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<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a lovely ___ with with a recent discharge (___) from ___ with a diagnosis as a strep A and fungal LLQ rash and inflammatory polyarthropathy, now presenting from home for 3 days of worsening LLQ and groin redness and purulent oozing, as well as new areas of redness, weeping, and pain under the L breast and L ear. She was in usual health until ___, when she developed LLQ/groin redness. She was admitted to ___, and her workup there was notable for a wound culture was postive for beta hemolytic group A strep. she had negative bcx and urine cx. During this stay, she developed difuse joint pains and myalgias, including her shoulders and most significanly her knees and thighs. She had negative ___, anti-CCP, CK, and uric acid. Her RF was positive at 24 and her ESR was high at 111. Her synovial fluid showed no crystals but had a high white count at ___ with 95% PMNS and red count of 200. She was discharged ___ with a diagnosis of yeast infection and cellulitis of the left abdominal wall as well as an inflammatory polyarthritis. She was sent to rehab on a prednisone taper (30 mg for 4 days, 20 for 4 days, 10 for 4 days, 5 for 4 days and then cessation, ended in ___ per patient) to which she responded very well, as well as three topical medications for her abdominal wounds (zinc oxide, hydrocortisone, and miconazole nitrate). Radiology showed No evidence of acute cardiopulmonary abnormalities. Radiology showed 1. Calcified loose body within the anterior aspects of the left glenohumeral joint. 2. Moderate degenerative disease involving the acromioclavicular joint and mild degenerative disease involving the glenohumeral joint. Radiology showed 1. Prominent edema and heterogeneous enhancement both within the acromioclavicular joint as well as the surrounding soft tissues concerning for septic joint, however findings could also be seen in the setting of an inflammatory arthropathy. 2. Large 1.5 cm loose body inferomedial to the coracoid process of indeterminant etiology, may be degenerative in etiology. 3. Superior labral tear. 4. Tendinosis of the supra- and infra-spinatus tendons with articular surface fraying of the supraspinatus tendon. Findings conveyed to Dr ___ at 10:15 am on ___ via telephone ___, phone). Radiology showed 1. Successful ultrasound-guided aspiration of left acromioclavicular joint. Aspirated specimen was sent directly to the lab for microbiology analysis. Joint aspirate was not sufficient for cell count and differential, and was only sent for culture and sensitivity. 2. Fluid collection at the left acromioclavicular joint with surrounding inflammation as described. The attending radiologist, Dr. ___, was present for the entire procedure and provided direct supervision. Radiology showed 1. Bilateral prominent chondrocalcinosis within the medial and lateral menisci. Finding may be secondary to CPPD. 2. Small left knee effusion. 3. Mild degenerative joint disease of the patellofemoral compartments of the knees. The patient was diagnosed with CELLULITIS/ABSCESS OF TRUNK, HYPERTENSION NOS. The patient was treated with ___ Radiology guided arthrocentesis of the left acromio-clavicular joint ___ Left knee arthrocentesis. At the time of discharge, the patient had PRIMARY: Inverse psoriasis Calcium pyrophosphate dihydrate deposition disease (CPDD) Iron deficiency anemia Anemia of chronic disease Gait instability Cervical spondylosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>CHIEF COMPLAINT: Rash and joint pains REASON FOR ADMISSION: ___ with with a recent diagnosis of strep A and fungal LLQ cellulitis and inflammatory polyarthropathy, now presenting from home for 3 days of worsening L groin redness and oozing, as well as new areas of redness, weeping, and pain under the breasts and behind L ear, in addition to neck and upper arm soreness. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ G3P2 on PPD#21 presenting for eval of vaginal bleeding, back pain. She reports undergoing a planned repeeat c-section at term on ___ at ___. She denies requiring antibiotics, transfusion, prolonged lenghth of stay. Since d/c home, reports she feels vaginal bleeding has become increasingly heavy, never tapered. She reports currently changes 7 pads per day, saturated, and passing quarter-half dollar size clots. No foul smelling vaginal dishcarge. No fevers/chills. Some cramping controlled with tylenol. Not breastfeeding. Reports pain and discomfort with urination that is hard to describe, denies burning with urination or hematuria. She has also noticed pleuritic pain on R back, diffuse. Denies trauma to area. No chest pain. No SOB, change in exercise tolerance, wheezing. CHEST (PA AND LAT) showed As compared to the previous radiograph, the bilateral pleural effusions have slightly increased in extent and severity. No new focal parenchymal opacities. Moderate cardiomegaly. No pulmonary edema. Radiology showed Cardiomediastinal silhouette is within normal limits. There are bilateral pleural effusions, right greater than left which are stable in size. Bibasilar atelectasis is seen. There are no pneumothoraces. No pulmonary edema or focal consolidation is seen. CTA CHEST WANDW/O CANDRECONS, NON-CORONARY showed 1. Right upper and lower lobar and segmental ; left lower lobar and segmental pulmonary emboli without evidence of right heart strain as described above. 2. Moderate cardiomegaly, with biventricular enlargement. 3. Wedge shaped areas of subsegmental atelectasis versus infarcts in the right middle lobe and at the base of the right lower lobe which may represent areas of atelectasis or pulmonary infarction. 4. Small right pleural effusion. NOTIFICATION: Findings discussed with Dr. ___ telephone at 00:40 on ___ by Dr. ___. ___ DUP EXTEXT BIL (MAP/DVT) showed No evidence of deep venous thrombosis in the bilateral lower extremity veins. The patient was diagnosed with PULMON EMBOL NEC-POSTPAR. At the time of discharge, the patient had bilateral pulmonary emboli. The patient was given written instructions concerning 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 s/p rLTCS presenting with vaginal bleeding and chest pain, found to have bilateral pulmonary embolism. The patient was admitted to the Post Partum floor for therapeutic anticoagulation and pain control, as well as monitoring of her vaginal bleeding. *) Pulmonary embolus: The patient remained hemodynamically stable, with normal 02 sats on RA, and no evidence of heart strain on a chest CT. Thus, there was no indication for thrombolytic therapy. On HD1, a heparin gtt was started per protocol. Hematology was consulted and the patient was transitioned to therapeutic lovenox and coumadin. The patient was started on coumadin on hospital day 3. She continued this until discharge, although coumadin was held on hospital 5. Plan for going forward was to continue on lovenox 95mg twice daily with bridge to warfarin at starting dose 5mg qd, goal INR ___. Per hematology, patient should be maintained on anticoagulation for 3 months with outpatient follow up in ___ clinic. Patient will be followed by ___ initially, as this is location of primary care. *) vaginal bleeding Regarding her vaginal bleeding, she had minimal bleeding on exam. A pelvic ultrasond demonstrated a clot, but no evidence of retained products of conception. She was monitored closely throughout her admission and had very minimal vaginal bleeding. *) Low grade fevers: On hospital day ___, the patient was noted to have low grade fevers. A U/A was done and not consistent with infection and a white count was normal. She did endorse shortness of breath on hospital day 3 and had a chest-xray that showed bilateral effusions but no consolidation. By hospital day 5, she was feeling overall well and remained afebrile throughout the day. Her white blood count was normal, and a repeat Chest X-ray demonstrated no changes from prior. *) social: pt reports minimal family support, very concerned about ability to care for children during her hospitalization. Social work was consulted, but patient reported no concerns to social worker. By hospital day 5, patient was doing overall well, ambulating without oxygen desaturation and on anti-coagulation with follow-up arranged. In addition, while she had low grade temperatures, she had remained afebrile for the day with no signs of infection. It was thought that the low grade temperatures were due to blood clots. Precautions were reviewed and patient discharged home.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ with PMHX of CMT (with neuropathy), HTN, HLD who was brought to ___ by EMS from an OSH after experiencing a sudden onset of left facial droop, dysarthria, and left arm weakness while being worked up for an episode of anaphylactic shock after eating some hummus on the beach with his girlfriend (known severe allergy to peppers). During the allergic reaction (started at 3pm), he received several doses of epi by EMS and had to be assisted with his airway (not intubated). He was starting to feel better when at 5:30pm his mother noticed left facial droop, dysarthria, and left arm weakness (while still in the ED). He had a CTH at the outside hospital 15min after the onset of symptoms (which was read as negative for acute pathology). He was transferred to ___ for advanced management. CT BRAIN PERFUSION showed Elevated mean transit time in the right frontal and right parietal lobes with corresponding loss of normal gray-white matter differentiation on noncontrast CT scan. Findings consistent with acute/ subacute right MCA territory infarction. Radiology showed Mild pulmonary edema. MRI AND MRV BRAIN showed 1. Acute/subacute right MCA territory infarct with associated hemorrhage. 2. No clear evidence of dural venous thrombosis -- attenuated left transverse sinus is presumably on a developmental, hypoplastic basis. NOTIFICATION: Findings were discussed with the ___, by Dr. ___ the telephone, at approximately 1234 ___. CT HEAD W/O CONTRAST showed Interval evolution of the previously seen right MCA territory infarct with hemorrhagic conversion. Increased edema resulting in increased effacement of the right lateral ventricle and increased leftward midline shift, which now measures 7 mm (previously 3 mm). No evidence of new infarction. NOTIFICATION: Findings communicated to Dr. ___ at 1:21 a.m. on ___ by phone. CT HEAD W/O CONTRAST showed No increased hemorrhage, extension of the infarction though or increased mass effect from the previous study. CT HEAD W/O CONTRAST showed 1. There is no increased hemorrhage, extension of infarction or increased mass effect from the previous study. The patient was diagnosed with ALTERED MENTAL STATUS . The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ yo M with PMHx of Charcot ___ (with neuropathy), HTN, HLD who had acute onset of left facial weakness and left arm pronation during an ED admission at an OSH for anaphylactic shock (allergic to peppers). He was sent to ___ after CTH (15 minutes after symptom onset) was negative for stroke. Admission labs were significant for HA1c=5.4, LDL=104. LP in the ED showed 800+ RBCs but no WBCs. CT/CTA showed elevated mean transit time in the right frontal and right parietal lobes with corresponding loss of normal gray-white matter differentiation. MRI showed acute/subacute right MCA territory infarct with associated hemorrhage. Patient transferred to ICU and started on mannitol on ___ for concern for worsening cerebral edema. He improved clinically and was transferred back to the floor without any additional interventions. Work up for hypercoagulation was unrevealing ___, beta-2-glycoprotein-neg, lupus-neg, protein c/s-neg, homocysteine-neg, antithrombin III-p). TEE showed no intracardiac source of embolism identified (no asd, no pfo, EF>55%) but did reveal an extensive, complex, mobile atheroma in the descending aorta. Etiology of stroke remains unknown. He will need outpatient genetic testing (Factor 5, prothrombin, MTHFR mutations). He was discharged on aspirin 81 and atorvastatin 40mg. We scheduled follow up with both Dr. ___ ___ follow up with genetic testing) and the patient's existing outpatient pcp. The patient was informed he will not be able to drive until cleared ___ ___. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (X) Yes [performed and documented by admitting resident] – () No 2. DVT Prophylaxis administered by the end of hospital day 2? () Yes - (X) No, hemorrhagic conversion 3. Antithrombotic therapy administered by end of hospital day 2? () Yes - (hemorrhagic conversion) No, hemorrhagic conversion 4. LDL documented (required for all patients)? (X) Yes (LDL =104) - () No 5. Intensive statin therapy administered? (X) Yes - () No [if LDL >= 100, reason not given: ____ ] (intensive statin therapy = simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL >= 100) 6. Smoking cessation counseling given? (X) Yes - () No [if no, reason: (X) non-smoker - () unable to participate] 7. Stroke education given (written form in the discharge worksheet)? (X) Yes - () No (stroke education = personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) 8. Assessment for rehabilitation or rehab services considered? (X) Yes - () No [if no, reason not assessed: ____ ] 9. Discharged on statin therapy? (X) Yes - () No [if LDL >= 100 or on a statin prior to hospitalization, reason not discharged on statin: ____ ] 10. Discharged on antithrombotic therapy? (X) Yes [Type: (X) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No [if no, reason not discharge on anticoagulation: ____ ] - (X) N/A</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ y/o male with UC diagnosed in ___, recently started his care with Dr ___ here at ___ in ___, who has started him on humira and mercaptopurine. For at least the past few weeks, has had increasing frequency of bowel movements, up to every hour, including at night, with approximately ever other one with blood. + fatigue, + shortness of breath, felt "foggy", + abdominal pain which is relieved by moving bowels. Fevers for the past week. At last office visit, Dr ___ prednisone as well as Bactrim. Given worsening symptoms, he presented to ED where he was found to be tachycardic, CT scan showed severe colitis, and he was found to be C diff positive. He was given two units of prbcs for hct of 17 that was found after he received IV fluids. He feels better since the blood transfusion. Some weeks back, he had some "aches" in his fingers and toes, now resolved. Has lost 35 lbs since his diagnosis with UC. CT abdomen pelvis with contrast showed 1. Extensive mural edema, mucosal hyperemia and pericolonic engorgement of vessels affecting almost the entire colon the rectum sparing the cecum, most consistent with acute ulcerative colitis flare, in this patient with known ulcerative colitis. No perforation or pericolonic abscess. 2. No drainable fluid collection. MRI of the Pelvis showed 1. Single intersphincteric fistula tract located at the anal verge in the left anterolateral position exiting at the left gluteal cleft. No associated abscess. 2. Severe proctocolitis with reactive lymphadenopathy and small volume free fluid. MR ___ showed 1. No evidence of small bowel inflammation. 2. Proctocolitis, with involvement of descending, sigmoid colon, and rectum. The patient was diagnosed with Ulcerative colitis, unspecified, without complications. The patient was treated with flex sig. At the time of discharge, the patient had c.diff colitis ulcerative colitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o male with UC diagnosed in ___, admitted with increased frequency of bowel movements, bloody diarrhea, tenesmus, fevers, fatigue. He was found to have diffuse colonic inflammation on his CT scan and flex sig, c.diff and have anemia requiring transfusion. #severe C diff colitis, severe disease given underlying IBD: No evidence of megacolon or perforation on imaging. Given flex sig results, increased vanco to 500mg QID (per pharmacy) vancomycin and add IV flagyl. Symptoms improved. Downtitrated to 125 QID per GI upon discharge. 2 weeks from discharge date and then to continue on daily PO vanc after that which can be started by GI as patient is to have GI f/u in 2 weeks. ##Ulcerative colitis flare - likely due to C.diff and IBD, also awaiting CMV pathology. Azathioprine on hold per GI. Continue home dose prednisone 20mg for now. Remicade 10mg/mg x 1 given ___. F/u with Dr ___ in 2 weeks. -lactose free diet. s/p MRI of the pelvis. -MRE done and reviewed, no signs of fistula or crohns. -- CRS consulted this AM to review surgical options #acute blood bloos Anemia: Due to #hematochezia. Transfused 3 units prbc and will trend closely. Transfuse for hct less than 21. Last transfusion ___ - hb 9 on DC. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: (Gathered from pt's daughter/HCP) ___ is a ___ woman with PMH significant for dementia who presents with 4 days of progressive symptoms of a left MCA syndrome. The patient lives in an assisted living. Her daughter saw her on ___ and noticed that she was making some language errors. Specifically using the incorrect words in sentences. On ___ She was starting to use nonsense words in addition to word substitutions. She was noted to be fluent, singing, and in a great mood. She was also noted to be more tired than usual over the weekend into ___. The patient's daughter asked for the patient to be evaluated by an MD over the weekend. Radiology showed No definite acute cardiopulmonary process. CTA HEAD WANDW/O C AND RECONS showed 1. Left MCA infarct involving the left temporal, parietal and frontal lobes with associated edema and effacement of the sulci. No shift of midline structure or central herniation. 2. Widespread atherosclerotic disease of the intracranial vessels results in varying degrees of irregularity and moderate narrowing of most of the circle ___ and ___ branches as detailed above. 3. Incompletely imaged right parotid lesion. The patient was diagnosed with Cerebral infarction, unspecified. At the time of discharge, the patient had Acute ischemic stroke Hyperlipidemia 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 a ___ woman with dementia who presents with 4 days of evolving left MCA symptoms. on exam she is globally aphasic with right sided weakness of the face and arm more so than the leg. Her NCHCT shows an evolving left MCA stroke. Etiology is likely embolic from atherosclerotic disease. She was started on 300mg aspirin PR for stroke prevention. She is not diabetic and a non-smoker. Her ability to swallow was assessed by speech and swallow with recommendation for NPO as diet and education on aspiration risk if family would like to feed her for comfort. A family meeting was held with palliative care to discuss the severity of her imaging and symptoms. The decision was made to make her CMO. At this time aspirin and IV fluids were discontinued. ======================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Reason for Consult: cluster of seizures HPI: The pt is a ___ F with a history of CP, refarcatory epilepsy and severe cognitive disability, who was transferred to ___ ED after about ___ seizures this morning. Shje had just been discharged from ___ yesterday, where she had been treated for one week for ESBL UTI (7d of ertapenem), and aspiration PNA. Apparently her WBC on dishcarge was 4.2, her last PHT level there 13. She then had one seizure yesterday and a slightly elevated temperature compared to her baseline (98.4), received Diastat and was fine. Starting at 7AM this morning, she had a cluster of 5 seizures at her home, each lasting between ___, consisting of a head version to the L, R arm flexion, and some twitching of her mouth. She receive 10mg Diastat, and EMS was called after she had another seizure after Diastat. She received another 4mg of ativan at the OSH ED, and was transferred here after she kept intermittently seizing. On the way to ___ she had 3 more seizures and received 5mg of diazepam. Here, her labs showed a WBC of 19 with 90% neutrophils, as well as a PHT level of 2.2. Her UA was clean, her CXR showed a retrocardiac infiltrate c/w old or new aspiration PNa. According to her facility, she did no miss any doses, and had no vomiting or diarrhea. She is nonverbal with minimal interaction and no purposeful hand or leg movements at baseline, and entirely fed per tube. She rarely seizes at baseline, usually in the context of infections. She is currently treated with Keppra, Trileptal, Neurontin, Klonopin, Dilantin and Banzel. Her most recent medication change was a change from Dilantin 275mg QHS to 100-175mg. Radiology showed Limited exam with low lung volumes causing crowding of the bronchovascular structures. Retrocardiac opacity could reflect aspiration or pneumonia. Radiology showed Parenchymal opacities in both lower lobes and in the right upper lobe, consistent with aspiration pneumonia. Limited evaluation of the lung parenchyma, no pleural effusions. The airways are patent. Calcified granuloma in the right upper lobe. Radiology showed 1. Interval placement of a right subclavian PICC line which has its tip likely within the proximal right atrium. A pullback of approximately 2 cm would position the tip in the distal SVC. Rods overlie the visualized thoracolumbar spine. Lungs remain low in volume with persistent patchy airspace opacities and reticulonodular interstitial abnormality which appears to be worsening. These findings may reflect worsening interstitial edema, though pneumonia should also be considered. Clinical correlation is advised. Overall cardiac and mediastinal contours are likely stable given differences in patient rotation and positioning. No large pneumothorax is seen, although the sensitivity to detect a pneumothorax is diminished given supine technique. Results of this examination were conveyed to ___, the ___ line nurse on ___ at 10:16 a.m. by phone at the time of discovery. The patient was diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY, PNEUMONIA,ORGANISM UNSPECIFIED, CONGENITAL QUADRIPLEGIA. At the time of discharge, the patient had Seizure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to the neurology ICU for altered mental status after having multiple generalized seizures. These seizures were likely secondary both to the recent use of a penum antibiotic in treating an ESBL UTI, as well as a subtherpeutic phenytoin level of 2.2. #NEURO - SEIZURES On admission, she was loaded with IV fosphenytoin, and her PO BID dose was increased from 125/100 to 175/100. Her mental status quickly returned to baseline and she was transferred to the floor on ___. By the day of discharge, her dilantin level was therapeutic at 13.5. She was monitored on EEG, and continued to have generalized slowing with occasional spikes which is likely her baseline. On the day of discharge, she was at her baseline mental status. Trileptal and Keppra levels are pending. #ID Her WBC count was 19 on admission, for which she was started on vancomycin and zosyn, however WBC downtrended to 6 the next day and was likely a result of her seizure, antibiotics were discontinued the following day. She was afebrile. CXR was notable for a retrocardiac opacity from a recent pneumonia which had already been completely treated. Also, as above, she had recently been completely treated for a UTI. Urine culture was no growth. On ___, she spiked a fever and her white count uptrended, CXR showed bibasilar opacities and CT thorax showed bilateral consolidations suggestive of aspiration pneumonia. She was started again on vancomycin and zosyn to treat hospital acquired/aspiration pneumonia. PICC was placed and she is being discharged with a 14 day total course. She was discharged to a rehab facility for continued IV antibiotics, she will require less than 30 days at rehab. INACTIVE ISSUES She was continued on all of her home medications as previously prescribed, these are detailed in the attached medicatin list. OUTSTANDING ISSUES - Check dilantin trough level morning of ___ and adjust dosing if needed - Continue vancomycin and zosyn until ___ (14 day course for treatment of hospital acquired/aspiration pneumonia) - Check vancomycin level after 4th dose and adjust dose as needed. - F/U Trileptal, Keppra levels - F/U final blood cultures</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 a hx of HTN, HLD, DM, and COPD who presents with lightheadedness, slurred speech and numbness/tingling. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. No evidence of hemorrhage or infarction. 2. Patent intracranial and cervical vasculature without stenosis, occlusion, or aneurysm. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had Primary diagnosis: Orthostatic hypotension Secondary diagnosis: 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>Mr. ___ is a ___ y/o male with a hx of HTN, HLD, DM, and COPD who presents with lightheadedness and multiple neurologic complaints of unclear etiology. #Slurred speech: The patient presented with slurred speech and possible word finding difficulty on day of admission following sitting up during an outpatient MRI brain (being obtained for research purposes). There was initial concern for an acute stroke given this focal finding and a code stroke was called. NCHCT was negative, as was CTA of the head and neck. He received 3 liters of IV fluid and his speech pattern returned to baseline (with baseline stutter). Neurology felt that given his negative imaging and lack of continued focal deficits, primary neurologic cause was unlikely, and they did not recommend more advanced head imaging. Per neurology recommendations, he was started on ASA 81mg daily for stroke prevention, although suspicion for TIA was low. No clear infectious process uncovered, negative tox screen, no events on tele. Ultimately his symptoms were attributed to orthostasis as below. #Lightheadedness #Vertigo Describes acute onset of lightheadedness with standing associated with sitting up and standing. As above, no focal deficits, and prodrome with sitting up prior to onset of symptoms indicative of vasovagal vs. orthostatic hypotension (although no documented orthostasis in house). The patient was given IV fluids with improvement in symptoms, and was evaluated by physical therapy who cleared him for discharge home. He was normotensive while inpatient, and his home losartan/HCTZ was held on discharge pending PCP ___. Given that his labs and presentation were consistent with some degree of intravascular volume depletion, would continue to hold his HCTZ. If he is hypertensive at his follow up apt, would start by adding back his Losartan. # Atypical chest pain Presenting with one day of left-sided chest pain. EKG without ischemia and troponin negative x 2, making ACS unlikely. CXR negative for pulmonary source, such as pneumonia. PE unlikely given lack of tachycardia, SOB, or hypoxemia. Chest pain resolved without intervention and did not recur. ___ Cr 1.3 on admission, improved to 1.0 on discharge with 3L IV fluid suggesting prerenal etiology. Discharge creatinine 1.0. ===============</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 achondroplasia, morbid obesity, obesity hypoventilation syndrome c/b pulmonary hypertension and right heart failure, diabetes mellitus and hypertension, with a recent admission for PNA/UTI in ___ who presents with fevers, cough, low sats. He also endorsed some pain with urination. Radiology showed Dense atelectasis of the left lung base, less likely pneumonia. Radiology showed No evidence of pneumonia. Left lower lobe pleural density likely represents thickened pleura and/or effusion. Radiology showed Normal wall-to-wall color flow and augmentation of the examined left lower extremity veins. Compression could not be assessed due to patient body habitus and intolerance. No definite evidence of deep venous thrombosis on this extremely limited exam. Radiology showed Ultrasound and fluoroscopically guided 5 ___ double lumen PICC placement via the right basilic venous approach. Final internal length is 41 cm, with the tip positioned in the SVC. The line is ready for use. Radiology showed Subcutaneous edema, without visualized abscess formation or drainable collection. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPOTENSION NOS. At the time of discharge, the patient had Pneumonia Cellulitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male with PMH of achondroplasia, morbid obesity, obesity hypoventilation syndrome c/b pulmonary hypertension and right sided congestive heart failure presenting with sepsis, including fevers, hypoxia/elevated respiratory rate, and elevated WBC count requiring ICU level care. This was accountable to primarily leg cellulitis, as well as likely pneumonia. ACTIVE ISSUES BY PROBLEM: # Leg cellulitis: noted to have increase erythema, warmth, and swelling of left lower extremity suspicious for cellulitis/erysipelas. Given the clinical severity, surgery was called for concern of necrotizing fascitis and clindamycin was added. Surgery felt his exam was not consistent with necrotizing fasciitis. LENIs were negative for DVT or any drainable collection. ID was consulted and felt his symptoms to be most consistent with cellulitis. Slowly, the infection regressed on vancomycin and clindamycin. He was discharged on a regimen of linezolid ___ BID to be continued for another 8 days for a 14 day course. # Respiratory distress/Pneumonia: Has history of recurrent pneumonia with CXR at ___ reportedly consistent with R-sided infiltrate prior to transfer here. Given tenous clinical status on presentation, he was initially admitted to the MICU and treated empirically for HCAP. On transfer to the unit, he was tachycardic, sat 94% on 3 L, but he was very somnolent. ABGs showed CO2 retention and the patient was placed on BiPAP. While in the ICU, he was started on Vancomycin, levofloxacin and Tobramycin (unusual HCAP regimen due to multiple drug allergies). He was given standing nebs with albuterol and ipratroprium. Home fluticasone was continued. He was also placed on droplet precautions, respiratory viral panel was ordered and Tamiflu was started empirically, however these were discontinued when his viral screens came back negative. Urine legionella antigen was also negative x2. His respiratory status improved and he was weaned off levofloxacin and transferred to the medical floor. On the medical service, he reported his breathing was back to baseline and he required BiPAP only at night and occasional ___ L NC, which is his baseline due to COPD. INACTIVE CHRONIC ISSUES BY PROBLEM: # Hypertension: Initially held home metoprolol and losartan given borderline pressures, however these were restarted prior to discharge. His BP was actually borderline high on discharge, may consider increasing losartan dose as an outpatient. . # BPH: Initially held terazosin and tamsulosin while blood pressures were borderline low, however these were restarted prior to discharge. . # Diabetes mellitus: Held home metformin at home and started on lantus with ISS while inpatient. Metformin restarted on discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ otherwise healthy who presents with abdominal pain that started yesterday at 1030 am. She reports initial onset of constant supra-umbilical pain with later development of associated nausea and dry-heaving. At 1am today, the pain migrated to her RLQ. She also reports associated chills and loose stools x1 day but no fevers. No sick contacts or recent travel. No other complaints. US APPENDIX showed 1. Evaluation limited by low overlying bowel gas. 2. Apparent blind-ending tubular structure in the right lower quadrant measuring up to 7 mm in diameter may represent the appendix. CT ABDOMEN PELVIS WITH CONTRAST showed Dilatation of the appendix up to 1.0 cm with wall hyper enhancement, consistent with acute appendicitis. NOTIFICATION: The updated findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 10:00 am, 5 minutes after discovery of the findings. The patient was diagnosed with Unspecified acute appendicitis. The patient was treated with ___: Laparoscopic appendectomy. At the time of discharge, the patient had Acute appendicitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ y/o F who was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed acute appendicitis, WBC was elevated at 13.6. The patient underwent laparoscopic appendectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor tolerating a clear liquid diet, on IV fluids, and IV acetaminophen and IV hydromorphone for pain control. The patient was hemodynamically stable. When tolerating a diet, the patient was converted to oral pain medication with continued good effect. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ yo man with stage IV rectal cancer (retroperitoneal LAD, liver), HTN, who presents after failing outpatient management of cancer associated pain. Chest: Frontal and lateral views showed Left-sided port terminates in the mid to low SVC, without evidence of pneumothorax. The patient was diagnosed with Low back pain, Generalized enlarged lymph nodes, Malignant neoplasm of rectum, Essential (primary) hypertension. At the time of discharge, the patient had Rectal Cancer Pain Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o M with metastatic rectal CA, HTN, HLD, DM, CAD who presents with 3 months of worsening back pain despite uptitration of narcotic pain medications as an outpatient. # METASTATIC COLON CANCER # MALIGNANCY-RELATED PAIN # CONSTIPATION The patient presented with 3 months of worsening back pain despite uptitration of his narcotic pain medications at home. The pain has been attributed to his retroperitoneal metastatic disease. Recent MRI was reassuring against any evidence of cord compression. Neuro exam is also reassuring with no weakness or focal findings noted. Palliative care was consulted and patient's regimen titrated to fentanyl patch 75 mcg and q3h PRN 10 mg PO oxycodone. His pain was adequately controlled on t his regimen and he showed no signs of adverse CNS effects of narcotics. However he did not have a bowel movement during the admission and so received an aggressive home bowel regimen. He was given careful narcotic safety instructions and a narcan prescription. He did not have follow-up scheduled at the time of discharge, but he plans to call and set this up tomorrow. He will discuss amongst his outpatient providers who will be prescribing his narcotics moving forward. His PCP was contacted prior to discharge about this issue. (Of note, the patient preferred not to stay in house for addressing his constipation and follow-up plans, which was reasonable and medically acceptable). ========================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with with HTN, DL, congenital deafness, and borderline resectable pancreatic head adenocarcinoma on neoadjuvant C2D12 Folfirinox who presents with nausea/vomiting, diarrhea, and inability to tolerate POs. Radiology showed 1. No evidence of acute intra-abdominal process. 2. Pancreatic head hypodensity is unchanged and associated peripancreatic soft tissue density is less conspicuous, potentially due to interval improvement or differences in technique. 3. Left pelvic vein engorgement and left gonadal vein enlargement are nonspecific findings but may be seen in the setting of pelvic congestion syndrome. CHEST (PA AND LAT) showed In comparison with the study of ___, there is little interval change. The cardiac silhouette remains within normal limits with no evidence of vascular congestion or acute focal pneumonia. There is blunting of the left costophrenic angle on the lateral view, suggesting small interval pleurally fusion. The right Port-A-Cath again extends to the lower SVC. The patient was diagnosed with Nausea with vomiting, unspecified, Diarrhea, 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>___ female with with HTN, congenital deafness, and borderline resectable pancreatic head adenocarcinoma on neoadjuvant C2D12 Folfirinox who presents with nausea/vomiting, diarrhea, and inability to tolerate POs. # Diarrhea/Nausea/Vomiting: Most likely due to side effects of FOLFIRINOX. Abdominal CT without acute process and exam benign. Similar symptoms in past after chemotherapy. Less likely infection especially given negative stool studies. C. diff negative so after consultation with outpatient oncologist, treated with typical antidiarrheal regimen of loperamide and lomotil with resolution of diarrhea. Beginning to improve, mildly increased PO intake but solid foods still limited. Diarrhea largely resolved. After discussion with patient and outpatient oncologist was started on Decadron 2 mg PO daily to help improve appetite/reduce nausea in order to allow adequate PO intake for safe discharge. - Continue 2mg dexamethasone daily, likely will stop after 7 day course if continued improvement - Continue anti-emetic regimen - Continue PPI #Cough: Having cough intermittently productive of yellow sputum. Lung exam reassuring, CXR shows no evidence of pneumonia, afebrile without leukocytosis. -Monitor off antibiotics, if symptoms worsening consider repeat chest imaging -Cont IS -Encourage ambulation # Pancreatic Cancer/neutropenia: s/p FOLFIRINOX cycle 2 on ___. GI sx likely ___ further plans for administration of this drug. Neutropenic with ANC ___, likely ___ recent chemotx, no fevers to date, WBC now improved with ANC >2800. Will follow with Dr. ___. - Continue tramadol for pain # HTN: - Lisinopril was held initially, restarted on discharge # Anxiety: She reports having anxiety about leaving the hospital as after multiple recent discharges she quickly went to a local ED. She was counseled extensively that she had made gradual improvement and there was no further treatment recommended in the hospital at this time. -Consider outpatient social work or palliative care referral to help with anxiety and symptom management. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ w/ PMH UC, fibromyalgia, connective tissue disorder p/w sore throat and rash. States 5 days prior developed both sore throat and rash. Both have been progressively worse, especially the rash which is pruritic and progressing over most of her body, including the palms of hands, but not soles of her feet. Her lips are also progressively chapped and dry. She has only been able to take in pudding over the past few days. No nausea, but did have one episode of emesis today. Denies any fevers or chills the past five days. Also denies cough, SOB, chest pain. No sick contacts, recent travel, or exposure to woods. No IV drugs nor is she sexually active. Stopped prednisone 1mo ago and started celebrex and nortyptiline 3 weeks prior for worsening joint pains associated with her undefined connective tissue disease. She has received MMR, and also had the measles and chicken pox as a child. The patient was diagnosed with THROAT PAIN, NONSPECIF SKIN ERUPT NEC. The patient was treated with punch biopsy. At the time of discharge, the patient had ___ Syndrome. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Pt is a ___ w/ ___ UC, fibromyalgia, connective tissue disorder p/w sore throat and rash. # ___: The patient presented with a progressively worsening erythematous rash that involved her lips and oral mucosa. Dermatology was consulted and believed her presenation was most consistent with ___ Syndrome caused by medication, most likely celecoxib which the patient recently started. They also considered infectious causes or erythema multiforme but believed this was less likely. Celecoxib, NSAIDs, and nortriptyline were discontinued. Her rash stabilized with symptomatic and supportive treatment. GYN was consulted to ensure to vaginal lesions, and the patient did not have ophthalmologic symptoms confirmed on exam by Ophtho. She was able to tolerate a shower on ___ and was discharged later that day. She will need to follow-up with dermatology within 7 days. She will also have to follow-up with allergy after her rash resolves to determine if she had a reaction to medications. Unncessary medications should be avoided in this patient. #Pharyngitis: likely due to SJS as above. Viral etiologies were entertained but monospot and viral serologies were negative. She was managed symptomatically with viscous lidocaine and chloraspetic spray. #Thrombocytopenia: Patient had low platelets on admission (110's) that continued to downtrend with a nadir of 77. Etiology is unclear - her 4T score for HIT was low (1). Other possible etiologies include medication effect and her omeprazole was discontinued. Her platelets remained stable in the 80's for the last three days of her admission. #Acute Kidney Injury: The patient had elevated Cr on 1.9 on admission (baseline 1.1). This was likely prerenal azotemia from poor po intake due to oral lesions. She was given IV fluids until she was able to tolerate more intake. Her Cr was back to baseline at the time of discharge. Chronic Issues #CTD/Fibromyalgia - patient was continued on hydroxychloroquin, bentyl, gabapentin #UC - she showed no signs of flares during this admission #HTN - was continued on her nifedipine, triamterene/HCTZ Transitional Issues - Avoid unnecessary medications - f/u with derm over the next week - when improved, Allergy/Immunology evaluation to determine if TCA's or Acetaminophen can be re-introduced or used in the future</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ gentleman with history of prior MI, hypertension, hyperlipidemia, and crohns who presents with acute onset left-sided weakness. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Dental amalgam streak artifact limits study. 2. No evidence of acute intracranial hemorrhage, edema, mass effect or acute large territorial infarction. Please note MRI of the brain is more sensitive for the detection of acute infarct. 3. Extensive nonocclusive carotid siphons calcifications. Otherwise, grossly patent circle of ___ without definite evidence of occlusion, stenosis, or aneurysm. 4. Mild atherosclerotic narrowing at the origins of bilateral internal carotid arteries without definite high-grade stenosis by NASCET criteria. 5. Moderate nonocclusive atherosclerotic narrowing at the origin of the right vertebral artery. 6. Otherwise, no definite evidence of cervical carotid or vertebral artery dissection, stenosis or occlusion. 7. Bilateral subclavian artery nonocclusive probable atherosclerotic disease as described. 8. Left anterior mandibular canine ___ 22) demonstrates a dental ___ and periapical lucency. 9. Paranasal sinus disease , as described. 10. Mildly prominent nonspecific subcentimeter cervical and mediastinal lymph nodes without definite enlargement by CT size criteria as described, which may be reactive. 11. Limited imaging of cervical spine demonstrates multilevel degenerative changes with mild-to-moderate vertebral canal narrowing from C3-4 through C6-7. If concern for cervical spinal cord compression, consider cervical spine MRI for further evaluation. 12. 4 mm right thyroid lobe nodule. Please see recommendation below. RECOMMENDATION(S): Thyroid nodule. No follow up recommended. Absent suspicious imaging features, unless there is additional clinical concern, ___ College of Radiology guidelines do not recommend further evaluation for incidental thyroid nodules less than 1.0 cm in patients under age ___ or less than 1.5 cm in patients age ___ or older. Suspicious findings include: Abnormal lymph nodes (those displaying enlargement, calcification, cystic components and/or increased enhancement) or invasion of local tissues by the thyroid nodule. ___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR Incidental Findings Committee". J ___ ___ 12:143-150. NOTIFICATION: The impression and recommendation above was entered by Dr. ___ on ___ at 20:35 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 evidence of hemorrhage, edema, mass effect or infarction. CHEST (PA AND LAT) showed New right middle lobe consolidation concerning for pneumonia. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 2:10 pm, 20 minutes after discovery of the findings. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Study is moderately degraded by motion. 2. Question right precentral gyrus artifact versus acute infarct as described. 3. Global volume loss and probable microangiopathic changes. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 1:40 pm, 25 minutes after discovery of the findings. Radiology showed Multiple dilated loops of small bowel measuring up to 5.2 cm associated with multiple air-fluid levels and a paucity of colonic gas is highly concerning for high grade small bowel obstruction. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 9:23 am, 20 minutes after discovery of the findings. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed New enteric tube terminates in expected location of the stomach. No significant change in right middle lobe consolidation when allowing for lower lung volumes. Small bilateral pleural effusions. CT ABDOMEN PELVIS WITH CONTRAST showed 1. High-grade small bowel obstruction with transition point at the terminal ileum, which is entrapped in a moderate right inguinal hernia. No definite evidence of bowel ischemia. Urgent surgical consultation is recommended. 2. Multiple areas of abnormal small bowel wall thickening interspersed with areas of dilatation, in combination with mesenteric lymphadenopathy, suggest lymphoma. 3. Sequela of aspiration in the right lower lobe. 4. Moderate bibasilar atelectasis and moderate bilateral dependent pleural effusions. 5. Moderate amount of ascites NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 5:15 pm, 5 minutes after discovery of the findings. CT abdomen and pelvis with contrast showed -The reduced distal ileum again demonstrates extensive wall thickening and mild (improved) dilatation but no pneumatosis or other signs of bowel infarction. Unchanged mildly enlarged mesenteric lymph nodes. Again, underlying mass such as lymphoma is difficult to exclude. None of the enlarged lymph nodes appear amenable to percutaneous biopsy and would require surgical biopsy. -Anasarca is worse including slightly increased small quantity of ascites. There is no free intra-abdominal air. -Subcutaneous edema and bilateral pleural effusions slightly increased as well, right is moderate, left is small. Adjacent consolidations are likely due to atelectasis. -Minimal aspirations to the right lower lobe, unchanged. The patient was diagnosed with Cerebral infarction, unspecified, Pneumonia, unspecified organism. At the time of discharge, the patient had ischemic stroke, likely embolic. