she will be completing
her last dose of prednisone on that day.
# Acute Gout Flare
- Patient will complete a 7 day course of prednisone on ___.
# Dry weight: 74.7 kg
# CODE: Full code
# CONTACT: Patient, Daughter ___ (___) </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with history of AS, presents s/p fall at
assisted living, right arm puncture wound, sent in via EMS. Radiology showed No evidence of acute cardiopulmonary process. Radiology showed 1. Bibasilar consolidations, left worse than right, might represent
atelectasis versus early pneumonia versus aspiration.
2. Endotracheal tube ending 4 cm above the carina. Nasogastric tube in
appropriate position. Radiology showed No evidence of acute intracranial process. Lytic lesions in a
permeative pattern of the clivus and greater alae of the sphenoid raises
concern for metastatic disease. Clinical correlation is recommended.
NOTE ADDED AT ATTENDING REVIEW: The low density regions in the clivus are
highly unlikely to reflect malignancy. They have well defined sclerotic
margins and foci of internal calcifications. These suggest hemangiomas, with a
smaller possibility of fibrous dysplasia. Myeloma or other malignant neoplasm
is of so little concern that further evaluation of this finding is not
warranted. Radiology showed No evidence of fracture or dislocation. Severe degenerative
changes of the cervical spine as described above. Radiology showed 1. No evidence of pulmonary embolism or acute aortic dissection.
2. Aneurysmatic dilatation of the ascending aorta, reaching 4.3 cm.
3. Bibasilar atelectasis.
4. Endotracheal tube ending 3 cm above the carina. Radiology showed No evidence of fracture of the forearm or dislocation at the
elbow or right wrist. Radiology showed Thrombus in the basilic vein near the antecubital fossa with
patent basilic vein downstream from this clot.
Findings were reported to Dr. ___ by Dr. ___ by telephone
at 5:12 p.m. on ___ at the time of discovery of this finding. Radiology showed 1. Degenerative changes of the right glenohumeral and acromiohumeral joints
with findings suggestive of a chronic rotator cuff tear. No evidence of acute
displaced fracture or dislocation. The patient was diagnosed with ALTERED MENTAL STATUS , OPEN WOUND OF FOREARM, UNSPECIFIED FALL, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with Intubation and mechanical ventilation with successful extubation. At the time of discharge, the patient had Metabolic encephalopathy (delerium)
mechanical ventillation for acute respiratory distress
Tremor, NOS
cellulitis/phlebitis
constipation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is an ___ with PMH of AS s/p valve repair,
orthostatic hypotension, multiple falls at home, who presents
with agitation and AMS who was intubated in the ED for CT scans,
now s/p extubation with waxing and waning mental status.
# ICU Course ___: Pt was quite sedated on arrival. Waxing
and waning mental status currently. Lack of sleep likely
contributing to worsening mental status this morning. No clear
source of infection given UA clean and no clear infiltrate on
initial CXR. No evidence of acute intracranial process, though
pt with lytic lesions on prelim CT imaging. However, on further
Attending review these are unlikely to be malignancy related
(sclerotic). Hypercarbic respiratory failure: Resolved and he
was extubated on ___ without difficulty and was breathing on
room air.
# Metabolic Encephalopathy/Delerium: Multifactorial secondary to
ICU stay, disturbance of sleep wake cycle, and possibly related
to benzodiazepines. He was reoriented, and discontinued on his
lorazepam since this was thought to be contributing to this
picture. He was transferred to the medical floor and with time
his mental status gradually improved and he is now AOX3,
interactive and appropriate. His nephew, HCP noted significant
improvement over the course of the hospitalization. He was seen
by both the neuro and psych consultants per the HCP's request
and at this time he is not requiring neuroleptic medication to
control behavior, but seroquel was advised as PRN in case of
significant agitation.
# Anxiety: Continued on home sertraline. However, as above,
discontinued benzodiazepine given likely contributing to
delirium
# Mutliple falls: Most likely mechanical. Severe cervical
spondylosis thought to be contributing. Pt had planned neurology
evaluation as an outpatient. ___ was consulted and recommended
rehab.
#Tremors and Memory difficulty: noted gradual decline over
months, but no prior h/o Dementia and prior neuro-psych testing
in ___ without significant abnormality per family. Neuro
consult suspected possible ___ Body Dementia, but nephew (HCP)
who is geriatric psychiatrist felt this would be unlikely given
limited prior history of memory or mood problems. Nevertheless
he should be referred to outpatient neurology for further
assessment and repeat neuro-psych testing.
#He received several days of keflex/bactrim for local
redness/phlebitis following PIV placement in his L arm, that was
then removed. He no longer requires antibiotics on discharge.
#CONSTIPATION: Patient reported >4d of constipation prior to
discharge. Bowel regimen increased with use of mirlax and
dulcolax on ___. Please monitor closley and assess for
obstipation and need for enema, etc.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with chief complaint of shortness of breath.
Patient with cardiac risk factors of hyperlipidemia, diabetes,
obesity, sedentary lifestyle and obstructive sleep apnea. He was
referred by PSP Dr. ___ - patient reports a few weeks
of progressive dyspnea, worse with exertion, orthopnea,
occasional cough porductive of pink, frothy sputum, no
hemoptysis, URI symptoms, fevers, chills. No chest
pain/pressure, palpitations. Wife reports that he grunts and
uses stomach muscles to breathe, escpecially when lying down,
which has been going on for weeks. Also notes b/l ___ edema,
reduced appetite recently. Radiology showed Small bilateral effusions with basilar opacities, likely
atelectasis. Possible mild pulmonary edema. Radiology showed No lower extremity DVT. The patient was diagnosed with CONGESTIVE HEART FAILURE, UNSPEC. The patient was treated with Left heart catheterization. At the time of discharge, the patient had primary diagnoses:
Acute decompensated heart failure (systolic)
coronary artery disease
secondary diagnoses:
type 2 diabetes mellitus not on insulin no complications
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>___ male with T2DM, HLD presenting with symptoms consistent
with acute presentation of sCHF, new diagnosis on this
admission.
#) ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE (LVEF 20% ___:
Also valvular dysfunction (MR, TR), but this may be secondary to
annular dilation. This is new onset on this admission. Was not
previously on diuretics. Cath showed LMCA 40% distal stenosis,
LAD with 50% stenosis, LCX 100% occluded. Nevertheless, his
systolic dysfunction was felt to be out of proportion to his
CAD. Contributing etiology differential includes silent infarct
(has DM), metabolic (ex. EtOH), infectious (postviral DCM). He
was started on furosemide 80mg, metoprolol, lisinopril, and ASA.
Discharge weight was 77.8 kg.
#) LOWER EXTREMITY SWELLING: Given recent ortho procedure,
tachycardia, dyspnea, considered DVT, but LENIs showed no
evidence of DVT
CHRONIC ISSUES
--------------
#) OSA: Continued home CPAP.
#) HLD: Continue simvastatin 40mg daily
#) T2DM: Transitioned to HISS while in house, but switched back
to oral agenst (glyburide, metformin) upon discharge
#) BPH: Continued home doxazosin, finasteride
#CODE: Full code
#CONTACT: wife, ___, ___
#DISCHARGE WEIGHT: 77.8 kg</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ years old morbidly obese male with history of
lap sleeve gastrectomy ___ years ago in ___ who presented as
a transfer from ___ with concern for acute cholecystitis.
Patient presented with 3 days of RUQ pain and tenderness, which
started after eating garlic knots, low grade temperature and
chills. Patient presented to ___ where RUQ US revealed
stones and sludge in a mildly distended gallbladder and patient
was transferred to the ___ for further management. Patient
reports similar episodes in the past, however never as severe as
this episodes. Patient reports no nausea, no emesis, no change
in bowel movement. CHOLANGIOGRAM,IN OR W FILMS showed Intraoperative images were obtained during laparoscopic cholecystectomy..
Please refer to the operative note for details of the procedure. The patient was diagnosed with Right upper quadrant pain. The patient was treated with ___: ERCP with sphincterotomy and stone removal
___: Laparoscopic cholecystectomy with intraoperative
cholangiogram.. At the time of discharge, the patient had Acute cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is a ___ years old morbidly obese male with history of
lap sleeve gastrectomy ___ years ago, who presented to ___
___ with RUQ pain and a RUQ US revealed stones and sludge in
a mildly distended gallbladder and he was transferred to the
___ for further management. The patient was admitted to the
Acute Care Surgery service and was made NPO with IV fluids and
IV antibiotics.
On HD2, the patient had transaminitis and he underwent ERCP with
sphincterotomy and single gallstone removal. The patient was
then taken to the operating room on HD3 and underwent
laparoscopic cholecystectomy with IOC. This procedure went well
(reader please refer to note for further details). After
remaining stable in the PACU, the patient was transferred to the
surgical floor.
Pain was managed with acetaminophen and ibuprofen. Diet was
advanced to regular which the patient tolerated well. The
patient voided without problem. During this hospitalization, the
patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge on ___, 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. He will follow up in ___ clinic. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old man with a recent history of
disseminated tuberculosis involving the lung, mediastinum,
spine, lymph nodes, peritoneum (miliary, lymphadenitis, Potts,
scrofuloderma), and skin who has been on TB therapy since
___ and presented to the ___ ED on ___ with fever and
tachycardia. CHEST (PORTABLE AP) showed 1. Right IJ central line terminates in the right atrium and can be pulled back
approximately 2 cm to be in the cavoatrial junction.
2. Bibasilar atelectasis.
3. Paramediastinal widening similar to prior. CT torso. showed 1. No significant interval change in the numerous fluid collections from
disseminated TB since outside study from ___. ULTRASOUND-GUIDED PLEURAL ASPIRATION showed Successful ultrasound-guided drainage of the right pleural fluid collection. CHEST (PORTABLE AP) showed Comparison to ___. In the interval, the patient has undergone a
right thoracocentesis. There is no evidence of pneumothorax. No larger fluid
accumulations are seen in the right pleural space. Stable borderline size of
the cardiac silhouette. Minimal atelectasis at the right and at the left lung
basis. No overt pulmonary edema. CT-guided drainage of a left flank collection showed CT guided drainage as described above The patient was diagnosed with Fever, unspecified. The patient was treated with ___: CT-guided drainage of a left flank collection
___: Successful ultrasound-guided drainage of the right pleural
fluid collection.. At the time of discharge, the patient had Primary diagnosis
===================
#Sepsis ___ malaria
#Soft tissue abscess
#Disseminated TB
#Acute on chronic anemia
#Acute thrombocytopenia
#Hypoglycemia
#Hepatitis B infection
#Leukocytosis
Secondary diagnosis
====================
#Hypercalcemia
#Hx of light chain proteinemia. The patient was given written instructions concerning 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:
--------------------
Mr. ___ is a ___ year old man with a recent history of
multiple admissions for disseminated tuberculosis involving the
lung, mediastinum, spine, lymph nodes, peritoneum (miliary,
lymphadenitis, Potts, scrofuloderma) and skin, also with
multiple
abdominal fluid collections, who has been on RIPE since ___
and presented to the ___ ED on ___ in septic shock found to
be positive for malaria (plasmodium falciparum) parasitemia who
has successfully completed treatment.
==============
ACTIVE ISSUES:
==============
# Septic shock ___ malaria (plasmodium falciparum)
Patient presented with hypotension in the setting of fevers and
episode of emesis. Due to requiring pressors he was admitted to
the medical ICU. He was started on broad spectrum antibiotics
for concern for bacterial infection, with large concern of
infected abscesses in his abdomen and chest. These were drained
by ___ and a JP drain was placed in his left para-renal abscess.
He received 2 L of IVF in ED, and lactate was 2.0. He was worked
up for possible distributive shock secondary to possible
bacterial infection, disseminated TB, or parasitic infection
given his recent travel status to ___. He was given broad
spectrum coverage with vancomycin and zosyn and his blood
evaluated for parasites in a smear. It was found on Plasmodium
falciparum PCR that he was positive for malaria, for which he
was treated with a 3 day course of 1000mg-400mg malarone, his
vancomycin and zosyn were discontinued. He had nocturnal fevers
for the first 24 hours of his antimalarial treatment requiring 6
L of IVF boluses. Hemolysis labs during these episodes revealed
no findings of acute hemolysis except for increasing bilirubin.
His parasite load decreased from 2.0% ___ to 0.2% ___, then
subsequently NEG. He did not require further pressors and was
downgraded to the floor. His drain cultures showed no growth on
cultures with negative gram stains. In addition, blood and urine
cultures were collected with showed no growth to date. He was
successfully treated with 3 days of Malarone with improvement in
his vitals, labs, and with resolution of parasitemia on
peripheral smear. His dengue fever antibodies, blood culture,
and fluid collection cultures were pending at discharge. He will
have ___ at home that monitor his drain output. When these drop
below 10 cc per day for 2 days, he should follow up in
___ clinic and have the drain removed.
#Disseminated TB
Patient has known complicated TB that was being treated as an
outpatient with rifampin, isoniazid, and pyrazinamide. He was on
a course that would be continued for a total of ___ months. His
CT on admission demonstrated new intra-abdominal collections
concerning for progression of his TB disease. He had his chest
wall collection and left pararenal abscess drained and cultured,
which showed no growth to date at time of discharge. He will
follow up with Dr. ___ at ___
after discharge.
# Hepatitis B
He arrived at ___ with a mild transaminitis and Tbili of
1.9-2.0. His liver functions were trended while he was in the
MICU and his transaminitis improved. His Tbili began to climb in
the context of malarial fevers and possible hemolysis, peaking
at 3.8 on ___. He was transferred to the general medicine floor
as his total bilirubin began to decline, he had declining
parasitemia, his fevers had resolved, and he was hemodynamically
stable. HBV viral load 2.2 He had hepatitis B viral studies sent
including cAb, eAb, and eAg which were pending at discharge. He
will follow up with Infectious Diseases as an outpatient to
discuss further treatment.
# Acute on chronic hemolytic anemia ___ malaria
Admitted with Hb of 12.2 trending down. He was also noted to
have elevated AST and T.bili, consistent with hemolysis from
malaria. His AST and T.bili normalized on the day of discharge.
Discharge hemoglobin was stable at 8.3.
# Acute thrombocytopenia
Platelets on admission 245 with nadir of 98. Likely due to
sepsis in the setting of TB and active malarial infection, as
patients platelets rebounded with treatment of his infection.
His discharge platelet count was 206.
# Hypoglycemia
Patient with intermittent hypoglycemia with BGs in ___ of
unclear etiology. Patient was given amps of dextrose. He was
evaluate for adrenal insufficiency, which showed a normal AM
cortisol of 18.1. His blood sugars improved without further
intervention.
===============
CHRONIC ISSUES:
===============
# Hypotension
Patient with SBPs in ___ at baseline. Patient returned to this
after his brief MICU stay for septic shock.
# Hx of hypercalcemia with light chain proteinemia
Patient reportedly with possible MGUS, although not clear in our
records. He was normocalcemic during his admission with normal
renal function. We will schedule follow up with
Hematology/Oncology as an outpatient for further workup.
=====================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: History is difficult as the patient is sleepy and relatively
unwilling to provide history. FOOT AP,LAT AND OBL BILATERAL showed Soft tissue defect over the right distal second phalanx. No findings to
suggest osteomyelitis in either foot. The patient was diagnosed with Cellulitis of left lower limb. At the time of discharge, the patient had Cellulitis
Frostbite injury progressive to dry gangrene of ___ and ___ toes
on right foot, slowly healing. The patient was given written instructions concerning 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 ___ with untreated HIV, homelessness, IV drug use
(notes state methamphetamine and heroin, but patient denies
history of use), alcohol use, neuropathy, depression, and
frostbite injury this past winter with resultant dry gangrene of
the toes on the right foot complicated by slow healing, who
presents with worsening pain, redness, and swelling of the right
foot and toes, consistent with cellulitis. Cellulitis improved
with antibiotic therapy (IV, transitioned to PO at discharge).
# Cellulitis
# Dry gangrene related to frostbite injury: He has been seen by
podiatry. The overall impression is that there is some
cellulitis proximal to the areas of necrosis but that the
"digits appear relatively stable at this time and appear to show
signs of healing in comparison to prior evaluations."
Inflammatory markers/CRP are lower than last admission.
- Continued dressing changes to right foot - he has been doing
this at home and has been doing a fairly good job
- Complete course of doxycycline 100 BID x5 days and Augmentin
875 BID x5 days
- Per podiatry he can remain weightbearing as tolerated.
Obtained a boot for him.
- Podiatry and PCP followup scheduled prior to discharge
# Untreated HIV infection
# History of cervical adenopathy: He tells me that he has been
considering resuming HAART therapy but has not yet done so. His
last CD4 count in ___ was 228. Of note he has a history of
cervical adenopathy of unclear etiology (was thought to be a
manifestation of potential syphilis status post treatment). I
have been unable to examine him very thoroughly but have not
appreciated any adenopathy on limited exam.
- F/u CD4
- Continued home at___
- I counseled him extensively about follow up with PCP and
___ of HAART
# Possible drug abuse at risk for multidrug withdrawal syndrome:
He denied any drug use recently or in the past, though his chart
is strewn with references to intravenous drug use. Urine
toxicology positive only for amphetamines. No signs of
withdrawal symptoms here.
# Homelessness: This appears to be a chronic issue, which is
almost certainly contributing to his recurrent admissions and
slow wound healing. He has recently been living with his mother,
which I think is a stabilizing factor for him. He was seen by
social work here.
# Metabolic disarray with hypok, hypomg - likely lab error
# Possible malnutrition - likely lab error
# Mild hyperkalemia after supplementation: Initial laboratory
evidence of fairly advanced malnutrition, but markedly improved
on repeat with rising K after supplementation overall suggestive
of laboratory error (possibly drawn off of vein getting IVF). He
is at risk for malnutrition given social situation, chronic
wound, and HIV infection and I was initially concerned by
admission albumin of 1.6, but repeat albumin came back at 3.3
suggesting spurious initial value.
- Continued home thiamine, folate, multivitamin
# History of syphilis: He had a positive RPR in ___ and was
treated. His repeat RPR in ___ was negative.
# Pancytopenia: Resolved. Likely spurious lab values (perhaps
drawn off of line getting IVF). B12 and folate checked, WNL.
>30 minutes spent coordinating discharge home</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PORTABLE AP) was done. Chest radiograph, portable AP upright. showed Mild increase in left basilar opacity, probably atelectasis. Sequela of
aspiration is possible, however. Enlarged heart. Chest radiograph, portable AP upright. showed Status post three lead ICD device. No pneumothorax. Similar left basilar
opacities and trace pleural effusions. CHEST (PA AND LAT) showed Overall, interval improvement of the mild pulmonary vascular congestion and
mild pulmonary edema.
Lead position, unchanged compared to the prior exam. The patient was diagnosed with Dyspnea, unspecified. The patient was treated with ___ R-femoral CVL insertion
___ DCCVx3 (failed)
___ A-line insert. At the time of discharge, the patient had Primary:
-cardiogenic shock
-atrial fibrillation with rapid ventricular rate
-acute on chronic heart failure with reduced ejection fraction
Secondary:
-mitral regurgitation. The patient was given written instructions concerning 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:
=====================
Mr. ___ is a ___ year old man with a history of HFrEF (EF
___ NiCM, MR, recent diagnosis of AF who presented with
HFrEF exacerbation secondary to AF with RVR, found to be in
cardiogenic shock. Cardioversion was attempted 5 times but was
unsuccessful each time. His HFrEF was managed and was
subsequently called out to the floor, where he underwent
placement of an ICD w/ his-bundle pacing wire for long
conversion pauses. Despite recommendations for ablation while
inpatient, he deferred this to an outpatient procedure,
understanding the risks of prolonging the amount of time in afib
w/ RVR.
TRANSITIONAL ISSUES
===================
[ ] Follow up with Dr. ___ on ___ to discuss medication
changes and future ablation. Please obtain BMP for potassium
monitoring given issues with hyperkalemia while inpatient and
INR for warfarin monitoring.
[ ] Plan for TTE in 3 months after optimization of volume status
and BNP to assess if candidate for intervention
Discharge Cr: 1.3
Discharge Weight: 141 lbs
Discharge K: 5.1
Discharge INR: 2.0</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: . ___ is a ___ year old ___ gentleman with
history of abscesses ___ the sternum and axillae p/w worsening
abscesses pain/drainage. CHEST (PORTABLE AP) showed Prominent left hilum is nonspecific, underlying lymphadenopathy,
consolidation, or pulmonary lesion not excluded.
Left base retrocardiac opacity could be due to pneumonia, underlying other
pulmonary lesion not excluded.
Bibasilar subtle reticulonodular opacities may be due to small airways
disease.
Consider dedicated PA and lateral views of the chest or CT for better
evaluation. Radiology showed 1. Diffuse necrotic lymph nodes throughout the abdomen and pelvis as
described above. Partially visualized confluent posterior mediastinal and
left lower lobe mass as well as diffusely sclerotic thoracic vertebrae. These
findings are highly worrisome for diffuse metastatic disease, although noting
a provided clinical history of multiple abscesses, infectious etiology such as
TB cannot be excluded. The cluster of left inguinal lymph nodes are amenable
to percutaneous sampling.
2. Sigmoid diverticulosis.
3. Please see separate report on CT chest performed on the same day for
discussion of intrathoracic findings.
RECOMMENDATION(S): Left inguinal lymph nodes are amenable to percutaneous
sampling if indicated. CT CHEST W/CONTRAST showed Findings most likely in keeping with progressive pulmonary and extrapulmonary
TB as evidenced by airspace consolidation in the left lower lobe, diffuse
miliary and micro nodules throughout the lungs, pleural, mediastinal,
paraspinal as well as soft tissue rim enhancing collections/abscesses.
Involvement of the superior aspect of the sternum as well as adjacent ribs
suggesting osteomyelitis.
Note is made of sinus drainage tracts to the skin in bilateral axilla as well
as anterior to the sternum as noted above.
Sclerotic (osteomyelitis or a reactive) changes of the thoracic vertebral
bodies and dedicated imaging with MRI is advised.
Please refer to CT abdomen report for abdominal findings.
In the differential diagnosis consider a Staphylococcus abscesses, but in the
absence of compromised immunity this is thought to be unlikely.
RECOMMENDATION(S): T-spine MRI.
Correlate with labs. MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE showed 1. Increased STIR signal abnormality involving the vertebral bodies of T3
through T11, is concerning for osteomyelitis. There is likely cortical
disruption of the vertebral bodies and costovertebral junctions at T3, T4, T8,
T9 and T10 levels. Although the lower thoracic paraspinal abscesses appears
to encroach upon the left neural foramina, there is no evidence of significant
neural foraminal narrowing. There is no abnormal signal were enhancement
within the spinal canal or of the cord. No intrathecal abscess is identified.
Given the relative lack of disc involvement, this may represent tuberculosis.
Clinical correlation is recommended.