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ gentleman with history of prior MI, hypertension, hyperlipidemia, and Crohn's disease who presented with acute onset left-sided weakness. #Stroke NIHSS in ED 7 for left facial and left hemiparesis. CT head without acute process. CTA head and neck showed some atherosclerotic disease with adequate flow-trough. He was given tPA at 10:58 am with initial improvement of his NIHSS to 1 (left nasolabial fold flattening). Post-tPA events notable for transient episode of hypotension that resolved with IVF. NIHSS at that time worsened to 4 with improvement s/p hydration. Within 24 hrs, his post-tPA NIHSS improved to 2 (left facial, left arm drift). MRI brain with subtle foci of right frontal foci of diffusion restriction corresponding to precentral gyrus with ADC correlate suggestive of acute infarct/embolus with lysis from tPA. Transthoracic echo demonstrated large atrial volume, increasing risk of arrhythmia and an EF of 55% with no clots visualized. He was monitored on telemetry, but no atrial fibrillation was seen while inpatient. He will need a cardiac event monitor while in rehab or on discharge from rehab to look for occult atrial fibrillation. ___ was continued on aspirin 81mg daily for stroke prevention. His stroke risk factors were LDL 41, TSH 1.7, and hemoglobin a1c 5.7. There was no clear cause of his stroke, so occult atrial fibrillation causing a cardioembolic stroke was thought to be the most likely culprit. If atrial fibrillation is found, either a DOAC such as apixiban or Coumadin should be initiated. #HTN/HLD Blood pressure medications were held on admission to allow for permissive hypertension to SBP 180. Blood pressure medications were slowly reintroduced, with adequate blood pressure control (goal SBP <160) achieved on no antihypertensives. On discharge, we restarted metoprolol XL 12.5mg (half his home dose) and continued to hold losartan. These medications can be titrated up as needed at rehab to achieve SBP <160. His home atorvastatin was continued, as his cholesterol is under good control on current regimen. #PNA On admission, he was also found to have a right middle lobe pneumonia, for which he was treated with ceftriaxone (7 days) and azithromycin (5 days), and we covered for potential MRSA with vancomycin. MRSA swab was negative on ___, and vancomycin was discontinued. His white blood count was notable for leukocytosis of 37 and he was significantly dehydrated. We rehydrated him and consulted nutrition for re-nourishment recommendations, as he was frail on admission. He also had stage II pressure ulcer on his coccyx, for which a wound consult was placed. Social work was also consulted to help evaluate and supplement home care. Physical therapy recommended rehab on discharge, so patient was sent to rehab on ___. #CLL Patient was noted to have abnormal blood counts, which we discussed with hematology. There was concern for CLL, for which they recommended workup as an outpatient. We ordered a d-dimer, which was elevated to 8520. Serum viscosity was normal. They also recommended sending flow cytometry and cytogenetics, as well as hepatitis B, hepatitis C, and HIV, which we sent prior to discharge. One of the CT scans of his abdomen was read as lymph nodes concerning for lymphoma. We discussed with hematology, who felt the lymph nodes were more likely reactive in the setting of a small bowel obstruction. They recommended outpatient follow up, which we scheduled for after discharge. #SBO On ___ AM, patient vomited bilious fluids. KUB showed acute small bowel obstruction. Patient was made NPO. ACS was consulted, and colorectal surgery saw patient on ___, recommended NG tube to suction, and CT abdomen with PO contrast to look for etiology of obstruction. CT showed a small bowel obstruction. Surgery reduced a hernia. Patient remained NPO for the weekend, and vomiting resolved. Surgery did not feel that the SBO was due to the patient's hernia, and GI did not feel that the SBO was due to Crohn's flare. The CT scan had lymph nodes concerning for lymphoma, so we consulted ___ for biopsy. ___ recommended repeating the CT abdomen, which showed a resolved small bowel obstruction and thickening of the small bowel. There were lymph nodes that were not amenable to biopsy. Hematology and ___ both felt lymph nodes were more likely reactive, so we did not further pursue biopsy. CT scan may need to be repeated as an outpatient with hematology at follow up to look for change in lymph nodes. We spoke with GI, who said that he should resume his home GI medications on discharge. They are not sure if this is a Crohn's flare or not, but the biopsy will give us the answer. They deferred starting steroids, as they possibility of lymphoma was present and this would change his treatment course. The morning after his colonoscopy, patient had a small amount of diarrhea on the bed. Per report, it was dark, and concerning for blood. His next BM witnessed by medical team was diarrhea that was bilious in color, no bright red blood or melena. We repeated a CBC, which was stable. We discussed with GI, who said there could be a small amount of blood that would be expected after biopsy of the terminal ileum. Since his CBC was stable, there was no further workup needed, and patient was scheduled to follow up with GI. Transitional Issues =================== [ ] Follow up with hematology after discharge for workup of CLL, to follow flow cytometry and cytogenetics, consideration of repeat abdominal imaging to see if lymph nodes are reactive or suspicious for lymphoma [ ] Follow up with GI in clinic as scheduled by GI. Patient will be notified of biopsy results. [ ] Follow up with neurology in ___ months [ ] ___ of Hearts (cardiac event monitoring) while in rehab [ ] Repeat CBC at least weekly to evaluate for ongoing blood loss from the GI tract 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. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No. If not, why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL =41 ) 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 6. Smoking cessation counseling given? () Yes - (x) 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: [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - (x) No - no a fib documented </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o M with history of COPD and esophagitis presents with 6 weeks of low back pain after lifting a 6 or 7 pound object at work. He states that he felt something pop in his back, but ignored the pain and continued to work. He later developed severe back pain which hindered his ability to ambulate. He was evaluated by ___ and determined that it was a strain, he was given pain medication and sent home. Pain was not relieved and he later returned to the ED where this time an MRI was performed that showed a chronic compression fracture and a disc bulge. He was treated with prednisone and pain medication then sent home once again. Pain then continued and he was evaluated by his PCP who recommended another MRI. MRI showed worsening of the compression fracture and he was then sent to ___ for further evaluation. Radiology showed 1. Diffuse osteopenic and heterogeneous osseous structures, raises concern for multiple myeloma. A few rounded lytic lesions are present, including within the right iliac bone and vertebral bodies. 2. Compression fracture of T12 vertebral body with 6-mm of retropulsion is unchanged in appearance. Compression deformities of T10 and L2 vertebral bodies are similar to prior. A few incompletely healed left rib fractures are present. 3. Cholelithiasis with extrahepatic bile duct dilation without intrahepatic bile duct diltation, could represent an early obstructive process. If LFTs are elevated, MRCP may be obtained to evaluate for choledocholithiasis. 4. Dilation of proximal small bowel up to 3.7 cm without defined transition point, likely secondary to oral contrast bolus. 5. Pulmonary arterial hypertension. Right lung base scarring and atelectasis. Findings were communicated via phone call by ___ to ___, neurosurgery, on ___ at 3:18 pm. Radiology showed 1. Several lucencies throughout the calvarium, suspicious for metastatic disease or myelomatous deposits. 2. Compression deformities of T10 and T12. 3. Degenerative changes as described above. The patient was diagnosed with FX DORSAL VERTEBRA-CLOSE, FX LUMBAR VERTEBRA-CLOSE, OTHER OVEREXERTION AND STRENUOUS AND REPETIVE MOVEMENTS OR LOADS. At the time of discharge, the patient had back pain spinal lesions 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>Pt was admitted to the Neurosurgery service and was placed on bedrest. His wife was able to obtain his MRI from ___ ___ (was not transported with patient). Upon review of this MRI it was found that there were multiple concerning lesions throughout the spine as well as a new L2 compression fx (approx 25% loss of height). On ___ oncology was consulted and the patient underwent multiple lab tests as well as a CT Torso and skeletal survey. The patient recieved a TLSO brace. He was noted to have hypercalcemia and was treated with IVF and lasix. This remained stable on repeat check and was cleared for discharge home per the patient's request and this was cleared by neurosurgery and oncology. The patient will follow up in the ___ clinic on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male with stage IIB pancreatic adenocarcinoma s/p neoadjuvant FOLIFIRNOX followed by pancreaticoduodenectomy ___, radiation therapy gemcitabine/capecitabine and now single agent gemcitabine (last dose ___, also history of splenectomy and distal pancreatectomy in ___ ___ Radiology showed No acute cardiopulmonary process. The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS: Fever SECONDARY DIAGNOSES: Stage 2a pancreatic cancer S/p splenectomy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo M with hx of main duct IPMN s/p distal pancreatectomy with stage IIB pancreatic adenocarcinoma s/p neoadjuvant FOLIFIRNOX followed by pancreaticoduodenectomy ___, radiation therapy gemcitabine/capecitabine and now single agent gemcitabine (last dose ___ who presented with fever. #FEVER Pt reported fever at home w/o other focal infectious symptoms. He called his hematology/oncology MD who recommended he come to the ED. No leukocytosis. CXR was w/o PNA. Flu swab was negative. U/a was normal. Pt was initially treated with vancomycin and zosyn in the ED, which was then transitioned to cefepime upon admission. Pt was HDS and w/o fever in the hospital. Of note, he had a recent MRCP that showed evidence of cholangitis and was seen by GI who did not start abx as he had no clinical evidence of cholangitis. Bilirubin was slightly elevated in hospital at 2.4, but patient had no clinical evidence of cholangitis. He was discharged with levofloxacin 750 mg daily to be taken for four days unless culture data came back positive. He will be notified if that is the case and instructed to come to the hospital. He was also given extra levofloxacin given his splenectomy and instructed to take one pill and call his doctor if he develops a fever in the future. # Pancreatic adenocarcinoma stage IIB, On Chemotherapy with a curative intent, status post four cycles of neoadjuvant FOLFIRINOX with CyberKnife radiation and surgery on ___ C3D9 of Gemcitabine. Last chemo on ___ #Patient was continued on home medications for chronic medical problems **TRANSITIONAL ISSUES** -Discharged w/five day course of levofloxacin -Discharged with extra levofloxacin given splenectomy and instructed to take one pill and call his MD if he develops a fever -Please ensure that he has had proper immunizations given lack of spleen -F/u with hematology scheduled -Blood and urine cx pending upon discharge -Of note, sugars were slightly elevated in hospital (200s) and should be followed up upon discharge </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with h/o severe smoking-related interstitial lung disease recently admitted ___ for decompression of spontaneous L PTX. A left chest tube was placed in the ED and was subsequently removed after confirming absence of air leak and resolution of PTX. Post pull film also failed to show recurrent PTX and patient was discharged home on ___ ___. He contacted Thoracic Surgery Clinic this AM with concerns for sensation of air leaking from his prior CT site. He was instructed to return to clinic with repeat CXR showing recurrent L PTX and mild R mediastinal shifting. He reports some increased fatigue/DOE on baseline home O2 requirement of 2L NC, but has otherwise remained hemodynamically stable and denies significant SOB/CP, fevers/chills, worsening cough. CHEST (PA AND LAT) showed 1. Compared to ___, new moderate-sized left pneumothorax with rightward shift of the trachea and mediastinum suggesting a degree of tension. 2. Interval increase in left-sided subcutaneous gas, which now extends to the left neck. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 10:05 am, 2 minutes after discovery of the findings. Radiology showed Interval placement of left-sided chest tube. Left pneumothorax has decreased in size and is now barely visible. CHEST RADIOGRAPH showed 1. Low lung volumes with re-demonstration of extensive subcutaneous emphysema overlying the left chest wall and neck. No appreciable pleural effusion. New pneumomediastinum is probably not clinically significant. 2. Previously described small left pneumothorax is not well seen on today's exam. 3. Improving mild pulmonary edema. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date and the study of 221, there again is a left chest tube in place with small residual pneumothorax an extensive gas along the left chest wall extending into the neck. Some residual pneumomediastinum is seen in the upper region. Slightly improved lung volumes with little change in the appearance of the heart and lungs except for poor definition of the left hemidiaphragm, suggesting atelectatic changes and pleural fluid in this region. CHEST (PORTABLE AP) showed In comparison with the study of ___, the left chest tube remains in place and there is no evidence of pneumothorax. Extensive subcutaneous gas is again seen along the left lateral chest wall extending into the neck. Pneumomediastinum is clearing. Little overall change in the appearance of the heart and lungs except for some mild increased opacification at the left base. CHEST (PORTABLE AP) showed Improvement since prior. No pneumothorax. The patient was diagnosed with Other pneumothorax. The patient was treated with ___: s/p left chest tube placement (___) and chemical pleurodesis (talc). At the time of discharge, the patient had recurrent spontaneous left pneumothorax urinary retention. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was evaluated in the Thoracic Clinic and a chest xray demonstrated a recurrent left pneumothorax. He was sent to the Emergency Room for urgent placement of a chest tube. He tolerated the procedure well and initially had a large air leak. A subsequent chest xray confirmed placement of the tube at the left apex and a tiny residual apical pneumothorax. he was transferred to the Surgical floor for further management. Later that day he underwent talc pleurodesis with 4 Grams of sterile talc. Towards the end of the procedure he had some burning pain which was relieved with IV Dilaudid. The tube was placed above the level of his heart for 2 hours post pleurodesis and he repositioned himself frequently to coat the lung then the tube was placed on -20 cm suction for 48 hours. About 6 hours later he developed sinus tachycardia to 130 and desaturated to the low 80's eventually requiring a non rebreather. He was transferred to the SICU for further management of what seemed to be talc related SIRS. He was never intubated but required high flow O2 to maintain sats > 88%. His chest xray showed no pneumothorax and his pain was controlled with oral Dilaudid. He spent time in ICU for weaning off of high flow oxygen and his chest tube was eventually removed on ___. His post pull film showed no evidence of PTX and he remained hemodynamically stable without need for repeat CT placement. He was evaluated by the Pulmonary service and recommendations were made for reducing his Prednisone to 10 mg daily from 20 mg daily during this acute phase to allow for appropriate inflammation and ensure adequate pleurodesis. Given that his surgical problems had resolved (no recurrence of PTX following pleurodesis), the deicision was made to transfer patient to Medicine Service for continued O2 wean and medical management of his known ILD. On medicine service, O2 requirement rapidly decreased without intervention. On DC, satting in low ___ on 2L O2, which is home O2 requirement. Course also complicated by urinary retention requiring foley catheter, which had resolved on discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: The patient is a ___ PMHx afib on Xarelto, HTN, HLD, pre-DM, aortic stenosis, OSA, and RCC s/p nephrectomy who presents to the ___ ED ___ with transient visual symptoms. CT HEAD W/O CONTRAST showed No acute intracranial process. Chest: Frontal and lateral views showed Mild cardiomegaly without overt pulmonary edema. MRI AND MRA BRAIN AND MRA NECK PT11 MR HEAD NECK showed 1. No acute intracranial abnormality including infarct, hemorrhage or suggest a mass. 2. Patent intracranial vasculature without significant stenosis, occlusion, or aneurysm. 3. Patent cervical vasculature without significant stenosis, or occlusion. Note that the origins of the great vessels are not assessed. The patient was diagnosed with Transient cerebral ischemic attack, unspecified. At the time of discharge, the patient had Visual disturbance. The patient was given written instructions concerning 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 multiple vascular risk factors including afib on Xarelto, HTN, HLD, pre-DM, aortic stenosis, OSA, and RCC s/p nephrectomy who presented with transient visual symptoms (described as images breaking up), disorientation and lightheadedness. These symptoms had resolved by the time of admission to the hospital and did not recur. Her neurological exam after admission was normal. Her visual symptoms were not consistent with stroke or TIA and MRI was negative for stroke. Her symptoms were possibly due to migraine or intraocular cause (fragmented, kaleidoscope images). ***Transitional issues: - follow up with outpatient ophthalmologist - follow up with neurology</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old female with recurrent, metastatic cervical CA complicated by rectovaginal fistula (s/p diverting ostomy), vesicovaginal fistula, b/l ureteral strictures c/b obstruction s/p multiple PCNs and immune check point inhibitor induced adrenal insufficiency presents from home with weakness and fevers. CHEST (PORTABLE AP) showed Redemonstration large left upper lobe mass with adjacent osseous rib destruction with the size of the mass appearing increased from the prior chest radiograph. Mild atelectasis in the lung bases. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial abnormality. CTA CHEST WITH CONTRAST showed 1. Substantial interval increase in size and invasiveness of large left upper lobe mass, with worsening destruction of the left third through 8 posterior ribs, right fifth posterior rib, and T4 through T7 vertebral bodies with marked soft tissue extension into the spinal canal at T4 and T5. 2. New destructive metastasis that destroys the right proximal clavicle measuring 4.9 cm x 2.6 cm x 3.2 cm. 3. Increased mediastinal lymphadenopathy. 4. Small left pleural effusion. 5. Limited assessment of the segmental and subsegmental pulmonary arteries due to motion. No evidence of pulmonary embolism to the level of the proximal segmental arteries. No acute thoracic aortic abnormality. SHOULDER ___ VIEWS NON TRAUMA RIGHT showed No comparison. Three views of the right shoulder are provided. The periarticular soft tissues are unremarkable. No dislocation. No evidence of fracture. No osteolytic lesions. HUMERUS (AP AND LAT) RIGHT showed No comparison. Two views of the right humerus are provided. The cortical structures are intact. The shaft is unremarkable. The bony matrix radiographically appears normal. No evidence of fractures, no osteolytic lesions. The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had Pt was discharged and admitted to inpatient hospice, please see discharge summary from ___. The patient was given written instructions concerning 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 was discharged and admitted to inpatient hospice, please see discharge summary from ___</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 a past medical history of CAD s/p CABG ___, LIMA-LAD, reverse SVG-PDA) poorly controlled Type 2 DM, hypertension and hyperlipidemia, who presents with 1wk dyspnea on exertion CTA CHEST WITH CONTRAST showed 1. Of note, this is a suboptimal study due to patient respiratory motion artifact, particularly in the lung bases. Given these limitations, there is no evidence of pulmonary embolism to the segmental level or aortic abnormality. 2. Main pulmonary artery is moderately dilated, measuring up to 3.4 cm, which can be seen in pulmonary hypertension. The patient was diagnosed with Dyspnea, unspecified. The patient was treated with Cardiac Catheterization ___. At the time of discharge, the patient had Primary: NSTEMI Secondary: Systolic Heart Failure, Atrial tachycardia. The patient was given written instructions concerning 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 T2DM, CAD s/p CABG, and HTN who presents with progressive DOE, found to have elevated troponin c/f ACS. # Dyspnea on exertion hx CABG two mos ago w/o complications, active at baseline, then acute onset sob x1-2wks progressively worsening, associated with palpitations, found to have Trop .04-->.09, started on heparin gtt, got full dose ___. Given no obvious ischemic EKG changes, third trop stable (0.09) thought to be due to atrial tachycardia, heparin gtt stopped. However on repeat ECHO, EF newly depressed to 35% and "moderate regional systolic dysfunction c/w CAD in the LAD territory," and heparin restarted prior to cath. R groin access was obtained and cardiac catheterization revealed 90% stenosis of native LAD and 90% stenosis of LIMA-LAD graft. A drug eluting stent was placed in the native LAD. Pt was continued on ___, atorvastatin 80mg, metoprolol (increased to 200mg XL), and was started on Lisinopril 2.5mg. Also considered PE but r/o by CTA (which also showed moderate PA dilatation). Lung processes considered--no hx asthma, smoking, CT negative for ILD process. # Systolic heart failure Presented w/ DOE w/o ___ edema, ProBNP 697, Echo this admission w/ EF 35%. Did not get diuresis at this time as no e/o hypervolemia on exam. # Atrial tachycardia Heart rate to 100s at rest, to 130s when up to bathroom; EKG change in pwave from baseline c/w atrial tachycardia. Likely due to scarring from cardiac surgery vs CAD. Likely contributing to DOE. Improvement in rate and symptoms with metoprolol (increased to 200mg XL) # Microcytic Anemia MCV 75, on Iron supplementation, Hgb relatively stable (9.6-->9.8-->9.1). Repeat labs during admission: Iron: 29, calTIBC: 369, Ferritn: 27, TRF: 284. Was continued on home dose Iron # DM On Lantus 40u qAM at home w/ SS Humalog for meals (usually ___, maintained to Lantus 30u qAM + SS Humalog. No hypoglycemic events # Right ankle wound: 3x2cm wound at medial/anterior right ankle which is healing by second intention with assistance of wound VAC. Being followed by Dr. ___. Original insult was saphenous vein harvesting with wound repair c/b her peripheral vascular disease. Podiatry consulted, who took down wound vac, found granulation tissue, no signs of infection, and replaced vac</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ yo female presenting with left hip pain after falling down approximately 8 stairs in her house and landing on her left hip and shoulder. She immediately noted pain and inability to bear weight. She was initially taken to ___ ___ where a full trauma workup was conducted, and while other injuries to her head, neck and spine were ruled out, she was noted to have a left acetabular fracture. She was then transferred to ___ for management. At baseline, she ambulates independently without assistance and works full-time as a ___, spending a great deal of time on her feet. She notes some bumps and bruises from the fall around her left shoulder and back, but no other serious injuries. Radiology showed 1. Comminuted left acetabular fracture involving the medial wall and roof, with extension into the anterior column, as described above. There are also fractures of the iliac wing and pubic rami. 2. Moderate amount of extraperitoneal and intramuscular hemorrhage. Radiology showed Traction pin extends through the left femoral distal metadiaphysis, without evidence of hardware complication. PELVIS (AP, INLET AND OUTLET) showed Images from the operating suite show fixation device about the left acetabular fracture. Further information can be gathered from the operative report. PELVIS W/JUDET VIEWS (3V) showed Surgical fixation hardware about the left acetabular fracture, without complications. PELVIS (AP, INLET AND OUTLET) showed ORIF ofa left acetabular fracture without complications. Radiology showed Diffuse dilatation of small and large bowel loops, consistent with ileus. Portable chest radiograph showed 1. Interval placement of an enteric tube is coiled within the distal esophagus. 2. New platelike atelectasis at right lung base. NOTIFICATION: Finding #1 was telephoned to Dr. ___ by Dr. ___ on ___ at 10:23AM, approximately 10 minutes after discovery. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the nasogastric tube is now in correct position. No evidence of complications, notably no pneumothorax. The platelike atelectasis at the right lung bases is constant in appearance. Radiology showed 1. Interval placement of NG tube with its tip in the stomach. 2. Diffuse bowel dilatation consistent with ileus, not significantly changed compared to prior study. Radiology showed Compared with ___ at 10:37 a.m., the small bowel dilatation is more pronounced and the possibility of an early or partial small-bowel obstruction cannot be excluded. Please see report of abdominal CT obtained slightly later the same day. Radiology showed Slight interval improvement in the degree of both large and small bowel distention. CT ABD AND PELVIS WITH CONTRAST showed 1. Dilation of the small bowel, ascending colon, and transverse colon with a transition point at the splenic flexure and collapse of the descending colon. There is mild associated free fluid within the mesentery, but no free air or bowel wall thickening. Findings may represent paralytic ileus versus focal ischemic stricture at the splenic flexure of the colon. 2. Cholelithiasis without acute cholecystitis. 3. Colonic diverticulosis. 4. Left comminuted acetabular fracture status post ORIF. NOTIFICATION: Findings were conveyed by Dr. ___ to Dr. ___ telephone at 09:54 on ___, 1 min after interpretation. Radiology showed Dilated small and proximal large bowel. Compared with one day earlier, the appearance is similar, without gross improvement. CHEST (PORTABLE AP) showed Right lower lobe linear atelectasis is unchanged. NG tube tip is most likely in the stomach. Of the bowel wall is demonstrated, overall unchanged. Heart size and mediastinum are stable in appearance. Lungs are essentially clear and there is no pleural effusion or pneumothorax appreciated. Radiology showed Ileus with moderately dilated small bowel loops and cecum. Continued follow up is recommended. Radiology showed Stable dilatation of the small bowel and cecum since ___, likely ileus, however underlying obstruction cannot be excluded. COLON (GASTROGRAF) showed No evidence of obstruction or mass lesions. Contrast passes to the more dilated splenic flexure promptly and drains promptly as well. However, multiple diverticula and spasm noted in the lower descending colon. Radiology showed Comminuted fracture of the left acetabulum, inferior and superior pubic rami as well as the left iliac wing. The patient was diagnosed with FRACTURE ACETABULUM-CLOS, FRACTURE OF ILIUM-CLOSED, FALL ON STAIR/STEP NEC, HYPERCHOLESTEROLEMIA. The patient was treated with ORIF left acetabuler fracture. At the time of discharge, the patient had Left acetabular 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. She was found to have left acetabular fracture and was admitted to the orthopedic surgery service. She was taken to the operating room on ___ for ORIF left acetabuler fracture, and again on ___ for exam under anesthesia and anterior column percutaneous screw, which she tolerated well (for full details please see the separately dictated operative reports). She was initially given IV fluids and IV pain medications, and although her diet was advanced to regular, she was made NPO again after failing to have a bowel movement for 5 days and developing significant distention and ileus. ACS was consulted, and they ultimately recommended bowel decompression with neostigmine in the TSICU, which the patient tolerated well. After successful bowel decompression, the patient was transferred back to the floor, NG tube was discontinued, and her diet was once again advanced to regular. She passed flatus and had watery bowel movements. Her distention improved with Reglan. She was also encouraged to ambulate, which improved her abdominal distention as well. She was given perioperative antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. She worked with ___ who determined that discharge to rehab was appropriate. Her 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 she was voiding/moving bowels spontaneously. She is touchdown weight bearing in the left lower extremity, and will be discharged on lovenox for DVT prophylaxis. The patient will follow up in 7 days. 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: Mr. ___ is a ___ year old M visiting ___ from ___ with a past medical history significant for a PTX X 2 who presents with acute central chest pain. The pain began yesterday morning and is located substernally. It is non-radiating and worse with deep inspiration. He also felt fatigue and chills at home. He had mild shortness of breath with exertion due to the pain he felt with deep inspiration but no dyspnea at rest. He also denies nausea, vomiting, diarrhea, urinary symptoms, leg swelling or calf pain. He reports a mild sore throat yesterday and a cold ___ weeks prior to this presentation. In the ED, initial vital signs were: T:100.4 (Tm: 101.4F) 85 131/85 16 100RA. ED course was notable for a negative D-dimer and negative UA as well as negative Troponin X 3. Initial EKG was unremarkable but subsequent EKGs showed diffuse ST elevations without reciprocal depression. He received about 4L of fluid during his ED course and was started on ibuprofen and colchicine. Blood cultures were initially sent but later canceled. Upon arrival to the floor, the patient was hemodynamically stable with vitals of 98.4F, RR 16, O2 Sat 97% RA. He reports feeling much improved since arrival but continues to report focal central chest pain without radiation, worse with deep inspiration. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality. Radiology showed 1. No acute cardiopulmonary process. No pulmonary embolism. 2. Mild paraseptal and centrilobular emphysema. The patient was diagnosed with CHEST PAIN NOS, FEVER, UNSPECIFIED. At the time of discharge, the patient had Primary Diagnosis: Pericarditis. The patient was given written instructions concerning 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 on vacation in ___ from ___ with a past medical history significant for pneumothorax X 2 and presenting with acute-onset substernal chest pain with negative cardiac enzymes, clear CXR and negative CTA; now clinically stable and being treated for pericarditis. #ACUTE PERICARDITIS Mr. ___ presented with signs and symptoms concerning for pericarditis, namely central pleuritic chest pain worse with deep inspiration, a fever to ___ on admission, fatigue and classic diffuse ST elevations/PR depressions on EKG. The differential initially included ACS, though this was ruled out based on the EKG findings and negative cardiac enzymes X 3. Pulmonary Embolism was also ruled out with a negative D-dimer and negative CTA of the Chest. Of note, UA was also negative. These findings, in combination with a history of recent viral symptoms were most consistent with pericarditis. Mr. ___ underwent multiple laboratory studies and the results of these studies at the time of discharge are contained elsewhere in this report. He was also given ample fluid resuscitation and started on a regimen of Ibuprofen 800mg q8hrs and Colchicine 0.6mg twice daily for presumed pericarditis. He remained afebrile and clinically stable during his admission and was discharged home on this medication regimen. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with a past medical history of breast cancer status post chemoradiation and mastectomy and hypertension presenting with shortness of breath. CHEST (PA AND LAT) showed Finding suspicious for early cardiogenic pulmonary edema. No definite pneumonia. RECOMMENDATION(S): The findings followed up with ___ in urgent care by ___, M.D. on ___ at 12:35 pm, 2 minutes after discovery of the findings. CTA CHEST showed 1. Top normal heart size, mild pulmonary edema, small layering simple pleural effusions. 2. Enlarged main pulmonary artery, please correlate for pulmonary arterial hypertension. 3. No pulmonary embolism. The patient was diagnosed with Heart failure, unspecified. At the time of discharge, the patient had Primary: Acute systolic HF exacerbation Secondary: HTN Hypothyroidism 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>SUMMARY: ================= Mr ___ is a ___ y/o F with PMH significant for hx of breast cancer (s/p chemoradiation/mastectomy in ___, history of thyroid cancer (s/p thyroidectomy in ___, who presents with dyspnea with concern for possible new HF. The patient had an ECHO that revealed a newly decreased EF to 30% with concern for possible underlying ischemia. She underwent cath on ___ notable for 60% stenosis in LAD, 70% stenosis in diagonal for which percutaneous intervention was not felt to be needed. Etiology of her decreased EF was not entirely clear but ultimately felt most likely to be hypertensive heart disease. She will undergo outpatient CMR for further workup. She was discharged with plan for maximal medical therapy for new HFrEF and close cardiology follow-up. TRANSITIONAL ISSUES: =================== Discharge maintenance diuretic dose: Lasix 40mg Discharge weight: 151.9lb Discharge Cr: 1.0 [] Please check labs including Cr and K on ___ given new maintenance diuretic regimen of Lasix 40mg. Please also f/u volume status on this regimen. [] She will undergo cardiac MR as an outpatient for further workup for the etiology of her newly diagnosed HFrEF (with cath during this admission negative for obstructive CAD). [] Discharge HFrEF regimen included Lasix 40mg, metoprolol XL 25mg and valsartan 20mg BID (with plan to transition to Entresto once ACEi washout and pre-auth complete). [] Please follow-up on transition from valsartan to Entresto. [] Consider addition of spironolactone as able for further optimization of HFrEF regimen. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ ER+/PR-/HER2neu not amplified pT1cN1a invasive ductal breast cancer with ___ + lymph nodes s/p resection ___ and recently found to have bone mets on CT at ___ now w/ LLE pain x 1 month. This is getting worse to the point she is having trouble walking on it w/o a cane. The patient was sent in by oncologist for admission for pain control and further work-up. Pain is on the lateral aspect of the thigh and calf. Pain occurs on movement on bearing weight. ___ dull pain. No radiation. Radiology showed No evidence of DVT in the left lower extremity. Radiology showed No acute fracture or dislocation. Mild-to-moderate osteoarthritic changes of the left hip. Radiology showed 1. Innumerable metastatic osseous lesions. 2. Pathologic nondisplaced left subcapital fracture. Radiology showed Left femoral neck fracture. Please see MRI from the same day for further details of the pathologic fracture and other osseous lesions. Radiology showed 1. Intraoperative evaluation for left femoral neck fracture open reduction internal fixation. 2. Visualized surgical hardware appears intact. 3. Atherosclerosis within the left thigh. Please refer to the operative report for further evaluation. Radiology showed 1. No evidence of pulmonary embolism or aortic dissection. 2. Moderate bilateral pleural effusions with associated compressive atelectasis. 3. Small right lower lobe pulmonary nodule. Per ___ guidelines, a dedicated CT of the chest should be performed in one year for further evaluation. 4. Diffuse osseous metastases. The largest lesion is present in the lower lumbar vertebral body causing mild collapse of the vertebral body but no significant spinal canal narrowing. Results were discussed with Dr. ___, medicine resident at 8:45 p.m. on ___ via telephone by Dr. ___. Radiology showed Since the prior study, the patient has undergone a median sternotomy with aortic valve replacement. The heart appears upper limits of normal in size given portable technique. Lung volumes are lower, and there is prominence of the interstitium which may reflect age-related changes, small airways disease or smoking-related changes. Clinical correlation is advised. There is more patchy, streaky opacity at the left base which could reflect an area of patchy atelectasis or post-inflammatory scarring, although an acute infectious process cannot be entirely excluded. Both costophrenic angles appear mildly blunted and therefore raise the possibility of small bilateral effusions. No pneumothorax is seen. No pulmonary edema. Radiology showed Interstitial pulmonary edema and bilateral small-to-moderate pleural effusions. No evidence of focal consolidation or pneumothorax. Radiology showed FLAIR hyperintense foci in cerebral white matter and pons likely the sequelae of chronic microangiopathy without evidence of abnormal enhancement or masses. No infarcts. Small right cerebellar developmental venous anomaly. Evaluation of osseous metastases is limited on the present study. The patient was diagnosed with PAIN IN LIMB. The patient was treated with ___ - Fixation of left femoral neck basicervical fracture with long intramedullary cephalomedullary nail and prophylactic treatment of more distal femoral bone lesions with intramedullary device. At the time of discharge, the patient had Primary diagnosis: Left hip pathologic subcapital fracture from metastatic breast cancer Secondary diagnoses: Hypoxia Transaminitis Anemia Aortic stenosis IBS Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ y/o female with a hx of stage IIA (pT1c, N1a, M0) ER positive, PR negative, HER-2 negative, grade II invasive ductal carcinoma of the left breast, s/p RT and aortic stenosis s/p AVR who presented to her outpatient oncologist with severe left hip pain and was subsequently found to have a pathologic left subcapital fracture due to metastatic breast cancer.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M had sudden onset severe headache in context of receiving treatment for anaphylaxis to shrimp at another hospital (23:30 on ___. He was subsequently discharged. He returned home and had a second sudden onset severe headache during intercourse at 15:30 on ___ and a second time at 18:00 on ___. Radiology showed Unremarkable CT and CTA of the head. Radiology showed ___ underwent cerebral angiography which revealed diffuse vasculitis involving the anterior circulation in both hemispheres. The patient was diagnosed with HEADACHE, EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY, ASTHMA, UNSPECIFIED. The patient was treated with ___ Diagnostic cerebral angiogram. At the time of discharge, the patient had Cerebral Vasculitis. The patient was given written instructions concerning 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 Neuro-ICU for work up to rule out to aneurysm or vascular abnormality. He underwent a diagnostic cerebral angiogram that was negative for aneurysm but demonstrated diffuse cerebral vasculitis. Post-Procedure he remained flat x2 hours for hemostasis. Pulses remained bounding and intact and the groin was without hematoma. There was a mild ooze from groin that did not extend the boundaries of the dressing. Stroke neurology was consulted and felt that it was cocaine induced vasculitis. The patient remained neurologically intact throughout his hospital stay and his headache improved. Neurology felt that since his headache improved there was no need to start a new agent for headache control. They recommend follow up in 3 months in outpatient clinic or sooner if his headaches increase in frequency. The patient was counselled on stopping all cocaine use. At the time of discharge the patient was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old female with a history of bladder cancer s/p bladder resection with ostomy presenting with fevers at home. She recently started chemotherapy and neupogen last week; she presented with fevers and chills at home to 100.9. She also reported 2 episodes of watery diarrhea and foul smelling cloudy urine from ostomy bag. She recently had a UTI treated with macrobid; during that episode, she also had described foul smelling cloudy urine. Review of systems otherwise negative. Radiology showed No acute cardiopulmonary process. Radiology showed 1. Normal appearance of the ileal conduit. 2. Rapid opacification of the right ureter and mildly dilated right renal collecting system. 3. Rapid opacification of the left ureter, midway up the vertical portion, with no opacification of the left renal collecting system. Radiology showed New moderate left-sided hydroureteronephrosis with transition at the level of the ileal conduit consistent with stricture at the surgical anastomosis. The patient was diagnosed with URIN TRACT INFECTION NOS, FEVER, UNSPECIFIED. At the time of discharge, the patient had Urinary Tract Infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old female with a history of stage IV bladder cancer presenting with fevers at home, consistent with UTI as she has had several over the past few months since her ileoconduit in ___, confirmed EColi, Klebsiella and Enterococcus on urine culture, now with possible evidence of narrowing of left side of urinary drainage system. # UTI- UA reveals > 180 WBCs and patient reported foul smelling urine from ostomy consistent with prior episodes of UTIs. In the past, has had E Coli, sensitive to cefepime and macrobid. She also reports having had enterococcal UTIs in the past. WBC improved to 7.1, however downtrending was attributed to chemo-effect in addition to resolving infection. Urine culture confirmed on ___ dual infection with EColi and Klebsiella, both sensitive to cefepime. Patient remained febrile until ___ and remained on IV antibx until transitioned to PO on day of discharge. Loopogram ___ showed free reflux of contrast to the right kidney, and some reflux through the ureter of left kidney, but abruptly stopped before reaching the left renal collecting system. Urology then asked for a CT abd/pelvis to further evaluate this issue. Abd/pelvis CT showed no pyelonephritis, no abscess but possible narrowing at left ureteroileal anastamosis possibly contributing to frequent UTIs. Urine culture from ___ growing 10,000-100,000CFU of enterococcus, most likely colonization, but pansensitive per micro lab so she was started on a course of macrobid based on her risk for repeat UTI. Blood cultures continued to be negative to date. Her po intake, nausea and diarrhea improved by discharge. # Bladder cancer - recently started cycle 1 of adjuvant chemo s/p cystectomy (on paclitaxel, gemcitabine, and cisplatin); recently also started neupogen. Was scheduled to begin second cycle ___, however remained an inpatient and starting chemo was undesirable in this setting. The ostomy nurse was consulted and she received different supplies for her stoma that appeared to work better for her than the previous ones. #Neutropenia: Despite neupogen use after last cycle of chemo, patient was neutropenic on AM labs on the day prior to discharge with ANC of 940. She was placed on neutropenic precautions. She remained afebrile. She was discharged with instructions to continue taking neupogen as per home dosing schedule. #Diarrhea: Patient had episodic diarrhea with incontinence which was likely secondary to antibiotics and recent chemotherapy. C diff, CMV were both negative. She was supported with IVF and was started on low-dose loperamide and diarrhea resolved. # Acute renal failure - Creatinine increased to 1.4, likely in the setting of insensible losses with fever and poor PO intake. Resolved with IVF and improved PO intake. # Hypotension - She was admitted with low BP (90s) in the setting of possible urosepsis. Patient was not taking lisinopril of HCTZ prior to admission and these medications were held and discontinued on discharge. # Diabetes mellitus type 2 - Currently not on medications but was well-controlled throughout entire admission. # Hyperlipidemia - continued crestor # Anxiety - continued lorazepam PRN</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ s/p left MCA aneurysm clipping ___ presents with a CHEST (PORTABLE AP) showed Loss of height of the L3 vertebral body with dextroscoliosis which appears new since ___. Although potentially projectional, further dedicated spine imaging may be helpful to exclude an acute fracture CT HEAD W/O CONTRAST showed 1. Status post left frontotemporal craniotomy and left MCA aneurysm clipping with expected postsurgical appearance of the cranium. 2. 9 mm left frontal subdural fluid collection is likely a function of recent surgery. 3. No evidence of acute traumatic injury. NOTE ON ATTENDING REVIEW: The aforementioned left frontal subdural fluid collection is slightly mixed side attenuation with a few foci of increased density and may relate to subacute component of blood products. This can be related to recent surgery or trauma. No postoperative studies are available for comparison. On the bone algorithm images, there is a linear lucency in the left frontal bone series 3, image ___ - can relate to a fracture OR recent surgery however slightly remote from the surgical hardware. This was not seen on the preoperative study. Correlate clinically and consider a close followup as needed. CT C-SPINE W/O CONTRAST showed 1. Severe bony demineralization and multilevel, multifactorial degenerative changes with chronic appearing alignment abnormality of the cervical spine. No acute fracture. 2. At least moderate spinal stenosis at C4-5 and C5-6. Moderate to severe foraminal narrowing from C3-T1 levels. Mild asymmetry in the lateral atlanto axial distance is right more than left -question positional or related to ligamentous changes. Series 601 be, image 13, partly also seen on the prior CTA head and neck study ___. Correlate clinically to decide on the need for further workup. Prominent lingual tonsils more onto the left side with hypodense foci with, with fullness in part of the right vallecula along with a few calcifications. Correlate with the ENT examination; further workup as needed to exclude focal lesion. Please see concurrent CT head, T and L-spine studies CT LUMBAR SPINE WITHOUT CONTRAST showed Diffuse bony demineralization and mild dextroconvex scoliosis of the lumbar spine, but no evidence of acute fracture. Multilevel, multifactorial degenerative changes with mild to moderate canal and foraminal narrowing from L3-S1 levels. Limited assessment of cord, intrathecal details and ligaments on CT. Other details as above. CT THORACIC SPINE WITHOUT CONTRAST showed No evidence of traumatic injury to the thoracic spine or imaged ribs. Diffuse osseous demineralization and multilevel, multifactorial degenerative changes. No significant canal or foraminal narrowing. A partially calcified focus common in the midline in proximity to/ inferior to the right lobe of the thyroid, may relate to a nodule in the thyroid or related to vascular calcifications. Assessment limited on the noncontrast study. Correlation with ultrasound can be helpful. Please see concurrent CT head, C-spine and L-spine studies. CT HEAD W/O CONTRAST showed 1. Little to no change in the left frontal subacute subdural hematoma, which could be related to postoperative changes or recent trauma. 2. Linear lucency in the left lateral frontal bone which may be related to trauma or be postoperative in nature. CT HEAD W/O CONTRAST showed No change in small left frontal subdural fluid collection. The patient was diagnosed with SYNCOPE AND COLLAPSE. At the time of discharge, the patient had Right subdural fluid collection.. The patient was given written instructions concerning 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 ___ after striking her head. She was found to have a fluid collection at the previous surgical site that did not appear to be a hemorrhage. She was kept for observations. Medicine service was consulted for work up of possible syncopal episode. The EKG and Troponins were negative, and medicine felt that the syncopal episode was related to orthostatic hypotension due to possible dehydration. The patient was hydrated and orthostatic blood pressures were obtained and were within normal parameters. On ___ the patient remained neurologically and hemodynamically intact and expressed readiness to be discharged home. The patient was discharged home in stable conditions. All discharge paperwork and follow up were given prior to discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F with PMHx ___ cirrhosis (c/b grade I varices, no hx of ascites, SBP, or HE), DM2 (A1c 8.2 ___, severe AS (area <1.0cm2 TTE ___, syncope s/p ILR, post-menopausal bleeding with recent ___ and IUD placement (___) c/b vaginal bleeding, recently discharged to rehab ___ presents from rehab for anemia and hypokalemia. Per chart biopsy Dr. ___ (___) had received lab results that showed an hgb of 7 and K of 3.0. He called the rehab and instructed them to give 1u PRBCs and potassium on ___. The rehab decided to transfer her to the hospital instead. She did not receive a unit of blood there. On arrival here her hgb was 6.3. Per the patient, her only symptoms prior to her transfer back here was extreme fatigue and chronic ___ edema that she says does not seem worse than usual. She otherwise denies fever, chills, cough, sore throat, dysphagia, odynophagia, hemoptysis, hematemesis, chest pain, palpitations, light headedness, dizziness, SOB, abd pain, N/V/D/C, black or bloody stools, vaginal bleeding since discharge, dysuria, hematuria, numbness, weakness, falls. Of note on medication review from the rehab it looks like her torsemide was increased to 80 daily on ___. In the ED, initial VS were: 97.9, 83, 110/60, 16, 100% RA ED Exam: fatigued, III/VI SEM RUSB, CTAB, soft obese, NT abdomen, no distension, no vag bleeding, brown guaiac negative stool with ext hemorrhoids, ___, +MOYB, trace asterixis with essential tremor Labs showed: Anemia worse, Cr stable at baseline 1.3, Tbili stable 1.4, LDH normal, INR stable 1.3, Trop negative, lactate 2.2. CT ABD showed: no source of bleeding (full report below) Received: slow IVF (less than 1L) and 1u PRBCs Transfer VS were: 88, 110/84, 18, 99% RA Hepatology was consulted. HEPATOLOGY RECS: - hemolysis labs - 2 unit of PRBCs due to hx of elevated trops when last admitted with anemia & cross match 2 more - consider cards consult especially if trops come back positive - CT abd ___ ___ Decision was made to admit to medicine for further management. Radiology showed 1. No acute process in the abdomen or pelvis. No evidence of intraperitoneal or retroperitoneal hemorrhage. 