2. Cervical and lumbar spondylosis, as described in detail above.
3. Innumerable paraspinal abscesses, better evaluated on the CT of the torso
from ___. MR HEAD W AND W/O CONTRAST ___ MR HEAD showed 1. Encephalomalacia of the posterior aspect of the left temporal lobe with
encephalomalacia and ex vacuo dilatation of the temporal horn of left lateral
ventricle. Adjacent temporal calvarial defect is identified.
2. No acute infarction or hemorrhage.
3. No concerning enhancing lesions identified at this time. SKULL APANDLAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING showed No radio-opaque foreign body is detected over the skull or cervical spine. Ultrasound-guided lymph node biopsy showed Successful ultrasound-guided left inguinal lymph node 18 gauge core biopsy x4 CT-GUIDED BIOPSY showed Technically successful biopsy of the T9 vertebral body, and pigtail drainage
catheter insertion into a paraspinal fluid collection. Samples were sent for
microbiology. The patient was diagnosed with Cutaneous abscess of chest wall, Cutaneous abscess of back [any part, except buttock], Cutaneous abscess of left axilla, Cutaneous abscess of right axilla. The patient was treated with Inguinal node aspiration
Core skin biopsy
Paraspinal abscess drainage
Vertebral body biopsy. At the time of discharge, the patient had Disseminated TB
Pott's disease
TB Lymphangitis
Scrofuloderma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old ___ gentleman with
innumerable cutaneous abscesses ___ the sternum, back,
supraclavicular area and axillae , weight loss, pulmonary
nodules, and LLL mass, found to have disseminated TB.
# Disseminated tuberculosis - progressive pulmonary and
extrapulmonary TB
# Tuberculous scrofuloderma and lymphadenitis
# Likely TB involving the Thoracic Spine (see MRI read)
Patient originally presented for multiple draining purulent
wounds located on back, axilla and chest, first noted ___ years
ago, and now progressive. He presented with fatigue, poor PO
intake, unintentional weight loss, and night sweats, with
increasing pain and drainage at the site of these wounds. Skin
biopsy ___ microbiology shows +AFB. Concentrated sputum AFB
stain, positive ___ and ___. c/w pulmonary and
extra-pulmonary TB. MTB sputum consistent with TB. S/p spinal
drainage and vertebral biopsy w/ drain, now removed. Spinal
abscess drainage +AFB, otherwise no ___ negative. Vertebral
bx tissue w/ negative AFB.
Mr ___ symptoms improved substantially and wounds were
addressed by acute care surgery. Recommendation is I/D as needed
for abscess formation w/frequent dressing changes. Given high
degree of anticipated nursing care for wounds and risk for
superinfection it was felt he would be best cared for ___ long
term care and was discharged to ___.
-- Wound care (adaptic /AquaCelAg/Sofsorb for now)
-- See transitional issues below as there are many
# Cutaneous abscesses:
Patient was treated for bacterial superinfection of his
tuberculous skin abscesses, first with broad spectrum
antibiotics, then he was narrowed to Keflex. He completes his
course on ___.
# Chronic hepatitis B infection - Chronic hepatitis B infection
with normal LFTs and low viral load. Consistent with likely
immune-controlled hepatitis B and would therefore not start
treatment. He is HIV and hepatitis C negative. Ferritin was
>1000, however felt that likely related to severity of
infection. Should have iron studies rechecked and if lack of
resolution would evaluate for cirrhosis and screen accordingly.
-- HBcore Ab Positive / HBsAb Negative / HBsAg Positive/HepBe Ab
positive/HepBe negative
-- HBV viral load low (35)
-- Will need follow up PCP/ID to determine frequency of Hep B VL
screening
-- Outpatient RUQ ultrasound and LFTs for evaluation of
progressive liver disease / cirrhosis.
# Question pulmonary masses: CT chest reads
"Focal areas of confluent airspace opacity ___ the left lower
lobe superior
subsegment and medial basal subsegment may represent
postobstructive pneumonia
given the presence of air bronchograms, or less likely primary
pulmonary
masses"
This finding was discussed with pulmonary specialists, who felt
that the finding was likely due to pulmonary tuberculosis, and
recommended checking a repeat CT ___ ___ weeks to evaluate for
underlying primary pulmonary mass, and further workup depending
on that scan. Patient and family were counseled on this
finding.
==========
NOT ACTIVE
==========
# Hyponatremia - Likely etiology ___. Resolved.
# Anemia, slightly microcytic - no active bleeding. Ferritin >
1000 indicating adequate storage and not iron deficiency. ACD
likely.
#Thromboyctosis: Elevated platelets ___ the 500s. Likely reactive
___ the setting of underlying infection.
# R shoulder pain - Improving. Had limited ROM d/t pain ___ the
axillae and likely some referred pain from pathology ___ T spine
per MRI. Pain well controlled w/standing APAP and prn Oxycodone.
# Sinus Tachycardia: Resolved w/treatment. Likely secondary to
hypovolemia due to persistent poor PO intake. Also tachycardic
to the 130s-140s when febrile.
*****TRANSITIONAL ISSUES*****
# CODE: Full
# HCP: Daughter, ___ ___
# Started on RIPE w/pyridoxine on ___, end date to be
determined 6 to 9 months
# Weekly LFTs; fax labs to ___ clinic ___ (LAST
CHECKED ___
# Keflex ___ q6mg until ___
# ___ ID will not establish formal follow up as being
discharged to ___ and they have ID Department, however (see
below)
# Cleared by ophthalmology prior to initiation of RIPE HOWEVER
will need o/p follow up. This appointment is pending
# Pulmonary recommendation of repeat CT chest ___ weeks to see
if mass has resolved/improved
# Will need to be on precautions until negative sputum. This
sputum sample should be taken on ___.
# Repeat iron studies following substantial treatment of TB.
Given Chronic Hep B and high ferritin would perform RUQ and
liver function tests to evaluate for cirrhosis to guide needs
for screening if indicated.
# If any focal abscesses (currently has one ___ the L clavicular
area) not spontaneously draining, will need ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI - ___ presenting with abdominal pain × 3 days. Began in
lower
abdomen on ___ but spread to her upper abdomen/flanks as
well on ___. Gradual in onset, intermittent in waves with
fluctuations in intensity. Made worse by moving, walking and
eating. Passing flatus and having regular BMs, last ___
morning. Denies nausea, vomiting, F/C, rash, dysuria, hematuria,
melena or BRBPR. She has not been eating much ___ the pain.
Denies history of similar symptoms. MRI of the Pelvis showed 1. 6.3 x 3.4 x 5.4 cm right adnexal mass, in close proximity to the right
ovary, is suggestive of a fibrous tumor such as fibroma or fibrothecoma.
___ tumor is less likely. Consider surgical consult for resection.
2. Small ascites. The patient was diagnosed with Epigastric pain. At the time of discharge, the patient had -Abdominal Pain
-Right adnexal 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>Ms ___ was admitted to the hospital on ___ for
management of her abdominal pain. A CT scan of her abdomen and
pelvis showed a pelvic mass in close proximity to her ovary but
was non-diagnostic for the origin of the mass, a US showed a 4.4
cm right adnexal lesion which appears adjacent to, but separate
from the right ovary. Therefore, the patient was admitted to the
___ service for pain management and further workup. An MRI was
done which showed: "a 6.3 x 3.4 x 5.4 cm right adnexal mass, in
close proximity to the right ovary, is suggestive of a fibrous
tumor such as fibroma or fibrothecoma. ___ tumor is less
likely".
Gynecology service was consulted again on the floor and they
recommended an outpatient follow up. the patient was discharged
on ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is a ___ with hx tracheomalacia, OSA, anxiety, htn,
asthma, DVT, COPD, epilepsy, hypothyroidism, migraines,
recurrent mantle cell lymphoma
(currently in remission), HTN, presenting w/HA and
hemoptysis/SOB
since tues. She has been on doxy since tues, prescribed by Dr
___. During this time, patient has had
subjective
worsening shortness of breath (increased home O2 to 4L) and some
chest pain/pressure with cough as well. She also had worsening
exercise tolerance during this time and has only been able to
move from her bed to the bathroom whereas she is usually able to
get around her house without difficulty. She also endorses
headache which was gradual in onset, not associated with neuro
deficits and consistent w/her chronic daily migraines (pt has hx
of failing ppx migraine treatment). CHEST (PA AND LAT) showed Right middle lobe pneumonia. CTA CHEST showed No evidence of pulmonary embolism or acute aortic abnormality. The patient was diagnosed with Pneumonia, unspecified organism. The patient was treated with CTA. At the time of discharge, the patient had Bronchitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s># Bronchitis
# Hypoxia (resolved)
# hemoptysis (resolved)
# Chest pain/pressure
Pt with multiple underlying pulmonary issues including OSA,
COPD,
asthma, now presenting with hemoptysis and c/f PNA (?patchiness
in RML). Symptoms did not improve with outpt doxy. CTA was
negative. IP team evaluated with recommendation for 5 days PO
antibiotics as outpt for likely bronchitis as no infiltrate was
seen on CT chest.
- transitioned from doxy (GI upset) to levaquin on d/c.
- encourage acapella use in setting of infection
- advised to follow up with PCP
- ___ NGD2 but still pending on day of discharge
- UCx showing MMF
# Migraines: seems consistent with her chronic daily headaches.
Neurology evaluated and will follow up as outpatient.
- received abortive therapy with Phenergan, torodol and Benadryl
on ___
- verapamil dose needs verification
#Asthma/COPD on home O2. She tolerated down titration of O2 to
2L
-continued home breo, nebs
-continued ipratropium albuterol
-continued mometasone
-continued home montelukast
#Epilepsy: Continued home topamax, zonesimide
#Chronic back pain:
-continued lyrica
#Depression/anxiety:
-continued paroxetine, diazepam, trazadone for sleep
-Ativan Po x1 now for anxiety.
-SW consult given patient expresses concerns about getting
transporation to medical appointments and is perseverating on
issues with her husband
___:
-Receives monthly IVIG (due on thurs per pt)
#Hypothyroidism:
-continued home levothyroxine
#GERD:
-continued PPI
Transitional Issues
[ ] verapamil dose needs verification - unclear if 80 mg qhs or
40 mg BID
[ ] Pt to complete course of levaquin as outpatient for
bronchitis
[ ] Blood cultures still pending on day of discharge (NGD2).
Will call pt if growth on Day 3+.
[ ] prescribed miconazole for rash around introitus
[ ] restarting home Lasix on d/c. held I/s/o possible infection.
>30 min spent on discharge planning including face to face time. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female here with increasing sternal pain,
shortness of breath, nausea and dizziness. She sustained a
fall 5 days ago, she thinks that she rolled out of bed in
the middle of the night. Was seen here yesterday for mid
chest pain after the fall, had a CAT scan demonstrating a
sternal fracture into right-sided rib fractures. She denies
any other injuries. Denies any head injury, neck pain,
abdominal pain, extremity injury.
Timing: Gradual
Quality: Dull
Severity: Moderate
Location: chest CHEST (PA AND LAT) showed 1. No acute cardiopulmonary process.
2. The patient was diagnosed with FRACTURE OF STERNUM-CLOS, FRACTURE ONE RIB-CLOSED, FALL FROM BED. At the time of discharge, the patient had Trauma:
acute on chronic sternal fracture
Right ___, 8th rib 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>___ year old female who was seen in the emergency room on ___
after a fall from bed in which she reported right rib and chest
wall pain. Imaging was done which showed a sternal fracture and
right sided rib fractures. The patient was discharged from the
hospital with analgesia. She returned to the hospital 24 hours
later with increased sternal pain. A chest x-ray was done which
showed a minimally displaced sternal fracture which was stable.
The patient's pain regimen was re-evaluated and resumed. A
tertiary survey was completed and no new injuries were
identified. The patient's vital signs remained stable and she
was afebrile. She was ambulatory without assistance. The
patient was discharged home on HD # 2 in stable condition. An
appointment for follow-up was made in the acute care clinic.
The patient was instructed to follow-up with her primary care
provider and with the her endocrinologist, Dr. ___.
**************
E-mail to Dr. ___ thyroid finding on CT chest and
follow-up </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ year-old woman s/p accident on a moped.
She was riding on back of bike as friend driver lost control and
bike crashed, leaving patient
with lacerations on Left knee. Upon appraisal at OSH, patient
X-rays demonstrated foreign body around left patellar tendon and
patient was transferred to BI ED. Patient with persistent pain
in left knee. Loose dressing in place over knee lacerations. Radiology showed 1. No evidence of fracture or dislocation.
2. No definite evidence of a radiopaque foreign body. Radiology showed 1. Multiple small radiopaque foreign bodies are seen in the soft tissues
anterior to the knee measuring up to 3 mm.
2. Air and soft tissue stranding with a joint effusion along the anterior
knee is likely secondary to recent postoperative changes; however, a
superimposed infectious process cannot be excluded.
3. No evidence of fracture or dislocation. The patient was diagnosed with OPN WND KNEE/LEG W TENDN, MV COLLIS NOS-MOTORCYCL. The patient was treated with ___: Left knee irrigation & debridement. The patient was given written instructions concerning 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 knee pain and retained foreign bodies (glass) and
was admitted to the orthopedic surgery service. In the ED, she
had a left knee bedside washout and removal of foreign bodies.
On imaging, there were concerns for air in the knee joint and
arthrotomy, so the patient was taken to the operating room on
___ for left knee irrigation and debridement, which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home with home ___ was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity, and will be discharged on aspirin for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ ___ left handed man with hx of HTN, no
hx of headache, developed headache on ___.
At the beginning it was ___, throbbing pain in the frontal
area,
over the past 2 days the headache became worse, up to ___,
with
nausea.
He mentioned that the headache was worse in flat position and
improved in sitting position. he did not sleep well over the
past 2 nights.
This morning as he still had a severe headache and vomited x 2,
he went to ___ Urgent care unit, where he had a 30
sec episode of left hand shaking, with impaired level of
consciousness, his wife was calling his name but he was not
answering, she could not say if he had gaze deviation, he does
not remember the event.
After this event which stopped without any intervention, he was
transferred to ___ ED, on his way here he had another episode,
witnessed by the EMT, lasted about 3 minutes, per what he heard
it started with left hand and arm shaking, spread to the right
arm.
After the event he was confused and did not know where he was.
Post ictal confusion lasted about 10 minutes.
He never had similar events in the past, he usually does not get
headache.
He denied blood in his urine, cough, weight loss.
He denied recent fever, URT infection or other symptom of
infection, no recent travel or sick contact were reported.
Lumbar puncture which was done in ED, was traumatic, OP was not
measured, showed elevated Pr( even corrected with RBC), WBC (
lymphocyte).
He is started on triple meningitis and encephalitis coverage.
Performed CTA in the ED did not show any aneurysm. CT HEAD W/O CONTRAST showed No acute intracranial process. CTA HEAD AND CTA NECK showed Patent head and neck vessels. No evidence of intracranial AVM. CHEST (PORTABLE AP) showed As compared to ___ chest radiograph, cardiomediastinal contours are
stable in appearance considering positional and projectional differences.
Known small pulmonary nodules on prior chest CT of ___ are
likely below the resolution of a portable chest radiograph. MR HEAD W AND W/O CONTRASTMRI of the head with and without
contrast.MR HEAD W AND W/O CONTRAST showed There is no evidence of acute intracranial process. Few scattered foci of
high signal intensity detected on FLAIR and T2 weighted images, distributed in
the subcortical and periventricular white matter, are nonspecific and may
reflect changes due to small vessel disease.There is no evidence of abnormal
enhancement. The patient was diagnosed with OTHER CONVULSIONS, HEADACHE. The patient was treated with Lumbar puncture. At the time of discharge, the patient had Viral meningitis, organism unknown. The patient was given written instructions concerning 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 ___ ___ left handed man with hx of HTN,
Chronic diarrhea (? lisinopril side effect), hx of +50 P/Y
smoking quit in ___, colon polyp, lung nodule (2mm, 3mm,
detected in ___, remained stable in ___, remote hx of IVDU,
presented with progressive headache started about 3 days prior
to admission, and got worse over 2 days. LP showed >500 WBC with
lymphocytic predominance. The patient's symptoms improved
spontaneously, and his headache was almost completely gone at
the time of discharge. His current diagnosis is viral
meningitis.
#Neurology: inflammatory/infectious CSF, but neuro exam normal
so that makes TB and leptomeningeal carcinomatosis less likely.
Diagnosis viral meningitis.
- HIV negative, HSV negative
- serum cryptococcus, quantiferon gold, Lyme, Anaplasma, ___, RPR pending upon discharge (tests ordered based on ID
Consult recommendations)
- MRI with and without contrast: normal, no leptomeningeal
enhancement
- Empiric bacterial meningitis and HSV medications discontinued
- Started Keppra 750 bid for concern for seizure witnessed by
outside physician
- EEG normal
- droplet precautions discontinued
Seizure semiology: left hand shaking spread to the right arm</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH HTN, HLD, COPD, CHF, Dementia s/p mechanical fall from
bed w/ R fem frx. She reports a mechanical fall upon getting out
of bed at her nursing home. She denies head strike, LOC,
dizziness, or history of syncope. She initially presented to an
OSH, and was then transferred to ___ for further care. On
pan-scan performed on arrival, an incidental descending thoracic
aneurysm 6x7cm was noted. Ms. ___ denies chest pain,
history
of thoracic aneurysm, or other symptoms related to her aneurysm. PELVIS (AP ONLY) showed Spiral fracture involving the distal femur, with approximately 1.4 cm lateral
displacement of the distal fragment.
Background diffuse demineralization.
Severe degenerative changes of the right hip and knee joints. CHEST (PRE-OP AP ONLY) showed 1. No acute cardiopulmonary abnormality. Clear lungs.
2. Rounded large left retrocardiac opacity may represent a hiatus hernia,
however this single AP view is inadequate to optimally characterize the
etiology of this retrocardiac density. Correlation with CT of the chest is
recommended.
RECOMMENDATION(S): CT chest, is recommended for further evaluation of the
above described dense left retrocardiac opacity, please note, this single AP
view is insufficient to optimally characterize etiology of this dense
retrocardiac opacity.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 09:48 into the Department of
Radiology critical communications system for direct communication to the
referring provider. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute hemorrhage.
2. Extensive supratentorial white matter abnormalities are nonspecific but
likely sequela of chronic small vessel ischemic disease in this age group. No
CT evidence for an acute major vascular territorial infarction, but evaluation
for a small infarction is limited in the setting. CT C-SPINE W/O CONTRAST showed 1. No evidence for cervical spine fracture.
2. Minimal retrolisthesis of C3 on C4 is almost certainly degenerative, though
there are no comparison exams to confirm chronicity.
3. Multilevel cervical degenerative disease with moderate to severe spinal
stenosis at C3-C4, and up to moderate spinal stenosis from C4-C5 through
C6-C7.
4. Left greater than right proximal internal carotid stenosis, not adequately
quantified on this noncontrast exam. CTA CHEST WITH CONTRAST showed 1. Large descending thoracic aortic aneurysm measuring 6.0 x 7.0 cm with
findings concerning for ruptured penetrating ulcers into the aneurysmal sac.
Right aortic arch.
2. No evidence of pulmonary embolism to segmental level.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:07 am, 2 minutes after
discovery of the findings. FEMUR (AP AND LAT) RIGHT was done. The patient was diagnosed with Oth fracture of lower end of right femur, init for clos fx, Fall on same level, unspecified, initial encounter, Urinary tract infection, site not specified. The patient was treated with ___ - Right femur open Reduction and surgical fixation with
nail. At the time of discharge, the patient had Primary:
------------
Right femur fracture
Thoracic aortic aneurysm
Acute kidney injury
.
Secondary:
--------------
Pyuria
Dementia
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/pmh dementia, COPD, CHF, HTN presenting with right leg
pain after a fall out of bed and found to have a right femur
fracture, UTI and incidental large descending thoracic aortic
aneurysm.
.
# Closed displaced femur fracture
# Osteoporosis
Patient is s/p intermedullary nail to R femur without
complication on ___. Some worsening anemia after surgery but
stabilized with Hgb of 8.4 on discharge. ___ recommended acute
rehab. Patient may benefit from outpatient endocrine follow up
given osteoporosis and fracture, and consider starting calcium
and more frequent vitamin D as outpatient. Lovenox 40mg daily
prophylaxis for 4 weeks.
.
#Thoracic aortic aneurysm
This was seen incidentally on imaging. Vascular followed while
patient was in the hospital, and stated that she would not be
operative candidate given comorbidities. Was not active during
admission. Plan to follow up in a couple weeks in ___
clinic. We continued patient's beta blocker.
.
#Anemia
Occurred in setting from likely bleed from fracture as well as
from surgery. Stable prior to discharge
.
# Pyuria
# Leukocytosis
Patient presented with elevated WBC and pyuria, without
significant symptoms. Urine culture showed pan-sensitive
proteus, and patient was
Patient denies dysuria, unclear if true UTI.
.
# ___ vs CKD
Cr 1.2 on admission. Improved to 0.9 with light hydration.
Likely in setting of hypovolemia and UTI.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo woman with history of refractory
complex
partial epilepsy on LTG and ZNS(pt of Dr. ___ who
presents with seizure. Radiology showed No acute cardiopulmonary process. Radiology showed Mild fecal loading within the large bowel without significant distention. CT HEAD W/O CONTRAST showed 1. No acute intracranial process.
2. Unchanged postsurgical changes from right temporal lobectomy. The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ yo woman with history of refractory
complex
partial epilepsy on LTG and ZNS (follows with Dr. ___
who
presents with seizure. Initial exam notable for decreased
attentiveness which was thought to be worse from her baseline.
She was seen by Dr. ___ in the hospital, who said she
was at her cognitive baseline. She thought that her visiting
nurse had inadvertently given her an extra dose of medication,
and that she remembered falling out of bed but not much else.
Generally, her seizures involve movement of complex confusional
behavior, has fallen from being confused, but rarely falls from
secondary generalization. There were no medication changes in
her psychiatric regimen or her seizure regimen recently. An
X-ray in the ER showed mild fecal loading within the large bowel
without significant distention. She should be continued on her
bowel regimen.
Her VNS was interrogated while in the hospital, and it was shown
to be functioning properly. ___ was deemed stable for
discharge with no medication changes. She should follow up with
Dr. ___ ___ we contacted the office
to schedule a follow up appointment. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year-old male who fell off his scooter with +LOC
and was found to have a left wrist perilunate dissociation with
? scaphoid fracture and a T12 endplate fracture. Per report, he
fell off his scooter going ___ MPH and slid for about 20 feet
before hitting a parked car. He does not remember the event - he
remembers waking up in the ambulance. He was helmeted. Per
bystander report, he was unresponsive for about 1 minute but
alert and oriented when EMS arrived. He was taken to an OSH
where trauma work-up revealed a left perilunate dissociation and
T12 fracture and he was transferred to ___ for further care. CT left upper extremity without contrast showed 1. Mildly displaced scaphoid waist fracture with fragmentation of the medial
aspect of the distal pole at the fracture site.Alignment is otherwise
anatomic.