2. Cirrhosis, with sequela of portal hypertension, including splenomegaly and extensive varices. 3. Very mild wall thickening involving the cecum and proximal ascending colon are likely related to portal colopathy the in the setting of cirrhosis. 4. Cholelithiasis. The patient was diagnosed with Anemia, unspecified. At the time of discharge, the patient had Primary Diagnoses: - Anemia - GI bleed - NASH cirrhosis Secondary Diagonoses: - Diabetes mellitus type 2 - Cecal polyp. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ woman with PMHx ___ cirrhosis, DM2, severe AS, and post-menopausal bleeding recently discharged to rehab on ___ presented from rehab on ___ for anemia and hypokalemia. While at rehab, found to have acute on chronic anemia with hemoglobin of 6.7. She was transfused 2 units of PRBCs with an appropriate increase in Hb. Hemoglobin remained stable in the following days. A definite source of bleeding was not identified. She has known post-menopausal bleeding, though only minimal vaginal bleeding while inpatient. Her stool was guaiac positive in the ED, but repeat stool guaiac after admission was negative. She has a known cecal polyp, which was also implicated but given her severe thrombocytopenia colonoscopic resection of the polyp is deferred. She should follow up with her regular providers, especially ___ and hepatology, for continued outpatient workup of her anemia. ==============</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ male who was diagnosed with AML in ___, treated with Idarubicin and ARA-C, relapsed in ___. He is now status post an allogeneic stem cell transplant from a matched unrelated donor for relapsed AML in ___. Complications include GVHD of the oral mucosa, eyes, liver, joints and COP. Patient now presenting with fever in setting of cough, myalgias, malaise, fatigue, chills and decreased appetite. Chest radiograph showed No acute cardiopulmonary process The patient was diagnosed with Fever, unspecified. At the time of discharge, the patient had Primary Diagnosis: ILI Secondary Diagnosis: Relapsed AML Chronic GVHD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old male who is s/p MUD ALLO transplant for AML admitted due to concern for ILI symptoms. Major complications of transplant have been: chronic extensive severe GVHD with lung, eye, joint, liver changes. He has had multiple readmissions for the above complaints. #Fever with ILI Symptoms: likely ___ viral process more than a bacterial process. Chest x-ray and UA were unremarkable. Urine and blood cultures are NTD. Patient refused Flu swab, has refused in the past. His history of bronchiolitis obliterans following stem cell transplant/decreased FVC and FEV1 from most recent PFTs in ___ (although he has been stable from a pulmonary standpoint) increases his risk for bacterial super-infection. His exposure as a correction ___ also poses a risk. -Initiated on Tamiflu (d1: ___ x28D -Levaquin x 5D for atypical coverage (___) -continue supportive care; monitor fever curve #GVHD: chronic, extensive and severe -lung: continue 1mg Prednisone QOD -liver: LFTs stable on admission -oral: continued dexamethasone oral solution -eye: continued with restasis gtts #Depression/Anxiety/Insomnia: continued alprazolam 4 mg PO QHS as needed and Benadryl 50mg IV prn only during hospital stay -has history of directing own care, refusing testing, and overall being withdrawn/poor communication with staff. -continue to monitor on this admission #Infectious prophylaxis: -PCP: ___: Acyclovir -Antifungal: None #DVT Prophylaxis: Lovenox 40mg daily, history of refusal #Access: PIV. No central access #FEN: regular diet #Pain control: none currently #Bowel regimen: none #Disposition: home after afebrile >48hrs, f/u ___ or sooner if issues arise</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ who was diagnosed with AIH and PSC in ___ and developed ESLD manifested by ascites, spontaneous bacterial peritonitis and peripheral edema who is s/p OLT ___. His post-op course was complicated by coffee ground emesis, renal failure secondary to FK toxicity and SBP. He now presents with one week of increasing ___ crampy abdominal pain, distension and non-bilious, non-bloody emesis for the past 48 hours. He denies diarrhea and reports that he has been passing flatus and moving his bowels. He denies rashes, fevers chest pain, shortness of breath, lower extremity edema or sick contacts. He reports that he has been taking his medications regularly. His tacrolimus level was last checked on six days ago and was slightly high so he was transitioned from 1.5 BID to 1.0 BID. Radiology showed 1. Small bowel obstruction secondary to probable internal hernia with obstruction at the level of the jejunojejunostomy. Moderate volume ascites. 2. Malpositioned Roux tube with tip in the peritoneal space. Findings were discussed in person with Dr. ___ at 1700. Radiology showed Moderate ascites, predominantly seen in the right lower quadrant. Radiology showed AP chest compared to ___: Lung volumes remain quite low and increase in pulmonary, hilar, and mediastinal vascular caliber suggests volume overload reflected in increased heart size as well, and at least a small right pleural effusion, but there is no pulmonary edema. Bilateral infrahilar consolidation is probably atelectasis. Nasogastric tube loops in a normal caliber stomach ending close to the pylorus. Large and small bowel are still severely distended and the wall is thickened by edema. No substantial pneumoperitoneum. Radiology showed There are staples overlying the midline consistent with recent surgery. There are multiple air-filled dilated loops of small bowel with air-fluid levels on the upright study. Some air and stool is seen in nondistended ascending, transverse, and sigmoid colon. Although this may represent an ileus, these findings are more suggestive of a partial small-bowel obstruction. Clinical correlation is advised and followup imaging should be performed as clinically indicated. There is no evidence of free intraperitoneal air. The patient was diagnosed with HERNIA, SITE NEC W OBSTR, LIVER TRANSPLANT STATUS. The patient was treated with ___ Exploratory laparotomy, reduction of internal hernia, closure of mesenteric defect.. At the time of discharge, the patient had internal hernia/mesenteric defect hypothyroidism h/o liver 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>___ y/o male who received a liver transplant on ___. The patient presents with a weekof abdominal pain, worse over the last few days. An abdominal CT was obtained showing Small bowel obstruction secondary to probable internal hernia with obstruction at the level of the jejunojejunostomy. There was also moderate volume of ascites seen. The patient was taken on the evening of admission to the OR with Dr ___ for ___ laparotomy, reduction of internal hernia and closure of mesenteric defect. At the time of surgery, from the ligament of Treitz to the terminal ileum there was a large mesenteric defect between the jejunojejunostomy. Small bowel had herniated through the defect and was obstructed. The small bowel was reduced, the hernia defect closed with interrupted ___ silk sutures. Of note, a large amount of ascites was removed at time of surgery. He was stable during the procedure and was transferred to PACU in stable condition. The patient was kept NPO with an NG tube in place through POD 3. Although output was not high, the abdomen remained quite distended, and the patient was not passing flatus. On POD 3 the NGT was removed and he was started on sips to clears over the next 2 days, which were well tolerated. On POD he had a bowel movement. Diet was advanced to regular and was well tolerated. The admission creatinine was 3.2, with his baseline being around 2. The patient was aggressively hydrated on admission, and over the course of the hospitalization the creatinine was down to 1.2. Medications were adjusted accordingly. During the hospitalization, the fluconazole was stopped as he was close to 3 months out. Blood cultures drawn during the hospital stay have all returned as no growth. The patient did have a diagnostic tap in the ED during the admission process which was found to grow corynbacterium. He received a 7 day of course of Ampicillin, was afebrile during the entire stay. A CMV IgG and IgM were sent, he was neutropenic on admission. IgG was positive at time of transplant, donor was negative, and as he was at approximately 3 month, the valcyte was stopped at discharge. Prograf levels were followed daily and adjustemts made accordingly. Additionally the patient will be staying on 5 mg prednisone for pre transplant Dx of autoimmune hepatitis, PCS, and UC. TSH was checked as patient had an increase in levoxyl during last hospitalization. TSH was 0.78, and his dose was decreased. New TSH level should be checked at the end of ___. The patient was ambulating, had return of bowel function, was tolerating diet, less distended abdomen. Incision was C/D/I. He is discharge to home in ___ with ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with HCV cirrhosis, esophageal varices with history of bleeding (s/p TIPS on ___, and HCC who presents from liver tumor clinic today with hepatic encephalopathy and a new adrenal mass. His medical history is plagued by intermittent non-adherence and loss of insurance. He had a surveillance CT abd on ___, which revealed a lesion consistent with HCC, as well as a new, left adrenal mass of unclear etiology. He was seen in the liver tumor clinic on ___, at which time his presentation was concerning for hepatic encephalopathy, though he reports adherence to lactulose. He was referred to the hospital for evaluation of confusion and expedited tumor work-up. Chest: Frontal and lateral views showed No acute cardiopulmonary process. DUPLEX DOPP ABD/PEL showed 1. Patent TIPS, with stable velocities and appropriate direction of flow. 2. Stable hypoechoic lesion in the left lobe of the liver. An additional hypoechoic lesion with hypoechoic rim measuring 2.4 cm in the left lobe, not well seen on prior study. RECOMMENDATION(S): MRI further evaluation of a hypoechoic lesion in the left lobe of the liver not well seen on prior study. CT CHEST W/CONTRAST showed 1. No definite evidence of metastatic disease in the chest. cluster of nodules may be inflammatory/infection. Nonspecific micro nodules measuring less than 5 mm in the right upper lobe and right lower lobe as described above. 2. Moderate paraseptal and centrilobular emphysema predominantly in the upper lobes. 3. Findings compatible with chronic bronchitis. 4. Cirrhotic liver and left adrenal mass, better characterized on the multiphasic CT from ___. CT-GUIDED LEFT ADRENAL MASS BIOPSY showed Successful CT-guided left adrenal mass biopsy. The patient was diagnosed with Other specified disorders of adrenal gland. The patient was treated with Adrenal biopsy ___. At the time of discharge, the patient had PRIMARY: hepatic encephalopathy, adrenal mass SECONDARY: HCV/EtOH cirrhosis, hepatocellular carcinoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with HCV cirrhosis, esophageal varices with history of bleeding (s/p TIPS on ___, and ___ who presents from liver tumor clinic with concern for confusion and new adrenal mass. #ADRENAL MASS: Patient with concerning mass incidentally noted on imaging. He endorses significant fatigue and weight loss over the course of > ___ year (weight loss seems intentional). He was referred into the hospital for expedited evaluation. TSH, aldosterone, cortisol, ACTH, renin WNL. Normetanephrines just above upper limit of normal at 0.95, free metanephrines normal. CT chest w/o metastatic disease and notable for micro nodules, bone scan negative for metastatic disease as well. Adrenal biopsy occurred ___, and patient will follow up with oncology (Dr. ___ and liver doctor (___) on discharge for further management. #COAG NEGATIVE STAPH BACTEREMIA: Coag negative staph in ___ bottles from ___. CXR and UA without evidence of infection. No other evidence for nidus of infection, no recent instrumentation. No hardware. Recent dental appt but no extraction or invasive procedure. In the setting of possible decompensation of liver failure with HE (HE was not apparent on admission, but was noted in clinic prior to admission), patient was covered with IV vanc ___. ID was consulted and found that his overall picture was a contaminant and recommended discontinuing antibiotic (stopped on ___. Remained HD stable, febrile, no leukocytosis, no symptoms. Repeat blood cx negative. #CONFUSION: Patient endorses ___ year of confusion, although is oriented on neurologic exam without asterixis. TSH and cortisol normal. There was a question of coag negative staph bacteremia, as above, but felt to be due to contaminant and patient's mental status was felt to be at baseline, so do not that there was any infection nor any acute altered mental status. Maintained ___ BM's per day, no evidence of asterixis throughout admission. Continued on lactulose (dose changed to 30mg QID), with goal ___ BMs/day. #HCV CIRRHOSIS: #ESOPHAGEAL VARICES, s/p TIPS: MELD-NA 10, Child class A. Has failed HCV treatment with Harvoni and Epclusa plus Ribavirin. Cirrhosis has been complicated by esophageal varices, which have bled in the past. s/p TIPS at ___ in ___ TIPS appears patent on admission RUQ US. No evidence of PVT. History of hepatic encephalopathy and ascites, currently without enough ascites to tap. Mild transaminitis is improving, likely ___ untreated HCV. Continued on home lactulose (dose changed to 30mg QID), rifaximin, and spironolactone. #HCC: not yet treated; being seen in liver tumor clinic. According to liver tumor clinic note from ___, ___ would be amenable to directed therapy. Concerned that adrenal mass may be metastatic disease. Will follow up with liver tumor clinic as scheduled. #Bipolar disorder: Continued on home aripriprazole, Seroquel, trazodone, keppra. #Tobacco abuse: given Nicotine patch, but consistently went outside to smoke, so the patch was discontinued. TRANSITIONAL ISSUES =================== [ ] Adrenal biopsy will be followed-up by liver tumor team. [ ] Lactulose dose changed to 30mg QID. Can be titrated to achieve ___ BMs/day.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with past medical history of alcohol use disorder, COPD, hypothyroidism, seizure disorder, depression/anxiety who presents as a transfer from ___ s/p fall, found to be acutely intoxicated with tachycardia, hypoxia, and concern for sepsis. CTA CHEST showed 1. Pulmonary embolism in a few subsegmental and segmental branches of the right pulmonary artery without evidence of right heart strain. 2. Enlarged main pulmonary artery measuring 37 mm suggesting pulmonary hypertension. 3. Diffuse centrilobular pulmonary nodules and scattered ground-glass opacification in bilateral lungs likely represent an infectious process such as multifocal pneumonia. However, respiratory bronchiolitis cannot be excluded. 4. Moderate hepatic steatosis. RECOMMENDATION(S): 1.A follow up chest CT is recommended in ___ weeks after treatment of acute pulmonary process taken for resolution. 2. Radiological evidence of fatty liver does not exclude cirrhosis or significant liver fibrosis which could be further evaluated by ___. This can be requested via the ___ (FibroScan) or the Radiology Department with either MR ___ or US ___, in conjunction with a GI/Hepatology consultation" * * Chalasani et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the ___ Association for the Study of Liver Diseases. Hepatology ___ 67(1):328-357 CHEST (PORTABLE AP) showed Heart size and mediastinum are stable. Multifocal consolidations are similar to previous chest CT from ___. There is no appreciable pleural effusion. There is no pneumothorax. BILAT LOWER EXT VEINS showed Deep venous thrombosis of 1 of the 2 left posterior tibial veins. No evidence of deep venous thrombosis in the rightlower extremity veins. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 4:49 pm, 2 minutes after discovery of the findings. The patient was diagnosed with Pneumonia, unspecified organism. The patient was given written instructions concerning 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 past medical history of alcohol use disorder, COPD, hypothyroidism, seizure disorder, depression/anxiety who presents as a transfer from ___ s/p multiple falls, found to be acutely intoxicated with tachycardia, hypoxia, likely pneumonia and concern for sepsis/septic shock. ACUTE ISSUES =========== #Community Acquired Pneumonia #Sepsis Patient with possible LLL pneumonia on CXR from OSH. Has been feeling ill for "few days" prior to admission. Endorsing cough w/ mucus in chest, fevers/chills, nausea, diarrhea. lactate elevated to 5 at OSH, persistently elevated to 5 in ED here suggesting end organ damage. Admitted s/p 3L IVF, received additional 2L with downtrending lactate, BPs stable, never requiring pressors. Received CTX/Levofloxacin at OSH which was continued. Strep pneumo, legionella, RVP, blood cultures, urine culture, was found to have GPC growing at OSH. ID was consulted on the floor and was not concerned by final cutlure of ___ bottles Strep mitis, which was not found in BID cultures. On floor transitioned to Ceftriaxone, dropping vanco (MRSA swab neg) and levaquin. She completed the ceftriaxone course while inpatient. O2 needs weaned on the floor and she was breathing comfortably on room air on discharge. #Sinus tach PE vs volume depletion vs withdrawal. Persisted despite withdrawal management and fluids, so thought more likely ___ to PE. Stables in ___ on discharge. #Hypoxia #Multiple Subsegmental PEs Patient persistently tachycardic to 110-120s despite 5L IVF. EKG w/ sinus tachycardia. Patient not febrile, not complaining of pain so CTA Chest obtained which showed filling defects in 2 segmental right middle lobe pulmonary arteries, several subsegmental arteries of the right lower lobe, segmental artery in the left upper lobe. PE without clear provoking source, no hx clots in past, no recent long travel, no known active malignancy. Started on heparin gtt while in ICU then ultimately transitioned to po anticoagulation with rivaroxaban, completing introduction BID dosing at the time of DC. Weaned off O2 and worked well with ___, recommending home with home ___. #Intoxication #Alcohol Use Disorder Patient w/ history alcohol use disorder, reported heavy alcohol use recently though patient stating less over last week prior to admission. EtOH at OSH 380. Was given high dose thiamine, folate, MVI. Loaded with phenobarb then redosed ___. On floor, CIWA continued but received no further dosing. No complications noted. #Elevated LFTs Possibly mild alcoholic hepatitis given AST:ALT ratio vs mild shock liver iso septic shock. Downtrended without issue. No further workup #Diarrhea Unclear chronicitiy, per pt occurs on and off at home. C.diff negative. Resolved. #bacteriuria: some burning with urination but there was no inflammatory reaction in UA. UCx did grow Ecoli with numerous resistances. ID not concerned and initially elected not to broaden coverage. However, given persistent symptoms, discharged with three day course of Bactrim. CHRONIC ISSUES ============= #Depression #Anxiety -Continued home citalopram, mirtazapine #Hypothyroidism -continued home synthroid 75mcg daily, thyroid levels c/w mild hypothyroid while in house #Seizure Disorder Never on AED. Continued to monitor for seizure activity TRANSITIONAL ISSUES: ====================== RECOMMENDATION(S): 1.A follow up chest CT is recommended in ___ weeks after treatment of acute pulmonary process taken for resolution. 2. Radiological evidence of fatty liver does not exclude cirrhosis or significant liver fibrosis which could be further evaluated by ___. This can be requested via the ___ (FibroScan) or the Radiology Department with either MR ___ or US ___, in conjunction with a GI/Hepatology consultation" * Ensure resolution of urinary symptoms s/p antibiotic treatment. Patient needs sleep study as an outpatient to evaluate for OSA. PCP follow up scheduled on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F PMHx Cirrhosis of unknown etiology complicated by hepatic hydrothorax and peptic ulcer disease complicated by UGIB with hospitalization ___ presented to ___ with acute onset dyspnea. On evening of ___ EMS was called to her house, patient had SaO2 82% and SBP 100s and was tachypneic and not tolerating face mask or BiPAP. She was found sitting in wheelchair tripoding, relative said patient was having “a fluid problem". Patient was unable to say what was wrong aside from being unable to take a deep breath (denied chest pain), became confused and combative. Radiology showed 1. ET tube in satisfactory position terminating 2.9 cm above the carina. 2. Near complete opacification of the right hemi thorax with just a small amount of aeration of the right mid lung. This likely reflects a large pleural effusion. Radiology showed Right IJ terminates at the distal SVC. ___ DUP EXTEXT BIL (MAP/DVT) showed 1. No evidence of deep venous thrombosis in the bilateral lower extremity veins, though evaluation of the right calf veins is somewhat limited. 2. Abnormal enlarged bilateral groin lymph nodes. Clinical correlation is recommended, and followup either by palpation or imaging is recommended. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Heterogeneous nodular hepatic architecture. No concerning liver lesion identified. 2. Splenomegaly. 3. Moderate ascites in the upper quadrants. Of right pleural effusion is also noted. 4. Patent hepatic vasculature. No portal vein thrombus identified. CHEST (PORTABLE AP) showed Substantial interval decrease in right pleural effusion, which is now trace at best. Re-expansion of the right lung with extensive airspace opacities, which are most likely due to re-expansion pulmonary edema. CHEST (PORTABLE AP) showed Small to moderate right pleural effusion has recurred, severe consolidation in the right lung is stable and has worsened appreciably in the left lung. The left-sided component cannot be ascribed to re-expansion edema. ET tube, right internal jugular line and nasogastric tube are in standard placements respectively. No pneumothorax. Radiology showed There is paucity of bowel gas with a few nondilated loops of bowel in the mid abdomen. This appearance is non specific and does not exclude obstruction. If there is ongoing concern for obstruction, a CT abdomen and pelvis may be considered. Bibasilar lung opacities concerning for atelectasis and/or pneumonia. Radiology showed Interval worsening of diffuse pulmonary edema, ARDS is a consideration. Bilateral pleural effusions right more than left. Lines and tubes as above. Radiology showed Improving pulmonary edema and right pleural effusion. Stable position of lines and tubes as above. Radiology showed Support lines and tubes are unchanged in position. There has been worsening of the pulmonary interstitial edema since the prior study. There is also worsening of the opacification involving the entire right lung and the left upper lobe and left base. There are no pneumothoraces. CHEST (PORTABLE AP) showed In comparison with the study of ___, the monitoring and support devices are unchanged. Little change in the diffuse bilateral pulmonary opacifications, which remain more prominent on the right. CT HEAD W/O CONTRAST showed No acute intracranial abnormality. The patient was diagnosed with SEPTICEMIA NOS, SEVERE SEPSIS , ACUTE RESPIRATORY FAILURE, SEPTIC SHOCK, ACCIDENT NOS. The patient was treated with Thoracentesis on ___. At the time of discharge, the patient had Septic shock secondary to klebsiella Urinary tract infection Cirrhosis complicated by ascites and hepatic hydrothorax Delerium, Altered Mental Status. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F with a history of cirrhosis c/b hepatic hydrothorax presents with acute onset SOB and hypoxemic respiratory failure, likely secondary to large right sided pleural effusion complicated by septic shock from urinary source and pulmonary edema. # Goals of care: After extended hospital stay with failure to liberate patient from ventilator, persistant altered mental status, and worsening renal function unresponsive to albumin challenge, the decision was made with her brother to transfer her care to ___ which was closer to her home. This was done so that family members could visit the patient due to her poor and grave prognosis. She was also made Do Not Resuscitate. She remained intubated. After family visits, there will have to be continued decisions regarding management of her medical co-morbidities and whether or not to pursue comfort measures only. # Hypoxemic Respiratory Failure: Multifactorial in setting of hepatic hydrothorax with possible secondary infection, heart failure, or portopulmonary/hepatopulmonary syndrome. Patient was intubated prior to arrival, was started on broad-spectrum antibiotic coverage (vancomycin/meropenem/levofloxacin), was diuresed, and underwent thoracentesis (diagnostic but with additional large amount of fluid remova). Patient remained intubated through discharge due to poor mental status precluding liberation from ventilator. # Septic Shock from Urinary Source: Patient presented with T103 and very high band count with positive OSH urinalysis. Eventually found to be growing Klebsiella, Enterococcus, and ___ from her urine and klebsiella bacteremia. She was initially on broad-spectrum antibiotics and narrowed to ceftriaxone alone based on sensitivities under Infectious Disease consult guidance. Ascites fluid and pleural fluid did not grow any organisms and ___ blood/urine cultures remained negative. She was discharged on 0.4mcg/mcg/min of phenylepherine for continued blood pressure support. # Altered Mental Status: Remained minimally responsive throughout hospitalization despite minimal sedation. Lactulose was trialed without improvement in her mental status. She was discharged without sedation. NCHCT was negative for acute intracranial process. EEG was not read at time of discharge - this was because of the desire to transfer Mrs. ___ closer to home. # Acute kidney injury: At first thought to be from over-diuresis due to aggressive diuresis. However, her renal function failed to improve after albumin challenge. Thus, she likely has HRS. # Cirrhosis: Patient with newly diagnosed cirrhosis of unclear etiology on ___ complicated by thrombocytopenia, hepatic encephalopathy with paranoid/agitated delirium, and hepatic hydrothorax presents with MELD 20. Patient had unchanged RUQ ultrasound, was given albumin for volume resuscitation as needed, was given lactulose/rifaximin with some improvement in mental status, diagnostic paracentesis not suggestive of SBP when WBC was corrected for RBC, and was seen by Hepatology would did not recommend TIPS for hepatic hydrothorax treatment. # Guaiac-Positive Stool: Noted at OSH to have guaiac-positive stool (brown with some red around the other stool) but with hemoglobin improved from prior discharge (Hgb 10 from 9). She was started on pantoprazole BID. She was transfused on ___ for dropping H&H in an attempt to help her remain stable for transfer to ___. TRANSITIONAL ISSUES: -------------------- # Communication: ___ (brother/HCP) at ___ or ___ # Code: DO NOT RESUSCITATE/okay to intubate (as she is intubated) # Will need further discussion regarding goals of care - made do not resuscitate and family decision will be made regarding further care once everyone is together at ___ where she was transferred to</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M w no cardiac history who presented to ___ after a fall, sustaining a skin tear to the deltoid area, found to have elevated troponin, transferred here for management of NSTEMI. Per patient, he was putting the phone back, but instead fell on his left side has he was putting the phone back. He scraped his left arm. He denies any chest pain, chest pressure, palpitation, skipped beats, nausea, vomiting, dyspnea, radiating pain prior to the fall or in the days prior. He was then trying to clean the arm up because of the bleeding, and realized that it was difficult for him to do so; therefore, he went to ___ ___. While in the OSH, patient was noted to have heart rate ranging from 40-80s, and EKG showed ? sinus pause vs. block but no ST elevations. Patient was placed on the pad, but never required it. He was asymptomatic with stable BP. Patient was found to have + troponin, mildly elevated BNP, normal creatinine, and anemia. CXR showed cardiomegaly and pulmonary edema. Patient was given ___ and started on heparin gtt. He was transferred here for NSTEMI. Radiology showed No intracranial hemorrhage or calvarial fracture. The patient was diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE. The patient was treated with Pacemaker placement. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Hospital course by problem: # NSTEMI. No previous EKG for comparison on admission. EKG with T wave inversion and STD changes in the inferolateral leads and heart block. Trop positive x3 (first one was in ___, here 0.77, 0.56. Patient received ___ (unclear dose) and heparin gtt prior to arriving ___. Bradycardic but HDS on admission. Patient denied ever experiencing chest pain and denied chest paint throughout his hospital stay. Patient underwent exercise stress test with mibi perfusion showing decreased in SBP 30mmHg on exercise with uniform tracer uptake (see results section for full report). Given patient's age and the fact that he is and always has been asymptomatic, we did not proceed with cardiac cath in favor of medical management of CAD with Beta blocker, Aspirin, and statin. The patient received IV vancomycin fo 48 hours post pacemaker placement and was switched to ___ clindamycin on discharge per EP recommendations. He continued on his home dose lasix ___, atorvastatin while in hospital. His lisinopril was reduced to 2.5mg and his imdur was discontinued due to some low blood pressure (SBP to ___ the day prior to discharge. With these medication changes, his BP improved to 110s systolic. We also added low dose metop XL to his regimen. # Fall. Patient presented to ___ s/p fall with deltoid laceration. His troponins and EKG findings (see above) were found incidentally, which prompted his transfer to ___. Based on history, the fall was likely mechanical in nature. No LOC. Patient did not hit his head and CT head was negative for bleed. He had no complaints of chest pain or SOB during or after fall. ___ evaluation was done and determined that patient should be discharged to an extended care facility. Bradycardia - because of multiple conduction abnormalities seen on ECG and monitoring, the decision was made to place a dual chamber pacemaker. This was done without significant complication. He will follow up with device clinic for wound check and continued pacemaker evaluation. # Skin tear, ___ fall - patient received appropriate wound care with improvement in deltoid laceration TRANSITION OF CARE - follow up with primary cardiologist and device clinic</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: As per HPI by Dr. ___ in H&P dated ___: "Mr. ___ is a ___ male with history of Sickle Cell Disease with frequent admissions for sickle cell pain crises status post surgical splenectomy, recurrent episodes of acute chest syndrome, AVN of L femoral head with chronic hip pain, and history of R parietal intraparenchymal hemorrhagic stroke complicated by seizure disorder, who presents with chest pain back pain and abdominal pain. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with Hb-SS disease with crisis, unspecified, Chest pain, unspecified, Acute posthemorrhagic anemia. At the time of discharge, the patient had Sickle cell vaso-occlusive crisis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ male with history of Sickle Cell Disease with frequent admissions for sickle cell pain crises status post surgical splenectomy, recurrent episodes of acute chest syndrome, AVN of L femoral head with chronic hip pain, and history of R parietal intraparenchymal hemorrhagic stroke complicated by seizure disorder, who presents with chest pain back pain and abdominal pain consistent with acute vaso-occlusive crisis.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ was a ___ G4P1021 at 18 weeks when she was transferred from the ED with possible pre-term labor, after developing cramping the night prior to presentation which progressively worsen over the course of the night, which prompted her presentation to the ED. In the ED, she was found to be 2-3 cm dilated visually with bulging membranes. She continued to report cramping, mildly improved with Tylenol. She otherwise denied fever, chills, night sweats, vaginal bleeding or LOF. FULL FETAL LOW RISK showed 1. Cervical length 2.8 cm with open os on transabdominal imaging with bulging of the membranes through the cervical os. Recommend obstetrics consult. 2. Single, live fetus measuring size equals dates. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 7:17 am, 5 minutes after discovery of the findings. The patient was diagnosed with Uterine size-date discrepancy, second trimester, Lower abdominal pain, unspecified, 18 weeks gestation of pregnancy. The patient was treated with Dilation and Curettage (D&C). At the time of discharge, the patient had Chorioamnionitis, D&C. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>On ___, Ms. ___ was admitted to the gynecology service after undergoing a D&E complicated by chorioamnionitis for preterm labor. She was given 20 units of pitocin and 200ug methergine in the OR. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with tylenol and ibuprofen. She was continued on her antibiotics for her diagnosis of chorioamnionitis. By post-operative day 1, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. However, she continued to have fundal tenderness with intermittent tachycardia. At that time the decision was made to prolong her antibiotics to a total of 48 hours after presentation. Early morning on POD2, she endorsed some midline positional chest pain, only present when lying flat on her back in the setting of a large meal prior to sleeping. Her evaluation was benign and was given some heart burn medication with resolution of her symptoms. On POD2 the patient continued to do well and without any chest pain or other concerning symptoms. She no longer had fundal tenderness, was no longer tachycardic and after completing her 48 hours of antibiotics, she was then discharged home in stable condition with outpatient follow-up scheduled.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with history of recurrent c. diff colitis c/b toxic megacolon s/p subtotal colectomy, Child B ___ cirrhosis decompensated by malnutrition, hepatic encephalopathy, portal hypertension and ileal variceal bleed post TIPS (___) presenting with altered mental status. She is too confused to meaningful participate in an interview with emergency providers, so history was obtained from her family. Patient was coherent at her recent hepatology encounter on ___, but, reportedly, might have misinterpreted a recommendation to liberalize her cathartics and has thus been taking lactulose sporadically, if at all. Her visiting nurse detected mild confusion yesterday, which worsened by the next morning. She became increasingly somnolent and disoriented, prompting her family to seek care. They add she has concurrent abdominal discomfort and dry heaving for a few days. She is more anorexic, in that regard. She arrived afebrile, hemodynamically stable with normal oxygenation. CBC notable for WBC 10.3, hemoglobin 10.2. BMP within normal limits. ALT 33, AST 52, ALP 188, TB 1.3. INR 1.3 Lactate 1.6. Chest x-ray, abdominal ultrasound, and CT head without contrast were all unrevealing within the confines of motion degradation. She received one liter fluid bolus. She refused lactulose. DUPLEX DOPP ABD/PEL showed 1. Patent TIPS. 2. Coarse appearing cirrhotic liver with stable appearance of a 1 cm hypoechoic left hepatic lobe lesion since ___, without correlate on the MRI from ___ UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. The patient was diagnosed with Hepatic failure, unspecified without coma, Nonalcoholic steatohepatitis (NASH). At the time of discharge, the patient had PRIMARY DIAGNOSIS ================ Altered mental status secondary to hepatic encephalopathy and polypharmacy SECONDARY DIAGNOSES ==================== Chronic pain Depression/anxiety Seizure disorder ___ cirrhosis Left foot wound Pancreatic diabetes History of gastric bypass Chronic malnutrition Anemia Leg cramps Attention deficit disorder Migraine headaches Cardiomyopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY Ms. ___ is a ___ year old female with history of Child B NASH cirrhosis decompensated by portal hypertension and ileal variceal bleed post TIPS presenting with 48 hours of increasing somnolence and confusion concerning for hepatic encephalopathy in the setting of holding home lactulose. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old man w/ PMHx of NPH s/p Right VPS, HTN, undefined neurocognitive disorder, recurrent PE (now off DOAC), recent admission for collapsed right ventricle and VPS adjusted, now p/w confusion, increase in tremors, bilateral lower extremity weakness with shuffling unsteady gait. SHUNT SERIES AP AND LAT SKULL, AP CHEST, AP ABDOMEN showed Intact right-sided VP shunt catheter without evidence for kinking or discontinuity. LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE showed 1. Unsuccessful lumbar puncture attempt at L5-S1 despite the needle in good position on the radiographic images. 2. Very slow CSF return at L4-L5, allowing collection of only 3 mL of blood-tinged CSF. I, Dr. ___ supervised the trainee during the key components of the above procedure and I reviewed and agree with the trainee's findings and dictation. Radiology showed Nonspecific bowel gas pattern. No evidence of obstruction. CT HEAD W/O CONTRAST Q111 CT HEAD. showed 1. Significant interval decrease in size of right lateral ventricle now nearly completely effaced suggesting over shunting, please correlate. 2. Interval decrease in size of left lateral ventricle. 3. New focal hypodensity in left thalamus, concerning for sequela of subacute infarction. 4. No intracranial hemorrhage or territorial infarction. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:15 am, 10 minutes after discovery of the findings. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Given a clinical history highly suspicious for infection, findings are most consistent with meningitis, cerebritis, and small abscess formation most prominently in the right temporal lobe, but also involving the inferior frontal lobes, left temporal lobe, cerebellum, brainstem, and right mamillary body. 2. Early subacute thalamic infarcts. Given the combination of possible subacute infarcts with rim enhancing diffusion hyperintense lesions as described impression 1, recommend further evaluation with echocardiogram for possible source of septic emboli. 3. No evidence of intracranial hemorrhage. 4. A right frontal approach ventriculostomy catheter terminates in the right lateral ventricle, tenting the interventricular septum toward the left. Effacement of the right lateral ventricle is unchanged. RECOMMENDATION(S): Recommend echocardiogram to assess for vegetations as the findings may represent septic emboli. Recommend repeat examination following appropriate treatment to document resolution of enhancement to exclude solid lesions. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 9:51 am, less than 10 minutes after discovery of the findings. CT ABD AND PELVIS WITH CONTRAST showed 1. No evidence of acute process in the abdomen or pelvis. 2. Radiopaque portions of the ventriculoperitoneal shunt are unremarkable without evidence of complication. 3. Moderate colonic fecal loading in the ascending and proximal transverse colon and moderately sized stool ball in the rectum. Radiology showed Patient was scheduled for a head and neck CTA, but was uncooperative with the examination. Only scout images were obtained. Scout images demonstrate a right frontal approach ventriculostomy catheter and ventriculoperitoneal shunt tubing. The partially imaged lung apices are unremarkable. No displaced fracture identified. CHEST PORT. LINE PLACEMENT showed The tip of the right PICC line projects over the cavoatrial junction. No pneumothorax. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. Evolving thalamic infarctions. 2. Low-attenuation changes in the right middle cranial fossa involving the anterior right temporal lobe are better characterized on the recent MRI head. 3. CTA is limited by poor vascular opacification. 4. Within this limitation, the circle of ___ is patent with no evidence of stenosis or aneurysm formation. 5. Patent neck vasculature without evidence of internal carotid artery stenosis by NASCET criteria. 6. Unchanged size and appearance of the ventricular system in the setting of an unchanged right frontal approach ventriculostomy catheter. 7. Heterogeneous partially calcified nodule in the inferior left thyroid lobe measuring up to approximately 2 cm. 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. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Multiple heterogeneously and peripherally enhancing lesions throughout the brain, predominantly in the right anterior temporal lobe. Dramatic progressive development of leptomeningeal enhancement at the skull base and cervicomedullary junction as well as pachymeningeal enhancement. Marked choline elevation on spectroscopy. 2. Given the essentially negative clinical workup for infection, the constellation of findings is highly concerning for malignancy. Differential considerations include metastatic disease or primary malignancy of the CNS such as glioblastoma and lymphoma. 3. Evolution of thalamic infarcts with enhancement in the left thalamus. 4. Unchanged size and appearance of the ventricular system with partial effacement of the right lateral ventricle in the setting of a right frontal approach ventriculostomy catheter. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 10:17 am. PRE-SURGICAL WAND OR THERAPY PLANNING showed 1. No significant change since 1 day prior with numerous scattered nodular and rim enhancing lesions and extensive leptomeningeal enhancement. Differential considerations include atypical infection such as a fungal organism or tuberculosis or malignancy such as metastases or lymphoma. 2. A larger portion of the cervical spine was imaged on the current examination with nodular enhancement of the leptomeninges including a nodule measuring up to 8 mm in the right subarticular zone at C3-4 on the right resulting in mild mass effect on the adjacent lateral aspect of the cord. 3. Unchanged size and configuration of the ventricles. No hydrocephalus. CHEST (PORTABLE AP) showed In comparison with the study of ___, the patient has taken a better inspiration. The right PICC line is been removed. Cardiac silhouette is within normal limits and there is no evidence of vascular congestion, pleural effusion, or acute focal consolidation. Ventriculoperitoneal shunt remains in place. PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD showed Markedly degraded exam. Metal artifact versus small parenchymal hemorrhage left parietal, occipital lobes, diagnostic CT without contrast recommended. RECOMMENDATION(S): Diagnostic quality head CT without contrast. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 12:43 pm, 10 minutes after discovery of the findings. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. Interval right temporal lobe biopsy. 