2. Multiple additional displaced tiny fractures likely from the lunate, ulnar
styloid, and distal radius. The mini c-arm was used in the operating room for a left distal
wrist fx., orif. Films were submitted. Fluoro time was 5 minutes and 8
seconds. was done. The patient was diagnosed with FX DORSAL VERTEBRA-CLOSE, DISLOC CARPOMETACARP-CL, MV COLLIS NOS-MOTORCYCL. The patient was treated with Open reduction and internal fixation of scaphoid,
triquetral-lunate pinning & hamate-capitate pinning.. At the time of discharge, the patient had Left wrist fracture and T12 endplate 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 ED on ___ after scooter
accident, Trauma team seen and examined the patient. The patient
has been admitted to the regular floor. left writs x-ray showed
perilunate dissociation, scaphoid waist fracture, lunate/distal
radius avulsion fractures. CT spin was conclusive for T12 ship
fracture. Neursurgery and plastic surgery teams have been
consulted, TLSO for the spine and ORIF of scaphoid,
triquetral-lunate pinning & hamate-capitate pinning have been
recommended by the teams respectively. Given findings, the
patient was taken to the operating room for ORIF. There were no
adverse events in the operating room; please see the operative
note for details. Patient was extubated, taken to the PACU
until stable, then transferred to the ward for observation. The
patient was alert and oriented throughout hospitalization; pain
was well managed with oxycodone and Tylenol.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of CAD s/p CABG (___ ___, HFpEF (LVEF >55%
in ___, HTN, IDDM2 c/b neuropathy and nephropathy/CKD, OSA,
PAD, recent admission for MSSA bacteremia and LLE osteomyelitis,
and multiple diabetic foot ulcers of the RLE who presents from
___ clinic with concern for diabetic foot infection. Radiology showed 1. Soft tissue ulceration within the plantar soft tissues at the level of the
MTP joint and posterior heel without evidence for osteomyelitis or soft tissue
gas. Please note that MRI with contrast is more sensitive for detection of
osteomyelitis.
2. Charcot arthropathy of the midfoot, as seen previously. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. Limited evaluation of the left-sided peroneal veins. ART EXT (REST ONLY) showed Right: Noncompressible right DP, with significantly abnormal TBI. Doppler
waveforms and pulse volume recordings suggest significant arterial obstructive
disease disease below the ankle.
Left: elevated ABI suggestive of arterial calcification artifact with normal
to mildly abnormal Doppler pulse volume recordings.
Compared to ___, findings are overall similar. MR FOOT ___ CONTRAST RIGHT showed 1. Soft tissue ulceration and edema is identified overlying the plantar aspect
of the first metatarsal head and posterior calcaneus without evidence of
osteomyelitis. No abscess. Radiology showed Small left pleural effusion is unchanged compared to prior. No evidence of
pneumonia or pulmonary edema. RENAL U.S. showed 1. No hydronephrosis.
2. Incidental echogenic liver consistent with steatosis. Other forms of liver
disease and more advanced liver disease including steatohepatitis or
significant hepatic fibrosis/cirrhosis cannot be excluded on this study. US UPPER EXTREMITY, SOFT TISSUE showed No drainable fluid collection, including no evidence of abscess or hematoma
underlying the superficial tissues of the dorsal aspect of the right forearm,
distal to the elbow. The patient was diagnosed with Type 2 diabetes mellitus with foot ulcer. The patient was treated with Status post right lower extremity angiogram with POBA and DES x1
to the anterior tibial artery. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of CAD status post CABG (___), HFpEF (LVEF
>55% in ___, HTN, insulin-dependent T2DM complicated by
neuropathy and nephropathy/CKD, OSA, PAD, and recent admission
for MSSA bacteremia and LLE osteomyelitis who presents from
___ clinic with worsening of RLE diabetic foot infection.
He was treated with antibiotics and underwent RLE angiogram with
balloon angioplasty and placement of drug-eluting stent in the
right anterior tibial artery. His hospital course was
complicated by ___ thought to be contrast-induced nephropathy.
ACUTE ISSUES
============
#Diabetic foot infection:
#Peripheral arterial disease s/p POBA and DES to anterior tibial
artery:
Patient has a history of multiple chronic diabetic ulcers on his
right foot. He presented from ___ clinic after his
outpatient podiatrist noted clinical worsening of the ulcers,
concerning for infection. On admission, patient's lactate was
elevated, but he was afebrile and hemodynamically stable (and
remained so throughout his hospital course); two of his lesions
were purulent without crepitus. XR and MRI of the right foot did
not demonstrate evidence of osteomyelitis. He was treated with
antibiotics for a planned 14-day total course; per patient
report, he has a history of MRSA infection of the left foot, so
he was covered for MRSA. He was discharged on doxycycline 100mg
q12h and Augmentin 500mg q12h (renally-dosed, day 1: ___,
planned end ___. Patient was also evaluated for peripheral
artery disease given the chronic, non-healing nature of his foot
wounds. A non-invasive arterial study of his lower extremities
showed bilateral tibial artery disease, and he underwent right
lower extremity angiogram status post POBA and DES x1 to the
mid-segment of the anterior tibial artery by Dr. ___. He
was started on ASA 81mg daily and Plavix 75mg daily with
recommendations to continue DAPT for 12 months. Patient was
regularly seen by Podiatry while in-house for dressing changes
and Santyl debridement.
#Acute kidney injury on CKD
Patient presented with ___ (Cr 1.9) on admission from a
baseline of ~1.1-1.4. His kidney function improved with
initiation of antibiotics. However, after RLE angiogram, he
developed recurrent ___ with peak Cr of 2.1, thought to be
contrast-induced nephropathy in the setting of receiving 160 mL
of contrast +/- overdiuresis with IV Lasix due to subjective
dyspnea thought secondary to volume overload. He was switched
from PO Bactrim to PO doxycycline in the event that the Cr
increase was induced by Bactrim (although no evidence of
eosinophilia or WBC casts on spun urine to raise concern for
AIN). Renal ultrasound showed no hydronephrosis. His Cr was
downtrending and near-baseline by the time of discharge. His WT
had remained stable off diuretic as well, with only mild ___
edema. NOTE: patient's diuretics (home furosemide and HCTZ) were
held in the setting of this ___. He can restart furosemide 40mg
every other day and HCTZ 50mg daily once his Cr stabilizes. His
home valsartan 320mg daily was also initially held for his ___
but was restarted on discharge for HTN iso CKD and DM; please
continue to monitor his kidney function.
#HTN
Patient's blood pressures were noted to be in the 160's
systolics in the setting of holding home furosemide and HCTZ
given his ___. He was continued on home amlodipine 10mg daily
and isosorbide mononitrate 90mg daily. His home valsartan 320mg
daily was initially held for infection and ___ but restarted on
discharge. Please continue to monitor his blood pressures. He
can restart his home diuretics once his Cr normalizes (as above)
and as dictated by high BP trends.
#Right posterior forearm swelling
Patient noted a blister-like area of swelling on his posterior
forearm without erythema, TTP, or purulence, thought to be
induced by pressure on the arm. An ultrasound was performed and
demonstrated no fluid collection or abscess. Please continue to
monitor the area as it is adjacent to a healed incision, and
patient is at risk for infections.
#Otorrhea
Pt reported clear, painless ear drainage on the day of
discharge. On exam, some e/o middle ear effusion w/o erythema,
visible drainage debris or perforation. Possibly may be
secondary to resolved otits media (though no antecedent pain).
Less likely chronic suppurative otitis media in absence of
debris. Recommended continued monitoring clinically as pt had
already being treated with more than adequate treatment as a
typical duration of treatment for a mild OM infection is ___
days. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male with a PMH of asthma, htn, glaucoma who presents with
30 min of chest pain which began 45 min ago. Resolved after one
spray of nitroglycerin. CHEST (PA AND LAT) showed Patchy left basilar opacity concerning for pneumonia. Radiology showed Low lung volumes causing bronchovascular crowding and atelectasis. Allowing
for this difference, left lung base very sparse opacities are likely
unchanged. ANKLE (AP, MORTISE AND LAT) RIGHT IN O.R. showed Patchy osteopenia and patchy density in the right lateral malleolus, distal
tibia, and, , to a lesser extent,, talar dome, of uncertain etiology or
significance. While this could represent sequela of prior trauma or changes
related to disuse, the presence of associated soft tissue swelling raises the
possibility of an inflammatory or infectious process involving the bone and
soft tissues. No acute fracture and no discrete erosion is detected. A
near-term MRI of the right ankle is recommended for further evaluation.
Soft tissue density is seen extending into ___ fat pad and is nonspecific
but may represent an effusion. There is also soft tissue swelling about the
ankle.
Mild degenerative changes.
RECOMMENDATION(S): MRI right ankle to assess for inflammation or infection
about the right ankle.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 17:48 into the Department of Radiology
critical communications system for direct communication to the referring
provider. The patient was diagnosed with Chest pain, unspecified. The patient was treated with cardiac cath ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Assessment/Plan: ___ year old man who presented with chest pain
and ruled in for NSTEMI now s/p coronary angiogram revealing
severe 3 vessel disease.
#NSTEMI/unstable angina: Cath revealed severe 3 vessel
disease, but patient declining CABG. Patient offered PCI but
after discussion of risks and benefits with Dr. ___ Dr.
___ is deferring for now. Risk for potential fatal MI without
PCI or CABG conveyed.
-___ discontinued today
-continue statin, ASA
-Imdur 30mg started this am
-Labetolol 200mg BID (from 100mg BID)
-Ace Inhibitor dc'd due to CKI with cre 2.1
-start nitro SL PRN
-follow up cardiac rehab
-follow up with Dr. ___
#Hypercholesterolemia: ___ Total 135, Triglycerides 126, HDL
40, LDL 70
-Continue heart healthy diet post cath
-Continue Atorva 80mg
#Pneumonia: chest xray on admission with patchy left basilar
opacity concerning for pneumonia; has productive cough and
elevated WBC on admit; presumed community acquired pneumonia,
comorbid renal disease.
respiratory fluoroquinolone per IDSA recommendations; follow up
chest xray yesterday showed "Low lung volumes causing
bronchovascular crowding and atelectasis. Allowing for this
difference, left lung base very sparse opacities are likely
unchanged."
-Levofloxacin 750mg q48 hours for 5 doses
-continue tessalon pearls for cough
#chronic kidney injury: followed by Dr. ___
creatinine 2.2 with GFR 28
Stable
-renal dose medications
-Hold Lisinopril
-get creatinine checked outpatient in 48 hours
-follow up with renal on ___
#Pseudo Gout: Concern for worsening kidney function if pain
treated with Colchine. Pain is preventing weight bearing. Some
relief with cold compresses. Rheumatology consult suggests treat
gout flare, uric acid 7.7, ESR pending, CRP 145.0. family does
not want to aspiration. ankle xray showed no fracture, ? sift
tissue swelling or infectious process involving bone and soft
tissue, ? follow up MRI, however patient declined and Dr. ___
___ not feel that MRI is warranted at this time as patient's
symptoms are already improved with steroid taper
-Cold compresses and Tylenol PRN
-continue prednisone taper 40mg x days, 30mg x 2 days, 20mg x 2
days and 10mg x 2 days
#Hypertension: stable
-Discontinued Lisinopril and HCTZ
-Monitor BP closely up titrate Amlodipine if needed
-continue amlodipine
-Labetolol increased from 100mg bid to ___ bid
#Hypomagnesaemia: Mg ___ yesterday)
-follow up magnesium outpatient in 48 hours
#hypothyroidism: TSH normal in ___
-continue levothyroxine
#Insomnia: Slept well last night after Ramelton; No sleep night
prior d/t ankle pain and cough
-Codiene qhs prn cough
-Ramelton 8mg po qhs prn insomnia
#asthma: currently stable
-PRN atrovent neb
#Disp: Dc home with wife and ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with active IV drug use transferred from ___ for
abdominal and flank pain due to IVDU-related septic emboli with
bilateral renal infarcts and question LV thrombus vs
endocarditis. Radiology showed No acute intracranial abnormalities identified. MR HEAD W/O CONTRAST showed Acute right middle cerebral artery and left cerebellar infarcts. Radiology showed No additional evidence of acute intracranial injury. Known foci of restricted
diffusion consistent with acute infarction in the right basal ganglia, right
insular cortex, and left cerebellum are better delineated on dedicated MRI
from ___. CTA HEAD AND CTA NECK showed Evolving right basal ganglia and right insular region infarcts. The known left
cerebellar hemisphere infarct is not as conspicuous on CT. There is no new
infarct or hemorrhage.
There is occlusion of the proximal M1 segment of the right MCA with
reconstitution of the distal branches.
There is a 2-3 mm triangular out pouching at the origin of the left posterior
communicating artery likely representing a infundibulum.
Unremarkable neck CTA without evidence of significant stenosis, dissection or
other vascular abnormality.
NOTIFICATION: Case discussed with Dr. ___ telephone by Dr. ___ at
19:56 on ___, immediately after the findings were made. CHEST PORT. LINE PLACEMENT showed Expected postoperative appearance of the chest. CHEST (PORTABLE AP)CHEST (PORTABLE AP)i showed Worsened opacification at the lung bases, particularly the left follows
tracheal extubation, presumably atelectasis, but warranting followup
evaluation to exclude aspiration pneumonia.
Another phenomenon of tracheal extubation is a slight increase in heart size
and pulmonary vascularity, but there is no edema. No pneumothorax. Right
jugular line ends in the region of the tricuspid valve. CT HEAD W/O CONTRAST showed Expected changes with right basal ganglia and insular infarction with
minimally more effaced anterior horn of right lateral ventricle. No
intracranial hemorrhage. Radiology showed 1. No finding to suggest vertebral osteomyelitis, spondylodiscitis or
epidural or paraspinal phlegmon.
2. Normal spinal cord signal intensity.
3. No pathologic leptomeningeal, intramedullary or radicular enhancement.
4. Cervical spondylosis, most marked at the C3-4 and C4-5 levels, where
central protrusions remodel the ventral cord; there is also moderate right
neural foraminal narrowing at the C5-6 level.
5. Heterogeneously hypointense vertebral bone marrow signal, without
corresponding STIR hyperintensity, which may simply represent red marrow
reconversion in response to anemia, in a female patient of this age. However,
other entities, such as anemia of chronic disease or even, HIV infection
should be considered in this clinical setting; correlate with clinical and
laboratory data.
6. Status post median sternotomy with small-moderate bilateral pleural
effusions and bilateral renal infarcts, related to the known history of
endocarditis. CHEST PORT. LINE PLACEMENT showed Interval placement of a right sided PICC, which terminates below the
cavoatrial junction and could be pulled back 2.5 cm for positioning in the low
SVC.
Worsening left basilar atelectasis and/or consolidation with adjacent small to
moderate pleural effusion. CT HEAD W/O CONTRAST showed No acute intracranial process. No evidence of septic emboli.
NOTIFICATION: These findings were communicated to Dr. ___ at 4:43 p.m. on ___ in person. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. The patient was treated with Evacuation of left ventricular thrombus ___. At the time of discharge, the patient had asthma, newly diagnosed 2 months ago
pneumonia times two over past two months, most recently finished
antibiotics two weeks ago
"Slipped discs", previously taken Percocet and Baclofen for this
Anxiety
Depression
IV drug use of ___, opiates, amphetamines, heroine, cocaine. The patient was given written instructions concerning 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 active IV drug abuse and asthma presenting with left
flank pain and found to have bilateral renal infarcts and LV
thrombus versus vegetation.
# ENDOCARDITIS WITH SEPTIC EMBOLI. Etiology would be from recent
and continued IV drug abuse including ___, heroin, and
methamphetamines. She had renal infarcts and large LV thrombus.
Patient claims she only had 1-time ___ use, but outside
medical records state otherwise, including ___
admission ___ where she was in respiratory distress and
found to have used multiple IV drugs in her hospital room and
later left AMA. She was treated with vancomycin while blood
cultures were pending (no blood cultures were drawn at ___
___ prior to administration of vancomycin). TEE showed
large mobile ovoid mass in apex, LV thrombus vs vegetation.
Cardiology and Cardiac Surgery were consulted, who agreed with
antibiotics and anticoagulation. Possible set of events was
endocarditis from IV drug use, with emboli to LAD causing MI,
then LV hypokinesis leading to development of large LV thrombus.
CT head was initially negative for septic emboli, so heparin gtt
was started. Two hours later, she had acute stroke and heparin
gtt was stopped.
# CODE STROKE. Two hours after heparin gtt was started, she
developed acute facial droop, slurred speech, and left
hemiparesis. Code Stroke was called. CT head showed no bleeding,
but MRI was consistent with multifocal septic emboli. Heparin
gtt was stopped. She was transferred to CCU for closer
monitoring.
# LEUKOCYTOSIS. WBC 33 at OSH, 29 on admission here. Some
component attributable to multiple recent solumedrol doses for
asthma exacerbations at OSH, however cannot exclude infection
given endocarditis question on OSH CT scan.
- send Cdiff given recent levofloxacin use, no current diarrhea
but she has abdominal pain
# LEFT FLANK PAIN. Probably from bilateral renal infarcts,
consistent with L>R infarcts seen on OSH CT. ___ have had a
fracture given onset of pain directly after mechanical fall with
abdomen/flank region hitting desk. Some of it may be
drug-seeking behavior given known IV and opiate abuse history.
She was treated with dilaudid IV PRN and lidocaine patch.
# TRANSAMINITIS. ALT>AST in low 100's in 2:1 pattern. She has
had abnormal LFTs in the past per ___ records. She
has multiple risk factors for liver disease including alcohol
and IV drug use. HIV was negative.
- Hep B, Hep C serologies
# ACTIVE IV DRUG ABUSE. Patient declined this to me on exam, but
records show clearly she continues to abuse IV drugs, and was
found with them recently in her hospital room at ___ three
days prior to her presentation at ___. Serum tox screen was
negative on admission here. Urine positive for opiates only (has
received narcotics for pain control). Social Work consulted.
# ASTHMA. History of asthma and mild wheezes on exam.
Asymptomatic. She was treated with nebulizers.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ y/o man with poorly controlled HTN, DM1, and HD
dependent ESRD who was found down and unresponsive at home on
the day of admission. Per EMS report, he missed HD today; mother
contacted a neighbor, who found him down at home, unresponsive.
Per report, the neighbor thought he was having a seizure, though
no description of the events is available. EMS was called, BG in
the field was 30, received 1 AMP D50 with improvement in BG to
>100 with no improvement in his AMS.
.
In the ED, initial vitals were:
T 103 HR 93, BP 161/100, 100% on FIO2 60%, PEEP 10, Vt 500, RR
22
On arrival he was intubated and ABG was: ___. LP was
performed and showed 2 WBCs, 0 RBCs, Protein 29, Glucose 27.
Labs were otherwise notable for K 7.6, Lactate 1.6, HCO3 14. He
was given insulin, Ca Gluconate, D50, Vanc/Ceftriaxone/Zosyn and
Propofol for sedation. Renal was consulted for urgent HD.
.
On arrival to the MICU, initial VS were:
T 101 HR 88 BP 144/88 RR 22 O2 Sat 100%
Vent settings were: AC FiO2:60 PEEP: 10 RR:22 Vt: 500. Radiology showed Nonspecific focal hypodensity within the right frontal lobe with
differential consideration given to chronic small vessel infarction,
demyelination, or infection (such as Lyme disease) and further evaluation with
MRI is recommended. Radiology showed No fracture of the cervical spine. Radiology showed 1. Standard positioning of the endotracheal and orogastric tubes.
2. Mild pulmonary edema. Radiology showed No evidence of acute intracranial process. Radiology showed Extensive abnormally slow diffusion involving supra- and
infra-tentorial brain bilaterally, the majority of which is symmetric as
described above. Overall, these findings are most consistent with hypoxic
encephalopathy, though hypoglycemic encephalopathy can have a similar
appearance. Radiology showed 1. Endotracheal tube is in adequate position, terminates 5.4 cm above the
carina.
2. Possible mild interstitial abnormalities. Radiology showed Left PICC line terminates at the confluence of the
brachiocephalic veins, new PICC line should be positioned at least 9 cm from
this point.
These findings were discussed with the IV team by ___ via
telephone on ___ at 4:20 p.m., at time of discovery. Radiology showed AP chest compared to ___:
Previous moderate cardiomegaly has not recurred. Normal cardiomediastinal
silhouette. The lungs grossly clear. No appreciable pleural abnormality.
Tip of the endotracheal tube with the chin down at the thoracic inlet is no
less than 6 cm from the carina. It should be advanced at least 3 cm for more
secured seating. A dual-channel dialysis catheter ends in the region of the
superior cavoatrial junction. Upper elementary drainage tube ends in the
upper portion of a non-distended stomach. Left PIC line tip is in the low
SVC. Radiology showed 1. No intracranial hemorrhage or increased mass effect.
2. Stable nonspecific bilateral white matter hypodensities. Radiology showed No acute abnormalities detected. Decrease in the severity of diffusion
abnormality. The FLAIR images appear unchanged. The changes remain
compatible with encephalopathy T2 axial, hypoglycemia, or both. Radiology showed Endotracheal tube has been replaced with new tracheostomy. intraperitoneal
air is seen consistent with recent PEG tube placement. Right middle lobe
opacity seen which may be consistent with pneumonia. Radiology showed Coiling of the left PICC line in the subclavian vein. No complications from
the procedure are seen.
The findings concerning the coiling of the PICC line were relayed via
telephone to the IV team immediately following discovery. Findings were
discussed at approximately 3:30 p.m. on ___ by Dr. ___. Radiology showed Removal of old malpositioned PICC line with placement of new 5 ___ PICC.
PICC ready to be used at this time. The patient was diagnosed with ALTERED MENTAL STATUS , END STAGE RENAL DISEASE. The patient was treated with R Femoral CVL Placement (___)
Tracehestomy/PEG ___. At the time of discharge, the patient had Hypoglycemic encephalopathy
Ventilator associated 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 Reason for Admission: This is a ___ y/o man with poorly
controlled HTN, DM1, and HD dependent ESRD who was found down
and unresponsive at home on the day of admission with FSBG of
30.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with morbid obesity, playing kickball earlier, twisted
wrong and landed on his R knee with immediate pain and
deformity.
No HS, No LOC. BIBA. He is in extreme pain. Has some numbness
over the dorsal foot, and unable to dorsiflex the R foot. Radiology showed Medially and anteriorly dislocated right knee. Recommend
post-reduction imaging to assess for fractures. The patient was diagnosed with DISLOCAT KNEE NOS-CLOSED, UNSPECIFIED FALL. The patient was treated with ___:
- Closed reduction right dislocated knee
- Examination under anesthesia (application of manual stress
using fluoroscopy) right knee
- Application of multiplanar external fixator, right lower
extremity. At the time of discharge, the patient had Tibio-femoral dislocation
ACL rupture
PCL rupture
LCL rupture. The patient was given written instructions concerning 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 surgery service on
___ with R knee dislocation. Patient was taken to the
operating room and underwent closed reduction of R knee
dislocation with external fixator placement. Patient tolerated
the procedure without difficulty and was transferred to the
PACU, then the floor in stable condition. Please see operative
report for full details.