2. Intracranial lesions are better seen on prior MRI. 3. No occipital or parietal lobe hemorrhage. The patient was diagnosed with Altered mental status, unspecified. The patient was treated with ___ guided LP. At the time of discharge, the patient had High grade glioma Encephalopathy Nausea Headache. The patient was given written instructions concerning 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/ PMHx of NPH s/p Right VPS, HTN, undefined neurocognitive disorder, recurrent PE (now off DOAC), recent admission for collapsed right ventricle and VPS adjusted, now p/w encephalopathy and imaging findings c/f meningitis c/b brain abscesses and subacute strokes, however no signs of recovery on broad spectrum antibiotics and ultimately underwent brain biopsy, which diagnosed high grade glioma, after which patient was transitioned to comfort care and discharged to home hospice. # Encephalopathy # Glioblastoma Initially his encephalopathy was assumed to be ___ oxycodone, however the patient had ___ positive blood cultures with CoNS which raised suspicion for VP shunt infection. He was started on vanc/cefepime/Bactrim/acyclovir for empiric coverage. A bedside LP was attempted and was unsuccessful. ___ performed a guided LP which was grossly bloody, w/ lymphocytic predominance and high protein c/f viral/fungal meningitis. However, no specific micro data resulted. Due to an unwitnessed fall, he had a CT head that showed a subacute infarct which prompted more imaging. His MRI brain w/ & w/o contrast showed findings of meningitis, cerebritis, multiple brain abscesses and concern for septic emboli. At that point, TTE didn't show vegetations and a CTA Head/Neck w/o carotid stenosis. His mental status didn't improve after a week of antibiotics. There was concern that one of the lesions in the MRI could represent malignancy, so a brain biopsy was performed, which ultimately revealed glioblastoma. After extensive discussion with the neurooncology service, the family decided that the patient would prefer comfort care. He was discharged home on hospice. At the time of discharge the patient was intermittently oriented x3 but with waxing and waning of mental status and drowsiness. Mostly comfortable except intermittent nausea and headache. #Nausea - mostly mild and intermittent; zofran and reglan available #Headache - mild, intermittent, and responsive to tylenol #Urinary Retention - Foley kept in place for comfort # HTN - Stopped antihypertensives # Depression - Continued home citalopram, seroquel # GERD - Stopped home omeprazole # Hypothyroidism - Continued home levothyroxine >30 minutes in patient care and coordination of discharge</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo w/mild to moderated left sided ulcerative colitis presents from ___ in ___ for evaluation and treatment of a UC flare. . Pt dx w/UC ___ years ago, managed on oral prednisone and mesalamine. He developed severe flare in ___ worsened by Influenza infection and subsequent presumptive CMV conjuntivitis. He was admitted to ___ on ___ with severe dehydration, anemia, abdominal pain and more than 10 bloody BMs/day. No fevers. He did not respond to treatment with solumedrol 40 mg IV, mesalamine enemas and bowel rest. The CT scan detected initial signs of megacolon and he was placed on TPN and switched to Hydrocortisone 300 mg daily. Labs significant for negative HIV but positive IgG CMV serology with negative IgM serology. CMV PCR was not performed at that time and pt was started ganciclovir IV treatment empirically due to lack of significant improvement, however this was delayed by the fact the there was no ganciclovir or valganciclovir in the ___. CBC showed anemia and pt was transfused 1unit pRBCs. At the time of transfer pt was on omeprazole 40IVqd, hydrocortisone 100mg IV BID and ganciclovir 350mg IV q12hr. Radiology showed Left subclavian line terminates in mid SVC. Ulcerative colitis, refractory to steroids, evaluation for megacolon. Upright and supine AP radiographs of the abdomen were reviewed. There is no evidence of bowel obstruction. Substantial colonic wall thickening is consistent with history of ulcerative colitis, partially imaged on the current study. No free air below the diaphragm demonstrated. Levoscoliosis of the lumbar spine is seen. was done. PICC line placement. AP radiograph of the chest was reviewed in comparison to ___. The right PICC line tip is at the level of mid SVC. Heart size and mediastinum are unremarkable. Lungs are essentially clear. No pleural effusion or pneumothorax is seen. was done. Radiology showed Uncomplicated ultrasound and fluoroscopically guided double-lumen PICC line placement via the left brachial venous approach. Final internal length is 53 cm, with the tip positioned in SVC. The line is ready to use. The patient was diagnosed with ULCERATIVE COLITIS UNSPEC. The patient was treated with FLEXIBLE SIGMOIDOSCOPY WITH BIOPSY. At the time of discharge, the patient had ULCERATIVE COLITIS, ACUTE SEVERE FLARE STAPH LUGDUNINENSIS SEPTICEMIA MODERATE MALNUTRTION LATENT MYCOBACTERIAL TUBERCULOSIS 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>. ___ yo w/ulcerative colitis presents from ___ ___ in ___ for evaluation and treatment of a UC flare refractory to steroids. . # moderate to severe UC He underwent evaluation by GI and ___ surgery with a plan to manage him medically. Steroids were continued with IV Solu-Medrol and hydrocortisone enemas. Infectious stool studies (cdiff, culture, O+P, crypto) were all negative. He underwent flex sig on ___ with the following findings: Diffuse erythema, congestion, ulceration, with old blood in lumen. The disease appeared worse more proximal than in the distal rectum with otherwise normal sigmoidoscopy to descending colon. His biopsy showed chronic moderately active colitis, without granulomata or dysplasia identified and no evidence of CMV colitis, despite a serum CMV VL of 1,200 copies. Given this biopsy, she was not treated with ganciclovir. His symptoms continued to improve and his stools returned to ___ at a quantity of about 5 a day (2 of which followed his enemas). The patient had been started on vitamin C/iron for microcytic anemia and he had a increased stool output. This resolved the next day following discontinuation of the vitamin C and supportive care. The patient was transitioned to po steroids several days prior to his discharge and he tolerated this well. Our plan is to taper his ___ by 10mg weekly until he gets to 20mg, and then taper by 5mg weekly. If the patient has a longer course of prednisone, proton pump inhibitors should likely be started for ulcer prophylaxis. The patient received his first loading ___ of Remicade on ___ (5mg/kg), and his repeat ___ would be on ___, and then 4 weeks after that. His hydrocortisone enemas where discontinued prior to discharge. . # Latent TB He had two INDETERMINATE guantiferonGOLD assays for latent TB and his CXR did not show any infiltrates or lesions. With the input of ID consultation, he was started on INH therapy for treatment of possible latent TB given prior epidemiological exposures. Started INH 300mg qd with B6 (pyridoxine) 50mg qd on ___. He should have monthly LFTs monitored. Plan for 9 months of therapy. . # line related s. lugdunensis bacteremia He was diagnosed and treated for a catheter related bacterial infection with growth of staph LUGDUNENSIS growing on cultures on ___. His L IJ placed at the OSH was the suspected source and it was immediately removed. He received empiric vancomycin and then nafcillin when sensitivities were known. He underwent TTE and TEE both negative for endocarditis or vegetations. A PICC line was placed but then removed given the concern that he may have still bacteremic since there was a gap in the time till his blood cultures were repeated on ___ (negative). This PICC was removed and he had no central lines for 48hrs and then a new PICC placed on ___ for access to complete his IV antibiotics which ended on ___ (2 week course from ___. All subsequent blood cultures were negative. . #normocytic anemia The patient presented with a Hgb between ___. The patient had symptoms of fatigue which gradually improved over the course of his treatment. The patient also experienced some mild dizziness after ambulating in the setting of a Hgb of 7.1. The source of this was thought to be slow GI related blood loss with a component of anemia of chronic disease. As a result it was decided to transfuse the patient 2 units of PRBC's. He tolerated this well. He will be discharged on iron 3 times a day. . # HBV exposure His Hep B serologies show prior cleared infection with positive HBVcAb, positive HBVsAb, negative HBVsAg. His HBV and HCV viral loads are negative. His HBsAb titer is between 100-500 IU/mL. Plan was to watch this every 3 months and start lamivudine if titer dropped to ___ IU/mL. . # TRANSITIONAL ISSUES []MONTHLY LFTS WHILE ON INH []INH WITH B6 FOR LATENT TB 9 MONTH COURSE TO END ON ___ [] HbsAb titers every 3 months []continue Remicade dosing and prednisone taper-consider adding a proton pump inhibitor for ulcer prophylaxis [] Follow up with ___ physician and PCP in ___ and re-check a CBC in ___ weeks and have it faxed to these physicians-his GI in ___ is Dr. ___ is ___ .</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ F with distant history of gastric volvulus s/p repair, s/p appy and s/p CCY, recent admission for ischemic colitis ___ and also with history of prior C.Diff colitis who presents now with abdominal pain and vomiting that started around noon ___. Daughter, ___, accompanies patient and corrobarates story. The patient initiall started feeling slightly unwell last week, with some stomach discomfort and so starting eating a BRAT diet with improvement in symptoms. Symptoms resolved until ___ when after dinne she began feling unwell again, again symptoms resolved. Morning of admission (___) she ate breakfast and then 1 hour later began having terrible abdominal pain, nausea, vomiting and profuse watery diarrhea. Patient reports that pain is mostly left-sided and she has had frequent non-bloody, non-bilious emesis thoughout the afternoon as well as non-bloody, non-melanotic diarrhea. She has not had fevers, chills, has not traveled and has no sick contacts. In the ED, initial VS were: 97.5 89 146/75 16 97%. CT abdomen was peformed showing evidence of colitis but without evidence of obstruction. ED evaluation not concerning for mesenteric ischemia or ischemic colitis and given CT abdominal findings not showing obstruction surgery was not consulted. Lactate was normal so no concern for end organ damage. She received 2L NS, Cipro and Flagyl pior to transfer. Vitals prior to transfer 99.2 67 119/53 18 96 On arrival to the floor, the patient arrives overall stable appearing, continued abdominal pain but without nausea, vomiting or diarrhea. Cipro is infusing. She is in good humor and making jokes throughout interview, she is also accompanied by daughter. REVIEW OF SYSTEMS: (+) pe HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, ___, melena, hematochezia, dysuria, hematuria. Radiology showed 1. Mild bowel wall thickening and mucosal enhancement with surrounding inflammatory change of the sigmoid colon and to a lesser degree the descending colon tapering to the level of the splenic flexure, consistent with colitis with etiologies including infectious, inflammatory or ischemic. Of note, the ostia of the celiac and superior mesenteric and inferior mesenteric arteries do not appear to have critical stenosis and mesenteric vessels are overall patent. 2. Moderate stable intrahepatic and extrahepatic biliary ductal dilatation, not significantly changed. 3. Prominent intermittent fluid filled loops of small bowel with intervening areas of collapse without secondary evidence of obstruction; however, if abdominal symptoms worsen, low threshold to repeat scan to assess for developing small bowel obstruction. The patient was diagnosed with NONINF GASTROENTERIT NEC. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient is a ___ woman with distant history of gastric volvulus s/p repair, s/p appy and s/p cholcystectomy, recent admission for ischemic colitis ___ and also with history of prior C.Diff colitis who presents now with abdominal pain, vomiting, and diarrhea, found to be C diff positive. # C diff infection: likely causing abdominal pain, nausea, diarrhea. The patient has a prior h/o C diff infection, and per daughter she was told she had to take oral Vancomycin for that infection. Since this represents a recurrent infection and the patient required Vancomyin during last infection, we decided to pursue PO vanc as treatment. GI also saw the patient and recommends probiotics as well upon discharge. The patient was able to tolerate a BRAT diet upon discharge, and pain was greatly improved since admission. First day of oral Vancomycin therapy was ___. - Oral Vancomicin 125 mg Q6 for 2 weeks, followed by a taper (1 weeks of BID the 1 week QD). Thus, the patient will get a total of 4 weeks of therapy including the taper. First day of therapy was ___. - Supplement with probiotics: Florastor (Take two sachets daily during treatment with Vancomycin and once daily thereafter) # Colitis: Recent CTA scan did not show evidence of ischemia, lactate not elevated. IV fluids were continued in the hospital to prevent ischemia from developing in the setting of dehydration. HCTZ was held. The patient was also found to have guiac positive stool. Patient was diagnosed with iron deficiency. Because of the prior noted CT findings of extensive colitis in ___ in ABSENCE of C.diff or mesenteric stenosis, GI was consulted. They recommended outpatient follow up once acute C diff infection resolved, and further discussion of the need for colonoscopy vs flex sigmoidoscopy. The patient was also started on iron supplimentation. # Dirty UA: UCx shows contamination. No Sx of UTI - no treatment indicated at this time # PUD: Chronic, stable - Hold off on Omeprazole 40mg BID given C.Diff # CAD, stable angina: No acute changes in SOB or chest pain. - hold HTN meds (See below) - maintain hydration # HTN: Chronic, stable. Held HCTZ and metoprolol on admission given concern for prior ischemic colitis, and current dehydration. Her BP remained well controlled without either of these medications. Metoprolol was restarted at home dose and HCTZ was continued to be held. - recommend holding HCTZ indefinently given history of questionable ischemic colitis and well controlled BP on metoprolol - Coninue Aspirin 81 mg PO DAILY # HYPOTHYROIDISM: Chronic, stable - Continue Levothyroxine Sodium 75 mcg PO DAILY # DEPRESSION: Chronic, stable - Continue Citalopram 20 mg PO DAILY # HLD: Chronic, stable - Continue Simvastatin 20 mg PO DAILY # PPX: heparin SQ, hold off on bowel regimen given diarrhea # CODE: DNR/DNI(confirmed with patient and HCP) # CONTACT: Daughter and HCP ___ ___, ___ Son ___ ___ TRANSITIONAL ISSUES - F/U with GI once infection resolved - follow up with PCP</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ old woman with a history of hypertension on multiple anti-hypertensive medications who was brought into the ED by ambulance after suffering a syncopal event while having her nails done. Radiology showed No acute cardiopulmonary process. CT HEAD W/O CONTRAST showed 1. No acute intracranial pathology. 2. Chronic changes, as described above. CT C-SPINE W/O CONTRAST showed 1. No evidence of cervical spine fracture or acute malalignment. 2. Multilevel severe degenerative changes are most severe at C4-5, where there is unchanged mild anterolisthesis. 3. 1.6 cm hypodense right thyroid nodule. RECOMMENDATION(S): If not previously performed elsewhere, a non urgent thyroid ultrasound is recommended for findings described in IMPRESSION #3. The patient was diagnosed with Syncope and collapse. At the time of discharge, the patient had Primary: Syncope, reduplicative paramesia Secondary: Hypertension, stage III chronic kidney disease, history of breast cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Brief Hospital Course: Ms. ___ is a ___ year old female with PMH HTN, breast cancer s/p XRT and lumpectomy, and known thyroid nodule who presented to the ED following a syncopal episode likely vasovagal in nature. Specifically, the patient suffered sudden loss of consciousness when placing her feet in warm water when getting a pedicure. Had associated diaphoresis, but no preceding palpitations, nausea, vomiting, changes in vision. No post-ictal confusion or bowel or bladder incontinence. Neurology consulted and neuro exam unremarkable (has known left sided ptosis and pupillary dilation following cataract surgery). ___ negative for intracranial process. Cardiac w/u negative. No signs/symptoms of infection and no leukocytosis. Monitored on telemetry without events. Likely vasovagal in the setting of placing feet in warm water. Plan to follow-up with primary care physician ___ further management. Of note, the patient an episode where she thought the people in the television were speaking to her. Neuro consulted and deemed to be a fixed delusion secondary to reduplicative paramesia. Specifically, this condition arises from hypoperfusion of the frontal lobes as a result of longstanding hypertension and microvascular disease. Per their recommendation, no need for further neurologic work up or neuro imaging. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o M with a 1cm left UPJ stone and persistent ___ despite IVF resuscitation. He ___ persistent pain and given the ___, required urgent decompression of his upper GU tract with a left ureteral stent. CT ABD AND PELVIS W/O CONTRAST showed 1. 1.0 x 1.5 cm left UPJ stone with subsequent mild-to-moderate hydroureteronephrosis. Additional smaller nonobstructing renal calculi measuring up to 6 mm. 2. A 4.1 cm right renal hypodensity with rim calcifications, better characterized on prior MRI as a Bosniak ___ lesion in ___. One year follow-up MRI had been suggested at that time. 3. Prostatomegaly. The patient was diagnosed with Unspecified abdominal pain. The patient was treated with Cystoscopy with urethral dilation and left retrograde ureteral pyelogram and left double-J stent placement.. At the time of discharge, the patient had nephrolithiasis; Left obstructing stone, complex (>1cm) acute kidney injury (creatinine 1.5-->1.8 w/ baseline 1.1) flank pain; left renal colic. The patient was given written instructions concerning 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 ___ for urgent decompression after fluid resuscitation and pharmaceuticals failed. He was admitted with left obstructing stone and acute kidney injury and underwent cystoscopy with urethral dilation and left retrograde ureteral pyelogram and left double-J stent placement. He tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. See the dictated operative note for full details. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. On POD1, catheter was removed and he voided without difficulty. Mr. ___ was then discharged to home with oral pain medications, tolerating regular diet, ambulating without assistance, and voiding without difficulty. He was given explicit instructions to follow up with Dr. ___ as the indwelling ureteral stent must be removed and or exchanged and definitive stone management addressed. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ MD: Ms. ___ is a ___ year old F w/ metastatic pancreatic cancer to her lung and liver on FOLFIRINOX cycle 2 (start date ___, last dose of chemo ___ who was recently discharged from the hospital (___) who presented to ___ clinic after paracentesis today (2.5L removed) with BP 65/49 and HR 170s, reportedly afebrile at home. In the last week, patient notes worsening diarrhea (5+ episodes of non-bloody diarrhea per day). She believes they have worsened on the tube feeds. She also states emesis (two episodes of bilious emesis today) and non-bloody bilious emesis yesterday. She reports being afebrile at home. She states that she does have flu positive members of family. Ultrasound-guided paracentesis. showed 1. Technically successful ultrasound guided therapeutic paracentesis. 2. 2.5 L of fluid were removed. CHEST (PORTABLE AP) showed Probable trace left pleural effusion. Otherwise, no acute cardiopulmonary abnormality. CT ABD AND PELVIS WITH CONTRAST showed 1. Increased extensive portal vein thrombosis with cavernous transformation. Probable focal superior mesenteric vein branch thrombosis. 2. Relatively diffuse small and large bowel wall edema could reflect venous outflow obstruction, though alternative etiologies such as third spacing or infection should be considered given the extent of portal vein cavernous transformation. 3. Two new linear areas of hypoenhancement in the posterior interpolar right kidney could reflect developing pyelonephritis or tiny infarcts. 4. The pancreatic tail mass and scattered metastases are not significantly changed. 5. A splenic infarct is not significantly changed. NOTIFICATION: The findings were discussed with ___, m.D. by ___ ___, M.D. on the telephone on ___ at 10:44 pm, approximately 15 minutes after discovery of the findings. BILAT LOWER EXT VEINS showed Small amount of occlusive thrombus involving the proximal segment of a single right peroneal vein. More proximal veins are patent. NOTIFICATION: The findings were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 1:25 pm, approximately ___ minutes after discovery of the findings. DX CHEST PORT LINE/TUBE PLCMT 3 EXAMS showed The tip of the Dobbhoff projects over the stomach. Air-filled colon projects over the upper abdomen. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed The Dobbhoff tube tip projects over the stomach. Right-sided Port-A-Cath is unchanged. Lungs are well expanded and clear. No new consolidations. Heart size is normal. There is no pleural effusion. No pneumothorax CT of the abdomen and pelvis. showed 1. Persistent but decreased size of thrombus in the main portal vein. Massive collaterals, unchanged. 2. Metastatic disease to the liver including possible new and/or increased lesions. It may be appropriate to consider MR, which could delineate the lesions more precisely versus, less desirably, consideration of a dedicated multiphasic liver protocol if needed clinically, if oncological followup information is needed at this time on clinical grounds. 3. Increased extent and density of blastic metastases. 4. Increased ascites. Chest radiograph, PA upright view. showed PICC line terminating in the superior vena cava. DX CHEST PORTABLE PICC LINE PLACEMENT showed Left PICC line tip appears to be at the junction of left brachycephalic vein in right brachycephalic vein and is unclear if is within the SVC. It might be potentially advanced for at least and other 2 cm. Port-A-Cath catheter tip is in the right atrium, unchanged. Heart size and mediastinum are unremarkable. Bilateral basal nodular opacities are consistent with nipple shadows. Ultrasound-guided therapeutic paracentesis showed 1. Technically successful ultrasound guided therapeutic paracentesis. 2. 1.65 L of fluid were removed. The patient was diagnosed with Other neutropenia, Fever presenting with conditions classified elsewhere, Tachycardia, unspecified. The patient was treated with Paracentesis (___) PICC line placement (___) Paracentesis (___). At the time of discharge, the patient had Hypovolemic shock Diarrhea UGT1A1 deficiency Malignant ascites Hypokalemia Hypophosphatemia Hypomagnesemia Nausea/Vomiting Cancer-related abdominal pain febrile neutropenia Anemia Thrombocytopenia Portal Vein Thrombus SMV thrombosis R peroneal vein DVT Severe Protein Calorie Malnutrition Metastatic Pancreatic Adenocarcinoma Secondary Neoplasm of Liver Secondary Neoplasm of Lung Mucositis GERD Fatigue Pancreatic insufficiency Hypothyroidism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with history of metastatic pancreatic adenocarcinoma on FOLFIRINOX and recent admission for N/V/D who presents with hypovolemic shock in the setting of recurrent nausea, vomiting, diarrhea after therapeutic paracentesis. In the ED, she was found to be hypotensive so was given 2L IVF, started on Vancomycin + Cefepime + Flagyl, bedside U/S without evidence of ascites, and a CT A/P which showed complete occlusion of her portal vein with cavernous transformation and possible focal superior mesenteric vein branch thrombosis with diffuse small/large bowel edema and 2 linear areas of hypoenhancement in right kidney c/f pyelo versus tiny infarcts. Patient was initially admitted to the MICU for undifferentiated shock. She briefly received vasopressors in addition to aggressive volume resuscitation and broad-spectrum antibiotics in the setting of neutropenia. Her blood pressure improved she was transferred to the oncology hospitalist service on ___. Her hospital course was complicated by persistent diarrhea for which GI was consult. She was started on antidiarrheal medications and TPN with gradual improvement of her symptoms. ___ was consulted for possible intervention on her portal vein thrombus/SMV thrombus given suspicion for clot burden contributing to bowel edema and subsequent diarrhea. ___ deferred intervention given repeat imaging showing decreased size of thrombus in the main portal vein and recommended continued anticoagulation. Patient was transitioned from a heparin drip to Lovenox and an antifactor Xa was noted to be slightly low. In setting of thrombocytopenia and anemia likely ___ recent chemotherapy, patient was discharged on 50mg/kg BID of lovenox with instructions to follow closely in outpatient ___ clinic. # Diarrhea: Improved. Likely multifactorial including tube feeds, portal vein thrombus leading to bowel wall edema and resulting malabsorption, and chemotherapy (irinotecan). Infectious studies negative. GI consulted and suspect large component of diarrhea related to worsening PVT causing venous outflow obstruction leading to extensive bowel wall edema causing inability to absorb fluid contained in intestines. Repeat imaging showed persistent but decreased size of thrombus in the main portal vein. -UGT testing revealed that she likely has decreased UGT1A1 enzyme levels conferring increased sensitivity to irinotecan, which may explain why her diarrhea worsened significantly s/p chemotherapy administration -c/w lomotil, loperamide PRN -Feeds attempted = ___ most recently x4 days, Vivonex Elemental prior to that, and vital 1.5. No difference in diarrhea between each formulation -Tube feed holiday started ___ with improvement of diarrhea -c/w TPN, will require on discharge -c/w lovenox for PVT # Malignant Ascites: Has required paracentesis with cytology positive for malignant cells. Also worsening portal vein thrombus likely contributing. - Monitor and drain PRN, s/p ___ para ___ # Non-Anion Gap Metabolic Acidosis: Resolved. Likely due to diarrhea. Responded well to intermittent bicarb administration - weekly ___ as outpatient while on TPN # Hypokalemia: # Hypophosphatemia: # Hypomagnesemia Resolved. Secondary to diarrhea and malnutrition - weekly ___ as outpatient while on TPN # Nausea/Vomiting: ___ have be related to ascites vs. chemotherapy vs. tube feed intolerance, has since resolved - zofran, compazine and ativan PRN # Cancer-Related Abdominal Pain: Due to tumor burden and also portal vein thrombus. - Continue PO dilaudid PRN # Febrile Neutropenia Resolved. - Monitor for fevers - s/p neulasta support following this round of FOLFOX # Portal Vein Thrombus: # Superior Mesenteric Vein Branch Thrombosis: # Right Peroneal Vein DVT: Abdominal CT on admission noted worsening of PVT. Bilateral LENIs showed right peroneal DVT. Given diarrhea in outpatient setting patient may have had ineffective absorption of apixaban leading to clot progression - s/p heparin gtt, started on lovenox BID, anti-factor Xa level subtherapeutic, will recheck as outpatient with oncologist given concern for supratherapeutic dosing in setting of low weight and thrombocytopenia # Anemia in Malignancy: # Thrombocytopenia: Secondary to malignancy and chemotherapy. DIC and hemolysis labs negative. Counts stable though noted to be decreasing after most recent round of chemotherapy [] will require CBC w/ diff on ___ with results to be faxed to outpatient oncologists office (Dr. ___ - ___ for Hb<7, plt<10 # b/l ___ edema In setting of severe malnutrition and hypoalbuminemia as well as R DVT c/f PTS. Received intermittent diuresis with albumin support with improved edema # Severe Protein Calorie Malnutrition: In setting of weight loss, muscle depletion, and decreased PO intake. Feeds attempted = ___ most recently x4 days, Vivonex Elemental prior to that, and vital 1.5. No difference in diarrhea between each formulation - continue TPN as outpatient - Multivitamin daily # Metastatic Pancreatic Adenocarcinoma: # Secondary Neoplasm of Liver: # Secondary Neoplasm of Lung: Previously on palliative FOLFIRINOX. CA ___ Downtrending. - s/p FOLFOX (Day ___ as per outpatient oncologist, s/p neulasta after this cycle - will follow up with Dr. ___ 1 week after discharge on ___ # Coagulopathy: Elevated INR likely secondary to malnutrition. She is s/p Vitamin K 5mg IV x 3 days with improvement. # Mucositis - Viscous lidocaine and magic mouthwash PRN # Fatigue - c/w Dexamethasone 1mg daily # GERD - Continue home PPI - Continue simethicone # Pancreatic Insufficiency - Continue home Creon with meals and snacks # Hypothyroidism - Continue home levothyroxine # Peeling of hands In setting of chemotherapy - hydrocortisone ointment PRN # Hemorrhoids - HC ointment PRN</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: History of Present Illness: ___ is an ___ F with a PMHx of paroxysmal a fib, recent L MCA stroke, HTN and HLD presents with 1 week of worsening abd pain. The patient's daughter notes that she developed abd pain approximately one week ago and was diagnosed with a urinary tract infection on ___. The patient was started on cipro, but immediately developed nausea, emesis, and diarrhea with this. She was thus switched to macrobid on the second day of therapy. She reports one additional BM 2d PTA, but denies any continued symptoms of diarrhea or emesis, just notes nausea and L sided abd pain at this time. The patient dates her abd and back pain to beginning approximately one week ago, however started requiring a lidocaine patch to L back during her last week in rehab (discharged home on ___ following her hospitalization for her stroke in ___. At this time she notes it is extremely painful to move around in bed and prefers lying still. Pt denies gross hematuia, hx of nephrolithiasis, dysuria or vaginal discharge. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial hemorrhage or acute large vascular territorial infarction. 2. Encephalomalacia within the left basal ganglia, caudate nucleus, and posterior limb of the internal capsule is consistent with sequela of chronic infarct. 3. Fluid in scattered right-sided mastoid air cells. Recommend correlation with patient's symptoms. RECOMMENDATION(S): Fluid in scattered right-sided mastoid air cells. Recommend correlation with patient's symptoms. NOTIFICATION: Updated wet read was discussed with Dr. ___ by Dr. ___ ___ telephone at 05:00 on ___, 2 min after discovery. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No acute fracture or subluxation. 2. Multilevel, multifactorial degenerative changes are present. Widening of the anterior disc space at C4-5, C5-6, and C6-7 is presumed to be degenerative in nature. Prominent degenerative atlantodental pannus. 3. Bilateral pulmonary nodules, measuring up to 5 mm. Consider nonemergent CT of the chest for further evaluation, if clinically indicated. RECOMMENDATION(S): Point 2: Multilevel cervical spondylosis. If clinically symptomatic and there are no contraindications, this could be further evaluated with MRI. , Point 3: Bilateral pulmonary nodules, measuring up to 5 mm. Consider nonemergent CT of the chest for further evaluation, if clinically indicated. CT ABD AND PELVIS WITH CONTRAST showed 1. Moderate to severe left-sided hydroureteronephrosis, without obvious obstructing etiology. Possible focus of enhancing soft tissue at the left ureter vesicular junction, although this is difficult to assess completely secondary to metallic streak artifact from a right hip prosthesis. Recommend direct visualization with cystoscopy for further evaluation. 2. Urothelial enhancement is seen throughout the left ureter. 3. A 6 mm hypodensity in the body of pancreas is most consistent with an IPMN. 4. Mild focal ectasia of the infrarenal abdominal aorta. RECOMMENDATION(S): Moderate to severe left-sided hydroureteronephrosis, the cause of obstruction is not identified. Possible focus of enhancing soft tissue at the left ureter vesicular junction, although this is difficult to assess completely secondary to metallic streak artifact from a right hip prosthesis. Differential diagnosis includes TCC or inflammatory change from recent stone passage. Recommend direct visualization with cystoscopy for further evaluation. NOTIFICATION: Updated read was discussed with Dr. ___ by Dr. ___ telephone at 8:33am on ___, 20 min after discovery. ABDOMEN US (COMPLETE STUDY) showed Status post cholecystectomy with no findings to explain elevated liver function tests. Moderate left hydronephrosis (please see CT report for full evaluation). The patient was diagnosed with HEADACHE, ABDOMINAL PAIN LLQ, PANCREATIC DISEASE NOS. At the time of discharge, the patient had Primary Diagnosis: Pyelonephritis Hydroureteronephrosis Transaminitis Secondary Diagnosis: Atrial fibrillation Pulmonary nodules. The patient was given written instructions concerning 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 ___ F with a PMHx of paroxysmal a fib, recent L MCA stroke, HTN and HLD who presented with 1 wk of L sided abd pain and severe HA x2d found to have severe hydroureteronephrosis. #Pyelonephritis: Pt with L sided abd pain, nausea and vomiting with severe L sided hydroureteronephrosis on CT scan w/o obvious obstructing etiology but c/f enhancing lesion at UVJ with evidence of UTI consistent with a complicated pyelonephritis. At this time ddx for possible obtruction at UVJ include impacted stone vs malignant mass vs less likely polyp. Pt with remote hx of smoking and no personal hx of kidney stones, also with pulmonary nodules on CT c-spine concerning for mets. Pt also requiring lido patches to L lumbar area possibly MSK in origin though this is a dx of exclusion at this time given more worrisome GU pathology. Urology was consulted who noted that both kidneys were draining contrast appropriately on CT. They were initially concerned for neurogenic bladder as the cause, however the patient had very low post-void residuals. She was treated with ceftriaxone in the interim given her clinical signs of pyelonephritis. Her creatinine remained at 0.5 during her admission, without evidence of kidney disfunction. The patient's pain was controlled with tylenol. Cx results from patient's initial diagnosis of urinary tract infection revealed e.coli sensitive to bactrim, fluoroquinolones, and cephalosporins. Given that the patient was also on propafenone, it was decided to complete her course with bactrim as an outpatient, and to have the patient follow-up with urology as an outpatient for possible future cystoscopy vs ultrasound. #HA/neck pain: pt with x2 days of severe HA and neck pain, noted visual changes but no photosensitivity. DDx included meningitis vs SAH vs GCA vs malignancy vs mastoid sinusitis. Pt initially tender over temporal arteries with limited flexion of her neck, however this quickly improved on HD2 with transdermal lidocaine patches and was believed to be secondary to MSK stiffness and strain rather than an underlying rheumatologic or infectious process. #Afib/flutter- pt s/p ablation procedure EKG in NSR with PAC's and recent ischemic stroke, with strong suspicion for cardiac origin. Pt was recently d/c'd off ASA but kept on coumadin. Coumadin was stopped in the setting of cipro tx per her PCP. INR 1.3 on admission. The patient continued to be in NSR on telemetry during her admission, and a heparin drip was started while she bridged to an appropriate INR. The patient was transitioned to lovenox subcutaneous shots to continue bridging therapy as an outpatient. Her propafenone was continued while in house for rhythm control. #Elevated alk phos, transaminitis- Pt with elevated liver function tests, most prominently alkaline phosphatase and GGT which are markedly elevated, concerning for possible primary biliary cirrhosis. However, AMA was negative. Imaging including RUQ US and CT scan showed no evidence of disease. She should have her LFT's re-checked to evaluate for resolution and further work-up at PCP discretion including ___. #Anemia: baseline hemoglobin ___, hgb 9.7 on admission, without evidence of active bleeding from GI source or otherwise. Recent iron studies with elevated ferritin, concerning for AoCD. Likely decreased production, reticulocyte studies showed hypoproliferation in the setting of anemia. Concerning for possible myeloproliferative process given occasional tear drop cells on red cells. Her hemoglobin remained stable throughout her admission. #Pulmonary nodules: noted on CT c-spine, pt with h/o BOOP, CXR on ___ poor film quality and nodules not noted at that time. Concerning for scar from previous BOOP vs malignant process. Pt should have dedicated chest imaging in AM CXR vs CT #Pancreatic mass- As seen on CT abd/pelvis, appears c/w ___, ___ need f/u imaging as outpatient. Low suspicion for cause of elevated Alk phos. #HTN: pt mildly HTN during admission without need for pharmacologic intervention. #HLD/ history of stroke: pt was re-started on coumadin and bridged with heparin as above. The patient's aspirin was discontinued and her home gabapentin was continued for post-stroke nerve pain. TRANSITIONAL: -Last day of bactrim ___, dose adjusted because of coumadin per pharmacy -Will need dedicated Chest CT to further evaluate her pulmonary nodules noted on C-Spine CT -Pt with elevated liver function tests, alkaline phosphatase and GGT, concerning for possible primary biliary cirrhosis. She should have her LFT's re-checked to evaluate for resolution. Her imaging here was negative. Consider ___ as outpt. -Pt will be discharged on lovenox to contiue bridging to coumadin until she is at therapeutic goal of ___, will continue taking 2mg coumadin QPM during this bridge. Will need INR checked ___ and faxed to ___ Attn: Dr ___, patient with hypoproliferative anemia with normal MCV concerning for anemia of chronic disease, with recent elevated ferritin so unlikely d/t iron deficiency. -Pancreatic mass- As seen on CT, appears c/w ___ # Code Status: DNR/DNI # Emergency Contact/HCP: ___ ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male with a history of DM1 and multiple prior episodes of DKA presenting with weakness, abdominal pain, nausea, and vomiting in the setting of not taking insulin for 24 hours, now with DKA Radiology showed Nonobstructive bowel gas pattern. No evidence of large volume free intraperitoneal air. The patient was diagnosed with Type 1 diabetes mellitus with ketoacidosis without coma, Long term (current) use of insulin, Acute kidney failure, unspecified, Hypokalemia. At the time of discharge, the patient had PRIMARY: =========== Insulin Dependent Diabetes Mellitus Diabetic Ketoacidosis SECONDARY: ========== RASH Acute Kidney Injury Anemia Thrombocytopenia Steatorrhea. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY: ======== ___ y/o male with a history of DM1 and multiple prior episodes of DKA presenting with weakness, abdominal pain, nausea, and vomiting in the setting of not taking insulin for 24 hours, found to have DKA. He was admitted to MICU and treated with insulin drip, IV hydration, and electrolyte repletion as needed. ___ Diabetes team was consulted and assisted with insulin titration. ICU course complicated by persistent abdominal pain and nausea preventing ___ from taking adequate po. Insulin drip able to be discontinued and ___ maintained on subcutaneous insulin regimen starting ___. ACTIVE ISSUES: ============== # Discharge: Attempts were made to obtain scripts for insulin with the help of social work, case management and the financial aide office. These were unsuccessful as of ___. Despite not having secure scripts ___ chose to leave and because he did not have insulin scripts this was against medical advice. ___ stated he would go to ___ on ___ to obtain insulin. # DKA # Type 1 Diabetes ___ initially presented with nausea, vomiting, abdominal pain, muscle pain, and fatigue after not taking insulin for 24 hours. Found to have laboratory evidence of hyperglycemia, elevated anion gap, low Bicarb, low pH all consistent with DKA. ___ admitted to ICU for continuous IV insulin infusion according to DKA protocol. Provided with IV hydration and electrolyte repletion per protocol. ___ Diabetes team consulted and assisted with insulin titration. Able to transition to subcutaneous insulin from IV insulin ___. Social work was consulted for assistance with affording insulin and diabetes supplies as access to medicine/supplies identified as barrier for this ___. He will be going home on Tressiba 15 units at night and Humalog ___ with meals. # Rash: ___ found to have lesion on R forearm and back of neck w/ violaceous borders and associated scaling. R forearm lesion has been present for 6 months. Neck lesion present for over a year. Non-pruritic, non-tender, unclear what this etiology is. ___ had recent negative HIV testing and testing for syphilis was pending at the time of discharge. Will need follow up with dermatology. # ___: Presented with creatinine elevated above baseline. Felt to be most likely pre-renal injury iso hyperglycemia causing polyuria and volume depletion. Cr improved after volume resuscitation. # ALT elevation: Unclear etiology. Has had transaminitis during past admissions for DKA. ___ be related to viral illness or mild fatty liver disease. Improved without further intervention. # Pancytopenia: ___ w/ Hgb down-trending to ~9.6 and stable for last several days prior to discharge, with a MCV > 100. Folate/B12 in normal range. Retic and iron studies were pending at the time of discharge, low concern for ongoing bleed. Also mildly thrombocytopenic at ~150 and leukopenic ~ 3.5 w/ similar values during prior admissions. Continue to follow in outpatient setting. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The pt is a ___ yoM with hx of intractable seizures (includingvGTCs, drop attacks, "rocking spells with preserved consciousness, laughing fits), dev delay, who presents for LTM admission in the setting of worsened seizure/gait. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY. At the time of discharge, the patient had Intractible epilepsy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yoM with intractable epilepsy followed by Dr. ___ presented with worsening gait/ataxia and worsened seizure frequency. # NEURO: Patient was admitted to the Epilepsy Monitoring Unit where he was placed on continuous EEG long-term monitoring. Exam on admission was notable for marked gait imbalance (Romberg positive). He denied vertigo, nausea. Overall, his seizure frequency over the past several months has been quite variable and at times has acheived good control. On other occasions it appears that his medication regimen was leading to an intolerable side effect profile resulting in ataxia and increased falls (for example when increasing lamictal several months prior). Several changes were made to anti epileptics: discontinued tegratol, started vimpmat 200mg bid, increased pm lamotrigine dose to 400mg, decreased zonisamide to 500mg qhs. Mr. ___ will follow up with Dr. ___ in clinic. # PSYCH: continued home haldol and celexa for bipolar disorder. # ORTHO: continued outpatient alendronate for osteoporosis. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ h/o IDDM and complicated surgical history including colectomy for multiple polyps, c/b incisional hernia s/p repair with component separation and mesh which had been chronically infected, including a part of exposed mesh, s/p ex lap, mesh removal, component separation, biologic mesh placement, and incisional hernia repair on ___ ___. His postoperative course was complicated by an ECF with multiple ___ drains by ___, recent admission in late ___ for PICC sepsis (staph epidermidis) and a DVT, treated with clindamycin for 10 more days after discharge on ___, which he stopped this ___, and warfarin for 6 months for his DVT. Radiology showed Large subcutaneous anterior abdominal wall midline collection containing fluid and air. A smaller rim enhancing fluid and air collection tracks posteriorly as well as superiorly at the abdominal wall hernia repair site. No intraperitoneal or enteric communication detected. NOTIFICATION: Findings were discussed with Dr. ___ by Dr. ___ at 11:25 on ___. The patient was diagnosed with Cutaneous abscess of abdominal wall, Fever, unspecified. The patient was treated with abdominal wall exploration and wound vac placement. At the time of discharge, the patient had Abdominal wall fluid collection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted on ___ under the acute care surgery service for management of her acute cholecystitis. He was taken to the operating room and underwent an exploration of his abdominal wound, and placement of a wound vac. Please see operative report for details of this procedure. He tolerated the procedure well and was extubated upon completion. He was subsequently taken to the PACU for recovery. He was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. Preoperatively, he had been on antibiotics for the collection, but once it was opened and washed out in the OR it was determined that antibiotics were no longer indicated, and they were discontinued. He was initially given IV fluids postoperatively, which were discontinued when he was tolerating PO's. His diet was advanced on the morning of to regular, which he tolerated without abdominal pain, nausea, or vomiting. He was voiding adequate amounts of urine without difficulty. She was encouraged to mobilize out of bed and ambulate as tolerated, which he was able to do independently. His pain level was routinely assessed and by the time of discharge he was not requiring any medications for pain. On ___, he was discharged home with ___ and instructions to follow-up with Dr. ___ in ___ days.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ with PMH ILD (not on home O2, on home MMF and prednisone) and RA who presents with one day of abdominal pain. The pain began yesterday afternoon after eating a large salad. It was been severe though it fluctuates in degree of pain and has been primarily periumbilical in location. Denies any associated n/v. Last BM was yesterday afternoon after his pain had started; it was reportedly brown and normal in appearance. He is unsure of last flatus. He does endorse a history of constipation and an episode that was similar in sensation but milder and self-resolving several weeks ago; otherwise he has never had a bowel obstruction. He also endorses bloating. CHEST (PA AND LAT) showed Slightly low lung volumes with bibasilar atelectasis. No focal consolidation. No frank pulmonary edema. No evidence of free intraperitoneal air. CT ABD AND PELVIS WITH CONTRAST showed 1. Small-bowel obstruction with transition point in the right mid abdomen, where there is a short segment of hyperemic/thickened small bowel. The short segment has a targetoid appearance with intramural edema or inflammation. Possibilities include that this is due to congestion associated with small bowel obstruction, including the possibility of early ischemic change, versus intrinsic small-bowel abnormality such as a short-segment of inflammatory bowel disease. The latter possibility seems less likely, however. This appearance is not suspicious for a tumor but it may be appropriate, particularly to exclude a background inflammatory process, to consider follow-up imaging within a few months. 2. Hyperemic sigmoid colon may represent a skip lesion in the setting of inflammatory bowel disease. However, this apparent hyperenhancement may be due to under distension and is an equivocal abnormality. 3. No evidence of free intraperitoneal air. 4. Colonic diverticulosis without evidence of acute diverticulitis. 5. Small to moderate sized fat containing umbilical hernia without significant secondary inflammatory changes. 6. Small hiatal hernia. RECOMMENDATION(S): Follow-up cross-sectional imaging, CT or MR, may be appropriate within 3 months in order to assess for any possibility of an underlying small-bowel process to explain obstruction. However, obstruction due to adhesion is favored as the most likely etiology. NOTIFICATION: Findings and recommendations discussed with Dr. ___ at approximately 12:45 by telephone. CHEST (PORTABLE AP) showed NG tube coiled within the stomach. Low lung volumes. Mild cardiomegaly. Small right pleural effusion cannot be excluded. Radiology showed The enteric tube terminates in the fundus of the stomach. Multiple dilated loops of small bowel measuring up to 4.1 cm appear unchanged compared to study from earlier today. Oral contrast is seen within the colon. There are no abnormally dilated loops of large bowel. There is no free intraperitoneal air, although evaluation is limited by supine technique. There are no unexplained soft tissue calcifications. Levoscoliosis of the lumbar spine is noted. Radiology showed The enteric tube is in stable position. The dilated small bowel loops are slightly decreased in size now measuring up to 3.7 Cm. There is overall decreased oral contrast in the contrast. No free intraperitoneal air is identified. There are no radiopaque calculi or acute osseous abnormalities. The patient was diagnosed with Other intestnl obst unsp as to partial versus complete obst, Periumbilical pain. At the time of discharge, the patient had Small Bowel Obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient is a ___ year old male with pmh significant for ILD, RA. Patient presented to the emergency department with complaints of abdominal pain. Imaging was completed which demonstrated 1.Small-bowel obstruction with gradual transition point in the right lower quadrant where there is a segment of hyperemic and thickened small bowel which may represent inflammatory bowel disease such as Crohn's disease. 2. Hyperemic sigmoid colon may represent a skip lesion in the setting of inflammatory bowel disease. 3. No evidence of free intraperitoneal air. 4. Colonic diverticulosis without evidence of acute diverticulitis. 5. Small to moderate sized fat containing umbilical hernia without significant secondary inflammatory changes. 6. Small hiatal hernia. Therefore nasogastric tube was inserted for decompression with good effect. Once pain was well controlled, and the patient experienced a return of bowel function, their diet was advanced as tolerated. During this hospitalization, the patient voided without difficulty and ambulated early and frequently. The patient 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. He was afebrile and his vital signs were stable. The patient was tolerating a regular diet, ambulating, voiding without assistance, and their pain was well controlled. The patient was discharged home without services. Discharge teaching was completed and follow-up instructions were reviewed with reported understanding and agreement.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with known spondylisthesis and spinal stenosis on MRI who injured his back while bending over 10 days ago. He initially went to an OSH ED ___ without imaging. On ___, he fell ___ pain using his walker, and had an MRI that showed multilevel canal stenosis, L4 on L5 anterolisthesis with spondylosis without evidence of cord impingement. He was set up with neurosurgical f/u three days from presentation at that hospital Today he visits ___ with concerns about his persistent back pain and right foot weakness. No fevers, no bowel/bladder issues, no history of IVDU. Radiology showed No evidence of deep venous thrombosis in the right lower extremity. Radiology showed Extradural lesion right L2-3 level with mixed signal characteristics which may represent a synovial cyst with calcification or pulsation artifact centally. Multilevel spondylosis with neural foraminal stenosis and spinal canal narrowing most severe at L2-L3, L3-L4, and L4-L5 as described. Radiology showed 1. 6 mm abnormal motion associated with anterolisthesis of L4 on L5 between flexion and extension, indicating instability. 