Musculoskeletal: prior to operation, patient was NWB RLE.
After procedure, patient's weight-bearing status was
transitioned to WBAT RLE in exfix at all times. Throughout the
hospitalization, patient worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by IV
morphine and oxycodone and was subsequently transitioned to PO
dilaudid with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient's HCT remained stable throughout the
hospitalization. He did not receive any blood transfusions
while in the hospital.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received aspirin during this stay, and
was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #3, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating with his exfix on, voiding without
assistance, and pain was well controlled. The extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on aspirin for
DVT prophylaxis for 6 weeks post-operatively. 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: ___ with history of type 1 choledochal cyst
s/p duct excision RnY HJ ___ and subsequent biliary
stricture status post multiple ___ procedures for PTBD and drain
placement who was discharged recently with a capped PTBD. She
was due for a drain check on ___. She has had increasing
abdominal discomfort over the past week, and on ___
uncapped her PTBD at Dr. ___. Labs were done
on ___ showing ALT 605 AST 366 ALP 1624 Tbili 0.5. She
continued to have abdominal pain, nausea, and chills with
subjective fevers, and was sent to the ___ ED for further
workup. Radiology showed Left internal external biliary drain exchanged over the wire. The patient was diagnosed with Sepsis, unspecified organism, Epigastric pain, Nonspec elev of levels of transamns & lactic acid dehydrgnse. At the time of discharge, the patient had cholangitis
Near Occluded biliary catheter
___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ female with history of type 1 choledochal cyst, pancreatic
divisum s/p robot-assisted laparoscopic bile duct excision, RNY
hepaticojejunostomy (___), c/b HJ stricture requiring
balloon dilation and PTBD placement (___) who
presents to the ED with abdominal pain at her drain site and
chills. On ___, ___ found nearly completely occluded PTBD and
the catheter was exchanged. Post procedure, she had some nausea
that resolved and LFTs decreased with alk phos decreasing from
1414 to 666. She remained afebrile. The PTBD was capped and her
abdominal discomfort was minor at the PTBD insertion site.
Creatinine was increased to 1.4 from baseline of 0.7. One liter
of IV fluid was given with creatinine decrease to 1.6 on ___.
She was encouraged to drink at least 2 liters of fluid per day.
She was given a script for a chem 10 to be drawn on ___
___ at her local lab. Diet was advanced and tolerated. She was
discharged to home on Augmentin that was filled by ___ on
___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ was at home today alone and tripped and fell down four
stairs onto his right side with sudden pain in his chest and
shoulder. He denies LOC and has full recall of the event. He
note
some mild pain in his right hip as well. He denies pain
elsewhere. He was initially taken to an OSH (___)
where some imaging was done discovering a clavicular and 8 rib
fractures on his right side. An epidural catheter was placed. He
was transferred to ___ for further evaluation and management. CHEST (PORTABLE AP) showed Multiple right-sided rib fractures and small to moderate right pleural
effusion. Possible small left pleural effusion. No discrete pneumothorax
seen although CT would be more sensitive.
Comminuted mid right clavicular fracture is seen. HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT showed No acute fracture or dislocation seen.
Chronic changes, as above. CT HEAD W/O CONTRAST showed No acute intracranial process. CT ___ W/O CONTRAST showed 1. Minimal retrolisthesis of C4 on C5, which is likely degenerative in nature.
2. No acute cervical fractures.
3. Right clavicular and right rib fractures are better visualized on the chest
CT with the same date.
4. Air throughout the epidural space is likely due to reported recent
intervention. CT chest, abdomen, and pelvis with IV contrast. showed 1. Acute fractures of the right clavicle and right first through eighth ribs.
No pneumothorax.
2. Small right pleural effusion with ground-glass opacity and lucencies within
the right mid lung, which may represent contusion with small traumatic
pneumatoceles.
3. Likely dependent atelectasis bilaterally, however aspiration/infection
cannot be entirely excluded.
4. Extensive fat stranding along the right flank, with 2 hematomas overlying
the right gluteal muscles measuring up to 5.9 cm.
5. Chronic L1 vertebral body fracture with mild retropulsion of bony
fragments. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. Radiology showed Displaced comminuted mid right clavicular fracture as described above. The patient was diagnosed with Multiple fractures of ribs, right side, init for clos fx, Fall (on) (from) unspecified stairs and steps, init encntr. At the time of discharge, the patient had Right clavicle fracture
Right ___ rib 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>___ with known right sided rib fractures and clavicle fracture
on right after fall on transfer from OSH. Patient was admitted
to the ACS service for polytrauma. Patient received pan-scan to
evaluate for fractures causing SOB, tachycardia, and tachypnea.
CT head demonstrated no intracranial abnormalities, CT Chest
demonstrated Right ___ rib fractures and a comminuted
fracture of the mid third of the right clavicle with inferiorly
displaced butterfly fragments, and hip x-rays demonstrated no
fractures.
Patient remained stable after scans, SOB and tachycardia
improved with better pain control, and vital signs normalized.
Patient was admitted to ACS service for pain control and oxygen
support. Chronic pain service was consulted to assist with pain
control given patient's history of opioid use. A combination of
Lidocaine patch, Cyclobenzaprine 5 mg PO/NG TID, Acetaminophen
1000 mg PO/NG Q6H, OxyCODONE (Immediate Release) 20 mg PO/NG
Q4H:PRN Pain, and Gabapentin 900 mg PO/NG TID appeared to
control the patient's pain. Incentive spirometry was encouraged
early on. The patient worked with physical therapy and was
cleared for discharge home.
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: ___ w/ PMH DM, HTN, ESRD on dialysis MWF via left IJ tunnel line
presents with fever and tachycardia. Patient stated that he did
not feel well on ___, was found to have fever, did not go
for HD. had peripheral blood cultures drawn in rehab at that
time. H went to HD unit for catch up session yesterday (___),
was noted to be tachycardia with low grade temp(100.2), was able
to complete HD treatment with 1.6L UF. Blood culture turned out
positive today, patient was then sent to ED for further
management. Per ED, all blood cultures grew MRSA; gram stain
with GPCs and GPRs. Chest: Frontal and lateral views showed No acute cardiopulmonary process. Radiology showed Successful removal of a left chest tunneled line. Radiology showed Successful placement of a 27cm tip-to-cuff length tunneled dialysis line.
The tip of the catheter terminates in the right atrium. The catheter is ready
for use. The patient was diagnosed with Bacteremia. The patient was treated with Removal of tunneled HD line ___
Placement of tunneled HD line ___
TEE ___. At the time of discharge, the patient had MRSA Bacteremia
ESRD on HD
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>___ is a ___ with DMII c/b ESRD on HD MWF p/w 2 days
of fevers and positive blood cultures with MRSA, now s/p HD
port removal and identification of aortic valve vegetation.
# MRSA BACTEREMIA LIKELY DUE TO LINE INFECTION
# MRSA ENDOCARDITIS OF AORTIC VALVE
Patient presented from his ___ facility on ___ after
episode of fevers, rigors, found to have high grade MRSA
bacteremia (positive culture at rehab ___ 1 of 4 cultures on
___ with MRSA). Likely etiology is line sepsis from infected
tunneled HD catheter and this was removed on ___. TTE was done
which was suboptimal quality but did not show any vegetations.
TEE on ___ndocarditis with mod vegetation on AV
cusp. No paravalvular abscess seen. Repeat surveillance blood
cultures were negative. New tunneled hemodialysis line was
placed ___. Plan is to treat with 6 weeks of vancomycin dosed
with HD through ___. Will follow-up in ___ clinic.
#ESRD on HD MWF
#Hyperkalemia
Patient was initiated on HD during his last hospitalization
___. Renal failure is secondary to diabetic nephropathy.
Still makes urine. He was given a line holiday and missed
dialysis session on ___ and ___. CMP checked daily, hyperK+
and hypervolemia treated with insulin/dextrose and 100 mg Lasix
and insulin/dextrose PRN. HD tunneled line was replaced on
___. He was kept on strict low K+ diet, strict ___ mL fluid
restriction and continued on home nephro caps, calcitriol,
calcium carbonate and Vitamin D. Last dialysis session on ___.
His home Lisinopril was held and then restarted on discharge.
#s/p right toe amputation
Healing well, no signs of infection. Podiatry curbsided and had
a very low suspicion for infection, but recommened x-ray to
ensure no signs of osteo, though patient declined. CRP ~11.
#DIABETES MELLITUS II
Previously followed by ___. Most recent A1C 6.6%. Continued
home glargine and Humalog SS.
#HYPERTENSION
SBP 140-150s. Continued on Lisinopril on discharge.
#HLD: Continued on atorvastatin 20mg QHS and ASA 81mg daily
#ANEMIA
Hb 11.3, bl ___. Unclear why higher than usual, maybe some
component of hemoconcentration in setting of fever and
bacteremia. Iron studies from ___ suggestive of anemia of
chronic inflammation; B12 normal. Anemia likely due to ESRD.
EPO 10,000units q14 days per renal recs.
TRANSITIONAL ISSUES
===================
- Continue vancomycin with hemodialysis sessions (end date ___
for a total of 6 weeks.
- Weekly CBC/diff, vanc levels at least every other week, and
CRP every ___ weeks, and surveillance blood cultures at the end
of his course. PLEASE DRAW DURING HD SESSIONS, ALL LAB RESULTS
SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___
- ___ clinic follow-up, likely surveillance culture after abx</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a PMH of DM, HTN who presents with ___ of
non-productive cough, congestion, mild SOB. Radiology showed No definite focal consolidation. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Left lower lobe opacity distal to bronchial secretions could reflect a
developing infection, aspiration, or atelectasis.
3. Diffuse bronchial wall thickening and multifocal bronchial secretions
suggests small airways inflammation.
4. Mediastinal and left hilar lymphadenopathy may be reactive. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had COPD exacerbation
Secondary:
Diabetes Mellitus
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>___ with PMH of chronic bronchitis, DM2, HTN, chronic pain on
methadone, homelessness p/w SOB and cough, likely secondary to
COPD exacerbation, now improving.
# Cough:
# SOB:
# Likely COPD w/acute exacerbation:
Patient p/w cough and SOB, likely exacerbation of undiagnosed
COPD in setting of significant smoking history, with CT evidence
of diffuse bronchial wall thickening suggestive of small airways
inflammation. Possible trigger viral URI. No e/o PE. LLL opacity
on imaging
likely atelectasis, with no fevers or leukocytosis to suggest
PNA. She was treated with prednisone 40mg daily x 5d (through
___ and standing duonebs. She received one dose of
levofloxacin and was transitioned to azithromycin to complete a
5d course (through ___, QTC 413 on ___. Her symptoms improved,
and she remained on RA. Non-ambulatory at baseline
(wheelchair-bound from chronic pain), but was maneuvering to and
from her wheelchair independently at discharge. She was
discharged on her home albuterol PRN with addition of Spiriva
for COPD maintenance. She would likely benefit from outpatient
PFTs and pulmonary f/u. Smoking cessation was encouraged.
# Diabetes mellitus:
# Peripheral neuropathy:
A1c 10.2 on ___ with peripheral neuropathy. Previously
prescribed ___ 20u QHS in addition to metformin, which she
was taking only intermittently prior to presentation in setting
of homelessness. Fingersticks were elevated to the 300s this
admission in setting of steroid administration. After discussion
with her PCP, ___ was increased to 30u QHS and home metformin
- held while in house - was continued at discharge. She was
provided with a glucometer on discharge, but unfortunately test
strips are not covered by her insurance. She was encouraged to
buy test strips over the counter and check fingersticks daily;
her PCP was made aware and will work to obtain insurance
coverage for strips going forward.
# Chronic pain:
# Arthritis:
Continued home gabapentin and methadone 10mg BID (dose confirmed
with PCP). She was given a 7d supply of methadone on discharge
to bridge her to her PCP ___ (scheduled for ___.
# Anxiety:
Continued home clonidine BID PRN (previously prescribed).
Patient frequently requested benzodiazepenes, which were
avoided.
# HLD:
Continued home atorvastatin 80mg daily.
# HTN:
Continued home lisinopril 20mg daily on discharge.
# Housing instability:
Patient intermittently housed at shelters, complicated by need
for wheelchair accessibility and patient's desire to keep her
cat with her. SW was consulted and investigated options for
discharge. Unfortunately, no shelters will allow patient to keep
her cat with her unless the animal is certified as a service
companion. Patient was discharged to a shelter, where a social
worker had previously been helping her to arrange long-term
housing. All medications were delivered to the bedside prior to
discharge.
TRANSITIONAL ISSUES
- Continue azithromycin and prednisone through ___
- Would likely benefit from pulmonary referral and PFTs
- F/u DM; likely will require insulin titration
- Ensure follow-up with Dr. ___ close management of
multiple co-morbidities; Dr. ___ this patient very well
- medical and psychosocial concerns alike.
- Please continue to assist the patient with finding housing
- Please assist the patient with getting ownership of her cat
back from shelter; the animal is extremely important to her.
Patient is medically stable for discharge today. Greater than 30
minutes were spent on discharge planning and counseling.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient presents with 24 hours of diffuse cramping abdominal
pain. She states that she ate some rice pudding 24 hours prior
to
admission and that since then she has had worsening abdominal
pain, nausea and vomiting. She says that this has happened
previously when she eats foods because of her short gut syndrome
and once when she had similar symptoms she was found to have a
bowel obstruction. She denies fevers but did have rigors last
night. She tried to treat herself with her home IV Zofran
administered through her central line but this did not improve
her nausea and vomiting. The patient also felt she was
dehydrated
and gave herself one liter of IV fluids. Her last bowel movement
was one day ago and was normal. She denies recent changes to her
bowel habits. She does endorse some pain with urination
yesterday. Radiology showed Nonobstructive bowel gas pattern with few air-fluid levels in the left upper
quadrant. This could be secondary to very mild ileus. CT ABD AND PELVIS WITH CONTRAST showed 1. Status post Roux-en-Y gastric bypass without evidence of an acute
intra-abdominal process.
2. Hepatic steatosis.
3. Sequela of osteomyelitis at T10-11, similar in appearance to prior exam. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality. CT ABDOMEN AND PELVIS WITH CONTRAST showed 1. No acute abdominopelvic pathology.
2. Postsurgical changes from Roux-en-Y gastric bypass and multiple small
bowel resections. No evidence of obstruction. The patient was diagnosed with Unspecified abdominal pain, Nausea with vomiting, unspecified, Tachycardia, unspecified. The patient was treated with Endoscopy. At the time of discharge, the patient had PRIMARY DIAGNOSES:
Acute on chronic abdominal pain and nausea
Impaired bowel motility
History of Roux-en-Y gastric bypass and bowel resections
Short gut syndrome on chronic TPN
Chronic pain syndrome on chronic opioid therapy
Uncomplicated UTI
SECONDARY DIAGNOSES:
Anxiety
Insomnia
History of DVT
___ Edema. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Brief Hospital Course
======================================
Ms. ___ is a ___ ___ retired ___ with a history of RnY gastric
bypass c/b short gut syndrome (on TPN via tunneled central line)
who was admitted for acute on chronic abd pain, nausea, and
vomiting. CT showed no evidence of obstruction or other acute
pathology. EGD showed no ulcers but did reveal a bezoar that
have been contributing to symptoms. Patient gradually improved
and was discharged home at baseline with close f/u.
Active Issues
======================================
#Abdominal Pain:
#Nausea:
#Short gut syndrome:
#Slow Transit:
Patient presented with 24 hours of nausea and vomiting, similar
to prior episodes. CT showed no evidence of obstruction,
infection, or other acute pathology. EGD on ___ demonstrated
large bezoar in jejunal limb, thought to be blind limb, that may
have led to her symptoms. She displayed evidence of slow
transit, with residual fecal matter on CT and retained food at
EJ anastomosis on EGD. Slow transit may be secondary to opioid
use for abdominal pain, and was not treated given patient's
history of short gut syndrome. EGD was also negative for
anastomotic ulcer. Patient's pain was managed with home
buprenorphine and morphine. Nausea was controlled with standing
promethazine and prn ondansetron, prochlorperazine and
lorazepam. By the time of discharge, her pain and nausea had
improved to baseline.
#Hypotension: One episode of hypotension with BP ___.
Patient was asymptomatic and lacked any localizing signs of
infection. Improved with IVF bolus.
#Uncomplicated UTI: Experienced dysuria and urgency. UCx grew
coagulase negative Staph. Started on Bactrim DS BID on ___ for 3
day course.
#Nutrition: Continued on home TPN
#Anxiety: Continued on home mirtazapine and started on zolpidem
10 mg QHS.
#History of DVT: Continued on home Enoxaparin Sodium 80 mg SC
Q12H for history of provoked DVT. Note dose is higher than
standard 1mg/kg due to c/f prior treatment failure. Has
Hematology f/u soon.
#Chronic anemia: Stable this admission. Due to iron infusions as
outpatient.
___ Edema: Home Lasix held, no edema.
Transitional Issues
======================================
- Continue Bactrim DS BID through ___
- No other medication changes made this admission
- Note: patient was recommended to initiate care as outpatient
with gastroenterology but declined at this time.
- GI recommended small bowel follow through to ascertain if
bezoar is in blind limb vs. jejunoileal limb; patient declined
test as inpatient but amenable to doing test as outpatient.
- Has Hematology follow-up scheduled to discuss enoxaparin
dosing and iron infusions for chronic anemia
CONTACT: ___ (Wife) Phone: ___
CODE STATUS: DNR/DNI</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant ___ h/o HTN/HLD, afib on
Eliquis, DM2 c/b neuropathy with diabetic foot ulcers, chronic
dCHF, and CKD Stage III who presents with right leg wound. At
baseline, she lives with her great-niece and reportedly was able
to walk with walker - and go from bed to bathroom with some -
but
minimal - assistance. Over the past 2 weeks, she is reported to
have difficulty walking - and tough time climbing the 4 steps
needed to get to the front door. Describes having tough time
with
her R side (arm and legs) with the need, at times, to manually
lift her R leg while going up the stairs.
She has had multiple follow-ups for her diabetic ulcers.
However, in the past 3 days, she developed some erythema
surrounding the right shin ulcer with some warmth. She has had
no
fevers, nausea, vomiting or diarrhea. She is been tolerating
p.o.
She has had difficulty ambulating due to the pain in her
feet/shin. Yesterday, her great-niece notices swelling and
bullae formation on the R shin. Due to increased pain, warmth,
and worsening weakness, she was brought into the ED for further
management.
Of note, She has had multiple falls over the past several
weeks. Her niece thinks the most recent fall was greater than 10
days ago. She has a bruise of her right flank but has had no
chest pain or shortness of breath. She was also intermittently
hallucinating in the middle of night - and she was noted to have
some worsening of her short-term memory, but otherwise has been
interactive and alert.
In the ED, she was evaluated by podiatry who made the
following assessment: "Right foot w/ no local signs of infection
as wound to the dorsolateral aspect of the foot is completely
epithelialized. There is another superficial wound to the
plantar
medial aspect of the R hallux that does not probe deep and does
not have any surrounding erythema, proximal streaking, purulent
drainage or malodor present. There are several other
pre-ulcerative lesions present to the right foot (sub ___ met
head, sub ___ met head) which are stable at this time. Of most
concern is the appearance of the right lower extremity at the
mid
shin area where there is significant erythema and bullae
formation w/ serous drainage. Patient would benefit from
admission for IV abx for the RLE cellulitis and non-adherent
dressing to the R leg wound. No plan for any surgical
intervention from a podiatric surgery perspective." CHEST (PA AND LAT) showed Stable cardiomegaly. No fracture seen. CT HEAD W/O CONTRAST showed No acute intracranial abnormality. Chronic microvascular ischemic disease.
Stable ventricular prominence. CT C-SPINE W/O CONTRAST showed 1. No acute cervical spine fracture or prevertebral soft tissue swelling.
2. Redemonstration of cervical spine degenerative changes, again with
mild-moderate canal narrowing at C6-7 and multiple levels of mild neural
foraminal narrowing.
3. Multinodular thyroid. HAND (PA,LAT AND OBLIQUE) RIGHT showed No acute osseous abnormality of the right wrist seen. If pain persists
recommend repeat radiographs in ___ days. The patient was diagnosed with Cellulitis of right lower limb. At the time of discharge, the patient had Right leg cellulitis
Wrist pain
Diabetes with hypoglycemia
Acute kidney injury. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with history of hypertension,
hyperlipidemia, atrial fibrillation on apixaban, type 2 diabetes
c/b neuropathy with diabetic foot ulcers, chronic diastolic CHF,
and CKD Stage III who presents with right leg wound.
# Right anterior shin cellulitis
# Stable bilateral foot ulcers
# Possible fever
Admitted with right shin ulcer, pain, erythema c/w cellulitis.
Foot ulcers appearing epithelized and non-infected. Low
suspicion for DVT given she is on chronic apixaban. Patient
with low-grade fevers initially that then resolved with further
antibiotics. Podiatry was consulted and recommended no surgical
therapy. She was placed on IV vancomycin, transitioned to PO
doxycycline and amoxicillin for total 10 day course. She will
need to follow up with Podiatry on ___.
# Immobility
# Mechanical Falls:
Usually, at baseline able to walk with a walker but recently has
been unsteady, unable to get out of a seated position, and prone
to falls (3 falls in last couple weeks). Head CT, C-spine CT
without clear pathology. ___ evaluated patient and
recommended rehab. She will continue work with ___ at rehab.
# Wrist pain: patient endorsed wrist pain after fall, X-ray
showing no evidence of fracture or deformity. She was provided
with acetaminophen and lidocaine ointment for pain.
# Acute kidney injury: patient has labile creatinine, with
elevation to 1.9 one day prior to discharge. She was given IV
fluids with improvement to Cr 1.6.
# Diabetes
# Hypoglycemia: patient hypoglycemic to ___ during admission, so
insulin glargine dosing was decreased from 22 units at night to
16 units. Dosing of insulin will likely need to be uptitrated
again at rehab, and attention should be paid to this.
CHRONIC ISSUES
======================
# HTN/HLD: on lisinopril, torsemide, atorvastatin, which were
continued
# Atrial fibrillation: continued home apixaban
# History of breast cancer: continued home tamoxifen
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will need to follow up with Podiatry on
___. Dosing of insulin will likely need to be uptitrated again
at rehab, and attention should be paid to this. She will
continue work with ___ at rehab.
# CODE STATUS: DNR/DNI, but ok to hospitalize
# Contact: niece ___
Phone number: ___
Cell phone: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ year-old female with history of DM,
HTN, and CKD who presented to ___ with 1 week of
increasing SOB and non-productive cough. She reports a dry
cough, wheezing and shortness of breath predominantly when
laying down or eating food. She denies dyspnea on exertion.
Cough wakes her from sleep. She denies sick contacts. She denies
CP, fever/chills, abdominal pain, N/V. Workup included a non-con
CT chest which demonstrated bilateral pleural effusions, RLL
atelectasis vs. penumonia. Labs demonstrate an elevated Troponin
to 0.31 with Cr of 2.4 (baseline 2.1-2.6). An EKG showed
flattned T waves in anterolateral leades. She was started on a
Heparin drip, given ASA 325mg, and 1 dose of Levaquin and
transferred to ___.
In the ED initial vitals were: 97.6 66 116/58 18 98% RA
- Labs were significant for troponin 0.26, CK-MB flat, Cr 2.0
(baseline 2.1-2.5), CBC normal, INR 1.1, UA bland.
- Patient was given heparin gtt and 1 amp D50 for BS 42 (recheck
was 200)
Vitals prior to transfer were: 97.5 72 116/45 20 100% RA
On the floor, patient is chest pain free. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the visualized bilateral lower
extremity veins. The peroneal veins in the left calf were not well
visualized. CHEST (PORTABLE AP) showed Slight increase in vascular plethora CHEST (PORTABLE AP) showed No pneumothorax. NONINVASIVE ARTERIAL STUDY OF THE LOWER EXTREMITIES showed No evidence of significant arterial insufficiency to the lower extremities
bilaterally. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, ABN CARDIOVASC STUDY NEC. The patient was treated with R Thoracentesis ___. At the time of discharge, the patient had Diastolic Heart Failure
Community Acquired Pneumonia
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>Ms. ___ is an ___ year-old female with history of DM,
HTN, and CKD who presented to ___ with 1 week of
increasing SOB and non-productive cough.
#Systolic CHF: New diagnosis. Previous ECHO at ___
in ___ showed normal LV function and EF 60%. ECHO here ___
showed EF 40-45% and mild to moderate systolic dysfunction. Her
NTBNP was 7000, she had bilateral transudative pleural effusions
(did not meet any of Lyte's critera) and a pleural fluid pro BNP
of 16000+. She was not diuresed as she was not grossly
overloaded and her diagnostic pleural effusion was in fact
partly therapeutic. She may need to be started on a diuretic as
an outpatient but was relatively euvolemic on exam so were not
started here. Discharge weight: 48kg.
-started metoprolol 50 XL daily
-cont'd Bumex
-cont'd asa 81
# Type 2 NSTEMI (demand): Elevated troponin to
0.26-->0.23-->0.20 with flat MB. Patient denies history of chest
pain. Has been experiencing cough symptoms and shortness of
breath over past week. DVT workup was negative. She initially
got heparin gtt x24hrs after transfered from ___ when there
was concern for Type 1 NSTEMI, but her ECGs were not consistent
with this and so it was stopped. She was initially started on
asa 325mg but changed to 81mg prior to discharge.
(ECG: Sinus rhythm. Diffuse low voltage. Right bundle-branch
block. Left anterior
fascicular block.)
- cont asa 81mg daily
- outpt f/u & workup
# ?Community Acquired Pneumonia: CXR and CT initially concerning
for RLL PNA at OSH and patient was started on oral Levofloxacin
q48 (renally dosed). Urine legionella negative. Strep pneumo Ag
still pending. She received nearly 5 days of oral Levoquin for
CAP to ensure coverage if pneumonia was playing a part in her
dyspnea. However, it is most likely that she was not infected
since her only symptom was cough and dyspnea with no fever or
leukocytosis.
- f/u s. pneumo ag
- finish course of levoquin x1 more day.
# Bilateral pleural effusions: Consistent with CHF.
Transudative, elevated proBNP.
See above. She had a right-sided thoracentesis on ___ and 250cc
was collected.
# CKD: Cr 2.0 on admission and ranged 1.8-2.0 (baseline
2.1-2.5).
- Cont home bumex (bumetanide)= loop diuretic
# Glaucoma
- Continued home eyedrops
# Emergency Contact: ___ (son) ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with HCV cirrhosis c/b HCC (Child A, MELD 20)
with presumed right lung metastasis, hepatic hydrothorax,
esophageal varices, and hepatic encephalopathy, also with CAD
and
CKD p/w altered mental status and hypoglycemia. UNILAT LOWER EXT VEINS RIGHT showed Extensive deep venous thrombosis throughout the right lower extemity veins,
not significantly changed since ___. The patient was diagnosed with Bradycardia, unspecified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF SUMMARY:
==============
___ male with HCV cirrhosis c/b HCC with presumed right
lung metastasis, hepatic hydrothorax, esophageal varices, and
hepatic encephalopathy, also with CAD and CKD p/w altered mental
status and hypoglycemia. His insulin regimen was lower and he
was discharged at baseline mental status.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with a history of hypertension, neuropathy,
osteoarthritis, who presented to the ED with a six week history
of L shoulder pain, with outpatient imaging concerning for a
left
scapular fracture. Per patient and family ( 2 children at
bedside), she has had 6 weeks of left shoulder pain which has
started since she had her shingles vaccination in her left arm,
which was accompanied by pain in her arm and shoulder. She
reports pain in the area throughout the last six weeks that has
worsened to the point she in unable to move her left arm. An
X-ray of her shoulder was taken at her senior living facility
___ ___ in ___) which revealed a fracture of
the superior scapular body and spine. Upon admission, her pain
was a ___. She is unable to move her arm and reports that it
has been tender to palpation. KNEE (AP, LAT AND OBLIQUE) LEFT showed 1. No fracture or dislocation.
2. Chronic medial femoral condyle osteochondral lesion. CT HEAD W/O CONTRAST Q111 CT HEAD. showed There is no evidence of acute intracranial process or hemorrhage.
No fractures are identified. CT ___ W/O CONTRAST. showed 1. No fracture or malalignment.
2. Severe multilevel degenerative changes of the cervical spine, worse at C4-5
and C5-6. CT CHEST/ABD/PELVIS W/ CONTRAST showed 1. Again seen is a moderately displaced, obliquely oriented acute fracture
traversing near the insertion of the left scapula spine onto the body. No
other fractures seen. However, given severe multilevel degenerative changes
of the thoracolumbar spine, if there is focal point tenderness along the
spine, recommend further evaluation with MRI.
2. 1.1 cm right upper lobe lung nodule. Recommend follow-up CT in 3 months, a
PET-CT, or tissue sampling.
RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule
bigger than 8mm, a follow-up CT in 3 months, a PET-CT, or tissue sampling is
recommended.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___ The patient was diagnosed with Disp fx of body of scapula, left shoulder, init for clos fx, Exposure to other specified factors, initial encounter. The patient was given written instructions concerning 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 who has presents with left shoulder pain
and an xray taken at her sernior living facility revealed a
fracture of the superior scapular body and spine. She denies
recent fall or trauma but did have a fall in ___ with a
left rotator cuff injury. Orthopedic surgery was consulted and
after reviewing imaging and physical exam, recommended
non-operative management with a sling and weightbearing and
mobility as tolerated. She was admitted to the trauma service
for pain control and care planning. Pain was managed with oral
Tylenol and a lidocaine patch. She tolerated a regular diet
without difficulty. The patient voided without problem. During
this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assistance, voiding without assistance,
and pain was well controlled. The patient was discharged to a
rehabilitation center to further assist with her mobility. A
follow-up appointment was made with the Orthopedic service. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ gentleman with a history of
anxiety, HTN, and alcohol abuse who presents with worsening
lower extremity edema x 1 week. He is also concerned about his
increasing alcohol use.
Patient began to notice bilateral ___ edema, L > R, approximately
3 days ago. This has never happened before, and he has no
personal or family history of VTE. No known history of liver,
heart, or kidney disease.
Patient reports he has been drinking consistently for the past
___ years but more heavily x ___ year. He feels drinking helps with
depressed mood and anxiety/panic and is now drinking by himself
nightly, usually ___ glasses of wine (> 1 bottle). He tends to
get shaky if he skips a night of drinking but has never required
treatment for withdrawal (no DT's/seizure). Girlfriend recently
ended their relationship due to heavy EtOH and low interest in
doing activities. Mom and step Dad also concerned about
drinking. He reports low interest, depressed mood, trouble
falling alseep, early morning awakenings, poor appetite, low
energy, difficulty concentrating. No SI/HI or A/VH.
Of note, patient underwent stress ECHO in ___ to evaluate
palpitations. Study showed good exercise capacity, no inducible
ischemia, and mild aortic root dilation; otherwise normal. He
reports that palpitations have actually been much better over
the past few months, and he has not had CP, chest pressure, or
SOB.
In the ED, initial vitals were 97.0 100 125/62 16 100% RA. Labs
were notable for ALT: 140 AST: 614 AP: 294 Tbili: 6.5, new
macrocytic anemia, negative tox screen. Baseline LFT's at ___
in ___ were AST 61, ALT 55, Tbil 0.4, AP 41. EKG SR @ 87.
Patient received folate, MVI, thiamine. Vitals prior to transfer
were: 100.2 98 121/61 20 96% RA.
On the floor, patient reports ongoing heaviness in both legs. He
says that he plans to stop drinking entirely and is very worried
about the possibility of developing cirrhosis. He has a
subjective fever and notes that his urine is dark and he has
been urinating less than normal. He has a large bruise on L
thigh from bumping into furniture; no other easy bruising or
bleeding. No recent travel, sick contacts, unusual foods. Of
note, patient recently took 4 days of baclofen for intractable
hiccups, no longer taking. He has had no other medication
changes and takes no supplements. Unsure if he has been
vaccinated for Hep B or Hep A (no documentation of vaccination
in ___ records, at age ___ have just missed "catch up" of
HBV vaccine in ___ public schools). Last drink 48hrs prior to
admission. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Diffusely echogenic liver, compatible with hepatic steatosis, with no
evidence of focal liver lesion or ascites. More advanced forms of liver
disease such as fibrosis/ cirrhosis cannot be excluded on the basis of this
study.
2. Diffuse gallbladder wall thickening is likely due to underlying liver
disease or third-spacing.
3. Splenomegaly. The patient was diagnosed with SWELLING OF LIMB. At the time of discharge, the patient had PRIMARY:
1. alcoholic hepatitis
2. bilateral lower extremity edema
3. alcohol abuse. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M w/ PMHx of alcohol abuse, depression/anxiety, HTN p/w
worsening ___ edema found to have transaminitis consistent with
alcoholic hepatitis.
# alcoholic hepatitis - Supported by elevation of AST>ALT and
radiographic evidence of steatosis. Clinical history also
supportive as he was drinking over a bottle of wine per day for
a year or two. LFTs downtrending during hospitalization.
Encouraged pt to abstain from alcohol use, which he is highly
motivated to do.
# lower extremity edema - Has a normal albumin with intact
synthetic function as evidenced by normal INR and no protein on
UA indicating that underlying liver disease and nephrotic
syndrome. Was not pitting on exam. Given compression stockings
with improvement.
# alcohol abuse - Pt endorses a desire to quit alcohol all
together. He was seen by social work in the ED and with
continued counseling on the floor, he remained motivated to
change. He was given serveral community resources to help him
remain sober. He was maintained on CIWA scale but did not score.
He was not discharged with any valium but instructed on the
warning signs of withdrawal including nausea, tremors, visual
and tactile hallucinations.
# macrocytic anemia - Likely from bone marrow suppression
secondary to chronic alcohol abuse. Nutritionally supported with
a multivitamin with minerals, thiamine, and folate.
# HTN - Atenolol downtitrated to once daily given normotensive
during admission. Would consider switching from atenolol since
beta-blockers aren't recommended as first line therapy in
hypertensive patients without co-morbidities like CAD or atrial
fibrillation. Further, beta-blockers probably aren't helping his
depression.
# depression/axiety - Started on prozac, will follow-up as
outpatient with PCP.
# subclinical hypothyroidism - Elevated TSH with normal free T4.
TSH checked secondary to peripheral edema that pt was
complaining of. Deferred starting any thyroid replacement
therapy.
TRANSITIONAL ISSUES:
* consider transitioning off atenolol to different
anti-hypertensive
* re-assess mood, started on prozac ___
* has subclinical hypothyroidism - can consider anti-TPO
antibodies for further evaluation</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Primary Care Physician: ___ Complaint: abdominal pain, nausea/vomiting
HPI:
___ with a history of HTN, IDDM, ___, and chronic abdominal
pain
of unclear etiology who presents with 1 week of worsening
generalized weakness, dizziness, and abdominal pain. She also
endorses 1 day of N/V and diarrhea. RENAL U.S. showed No hydronephrosis, renal calculi, or renal mass. CHEST (PA AND LAT) showed In comparison with study of ___, the patient has taken a better
inspiration. Cardiac silhouette is at the upper limits of normal and there is
tortuosity of the descending thoracic aorta. No evidence of vascular
congestion, pleural effusion, or acute focal pneumonia.
Clip again projects over the right breast. The patient was diagnosed with Acute kidney failure, unspecified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Summary:
Ms. ___ is an ___ year-old female who presented with 1 week of
worsening abdominal pain, weakness, and was found to have ___
concerning for pre-renal etiology and obstructive etiology. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o T2 parapalegia, restrictive ventilatory defect on 2L
home O2, and multiple recent hospitalizations (including ICU
stay) for recurrent pneumonia/UTIs admitted with dyspnea x1 day.
In usual state of health until waking on morning of admission
with productive cough and low grade temperatures to 99 today,
reportedly found by PCA to be hypoxic to ___ on home 2L O2 and
91% on 3L NC following albuterol treatment. She was due for PCP
appointment on day of admission, but was sent to ED prior to her
appointment due to her symptoms. Of note, patient recently
discharged from ___ 2 weeks ago for COPD
flare and UTI, completed course of levofloxacin and steroids 2
days PTA. Dysuria occasionally, straight caths herself q4hrs.
In the ED, initial VS were: 98.2 76 92/66 24 100% 3L Nasal
Cannula. Exam remarkable for rales in LLL and no ___ edema.
Initial labs remarkable for WBC of 14.8, Hct 29.1, lactate 1.4.
UA with trace leuks and moderate bacteria. CXR showed
persistent right base opacity and possible atelectasis/scarring
in the left lower lung. Due to continued hypoxia, decision was
made to persue CTA to r/o PE. While awaiting study, patient
spiked fever rectally to 101.4, with corresponding tachycardia.
CTA showed new left lower lobe opacities and additional
right-sided perihilar opacities concerning for infection, also
showed previous pulmonary edema greatly resolved. She was given
a total of 4L IVF, tylenol, flu swab, started Tamiflu, and
treated for HCAP with Vanc/cefepime. During her course in the
ED, her blood pressures dropped as low as 85/64.
On arrival to the MICU, afebrile with vitals HR 97, BP 97/66, RR
24, 94% 3L. She reports being fatigued and mildly dyspneic, but
otherwise denies any new pain. Her BP decreased to as low as
60/30 despite additional fluids, and so norepinephrine was
started with good effect. Radiology showed 1. No pulmonary embolism.
2. Slight interval progression of the left lower lobe opacities which may
represent developing infection.
3. Stable chronic collapse of the right lower lobe with associated pleural
effusion. Radiology showed Worsened CHF. An infectious infiltrate, particularly on the right cannot be
exclude. Radiology showed Limited evaluation of the abdomen given significant overlying soft tissue,
however, no distended loops of bowel are seen. No definite evidence of
obstruction. The patient was diagnosed with FEVER, UNSPECIFIED, HYPOXEMIA. The patient was treated with Removal of tunneled line. At the time of discharge, the patient had Primary Diagnosis:
Stenotrophomonas bacteremia
Staph aureus pneumonia
Secondary Diagnosis:
Restrictive lung disease
T2 paraplegia. The patient was given written instructions concerning 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 T2 paraplegia, restrictive ventilatory defect on 2L
home O2, ___, neuromuscular weakness, impaired secretion
clearance, and multiple recent hospitalizations for pneumonia
and UTI requiring pressors in the ICU (___)
presenting with dyspnea.
# SEPTIC SHOCK / STENOTROPHOOMAS BACTEREMIA / PNEUMONIA: She
presented with dyspnea and was found to have an increased
respiratory rate and hypotensive with labs showing leukocytosis.
CXR was concerning for possible LLL pneumonia. Influenza DFA
was negative for influenza. She was started on
vancomycin/cefepime for HCAP (___). Oseltamivir and azithromycin
were also started initially but were discontinued with negative
influenza and legionella testing. Her blood culture grew
Stenotrophomonas and she was started on bactrim. Surveillance
cultures were obtained and are no growth but not finalized at
the time of discharge. Her sputum grew MRSA and she was
initially treated with vancomycin although this was later
stopped as it was sensitive to bactrim. Her indwelling tunneled
line was removed. Her urine grew Klebsiella ESBL although this
was thought to represent colonization as her urinalysis was more
bland. She will complete a 2 week course of bactrim from the
time the line is removed/first negative culture.
.
TOXIC / METABOLIC ENCEPHALOPATHY: She was inattentive and
lacked proper orientation on exam. This was likely due to her
acute medical illness. TSH was within normal limits. Sedating
medications (trazadone, benzodiazepine) were initially held. Her
condition improved and she was felt to be at baseline at the
time of discharge.
.
# POLYSUBSTANCE ABUSE: Urine toxicology screen was positive for
cocaine and methadone. There was some concern in the ICU that
her visitors were supplying her narcotics. She was initially
monitored with a 1:1 sitter and psychiatry as consulted. When
her mental status improved she admitted to taking methadone at
home for her chronic pain. This is not a prescribed medication
and she reported getting it from a friend. She had been
previously prescribed narcotics by her PCP but was in violation
of her narcotics contract so this was stopped in ___. She was
noted to have increased anxiety and abdominal pain during her
hospital stay that could be seen in narcotics withdrawal. We
discussed that she consider a substance abuse treatment program
to wean her off narcotics and so that a better treatment plan
could be developed. Social work met with her to discuss
resources. She was not interested at this time.
.
# CHRONIC NEUROPATHIC PAIN: She has a history of spinal cord
injury and chronic neuropathic pain. She was continued on her
home pain control regimen of gabapentin, baclofen, lidocaine
patch and tylenol. The patient ask her ICU and floor providers
for narcotics. She did not receive narcotics during the
hospitalization as her pain was chronic and there was no plan in
place to continue narcotics as an outpatient. She will follow
up with ___ pain clinic and has an appointment within one week
of discharge.
.
# ANEMIA: She was transfused one unit of blood for anemia and
her hematocrit responded appropriately.
.
#ANXIETY: The clonazepam was initially held due to her toxic
metaboic encephalopathy. This was later restarted as her mental
status improved and up-titrated to her home dose. :
.
CHRONIC ISSUES:
# GI: continued home sucralfate and omeprazole
# Hypothyroidism: continued home levothyroxine
# Code: Full confirmed
# Communication: husband ___ ___, best friend /
PCA ___ ___
.
TRANSITIONAL ISSUES:
-blood cultures are pending but not finalized at discharge </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with a history of type 1
diabetes on 14 units of Tresiba and NovoLog sliding scale, prior
alcohol use disorder, chronic pancreatitis status post
pancreatic
necrosectomy, status post cholecystectomy, neuropathy, recent
colectomy, who presents with abdominal pain. Diagnostic and therapeutic paracentesis. showed 1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 430 cc of fluid were removed and sent for requested analysis. AORTA AND BRANCHES showed 1. Nonvisualization of the ___ and splenic artery, likely due to poor
sonographic penetration in the setting of bowel gas.
2. No evidence of low flow or ischemia within the SMA or celiac arteries. SECOND OPINION CT ABD/PELVIS showed 1. Post right hemicolectomy. A moderate wall thickening throughout the
remnant colon, with mild stranding, remains compatible with colitis.
Correlate with pathology results from recent colectomy. No pneumatosis or
free air.
2. Moderate abdominopelvic ascites has increased since ___.
3. Hepatic steatosis.
4. Extensive calcifications throughout and atrophic pancreas, reflecting
sequela of prior pancreatitis. No CT evidence for active pancreatitis. ABDOMEN US (COMPLETE STUDY) showed 1. Cirrhotic liver, without evidence of focal lesion or splenomegaly.
2. Small to moderate ascites.
3. Patent main, left and right portal veins with appropriate direction of
flow.
4. Mild left hydronephrosis, similar to prior CT. The patient was diagnosed with Noninfective gastroenteritis and colitis, unspecified. The patient was treated with Paracentesis, diagnostic on ___. At the time of discharge, the patient had Acute on chronic abdominal pain
Colitis
Cirrhosis
Type 1 diabetes mellitus
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>Ms. ___ is a ___ woman with a history of type 1
diabetes, prior alcohol use disorder, chronic pancreatitis
status post pancreatic necrosectomy, status post
cholecystectomy, neuropathy, recent colectomy, who presented
with abdominal pain and imaging findings concerning for
recurrent colitis.
# Abdominal pain:
# Colitis, NOS:
# Recent hemicolectomy with wound dehiscence:
# Chronic pancreatitis:
She has had prior colectomy for unclear reasons and presented
with abdominal pain. CT showed signs of recurrent colitis based
on imaging (moderate wall thickening throughout remnant colon
with mild stranding, compatible with colitis). Unlikely to be
ischemic per surgery. Infectious etiology was considered but C
difficile was negative. She had similar presentation in ___
and had extensive work up at that time, including flex sig with
normal biopsy. Hemicolectomy specimen from ___ did not show
IBD. Her CRP and ESR was normal. Doppler US was negative for
significant vascular disease. She was treated supportively with
bowel rest, IVF and IV (then changed to PO) opioids with gradual
improvement. GI was consulted for ___ opinion. They agreed
with assessment above. Once cirrhosis was found on RUQ
ultrasound, congestive colopathy was also considered. GI
recommended supportive care and follow up after discharge.
- PATHOLOGY from ___ colectomy deposited to ___ PATHOLOGY for
___ opinion and future GI follow up
- Pain control with home morphine with stool softeners. She was
given a temporary increase in her morphine dose. She was given
15mg tablets to take with her home 30mg tablets for total 45mg
dose q4 PRN. She will follow up with her pain provider
regarding this.
# Cirrhosis, NOS:
She has a history of fatty liver and alcohol use. She was found
to have cirrhosis based on imaging when suspected based on lower
leg edema and ascites seen post-op with slight elevation in INR.
This could be contributing to finding of "colitis" on imaging.
She underwent para with SAAG >1.1 c/w portal HTN. She was
started on IV Lasix 20mg daily, but had SBP down to ___ that
resolved with IV fluids on ___, so decreased to 20mg oral Lasix
daily on discharge.
- Hepatology follow up arranged
# Hypotension:
SBP 80-90s, asymptomatic, which was suspected to be related to
opioids and possibly tizanidine. She triggered on ___ for
SBP down to ___, again likely medication related and in the
setting of getting IV Lasix 20mg earlier in the day. She was
symptomatic with lightheadedness. Her tizanidine was HELD and
she was given 1L IVF with improvement in SBP to 130s. Her MS
___ was decreased back to daily. Lasix was changed to PO
20mg daily on discharge and I personally discussed with her that
if she feels lightheaded again, to drink fluids and talk with
her doctor about whether or not she should remain on Lasix.
# Qtc prolongation: QTC was prolonged to 466ms and down to 399ms
on ___.
# Hypokalemia: K was 3.1 on admission and resolved and was
self-limited. K was 4.9 on discharge, but should recheck as
outpatient since on Lasix now.