2. Retrolisthesis of L1 on L2. 3. Severe degenerative change in the lumbar spine without evidence of acute fracture. Radiology showed 1. Extradural lesion seen on MRI(synovial cyst), is not visualized on CT. 2. Multilevel degenerative changes of the lumbar spine with disc bulges and spinal canal narrowing at multiple levels. 3. Grade 1 anterolisthesis of L4-5 The patient was diagnosed with LUMBAGO, MUSCSKEL SYMPT LIMB NEC, HYPERTENSION NOS. At the time of discharge, the patient had Multiple levels of spinal canal stenosis and L4 on L5 anterolisthesis with spondylosis.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ presented to the ED on ___ with back pain and right lower extremity weakness. He was admitted to the neurosurgical team for pain control. He was transfered to the floor and started on Oxycodone and valium with fair effect. Dexmathasone was added and he had great improvement to his back pain. An MRI of the L spine was obtained and showed multiple levels of spondylosis with neural foraminal stenosis and spinal canal narrowing most severe at L2-L3, L3-L4, and L4-L5 as described. On the MRI of the Lspine it was noted that there was a lesion, questionable for synovial cyst at the level of right L2 to L3. Images of the lumbar spine were also obtained and showed abnormal motion of L4 and L5, related to anteriorlisthesis. On ___ Dr. ___ with patient the need for surgery and was placed on the OR schedule for ___. On ___, A CT of the lumbar spine was obtained and was consitant with the findings on the MRI, for the exception the synovial cyst, which was not visualized on the CT. The patient decided to hold of from having surgery and wanted some time to think about doing the surgery. On ___, the patient was discharged in stable conditions and neurologically intact, and pain under control. He was was discharged with a prednisone taper and will follow up with Dr. ___ to schedule his surgery within the next week or two. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ s/p hemorrhoid surgery presents with persistent nausea, vomiting and abdominal pain. Patient said she had her surgery 2 days ago by Dr. ___ at ___ and developed nausea and vomiting immediately following surgery. Reports that she developed periumbilical abdominal pain soon after. Some lower abdominal pain. Says she actually does not have pain at the site itself. No fevers or chills. No urinary symptoms. Passing gas. Has had multiple bowel movements, but denies diarrhea. First bowel movement had some bright red blood coating it, subsequent bowel movements were brown. She is currently having her period. Denies any urinary symptoms. She denies having any prior issues with nausea/vomiting in the past, although on review of records, she was hospitalized with similar symptoms in ___ and had multiple ED visits for similar symptoms prior to that time. On this occasion, she reports that symptoms improved transiently with hot showers. Tried mylanta and procholperazine from her PCP at home without relief. In the ED, initial vitals were ___ pain, T 98.5, HR 60, BP 113/67, RR 16, SaO2 100% on RA. Labs notable for Was given ondansetron 4mg x3, APAP 500mg, lorazepam 2mg, metoclopramide 10mg, and a scopolamine patch. ED felt that, as patient was unable to tolerate any PO and immediately vomits, she was not safe to go home; colorectal surgery team was FYI’d and patient was admitted to general medicine. On the floor, patient complaining of nausea and abdominal discomfort, requesting to take a hot shower. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Radiology showed No evidence of obstruction noting limited evaluation due to paucity of bowel gas. The patient was diagnosed with PERSISTENT VOMITING, ACIDOSIS. At the time of discharge, the patient had Cannabinoid Hyperemesis Syndrome / Post-Operative Nausea and Vomiting. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___, a ___ yo F PMHx chronic daily marijuana use and hemorrhoids s/p hemorrhoidectomy ___ presents with persistent nausea/vomiting with abdominal pain and inability to tolerate PO and refractory to numerous anti-emetics. On ___ AM, she was able to tolerate clears diet and crackers and was willing to go home. # Cannabinoid Hyperemesis Syndrome / PONV: Persistent post-operative nausea with inability to take PO. Has elevated lactate with leukocytosis and ketonuria but has normal BMP/LFTs/Lipase/hCG/AXR. Most likely post-op nausea and vomiting given time course, although marijuana-induced hyperemesis also in ddx given daily marijuana use and relief with hot showers. Patient previously had recurrent episodes of nausea and vomiting attributed to cyclic vomiting vs marijuana hyperemesis. Also with significant psychiatric history, which may be contributing to symptoms. eosinophilic esophagitis also a possibility given hx of ectopy but less likely. EKG in AM showed bradycardia to 48, sinus, QTc 457. She was initially treated with ondansetron, prochlorperazine, and lorazepam IV along with scopolamine patch and famotidine for symptomatic relief. She went home with PO/PR anti-emetics and instructions to avoid marijuana as it was causing her nausea/vomiting. # Hypokalemia: K 2.8 on AM labs from 3.3 in ED, likely related to repeated emesis. She was given several IV K+ repletions as part of maintenance IV fluids and as an initial bolus. Final K+ was 3.5 on discharge. # Bradycardia: HR ___ without clear lightheadedness, dizziness, pre-syncope, or chest pain. Possibly constitutional (otherwise healthy patient) and parasympathetic tone from repeated Valsalva maneuvers. She remained hemodynamically stable in sinus throughout her hospital stay. # Abdominal Pain: Epigastric likely related to vomiting, improved with PR acetaminophen and famotidine. Patient requested avoidance of opioids as this may increase her nausea. Substantially improved on discharge. # Status-Post Hemorrhoidectomy ___: Post-operative nausea/vomiting was at least a component but hard to define feature of her presentation. She was continued on a Senna/Docusate bowel regimen to avoid constipation. # Mood Disorder: Variable but stable history of depression, anxiety and agorophobia continued on home olanzapine 10mg qHS. # Atopy: Chronic stable issues, but eosinophilic esophagitis is a potential cause of nausea/vomiting in this patient (less likely with prompt improvement). Continued on home albuterol inhaler, fluticasone nasal spray # Iron-Deficiency Anemia: Patient has had chronic issues with anemia, attributed to bleeding from her hemorrhoids. Home ferrous sulfate held during hospital stay given risk of constipation but restarted on discharge. # Code Status: Full Code, no health care proxy documented.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ ___ gentleman with history of Stage IV CKD (urate nephropathy), hx pulmonary TB s/p RIPE ___, and mild dementia admitted due to hypotension with BP 84/60 at his nephrologist's office today. Pt. had not mentioned any symptoms to his family, but on direct questioning reports cough (inknown if productive or nonproductive), shortness of breath, and fatigue for about 2 weeks. Daughter is unable to confirm further details but believes he was otherwise feeling well without fevers/night sweats/chills or chest pain. Upon arrival to ED, pt.'s VS were 97.6 79 124/88 16 98% RA. He was given 2L IVF, duonebs, and azithromycin with good improvement in symptoms. His CXR did not show acute consolidation, volume overload, or other concerning intrathoracic process. On arrival to the floor, 97.6, 86, 144/87, 22, 100% RA. Pt. appeared to be comfortable. Radiology showed Possible minimal central pulmonary vascular congestion. Otherwise, no acute cardiopulmonary process. The patient was diagnosed with RESPIRATORY ABNORM NEC, CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE), HYPERCHOLESTEROLEMIA, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE. At the time of discharge, the patient had Primary diagnoses: Chronic obstructive pulmonary disease Hypovolemia Secondary diagnoses: Stage IV Chornic 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>___ ___ gentleman with history of Stage IV CKD (urate nephropathy), hx pulmonary TB s/p RIPE ___, and mild dementia admitted due to hypotension and dyspnea. # Dyspnea. Pt. admitted with 2 week history of mild acute on chronic dyspnea. Pt. was afebrile, saturating well on room air, without leukocytosis. Pt. did have wheezes on exam, but no other features concerning for pneumonia or CHF exacerbation. CXR with evidence of COPD but no acute findings. Suspect bronchitis or URI with mild COPD exacerbation. Pt. improved significantly with nebulizers alone. He was saturating well on room air at rest and with exertion at the time of discharge. # Hypotension. Pt. hypotensive with systolic in the ___ at outpatient office visit prior to admission. Hypotension resolved rapidly with IVF administration, though pt. remained orthostatic. IVF resusicitation limited by hypertension. # Hypertension. Pt. hypertensive at time of discharge, though asymptomatic. This was likely due to IVF administration in setting of poor renal function. Pt. declined to stay for further monitoring, but he and his family were given strict instructions for home blood pressure monitoring and return to care guidelines. # Acute on Chronic Kidney Disease. Due to urate nephropathy. Creatinine elevated to 3.4 on admission, increased from baseline of 3.0. Pt. reports poor PO intake recently. Creatinine returned to baseline on discharge after administration of IVF. # Transitional issues: - blood pressure check - confirm pt. using mometasone-formoterol and albuterol; pt reported some trouble obtaining these medications at the pharmacy, but does not seem to be an entirely reliable historian - encourage hydration - consider pulm eval with PFTs - flu vaccine and pneumococcal vaccine </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 h/o recurrent pericarditis and undifferentiated episodic tachycardia who presents with chest pain, shortness of breath, and ___ lbs weight gain. He was initially diagnosed with viral pericarditis in ___ ___ after presenting with pleuritic chest pain and an ECG showing diffuse STE. He was started on colchicine and NSAIDs and despite this therapy had a recurrence of his symptoms and represented to ___ (___). At the time of representation he was not on any medication and was restarted on colchicine/ibuprofen and sent home. He was again hospitalized ___ to ___ at ___ for recurrent tachycardia and chest pain. At that time, it was thought that he experienced another bout of pericarditis. He was treated with colchicine and Motrin. His EKGs, chest x-ray and TTE per report were within normal limits. The patient was initiated on Lopressor 12.5 mg b.i.d for his tachycardia. However, his beta-blocker therapy resulted in decrease in bradycardia and his was stopped by his PCP. He presented to the ED ___ for an episode of palpitation with heart rate to the 150s. At that time, he had a normal EKG and a negative chest x-ray. He presented to his PCP with intermittent chest pain ___ and was started on ibuprofen 800mg TID and referred to cardiology, who he saw him ___. At that time he was thought not to have active pericarditis or PE, ibuprofen was discontinued and indomethacin 25mg TID x14 days was started with plan for followup echo. In the ED initial vitals were 100.0 147 149/76 18 100% RA. WBC 10.5 down from 13.9 ___. CXR with no cardiomegaly, pleural effusions, pulmonary edema. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery or other episodes, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Radiology showed No acute cardiopulmonary abnormality. The patient was diagnosed with CHEST PAIN NOS, TACHYCARDIA NOS. At the time of discharge, the patient had Primary diagnosis: chest pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>CHEST PAIN: The patient had had multiple admission for chest pain consistent with pericarditis over the last year. At the time of admission, the only therapy he was on was indomethacin. He presented to ___ ED on ___ with chest pain and shortness of breath. There, he was administered morphine with improvement in his chest pain. An EKG was negative for conduction delay and ST/T changes. He was seen by Cardiology (Dr. ___, who recommended that the patient be admitted and restarted on colchicine (and continued on his home indomethacin) for a concern of pericarditis. During this hospitalization, the patient's EKG remained without conduction abnormalities or ischemic changes. Telemetry showed occasional sinus tachycardia but was negative for arrhythmia. The patient had a repeat transthoracic echocardiogram on ___ that was normal (EF 65%, normal cavity sizes/pressures, normal systolic and diastolic function) other than some borderline/mild bileaflet mitral valve prolapse. The Rheumatology team was consulted for a possible autoimmune etiology for his recurrent pericarditis. They recommended that the patient be seen by Rheumatology as an outpatient for further work-up of causes of recurrent pericarditis such as lupus, rheumatoid arthritis, mixed connective tissue disease, adult onset stills, scleroderma, and Sjorgens as well as Familial mediterranean fever and Tumor necrosis factor receptor-1 associated periodic syndrome (TRAPS). The patient remained stable in the hospital, and was discharged on daily colchicine and indomethacin. At the time of discharge, he was scheduled to see Cardiology and Rheumatology as an outpatient. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ reportedly homeless who will not provide any history. Per ED and EMS pt was struck by car going about 10mph and found sitting down on the ground. Radiology showed Acute comminuted, impacted proximal left tibial fracture involving both the medial and lateral tibial plateaus. Radiology showed Partially visualized, intra-articular proximal left tibial fracture. No visualized pelvic or left femoral fracture. Radiology showed No acute cardiopulmonary process. CT HEAD W/O CONTRAST showed No acute intracranial abnormality. CT C-SPINE W/O CONTRAST showed No evidence of fracture or traumatic malalignment. CT TORSO W/CONTRAST showed 1. No evidence of trauma within the chest, abdomen or pelvis. 2. Thickening of the endometrial stripe versus fluid in the endometrial canal. RECOMMENDATION(S): Non urgent pelvic ultrasound suggested NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 4:53 ___, 2 minutes after attending readout. Radiology showed As above. Radiology showed No fracture or dislocation. Radiology showed 1. Severely comminuted fracture of the left proximal tibia involving mostly the lateral tibial plateau. There is impaction and depression of the lateral tibial articular surface. 2. Small fractures off of the lateral aspect of the patella and the posterior aspect of the fibular head. 3. Lipohemarthrosis. Radiology showed As above. Radiology showed As above. TIB/FIB (AP AND LAT) LEFT was done. Radiology showed Since the previous study, there is apparent medial migration of the medial tibial plateau fracture fragment in relation to the tibial shaft. Moreover there appears to be more impaction at the fracture site. The fracture gap measures 1.3 cm. I doubt this is all due to patient positioning. There is prominent soft tissue swelling. NOTIFICATION: Findings have been placed in the Radiology reporting dashboard. WRIST(3 + VIEWS) RIGHT showed Distal radial fracture probable interval healing, however obscured by overlying cast material. Background degenerative changes. TIB/FIB (AP AND LAT) IN O.R. LEFT was done. KNEE (2 VIEWS) LEFT was done. The patient was diagnosed with Displaced bicondylar fracture of left tibia, init, Oth intartic fracture of lower end of right radius, init, Ped on foot injured pick-up truck, pk-up/van in traf, init. The patient was treated with ORIF L tibial plateau ___ ___, Revision ORIF L tibial plateau ___ ___. At the time of discharge, the patient had Left tibial plateau fracture, right distal radius fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left tibial plateau fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for open reduction internal fixation of left tibial plateau fracture and again on ___ for revision ORIF of same 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 rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touchdown weightbearing in the left lower extremity, and will be discharged on <<>> 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: ___ with history of HTN, HLD, C2-C6 laminectomy, b/l carotid stenting ___ on Plavix, presents after fall at home. Radiology showed Large left-sided pneumothorax with slight increase in size over the interval and rightward shift of the mediastinum, consistent with tension pneumothorax. NOTIFICATION: These findings were discussed with ___, NP by Dr. ___ telephone at 12:11 on ___, 10 minutes after discovery. Radiology showed Interval decrease in size of the left pneumothorax status post left-sided chest tube placement. Radiology showed 1. Small apical left-sided pneumothorax is not significantly different from the most recent prior radiograph. 2. Increased interstitial markings in bilateral lungs, which have increased over the interval, consistent with worsening pulmonary edema superimposed on chronic fibrotic changes. Radiology showed Stable left apical pneumothorax. CHEST (PA AND LAT) showed In comparison with the earlier study of this day, the left chest tube has been removed. There is little changed in the apical pneumothorax on the left. Radiology showed 1. Small left apical pneumothorax and small left pleural effusion are unchanged. 2. Slight interval increase in interstitial markings, consistent with mild interstitial pulmonary edema. CHEST (PORTABLE AP) showed Left apical pneumothorax is unchanged to slightly smaller The patient was diagnosed with TRAUM PNEUMOTHORAX-CLOSE, FRACTURE THREE RIBS-CLOS, FX CLAVICL, ACROM END-CL, FX SCAPUL, ACROM PROC-CL, UNSPECIFIED FALL. The patient was treated with ___ chest tube placement by ACS service ___ chest tube removal. The patient was given written instructions concerning 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 HTN, HLD, C2-C6 laminectomy, b/l carotid stenting ___ on Plavix, presents after fall at home. The patient was admitted to the hospital after she sustained a mechanical fall at home landing on her right shoulder. She did not have loss of consciousness. She followed up the following day at an OSH where imaging was done. She was reported to have left ___ rib fractures, left pleural effusion, small left pneumothorax and a right distal clavicle fracture and a S5 body fracture. She was transferred to ___ for further management. See below for details of hospital course. She is now being discharged to rehab.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ yo lady with PMH significant for childhood R AVM s/p coil/embolization, stroke and seizure disorder complicate by left side hemiplegia and VP shunt who presents via medflight for seizure. The patient was reported to have a 1 hour long seizure at home taken to ___ where she received a total of 4mg of Ativan and was intubated for airway protection prior to med-flight here. Her neurology care is at ___ ___) but she is transitioning to neurology at ___. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No intracranial hemorrhage or infarction. 2. There is mild indistinctness of the gray-white interface suggestive of diffuse edema. 3. Unchanged size of the ventricles without evidence of ventriculomegaly. 4. There is diffuse sinus disease and nearly complete opacification of the mastoid air cells bilaterally CHEST (PORTABLE AP) showed ET tube tip is 3.5 cm above the carinal. NG tube tip is in the stomach. IVC filter is in place. Right internal jugular line tip is at the level of the right atrium and might be pulled back 3 cm. Cardiomegaly is unchanged as well as wide involvement of the lungs by consolidations and pulmonary edema. The findings are also concerning for multifocal infection. Further assessment with chest CT would be recommended if clinically feasible. CHEST (PORTABLE AP) showed Worsened appearance to the lungs. CHEST (PORTABLE AP) showed In comparison with the study of ___, there is little overall change. Monitoring and support devices are stable. Extensive bilateral pulmonary opacifications persist, most likely representing some combination of pulmonary edema and multifocal pneumonia. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, there is been placement of a Dobhoff tube that extends to the upper stomach. Otherwise little change. CHEST (PORTABLE AP) showed Persistent bilateral opacifications, most likely representing pulmonary edema and/or multifocal pneumonia, with slightly improved aeration of the right lung. CHEST (PORTABLE AP) showed Moderate bilateral pleural effusion increased since ___. Severe consolidation in both lungs has also worsened. Moderate enlarged of the cardiac silhouette unchanged. ET tube in standard placement. Feeding tube ends in the distal stomach. Right jugular line ends in the upper right atrium. Ventriculoperitoneal shunt traverses the right neck chest and upper abdomen. Caval umbrella filter noted at the level at the L3 level. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, there is no convincing evidence of pneumothorax. Monitoring and support devices are essentially unchanged, as is the appearance of the heart and lungs. Radiology showed IVC filter overlying the mid abdomen in the expected location of the IVC not likely in a renal vein; relationship to where the renal veins flow into the IVC can not be determined on this study. CT CHEST W/O CONTRAST showed 1. Low lung volumes and diffuse airspace consolidations, most severe within the bilateral lower lobes. Findings are most compatible with severe multifocal pneumonia. 2. Moderate cardiomegaly and mild smooth interlobular septal thickening suggestive of concurrent mild pulmonary edema. 3. ETT in appropriate position. CHEST (PORTABLE AP) showed Comparison to ___, 03:10. Increased transparent see of the lung parenchyma suggests improved ventilation. However, the pre-existing parenchymal opacities bilaterally are still severe. The overall lung volumes remain low. Moderate cardiomegaly persists. The monitoring and support devices continue to be in correct stable position. CHEST (PORTABLE AP) showed Worsening right lower lobe atelectasis, persistent left lower lobe pneumonia. Unchanged low lung volumes and bilateral pleural effusions. CHEST (PORTABLE AP) showed No change. DX CHEST PORTABLE PICC LINE PLACEMENT showed Right PICC line terminates in the mid to lower SVC. CHEST (PORTABLE AP) showed Severe pulmonary consolidation is symmetric and basal predominant, and therefore largely attributable to pulmonary edema. However the predominantly basal consolidation has been present since at least ___ and therefore multifocal pneumonia is likely. Severe cardiomegaly is stable. There are no findings to suggest that pleural effusions have developed since the let the ___ chest CT which showed none present at that time. ET tube in standard placement. CHEST (PORTABLE AP) showed As compared to prior radiograph of 1 day earlier, enlargement of the cardiomediastinal contours is unchanged, accompanied by worsening diffuse alveolar opacities, worse on the left than the right. Moderate left and small right pleural effusions persist. No definite pneumothorax. CHEST (PORTABLE AP) showed Constant correct position of the monitoring and support devices. Low lung volumes. Diffuse bilateral parenchymal opacities with air bronchograms are unchanged in extent and severity. Moderate cardiomegaly persists. No larger pleural effusions. CHEST (PORTABLE AP) showed Severe widespread pulmonary consolidation has worsened. Some accompanying pleural effusion is presumed, but it may be minimal. Severe cardiomegaly has not improved. Tip of the endotracheal tube is above the upper margin of the clavicles, no less than 5 cm from the carina with the chain elevated. It could be advanced one are 2 cm for more secure positioning. Right jugular line and right PIC line both pass through the superior vena cava but the tips are obscured, probably in the right atrium. No pneumothorax. CHEST (PORTABLE AP) showed No comparison. Moderate overinflation. Non characteristic scarring at the right lung basis. No pneumonia, no pulmonary edema, no pleural effusions. Normal size of the heart. No pneumothorax. CHEST (PORTABLE AP) showed Newly distended stomach and colon. No change in severe bilateral pulmonary opacities. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephoneon ___ at 11:27, 60 minutes after discovery of the findings. CHEST (PORTABLE AP) showed Distended stomach and colon. Unchanged severe bilateral parenchymal opacities. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephoneon ___ at 11:27, 60 minutes after discovery of the findings. Radiology showed Diffuse air-filled loops of bowel suggesting ileus. CHEST (PORTABLE AP) showed Right subclavian PICC line, VP shunt, endotracheal tube, and feeding tube are unchanged in position. The heart remains markedly enlarged which may reflect cardiomegaly, although pericardial effusion should also be considered. Lung volumes are low with layering bilateral effusions and patchy bibasilar opacities suggestive of atelectasis, although pneumonia cannot be entirely excluded. No obvious pneumothorax. An IVC filter is incompletely visualized. CHEST (PORTABLE AP) showed In comparison with the study of ___, the endotracheal tube is been removed and a tracheostomy tube is now in place. What appears to be a ventriculoperitoneal shunt remains in place. Right subclavian PICC line is in the right atrium. The Dobhoff tube is been removed. Continued low lung volumes with substantial enlargement of the cardiac silhouette and unchanged pulmonary edema. CHEST (PORTABLE AP) showed Airspace opacity now appears more confluent in the right upper lobe. Bilateral airspace opacities persist. Otherwise, no significant interval change. CHEST (PORTABLE AP) showed Repositioning of the tracheostomy with improved aeration of the right upper lobe. Persistent cardiomegaly. CHEST (PORTABLE AP) showed No significant interval change when compared to the prior study. Persistent cardiomegaly and pulmonary vascular congestion. CHEST (PORTABLE AP) showed Increased opacity at the left lung base with partial silhouetting of the left heart border suspicious for lingular consolidation. Unchanged mild pulmonary edema. CHEST (PORTABLE AP) showed Opacification in both lower lungs could be pneumonia or dependent edema. Precise volume of presumed pleural effusions is difficult to assess, probably not large. Severe cardiomegaly is chronic. No pneumothorax. Right PIC line ends in the right atrium. Shunt catheter traverses the right neck paramedian chest and upper abdomen, passing out of view. Chest radiograph. showed 1. An endotracheal tube ends 1 cm above the carina. Recommend withdrawal for standard positioning. 2. A consolidation in the right upper lobe may be consistent with aspiration or infection. Bilateral perihilar and basilar opacities may reflect edema and or aspiration. CHEST (PORTABLE AP) showed Tracheostomy midline. Lung volumes are still very lower exaggerating severity of at least moderate cardiomegaly. Distribution of alveolar abnormality in the lungs is relatively symmetric, most likely edema. Residual consolidation in the left lower lobe has improved. Right PIC line ends close to the superior cavoatrial junction. Ventriculoperitoneal shunt traverses the right neck chest and upper abdomen. Gastrostomy tube and caval umbrella filter noted. CHEST (PORTABLE AP) showed Right subclavian line tip projecting over upper right atrium, slightly more distal on the prior study. Clinical correlation requested. Possible slight interval improvement in the bilateral alveolar opacities. Otherwise, I doubt significant interval change. RECOMMENDATION(S): Right subclavian line tip projecting over upper right atrium, slightly more distal on the prior study. Clinical correlation requested. CT ABD AND PELVIS WITH CONTRAST showed 1. No evidence of intra-abdominal infection. 2. Small volume non-hemorrhagic free fluid in the cul-de-sac, adjacent to the VP shunt tip. 3. Bibasilar parenchymal opacities at least partially due to known pulmonary edema, although superimposed pneumonia should be considered in the appropriate clinical setting. MR HEAD W AND W/O CONTRAST showed 1. Status post AVM embolization in the area of the vein ___ as described above, there is a prominent straight gyrus, apparently with embolization material, which appears partially thrombosed, expected for the embolization procedure. 2. Unchanged right frontal EVD terminating in the region of the foramen of ___, unchanged asymmetry of the lateral ventricles, there is no evidence of transependymal migration to indicate hydrocephalus. 3. There is hypoplasia of the corpus callosum, more significant in the body and splenium. 4. Diffuse pachymeningeal enhancement, likely related with EVD placement. 5. Nodular area of enhancement in the right frontal convexity, extra-axial, likely consistent with dural calcification, however a small meningioma cannot be completely excluded CHEST (PORTABLE AP) showed Low lung volumes and marked patient rotation limit overall assessment of the chest. With these limitations in mind, it cardiomegaly is apparently stable. New hazy increased opacity is evident in the right infrahilar region, and could be due to a developing pneumonia or a focus of aspiration. Short-term followup radiographs with improved positioning may be helpful for more complete assessment when the patient's condition permits. CT CHEST W/CONTRAST showed Multifocal consolidation throughout the lungs has substantially improved since ___. Progression of widespread ground-glass opacification without septal thickening or pleural effusions makes diffuse alveolar damage more likely than cardiac edema. Hypersensitivity or toxic drug reaction should be considered. Active widespread infection is unlikely. Radiology showed There is a VP shunt device seen with the distal tip extending into the expected location of a lateral ventricle. A cortical defect is seen in the region of the parietal bone. Please refer to the procedure note for additional details. Chest radiograph showed 1. An endotracheal tube terminates 1.0 cm above the carina and should be pulled back a few cm for standard positioning. 2. Interval placement of a right central venous line ends at the SVC/RA junction. CHEST (PORTABLE AP) showed Comparison to ___. The pre-existing parenchymal opacities, bilaterally in the lung parenchyma, have minimally increased in extent and severity. Lung volumes continue to be low. Moderate cardiomegaly persists. The presence of a small left pleural effusion cannot be excluded. Signs of pulmonary edema are mild. CHEST (PORTABLE AP) showed Severe bilateral pulmonary consolidation has worsened, moderate cardiomegaly and mediastinal vascular engorgement have increased and pleural effusions at least moderate in size are larger. Overall findings point to cardiac decompensation, perhaps in a setting of worsening pneumonia. ET tube in standard placement. Nasogastric drainage tube ends in the distal stomach. Right jugular line ends in the right atrium. No pneumothorax. CHEST (PORTABLE AP) showed Severe bilateral pulmonary consolidation, severe cardiomegaly, presumed moderate to large pleural effusions, all unchanged since ___. No pneumothorax. ET tube, nasogastric drainage tube in standard placements. Right jugular line ends in the right atrium. Tip of the inferior vena caval filter ends at the L one level. The patient was diagnosed with Epilepsy, unsp, not intractable, without status epilepticus. The patient was treated with Endotracheal intubation, extubation with reintubation Lumbar puncture Tracheostomy and Percutaneous endoscopic gastrostomy tube ___ Flexible bronchoscopy and tracheostomy revision ___ Tracheobronchoscopy ___. At the time of discharge, the patient had Primary Diagnoses ================== Status Convulsive Epilepticus Hypoxemic Respiratory Failure Ventilator Associated Stenotrophomonas Pneumonia Acute Respiratory Distress Syndrome Acute Kidney Injury Stress Cardiomyopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ year old woman with a history of a right AVM status post embolization, complicated by pediatric stroke ___ ___ status post VP shunt, with resultant seizure disorder and recent frequent breakthrough seizures, who presented to ___ ___ with a prolonged convulsive seizure. She was intubated for airway protection and transferred to ___. She was admitted to the ICU. She had a complicated medical course with failure to wean from the ventilator, stenotrophomonas VAP, stress cardiomyopathy, and ___ due to ATN, s/p tracheostomy and PEG placement. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ history of ESRD on HD ___, ischemic cardiomyopathy (CAD s/p 3V CABG ___, EF 45% with moderate MR, pacemaker) and OSA recently admitted last week with pulmonary edema and hypoxia in setting of CHF exacerbation now presenting from HD with hypotension and bradycardia. Patient was most recently admitted to ___ from ___ with presumed CHF exacerbation causing hypoxia in setting of pulmonary edema. Patient known to have poor compliance to low salt diet and reportedly had significant dietary indiscretion leading to his presentation. Patient was diuresed using ultrafiltration given lack of response to lasix with reduction of O2 requirement from 5L->2L. Of note, patient had asymptomatic bacteruria on admission last time that was not treated given lack of symptoms. Given his CAD, patient was started on metoprolol XR 50mg daily on discharge. On discharge ___, patient was . Overnight, patient felt a little off with some shortness of breath but overall well. However, this morning, patient woke up feeling awful and reports that he had some shortness of breath with walking and felt weakness and shakiness with walking. He denies fevers, chills, cough, rhinorrhea, chest pain, palpitations, n/v/d, dysuria. This morning he presented to hemodialysis where he was noted to be hypotensive with bradycardia to ___ and he was referred to ___ ED for evaluation. In the ED, initial vs were: 98.4 65 90/53 20 100% 2L. Labs were remarkable for WBC of 8.8, Hct 33.5, Cl 88, Cr 9.1, Trop of 1.41, CKMB of 2, Mg of 2.7. EKG per report: paced, 65, QRS 172, QTc 488, intermittently paced with abnormal complex (very low amplitude) after pacer spike. Patient was reportedly seen by EP who felt pacer was ok and wanted to admit to medicine for HD and trending of troponins. Patient was written for calcium gluconate which was not given apparently. He had CXR which showed improvement in pulmonary edema with likely ongoing pulm edema at bases though couldn't rule out possible apical opacity representing pna in right clinical context. Vitals on Transfer: 97.7 35 135/38 21 97% RA. Patient then went immediately to dialysis where 4 hours of dialysis was performed with no fluid taken off. HR ranging ___. On the floor, vs were: 97.9 84 133/65 16 93%RA. Patient reported feeling reasonably well without significant shortness of breath, weakness or dizziness. Radiology showed Improvement in the appearance of the pulmonary edema when compared to prior. Persistent bibasilar opacities are likely chronic. Some residual right apical opacity could represent continued resolving edema although superimposed infection is also possible. The patient was diagnosed with CARDIAC DYSRHYTHMIAS NEC, OTHER NONSPECIFIC FX ON EXAM, END STAGE RENAL DISEASE, RENAL DIALYSIS STATUS, HYPERCHOLESTEROLEMIA. At the time of discharge, the patient had Primary diagnosis: New onset of bigemny Secondary diagnosis: 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>Mr. ___ is a ___ w/ h/o CAD s/p CABG ___, pacemaker for bradycardia due to heart block, ESRD on HD recently admitted with CHF exacerbation presenting with bradycardia, hypotension and shakiness at dialysis, condition much improved s/p 2 sessions of HD. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PORTABLE AP) showed Findings concerning for multifocal atypical pneumonia. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had Pneumonia Leukocytosis Acute hypoxic respiratory failure Chronic pain Urinary retention Constipation Acute renal failure Diabetes mellitus. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ is a ___ woman with a history of breast cancer s/p resection, hypertension, and hyperlipidemia, who presentED with hypoxia and somnolence, found to have a multifocal pneumonia and with hypoxic hypercarbic respiratory failure that required initial BiPap and ICU admission but improved to nasal cannula with ceftriaxone and azithromycin. #Multifocal PNA #Leukocytosis - #Acute hypoxic respiratory failure Flu neg. CXR c/w multifocal PNA. Legionella Ag neg. Blood cx drawn ___ NGTD. Strep Ag pending. Her hypoxemia improved quickly, although she but continued to require O2 with ambulation, likely the result of her pneumonia. Leukocytosis persisted, although given clinical improvement, this was not suspected to be caused by treatment failure. She was treated with ceftriaxone/azithro for a total 7 day course. She was discharged on Cefpodoxime to complete final 2 days of antibiotics. Ambulatory saturation improved prior to discharge and the patient did not require oxygen on discharge. #Cachexia #Poor PO intake #Poor mobility #Chronic pain #Somnolence on presentation likely due to polypharmacy Patient takes 4 mg TID of dilaudid at home, although may take more intermittently. Also on amitriptyline HS. Per report no longer on gabapentin or tizanidine. Some concern was raised that she presented with excessive somnolence due to medications. She reported that her pain is poorly controlled on the current dilaudid regimen and indicated at times that she might take more than she is prescribed. Contacted PCP to discuss and consulted social work. Also consulted ___, OT, and nutrition. Ultimately she declined rehab and returned home with instructions to take her medications only as prescribed and with close PCP ___. Would consider weaning Dilaudid as outpatient as it does not seem to be managing pain adequately and may be causing adverse effects. #Urinary retention Patient intermittently retained during the admission, up to 700s-800s, although at other time she did not retain significantly. Per patient and family this was a new issue. Her amitriptyline was stopped and ambulation was maximized. The patient's urinary retention improved prior to discharge. #Troponin elevation ECG shows evidence of LVH but no acute ischemic changes. Troponin leak likely due to demand in setting of acute illness.. Patient did have elevated proBNP. TTE was performed which was normal. #Constipation Increased regimen during admission ___, resolved #HTN Restarted lisinopril 10 mg daily after initially holding #Parkinsonism Continued carbidopa/levopa, unclear why patient is on this medication. #Lower extremity edema Held Lasix 20mg daily during the admission as indication was unclear, please resume on follow up if indicated. #T2DM Continued slightly reduced insulin regimen. Victoza held. Per her daughter she is off other DM meds at this point due to hypoglycemia. #History of breast cancer Continued exemastane #HLD Continued simvastatin #GERD Continued omeprazole #?Mild cognitive impairment: Continued memantine 10mg BID #Allergies Held loratadine 10mg daily during admission. Continued fluticasone intranasal ==================== ====================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HMED ATTENDING ADMISSION NOTE . ADMIT DATE: ___ ADMIT TIME: 0300 . PCP: does not have a pcp ___ MD (___) GI: ___, MD ___ ___ . ___ yo F with pmhx significant for eosinophilic gastroenteritis with known gastric ulcer recently started on methotrexate who presents to the ED complaining of vomiting and inability to take po. . ___ has known eosinophilic/inflammatory gastroenteritis with a gastric ulcer from the eosinophilic inflammation managed with acid suppression, immunosuppressants and steroids. She is followed by Dr. ___ allergy and Dr. ___. ___ was recently admitted ___ - ___ with worsening abdominal pain and dehydration in the setting of prednisone taper. Given her worsening gastoenteritis symptoms ___ was restarted on higher dose of steroids and discharged on prednisone 60mg daily. After discharge she underwent an EGD by Dr. ___ on ___ which showed a stable prepyloric ulcer but worsening gastric antrum ulcer. Biopsies were taken to assess for eosinophils and superimposed infection with CMV/HSV. She also had very small duodenal erosions and question of candidal esophagitis in the distal esophagus. Biopsy results were positive for candidal esophagitis and ___ started on nystatin liquid QID. Given the worsening ulcers ___ was taken off ___ and started on methotrexate 15mg SQ weekly (first dose ___, second dose ___. . ___ self-administered her second dose of methotrexate today at home. She subsequently had approximately 6 episodes of non-bloody emesis and felt lightheaded. She reports her chronic epigastric abdominal pain is unchanged. Over the past week she has been feeling unwell however able to take good po. One episode of vomiting 5 days ago that was blood tinged, discussed with Dr. ___ felt that it was an isolated incident and no reason to seek medical attention. No recent fevers, no diarrhea, brbpr or melena. Had mild flu-like symptoms after first dose of methotrexate one week ago. Her prednisone was tapered to 40mg (from 50mg) one week ago. . ED: 97.0 107 150/93 18 100%; zofran, viscous lidocaine, morphine 5mg, ativan 1mg, maalox. Failed oral challenge therefore decided to admit for IVFs. Given 2L NS. . ROS as per HPI, 10 pt ROS otherwise negative Radiology showed 1. No evidence of gastric outlet obstruction or bowel obstruction. 2. Apparent dependent gastric antral mucosal hyperemia, likely related to known inflammation. 3. Left adnexal cyst and small amount of free fluid in the pelvis, likely physiologic in this age group. The patient was diagnosed with VOMITING, GASTRITIS NEC-NO HEMORRHAGE. The patient was treated with EGD. At the time of discharge, the patient had nausea and vomitting likely from methotrexate eosinophillic 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>___ yo F with PMHx significant for eosinophilic gastroenteritis managed with acid suppression and steroids, recently started on MTX after EGD showed worsening of gastric ulcers now admitted with severe nausea/vomiting after methotrexate dose. . #Nausea/vomiting: The likely etiology of this nausea and vomiting is a side effect from the methotrexate administration. The ___ was treated aggressively with IV fluids and anti-emetics. The ___ symptoms took several days to resolve. The ___ had an EGD to further investigate the etiology of these symptoms. The EGD showed moderate gastritis, mild duodenitis and a 1.5 cm pyloric ulcer. The ___ also got a CT of her abdomen and pelvis to assess for gastric outlet obstruction or another etiology of nausea and vomiting and none was found. The ___ symptoms eventually improved. She will be sent home on folate 5 mg QD. It is also advised that the ___ be pre-medicated with zofran prior to administration of MTX. It should also be considered that the MTX be dose reduced. The ___ was send home on zofran odt (if unable to tolerate pills). . # Eosinophillic gastritis A flare of the above was considered as an etiology of her symptoms. She has already failed ___ and often has worsening of her symptoms when her steroids are tapered. Her EGD showed only rare eosinophils. Malabsorption of her steroids was also considered and a cosyntropin stimulation test was performed. Her 60 minutes cortisol was 22.3. It would be expected that this ___ who is chronically on prednisone would be adrenally insufficient. Malabsorption vs. inability to convert to active metabolites was considered. As a result, the ___ was converted to IV dexamethasone. Her symptoms gradually improved and she was sent home on methyprednisolone 32 mg QD. Her budesonide was discontinued due to the presence of evidence of chemical irritation on her biopsies. She is to follow up with Allergy for administration of the next dose of MTX. . # Dysequilibrium The ___ experience significant dysequilibrium while ambulating while in house. This had no clear exacerbating factor and she had no ENT related symptoms. The ___ was not orthostatic but a midline was placed due to difficulty obtaining peripheral access and she was hydrated. She was also treated with mecilzine and she improved. She was sent home on prn meclizine. . # h/o ___ from prior biopsies Her most recent biopsies were negative and her nystatin was discontinued. . # H/o gastric and duodenal ulcers These appeared to be healing on repeat endoscopy. The patients budesonide was discontinued and she was sent home on carafate, ranitidine and omeprazole. . # Normocytic anemia Baseline Hgb is ___. On the day of discharge, her Hgb was 10.4. She showed no obvious clinical signs of bleeding. This should be followed up as an outpatient. . # Transitional Issues: -Follow up with GI and PCP to establish care in the ___ area -Follow up with Allergy for administration of next MTX dose</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ speaking ___ woman with history of Marfan Syndrome, who is known to the cardiac surgery department. She underwent repair of type A dissection with replacement of her aortic arch and reimplantation of the arch vessels using a 26 mm Gelweave Medusa graft and elephant trunk, Bentall procedure with a 25 mm ___ mechanical valve on ___. She was taken back to the operating room later that same day for bleeding. The remainder of her post-operative course was unremarkable and she was discharged to her brother's home upon discharge. Anti-coagulation management was arranged via her PCP, ___. On the morning of her readmission she developed worsening upper back pain with ongoing shortness of breath and therefore presented to the BI emergency department for evaluation. CHEST (PORTABLE AP) showed Comparison to ___. The pleural air component on the left is now minimal. The amount of pleural fluid on the left is stable. Stable borderline size of the cardiac silhouette. Unchanged normal appearance of the right lung. CTA CHEST showed 1. Status post repair of a type A aortic dissection with Medusa graft in place. 2. New focal dissection involving the native segment of the innominate artery. 3. Large pericardial effusion, increased, possibly containing components of blood. Clinical correlation for tamponade strongly recommended. 4. Large left and small-moderate right pleural effusion, increased on the left, difficult to exclude a component of hemothorax. 5. Compressive atelectasis, left greater than right. 6. Decreased size of a small left pneumothorax and decreasing pneumomediastinum. RECOMMENDATION(S): Cardiac echo NOTIFICATION: The findings were discussed with Dr. ___. by ___ ___, M.D. on the telephone on ___ at 4:05 ___, 5 minutes after discovery of the findings. Additional findings were discussed by Dr. ___ with Dr. ___ at approximately 17:00 on ___. CHEST (PORTABLE AP) showed Comparison to ___. Stable appearance of the left pleural effusion. New small right pleural effusion. Subsequent areas of basilar atelectasis are proportional to the extent of the effusions. CHEST (PORTABLE AP) showed In comparison with the earlier study of this date, there is an placement of a left chest tube with its tip just below the apex of the left lung. There may be a small pneumothorax. Allowing for differences in elevation of the patient, there is probably little change in the degree of pleural effusion and underlying compressive atelectasis. Portable AP chest radiograph. showed 1. Unchanged, tiny left apical pneumothorax. 2. Interval decrease in moderate left pleural effusion and adjacent atelectasis. CHEST (PORTABLE AP) showed Comparison to ___. There is no relevant change. The pericardial drain and the left chest tube are in stable position. A millimetric left apical pneumothorax is present. No evidence of tension. The extent of the moderate left and of the small right pleural effusion is stable. No change in appearance of the normal lung parenchyma on the right. CHEST (PORTABLE AP) showed Comparison to ___, 07:24. Millimetric left apical pneumothorax is stable. No evidence of tension. Unchanged pericardial drain and left chest tube. The extent of the bilateral pleural effusions is stable. CHEST (PORTABLE AP) showed Comparison to ___. The left chest tube and the pericardial drain are in stable position. A millimetric left apical pneumothorax is stable. Unchanged size of the cardiac silhouette. Unchanged extent of the bilateral pleural effusions. No pulmonary edema, no pneumonia. CHEST (PORTABLE AP) showed Comparison to ___. The chest tube and the pericardial drain have been removed. Stable extent of the known left pleural effusion. Minimal improvement of the retrocardiac atelectasis. No pneumonia. No pneumothorax. Chest radiograph. showed Small left apical pneumothorax. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on ___ at 5:05 ___, 15 minutes after discovery of the findings. Portable chest radiograph. showed 1. Small, bilateral pleural effusions, increased on the right and unchanged on the left. 2. Stable, tiny left apical pneumothorax. CHEST (PORTABLE AP) showed Comparison to ___. No relevant change in extent of the bilateral pleural effusions, left more than right. The subsequent areas of atelectasis are also unchanged. Cardiomegaly persists. No new focal parenchymal opacities. CHEST (PORTABLE AP) showed In comparison to prior radiograph of 1 day earlier, there has not been a relevant change in the appearance of the chest. Radiology showed In comparison to ___, a left PICC has been placed, with tip terminating at approximately the level of the cavoatrial junction. No other relevant change except for slight increase in size of small right pleural effusion. Radiology showed Support lines and tubes are unchanged in position. Heart size is upper limits of normal, but stable. There is no widening of the upper mediastinum. There remains a left retrocardiac opacity and left-sided pleural effusion which is stable. Small right-sided pleural effusion also seen. There are no signs for overt pulmonary edema. There are no pneumothoraces. CHEST (PA AND LAT) showed Comparison to ___. Minimal interval decrease of the pre-existing left pleural effusion that continues to be moderate in size. Minimal left pleural effusion is seen on the lateral radiograph only. The heart is borderline in size. The sternal wires are in stable position. No pneumothorax. No pneumonia. The patient was diagnosed with Dissection of unspecified site of aorta. The patient was treated with Pericardial drain ___ pleural chest tube ___. At the time of discharge, the patient had pericardial and pleural effusion, aspergillis in pericardial fluid. The patient was given written instructions concerning 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 from the emergency department when a chest radiograph revealed a large pleural effusion. A subsequent cardiac echo revealed a large pericardial effusion and she was taken to the cardiac catheterization lab for drainage. This procedure drained 480ml. A left pleural pigtail was placed to drain her pleural effusion. This was discontinued per protocol. Aspergillis grew from her pericardial fluid and the infectious disease service was consulted. She was started on an antibiotic and anti-fungal regimen. This was discontinued as growth was deemed contamination. Vascular surgery saw the patient given her residual type B dissection and lower back pain, but they recommended follow-up as an out-patient as her repeat CT showed no change in her dissection. Dysrhythmia was noted on tele and the EP service was consulted. Per EP attending: "Episodes of transient bradycardia/heart block are consistent with vagal episodes; there is P-P slowing, PR prolongation, and gradual onset/offset. The patient has not had any symptoms related to these episodes, most of which have occurred while sleeping. She has no prior lightheadedness or syncope. Her resting ECG has no conduction abnormalities. No further workup is required at this point in time. She had some AFib in the setting of having a pericardial drain in place, but she is anticoagulated because of her valve anyway." She was also seen in consultation by the ophthalmology service for a complaint of floaters, but they were felt to be benign. Coumadin was continued for mechanical AVR. Dr. ___ continue to follow this as an outpatient. The patient is stable for discharge on hospital day ___. She will be discharged to her brother's home with family support. She is instructed on appropriate follow-up. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ Y/o M presents with a-fib as a transfer from ___ ___. The patient had CABG ___, discharged home. He was also recently admitted to ___ 2 weeks ago for new A-fib and started on Coumadin and amiodarone. He was seen for follow-up and noted to have an elevated INR to 16, they also noticed that he had a sternal fluid collection (?abscess) at his surgical site, so they transferred him back to ___ for further management. CHEST (PA AND LAT) showed Status post median sternotomy for CABG with stable postoperative cardiac and mediastinal contours. There is deformity of the right posterior ribs consistent with prior trauma. Lungs are well inflated with no focal airspace consolidation to suggest pneumonia. No pulmonary edema or pleural effusions. No pneumothorax. Deformity of the right midclavicle consistent with old fracture. CHEST (PORTABLE AP) showed In comparison with the study of ___, there has been removal of all but the uppermost sternal wire. Decreased but no evidence of acute pneumonia or vascular congestion or pleural effusion. CHEST PORT. LINE PLACEMENT showed In comparison with the earlier study of this date, there has been placement of a right IJ catheter that extends to the upper right atrium. No evidence of post procedure pneumothorax. Otherwise, little change in the appearance of the heart and lungs. Radiology showed No pneumothorax. Left lower lobe atelectasis and bilateral small pleural effusions. Infection cannot be excluded if clinical concern. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 1:22 ___, 10 minutes after discovery of the findings. DX CHEST PORTABLE PICC LINE PLACEMENT showed Compared to chest radiographs ___ through ___. Right PIC line ends in the low SVC alongside a right internal jugular line. Lung volumes have increased and pulmonary edema has resolved. Heart is moderately enlarged. No appreciable pleural abnormality. The patient was diagnosed with Infection following a procedure, initial encounter, Cutaneous abscess of chest wall, Oth surgical procedures cause abn react/compl, w/o misadvnt, Unspecified atrial fibrillation. The patient was treated with ___ chest closure with plating and ties ___ sternal debridement-VAC- OPEN CHEST ___ CABG x2(lima>LAD,SVG>circ). At the time of discharge, the patient had Coronary artery disease s/p Coronary revascularization Thrombocytopenia secondary to blood loss and IABP resolved Anemia acute blood loss and iron deficient Carotid stenosis incidental finding on ultrasound Post-operative atrial fibrillation Secondary diagnosis MI x2 ___, ___ ___, ___) Hypertension Hyperlipidemia Back pain s/p motorcycle accident Throat Cancer s/p XRT at ___ ___ yrs ago Social History: ___ Family History: Father: ___, cirrhosis Mother: ___, MI, lung cancer Younger sister: ___, lung cancer 5 children: No health issues. Physical Exam: Admission PHYSICAL EXAMINATION Temp: 98.2 HR: 112 BP: 148/101 Resp: 17 O(2)Sat: 97 Normal Constitutional: No acute distress HEENT: Normocephalic, atraumatic Neck is supple Chest: midline vertical scar, with fluctuant lesion with surrounding erythema on the superior aspect, nontender to palpation. Clear to auscultation Cardiovascular: Tachycardic Abdominal: Soft, Nontender GU/Flank: No costovertebral angle tenderness Extr/Back: No BLE edema Skin: Diaphoretic, Warm and dry Neuro: Speech fluent Psych: Normal mentation, Normal mood ___: No petechiae Discharge Exam: VS: T 98.4 HR 83 Afib BP 131/77 RR 16 O2sat 95% RA Gen: no acute distress, sitting comfortably in chair Neuro: alert and oriented x3, moves all extremities, non-focal exam CV: Irreg-irreg, sternum stable, incision CDI, JP drain x2 with serosang drainage Pulm: rhonchi throughout Abdm: soft, non-tender, non distended, +bowel sounds Ext: warm, well perfused, trace edema bilat Pertinent Results: Admission Labs: ___ 03:32AM BLOOD WBC-7.1 RBC-4.15* Hgb-10.4* Hct-33.6* MCV-81* MCH-25.1* MCHC-31.0* RDW-15.8* RDWSD-45.5 Plt ___ ___ 03:32AM BLOOD ___ PTT-32.3 ___ ___ 03:32AM BLOOD Plt ___ ___ 02:58AM BLOOD ___ ___ 03:32AM BLOOD Glucose-105* UreaN-16 Creat-1.2 Na-138 K-4.0 Cl-98 HCO3-29 AnGap-15 Discharge Labs: ___ 04:15AM BLOOD WBC-7.7 RBC-3.03* Hgb-7.4* Hct-24.8* MCV-82 MCH-24.4* MCHC-29.8* RDW-17.6* RDWSD-50.3* Plt ___ ___ 07:04AM BLOOD Hct-24.1* ___ 04:15AM BLOOD Plt ___ ___ 04:15AM BLOOD ___ ___ 04:15AM BLOOD Glucose-86 UreaN-13 Creat-1.0 Na-140 K-4.5 Cl-105 HCO3-25 AnGap-15 ___ 04:15AM BLOOD Mg-2.0 ___ 05:50AM BLOOD CRP-36.7* ___ 05:50AM BLOOD Vanco-19.5 Radiology Report CHEST PORT. LINE PLACEMENT Study Date ___ 5:52 ___ UNDERLYING MEDICAL CONDITION: ___ year old man with new R picc Final Report EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT INDICATION: ___ year old man with new R picc // R DL 45cm PPICC, IMPRESSION: Right PIC line ends in the low SVC alongside a right internal jugular line. Lung volumes have increased and pulmonary edema has resolved. Heart is moderately enlarged. No appreciable pleural abnormality. ___, MD ___, MD electronically signed on ___ ___ 8:54 AM ___ ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Aortic Valve - Peak Velocity: *2.3 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *21 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 14 mm Hg Mitral Valve - E Wave: 1.0 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A ratio: 1.11 Mitral Valve - E Wave deceleration time: 171 ms 140-250 ms Findings This study was compared to the prior study of ___. LEFT VENTRICLE: Depressed LVEF. RIGHT VENTRICLE: RV function depressed. AORTIC VALVE: Mild AS (area 1.2-1.9cm2). PERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic signs of tamponade. GENERAL COMMENTS: Suboptimal image quality - body habitus. Conclusions LV systolic function appears depressed. with depressed free wall contractility. There is mild aortic valve stenosis is sugegsted. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of ___, no clear change. ___ Accredited Electronically signed by ___, MD, Interpreting physician ___ ___ 11:03 ___ 5:15 pm SWAB STERNAL WOUND CULTURES. GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. Medications on Admission: MEDs ___: Amlodipine 5', Aspirin 81', Atorvastatin 80', Clopidogrel 75', Nitroglycerin gtt, Insulin Regular sliding scale, Metoprolol tartrate 50", Venlafaxine XR 150' Discharge Medications: 1. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheeze 2. Amiodarone 200 mg PO BID bid x 7days then decrease to 200mg daily 3. Artificial Tear Ointment 1 Appl BOTH EYES Q8H eye care 4. Artificial Tears ___ DROP BOTH EYES PRN dry eye 5. Aspirin EC 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Bisacodyl ___AILY:PRN constipation 8. FoLIC Acid 1 mg PO DAILY 9. Furosemide 20 mg PO DAILY 10. GuaiFENesin 5 mL PO Q6H:PRN cough 11. Heparin Flush (10 units/ml) 1 mL IV DAILY and PRN, line flush 12. Lidocaine 5% Patch 1 PTCH TD QPM 13. Pantoprazole 40 mg PO Q12H 14. Potassium Chloride 40 mEq PO DAILY 15. Simethicone 40 mg PO QID:PRN abdominal bloating 16. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush 17. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 18. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 19. Thiamine 100 mg PO DAILY 20. Vancomycin 1500 mg IV Q 12H 2 week course-Duration to be determined at infectious disease follow up appt. 21. Venlafaxine XR 150 mg PO DAILY 22. ___ MD to order daily dose PO DAILY16 afib goal INR ___ ***very sensitive to Coumadin dosing 23. Metoprolol Tartrate 37.5 mg PO TID 24. Ondansetron 4 mg IV Q8H:PRN nausea 25. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*40 Tablet Refills:*0 26. Outpatient Lab Work weekly: CBC, BUN/Creat, vanco through. Fax results to ___ infectious disease ___ 27. amLODIPine 2.5 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ___ chest closure with plating and ties ___ sternal debridement-VAC- OPEN CHEST ___ CABG x2(lima>LAD,SVG>circ) Coronary Artery Disease, MI x2 ___, ___ ___, ___), Hypertension, Hyperlipidemia, Back pain s/p motorcycle accident, Throat Cancer s/p XRT at ___ ___ yrs ago Past Cardiac Procedures: PCI vs angioplasty in the past (pt does not recall which one). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ s/p CABG ___, discharged home on ___. Had subsequent atrial fibrillation that was treated at ___ where he was started on Coumadin. Reported sought follow-up w/PCP and found to have INR 16. At that time also noted to have fluctuant fluid collection at superior pole of sternal wound and transferred to ___ for further management. Once here he received Vitamin K and started on Vancomycin. He was brought to the operating room for evacuation of sternal debridement and fluid evacuation on ___. Please see the operative report for details. Following surgery he was brought to the cardiac surgery ICU in stable condition with an open chest. He was kept paralyzed and sedated until he returned to the operating room on ___ for chest closure with plating and ties by the plastic surgery service, please see operative report for details. His paralytics and sedation were stopped and he weaned from the ventilator and extubated on POD1. Anticoagulation for atrial fibrillation was resumed. He transferred out of the ICU to the step-down floor on POD4. Once on the floor he worked with nursing and physical therapy to increase his strength and endurance. His wound culture came back with STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH, so Infectious disease was consulted. It was felt this was likely a contaminant but given new hardware antibiotics were to be continued for at least two weeks. At follow-up appointment with infectious diseases the duration of antibiotic treatment will be determined. On POD7 from chest closure he was discharged to rehabilitation at ___ at ___. He is to follow-up with plastic surgery in 1 week and with infectious diseases in 2 weeks, and with Dr. ___ in 1 month. All appointments were made before discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year old right-handed woman with h/o seizures, HTN, HL, who presents with slurred speech. The patient developed slurred speech at 8pm last night while watching "Dancing with the Stars", it came on gradually and worsened over the first hour or so, such that her son could not understand her over the phone. Her husband describes her speech was "low and slow" and hesitant, but made sense. She had a mild, dull headache (nonthrobbing). The patient has had slurred speech before, so decided to go to bed and see how she felt in the AM. This morning, the dysarthria was somewhat improved, she was able to speak on the phone at work and was understood. She had a scheduled appointment with her PCP about her HTN this morning, and when she reported her recent symptoms, she was advised to go to ED. The dysarthria has been gradually improving and continues to improve in the ED. On initial ED exam, she was reportedly slurring "L" most, and was moderately dysarthric. The patient has had episodes of dysarthria, ___ total, beginning around ___. The episodes typically last only ___ hours. The last episode was about one year ago. The duration of this current episode was the only difference from these prior episodes. Otherwise, she never had associated vision changes, numbness/tingling, weakness. Prior notes indicate she had episodic vertigo, but the patient cannot recall the relationship between dysarthria and vertigo. She endorses recent increase in stress, due to returning to work from vacation this week. Radiology showed No acute intracranial process. Radiology showed Prominent vascular looping close proximity to the left seventh, eighth nerve complex as described above, otherwise unremarkable MRI of the internal auditory canals and brain as described above. Radiology showed 1. Normal CT of the head. 2. Mild atherosclerosis of the bilateral common carotid artery at the level of the bifurcation without critical stenosis. 3. Focal calcified plaque at the origin of the left vertebral artery without significant stenosis. 4. Normal appearance of the intracranial vasculature. Radiology showed No radiographic evidence for dynamic instability. Probable calcifications of the anterior longitudinal ligament. The patient was diagnosed with OTHER SPEECH DISTURBANCE, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY. At the time of discharge, the patient had Probable episodic ataxia syndrome.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs. ___ improved markedly overnight after her admission without any intervention. Our working diagnosis during the admission was an episodic ataxia syndrome, but we needed to rule out other pathologies such as stroke or vertebrobasilar insufficiency. Her brain MRI showed an atrophic cerebellum, but no lesions. Of note, thin cuts through the brain stem were obtained. We obtained a neck and head CTA, and the vasculature looked normal without any evidence of stenosis. We also obtained a flexion extension neck X-ray to rule out any vertebral disease or spondylolisthesis, and it was normal. We started Mrs. ___ on diamox 250mg BID. Episodic ataxia syndromes, namely type II, is responsive to diamox. She will follow up in clinic with Drs. ___ further neurogenetic testing as indicated, and with Dr. ___ who is her primary neurologist.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o man with mental disability with history of chronic constipation requiring multiple hospitalizations for bowel obstruction, disimpaction, who now presents from group home with lack of BMs x 5 days and abdominal distension. Per care assisstant's record, his last "large" BM was last ___ and since he has been passing gas with small pieces of stool despite following his stringent regiment for constipation. he has been slightly more agitated over the past two days. Staff states that there have been no fevers, vomiting, hematochezia, melena or pain. . In the ED, initial vitals were 98.8 90 113/67 16 96% RA. KUB showed marked sigmoid dilitation and CT scan showed dilated sigmoid colon without distal obstruction "consistent with Ogilivie syndrome" Rectal tube was placed per recommendations of surgery with some relief of abdominal distension. . During my evaluation, patient was smiling and shook my hand. He did not appear to be in distress, and denied pain. He could not answer further questions Radiology showed Marked improvement in sigmoid dilatation after rectal tube placement, consistent with ___ syndrome. Radiology showed Unchanged ___ syndrome from one day prior. Radiology showed Unchanged ___ syndrome from approximately eight hours prior. Radiology showed New, marked dilatation of the sigmoid colon again consistent with ___ syndrome. These findings were discussed with Dr. ___ at 1003 hours by telephone on ___. The patient was diagnosed with INTESTINAL OBSTRUCT NEC, UNSPECIFIED INTELLECTUAL DISABILITIES, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with Rectal tube placement and removal Sigmoidoscopy. At the time of discharge, the patient had 1. Severe constipation with dilatation of the sigmoid colon. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o man with mental disability with history of chronic constipation requiring multiple hospitalizations for bowel obstruction, disimpaction, who now presents from group home with lack of BMs x 5 days and abdominal distension. His abdominal distension improved markedly after placement of a rectal tube and stool output was noted of 600cc over the next ___ hours with use of Miralax QID in milk. He initially underwent an evaluation by CT abdomen (see above) showing severe dilatation of the sigmoid colon without evidence of obstruction. Nonetheless, given the extent of the dilatation he underwent a non-prepped sigmoidoscopy (see above) which did not show any evidence of obstruction. It was felt that his findings were due to chronic constipation. He tolerated a liquid diet of milk and miralax. Serial exams were benign and KUBs noted above, showed recurrence of imaging on admission on ___, however patients clinical condition remained stable. Per discussion with GI team it was felt that these findings were consistent with chronic constipation. We discussed with caregiver team that ___ require to continue his home regimen and in addition the following should be instituted: - Miralax in milk TID - TID toilet positioning to encourage bowel movements - if no BM by 3 days after returning to his home, would recommend evaluation for a manual disimpaction. An additional option of partial colectomy was discussed, however give that more conservative approache have not be exhausted (above), this was deferred. Followup should be arranged with his PCP and his ___, Dr. ___. Finally ther were incidental findings on CT imaging as below which will reuqire f/u with his PCP: "There is an 11 x 8 mm hypodensity within the head of the pancreas seen on series 2, image 31....There is a simple-appearing cyst in the left renal interpolar region measuring approximately 3.2 x 2.9 cm" </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o LAR for diverticulitis (___) and known ventral umbilical hernias who p/w worsening umbilical and hypogastric pain since 4pm today. Over the past few months, patient has noted intermittent episodes of vague epigastric discomfort/pain for which she has been seeing her outpatient GI, Dr. ___ recently recommended surgical evaluation for ?hernias with intermittent PSBO. Today, she noted throbbing pain of increasing intensity throughout the day that acutely worsened at 4pm. Pain is ___ constant, sharp/burning without radiation aggravated by palpation and improved by lying flat. Associated with anorexia and fever to 100 but no chills, n/v/d/c. Last BM was at 6pm, formed without melena or hematochezia. Overlying skin feels sensitive and warm but without erythema or drainage. Radiology showed 1. Fat containing umbilical hernia with only minimal fatstranding in the hernia sac. Hernia neck measures 1.2 x 1.1 cm. 2. Fat containing infraumbilical hernia, slightly to the left, off midline with a 3 x 4.8 cm hernia neck. No fat stranding. 3. No bowel herniation or strangultion. 4. Diverticulosis, but no diverticulitis. The patient was diagnosed with VENTRAL HERNIA NOS. The patient was treated with ___: Repair of ventral hernia with mesh and primary repair of smaller incarcerated ventral hernia. At the time of discharge, the patient had Incarcerated ventral hernia x2. The patient was given written instructions concerning 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 on ___ under the Acute Care Surgery service for management of her incarcerated hernias. She was taken to the operating room and underwent hernia repair X 2. (see operative note for details). She tolerated the procedure well and was extubated upon completion. She was subsequently taken to the PACU for recovery. She was transferred to the surgical floor hemodynamically stable. Her diet was slowly advanced as tolerated over the next ___ hours. A foley catheter was placed perioperatively for urine output monitoring and was removed in the AM of POD1, at which time she voided without difficulty. She was encouraged to mobilize out of bed and ambulate as tolerated, which she was able to do independently.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yof with CHF w/ preserved EF, AFib not on anticoagulation, aortic stenosis, HTN, CKD, HLD, hx aortic dissection ___, and ulcerative colitis who presents with dyspnea and cough. She was unable to report how long she has had cough or dyspnea, but reports minimal yellow sputum without fever. Patient has been taking her Lasix 60mg po daily and reports a 2lb weight loss. Of note, patient had fall morning prior to admission with head trauma but no LOC. She complained of constant, throbbing pain in head. Also associated right hip pain. Took tylenol @ home with some relief. Able to walk with a walker which is her baseline without worsening right hip pain. No weakness/numbness. Radiology showed Mild persistent pulmonary edema and cardiomegaly. The patient was diagnosed with ATRIAL FIBRILLATION, CONGESTIVE HEART FAILURE, UNSPEC. At the time of discharge, the patient had - diastolic Congestive Heart Failure - Atrial fibrillation - Hx Aortic Dissection ___ - Chronic Kidney disease - Hypertension - Hyperlipidemia - Aortic Stenosis - Migraines - Ulcerative colitis - ___ yrs of symptoms prior to diagnosis. Not currently on any UC medications - Osteoporosis - Hx of upper GI bleed - s/p MVA ___ ago and presumed ___ ___ tear. Took advil and aspirin for fractured sternum. Received 5 unit transfusion. - Fall history - Hyperplastic polyps - Basal and squamous cell carcinomas - Hiatal hernia - Complicated by GERD - Rhinitis - Benign breast cysts - Cataracts surgery - Both eyes. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ yof with dCHF, AFib previously not on anticoagulation, aortic stenosis, HTN, CKD, HLD, hx aortic dissection ___, and ulcerative colitis who presented to OSH with dyspnea and cough the transferred to ___ ED where found to have AFib with RVR which converted with amiodarone shortly after admission. # AFib with recent RVR: CHADS 3. Unknown if acute or chronic, but was documented on ___ problem list. Not on anticoagulation. We initated heparin gtt, she loaded with Amiodarone and was converted spontaneously on ___ but remained hypotensive on neo gtt prompting her admission to the CCU. Neo gtt was weaned shortly after converting to sinus, Amio gtt was stopped and she was and restarted Metoprolol. Warfarin was initiated this admission due to CHADS score. -Metoprolol succinate 150mg daily -Aspirin 81mg po daily -started Warfarin 2mg daily titrate to INR ___. # Hypoxic Respiratory Distress: Unclear etiology. Likely some acute on chronic CHF in addition to HCAP pneumonia. Patient was given few moderate doses of IV Lasix which was unclear if helped her respiratory status. Patient also started on 10 day course of Cefepime, and completed 5 day course of Azithromycin. Patient needed up to 6L nasal cannula and improved to low 90's on room air at time of discharge. Patient was influenza negative this admission. # CHF, diastolic: EF over 55%. Please see full ECHO report attached. Patient may have had acute on chronic CHF on admission. She was given few moderate doses of IV Lasix which was unclear if helped her respiratory status. Oxygen requirement with mild pulmonary edema on CXR on admission. Improved at time of discharge with sats mid 90's on room air. -continue home Lisinopril 40mg po daily -continue home Metoprolol tartrate 50mg po TID -continue home Pravastatin 20mg po daily -Resumed home lasix dose of 40mg daily at time of discharge # HCAP: Initially presented with c/o dyspnea and minimally productive cough without fever. ON ___ she became more hypoxic with increased oxygen requirements, and on exam was rhoncherous and wheezing. She Tmax at 100.7 and WBC count elevated. UA was positive for WBC's only, no luekocytes. Flu swab negative. CXR without obvious signs of PNA but given luekocytosis and persistent O2 requirement intiated antibiotics for HCAP: Vanc/ Cefepime/ Azithromycin. Vanc DC'd on ___. Inhaled fluticasone started for wheezing given hx of smoking and likely some element of chronic lung disease. Hypoxia greatly improved and now weaned to room air. Patient also started on 10 day course of Cefepime, and completed 5 day course of Azithromycin. Since intiation of antibiotics pt afebrile and WBC count trending down to normal. Exp and Insp wheezes remain on exam and inhalers should be continued. # Urinary Retention: Developed urinary retention with incontinence on ___. PVR's every 8 hours revealed > 400mL of urine requiring startight cathing. UA sent and was negative and culture pending. Ipratropium inhaler changed to prn. Patient will require q6h bladder scan with straight cath for volumes over 400cc. # Delirium: Pt with episodes of agitation and delirium throughouot hospitalization. Intiated seroquel 12.5mg with initial relief and then somnulence after two days of administration. Gerentology consulted and weaned dose to 6.25mg only at night. Pt mental status has since greatly improved and she is now alert and oriented. # Brief Hypotension: Likely due to AFib w/ RVR. Transient and resolved once in normal sinus rhythm. Neo weaned and antihypertensive meds restarted. # Hx of Hypertension: added Amlodipine as new medication not on PAML for intermittent SBP's as high as 190's. -continue home Lisinopril 40mg -continue home Metoprolol XL 150mg daily -Initiated and continue Amlodipine 2.5mg daily -Continue home lasix 40mg daily # Hyperlipidemia -continue home Pravastatin # CKD: Creatinine 1.1 on admission which is her baseline. -renally dose meds # Ulcerative colitis -not currently on any UC medications # Hx Migraines -acetaminophen prn ## TRANSITIONAL ISSUES ## -continue ___efepime with last day ___ -q6h bladder scan with straight cath for volumes over 400cc -consider home lasix adjustment pending respiratory status and creatinine as outpatient</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with the PMH osteoarthritis, s/p bilateral TKAs (___) c/b DVT in requiring LT knee revision ___ after running injury, POD ___ s/p L knee washout on vanc/ertapenem, who is admitted for ___ and fevers. Pts recent health issues began in ___ when she twisted her knee while running, was subsequently found to have loosening of her L total knee replacement, underwent revision however course was complicated by L knee hematoma with bleeding from incision, subsequently required revision and debridement ___, discharged on ___ to complete a 6 week course of IV abx for polymicrobial joint infection (tissues growing grp B strep; enterococcus (vanc/amp susceptible); SCN; diptheoids; kleb pneumo ___ serratia (pan- ___ and mixed bacterial flora). Pt was seen in ___ clinic today for where she was noted to be weak and ill-appearing, temp was 103.0, therefore she was sent to the ED. Chest: Frontal and lateral views showed Increased basilar opacity seen on both the frontal lateral views could in part relate to overlying soft tissue, but underlying consolidation due to pneumonia or aspiration may be present. Radiology showed Status post left knee arthroplasty with prosthesis in anatomic alignment. No acute fracture or dislocation is seen. Probable joint effusion. Soft tissue swelling. Difficult to exclude small focus of soft tissue gas versus fat, measuring 7 mm just anterior to the inferior patella. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. Left groin lymphadenopathy/prominent lymph nodes may be reactive given history of left lower extremity infection. No drainable collection is seen in the area of concern as indicated by the patient. RENAL U.S. showed No hydronephrosis. The right kidney appears slightly more echogenic, correlate clinically for medical renal disease. INJ/ASP MAJOR JT W/FLUORO showed 1. Imaging Findings- as above 2. Technically successful fluoroscopic guided aspiration of the left knee. Samples were sent to the lab for requested analysis. The procedure was supervised by Dr. ___ attending radiologist, who was present for the critical portions of the procedure. The patient was diagnosed with Fever, unspecified. The patient was treated with -arthrocentesis/aspiration left knee ___. At the time of discharge, the patient had ___ Polymicrobial left septic knee 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>___ h/o osteoarthritis s/p bilateral TKAs ___ and ___ (complicated by DVT/PE) w/ left knee revision ___ (complicated by hematoma and polymicrobial joint infection on vanc/ertapenem for 6 weeks s/p revision/debridement ___ who is admitted for ___ and fevers. 1. ___ -Urine electrolytes consistent with pre-renal etiology likely due to poor PO intake w/ fever; however, she received 3L IV fluids without improvement in creatinine. In setting of supra-therapuetic vanco trough of 46 there was initial concern this is actually ATN. Vancomycin was stopped and Switched to IV Dapto. Renal US without hydronephrosis. Seen by nephrology. Also agreed w/ switch. Did not feel ___ was related to AIN either. Lisinopril held and to be stopped at discharge as well. Neohrology also recommended DC of PPI which was done. Cre steadily improved, down to 1.8 at discharge 2. Fever and leukopenia h/o left knee polymicrobial joint infection -Patient spiking fever while on vancomycin/ertapenem concerning for resistant organisms or inadequate coverage. ID was consulted who replaced vancomycin with daptomycin given ___, replaced ertapenem with meropenem, and added levofloxacin pending arthrocentsis culture, which did not show any growth. Ultimately discharged on IV Ertapenem and Daptomycin which pt will finish until ___ 3. Acute on chronic normocytic anemia -Unclear etiology with no reports of bleeding. ___ be related to knee surgery (?hematoma) vs anemia of chronic disease. She notes multiple blood transfusions over the past few months and is worried this contributed to her current infections; because of this she declined further transfusions. Anemia work up showed normal iron level but started on PO iron here. 4. h/o DVT/PE w/ supratherapeutic INR -h/o clots during previous surgeries and when coming off Coumadin. She was counted on prophylactic SC heparin until cleared by surgery and then transitioned back to home coumadin. Will be discharged on 4 mg as INR supratherapeutic at 3.5 today. She should hold warfarin tonight and then have INR checked daily until therapeautic 5. Acute encephalopathy -Likely multifactorial in setting of infection, fever, hospitalization, medications. Zolpidem, cyclobenzaprine, oxycodone, and lorazepam are all potentially contributing to sedation/confusion and tried to minimize polypharmacy. - Resolved, at baseline mentation at discharge 6. Hypomagnesemia -Repete and monitor. Chlorthalidone stopped. 7. HTN -Chlorthalidone stopped in setting of ___. >30 minutes spent on discharge planning. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Mr. ___ is a ___ who p/w acute on chronic visual deficits in the R eye. He first noticed double vision in ___ and then a cloud in the superior medial quadrant of his right eye. He was diagnosed with acute retinal artery occlusion, but delayed follow-up as a result of a colon cancer diagnosis in ___ and then R hemicolectomy ___ (Dr. ___. CAROTID DOPPLER ULTRASOUND showed 80-90% right internal carotid artery stenosis and less than 40% left internal carotid artery stenosis. Extensive homogeneous plaque in the bilateral internal carotid and common carotid arteries, right greater than left. Radiology showed Known pulmonary nodules are not identified on this chest x-ray; however, followup is suggested per recommendations on prior chest CT from ___. No acute cardiopulmonary process. CHEST (PRE-OP PA AND LAT)CHEST (PRE-OP PA AND LAT)i showed Normal heart, lungs, hila, mediastinum, and pleural surfaces. No evidence of intrathoracic malignancy or infection. The patient was diagnosed with OCCLUS CAROTID ART NO INFARCT. The patient was treated with Carotid Endarterectomy on the Right. At the time of discharge, the patient had Carotid artery stenosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted on ___ after Today, he presents 1 week after noticing that the cloud in his right eye vision had increased in size. Saw retinal specialist and, in consultation with PCP, was referred for carotid series US and echo at ___ on ___ which found 80-90%artery stenosis on the Right. He was started on a heparin drip and maintained on such and home meds until the day of surgery on ___. His procedure was uncomplicated requiring Neo for slight hypotension in PACU. This was weaned off POD0. On POD1 A line, Dextran drip were D/C'd. His diet was advanced to regular which he tolerated well and was ambulating independently. He is ready for discharge. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Patent TIPS, but with interval change in intra-TIPS velocity. Given the intra TIPS velocities are now nearly within normal limits, this interval change is of unclear significance. Suggest short interval follow up. 2. Cirrhosis. The previously described echogenic lesion within the right hepatic lobe was not seen, although dedicated nonurgent CT or MRI is still recommended. 3. Moderate splenomegaly. Small volume ascites. 4. Cholelithiasis without acute cholecystitis. No biliary ductal dilatation. CHEST (PORTABLE AP) showed No pneumonia or acute cardiopulmonary process. The patient was diagnosed with Unspecified jaundice. The patient was treated with therapeutic paracentesis ___ with 4L fluid removal and albumin replet. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>TRANSITIONAL ISSUES: ======================= [] Discontinued diuretics (spironolactone, furosemide) given hyponatremia to 123 on admission to OSH. [] Given persistent hyponatremia ordered serum cortisol and cosyntropin stimulation test which were low however this was not with free cortisol --> if he continues to have refractory hyponatremia consider testing free cortisol levels. [] Will need intermittent therapeutic paracenteses as outpatient, he will arrange for these with his outpatient GI Dr ___ at ___. [] Discussed with patient his multiple hospitalizations recently at ___ and enrollment with ___ transplant teams, he voiced that he wishes to better establish his care within the ___ system and will follow up with Drs ___ his community and ___ GI, respectively. Discharge MELD: 28 Discharge Cr: 0.6 Discharge Na: 131</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ male with pmhx prostate ca s/p prostatectomy ___, COPD and blindness here for months of chest pain and abdominal pain. CHEST (PA AND LAT) showed No acute intrathoracic process. COPD. CTA CHEST AND CT ABDOMEN AND PELVIS showed 1. Heterogeneous right paraspinal soft tissue mass at the level of the right psoas measuring up to 7.1 cm, associated with cortical destruction of the adjacent vertebral bodies, concerning for neoplasm. 2. Heterogeneous appearance of bone matrix in the axial skeleton, concerning for metastatic involvement. 3. Probable acute/subacute compression fracture of L5 with mild loss of vertebral body height. 4. Extensive emphysema without focal consolidation or pleural effusion. 5. No pulmonary embolism. CT-guided right retroperitoneal mass biopsy showed Technically successful CT-guided biopsy of heterogenous mass arising from the right aspect of the L3 vertebral body. No immediate postprocedural complication. Radiology showed Lung fields are hyperexpanded suggestive of COPD. Symmetric small round densities along the lower lobes are consistent the patient's nipples. There is coarsening of the bronchovascular markings and bullous changes bilaterally. No focal consolidation or pneumothoraces are identified. The patient was diagnosed with Adult failure to thrive, Chest pain, unspecified, Unspecified abdominal pain, Dyspnea, unspecified. The patient was treated with R Psoas Mass Biopsy: ___. At the time of discharge, the patient had Primary: Metastatic prostate cancer Secondary: Chronic pain COPD 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 a ___ man with history of prostate cancer s/p prostatectomy (___), COPD, and blindness who presented with months of chest pain and abdominal pain, weight loss, and findings of R Psoas mass, now s/p biopsy with demonstration of metastatic prostate cancer. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ G0 hx of h pylori gastritis (by biopsy in ___ with ___)s/p triple therapy in ___ who presents with abdominal pain, nausea, and vomiting. Abdominal pain has been ongoing for about 6 months and has been associated with n/v and poor po intake. Work up has included EGD with bx as above at ___ which was consistent with H. pylori gastritis. She was placed on triple therapy in ___ and has completed the course. However, pain has not fully resolved and is associated with intermittent N/V. She was seen in ED 4 times in ___ for this nausea/vomiting and intermittent inability to take po. This current episode prompted ED visit because she was unable to keep food down. Vomit is NB/NB. Denies diarrhea. Has had infrequent BMs but denies constipation. Has IUD in place but does have intermittent spotting, about 1 month ago. No dysuria or urinary frequency. No pelvic discharge or bleeding. She has taken Compazine for nausea and Phenergan in the past with good effect. Chest: Frontal and lateral views showed No acute cardiopulmonary process. PELVIS U.S., TRANSVAGINAL showed Bilateral ovaries are normal in size and arteriovenous waveform without evidence of ovarian torsion. Hemorrhagic cyst in the right ovary. IUD is in appropriate position. CT abdomen pelvis showed 1. No acute intra-abdominal process to explain patient's abdominal pain. 2. Right hemorrhagic cyst. The patient was diagnosed with Left lower quadrant pain. At the time of discharge, the patient had Primary Diagnosis ================= Abdominal pain, nausea, vomiting Depression Bipolar Disease Secondary Diagnosis =================== H. Pylori 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>TRANSITIONAL ISSUES: ==================== [] Patient presenting with nausea and vomiting likely due to cannabinoid hyperemesis syndrome - patient should strictly avoid cannabis [] Could consider empiric rifaximin for SIBO as an outpatient if abdominal pain/ nausea/ vomiting not improving [] Consider adding TCA as an outpatient to control GI symptoms [] If ongoing abdominal pain, would trial low dose Levsin PRN [] Limit QTc prolonging meds since she was found to have QTc as high as 470 [] Patient requires GI ___ for her H Pylori gastritis 8 weeks after finishing her treatment (___) [] Patient requires close ___ with her psychiatrist (Dr ___ ___ from ___ and titration of her depression/bipolar medications. She was not taking any of her medications prior to this admission. [] Patient would benefit from a ___ to cope with her anxiety and depression [] Please provide patient with nutritional education or put her in touch with a nutrition expert to help her avoid foods which could trigger nausea/vomiting/abdominal pain. [] Patient found to have a 2.6 x 2.9 cm hemorrhagic cyst in the right adnexa. This will need to f/u as an outpatient by GYN. [] Discharged on omeprazole 40mg daily. Titrate on outpatient basis and consider discontinuation given that she will need repeat testing for h pylori. [] Had vaginal bleeding after pelvic ultrasound which decreased in amount subsequently, likely traumatic injury. Follow up on outpatient basis with GYN and ensure she is uptodate on her pap smear. HCG negative. [] Urine toxicology was positive for oxycodone although patient does not confirm use. Please follow up on outpatient basis. Code status: full code Health care proxy/emergency contact: ___ (sister) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ with PMH of ESRD on HD (MWF), CAD, dementia, severe AS, HTN, history of GIB secondary to AVM, who presented initially to BID-N with chest pain, found to have GIB and transferred to ___. Chest radiograph showed Diffusely increased interstitial markings and increased opacity at the right upper lung since ___ are most consistent with either mild interstitial pulmonary edema or an atypical infection. Recommend clinical correlation. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had acute coronary syndrome. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is an ___ with PMH of ESRD on HD (MWF), CAD, dementia, severe AS, HTN, history of GIB secondary to AVM, who presented initially to BID-N with chest pain, found to have GIB and transferred to ___. #GOC: GOC discussion held in ED by cardiology and ED attending with decision made to transition to ___ care/home hospice. Per daughter, prior to admission, they had been working on transitioning patient to hospice but had not yet been able to set up services. In setting of acute illness, they opted to decline further intervention or procedures, declined further HD, and declined further blood transfusions. #GIB: History of GIB in setting of AVM, requiring transfusion as an outpatient. Presented with Hgb 4, s/p 1U PRBC in ED prior to GOC. Was hypotensive to ___ on arrival and briefly on peripheral levophed, discontinued in ED after GOC. Patient and family decline further blood transfusions. #Chest pain: EKG c/f ACS with diffuse STD, and STE in AVR/V1. Declines catheterization or medical management at this time. Dilaudid PRN for chest pain in-house. Discharged with morphine and ativan. #ESRD on HD: Declines further HD. Discontinued home midodrine, calcitriol, sevelamer, nutritional supplements #HTN: continue home labetalol #HLD: discontinue atorvastatin Transitional issues: - will be discharged to home with Hospice with scripts for morphine and Ativan </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mrs. ___ is a ___ right-handed ___ woman presenting with headache since ___ with transient confusion, in the setting of diabetes, a mechanical mitral valve replacement, atrial fibrillation, anticoagulated with DC cardioversion on ___. Radiology showed Overall size and appearance of the right temporoparietal abnormality with adjacent edema is unchanged in over a short time interval, and has an unusual gyriform appearance with no mass-like enhancement or evidence of large intraparenchymal hemorrhage. These findings are nonspecific and of uncertain etiology, but diagnostic considerations could include cortical laminar necrosis. Investigation into specific contraindication for MRI imaging is recommended, as an MRI with contrast would be helpful in further evaluating this lesion. The above findings were communicated to Dr. ___ by Dr. ___ telephone at 3:00, 5 minutes after discovery. The patient was diagnosed with SWELLING IN HEAD & NECK, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, DIABETES UNCOMPL ADULT, HYPOTHYROIDISM 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>Pt admitted to neurosurgery service ___ with headaches and CT w ?stroke vs. mass, later determined to be c/w cortical laminar necrosis. Pt NVI, no focal deficits, motor/sensation intact throughout. Coumadin held. ___ pt remained intact, exam unchanged. Spoke to neurology who asked for pt to f/u in 2 wks w repeat head CT and felt that she was safe to restart coumadin. INR checked - 2.3, coumadin restarted and pt d/c'ed home in stable condition, pain contriolled. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male hx. HIV/AIDS (last CD4 23 ___ intermittently adherent with ART, hx. PCP PNA on dapsone presenting with c/o fever and weight loss. Patient reports 1 month of fatigue, dyspnea with exertion, weight loss as well as fevers. Is unclear what symptoms started first, but over the last ___ weeks developed on/off fevers as high as 101, cough productive of sputum, as well as shortness of breath. Says for the last week he gets short of breath with just walking 10 feet. These symptoms reminded him of his prior PCP diagnosis so made an appointment to be seen by his outpatient physician. Patient has also been having intermittent dysphagia with a sense of food getting stuck in the upper portion of his esophagus, with occasional regurgiation of undigested food. Denies pain with swallowing per se. He has lost about 5lbs in the last week and perhaps 30lbs in the last ___ months. Denies night sweats. He denies sick contacts, denies myalgia/arthralgias, denies abdominal pain. Denies recent travel. He works as a ___. Denies history of incarceration or homelessness, although he has traveled extensively (none recent). He notably is only intermittently adherent to his ART and was not taking it from ___ of this year up until last week. Reports his CD4 count hasn't been higher than 100 for 'years', does not give specific reason for lack of adherence. Patient was seen by his PCP 2d prior to admission with these complaints. Out of concern for ___ esophagitis he was started on fluconazole daily. He also had a CXR that was reportedly normal. There was concern was for peridontal disease, esophagitis, as well as ___, ?PCP vs ___. In the ED initial vitals were: 99.1 98 130/77 16 100% RA - Labs were significant for ___, lactate normal, cehmistries and LFTs normal including LDH. CXR was negative - Patient was given nothing and admitted. On the floor, patient currently c/o fatigue, otherwise no complaints. CHEST RADIOGRAPH showed No acute cardiopulmonary process. CT CHEST W/CONTRAST showed 1. Small focus of ground-glass opacity in left upper lobe likely secondary to an infectious/inflammatory process, the minimal extent of which is unlikely to be contributing to the patient's clinical presentation. 