# Reflexive sympathetic dystrophy (RSD) - medications confirmed
in ___. Continued home MS ___ 30mg daily plus the PRN
Morphine ___ increase to 45mg Q4H for pain. Held home tizanidine
as above. Continued home dicyclomine, pregabalin, desipramine.
# Type I diabetes - He is on 14 units Tresiba with novolog
sliding scale at home. She has been hypoglycemic related to
poor PO intake and was relatively hypoglycemic here. Long
acting insulin decreased to 7 units QHS plus home sliding scale
on discharge.
# Chronic pancreatitis: Creon with food
# Tobacco use: She was given and prescribed daily nicotine
patch.
# Left eyelid stye: She has a small stye on lower left eyelid
that she says has been present for several days and she has been
using warm compresses. She said she has an allergy to
erythromycin and has gotten steroid treatment in the past.
Recommended that she continue with supportive care with
compresses and if persistent by mid-week when she sees her PCP,
can consider whether to use steroids.
=============================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with Afib on Coumadin, HTN, DM, presenting with
lightheadedness and cough. The patient reports his symptoms
began 2 weeks ago with a cough productive of yellow sputum. He
was seen at his primary care physician's office last week and
had a CXR that was reportedly negative. He was diagnosed with
bronchitis and given an inhaler. He notes wheezing, lethargy,
and fatigue over the past 5 days and his cough evolved to a
non-productive cough. He also reports decreased po intake
including po hydration, and had felt lightheaded on exertion for
the past several days. The day of presentation, he was climbing
a flight of stairs and developed weakness and lightheadedness,
and was lowered to the ground by his family. He denies loss of
consciousness and did not feel himself for several minutes. He
also notes feeling warm so took his temperature today which was
102. He denies nausea, vomiting, abdominal pain, myalgias,
arthralgias, rhinorrhea, sore throat, headache, sinus pain,
rash, dysuria. Denies chest pain, palpitations, PND, orthopnea,
or shortness of breath. Of note, the patient was seen in primary
care clinic twice in the past month and was also on Doxycycline
for rosacea for the past 4 weeks.
.
In the ED, initial VS were: 96.8 88 99/52 20 98% 2L nc
EKG showed AF at 71bpm without acute ST segment changes. CXR
showed evidence of R sided pneumonia. Blood pressures were in
the mid 80's transiently which resolved with 2L NS with blood
pressures subsequently in the 90___s. A third bag of normal
saline was hung, and he was given Levofloxacin, and Tylenol in
the ED. CXR was obtained and blood cultures were sent. He was
admitted to the MICU for further evaluation. Radiology showed Findings consistent with multifocal pneumonia. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had Primary diagnosis: Pneumonia
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>___ with Afib on Coumadin, HTN, DM, admitted with multifocal
pnemonia and dehydration.
Brief course: He was treated with levofloxacin and improved. His
transient hypotension responded to fluids and was felt secondary
to dehydration.
Active issues:
#Pneumonia, multifocal: Patient was started on levofloxacin and
since patient was hypotensive during ED evaluation he was
admitted to the ICU. His blood pressure responded to IV fluids,
no pressors/intubation required. ICU course unremarkable and
patient was transferred to the floor. Levofloxacin was continued
and patient is to complete a 5 day course. Patient was sating
well on room air while at rest and ambulating and was
discharged. Recommended repeat chest x-ray in ___ weeks to
confirm resolution and ensure no underlying lung disorders in
this heavy smoker.
# Diabetes: Metformin was continued. As fasting blood sugars
were elevated to >200 patient was placed on standing 2 units of
insulin with meals and placed on an ISS.
#. Hypertension: The patient has a history of hypertension, but
in the setting of dehydration and hypovolemia his
anti-hypertensives were held overnight. Once stable, medications
Lisinopril, Labetalol, and Diltiazem were restarted.
# Acute kidney injury: pre-renal in setting of hypotension,
resolved with fluids.
#. Atrial Fibrillation: On coumadin with therapeutic INR. Held
coumadin on discharge due to supratherapeutic INR of 3.1 likely
due to interaction with levofloxacin. INR should be monitored
closely. Labetalol was continued and diltaizem restarted on
discharge.
#. Hyperlipidemia: Pravastatin was continued per outpatient
regimen.
# Thrombocytopenia: stable mildly low platelet count which
patient says is chronic.
# Elevated BNP: up to 1125, possibly due to atrial fibrillation;
no known heart failure and reported good exercise tolerance.</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 hx of DM, Hyperlipidemia,
Depression presented to OSH for evaluation complaining of
headaches over the past few months. Patient and family also
report over the last month patient has c/o nausea and vomiting
and ataxia resulting in falls. Patient himself minimizes his
symptoms and only presented to the ED today the urgent request
of his wife and daughter. At ___ patient underwent a
___ which reveals a large right sided brain mass with 4mm of
MLS. Patient was loaded with keppra and transferred to ___ for
further managment. Upon examination patient reports intermittent
headaches, nausea/vomiting, feeling uncoordinating. He denies
blurry vision, double vision, numbness, tingling or weakness. MR HEAD W AND W/O CONTRAST showed Peripherally enhancing mass centered in the right temporal lobe with
significant vasogenic edema as detailed above, most concerning for a primary
glial neoplasm, less likely metastatic disease. Given central restricted
diffusion, abscess is not excluded although considered less likely given solid
nodular enhancement of this lesion. Radiology showed No acute cardiopulmonary abnormality. CT ABD AND PELVIS WITH CONTRAST showed 1. No evidence of metastatic disease within the abdomen or pelvis.
2. Cholelithiasis without evidence of acute cholecystitis.
3. There is a 1 cm simple hepatic cyst within segment 7
4. Please refer to separate CT chest for additional details. Radiology showed 1. Nonspecific pulmonary nodules, suggest followup CT in 6 months.
2. Otherwise normal CT chest. MR HEAD W/ CONTRAST showed 1. Stable heterogeneously and peripherally enhancing 3.6 cm right temporal
lobe mass with surrounding edema.
2. Stable leftward midline shift and mild right uncal herniation. MR HEAD W AND W/O CONTRAST showed 1. Curvilinear enhancement along the anterior and medial aspects of the right
temporal surgical bed, with associated slow diffusion. This could represent
residual tumor versus intra-operative contusion. Recommend close follow up.
2. Persistent extensive vasogenic edema in the right cerebral hemisphere with
stable mild leftward shift of supratentorial midline structures. However,
right uncal herniation and mass effect on the midbrain have improved. CT HEAD W/O CONTRAST showed 1. Postoperative changes related to patient's interval right parietotemporal
brain tumor resection.
2. Stable degree of uncal herniation and 2 mm leftward midline shift.
3. Grossly stable right temporal and parietal edema.
4. New small nonspecific right mastoid fluid. The patient was diagnosed with SWELLING IN HEAD & NECK. The patient was treated with ___ right temporal craniotomy for tumor resection. At the time of discharge, the patient had Brain tumor. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to ___ on ___ after CT Head
demonstrated a large right-sided brain mass with surrounding
cerebral edema and 4mm midline shift. He was monitored overnight
in the ICU without significant events. He was started on Keppra
and Decadron. His neurologic exam remained stable. MRI was
obtained to further assess the lesion. He was transferred to the
inpatient floor with surgery planned for ___.
On ___, the patient was neurologically stable. A CT torso was
ordered which showed small pulmonary nodules, but no evidence of
malignancy.
On ___, the patient remained neurologically stable and
underwent routine pre-operative planning for surgery.
On ___, Mr. ___ was taken to the operating room for a right
temporal craniotomy for tumor resection. The surgery was
uncomplicated. He was taken to the PACU post operatively where
he was monitored. His post operative NCHCT showed expected post
operative changes. He was agitated post-operatively and his
blood pressure was difficult to control. A narcardipine drip was
started.
On ___, the patient remained neurologically stable. He was
started on lisinopril 5mg daily, and his blood pressure control
improved. The patient was transferred to the floor.
Post-operative MRI was completed and showed some enhancement in
the anteromedial surgical bed, likely residual tumor versus
intraoperative contusion, along with persistent vasogenic edema
in the right cerebral hemisphere.
On ___, the patient remained neurologically stable. He was
evaluated by physical therapy and occupational therapy, who
cleared him for discharge home without services. His dressing
was removed and his incision was noted to be clean/dry/intact
without erythema or discharge. At the time of discharge, the
patient was tolerating regular diet, voiding and moving his
bowels independently, and ambulating without difficulty. A
thorough discussion was had with the patient and his family
regarding post-discharge instructions and appropriate follow-up.
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 ___ y/o patient with a medical history significant
hypertension who presented at the ED for chest pain. PA and lateral chest x-ray. showed No acute cardiopulmonary process. The patient was diagnosed with CHEST PAIN NOS, RESPIRATORY ABNORM NEC, HYPERTENSION NOS. The patient was treated with Left heart catheterization. At the time of discharge, the patient had #chest pain
#microvascular CAD
#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 ___ y/o patient with a medical history significant
for hypertension who presented at the ED for chest pain and
dyspnea in the setting of shoveling snow and was found to have
neg troponin x2 with anterolateral TWI on EKG (unchanged from
prior EKG). He was admitted for concern of unstable angina.
.
#CHEST PAIN / POSSIBLE UNSTABLE ANGINA: Patient presented for
gradual onset substernal chest pain associated with dyspnea in
the setting of shoveling snow. His troponin was neg x 2 and his
EKG showed anterolateral TWI, similar to prior EKG from ___.
His CXR in the ED was unremarkable. He received 3 sublingual
nitroglycerin and 325 mg aspirin, which improved his pain. As
EKG showed signs of LVH and TWI were present in prior EKG, TWI
are more likely due to LVH than acute ischemic changes. On the
floor, his chest pain and dyspnea resolved without futher
nitroglycerin. He was monitored on telemetry. Patient underwent
catheterization on ___, which showed no flow-limiting CAD,
but diffuse artherosclerosis with tortuous vessels suggestive of
hyertensive heart disease. It also showed diffuse very slow flow
consistent with microvascular dysfunction and normal LV
diastolic function. Plan to continue aspirin 81 mg, atorvastatin
80 mg, lisinopril 20 mg, amlodipine 10 mg and isosorbide
mononitrate (Extended Release) 30 mg po dialy. Tox screen for hx
of cocaine abuse was negative. A differential diagnosis is
cold/stress- induced asthma, as patient noticed some wheezing.
We recommend outpatient PFTs.
.
#HYPERTENSION:Patient has a history of hypertension.
He was continued on his home medication: amlodipine 10 mg daily
and lisinopril 20 mg daily.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ ___ speaking male with past medical history of
vascular vs Alzheimer dementia presents with abdominal pain and
weakness. On ___, the patient began having abdominal pain,
with 4 episodes of nonbloody vomiting. On ___, per ED the
patient reported dysuria with possible hematuria. During this
time, the patient's abdominal pain has persisted, but + fever to
100, headache, body aches, and urinary frequency. The patient
then refused to eat out of fear of emesis. The patient's last
bowel movement was today, which was normal. The patient's
symptoms described above were preceded by approximately 2 weeks
of abdominal distention which was new for him. Patient denies
chest pain, shortness of breath, hematemesis, hematochezia. He
then went to see his PCP's coverage who referred him to the ED.
.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [X] All normal
GI: As per HPI
GU: [+] Per HPI
SKIN: [X] All normal
MUSCULOSKELETAL: [X] All normal
NEURO: [+] H/o dementia with worsening short term memory over
the past ___ years
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
. CHEST (AP AND LAT) showed No acute intrathoracic process. CT HEAD W/O CONTRAST showed 1. No acute intracranial process.
2. Minimal fluid within the left mastoid air cells, correlate with any
symptoms of mastoiditis. CT abdomen and pelvis showed 1. Findings consistent with acute pancreatitis. No fluid collection or
evidence of necrosis.
2. No bowel obstruction or free air. MRCP showed 1. Examination limited by use of non-breath-hold techniques.
2. Interstitial edematous pancreatitis. No necrosis. No choledocholithiasis
or other underlying cause is identified. No drainable fluid collections. No
pseudoaneurysm or venous thrombosis.
3. 10 mm cystic lesion in the pancreatic head most in keeping with a
side-branch IPMN. Per departmental guidelines, no dedicated follow-up
required.
4. Mild hepatic steatosis. The patient was diagnosed with Acute pancreatitis, unspecified. At the time of discharge, the patient had Acute pancreatitis
Dementia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient is an ___ year old ___ speaking male with h/o
dementia p/w acute interstitial pancreatitis.
.
ACUTE PANCREATITIS
- BISAP score = ___ with 1 point for age > ___, 1 point for SIRS
criteria (HR > 90 and WBC > 12K) ? altered mental status,
difficult to ascertain if pt is more confused than baseline
given language barrier. ___ nl, imaging without
choledocholithiasis, and no alcohol use. Namenda considered as
cause but felt unlikely. He improved with NPO, IVF. MRCP
performed showing no stones, PIMN incidentally, and interstitial
pancreatitis. He was ultimately discharged home after 48hrs of
improvement.
- We recommended GI referral and follow up MRCP vs EUS once his
inflammation subsides to evaluate for underlying process such as
malignancy. This was explained in detail to the patient's
daughter, and she expressed understanding of this.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F hx CHF, T2DM, obesity p/w nausea and melana x 2 weeks.
Starting 1.5 weeks ago she reports nausea and decrease in
appetite. 7 days PTA (___) she reports an episode of coffee
ground emesis without frank blood. In addition, around this time
she had melenotic stools x1 without BRBPR which was seen by the
staff at her nursing home (as she uses a bedpan and does not see
her own stool.) Radiology showed Calf veins not clearly visualized due to body habitus.
Otherwise, no evidence of DVT. Radiology showed 1. Circumferential mass involving the gastric wall in the mid body and antrum
region infiltration of the left lobe of the liver, concerning for
adenocarcinoma, less likely GIST.
2. Intermediate density renal lesion for which renal ultrasound can be
obtained for better characterization.
3. Atherosclerotic disease of the aorta.
4. Small left pleural effusion with overlying atelectasis. Radiology showed 1. Left upper and lower lobe atelectasis with small left pleural effusion.
2. Pulmonary nodules without specific features of metastasis measuring up to 6
mm for which continued surveillance should be performed in three months due to
history of malignancy The patient was diagnosed with GASTROINTEST HEMORR NOS, DIGESTIVE NEOPLASM NOS, NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED SITES. The patient was treated with Endoscopic ultrasound. At the time of discharge, the patient had Gastro-intestinal bleed secondary to gastric tumor. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with h/o with history of CHF, T2DM, morbid obesity, who
presents with GI bleed likely from newly diagnosed gastric
cancer.
# GIB: The patient was found to have hematocrit of 31.1 on
admission. With some fluctuations, her crit remained generally
stable, though downtrending, for the duration of her
hospitalization. She was discharged with a crit of 25.9. She did
not require any transfusions. Of note, she had recently
received transfusion prior to this hospitalization. She had 2
small episodes of coffee-ground emesis during hospitalization
and 2 brown/black bowel movements. An abdominal CT showed a
large mass in the lesser curvature of the stomach with invasion
into the liver (see below). The GIB was thought secondary to
this. She was started on an IV PPI and transitioned to PO
pantoprazole 40mg BID. The patient was initially kept NPO, but
on HD4 she was transitioned to PO diet, which she generally
tolerated well, though did endorse nausea that was controlled
with Zofran and Ativan. Multiple teams were consulted including
GI, Surgery, Surgical Oncology, Oncology, and Radiation
Oncology. The patient remained hemodynamicall stable throughout
this admission, though she did have one episode of afib with RVR
(please see below).
Given her GI bleeding, subcutaneous heparin was held during this
admission, and the patient was maintained on Pneumaboots. The
patient should continue to wear Pneumaboots while at ___.
# gastric cancer: As mentioned above, the patient was found to
have large stomach mass. Outside lab pathology from ___
___ showed poorly differentiated gastric adenocarcinoma
with signet ring features. An endoscopic ultrasound was done
which confirmed surgery's initial opinion that the cancer was
stage 3B non-operable, as per surgical oncology. After
conferring with the various teams, the patient, and the
patient's family, it was decided that she would follow up with
outpatient oncology upon discharge.
She has an appointment with Dr. ___, MD on
___ at 4:00pm, at the ___. Coordination of outpatient
oncological follow-up, plan for treatment, and further steps
will commence from there under the direction of Dr. ___.
Radiation oncology also saw the patient while in house and
thought it best to defer radiation therapy at the time given the
patient's co-morbidities. A possibility for palliative
radiation was discussed. If palliative radiation is deemed to be
helpful in the future, it may be logistically more feasible at
___ Oncology (___) in ___,
which Ms. ___ says is much closer to her living facility in
___.
# New Afib: Newly diagnosed during admission to ___
5 days prior to this admission. Metoprolol was started at that
time, which was held initially given her GI bleed. On HD 4 the
patient resumed a normal diet and in the midst of this became
tachycardic to the 180s and was given metoprolol. Her
metoprolol was then resumed at a higher dose, 37.5mg BID, for
rate control. Anticoagulation was held in the acute setting of
her GIB. On discharge, she was adivsed to use pneumatic
compression boots as DVT ppx since bleeding will be an ongoing
issue for her given her large tumor burden.
# CHF: Recent echo from ___ at ___ showed EF 50%, with mild LVH
and low normal systolic function. She did not have any CHF
symptoms during this hospitalization. Patient did not appear
fluid overloaded and was stable. Furosemide was initially held
but later restarted at her home dose 60mg PO QD.
# Proteus UTI: The patient complained of some dysuria which
resolved with treatment with pyridium. A Urine culture showed
pan-sensitive proteus. She was given a 3 day coure of Bactrim
which she finished with the resolution of symptoms.
# OSA: The patient uses 2L NC at home while sleeping at her
baseline. She was continued on this while in patient. She had
been on Bipap in the past, but did not tolerate it well. By
hospital day ___ or ___, she was noted to require an additional
liter of oxygen, with good saturations on 3 L. He bicarbonate
was also noted to be trending up at this time. She never
complained of any repsiratory distress. This was attributed to
obesity hypoventilation syndrome. A suggestion was made that
she should reconsider trying BiPAP, which per patient, had been
tried before but was poorly tolerated by her.
# DM II: The patient was initially placed on an insulin sliding
scale. Her sugars remained in good control. Nutrition was
consutled who recommended small frequent meals with a protien
source at each meal, and glucerna supplements TID. Her home
doses of 75/25 were held, as her diet was initially minimal.
However, upon discharge, her home dose of insulin can be
restarted and titrated as needed.
# Hypothyroidism: The patient was continued on her home
levothyroxine. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt was at ___, reported age felt like she was going to
have a seizure, into status. Pt received 2 mg IM Ativan without
break in seizure. Once IV access obtained, pt received 4mg IV
versed without break in seizure. Pt seizing on arrival to ED. No
oral trauma noted. No incontinence. Additional IV ascess
obtained. Pt received 2mg IV Ativan at 0918 and 100mg IV
propofol by MD ___ at 0920 followed by 60mg IV rocironium.
Patient was intubated in the ED. Admitted to the neuro ICU with
cvEEG. CHEST (PORTABLE AP) showed Appropriately positioned ET tube. CT HEAD W/O CONTRAST showed 1. No acute intracranial process.
2. Mild mucosal thickening throughout the paranasal sinuses, suggestive of
paranasal sinus disease. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. No large vessel intracranial or extracranial injury or aneurysm within the
head or neck.
2. No evidence of large vascular territory infarct or hemorrhage.
3. 1.9 cm heterogeneously enhancing lesion in the left thyroid lobe. If not
previously characterized, ultrasound is recommended for further evaluation.
RECOMMENDATION(S): Thyroid nodule. Ultrasound follow up recommended.
___ College of Radiology guidelines recommend further evaluation for
incidental thyroid nodules of 1.0 cm or larger in patients under age ___ or 1.5
cm in patients age ___ or older, or with suspicious findings.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150. Radiology showed Lungs are low volume with bibasilar atelectasis. Support lines and tubes are
in acceptable position. There is a trace left pleural effusion. No
pneumothorax is seen. There is bibasilar atelectasis. MR HEAD W AND W/O CONTRAST T9112 MR HEAD showed 1. No infarct or mass is identified. Radiology showed Enteric tube is looped within the stomach with tip directed toward the
diaphragm in the fundus. Otherwise, normal abdominal radiograph. The patient was diagnosed with Fever, unspecified. The patient was treated with Endotracheal intubation. At the time of discharge, the patient had Non epileptic events. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo female with history of PNES initially presenting with
generalized shaking, unresponsiveness, given multiple AEDs and
eventually intubated and transferred to the ICU. Multiple events
in the ICU without EEG correlate, consistent with PNES.
Neurologic examination unremarkable. Work-up also included
normal imaging (head CT, head and neck CTA, MRI brain) and bland
LP. Collateral confirmed that patient has history of PNES. AEDs
and empiric antibiotics were discontinued prior to transfer to
floor. Psychiatry consulted and recommended follow-up as planned
with Dr. ___ at ___ for PNES. Discharged on her home meds
which include: clonazepam and fluvoxamine.
Transitional Issues:
#Anemia: Patient noted to have microcytic anemia (hgb 6.3);
transfused with 1U pRBCs on ___. Discharge hgb 7.4. Labs not
consistent with hemolysis (normal LDH, bilirubin, haptoglobin).
Reticulocyte count 1%. TIBC 325, iron 15, ferritin 21. Could be
consistent with iron deficiency anemia, follow-up as
out-patient.
#Thyroid nodule: Noted incidentally on CT chest, recommend
follow-up thyroid ultrasound as an outpatient.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Difficult historian in that inconsistent / vague with many
answers. Radiology showed Nonobstructive bowel gas pattern. Moderate amount of stool in the colon. CT ABD AND PELVIS WITH CONTRAST showed 1. Wall thickening and edema affecting the distal descending and proximal
sigmoid, with minimal adjacent fat stranding, if any. In the setting of lower
abdominal pain and prior colitis, findings again are concerning for mild
descending colitis. No free intraperitoneal air detected.
2. Fibroid uterus is unchanged.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 02:06 on ___, 5 min after discovery. MRI of the pelvis, noncontrast examination. showed 1. Focal area of increased STIR signal within the left pubic symphysis and
subtle T1 signal irregularity. Although non-specific, given the history of
trauma, this is likely secondary to a bone contusion or, less likely, a non
-displaced fracture. No discrete fracture line or displaced fracture fragment
detected and there is no evidence of fracture in this location on the ___ CT scan.
2. Increased edema within the left pectineus and external obturator muscles,
may be secondary to muscle strain or contusion. There is adductor tendinosis,
but no abductor tendon tear is detected.
3. Increased edema surrounding the lower rectus abdominis muscle, may also
reflect muscle strain.
4. No marrow edema seen in the bones about the pelvic girdle or in the
visualized portion of the proximal femora to suggest other sites of bone
contusion or fracture. In particular, the sacrum and pubic rami are otherwise
within normal limits for age.
5. Prominent bilateral internal iliac lymph nodes, minimally increased
compared to prior exams dated back to ___. However, these are not
frankly enlarged by short axis criteria.
s The patient was diagnosed with Unspecified abdominal pain. At the time of discharge, the patient had Pubic symphysis fracture or osteitis pubis. The patient was given written instructions concerning 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 recurrent "colitis". In reviewing prior episodes has
had nml EGD/colonoscopy. In terms of etiology thought initially
maybe ischemic colitis or infectious. On most recent
hospitalizations had no diarrhea, bloody stools and thought
secondary to severe constipation. Has been treated aggressively
with anti-constipation meds in interim.
In terms of what brings her in today. I'm struck by the location
of her pain which is on the pubic symphsis and left inguinal
crease. Though she is not great in terms of history she says
this has never happened. I wonder if she had an occult pelvic
ring fx that is causing her pain. Her CT did not show anything,
but MRI shows "Focal edema in the left pubic symphysis, with
faint T1 linear defect. No displaced fractures. ___ represent
bone contusion or focal, tiny nondisplaced fracture. There is
edema in the adjacent left pectineus and external obturator
muscle with intermuscular edema." In speaking with orthopedics
they looked at films and this also could be osteitis pubis or
small fracture. In either case, conservative management will be
necessary. Follow-up is not critical, but follow-up with ortho
sports as they typically manage this issue. Unfortunately could
take some time to improve.
Had a long chat with her and her son that this could take
several weeks to months to improve. She is pain free when lying
or sitting, but certain movements cause severe pain.
Regarding her colitis, she does have constipation on KUB, but
her RLQ pain and constipation symptoms resolved without any
intervention. The CT scan findings are unchanged. she feels that
she has a good regimen in terms of addressing constipation and I
encouraged her to be a bit more aggressive based on KUB finding.
I think follow-up with GI as scheduled seems reasonable.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: with HIV and nephrolithiasis s/p stent placement 2 weeks ago and
stone treatment(unknown whether ESWL or laser litho) 2 days ago
who presents with fever and L flank pain. Urology consulted in
ED when patient began having rigors. Denies SOB or CP. Radiology showed Left pyelonephritis with interpolar phlegmon or early abscess.
These findings were discussed with Dr. ___ by Dr. ___ by telephone
at 3:30 a.m. on ___. Radiology showed Uncomplicated sonographic and fluoroscopic-guided placement of
and 8 ___ left percutaneous nephrostomy catheter with its retention pigtail
loop in the left renal pelvis. It was connected to an external bag. Dyspnea in a patient with HIV.
Portable AP chest radiograph was compared to ___.
Since the prior study, there is interval development of bilateral perihilar
opacities with interstitial nature, with perihilar and basal predominance,
with evidence of Kerley B lines. There is also interval development of new
small bilateral pleural effusion including the fissural fluid.
Heart size and mediastinum are unchanged including mild cardiomegaly. Note is
made of the prominence of the azygos vein, new. Overall, described findings
are most likely consistent with interval development of pulmonary edema.
Pneumonia is less likely but cannot be excluded. Evaluation of the patient
after diuresis to exclude the possibility of underlying infectious process,
for example such as pneumocystis pneumonia is recommended. was done. Radiology showed 1. Left pyelonephritis with heterogenous area of perfusion extending from the
interpolar region to the lower pole increased in size from the prior
examination is concerning for phlegmon, however unclear how much of this
related to intervention/ nephrostomy. Increased perinephric stranding.
2. Left uereteral stent in place. Small calculus adjacent to ureteral stent in
mid portion of the ureter. Nephrostomy tube placed in interval.
3. Vicarious secretion of contrast in the gallbladder.
4. Bilateral pleural effusions, right > left, with adjacent atelectasis. The patient was diagnosed with CALCULUS OF KIDNEY, HYDRONEPHPHROSIS, LEUKOCYTOSIS, UNSPECIFIED . The patient was treated with ___: LEFT PERCUTANEOUS NEPHROSTOMY TUBE PLACEMENT. At the time of discharge, the patient had Gram negative bacteremia, nephrolithiasis, hydronephrosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was admitted to the Urology service from the ED with
fevers to 102oF. On HD 2 the patient had a L percutaneous
nephrostomy tube placed for mild hydro nephrosis on CT scan and
concern for infected collection within his renal pelvis. We
consulted ID who recommended ceftriaxone, after his blood
culture and urine culture grew out E. coli. He continued to
spike fevers to 102 and on HD6 we obtained a CT scan that showed
no discernible collection that could be drained from his kidney,
but continued evidence of pyelonephritis. On HD6 the patient
did not spike any fevers and was feeling well. We had a PICC
line placed and ID recommend the patient continue 1gm of
ceftriaxone until ___. The patient was discharged home on
HD7 with a L PCN and a PICC line with follow-up with Dr.
___ infectious disease. On his day of discharge he was
tolerateing a regular diet, ambulating without assistance, and
his pain was well-controlled. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old man with a PMH of multiple myeloma on
Daratumumab/Pamolidomide, pAF on apixaban, HTN, HLD, severe MR,
AAA s/p repair, and CVA who presents with weakness starting this
morning which has since resolved. CHEST (PA AND LAT) showed Interval improvement in right lower lobe atelectasis. No evidence of
pneumonia. SKELETAL SURVEY (INCLUD LONG BONES) showed 1. Known multiple myeloma with innumerable osseous lesions.
2. Multiple thoracic and lumbar compression deformities, not significantly
changed since ___.
3. No acute fractures identified.
4. MR ___ AND W/O CONTRAST ___ MR SPINE showed 1. Severe artifact from the aorto bi-iliac endograft limits evaluation of the
vertebral bodies, particularly affecting the lower lumbar spine.
2. Severe compression deformities throughout the spine from T10 through L5, as
above, overall minimally changed from previous examination.
3. Multilevel degenerative changes of the cervical lumbar spine are also
similar to the prior examination.
4. Osseous retropulsion at the level of T12 results in moderate canal
stenosis, unchanged.
5. No evidence for abnormal enhancement within the canal itself.
6. Extensive infiltrative osseous disease compatible the patient's known
multiple myeloma appears progressed compared to the prior exam. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No evidence of an acute intracranial abnormality. Specifically, no
evidence of normal pressure hydrocephalus.
2. Extensive lucent osseous lesions compatible with patient's known multiple
myeloma. Radiology showed No acute intrathoracic abnormality. No significant interval change since the
chest radiograph of ___. CHEST (PORTABLE AP) showed Compared to chest radiographs of ___ through ___.
Lungs are clear. No pleural abnormality. Heart size top-normal.
Multiple lytic bone lesions reflect multiple myeloma. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. DX CHEST PORTABLE PICC LINE PLACEMENT showed Compared to chest radiographs since ___, most recently ___.
Slight interval increase in mild cardiomegaly, pulmonary and mediastinal
vascular engorgement and right pleural effusion all point to acute cardiac
decompensation. Atelectasis right lung base is slightly more pronounced.
New right PIC line can be traced in the right atrium as far as the diaphragm.
Conventional radiographs are recommended for better definition of the
catheter. CHEST (PA AND LAT) showed 1. Right-sided PICC line with tip ending at the cavoatrial junction. No
pneumothorax is seen.
2. Stable appearance of mild pulmonary vascular congestion with small right
pleural effusion and right basilar atelectasis.
3. Re-demonstration of multiple lytic bone lesions compatible with patient's
known history of multiple myeloma, as well as redemonstration of severe
compression deformities involving the lower thoracic spine. The patient was diagnosed with Weakness. The patient was treated with PICC placement ___
TEE ___. At the time of discharge, the patient had Strep viridans bacteremia
hematuria
bright red bleeding per rectum
multiple myeloma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>==================
SUMMARY STATEMENT
==================
Mr. ___ is an ___ year old man with a past medical history of
multiple myeloma s/p 40 cycles of daratumumab, pomalidomide,
dexamethasone, pAF on apixaban, HTN, HLD, severe MR, AAA s/p
repair, and CVA who presented with weakness and one presyncopal
episode, with no clear etiology discovered. He was briefly
admitted to the ICU for sepsis, found to have Strep viridans
bacteremia, treated with ceftriaxone. His course was complicated
by urinary retention and new hematuria as well as intermittent
bright red blood per rectum.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o metastatic laryngeal CA p/w epigastric abdominal pain.
___ at worst, worsened after recent d/c ___. Starts in
epigastrum radiates to over upper abdomen. Poor PO intake with
associated n/v. Denies cp/dyspnea/cough. Of note recently
admitted for laryngeal edema, treated supportively on OMED
service.
.
BIBA today to ___ where he was found to have stable vital
signs. CT Abd/Pelvis showed pancreatic mets obstructing
pancreatic duct, pancreatitis. Lipase 1522. Since admission his
VSS, his pain is improved w/ morphine, and he has been NPO.
Admitted to ___.
.
ROS: Pt currently denying n/v or abdominal pain. ROS otherwise
negative. Radiology showed Progression of metastatic disease in the abddomen as detailed
above. Large pancreatic metastatic mass with secondary pancreatitis. Radiology showed No acute intrathoracic process. Please refer to same day CT abdomen pelvis
for further details. Radiology showed 1. Known metastatic laryngeal cancer with numerous intra-abdominal visceral,
nodal, omental, and body wall metastasis, similar to ___, but allowing
for differences in technique have progressed since ___.
2. Numerous pancreatic metastasis, with a dominant lesion in the pancreatic
neck/proximal body causing ductal obstruction with mild upstream dilatation.
Changes of acute interstitial pancreatitis involving the distal body and tail
with a small peripancreatic fluid collection.
3. Mild interval increase in the perihepatic ascites since ___. Radiology showed No osseous destructive lesions of the ribs. A bone scan may be
performed if there is continued clinical concern for osseous metastasis. The patient was diagnosed with ACUTE PANCREATITIS, HX-LARYNGEAL MALIGNANCY. The patient was treated with ERCP with stent placement ___. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
Pancreatitis secondary to pancreatic tail mass
SECONDARY DIAGNOSIS:
Small cell laryngeal cancer with diffuse metastases
Hypokalemia from cesium toxicity. The patient was given written instructions concerning 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/ hx of metastatic small cell
neuroendocrine laryngeal cancer on carboplatin/taxol and recent
radiation therapy who presents with pancreatitis secondary to
pancreatic tail metastasis and intraabdominal progression of
known cancer.
# Pancreatitis: Mild (BISAP 0). Seen on CT abdomen on admission
and MRCP ___. This was thought to be secondary to pancreatic
duct obstruction from new pancreatic metastasis. He had clinical
improvement of his abdominal pain and nausea after the first few
days of IVF and bowel rest, however, due to ongoing pain and
nausea ERCP was consulted and they placed a stent in the
pancreatic duct at a 15 mm stricture seen at the neck of the
pancreas. There was mild post obstructive dilation and a 7cm by
___ pancreatic stent was placed successfully traversing the
obstruction to see if he will have symptomatic improvement. He
recovered from the procedure with brief bump in his LFTs that
then resolved. He was able to tolerate PO intake without emesis
by discharge. ERCP recommended repeat ERCP in 6 weeks.
# Hypokalemia/qtc prolongation: Patient presented with history
of taking significant potassium supplementation PTA. He had been
taking cesium chloride
as an over the counter anticancer treatment, which was suspected
to have caused a tubulopathy associated with impaired potassium
channel function. His QTc was not prolonged on admission, but he
was initially monitored for QTc prolongation given hypokalemia
and significant repletion needs. He was initially requiring
80-120 mEq of potassium to maintain K in a range of 3.0-3.7 and
in spite of adequate magnesium repletion. Serum ___ were
normal. He had sequential 24 hour urine collections to assess
kaliuresis, which seemed to improve when he was hypovolemic and
sodium avid. Send out tests for cesium showed significantly
elevated levels consistent with the original hypothesis. With
nephrology consultation he was started on amiloride 20mg BID and
his kaliuresis improved, eventually requiring no potassium
repletion in the 24 hrs prior to discharge, deriving everything
from his diet. He had outpatient follow up for this with lab
checks.
# Metastatic laryngeal neuroendocrine cancer: Metastatic small
cell neuroendocrine
laryngeal cancer. Dx ___. Has involvement of hilar,
mediastinal, cervical LNs, adrenals, likely liver, spleen,
abdominal wall, and now pancreas, all with interval enlargement
on imaging relative to ___. C2 of carboplatin/taxol at ___
and tx ___ of radiation therapy at ___ (on hold for
laryngeal edema). He was seen by palliative care. He will
followup with his outpatient oncologist for the consideration of
alternative chemotherapy regimens, including clinical trials,
versus hospice.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year-old-male who presented with sudden-onset severe
epigastric burning with
nausea and vomiting this morning, similar to symptoms on
___ morning when he was admitted to the ___ surgery
service for H. pylori gastritis and treated with antibiotics and
pantoprazole. He was discharged home on ___ and was
feeling well, tolerating regular diet. The morning of
presenting to the ED, he drank coffee, and thereafter
experienced epigastric "burning", and vomited the coffee. He
denied fever, chills, diarrhea, chest pain, SOB, and
other symptoms. Radiology showed 1. Cholelithiasis with possible very trace pericholecystic fluid. No
sonographic ___ signs, although the patient is medicated. Findings are not
specific for acute cholecystitis, but this cannot be excluded based on this
study.
2. Echogenic liver consistent with fatty infiltration. Other forms of liver
disease and more advanced liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study. The patient was diagnosed with CHOLELITHIASIS NOS. At the time of discharge, the patient had Epigastric abdominal pain, gallstones (with no evidence of
cholecystitis). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the General Surgical Service for
evaluation and treatment of his epigastric pain and vomiting on
___.
Upon arrival, a full set of laboratory studies was obtained, as
well a Right Upper Quadrant Ultrasound (reader referred to
'Pertinent Results' section for details). Of note, the h. pylori
serologies that were drawn on his previous admission were
positive. Thereafter, he was admitted to the general surgical
floor, where he was NPO, on IV fluids, and IV unasyn. His liver
enzymes were mildly elevated, but his abdominal pain resolved
throughout the day, and he had no pain in the RUQ even with deep
palpation. His vital signs were routinely monitored and he
remained afebrile and hemodynamically stable throughout his
stay. The patient was seen by the attending surgeon Dr.
___ discussed with the patient and his family the
options for further management. Because the patient's
pain/nausea/vomiting resolved and he had no evidence of acute
inflammation or infection, the patient was given the decision to
stay overnight for observation versus going home this evening
(hospital day 1). The patient opted to go home this evening on
___. He was given a Prevpac for 10 days to treat his h.pylori,
an appointment to follow up with Dr. ___ in 2 weeks (where
an elective lap chole will likely be scheduled), and
instructions for contacting the GI clinic to schedule an
outpatient endoscopy. He verbalized understanding and agreement
with the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o IBD on immunosuppressants p/w 2mo of his usual IBD flare
sx (rectal bleeding, diarrhea, ___ BMs/day, occ abd pain with
BM) in addition to 1wk of new fevers (101 on ___ gradually up
to 103.9 this AM). His outpatient GI doctor at ___
referred him to the ED. CT of the abdomen pelvis showed Acute pancolitis, likely inflammatory in the setting of UC. The patient was diagnosed with Crohn's disease, unspecified, without complications. The patient was treated with Flexible sigmoidoscopy (___). At the time of discharge, the patient had Primary:
Severe ulcerative colitis flare
Anemia
Diarrhea
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>___ h/o IBD on immunosuppressants p/w 2mo BRBPR/diarrhea + 1wk
fevers (CT A/P pancolitis, flex sig severe UC) c/f IBD flare.
#Diarrhea / BRBPR / fevers:
Given initial fevers/diarrhea, infectious workup (C diff, stool
studies) was performed and negative. Received 2 days of IV
steroids with rapid and positive response (stool frequency
decreased from 20 to 10 per day after the first day, less blood,
CRP down from 116 to 40). On day of discharge, patient continued
to have improved symptoms (although still notes somewhat
increased BM compared to baseline) and was transitioned to PO
steroids until outpatient GI follow-up.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old man with history of TBI (___) s/p VP
shunt, dementia, seizure disorder on Depakote who presents with
witnessed "vigorous shaking" at nursing home. He was reportedly
post-ictal after event with increased somnolence secondary to a
change in mental status. He was initially brought to ___ where
he was given a total of 4 mg IV Ativan (2mg en route and 2 mg in
ED) Per chart review, patient apparently received 4 mg Ativan in
total prior to arriving at ___ notable 13 at ___. He was
transferred to ___ for further workup. CHEST (PA AND LAT) showed 1. Apparent discontinuity of the shunt catheter overlying the right mid chest,
similar compared to prior.
2. Streaky opacities at the right base likely reflect atelectasis, although
infection should be considered. The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus. At the time of discharge, the patient had Breakthrough seizure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient is a ___ year old man with history of remote TBI w/
VP shunt, epilepsy, cognitive impairment, long time nursing ___
resident, who was admitted for prolonged breakthrough convulsive
seizure followed by prolonged somnolence, and found to have
leukocytosis, lactate elevation, and subtherapeutic Depakote
level (45) on admission.
# Breakthrough seizure
He was maintained on his home Keppra 500mg BID and received a
15mg/kg bolus of Valproic acid due to subtherapeutic level of 45
on admission. Post-load level was 112. He was treated with
short-acting Valproic acid ___ q6h during his stay, with
maintenance of a therapeutic level at 92 and 90 on discharge. He
was transitioned back to long-acting Divalproex ___ in the AM
and 1000mg in the evening. The reason for lability of level was
very unclear; it not appear that he had missed any doses, had
recent infection, or had any change or addition of other
medications that induce or inhibit hepatic metabolism. LFTs were
normal on admission. His mental status and neurologic
examination improved back to baseline.
# Leukocytosis, lactate elevation
The patient's WBC was elevated to 14.2 on admission, with a peak
of 15.7, and lactate elevated to ___. He was noted to be
tachycardic, and was treated with multiple boluses of IV fluids
for suspected hypovolemia, which helped to resolve his
tachycardia. Bicarbonate was also low to 21. He was afebrile
throughout his entire admission, vital signs otherwise normal,
and underwent thorough infectious workup including: UA/Urine
culture no growth, Blood cultures pending but no growth x3 days,
chest X ray showing streaky atelectasis. His mental status
remained at baseline and he developed no signs concerning for a
shunt infection. His leukocytosis and bicarbonate both
normalized spontaneously throughout admission and his discharge
WBC was 10.8. Due to these factors, leukocytosis and lactate
elevation were not felt to be due to acute infection and more
likely due to prolonged recovery after convulsive seizure.
#Tachycardia, PVCs
He had a period of persistent tachycardia in the 130s on the day
of admission, which improved with fluid boluses and was likely
secondary to hypovolemia. He was noted to have infrequent PVCs
on admission (also noted in OSH records), which increased in
frequency during his stay but improved with electrolyte
repletion (Mg 1.8 -> 2.0, Phos 2.6 -> 3.7). EKG revealed no
concerning ischemic changes, and his cardiac enzymes were
negative. This can be followed up as an outpatient.
Transitional issues:
[ ] Please obtain Valproate level in 1 week given recent
fluctuations of unclear etiology. Please communicate with his
neurology team here at ___ (Fax: ___ regarding his
level and whether his dose needs to be adjusted.
[ ] Continue Keppra at his previous dose, 500mg BID.
[ ] Follow up in Neurology clinic as above.
[ ] Please obtain CBC, complete metabolic panel in 2 days, to
ensure WBC continues to improve, as well as evaluate for
electrolyte abnormalities that may require standing repletion.
[ ] Follow up final results of blood cultures from ___ and ___
(thus far no growth).</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of HFpEF (last TTE on ___ with LVEF >55%),
moderate to severe MR, moderate AS (valve area 1.2 cm^2, peak
grad 36 mmHg, peak velocity 3.5 m/s) who presents with DOE,
weight gain and edema. Her symptoms have worsened acutely in the
past ___ days with dyspnea while walking across the room. She
also has chest discomfort that occurs transiently (usually while
walking) but has increased in frequency so that it has been
occurring daily. She also notes a ___ pound weight gain over the
last 3 days and endorses PND and orthopnea although says these
are chronic conditions. At baseline, she uses ___ O2 at home
and dry weight reported to be 70.9 kg. She also notes that her
oxygen saturation has been a bit lower than it normally is
(generally 98-100%, over last two days 93-95%). She had a low
grade fever (approximately 99.6F) two days ago. Given her weight
gain, she increased her home torsemide to 50 mg from 40 mg
daily.
In the ED, initial vitals were 98.4 71 104/43 18 95% RA. Exam
notable for bibasilar crackles and bilateral ___ pitting edema.
Labs notable for H/H 9.8/30.6, INR 1.8, Cr 1.2 (baseline
1.1-1.2), tropT neg x 2 and BNP 2475 (previously 1179 on
___. CXR showed new mild pulmonary edema with focal right
basilar opacity. CHEST (PA AND LAT) showed New mild pulmonary edema. More focal right basilar opacity may reflect
atelectasis though infection is not excluded. The patient was diagnosed with Heart failure, unspecified, Hypoxemia. At the time of discharge, the patient had Primary diagnoses:
Aortic stenosis
Mitral regurgitation
Acute on chronic diastolic heart failure
Secondary diagnoses:
Atrial fibrillation
Chronic kidney disease
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>___ is an ___ year old woman with a history of
diastolic heart failure (EF > 55%, TTE ___, moderate to
severe MR, and moderate to severe AS who presented with dyspnea
on exertion and edema consistent with heart failure exacerbation
likely due to worsening valvular disease.
# Acute on chronic decompensated diastolic CHF: Patient appeared
volume overloaded on exam and had elevated BNP at 2475. She
improved with IV Lasix. A repeat TTE showed 4+ MR and decreased
___, although this may have been misrepresented due to a low
flow state secondary to the MR. ___ it was thought that
her valvular disease (mitral regurgitation and/or aortic
stenosis) was the likely contributor contributor to her
worsening heart failure. She declined cardiac catheterization to
better characterize the extent of aortic stenosis and was not
interested in valve repair/replacement at this time. She
liekwise declined hospice services. She was discharged on an
increased dose of torsemide (60 mg PO instead of 40) with
instructions to take an extra 10 mg PRN for increase in weight.
# Atrial fibrillation: Patient has afib, rate controlled with
metoprolol and diltiazem and also on warfarin. These medications
were continued.
# Chest pain: Patient described chronic episodes of chest
pain/pressure likely due to aortic stenosis versus CAD. She
declined cardiac catheterization. She had a negative stress in
___. Troponins were negative x2 and she had an ECG without
ischemic changes.
# Acute on chronic renal failure: Patient with baseline
creatinine ___. She had a mild increase to peak 1.4 in the
setting of diuresis, thought to be due to pre-renal azotemia.
Diuresis was held and creatinine normalized. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx of dementia, A-Fib on aspirin (previously on coumadin and
lovenox but discontinued ___ frequent falls), CKD and recent GI
bleed while on aspirin only, who now presents from ___
for bilateral DVTs found incidentally following a TIA workup.