2. No evidence of thoracic malignancy. The patient was diagnosed with FEVER, UNSPECIFIED, COUGH, HIV DISEASE. At the time of discharge, the patient had PRIMARY DIAGNOSES =================== # Pneumocystic jirovecci pneumonia # Esophageal thrush # Elevated pulmonary pressures SECONDARY DIAGNOSES ==================== # HIV/AIDS (CD4 23 ___. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year old gentleman with HIV/AIDS (last CD4 23 ___ intermittently adherent with ART, h/o PCP PNA on prophylactic dapsone admitted with fevers, weight loss, and exertional dyspnea. # Fever/Weight loss/Dyspnea: Broad differential in setting of CD4 23. Only localizing sxs are respiratory with dyspnea on exertion and previously documented hypoxia to 83% with ambulation, here noted to be 94% with ambulation. High on the differential is recurrent PCP infection and pt. was empirically started on at___ for treatment. Beta-glucan elevated, though LDH normal. CT chest essentially clear without obvious evidence of PCP. Other infectious causes are on the differential including mycobacterial infection (no documented PPD and low risk), viruses including disseminated CMV, and fungal disease. Malignancy is also on the differential, though no e/o found on CT chest. Lymphoma less likely given no night sweats, no lymphadenopathy on exam, and normal LDH. HIV-associated pulmonary hypertension on the differential and TTE on day of discharge with evidence of new moderate pulmonary hypertension. Induced sputum negative x3 for AFB. Pt. was discharged home on 21 day course of atovaquone for pneumocystic jirovecci pneumonia. He will have close follow-up with his primary care physician for further discussion of his pulmonary hypertension and symptoms. # HIV/AIDS: Last CD4 23 ___. Long history of nonadherance to ART with persistently low CD4 count. Pt. was continued on ritonavir/darunavir, truvada. He was started on azithromycin 1200mg weekly for prophylaxis. # ? Esophageal thrush: Pt. denies any symptoms of dysphagia or odynophagia, No thrush noted on exam of the posterior oropharynx. Fluconazole discontinued on admission with no reoccurence of symptoms. # Transitional issues: - Atovaquone course: To be continued for 21 days (Day #1 ___ - Elevated pulmonary pressures: Seen on echocardiogram, requires outpatient work-up and follow-up with cardiology - Please f/up iron studies, B12, and vitamin D. - ___ AFB smear pending at discharge. - Code: DNR/DNI (confirmed twice) - Emergency Contact: ___ (brother) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ HepC/EtOH cirrhosis (Child's A) with known cholelithiasis observed on surveillance ultrasounds, who presented to his PCP ___ for a ___ day history of RUQ pain that began shortly after a meal of fried chicken and potato salad. The patient reported the pain has been intermittent but he has not eaten well the last few days for fear of exacerbating the pain. His PCP drew LFTs, which were significant for ALT 53, AST 72, TB 1.9. A CT scan was done, which showed a large stone impacted in the GB neck and severe GB wall thickening/edema, but no CBD stones or dilatation. Radiology showed Cholelithiasis with gallbladder wall thickening. Acute cholecystitis cannot be excluded. HIDA scan may be helpful for further evaluation. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. At the time of discharge, the patient had Cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ was admitted to the ___ Surgical service ___ for evaluation of right upper quadrant abdominal pain. He had mild transaminitis at the time of admission. He was kept on clear liquids and IV unasyn was started. By ___, the patient was free of abdominal pain. His exam was without tenderness. He tolerated a regular diet without any further abdominal pain. His transaminase levels were downtrending. He was afebrile throughout his hospitalization with a normal WBC count. He was transitioned to oral antibiotics on discharge. He was specifically counseled that if he has any further episodes of abdominal pain or high fevers to return to ___ ED. The patient was voiding independently, ambulatory and was in agreement with the plan for followup at the time of discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman who initially presented with a stab wound to left chest. She was seen at an outside hospital, where it was noted that she had a hemopneumothorax. A chest tube was placed and she was transferred to BID for further management. On arrival, she was hemodynamically stable and noted to have a trajectory that was concerning for possible diaphragmatic injury. CHEST (PA AND LAT) showed Compared to chest radiographs since ___ most recently ___. Small left apical pneumothorax is smaller. Small left pleural effusion and moderate left basal atelectasis are unchanged. Heart size is normal. Right lung is grossly clear.. CHEST (PORTABLE AP) showed Heart size and mediastinum are stable. Left pleural effusion is moderate. Left retrocardiac consolidation is extensive. There is no pneumothorax CHEST (PORTABLE AP) showed Small to moderate left pleural effusion and left retrocardiac opacity. CHEST (PORTABLE AP) showed Interval retraction of left-sided chest tube. No significant change in small to moderate left-sided pleural effusion. Radiology showed There has been readjustment of the left-sided chest tube with the distal tip projecting over the medial aspect of the left lung base. No definite pneumothoraces are seen. No definite consolidation or large pleural effusions are present. Radiology showed Trace left apical pneumothorax. A left chest tube is present. Radiology showed Left-sided chest tube is unchanged. Subcutaneous emphysema has improved. No obvious pneumothorax is seen. Lungs continue to be low volume. There is a trace left pleural effusion. No new consolidations. Cardiomediastinal silhouette is stable. Radiology showed Small left pneumothorax post removal of the chest tube.. NOTIFICATION: The findings were discussed with ___, M.D. by ___ ___, M.D. on the telephone on ___ at 9:49 pm, 5 minutes after discovery of the findings. The patient was diagnosed with Laceration w/o foreign body of left upper arm, init encntr, Assault by knife, initial encounter. The patient was treated with exploratory laparoscopy left-sided chest tube placement. At the time of discharge, the patient had stab wound to left chest. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ presents as transfer from ___ after a stab wound to L chest. At OSH, she had a chest tube placed for hemo/pneumothorax, with ~300cc blood initial ~5 hrs. Although she was hemodynamically stable, there was concern for diaphragmatic injury given trajectory and extensive discussion with radiology. She underwent exploratory laparoscopy which revealed no other injuries. The chest tube was put on suction and then to waterseal with continued output >100cc output though improving CXR. The chest tube was removed and CXR showed a small left pneumothorax, which resolved, and left basilar atelectasis and effusion. She also noted SOB/wheezing though improved with albuterol. Her vitals remained stable and she was discharged with ___ clinic 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 woman who had a witnessed fall off a step this afternoon. There was no loss of consciousness per her family. She was taken to an OSH where a head CT showed bifrontal traumatic SAH and she was transferred to ___ for further care. Radiology showed Mild pulmonary vascular congestion. No evidence for pneumothorax or pneumonia. Radiology showed 1. Subarachnoid and subdural hemorrhage, as described above, as well as bifrontal hemorrhagic contusions. 2. Nondisplaced fracture involving the right parietal bone extending longitudinally into the temporal bone. The right mastoid air cells and middle ear cavity are opacified, with fluid in the right external auditory canal which may reflect hemorrhage. Ossicles appear grossly intact, though further evaluation with a dedicated temporal CT can be obtained. Radiology showed No evidence of acute fracture or malalignment. Multilevel degenerative changes, as described above. Radiology showed Overall unchanged appearance to bifrontal contusions, subarachnoid and subdural hemorrhage, and right parietal and temporal bone fractures. The patient was diagnosed with CL SKL FX NEC/MENING HEM, FALL ON STAIR/STEP NEC. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to the Neurosurgery service in the setting of bifrontal contusions Left > Right after a mechanical fall for frequent neuro checks and systolic blood pressure control. She was started on Keppra 500mg BID for seizure prophylaxis. ENT consult was called for right ear laceration and right parietal-temporal bone fracture. They recommended ciprodex drops to the right ear BID and follow up in ___ clinic in 2 months for a formal audiogram. No hearing aide to right ear due to right external canal laceration. She must keep the right ear dry x 2 weeks. Repeat head CT on ___ showed slight blossoming of right frontal contusion with stable left frontal contusion and the patient remained neurologically intact. Social work was consulted, requested by family for unsafe home environment. She was hypotensive to the high ___ and low ___ and c/o dizziness with elevation of the HOB. Her Blood pressure improved. Her dizziness however persisted and was aggravated with movement. While working with physical therapy she experienced dizziness that precipitated emesis and she was started on PRN meclezine which helped with these symptoms. On ___, she remained stable on exam, her magnesium and potassium was repleted. She has been ambulatory so SQH was held. On ___ she was being seen by ___ and OT and she was discharged to rehab on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ significant peripheral arterial disease recently s/p R CFA w/ dacron patch angioplasty, stenting of R common and external iliac arteries to proximal portion of patch ___, ___ now presents as transfer from ___ w/ complaints of wound dehiscence and purulent drainage from cutdown site. Pt reportedly feeling well recently. Presented to OSH after daughter noted some bloody discharge from R groin wound. Radiology showed No evidence of acute intracranial process on this slightly motion limited study. The patient was diagnosed with DISRUPTION OF EXTERNAL OPERATION (SURGICAL) WOUND, ABN REACT-SURG PROC NEC, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERCHOLESTEROLEMIA. The patient was treated with ___: Debridement and washout of wound with VAC placement. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ who presented to the ___ ED for an infected and dehiscent inguinal wound. While in the emergency department she displayed seizure like activity and was intubated to protect her airway. She was admitted to the medical ICU for further management of her airway and was extubated on the morning of hospital day 2, approximately 12 hours after intubation. On hospital day 2, she was taken to the operating room for washout of her dehiscent wound with debridement and placement of a VAC. She tolerated this procedure well and was extubated in the PACU. After a brief PACU stay she was transferred to the vascular floor for the remainder of her hospital stay. Neuro: Neurology was consulted for the patient's seizure like activity in the ED and recommended close monitoring without any medical intervention unless further seizure activity was observed. CV: The patient had no cardiac issues during her hospitalization. Resp: The patient was intubated in the ED and was extubated after admission to the medical ICU. Pulmonary toilet was encouraged and the patient had no further respiratory issues during her hospitalization. GI: The patient was tolerating a diet at discharge. GU: The patient had a florid UTI upon admission to the ED. She was started on broad spectum antibiotics for her infected wound. Urine cultures drawn from her Foley on POD1 did not grow any bacteria and her initial UTI may have been contaminated from her dehiscent and draining wound. She was voiding independently at discharge. ID: The patient was started on broad-spectrum empiric coverage once admitted to ___. Wound cultures were obtained which grew out 1+ GPC/GNR/GPR with mixed bacterial growth and no speciation. She will be discharged on a 2 week course of bactrim. Heme: The patient's hematocrit remained stable during her hospitalization. On ___, the patient was discharged to home with a VAC in place. She will have visiting nurses to assist her with her vaccum changes and to monitor her wound. At discharge she was voiding independently, tolerating a diet, afebrile with stable vital signs, and her home wound VAC was in place. Discharge plans were communicated to the patient and she was in agreement. She will follow up in the clinic in 2 weeks. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with h/o obesity, chronic venous insufficiency, DM, h/o DVT currently on lovenox who recently underwent sleeve gastrectomy at ___ presenting with ___ pain with swelling. He reports that he is unable to ambulate ___ pain. He describes significant lower extremity pain starting during his recent hospitalization around post-op day 3. He states that he told his providers that he was having increasing pain and difficulty walking, but was told it would improve if he continued to ambulate. He was discharged home and the pain increased to the point where he could not walk. He was concerned that his symptoms could be the result of a gout flare, so he treated himself for 2 days, which would normally improve his symptoms, but he experienced no relief. He has also noticed increased swelling and erythema or both legs, R>L. He struggles with venous stasis and has used a pneumatic compression device for an hour twice per day for the past year. He describes one prior exacerbation of his venous stasis complicated by SSTI around ___ years ago. He believes the pain he is experiencing is similar to that episode. He denies any fevers or chills. He also complains of some left elbow pain and stiffness consistent with prior episodes of bursitis. Lovenox seems to be a post-op medication (40mg BID, which seems to be DVT ppx?), reports he skipped this AMs dose, but has otherwise been taking consistently. No h/o CHF, last TTE in our system ___, normal EF. Also complaining of L elbow pain. [x] right ___ - no DVT [x] IV vanco if LENIs negative [x] CBC, chem7 Given patient can not walk will admit for further management of his cellulitis In the ED, initial vitals were: 97.9 80 121/57 20 96% RA Exam was notable for edema of both legs to knee with chronic venous stasis changes, though right leg is noticeably warmer and slightly erythematous. Labs were essentially normal. The patient received a dose of vancomycin for presumed ___ cellulitis. On the floor, the patient complained only of ongoing lower extremity pain, R>L Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. UNILAT LOWER EXT VEINS RIGHT showed Study limited by body habitus. No evidence of deep venous thrombosis in the right lower extremity veins. FOOT AP,LAT AND OBL RIGHT showed Chronic changes. Soft tissue swelling. No acute fracture is seen. The patient was diagnosed with Cellulitis of right lower limb. At the time of discharge, the patient had Cellulitis Chronic venous stasis. The patient was given written instructions concerning 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 chronic lower extremity venous insufficiency presenting with worsening lower extremity pain and swelling after OSH admission for sleeve gastrectomy. #RLE pain: Patient has a history of chronic venous insufficiency with ___ R > L edema for which he does mechanical compression at home. However, he had worsening pain in the R foot and was ultimately unable to ambulate. He had RLE U/S that was negative for DVT. XR foot was negative for fracture. Given tenderness along R lateral midfoot and erythema, exam was most concerning for cellulitis. Podiatry was consulted and recommended several doses of IV then po antibiotics for cellulitis as well as compression given worsening edema. Patient had improvement in R foot pain with Tylenol and compression. He received 1 dose of vancomycin in the ED and two doses of cefazolin. He will complete a total of 7 day course of Bactrim/Keflex ending ___. With decrease in his swelling and pain, he was able to ambulate after working with ___ and so was able to be discharged. # Left knee pain: most likely secondary to osteoarthritis. Exam not concerning for septic arthritis, gout, or traumatic injury. He was continued on tylenol. NSAIDs should be avoided in setting of gastrectomy. # Diabetes: Insulin and oral hypoglycemic have been held by the patient's outpatient providers following his bariatric surgery. Patient reports well-controlled sugars at home, around 150 recently, off of his medication. His FSG were wnl around 120s this admission; resumption of DM medications can be considered in the outpatient setting.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of HTN, DM1 on insulin c/b recurrent DKA, asthma and hx of DKA who is presenting with abdominal pain for the past five days in addition to hyperglycemia despite taking his insulin normally. He has been having some shortness of breath, fever on ___, vomiting and diarrhea. He came to ___ ED on ___ for evaluation, but it was so busy that he left without being seen. He denies chest pain, persistent fevers. He is having diffuse abdominal pain and is very nauseous with no PO intake in the past two days. Chest: Frontal and lateral views showed Minimal patchy opacity within the right lung base, similar in appearance to the prior and likely representing atelectasis. Early infection is not excluded in the correct clinical setting. The patient was diagnosed with Type 1 diabetes mellitus with ketoacidosis without coma, Vomiting without nausea, Diarrhea, unspecified, Shortness of breath. At the time of discharge, the patient had DKA Pneumonia Chronic pancreatitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with hx of HTN, DM1 on insulin c/b recurrent DKA, asthma, depression, prior ETOH, chronic paincreatitis, HTN, HLD, GERD, chronic back pain from stabbing incident in past, presented with 5 dasy abdominal pain, found to have DKA, ___ in setting of pneumonia vs viral gastroenteritis. Initial concern for ST elevations on ECG, but repeat ECG was unchanged and enzymes were flat. He was fluid resuscitated, started on an insulin gtt and transitioned to subcutaneous insulin once his anion gap metabolic acidosis normalized. He was able to tolerate PO and was transitioned to a diet. He was transferred out to medical ward where insulin was uptitrated. He had multiple days of poor control and ___ team up-titrated his regimen. It was discovered that he hadn't been written for diabetic / carbohydrate consistent diet until ___ and this was changed with improvement in his BG levels. On discharge, the patient stated that he has no insulin at home. We wrote Rx for insulin, which was initially Glargine 60 units BID. However, ___, did not have this in stock without prior authorization, so I discussed with ___ who changed it to Tresiba (degludec) 120mg SC in AM only. This has the advantage of only needing once a day injections given his overall poor compliance. He was treated for CAP, and tested negative for norovirus. It was presumed that the diarrhea was either a viral gastroenteritis, or simply from his chronic pancreatitis. He complained of chronic abdominal and back pain for which toradol,gabapentin, duloxetine, and Tylenol were continued, with intential refrain from using opiates. He was started on ACE-inhibitor therapy with Lisinopril for BP control; beta blocker was stopped. His antidepressants were continued, and sleep aids were continued. Of note, there was a time where he was refusing insulin, as he has done on multiple different hospital stays, which seems in part, to be leverage to try and receive opiates. I explained very clearly that he would not be having any changes to his pain medications during his stay. He once said he was not going to take his insulin at home (without providing a good reason), but after discussion, agreed to do so. Given his multiple bounce-backs and non-compliance, if he were to get admitted again, a multidisciplinary care team meeting would be beneficial to discuss expectations and follow-up. I would have conducted this, given his behavior the morning of discharge, but because he was able to go home and eventually agreed to cooperate, the timing was not prudent this admission. # DKA w/ poorly controlled DM1 (A1C 11.1%) # AGMA - resolved # PNA - treated w/ Azithro/Cephalosporin # Diarrhea - resolved; negative noro # ___ resolved # Chronic Pancreatitis - on creon # HTN - started lisinopril # HLD - continued home treatement # GERD - PPI # Stabbing in ___- R upper thorax, axilla, mid lower back # Chronic back pain with self reported R sided motor weakness in # Depression w/ prior suicide attempts # Insomnia TRANSITIONAL ISSUES =================== - Should received follow up chest imaging to ensure resolution of pulmonary opacity</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o female with asthma and chronic low back pain ___ recurrent disc herniation at ___ s/p L4-S1 laminectomy in ___ (with baseline decreased bilateral lower extremity reflexes) who presented with worsening low back pain and difficulty urinating. Radiology showed 1. Perineural cystic formations identified from T8 through T11 on the left and right T10 and T11 levels. 2. Mild posterior disc bulging is identified at T11/T12 with no evidence of nerve root compression or significant spinal canal stenosis. 3. Articular joint facet hypertrophy and ligamentum flavum thickening, possibly calcified, noted at T9/T10 on the right. 4. No focal or diffuse lesions are noted throughout the thoracic spinal cord. No focal lesions are identified in the cauda equina. 5. Mild left hydronephrosis, partially imaged (image #21, series #6). MRI OF THE LUMBAR SPINE: The alignment of the lumbar vertebral bodies appears maintained. Disc degenerative changes are visualized at L1/L2 level, consistent with disc desiccation and posterior disc protrusion, causing mild anterior thecal sac deformity and bilateral neural foraminal narrowing, more significant on the left (image #7, series #8). At L2/L3 level, there is disc desiccation and mild posterior disc bulging with no evidence of nerve root compression or neural foraminal narrowing, mild articular joint facet hypertrophy is present. At L3/L4 level, there is disc desiccation and mild posterior disc bulge, apparently contacting the traversing nerve roots bilaterally (image #7, series 11), moderate articular joint facet hypertrophy is present. At L4/L5 level, there is disc desiccation and posterior disc bulge, more significant on the right, causing bilateral neural foraminal narrowing, contacting the traversing nerve roots, also moderate articular joint facet hypertrophy is identified at this level. At L5/S1, there is disc desiccation with a large left paracentral disc protrusion, impinging the S1 nerve root on the left, the patient is status post left laminectomy, mild pattern of enhancement is noted in the surgical bed and surrounding the lateral aspect of the thecal sac (image #19, series #14) likely consistent with granulation tissue. No fluid collections are visualized and the sacroiliac joints are unremarkable. IMPRESSION: 1. The patient is status post laminectomy at L5/S1, no fluid collection or epidural lesion is identified, however, there is a prominent posterior and left paracentral disc protrusion, impinging the thecal sac and the S1 nerve root on the left. 2. Multilevel degenerative changes throughout the lumbar spine as described above. A preliminary report was provided by Dr. ___ on ___. Radiology showed 1. Postoperative changes in the form of anterior fusion of L5 and S1 vertebrae, interbody spacer at L5-S1 disc and left L5 hemilaminectomy. T2 hyperintense prevertebral soft tissue at L5-S1 level which likely represents postoperative fluid collection. Hypointense focus is noted within this, which likely represents blood products or air- attention on f/u. CT can be obtained if clinically indicated for osseous and hardware details. 2. Residual central/left paracentral disc protrusion contacting the traversing left S1 nerve root. The disc material is smaller in size as compared to the prior study. Enhancing soft tissue is noted around the disc which likely represents postoperative granulation tissue. There is enhancement along the left S1 nerve root which is unchanged since the prior study. 3. Degenerative changes at other levels in the lumbar spine and at T10-T11 level, as described in the text. 4. A few small hypointense foci in the partially imaged uterus likely represent fibroids- correlate with pelvic ultrasound if not performed earlier. Assessment of the presacral soft tissues is limited as not targetted. Hypo and hyperintense foci may relate to recent procedure with fluid and edema- correlate clinically to decide on further dedicated imaging. ( se 7, im ___ Radiology showed Prior L5-S1 anterior fusion. Status post L5-S1 posterior fusion. The hardware appears intact. Unchanged alignment and degenerative changes. Please see operative report for further details. The patient was diagnosed with BACKACHE NOS. The patient was treated with Anterior.posterior lumbar fusion with instrumentation L5-S1. At the time of discharge, the patient had Lumbar disc herniation and degeneration Post-op urinary retention. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to the ___ Spine Surgery Service on ___ and taken to the Operating Room for L5-S1 interbody fusion through an anterior approach. Please 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 condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. On HD#2 she returned to the operating room for a scheduled L5-S1 decompression with PSIF as part of a staged 2-part procedure. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the PACU in a stable condition. Postoperative HCT was stable. A bupivicaine epidural pain catheter placed at the time of the posterior surgery remained in place until postop day. She was kept NPO until bowel function returned then diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2 from the second procedure. She was fitted with a lumbar warm-n-form brace for comfort. Physical therapy was consulted for mobilization OOB to ambulate. 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: ___ yr old woman w/ hx thyrotoxicosis ___ Graves disease s/p ablation and subsequent hypothyroidism, substance abuse, dyslipidemia and prior psychosis secondary to hypothyroidism requiring hospitalization p/w hypothyroidism in the context of not taking levothyroxine and psychosis. RENAL U.S. PORT showed Normal renal ultrasound. No hydronephrosis identified. The patient was diagnosed with Unsp psychosis not due to a substance or known physiol cond. At the time of discharge, the patient had Primary: hypothyroidism Secondary: 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>___ yr old woman w/ hx thyrotoxicosis ___ Graves disease s/p ablation and subsequent hypothyroidism, substance abuse, dyslipidemia and prior psychosis presumed secondary to hypothyroidism requiring hospitalization p/w hypothyroidism in the context of not taking levothyroxine. She was evaluated by the psychiatry team and they determined that she was exhibiting signs of psychiatric decompensation with psychosis and paranoia requiring transfer to inpatient psychiatry floor at ___ ___. ACUTE ISSUES # Hypothyroidism- Pt has been noncompliant with her levothyroxine in the past and admitted after a similar presentation of psychosis in the context of not taking levothyroxine. She again hasn't taken any in a couple of weeks. She presents with a TSH of 47. Continued home dose 175 mcg levothyroxine daily. Education about the importance of taking her medication daily was provided. # psychosis- Pt initially presented w/ psychosis endorsing hallucinations and paranoia. However, at the time of that evaluation she was drunk with a blood alcohol level of 197. During her admission she did not express any hallucinations, SI/HI and remained calm and cooperative. Psychiatry evaluated and thought she was unsafe to return home or leave the hospital. She was issued a ___ and was transferred to an inpatient psychiatry facility. She was started on risperidone 1 mg BID. # alcohol withdrawal: Patient did not score on CIWA. Thiamine 100 mg IV/IM initial dose, then 100 mg po daily x 5 days. MVI 1 tab po qd. Folate 1 mg po qd. # macrocytosis. This appears to be a chronic problem since at least ___. Folate was 9 and vitamin B12 >700 in ___ when it was last checked. ___ be secondary to B12 deficiency vs alcohol abuse. Continued vitamin supplementation. # Acute Renal FAilure. Pt also had ___ the last time she was admitted with psychosis thought to be ___ to levothyroxine. It appeared that she may be dehydrated based on her history but her BUN/Cr <20 so was unlikely to be pre-renal. Patient's creatinine improved to 1.3 and stayed steady. Renal US was normal. She should have f/u chem 7 in one week. # vitamin D deficiency- - 50,000 units vitamin D/week for 8 weeks, then outpatient recheck of vitamin D level to decide how to change dose TRANISITIONAL ISSUES LABS TO CHECK: Please check chem 7 in one week to ensure stability in renal function. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ PMH HTN, fibromyalgia, LDRT renal (brother) in ___ at ___ on Cellcept and Tacrolimus, w/ no known history of rejection, presenting w/ 1d fever, sore throat, muscle cramps, and cough. Chest radiograph showed Right lung base opacity in the appropriate clinical setting could represent pneumonia. UNILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the left lower extremity veins. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had #Community Acquired Pneumonia #Urinary tract infection #ESRD s/p transplant #Fibromyalgia #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>___ PMH HTN, fibromyalgia, LDRT renal (brother) in ___ at ___ on Cellcept and Tacrolimus, w/ no known history of rejection, presenting w/ 1 day of fever, sore throat, muscle cramps, cough, w/ evidence of PNA on CXR as well as urinary urgency c/f UTI. # CAP vs. Viral URI: Patient presented with respiratory symptoms, productive cough, fevers, and leukocytosis. Also, immunosuppressed in the setting of kidney transplant. Febrile and tachycardic on presentation. CXR with evidence of right lung base opacity concerning for pneumonia. Otherwise, no hypotension or hypoxia, saturating well on RA. Less likely strep throat, but does have tender LAD and reports exposure. Strep throat swab negative. Initially treated with CTX/azithromycin (___) for community acquired pneumonia, now narrowed to Levaquin to complete 5 day course (last dose: ___. Sputum and blood cultures with no growth to date. CMV viral load pending at discharge. # Urinary tract infection Patient reporting suprapubic discomfort and urinary urgency. UA with moderate leuks, few bacteria. First urine culture contaminated, second urine culture pending. Treating with Levaquin for CAP as above, which should also cover for urinary tract infection. Urine cultures no growth to date at discharge. # ESRD s/p LDRT renal (brother) in ___ ___ function at baseline on presentation. Continued home tacrolimus and cellcept. Tacrolimus level was monitored during admission (trough was felt to be poorly timed, thus home dose was continued). # GERD: Continue ranitidine 150 mg QHS. # HTN: Continue home losartan 25 mg, amlodipine 2.5 mg, and HCTZ 12.5 mg QD # HLD: Continue atorvastatin 20 mg QPM. TRANSITIONAL ISSUES: ==================== [] Complete 5 day total course Levaquin to complete 5 day course (last dose: ___. [] Follow up with PCP ___ 1 week of discharge. [] Please follow up urine culture which is pending at discharge. [] Please follow up CMV viral load which is pending at discharge. #CONTACT: ___ (son) ___ #CODE: Full</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female who was in her usual state of health when she slipped while ambulating in her kitchen and fell onto her bilateral outstretched hands. She does not believe she struck her head or loss consciousness. She presented to the outside hospital where she was found to have bilateral shoulder dislocations. Orthopedics at the outside hospital was consulted and recommended close reduction of bilateral shoulders. Right shoulder was successfully reduced. Left shoulder reduction was unsuccessful and patient sustained avulsion of the left humeral head with moderate to severe displacement. Patient was referred to ___ for orthopedics. She denied any preceding symptoms. She is not on anticoagulation. She has been feeling well recently with no recent illness. HUMERUS (AP AND LAT) LEFT IN O.R. showed Intraoperative images were obtained during manipulation of the proximal humerus under anesthesia. Please refer to the operative note for details of the procedure. SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT showed Status post interval reduction of three-part proximal humeral fracture with nominal alignment. Residual widening of the glenohumeral joint may represent ligamentous laxity or hemarthrosis. CT UP EXT W/O C BILATERAL showed 1. Three-part comminuted, displaced fracture of the proximal left humerus, as above. Residual widening of the left glenohumeral joint is likely due to ligamentous laxity and/or nonhemorrhagic effusion. 2. Sequela of prior anterior dislocation of the right shoulder with osseous Bankart fracture of the glenoid rim and ___ lesion of the humeral head. 3. Evidence of mild right rotator cuff tendinosis and probable partial thickness tears. 4. Trace right pleural effusion and bibasilar atelectasis. The patient was diagnosed with Pain in right shoulder, Fall on same level, unspecified, initial encounter. The patient was treated with Closed reduction left proximal humerus fracture dislocation under anesthesia. At the time of discharge, the patient had Left proximal humerus fracture/dislocation. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient presented to the emergency department and was evaluated by the orthopaedic surgery team. The patient was found to have a left proximal humerus fracture/dislocation and was admitted to the orthopaedic surgery service. The patient was taken to the operating room on ___ for close reduction of left proximal humerus/dislocation, 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 anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab next field was appropriate. Postoperative x-ray and CT demonstrated adequate reduction of the fracture/dislocation. On multiple occasions throughout hospitalization, patient was found to be retaining urine requiring intermittent catheterization. Patient will be discharged to rehab with instructions to monitor for urinary retention with regular bladder scans and catheterized/Place Foley as needed. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is NWB LUE ADLs as tolerated - start pendulums in 2 weeks; WBAT RUE - avoid extremes of abduction/external rotation and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ history of PCOS with L ovarian torsion s/p lap detorsion one year ago now presents with abdominal pain x 12 hours. Ms. ___ reports that she noted epigastric pain which began suddenly after eating dinner last night with associated fever and chills. Since symptom onset she had several episodes of non-bloody diarrhea without improvement in her pain. She has had no nausea or vomiting, but does report bloating and anorexia since her pain began. Given the persistence of her symptoms, she sought medical evaluation. PELVIS U.S., TRANSVAGINAL showed 1. Unremarkable pelvic ultrasound. Normal sized ovaries with demonstrable color flow. Very trace pelvic free fluid is within physiologic range. Chest: Frontal and lateral views showed No acute cardiopulmonary process. No evidence of free air beneath the diaphragm. CT abdomen and pelvis showed 1. Acute appendicitis with small amount of free fluid. No evidence of extraluminal gas or drainable fluid collection. NOTIFICATION: The findings and impression were discussed with ___, M.D. by ___, M.D. on the telephone on ___ at 2:23 pm. The patient was diagnosed with Unspecified acute appendicitis. The patient was treated with ___ - Laparoscopic appendectomy. At the time of discharge, the patient had Acute appendicitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed acute appendicitis. WBC was elevated at 11.3. The patient underwent laparoscopic appendectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor. The patient was hemodynamically stable. When tolerating a diet, the patient was converted to oral pain medication with continued good effect. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. Psychiatry was consulted due to patient's request. The patient reported she was not coping well with her eating disorder and wanted to speak to psychiatry about it. Psychiatry made recommendations for a partial outpatient program, no inpatient admission warranted. The Social Worker was at the bedside, helping to arrange this for the patient. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is an ___ woman with history notable for hypertension and suspected lumbar radiculopathy presenting with acute-onset aphasia. CTA HEAD AND CTA NECK Q16 CT NECK showed 1. 3.7 cm acute left frontal lobe intraparenchymal hematoma with surrounding vasogenic edema and mild mass effect. No herniation or midline shift. 2. Minimal luminal narrowing of the cavernous ICAs bilaterally due to calcification. Otherwise, unremarkable CTA head and neck. No evidence of active extravasation into the left frontal acute intraparenchymal hematoma, or underlying vascular lesion. 3. Chronic intracranial findings include global involutional changes and moderate changes of chronic white matter microangiopathy. MR HEAD W AND W/O CONTRAST T___ MR HEAD. showed 1. Large intraparenchymal hematoma in the left frontal lobe measuring 5.1 x 3.6 x 3.7 cm (AP X TR X CC) with mild mass effect and surrounding edema. No midline shift. 2. Mild leptomeningeal enhancement in the region of the hematoma is likely reactive. 3. No abnormal flow voids or large draining veins identified in the region of the hematoma to suggest an underlying vascular malformation. Compression of the smaller vessels due to the large size of the hematoma cannot be excluded. 4. White matter lesions in the pons, cerebral hemispheres bilaterally are nonspecific but likely sequela of chronic small vessel ischemic changes. Enteric tube placement showed The Dobhoff tube is kinked, with the tip projecting superior to the diaphragm, possibly within a hiatal hernia. RECOMMENDATION(S): Repositioning of the Dobhoff tube is recommended. NOTIFICATION: The findings were discussed with ___, R.N. by ___ ___, M.D. on the telephone on ___ at 6:00 pm. VENOUS DUP EXT UNI (MAP/DVT) RIGHT showed No evidence of deep venous thrombosis in the right lower extremity veins. The patient was diagnosed with Other nontraumatic intracerebral hemorrhage. The patient was treated with PEG placement.. At the time of discharge, the patient had Intraparenchymal hemorrhage. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ ___ year old woman with a history of hypertension who presented with acute-onset complete inability to produce speech. On initial exam she was found to have a global aphasia, agraphia, and impaired comprehension as demonstrated when asked to follow commands. CT shows a 3.7 x 3.1 cm IPH, exerting mild mass effect from cytotoxic edema and no midline shift. MRI redemonstrated this lesion and also shows chronic microvascular changes. Etiology unclear at this time. She was hypertensive during hospitalization, though the IPH is in a very atypical location of hypertensive bleed. There could possibly be underlying lesion given location at ___ or possibly first presentation of amyloid angiopathy (there are no microbleeds on MRI to support this diagnosis at this time). We will therefore control hypertension and reimage after blood has been reabsorbed. This IPH occurred on ASA 81mg daily, and given that she has no absolute indication for aspirin, it is being held indefinitely. She had persistent dysphagia and failed multiple SLP evaluations, eventually receiving a PEG on ___ without complications. She is tolerating TF at goal rate. Goal SBP <150, however patient consistently had high BP values requiring IV hydralazine, switched ___ to prn PO labetalol. Her antihypertensive regimen was uptitrated to: lisinopril 40mg daily, chlorthalidone 25mg and amlodipine 10mg with PRN PO labetolol 200mg. Holding all anti-platelets and NSAIDs. Course was also complicated by R knee pain with preserved ROM, attributed to known osteoarthritis. On ___, the pain was somewhat higher in the leg, and therefore DVT u/s was done of RLE, which showed no DVT. ===========================</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F w/ 48 hrs of lower abd pain. Pain started ___, initially ___ umbilical then migrating to RL and LLQ. Pain is sharp, continuous, associated with nausea and vomiting, nonradiating. First episode. No fevers or chills. Passing flatus but no BM today. Radiology showed 1. Uncomplicated acute appendicitis. 2. Tiny hepatic hypodensities are too small to characterize, some of which are not definitely simple cysts. Recommend further evaluation with ultrasound or MR. ___ point #1 was discussed with Dr. ___ by Dr. ___ at 2:45 p.m. via telephone on ___. Dr. ___ discussed impression point #2 with OR nurse ___ via telephone on ___, who in turn repeated the recommendation to Dr. ___. The patient was diagnosed with ACUTE APPENDICITIS NOS. The patient was treated with ___ laparoscopic appendectomy. At the time of discharge, the patient had Ruptured acute appendicitis with suppurative peritonitis. The patient was given written instructions concerning 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 on ___ under the Acute Care Service for management of her acute appendicitis. She was taken to the operating room that day for a laparoscopic appendectomy. Please see operative note from Dr. ___ details of the procedure. She tolerated the procedure well and was extubated upon completion. She was transferred to the PACU initially postoperatively, and then to the surgical floor when hemodynamically stable. Her pain level was routinely assessed and she was given IV analgesics initially as needed to control her pain. She was later transitioned to oral narcotics when tolerating PO's. She was started on clear liquids postoperatively and given additional IV fluids for hydration. On POD 1 she was started on a regular diet, which she tolerated without increased abdominal pain or nausea. Her vital signs were routinely monitored. Initially her urine output was borderline and she was noted to be slightly hypotensive in the low 80's systolic; however, it was noted that the patient's basline systolic BP's are in the 90's. By the day of discharge on POD 2, she was making adequate amounts of urine and her SBP's remained in the high 80's-90's. She remained afebrile without any signs of infection. She was started on IV ciprofloxacin and flagyl initially postoperatively for ruptured appendicitis noted in the OR, and was transitioned to PO antibiotics prior to discharge. She was encouraged to mobilize out of bed and ambulate, which she was able to do independently. On postop day 2 she is tolerating a regular diet and hemodynamically stable. Her pain is well controlled with PO pain medications and she is out of bed ambulating independently. She is being discharged home with scheduled follow up in the ___ clinic on ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with history of diastolic CHF, type 2 diabetes, hypertension, CKD, COPD, A. fib/flutter (status post ablation ___, not anticoagulated) with history of multiple lower GI bleeds, who presents via EMS after a fall. UNILAT LOWER EXT VEINS LEFT showed 1. No evidence of deep venous thrombosis in the left lower extremity veins. 2. ___ cyst. DX ANKLE AND FOOT showed No fracture or dislocation of the left foot or ankle. Central and marginal erosions at the left first MTP joint, which can be seen in the setting of an inflammatory arthropathy such as gout. WRIST(3 + VIEWS) LEFT showed Apparent soft tissue swelling about the wrist without underlying fracture or subluxation. CT CHEST W/O CONTRAST showed 1. Small left pleural effusion. No focal consolidation. 2. 10 mm pleural based right lower lobe nodule with spiculated margins has increased in size since ___. Consider PET-CT for further evaluation. 3. Mild bibasilar atelectasis. 4. Mild bronchial wall thickening in bilateral lower lobes suggest small airways inflammation. 5. Irregular nodular thickening of the right major fissure may represent sequelae of previously seen right loculated pleural effusion at this same site. 6. Calcified granuloma and calcified right hilar lymph nodes suggest exposure to prior granulomatous disease. RECOMMENDATION(S): PET-CT may be considered to evaluate the pleural based right lower lobe nodule with spiculated margins that has increased in size since ___. CHEST (PA AND LAT) showed Cardiomegaly is severe. There is mild vascular congestion. There is small bilateral pleural effusion. There is no evidence of pulmonary edema or new consolidations. CTA ABD AND PELVIS showed 1. The site of gastrointestinal hemorrhage is not elucidated. 2. Redemonstration of right pulmonary nodule, as on recent CT. 3. Stable bilateral adnexal cystic lesions for almost ___ years, therefore of uncertain significance at this age. The patient was diagnosed with Urinary tract infection, site not specified, Weakness. At the time of discharge, the patient had Acute Lower GI Bleed (likely diverticular) Acute on Chronic Diastolic CHF Acute Hypoxemic Respiratory Failure Urinary Tract Infection Atrial Fibrillation Fall. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mrs ___ is a ___ year old woman with history of chronic diastolic CHF, CKD stage 4, NIDDM2, COPD not O2 dependent, AFib s/p ___ ablation not on anticoagulation due to recurrent severe GIB, HTN, HLD who was admitted for fall at home, found to have a UTI, acute CHF exacerbation, ___ hospital course was complicated by an acute LGIB. ACUTE ISSUES # Acute Lower GI Bleed: After 3 days of diuresis and 5 days in the hospital, patient developed sudden onset of large-volume painless BRBPR with clots. GI was consulted and recommended colonoscopy, but patient initially confused. She remained hemodynamically stable despite ongoing large volume bleeding so I was of concern for contrast-induced injury for her CKD she was initially treated pull-through with 4 units PRBCs and remains stable. 