She had symptoms concerning for TIA several days ago and takes a
daily aspirin, which was held today. TIA was described as her
not being able to get her words out, having general lower
extremity weakness, and worsened short term memory loss. The
expressive issues resolved after 30 seconds, the gait
disturbance has been progressively getting better each day, and
the short term memory loss has persisted. CT head at OSH was
negative for head bleed. She has been at ___ in
___, but was previously living with daughter.
Was admitted to ___ from ___ for black guaiac
positive stool and low hematocrit of 9.2, on anticoagulation.
Patient was not aggressivelyt worked up for cause of GIB. She
was given 2 units of PRBCs and was discharged with a hct of 9.5.
Of note, her GIB occurred while on ASA only.
In the ED, initial VS were 98.2, 80, 150/84, 18, 97%RA. WBC 15.0
(82%N), INR 1.2, Cr 2.0 (baseline), K 5.4, otherwise
unremarkable. Patient was not started on anticoagulation or
given other medications in the ED. Transfer VS were 98, 77,
110/48, 23, 97% RA.
On arrival to the floor, patient is comfortable, denies
shortness of breath, chest pain, abd pain, or calf pain. Does
note left heel pain to palpation. Radiology showed 1. Heart remains stably enlarged. Mediastinal contours are difficult to
assess given patient rotation on the current study. Small bibasilar layering
pleural effusions with associated patchy airspace disease, likely reflecting
compressive atelectasis. In addition, there is increasing perihilar fullness
and slightly more prominent interstitial markings suggestive of mild perihilar
and interstitial edema. No pneumothorax. Patient's mandible obscures the
lung apices. The patient was diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY. At the time of discharge, the patient had Primary Diagnosis: Bilateral Deep Venous Thrombosis and Acute
Exacerbation of Diastolic Heart Failure
Secondary Diagnosis:
HYPERTENSION
OSTEOARTHRITIS
Chronic kidney disease
SPINAL STENOSIS - LUMBAR
Hypercalcemia
Hyperparathyroidism
history of Gastrointestinal bleed
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>___ hx of dementia, atrial fibrillation on aspirin (previously
on Coumadin and Lovenox but discontinued ___ frequent falls),
chronic renal disease and recent GI bleed while on aspirin only,
who presented from ___ for bilateral DVTs found
incidentally following a TIA workup.
# Bilateral DVTs: DVTs were found incidentally during a TIA work
up at ___ and notably have been asymptomatic. It is unclear
how long they have been present for. Given her continuing
decline, history of frequent falls and recent gastrointestinal
bleed, it was decided that the risks of starting systemic
anticoagulation outweighed the benefits. Specifically, given
her risk factors of advanced age, fall risk, chronic kidney
disease and prior gastroinsteinal bleeding, her bleeding risk
can be estimated to be 12.3 bleeds per 100-patient years (based
on HEMORR2HAGES score of 7) or > 8.7 bleeds per 100-patient
years (based on HAS-BLED score of 5). Additionally, given the
temporary nature of an IVF filter, the need for a procedure
(though minimally invasive), and the question of the acuity of
the clots, IVF filter placement was additionally declined.
Throughout the admission, Ms. ___ remained stable with 96-100%
O2 sat on room air, atrial fibrillation with rates in the
70-80s, normotension, and was without subjective pain or
shortness of breath.
.
# Acute exacerbation of diastolic heart failure: Patient was
satting well on room air, however there was evidence of volume
overload on CXR at OSH and here at ___. She imtermittently
noted some mild chest discomfort and tachypnea despite normal
sats and ECG with afib but no signs of ischemia. BNP was noted
to be 7770 and patient's home diuretics of lasix 40mg PO MWF had
been discontinued the week prior. She was given a dose of lasix
20mg IV x1 and restarted on her previous home regimen of lasix
40mg PO MWF.
.
# H/o GIB: Patient experienced a gastrintestinal bleed as
recently as ___ while on aspirin daily. Unknown source as
this was not worked up during admission. While inpatient, she
was continued on her home regimen of omeprazole 20 mg BID.
Anticoagulation for DVTs was not started as risk was felt to
outweigh the benefit.
.
# OSTEOARTHRITIS: Continued lidocaine 5 %(700 mg/patch) to back
daily x 12 hrs as needed and started tylenol ___ TID.
.
# Chronic kidney disease: Patient remained at baseline kidney
function, Cr 2.0.
.
# Hyperlipidemia: Continued on simvastatin 20 mg Qhs.
.
# Atrial fibrillation: Continued on home aspirin 325mg daily and
metoprolol succinate 50 mg daily.
.
Transitional Issues
Code Status: DNR/DNI
EMERGENCY CONTACT HCP: ___ ___
- Started tylenol ___ TID for generalized discomfort.
- Patient should remain on some regimen of lasix as she had
evidence of pulmonary congestion on CXR after having been off
her home diuretics for a week. BNP 7770 this admission. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with multiple comorbidities including dementia, strokes,
seizures, a-fib on pradaxa, nonambulatory at baseline who
presents from ___ after being found to have a right hip
fracture.
The patient is not able to provide any history regarding her
presentation due to dementia. Her facility was contacted and she
was reported to be in her usual state of health the day prior to
presentation. During the evening she was noted to be calling out
in pain from her leg with some swelling noted. She did not have
a
witnessed fall. There was no concern for any recent seizure
activity or syncope. She was initially brought to ___
where she was found to have new femur fracture and transferred
to
___ for further care. Radiology showed Multiple fluoroscopic images demonstrate placement of an intramedullary rod
with distal interlocking screw and proximal pin stabilizing a spiral fracture
of the right femur below the trochanteric region. There is improved anatomic
alignment. No hardware related complications are identified. The total
intraservice fluoroscopic time was 87.5 seconds. Please refer to the
operative note for additional details. The patient was diagnosed with Displaced intertrochanteric fracture of right femur, init, Unspecified fall, initial encounter. The patient was treated with ORIF R femur fracture. At the time of discharge, the patient had R hip fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a R hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF R hip fracture, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications 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 her assisted living
facility 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 her home medication of pradaxa 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: Mr. ___ is a ___ year-old man with ESRD on HD (___), HFpEF,
multiple myeloma, prior embolic strokes on warfarin, and IDDM
with recent hospitalization for weakness when he was treated for
UTI despite negative urine culture, who presents with AMS. CHEST (PA AND LAT) showed Congestion with mild edema. CT HEAD W/O CONTRAST showed No acute intracranial process. Chronic changes as described. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had Primary:
Altered Mental Status
Anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year-old man with ESRD on HD (___), HFpEF,
multiple myeloma, prior embolic strokes on warfarin, and IDDM
with recent hospitalization for weakness when he was treated for
UTI despite negative urine culture, who presents after AMS
during
HD that has now resolved. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ yo female ___
with an unremarkable PMH, presenting with ___ days of
epigastric abdominal pain. MRCP showed Hepatosplenomegaly, multifocal lymphadenopathy and focal abnormality within
the left mid kidney, all thought to represent sequela of patient's leukemia.
There is no evidence of cholecystitis, biliary obstruction or other biliary
pathology to account for patient's right upper quadrant pain.
NOTIFICATION: Findings were discussed via phone by Dr ___ with Dr ___
___ at 3pm on ___. SKELETAL SURVEY (INCLUD LONG BONES) showed No suspicious lytic or sclerotic bone lesions seen. L3 compression fracture,
stable. CHEST (PORTABLE AP) showed As compared to the previous image, no relevant change is seen. Bilateral small
pleural effusions with minimal atelectasis. Normal size of the cardiac
silhouette. Normal vascular and bronchial structures. ABDOMEN US (COMPLETE STUDY) PORT showed 1. Splenomegaly mildly increased when compared to prior examination may be
secondary to congestion.
2. Trace amount of perihepatic fluid not apparent on prior study.
3. Underdistended gallbladder with intraluminal sludge. No evidence suggestive
of acute cholecystitis. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen. Bilateral
pleural effusions at relatively low lung volumes, combined to areas of mild
parenchymal atelectasis, notably in the retrocardiac lung region. No
pulmonary edema. No pneumonia, no pneumothorax. CHEST PORT. LINE PLACEMENT showed Left subclavian central venous catheter terminates in the right atrium.
Withdrawl approximately 3.5 cm should place the tip near the cavoatrial
junction. Bilateral pleural effusions areslightly increased. There is
increased volume loss and alveolar infiltrate most marked at the bases
NOTIFICATION:
The findings were telephoned to ___ by ___ at 19:06,
___, 1 min after discovery. CHEST (PORTABLE AP) showed Line pulled back CHEST (PORTABLE AP) showed No significant interval change compared to the prior study. Small bilateral
pleural effusions with adjacent bibasilar opacities which could represent
atelectasis though infection is difficult to exclude in the correct
circumstance. CHEST (PORTABLE AP)CHEST (PORTABLE AP)i showed Combination of bibasilar atelectasis and small to moderate effusions improved
slightly since ___. Upper lungs clear. Heart size normal. Left
subclavian line ends in the low SVC. No pneumothorax. CHEST CTA FOLLOWED BY CONTRAST ENHANCED ABDOMINAL AND PELVIC CT showed 1. No evidence of pulmonary embolism or any other acute cardiopulmonary
process. No intrahepatic lesion identified.
2. Right hilar and subcarinal lymphadenopathy.
3. Small bilateral pleural effusions with associated compressive atelectasis,
right worse than left.
4. Persistent gallbladder wall edema with collapsed gallbladder. No evidence
of acute cholecystitis.
5. Redemonstration of a 2.5 cm intermediate density left renal lesion,
consistent with known leukemic involvement as characterized on prior MRCP.
6. Small to moderate amount of perihepatic and pelvic free fluid.
7. Stable L3 compression deformity. US ABD LIMIT, SINGLE ORGAN showed 1. Persistent mild gallbladder wall edema and gallbladder wall thickening,
improved when compared to study from ___. No evidence of acute
cholecystitis.
2. Small right-sided pleural effusion. Radiology showed There is a left-sided portacath with the distal lead tip at the cavoatrial
junction. Heart size is within normal limits. There are bilateral pleural
effusions which appear stable. No pneumothoraces are identified. There are
no displaced rib fractures. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Small amount of debris or sludge within the gallbladder with no evidence of
acute cholecystitis nor well formed stones. CHEST (PORTABLE AP) showed As compared to the previous radiograph, there is a decrease in extent of the
pre-existing pleural effusions. Normal size of the cardiac silhouette. The
retrocardiac atelectasis has decreased in extent. Left subclavian vein
catheter is in situ. No pneumonia. CT ABD AND PELVIS WITH CONTRAST showed 1. No evidence of acute intra-abdominal process.
2. Unchanged compression deformity of L3 vertebral body CHEST (PA AND LAT) showed Left subclavian central line is unchanged in position. Lungs are well inflated
without evidence of focal airspace consolidation, pulmonary edema or
pneumothorax. No pleural effusions. Overall cardiac and mediastinal contours
are stable. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Decompressed gallbladder without stones. No evidence of to suggest acute
cholecystitis. Mild gallbladder wall edema.
2. Mild splenomegaly.
3. Adenomyomatosis. CT ABD AND PELVIS WITH CONTRAST showed 1. Increased gallbladder wall edema since ultrasound from the same day, likely
secondary to fluid resuscitation. No evidence of acute cholecystitis.
2. 2.4 cm intermediate density left renal lesion, not completely characterized
on this study, recommend nonemergent MRI for further evaluation.
3. L3 anterior compression deformity, of uncertain chronicity.
4. Trace right pleural effusion.
5. Mild splenomegaly. CT CHEST W/CONTRAST showed Small volume of relatively infiltrative paratracheal, subcarinal,
paraesophageal and right hilar adenopathy does not interfere with vital
structures.
Possible pulmonary arterial hypertension, unexplained. Portable chest radiograph showed There are tiny bilateral pleural effusions but no pulmonary edema. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. The patient was treated with BM biopsy: Hypocellular bone marrow with an atypical
T-lymphocytic infiltrate. The lymphoid population in the marrow
appears to be predominantly comprised of T lymphocytes. They are
characterized by loss of CD7, as seen at diagnosis. This raises
concern form residual T-cell lymphoproliferative disorder.
GI biopsy: 1. Gastric body biopsy: Rare dilated gland, otherwise
no diagnostic abnormalities. Gastric body ulcer biopsy: Focal
chronic active gastritis. Immunostain for CMV is negative.
Antral biopsy: Mild chronic inflammation. Immunostain for
Helicobacter is negative. Antral ulcer biopsy: Chronic active
gastritis. A rare cell stains for CMV.. At the time of discharge, the patient had Primary Diagnosis: Adult T-cell Leukemia/Lymphoma, CMV gastritis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ previously healthy women who was diagnosed with HTLV-1
associated ATLL and completed part A of hyperCVAD therapy (cycle
1, day 1 = ___. Her hospital course was complicated by
pancreatitis, c. diff, and gastritis (gastric ulcers with biopsy
staining for CMV).
.
#T-ALL
Pt presented with leukocytosis and lymphocytic predominance. She
also had elevated lactate, LDH, and uric acid suggestive of TLS,
managed with IVFs and allopurinol.
Immunophenotyping and bone marrow biopsy suggested a T-cell
malignancy but was inconclusive; she was transferred to ___ for
further mgmt. Given +HTLV-1 antibodies, a diagnosis of
HTLV-driven T-ALL was made. HyperCVAD was initiated and she
completed part A. She was then started on IFN three times per
week (___) and AZT BID to treat the HTLV-1 infection.
.
#Chest wall discomfort
In the setting of HyperCVAD, pt developed tenderness to
palpation first in the R upper chest (below the clavicle,
between the midclav/ant axillary lines), exacerbated by
pectoralis contraction or palpation of the bony surface. As this
resolved, she had similar pain at the R costal margin, then
later in the L upper chest (same location/quality as R sided
pain but on the other side). ECG neg, no cardiac history. CTAP
obtained ___ showed no concerning intrathoracic or chest wall
lesions. Attributed to marrow expansion in setting of
malignancy, and pain is being managed with PO pain medications.
.
#Epigastric abdominal pain
1. Medicine service: Abd pain, nausea, early satiety on
admission, with mild transaminitis and alk phos elevation. RUQ
ultrasound demonstrated gallbladder wall edema. CTAP showed
gallbladder wall edema and a left renal lesion (cyst vs
malignant lesion). LFTs suggested biliary obstruction and pt had
RUQ tenderness with ___. HIDA was performed, showing no
cholecystitis but delayed tracer efflux c/f possible biliary
obstruction. MRCP was obtained, showing no evidence of
cholecystitis, biliary obstruction or other biliary pathology.
H. pylori stool Ab testing was positive. Clear etiology never
found.
2. BMT service: RUQ pain with ___ recurred, so
amp-sulbactam was started, surgery was consulted, and RUQ
US/CTAP were obtained ___. Her pain was determined to be most
likely due to pancreatitis (see below) She had ongoing RUQ
discomfort and repeat HIDA was performed, showing no biliary
pathology. She then underwent EGD which showed gastric ulcers;
biopsies showed some lightly staining CMV cells and she was
started on Valgan and PPI BID. Improved over hospital course.
.
#Pancreatitis
On BMT,pt noted some costal margin pain, prompting repeat Abd US
___ -> showed only gallbladder wall edema. CTAP ___ to look for
pleural or abd causes. HSM was again noted, but only
redemonstrated gallbladder wall edema c/w third spacing in
setting of large volume fluid admin. She began having epigastric
pain, so ___ were checked, demonstrating amylase/lipase
>3x ULN. The patient was made NPO, given morphine PCA, and
treated aggressively with IVFs. Over several days, the patient
was able to advance her diet as tolerated and her pancreatic
enzymes started to trend down.
.
#CMV infection
Patient had uptrending CMV viral loads and a positive CMV stain
on biopsy, so she was started on Valgan (900 mg BID x 2 weeks,
then 450 mg BID as prophylaxis)
.
#Shortness of Breath:
Pt intermittently had increased RR and mild SOB with large
volume fluid administration during chemotherapy and aggressive
hydration for episodic hypercalcemia. Brisk diuresis and
resolution of sxs with furosemide 20 PO daily.
.
#Uncomplicated cystitis/pyelonephritis:
Suggested by abnormal urinalysis and migrating lower
abdominal/flank pain. UCx grew E.coli and Klebsiella, both
Bactrim sensitive -> treated x3d with improvement.
.
#Acute Renal Failure/Acute Kidney Injury:
Pt ___ during first days of admission on medicine service,
ddx included constrast nephropathy v allopurinol v prerenal
azotemia due to osmotic diuresis of hypercalcemia. Resolved with
IVFs.
==================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo woman PMH uncontrolled HTN, DM2
(previously insulin dependent now diet controlled), ESRD on HD
(T, TH,S) who presents with dizziness and presyncope found to
have conversion pauses on EKG and ___ transferred to ___
from ___ for electrophysiology evaluation
and intervention. CHEST PORT. LINE PLACEMENT showed New transvenous right atrial and right ventricular pacer leads are continuous
from the new left axillary pacemaker generator. There is no pneumothorax.
Greater opacification in the already contracted left hemi thorax is probably
due to increasing atelectasis. This is associated with substantial increase
in distension of the stomach with air and fluid. If there was pleural
effusion prior to pacemaker insertion, that is unchanged. Patient has had
surgery in the left chest denoted by vascular clips at the hilus and in the
apex, perhaps lobectomy. Left heart border is entirely obscured and
assessment of heart size is not possible. Upright and lateral chest
radiographs would be very helpful in assessing the abnormalities in the left
hemi thorax.
Right lung is relatively clear, pulmonary vasculature not engorged, and free
of pleural effusion.
NOTIFICATION: Dr. ___ reported the findings to ___, J., M.D.
by telephone on ___ at 9:41 AM, 10 minutes after discovery of the
findings. The patient was diagnosed with CARDIAC DYSRHYTHMIAS NEC, CHRONIC AIRWAY OBSTRUCTION, DIABETES UNCOMPL JUVEN. The patient was treated with PPM Placement (___). At the time of discharge, the patient had PRIMARY DIAGNOSES
=================
1. Atrial Fibrillation
2. Sinus Node Dysfunction
SECONDARY DIAGNOSES
===================
1. ESRD
2. Hypertension
3. Type II diabetes mellitus
4. 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>Ms. ___ is a ___ yo woman PMH ESRD on HD ___, DM2, HTN,
lung cancer s/p lobectomy presenting with pre-syncope found to
have bradycardia and pauses on telemetry.
ACUTE ISSUES
============
# Pauses on telemetry/EKG: Unclear if she is having sinus pauses
secondary to sinus node dysfunction or conversion pauses as she
was intermittently in atrial flutter in ICU. Both possibilities
suggested some underlying sinus node disease. Therefore, she had
a pacemaker placed on ___. Her carvedilol was initially held,
but was restarted after PPM placement. She was given an initial
dose of vancomycin with HD for PPM placement. She will have her
last dose on ___ with HD to complete an adequate 3 day course.
She was scheduled follow-up in device clinic and with EP.
# Atrial flutter: The patient has no previous history of atrial
flutter and alsono known underlying valvular disease. She was
started on warfarin without a heparin bridge, as she went for
PPM placement. At the time of discharge, the patient was
informed that she would need to have her INR checked on ___ and
she was continued on the dose of warfarin 7.5mg at discharge.
CHRONIC ISSUES
==============
# ESRD: She continued on ___ schedule during this
hospitalization.
# HTN: She had diastolic HTN on admission as well as a history
of uncontrolled HTN per patient report. Her lisinopril was
initially held, and she was continued on her home hydralazine
and isosorbide. Her amlodipine was also restarted after her PPM
placement. Because her pressures were relatively well-controlled
on these 3 agents, her lisinopril was restarted at a decreased
dose of 20mg and this dose was continued on discharge.
# DM: Per report, diet controlled. She was maintained on ISS
in-house. Her blood sugars were under good control and no
insulin as continued at discharge.
# Lung cancer s/p lobectomy: Stable. She was continued on her
home oxygen 2L NC.
TRANSITIONAL ISSUES
===================
# Results pending: MRSA screen and CXR (final report)
# New/changed medications: Vancomycin 1000 mg IV x 1 (final
prophylactic dose at next HD session), warfarin 7.5mg daily.
Lisinopril decreased from 40mg to 20mg daily.
# Follow-up: Cardiology, device clinic, PCP
# ___ should get one more dose vancomycin in HD on ___
for post-pacemaker 72hr antibiotic coverage.
# Lisinopril dose was decreased to 20 mg daily as she did not
need as high of dose of blood pressure medications
# She will be discharged with visiting nursing services to
assist with medication management and pacemaker management
# ___ consider alternative statin as major drug interaction
between simvastatin and amlodipine
# CODE: Full
# CONTACT: ___ (son-in-law) ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ y/o male with PMH of COPD, CAD, seizure
disorder, schizophrenia, also recently discharged on ___ after
treatment for HCAP/aspiration pneumonia (d/c'ed home on Levaquin
and Flagyl, completed 8 day course) who presented after sudden
onset of dyspnea at home earlier today. He was sitting down at
home when he felt like he could not catch his breath all of a
sudden. His ___ called the ambulance and he was brought to
___. He did not have any chest pain, palpitations, or pain
with deep inspiration. He endorsed some nausea that had been
persistent for the past 2 months, but was not exacerbated by
lying down at nighttime. He denied any cough or choking on his
food. In addition, he denied fevers, chills, abdominal pain,
vomiting, diarrhea, constipation, hematuria, dysuria, or new
lower extremity swelling. Radiology showed New left lower lobe consolidation, worrsiome for aspiration/ infection. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION. At the time of discharge, the patient had Primary:
Recurrent aspiration pneumonia
Supratherapeutic INR
Secondary:
Deep vein thrombosis
COPD
Coronary artery disease
Schizophrenia
Seizure disorder
Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year-old male with a history of COPD,
coronary artery disease status-post stent, seizure disorder,
recent HCAP pneumonia who presented with sudden onset dyspnea.
He has had several recent hospitalizations for HCAP/ aspiration
pneumonias. He was recently diagnosed with a left lower
extremity DVT in ___, and is now on home warfarin,
discovered to have supratherapeutic INR on presentation to 5.6.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ ___ disease, chronic venous stasis, recurrent
cellulitis, h/o compartment syndrome in RLE s/p surg,
hypogonadism, anxiety, p/w slowed mental status, worsening b/l
leg swelling R>L. Radiology showed Mild bibasilar atelectasis. UNILAT LOWER EXT VEINS RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. The patient was diagnosed with SWELLING OF LIMB, PAIN IN LIMB. At the time of discharge, the patient had 1. Acute on chronic venous stasis
2. Altered mental status
3. Chronic headaches. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo male with ___ disease, chronic
venous stasis complicated by recurrent cellulitis and
compartment syndrome in RLE, hypogonadism, anxiety, p/w slowed
mental status, worsening b/l leg swelling that improved with
diuresis.
DISCHARGE WEIGHT: 163.2 KG
=============</s> |