3 days later, however she had another large episode of bleeding with a episode of relative hypotension and a CTA was performed that did not demonstrate any signs of active bleeding. Leading subsequently self resolved 2 additional units of PRBCs and did not recur. Hemoglobin remained stable for 3 days subsequently. She did undergo a colonoscopy which demonstrated large diverticuli and a few polyps but no signs of active bleeding. Blood counts and blood pressure remained stable for 4 additional days through the time of discharge. # Hypoxia # Acute on Chronic diastolic heart failure # COPD not previously O2 dependent: Patient presented with asymptomatic hypoxia after experiencing a fall at home. She did not have clear left-sided heart symptoms but was noted to have an elevated BNP JVD. LENIS and VQ scan were negative for VTE. Chest CT with small b/l effusions, but did not demonstrate significant emphysematous or bullous changes consistent with COPD, although she does carry this diagnosis. She was diuresed starting ___ hospital course with significant improvement in her hypoxia symptoms. Diuretics were temporarily held during her bleeding episodes as detailed above. Discharged home on home diuretics # Spiculated Mass: Seen on Chest CT, and was noted to have intervally increased in size since ___. PET-scan recommended for further eval. Patient was informed of finding, but further evaluation deferred to the outpatient setting. # Presyncope / Fall: Patient's initial presenting symptom was a fall. Bleeding or CHF symptoms prior to. She was found to have a likely UTI and was treated with 3 days of antibiotics. Her other issues were managed as above. Patient wa initially screened by ___ who recommended discharge to rehab, but patient firmly refused and wanted to go home, and so was discharged home with services. # Afib RVR: Developed early in her hospital course and did not recur. Likely triggered by infection and hypovolemia. Improved with fluids and antibiotics. Did not recur after initial HD #1 and HD #2. Remains off systemic anticoagulation given her history of severe GI bleeding (done prior to this admission). Notably she, she also had metoprolol increased to 75 mg tartrate 3 times daily which was later converted to 100 mg twice daily at time of discharge. # Left wrist/left foot pain: Radiographs rule out fracture. Likely gout flare based on past gout history and exam. Improved with colchicine/predisone (x 5 d course). # NIDDM2: Maintained on a Humalog sliding scale and nightly glargine while hospitalized. Home oral anti-glycemic's were resumed at time of discharge. # HTN: Losartan was continued through hospitalization, held only for contrast exposure. Metoprolol was increased to 100 mg twice daily. Amlodipine was held through time of discharge. # CKD stage 4: - stable # HLD: Continued home statin</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year old man with a history of depression, schizophrenia, asthma who presented with worsening depression and auditory hallucinations instructing to harm others. The patient describes worsening of his depression for months, namely poor energy, insomnia, hopelessness, and intermittent passive SI. He is homeless since moving to ___ and no longer has a shelter to stay in. Over the past two days prior to admission, he had auditory hallucinations consisting of voices that instruct him to hurt people, particularly men, without a particular plan to do so. In the past, taking medications has helped control with these hallucinations, however he has ran out of them for the past weeks. Reportedly, he has been seen in other neighboring EDs for similar complaints in the past couple of months. CHEST (PORTABLE AP) showed No acute cardiopulmonary abnormality. The patient was diagnosed with Homicidal ideations. At the time of discharge, the patient had PRIMARY DIAGNOSIS: ================= Command auditory hallucinations SECONDARY DIAGNOSIS: =================== Schizophrenia Depression Asthma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ year old male w/ ___ depression and schizophrenia who is presenting with auditory hallucinations and homicidal ideation. He was admitted under ___. ACUTE ISSUES ============= #Acute depressive episode with SI, HI #Auditory, visual hallucinations Episode appears similar to recent hospitalizations per record review by Psych. Current trigger likely medication non adherence. He was medically cleared in the ED but was admitted to medicine pending psychiatry bed. Psychiatry initially had patient under ___ but this was subsequently discontinued as the patient's auditory hallucinations resolved with initiation of anti-psychotics. He was cleared by psychiatry team for discharge home and was no longer felt to be a risk to himself or others. He was maintained on Abilify 10 mg for one day while in house and discharged on risperidone 1mg twice daily because of cost. He was given a free two-week supply. #leukocytosis Initial labs with leukocytosis WBC 15, no labs since ___. Per documentation no complaints of cough, fever, loose stool, skin breakdown. Urine culture negative and CXR w/o consolidation. Improved to 11 on discharge. #Med rec Patient with inconsistent medication history, reportedly taking both aripiprazole and valproic acid. However, recently discharged from OSH on risperidone. He was discharged on risperidone as above. CHRONIC ISSUES =============== #Asthma: Not on albuterol inhaler. Continue to monitor for symptoms #Tobacco use disorder: Smoker of 7 cigarettes daily. Did not want nicotine patch while in house. TRANSITIONAL ISSUES =================== Patient plans to take bus to return to ___. He was agreeable to pay the fee as quoted by ___. Unfortunately no further financial assistance regarding this could be given. MEDICATION: Risperidone 1mg twice daily</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is an ___ yr old man with a history of Afib not on anticoagulation, dementia. history of CVA, PE, intracranial hemorrhage ___ traumatic head injury, colon CA s/p colectomy, presenting s/p fall, found to have a new anemia. CT C-SPINE W/O CONTRAST showed 1. Acute odontoid fracture as described above, type II/III. This compromises the right vertebral foramen. CTA neck is recommended to evaluate the right vertebral artery. 2. No additional fractures are identified. 3. Multilevel cervical spondylosis is unchanged from prior exam. RECOMMENDATION(S): CTA is recommended for evaluation of the right vertebral artery secondary to transverse foramina compromise. CTA NECK WANDW/OC AND RECONS Q25 CT NECK showed 1. Occlusion of the right vertebral artery at the C2 transverse foramen with distal reconstitution of the right V4 segment, likely representing vertebral artery dissection related to a comminuted fracture of the odontoid process and body of C2. 2. No evidence of internal carotid artery stenosis by NASCET criteria. MRI CERVICAL SPINE WITH/WITHOUT CONTRAST showed 1. Type 3 odontoid fracture extending into the right lateral mass of C2 and disrupting the right transverse foramen, with associated disruption of the anterior and posterior longitudinal ligament, as well as disruption of the apical odontoid leg. Unchanged minimal anterior subluxation of the odontoid fracture fragment. 2. The right vertebral artery is better assessed on the preceding CTA. 3. Prevertebral edema from the craniocervical junction through C5-6. 4. Interspinous ligament edema from C1-2 through C4-5 and edema in bilateral posterior paravertebral muscles. 5. Small epidural hematoma posterior to the odontoid fracture fragment without spinal canal narrowing. 6. Normal spinal cord signal. 7. Multilevel degenerative disease from C2-3 through T1-T2. CT HEAD W/O CONTRAST showed 1. No acute intracranial hemorrhage or territorial infarct. 2. Left occipital scalp laceration, subgaleal hematoma and subcutaneous emphysema without underlying fracture. The patient was diagnosed with Laceration without foreign body of scalp, initial encounter, Oth disp fx of second cervical vertebra, init for clos fx, Unspecified fall, initial encounter, Anemia, unspecified. At the time of discharge, the patient had Primary Diagnoses =================== Cervical fracture Anemia Atrial fibrillation Secondary Diagnoses ===================== Colon Cancer status post resection Prostate Cancer Benign prostatic hypertrophy History of pulmonary embolism Glaucoma Hypelipidemia 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 an ___ yr old man with a history of Afib not on anticoagulation, dementia. history of CVA, PE, intracranial hemorrhage ___ traumatic head injury, colon CA s/p colectomy, presenting s/p fall, found to have a new anemia. HOSPITAL COURSE #s/p fall c/b C2 fracture: Patient with unwitnessed fall backward at ___ ___ in which he fell backwards and hit his head. The etiology of the fall is not clear. The differential for the possible fall included possible seizure, arrhythmia given atrial fibrillation, symptomatic anemia or mechanical etiologies. An EEG was done; results still pending. The patient has continued to be in atrial fibrillation, rate controlled with metoprolol, and was hemodynamically stable throughout. A TTE was also peformed and these results showed no structural cardiac cause of syncope identified. Normal global biventricular function. Mildly dilated right ventricle. Mild aortic and mitral regurgitation. ___ tricuspid regurgitation. EF: >55%. A CT head post fall was negative for acute intracranial pathology, but a CT C spine revealed an acute odontoid fracture which compromised the right vertebral artery. A subsequent CTA was done which revealed concern for vertebral artery dissection in the setting of the C2 fracture. Vascular surgery was consulted for assistance with managment. Given that the patient remained hemodynamically stable and without neurologic compromise from baseline, the patient was likely compensating through collateral circulation from his left vertebral artery. A subsequent MR ___ spine was without abnormal cord signal or spinal canal narrowing. He was managed non operatively by the orthopedic surgery team. He was continued in a ___ J collar at all times for a 6 week course. He will need to follow up with Dr. ___ in orthopedics in 2 weeks. In regards to the vertebral artery dissection with occlusion, Vascular surgery recommended 81 mg indefinitely. He will not need Vascular Surgery follow up. # Normocytic anemia The patient was found to have a new normocytic anemia with a drop from Hgb of 14.8 in ___ to 8.6 now. While the MCV was 83 the RDW was elevated suggesting a possible multifactorial picture. The patient was found to be iron deficient with a concomitant low ferritin, and was started in ferrous glucanate TID. The iron deficiency anemia was concerning given his history of colon cancer s/p resection. The family will discuss whether they will pursue a colonoscopy as an outpatient with the PCP. # Leukocytosis The patient was admitted with a leukocytosis to 12.5 that resolved when trended. This was likely reactive in nature. The patient had anegative UA, CXR, and was without any other localizing symptoms. He remained afebrile. # Atrial fibrillation On recent admission digoxin was held given bradycardia. Metoprolol decreased from 200 mg to 25 mg. Warfarin discontinued given history of intracranial hemorrhage. The patient had an episode of Afib with RVR which resolved with PO metoprolol. He was subsequently continued on a regimen of metoprolol 12.5 mg BID to good effect. CHRONIC ISSUES ==================== #CVA Patient continued aspirin and simvastatin. #HLD Patient continued simvastatin. #GERD Patient continued omeprazole. #Dementia Patient continued quetiapine, sertraline, trazodone. #Glaucoma Patient continued timolol eye drops. TRANSITIONAL ISSUES ======================= [ ] 1 week PCP ___ [] Follow up in ___ clinic with Dr. ___ in 2 weeks: ___ or ___. [] Continue ASA 81 mg indefinitely for vertebral artery dissection, no vascular follow up appointment necessary. [ ] CBC, Chem 7 at next PCP visit - trend H/H, BUN/Cr. [ ] Metoprolol started this hospitalization for episode of atrial fibrillation with RVR [ ] Please follow up with PCP regarding need for colonoscopy for evaluation of anemia. H/H improving with iron supplemenation CODE: DNR/DNI CONTACT; ___ ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ yo M with history of EtOH dependence and abuse for years (since age ___), presumed cirrhosis, HTN, and depression, thrombocytopenia, who presented with dizziness, tremulousness, and anxiety in the setting of heavy drinking as well as recurrent mechanical falls, the last of which was on the day of admission. CHEST (AP upright AND LAT) showed No acute intrathoracic process. Mediastinal prominence due to unfolded thoracic aorta. CT HEAD W/O CONTRAST showed Images are limited by motion artifact. Within this limitation, no evidence of acute intracranial hemorrhage. RIB UNILAT, W/ AP CHEST LEFT showed Minimally displaced fracture through the left ninth rib anteriorly. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Minimal abnormalities in the vicinity of the mammillary bodies and periaqueductal gray. These are of uncertain significance in a patient with suspected Wernicke's encephalopathy. 2. Minimal white matter hyperintensities on FLAIR images of doubtful significance. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhosis with splenomegaly and patent umbilical vein. 2. No biliary dilatation. 3. Probable tiny adherent gallstone without evidence for cholecystitis. The patient was diagnosed with Alcohol dependence with withdrawal, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSES: Wernicke's encephalopathy Alcohol intoxication Recurrent falls Lower extremity weakness SECONDARY DIAGNOSES: Cirrhosis Thrombocytopenia Megaloblastic 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>___ yo M with history of EtOH dependence and abuse, presumed cirrhosis, HTN, and depression, thrombocytopenia, who presented with dizziness, tremulousness, and anxiety in the setting of heavy drinking as well multiple mechanical falls the last of which was on the day of admission. #WERNICKE'S ENCEPHALOPATHY: He was found to have truncal and gait ataxia with intact proprioception, and also with nystagmus and encephalopathy with indifference and inattentiveness in setting of chronic alcoholism. MRI head without contrast showed minimal abnormalities in the vicinity of the mammillary bodies and periaqueductal gray. There was no evidence of stroke on MRI. His symptoms were thought to be secondary to Wernicke's encephalopathy and he was treated with IV thiamine. # ACUTE ALCOHOL DEPENDENCE WITH WITHDRAWAL: Longstanding significant alcohol dependence, who unfortunately is not able to stay sober and has failed multiple attempts of detoxification. He has no prior history of withdrawal seizures. In terms of his alcohol intoxication, he was initially placed on CIWA score with diazepam PRN. #RECURRENT FALLS: CT head was negative for any intracranial process and rib series showed left rib fracture. Recurrent falls were attributed to his alcohol intoxication and Wernicke's. As discussed above, he was found to have truncal and gait ataxia with intact proprioception. The ataxia was improving at time of discharge and patient was discharged to rehab. The expected length of stay at rehab is not more than 30 days. # THROMBOCYTOPENIA: This is a chronic issue. During his prior admission, blood smear was reviewed with hematology, and thrombocytopenia was thought to be likely related to cirrhosis, splenomegaly, and alcohol abuse. # LOWER EXTREMITY WEAKNESS: Patient has chronic lower extremity weakness, most likely related to deconditioning and excessive alcohol intake. He was noted to have right foot drop during prior admission, possibly related to prior injury to alcoholic neuropathy. At that time, he was seen by physical therapy, who recommended that patient be discharged with a walker, as well as with ___ physical therapy. Vitamin B12 was within normal limits. ___ was consulted and recommended acute rehab.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ Right handed man with a PMH significant for HTN, DM and alcohol abuse who presents with a small left temporal SAH and SDH after having fallen. Radiology showed 1. Right temporal subarachnoid hemorrhage. Subdural hemorrhage cannot be excluded. If prior exam is made available, we would be happy to compare. 2. Asymmetric prominence of the right frontal extra-axial CSF space; subdural fluid cannot be excluded. 3. Possible mild right temporal lobe edema. Discussed with ___ by phone by ___ at 1:17 p.m. on ___. The patient was diagnosed with TRAUM SUBARACHNOID HEM, TRAUMATIC SUBDURAL HEM, UNSPECIFIED FALL, HEAD INJURY UNSPECIFIED, ALCOHOL ABUSE-UNSPEC. At the time of discharge, the patient had Right temporal subarachnoid hemorrhage. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to Neurosurgery for monitoring of his small left temporal SAH and SDH. He was admitted to the floor for neuro checks. He was placed on a CIWA scale for his history of alcohol abuse and started on folate, thiamine, and a multivitamin. He was continued on his home metformin and placed on an insulin sliding scale with a diabetic carb-controlled diet. He received Tylenol as needed for headache. A repeat head CT scan on ___ showed stable appearance of the small left temporal subarachnoid hemorrhage. He was placed on Keppra 500 mg BID for seizure prophylaxis and should complete a total 7-day course. He remained neurologically intact. ___ and OT were consulted to evaluate him and recommended discharge home with outpatient ___ services, for which he was given a prescription. He will follow-up in 4 weeks with a non-contrast head CT scan.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year-old female with history of alcohol dependence and multiple traumatic head injuries resulting in subarachnoid/subdural hemorrhages, one of them even requiring right-sided cranioplasty in the recent past, presents today after mechanical fall. Reportedly, patient was in the bathroom and fell backwards while standing from the toilet. Positive head-strike resulting in upper lip laceration, unsure if there was loss of consciousness. Patient states he was unable to get up initially, but later was able to crawl his way into his neighbors' place and ask for help. He reports concomitant nausea and coffee-ground emesis. A surgical trauma evaluation was requested for recommendations in management. Radiology showed No acute fractures or dislocations are seen. There are moderate degenerative changes of the first MTP joint with joint space narrowing and spurring. No bony erosions are seen. There is normal osseous mineralization.Lisfranc interval is preserved. There is minimal spurring of the anterior tibial plafond. ___ fat pad is preserved. There are vascular calcifications posteriorly. MR CERVICAL SPINE W/O CONTRAST showed 1. Marrow signal abnormality within the left anteroinferior corner of the C5 vertebral body, either degenerative endplate change or a microfracture. Prevertebral edema at C2-C5 suggests that this may be a microfracture, although a fracture line is not evident on CT from ___. If this is a fracture, it is stable with no involvement of the middle and posterior columns and no evidence of ligamentous injury. 2. No evidence of spinal cord injury. The patient was diagnosed with FX MULT RIBS NOS-CLOSED, OTHER FALL. At the time of discharge, the patient had Left ___ rib fractures Right periorbital 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>The patient brought to ___ ED on ___ for trauma evaluation s/p mechanical fall. Pt was evaluated by the ED and the acute care surgery team.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with PMH of tracheobronchial malacia s/p trachea-bonchoplasty (___), trach on ___, and a T tube placed ___, as well as CHF with EF of 49%, COPD, Afib, RUE DVT on ___ presents with worsening shortness of breath and complaints of bright red blood per rectum. Chest: Frontal and lateral views showed No acute cardiopulmonary process. The patient was diagnosed with Dyspnea, unspecified, Heart failure, unspecified, Anemia, unspecified. At the time of discharge, the patient had Primary Diagnosis # Dypsnea - likely secondary to acute on chronic diastolic heart failure # Rectal bleeding, likely ___ hemorrhoids Secondary Diagnosis # h/o RUE DVT # COPD/Tracheobronchial Malacia # Afib # Rate-dependent LBBB # Coronary artery disease # Fibromyalgia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ female with PMH of tracheobronchial malacia s/p trachea-bonchoplasty (___), trach on ___, and a T tube placed ___, as well as CHF with EF of 49%, COPD, Afib, RUE DVT on apixaban presents with worsening shortness of breath and complaints of bright red blood per rectum. ============================ ACUTE ISSEUS ADDRESSED ============================ # Bright red blood per rectum # Anemia: Patient initially presenting with complaints of bright red blood per rectum and hemoglobin 8.9 from 9.4 at last hospitalization. She was started on an IV PPI and her apixaban was held. However, stool guaiac was negative, and patient was found to have hemorrhoids on exam. Hgb stayed stable at 8.4. It was felt that this was unlikely to be an active GI bleed. Her home medications were resumed. # Dyspnea: Patient with normal CXR and BNP elevated to 1000. She received IV Lasix 40mg in the ED with improvement of symptoms. She felt back to her baseline the following day, and was able to be discharged on her home medications. ============================ CHRONIC ISSEUS ADDRESSED ============================ # h/o RUE DVT: Diagnosed on ___ in the right axillary vein. Has been anticoagulated since then. Her apixaban was held on admission given concern for GI bleed, but given that her hemoglobin remained stable with no evidence of active bleed, was able to be restarted. # COPD/Tracheobronchial Malacia: Known COPD and tracheobronchial malacia. Patient felt that her breathing was at baseline. Continued home Albuterol, Benzonatate, Mucomyst, Fluticasone and T Tube maintenance. Dr. ___ notified via ___ fellow by phone of patient's admission. # Afib: # Rate-dependent LBBB: Currently with well controlled heart rates. Was continued on home metoprolol and dilt, and anticoagulation was restarted as above. # CAD: Continued aspirin and atovastatin # Rheumatoid Arthritis Currently follows with a rheumatologist. Has taken multiple RA meds at various points in the past, including MTX, plaquenil, Enbril, and Humira. Not currently on a DMARD or biologic. Continued home medications. # Fibromyalgia: Continued pregabalin 75mg PO TID. # T2DM: Held home glimepiride and start ISS while in house. Discharged on home medications. # GERD: Patient with recent NSAID use in the setting of RA. Last EGD demonstrated antral erythema. Initially given IV PPI given concern for GI bleed, but was discharged on home pantoprazole. # DEPRESSION: Continued home Fluoxetine, Buspirone, and PRN Ativan # RLS: Continued home Flexeril ============================ TRANSITIONAL ISSUES ============================ [] Patient was discharged on her home medications. [] should have CBC recheck on ___ at time of next appointment [] Found to have QTc of 576. Would avoid any QTc prolonging medications. Patient aware of prolonged QTc as well. Would continue to closely monitor. [] please ensure all health maintenance including colonoscopy are completed given iron deficiency anemia [] consider sleep apnea workup as cause of pulmonary issues [] urine with GNRs following discharge. Inpatient team will f/u results and contact patient to be sure not having symptoms HCP: ___ (sister) Phone number: ___ - Code: Full, Confirmed </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ y.o. female with PMH of granulomatous polyangiitis (Wegener's) on rituximab, subglottic stenosis (s/p multiple dilation procedures by ENT, last one in ___ & R breast lymphoma s/p XRT (___) presenting with 4-day history of sore throat, fever & dyspnea on exertion. She reports that her husband has also been ill with similar symptoms starting 4 days ago. She called her PCP's office regarding these sx and was empirically started on Tamiflu 2 days ago. She has had N/V and decreased appetite since starting Tamiflu. CHEST (PORTABLE AP) showed No parenchymal opacities to suspect pneumonia. The patient was diagnosed with Flu due to unidentified influenza virus w oth resp manifest, Stridor, Dyspnea, unspecified, Stenosis of larynx. The patient was given written instructions concerning 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 ___ y.o. female with PMH of granulomatous polyangiitis (Wegener's) on rituximab, subglottic stenosis (s/p multiple dilation procedures by Dr. ___ one in ___ & R breast lymphoma s/p XRT (___) presenting with 4-day history of sore throat, fever, stridor & dyspnea on exertion ___ to flu, admitted to ___ for airway monitoring given ~6-7mm patent airway #Stridor iso subglottic stenois Hx of Granulomatosis with polyangiitis c/b subglottic stenosis (~6-7mm patent airway) w c/f airway iso likely influenza vs. alternative viral larynogpharyngitis. Patient was admitted to SICU for airway monitoring. Sats were maintained >97% through out on RA, saline nebs, saline sprays and humidified O2. Started on steroids and abx. Scoped by ENT on ___ w improving airway edema. Fiberoptic exam In the context of the patient's clinical presentation and the need to visualize the regions in close proximity, the decision was made to proceed with an endoscopic exam. Accordingly, after verbal consent, the fiberoptic scope was passed to visualize the regions of concern. The findings were: Nasal cavity: Turbinate mucosa dry, red, scattered mucus and crusting throughout extending to NP. Minimal residual adenoid tissue, no lesions or masses Oropharynx: Symmetric soft palatal elevation, no mucosal lesions, masses, or erythema, tongue base without lesions Hypopharynx: No masses or lesions in vallecula, piriform sinuses, or post-cricoid area; no erythema; no pooling of secretions Larynx: Moderate erythema without edema of bilateral arytenoids, epiglottis non-edematous or erythematous; True vocal cords symmetric with normal movement bilaterally; Normal movement of vocal processes; no mass lesions. Subglottic stenosis w/ mild inflammation, ~7mm patent airway. ___: Ordered aztreonam as allergic to PCNs ___: + flu, contact/droplet precautions. stopped abx. clear liquid diet. currently asx. will watch overnight. can go floor/home tomorrow. ___: Discharged on Prednisone taper ___ with follow up with Dr. ___ </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PA AND LAT) showed No evidence of focal consolidation or pulmonary edema. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No definite evidence of acute intracranial abnormality on noncontrast CT head. Specifically no acute large territory infarct or intracranial hemorrhage. 2. Extensive area of encephalomalacia within the right MCA distribution, consistent with chronic infarct, unchanged in distribution from prior MRI allowing for technical differences. 3. If there remains high clinical concern for infarct, MRI would be more sensitive, if there are no contraindications particularly given the degree of right MCA territory encephalomalacia. MRI AND MRA BRAIN, W/O CONTRAST T715 MR HEAD showed 1. No evidence of acute infarct. Diffusion-weighted hyperintense signal of the right frontal operculum is unchanged from examination of ___ and is felt to be artifactual secondary to hemorrhage product. 2. Unchanged appearance of right hemispheric encephalomalacia in the MCA territory. 3. Occluded right M1 MCA with decreased trickle flow to the proximal M2 an absent distal right M2 and M3 arborization. The occlusion is seen on prior MRA of ___. Diminished flow through the distal M2 and M3 segments appears more pronounced when compared to prior exam. 4. Additional findings as described above including cortical laminar necrosis of the right frontal operculum. RENAL U.S. showed No hydronephrosis or evidence of obstruction. Normal appearing kidneys bilaterally. The patient was diagnosed with Acute kidney failure, unspecified. The patient was treated with N. At the time of discharge, the patient had ___ on CKD Generalized weakness. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY/ASSESSMENT: Mr. ___ is a ___ male with a PMHX of DM, CKD, HTN, HLD, and hx of multiple CVA presenting with ___ days of unsteadiness during urination found to have ___ on CKD # Dizziness, imbalance On admission, patient reported several days of imbalance that felt similar to prior stroke. Reported that symptoms worsen iso urination. Higher risk given known BPH. On arrival, had negative orthostatics vitals in the ED. CT scan similar to prior brain imaging. He received 1.5 L of fluids on admission. He reported persistent dizziness post fluids, hence MRI/MRA ordered that did not show evidence of acute infarct. Symptoms thought to be recrudescence of old CVA symptoms in the setting ___ on CKD. Continued on DAPT, statin therapy. Throughout hospitalization, pt was observed to be ambulatory without any concerns. ___ was consulted and reviewed case, however, given observed independence, they did evaluate him further. In discussion with patient, he reported discontinuing his ___ services a couple weeks ago because he was too fatigued to open the door for nurse. An OT consult to assess for cognitive functioning was considered to see if patient may benefit from short term rehab placement, however, he reported that he would decline SAR if option were presented to him. After stressing importance of close BP and symptom monitoring to patient, he was more amenable to restarting ___ services at home, which were done. # ___ on CKD Cr 4.5 on admission, was ___ in early ___. Had worsening ___ during recent hospitalization in ___ that improved with fluids. He has continued taking his lisinopril at home. On admission, FENa 2.4% consistent with intrinsic disease, and urine P/C found to be elevated. On review, patient had previously seen renal outpatient but has not followed up in several years. His Cr improved to 3.7 off of lisinopril and with fluid administration. Renal US was done that did not show any e/o hydronephrosis. Renal was consulted and recommended remaining off of lisinopril to assess if persistent improvement in Cr. They will follow up with patient in clinic in ___. # Hx of CVA Continued on home ASA/clopidogrel, atorvastatin 80mg. Needs TTE with bubble as outpatient # HTN Continued on home propranolol. Home lisinopril held and patient was started on amlodipine ___ for additional BP management. Plan to follow up with PCP on ___ for BMP and BP check and likely restart of lisinopril # T2DM Last A1c of 5.4. Cont diabetic diet</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a pleasant ___ w/ HTN, DL, NSTEMI, L parietal meningioma, and polycythemia ___ transformed to AML s/p MUD RIC allo HSCT ___ w/ relapse, now on decitabine, who p/w fevers and muscle aches, tmax 100.4 after receiving dacogen and platelets yesterday. SHe has no localizing sx. CHEST (PA AND LAT) showed No acute intrathoracic process. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS showed Minimal mucosal thickening in the left maxillary sinus and small mucous retention cysts in the right maxillary and right sphenoid sinuses are not significantly changed going back to ___. Findings are unlikely to represent acute sinusitis. The patient was diagnosed with Other neutropenia, Fever presenting with conditions classified elsewhere, Other pancytopenia, Acute myeloblastic leukemia, not having achieved remission. At the time of discharge, the patient had PRIMARY: ---------------- Neutropenic fever Acute Myeloid Leukemia, Relapse SECONDARY: ---------------- Pancytopenia Knee pain, acute on chronic Hypertension Elevated creatinine History of cavernous sinus thrombosis History of left parietal meningioma. The patient was given written instructions concerning 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: ___ w/ HTN, DL, NSTEMI, L parietal meningioma, and polycythemia ___ transformed to AML s/p MUD RIC allo HSCT ___ w/ relapse, now on decitabine, who p/w isolated fever to 100.4 and muscle aches after receiving dacogen and platelets, w/o localizing symptoms. </s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with a past medical history of CKD, HFpEF, hypertension, pulmonary hypertension. Her last known normal was ___. A welfare check was performed subsequently as the patient had not been seen since ___ she was found down covered in urine and feces and possibly coffee-ground emesis per report. She was taken to ___, where CT showed L MCA infarct. She was then transferred here. She was nonverbal on interview and not able to give any meaningful responses. Intubation was considered in the ___ however her level of consciousness improved and this was deferred. Per ___ note, she is DNR DNI per ___ discussion with the patient's son. Radiology showed Cardiomediastinal silhouette is within normal limits. There is again seen calcifications projecting over the right mediastinum and over the left lower heart. This may represent pleural plaques or less likely calcified lymph nodes. There is no focal consolidation. There is a small left-sided pleural effusion. There are no pneumothoraces. Degenerative changes of bilateral glenohumeral joints are seen. The patient was diagnosed with Cereb infrc d/t unsp occls or stenos of left mid cereb art, Long term (current) use of anticoagulants. At the time of discharge, the patient had Left MCA infarct. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Pt is a ___ female with a past medical history of CKD, HFpEF, hypertension, and pulmonary hypertension who was found down at her home and subsequently found to have large L MCA infarct on CT at OSH. She was transferred to ___ and admitted to Neuro ICU for monitoring. Prior to admission, pt was noted to be DNR/DNI by son in ___.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ with history of GERD, breast CA, osteoporosis but no psychiatric history who presents with paranoia. Patient reports that over the last 6 months she has had a decline in her ability to care for herself. It appears to be have been precipitated by selling her home of many years. She states that she sold that home because it was becoming too much for to maintain on her own. After selling it, she realized that she was "not ready" and ever since has been staying with several friends and relatives. Additionally, she reports feeling paranoid that others are plotting against her. She was recently started on risperidone recently by Dr. ___ in ___ for her paranoia. She continued to decline and after seeing her PCP today, she was asked to present to ED for evaluation. In the ED, initial VS were: 98 67 140/75 18 99% RA. Evaluation revealed positive UA. Other labs including serum and urine tox were negative. Head CT and CXR were both negative. Psychiatry was consulted for delusions and paranoia however recommended medicine admission for work-up for altered mental status. Of note patient did not meet criteria for ___. Patient received nitrofuratoin and 1LNS while ED. VS prior to transfer were 98.1 58 124/52 17 97%RA. On arrival to the floor, she is resting and had no complaints. REVIEW OF SYSTEMS: - POSITIVE: change in mood, decrease in concentration and energy, loss of appetite and interest, "no purpose in life," increased urgency - NEGATIVE: fevers, chills, night sweats, change in wt, SI/HI, CP, palpitations, nausea, vomiting, abodminal pain, constipation, change in bowel habits, bloody stools (last ___ ___ years ago), neuro ymptoms, dysuria Radiology showed No evidence of hemorrhage or recent infarction. Radiology showed Focal peripheral right upper lobe noduular opacity appears slightly more prominent than on prior studies, possibly due to overlap of the right scapula. However, further evaluation with a chest CT may be helpful to more fully characterize this region and to exclude the possibility of a slowly growing lung adenocarcinoma at this site. Findings and recommendation were discussed by telephone with Dr. ___ at 11 a.m. on ___ at the time of discovery. The patient was diagnosed with PARANOIA, PROLONG POSTTRAUM STRESS. At the time of discharge, the patient had Primary: Anxiety disorder NOS, Depressive disorder NOS, Paranoia Secondary: Uncomplicated urinary tract infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF HOSPITAL COURSE ___ with history of GERD, breast CA, osteoporosis, with no previous psychiatric history, who presented with subacute paranoia and inability to make decisions for herself. Many of her central issues with paranoia centered around money and bills. She was evaluated by Psychiatry, Social work, and Occupational therapy. She was medically stable during her admission, and was treated for an uncomplicated UTI. She was transferred in stable condition to ___ Mental Health-___ on day 13 of her hospital course. . ACTIVE ISSUES # Paranoia/Inability to make decisions - Likely Mood disoder NOS and Anxiety Disorder NOS. Appears to be subacute process occuring over the last 4 months. Other causes of mental status changes were unremarkable. B12, TSH, RPR were within normal limits. She was found to have a mildly positive urialysis without urinary symptoms, but she was treated with a 7 day course of antibiotics given question of mental status changes. The time course is not consistent with her several month decline, and this is likely an incidental finding. No other apparent toxic-metabolic abnormalities. Psychiatry evaluated the patient, and determined low concern for delirium or psychosis due to unremarkable cognitive exam, although she may have mild cognitive decline/dementia and underlying depression. Patient will likely benefit from formal inpatient Geriatric/Psychiatric evaluation and therapy, and patient is agreeable to this option. Left message for outside psychiatrist Dr. ___ at ___. Alt ___. Increased her risperdone 0.5mg QHS. She did not require ativan for anxiety during her admission. . # Uncomplicated UTI: From positive UA but unlikely to be major contribution to subacute change in mental status/anxiety - Treated with Bactrim x 7 days (last dose on ___ AM). Of note, patient became concerned about fungal infection of tongue mucosa (she had recently perused bactrim side effect list) - her tongue mucosa appears normal, with no sign of infection/abnormalities. . CHRONIC ISSUES # Osteoporosis: Continued calcium/vitamin D at reported home doses. . # Asthma: Continued albuterol inhaler prn. . # Persistent Right upper lobe nodular opacity on CXR - Discussed possible CT-scan of her lung nodule, but patient would like to defer scanning of that until later given her current psychiatric condition. She feels that deciding about repeat scans, any subsequent procedures on the nodule (if necessary), or a potentially distressing diagnosis would be too much for her to handle right now, and prefers to follow up on this once she improves. . TRANSITIONAL ISSUES 1) Focal peripheral right upper lobe nodular opacity appears slightly more prominent than on prior studies, possibly due to overlap of the right scapula. However, further evaluation with a chest CT may be helpful to more fully characterize this region and to exclude the possibility of a slowly growing lung adenocarcinoma at this site. 2) She needs skilled OT services to address areas of money and home management. 3) She will need a follow up appointment with her PCP ___ weeks after discharge from the psychiatric facility. 4) Consider starting daily baby aspirin in this patient.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: History taken from OMR and patient's two nieces, one of which was at the bedside, the other was over the phone. CHEST (PA AND LAT) showed Severe cardiomegaly without focal consolidation concerning for pneumonia. CT HEAD W/O CONTRAST showed No evidence of acute intracranial hemorrhage. The patient was diagnosed with Altered mental status, unspecified. At the time of discharge, the patient had PRIMARY Dementia Acute Kidney Injury E.coli Urinary tract infection SECONDARY 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 ___ year old woman with afib (not on anticoagulation) who presented with sudden onset of altered mental status x1 day, likely baseline vascular dementia given stepwise decline over time. ACTIVE DIAGNOSES: #DEMENTIA, likely vascular: Patient presented to ED with AMS x1 day prior to admission. Had been seen normal the evening prior, the was found 2 hours later banging on neighbor's door, demanding to speak to her husband and daughter, both of whom are deceased. Non-contrast head CT was normal. Urinalysis negative for infection. No leukocytosis or significant metabolic abnormalities. No changes in medications. Patient had been in her usual state of health prior and based on collateral from family she was very independent and interactive, though has significant visual and auditory impairment. Of note the patient had a similar episode a few weeks ago from which she recovered. Patient's home aides states that the patient had been feeling well prior to this event. No fevers/chills. No cough, no dysuria or abdominal pain and had not taken any OTC medications, specifically, no pseudophedrine or Benadryl. Patient received Haldol in the ED and then Zyprexa on the floor. This with time improved her agitation, but she was still confused. At the time of discharge, patient was calm, AAOx1-2 and not requiring antipsychotic medication. Given lack of an obvious underlying cause, in the setting of a step-wise decline per family in a patient with known atrial fibrillation, understandably not on anticoagulation, this is suggestive of vascular dementia. Patient was seen by physical therapy and occupational therapy who recommended long-term care placement. #URINARY TRACT INFECTION: UA and UCx were obtained upon admission and were negative. However, while in house the patient had urinary retention requiring intermittent catheterization. Given her increased frequency of retention a repeat UA and UCx were sent which returned with pan-sensitive E. coli. Patient was given 1 dose of CTX on ___ and then switched to Bactrim DS on ___ upon return of sensitivities with goal to treat for 7 days (last day ___. #METABOLIC ANION GAP ACIDOSIS: On presentation AG 16, delta/delta 1.3 which is consistent with a pure metabolic anion gap acidosis, further supported by elevated lactate of 2.7. Patient had been in ED for over 24 hours, likely had not been eating much. No IVF given. This in addition to likely agitated movements is likely sufficient to cause a slightly elevated lactic acidosis. Otherwise hemodynamically stable without signs of end organ damage or infection/sepsis. This resolved with IV fluid. #ACUTE KIDNEY INJURY: sCr 1.4 at presentation which appears to be near baseline based on labs over the last ___ years, likely CKD though no formal diagnosis made in chart. sCr improved to ___ s/p 500cc NS. Elevated lactate described as above. No hyponatremia or other electrolyte abnormalities. #ATRIAL FIBRILATION: Not on anticoagulation. Rate controlled with labetalol and diltiazem prior to the admission. Continued on diltiazem, but we reduced the dose because of bradycardia. Stopped labetalol because of hypotension and bradycardia. #HYPERTENSION: The patient was hypotensive and bradycardic during her admission. Her home labetalol and HCTZ were both stopped. Diltiazem was reduced from 240mg daily to 120mg daily. On discharge her systolic blood pressure was in the 120-150 range. #HYPERLIPIDEMIA: She was on simvastatin 20mg QHS at home. This was stopped because it interacts with diltiazem and because her life expectancy does not warrant further treatment with a statin. TRANSITIONAL ISSUES []Monitor urinary output and assess need for intermittent straight catheterization []discuss with family about feasibility of patient returning home []Bactrim last day ___ # CODE: DNR/DNI # CONTACT: ___ (Niece and Primary HCP) Cell: ___ Home: ___ ___ (Niece and other HCP) ___</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o male with PMH of cirrhosis due to primary biliary cholangitis and autoimmune hepatitis overlap syndrome, known portal hypertension with gastric varices, and recent travel to ___ presenting for ongoing BRBPR (~2 weeks). He initially presented to the ED on ___ for 10 days of watery diarrhea with diffuse abdominal pain, which developed into BRBPR. Hepatology was consulted with RUQ U/S demonstrating cirrhosis, cholelithiasis without additional findings. EGD demonstrated no varices, active bleeding or stigmata of old bleeding. Colonoscopy demonstrated large non-bleeding internal hemorrhoids and enlarged rectal bleeding without visualized active bleeding. CTA demonstrated a prominent rectal artery and possible underlying AVM in the same location. He did not appear to be in a decompensated state from his cirrhosis without confusion, ascites, lab abnormalities and he remained HDS. He received 2 u PRBCs for briskness of bleed with discharge H/H ___ on ___ and was directed to return to the ED with any further bleeding. Patient states that today, his bowel movements had actually become formed and he had no further diarrhea. However, each bowel movement (x3) was associated with bright red blood that filled the toilet. He also adds that over the last 3 days he has noticed dyspnea and palpitations on exertion, which resolve within a few minutes of rest. Radiology showed Successful embolization of the superior rectal artery branch supplying rectal AVM with EtOH and coils. RECOMMENDATION(S): Follow patient clinically for evidence of bleed. If persistent, an embolization from the venous side of the AVM may be performed. The patient was diagnosed with Gastrointestinal hemorrhage, unspecified. The patient was treated with Embolization of the superior rectal artery branch supplying rectal AVM with EtOH and coils (___) Mesenteric Arteriogram (___) Flexible Sigmoidoscopy (___). At the time of discharge, the patient had Primary diagnosis ==================== Acute blood loss anemia Rectal varices bleeding Rectal AVM Secondary diagnosis =============== Cirrhosis Primary biliary cholangitis Gastric varices Rectal pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY: ========= ___ old male with history of cirrhosis secondary to PBC with known gastric varices and autoimmune hepatitis who presented with recurrent BRBPR and downtrending hemoglobin. He was found to have a rectal AVM on CTA and underwent coil embolization of his superior rectal artery on ___, with expected small volume bloody stools following the procedure. He underwent flexible sigmoidoscopy on ___ and was found to have multiple ulcers, 1 enlarged and clotted, for which he will follow up in liver clinic in 1 month. His course was notable for asymptomatic hypotension which resolved, and sensation of urinary retention after starting tramadol. ============= ACTIVE ISSUES ============= # BRBPR # Rectal varices # Acute blood loss anemia Patient initially presented to the ED on ___ with BRBPR. Initial EGD showed no esophageal varices. ___ was consulted in ED who felt bleed likely secondary to small AVM seen on CTA. He was given 2u PRBCs and discharged home due to stability. Patient then presented back with recurrent bleed, downtrending hemoglobin. He remained hemodynamically stable throughout his course and did not require transfusion. Interventional radiology performed mesenteric angiography on ___ which showed "Superior rectal arteriogram demonstrates an early filling vein (prior to parachymal filling) suggesting AV malformation." He under went successful embolization of the superior rectal artery branch supplying rectal AVM with EtOH and coils. He had expected small volume bright red blood in his formed stools following the procedure, and received flexible sigmoidoscopy on ___ which showed multiple small ulcers and a large, cratered ulcer with overylying clot, for which he will ___ in liver clinic in 1 month. He was started on ceftriaxone for prophylaxis due to GIB in the setting of cirrhosis, but this was discontinued before discharge as he had minimal blood in his stools. He was observed for stability and discharged home with 1 week PCP ___ and CBC. [] Repeat CBC on ___ #Hypotension Patient had soft blood pressures ranging from 90-110 systolic, below his baseline 130-160 systolic starting ___. He was switched form oxycodone to tramadol and nadolol was discontinued. 50g albumin bolus was given twice on ___. Hb remained stable, he denied hypotensive sxs, and no signs of sepsis/infection throughout his course. BPs normalized to baseline values before discharge and he was restarted on half his normal dose of nadolol. [] Increase nadolol to original dose of 20 mg as tolerated #Urinary retention Patient reported new weak stream and retention on ___ after he had started tramadol. He had PVR showing residual volume of 0 on ___. He had no dysuria or frequency. UA on ___ showed no evidence of UTI but did show trace urine protein. [] Follow up urine culture [] Repeat UA for proteinuria CHRONIC ISSUES ============== #Gastric varices EDG in ___ showed non-bleeding type II gastric varices in the cardia. EGD in ED on ___ showed no esophageal varices. Continued home omeprazole and nadolol was held then resumed at half home dose as above. #Cirrhosis #Primary biliary cholangitis Patient has cirrhosis secondary to PBC and autoimmune hepatitis. His Meld-Na was calculated to be 7, and he was ___ Class A. RUQUS on ___ showed no evidence of ascites and he was without evidence of hepatic encephalopathy or decompensated cirrhosis on exam and labs throughout his course. Continued home omeprazole and ursodiol. nadolol was held then resumed at half home dose as above.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a very pleasant ___ nurse ___/ CLL/SLL currently on treatment with ibrutinib presents with dizziness and oliguria. Radiology showed New left basilar opacity silhouetting the hemidiaphragm could be due to atelectasis or infection noting that effusion is also possible. CT chest showed 1. No evidence of pulmonary embolism or aortic abnormality.The main pulmonary artery and the right pulmonary artery are top normal and may suggest underlying pulmonary hypertension. 2. Stable appearance of chronic bilateral bronchiectasis and bronchial wall thickening since ___. 3. Significant improvement in number and size of mediastinal and hilar lymph nodes since ___. 4. Stable hypodense hepatic lesion in segment 2. CHEST (PA AND LAT) showed Left pleural effusion has increased. The patient was diagnosed with Unspecified atrial fibrillation. The patient was treated with ___ TEE with cardioversion. At the time of discharge, the patient had New onset atrial fibrillation with RVR Hypo-osmolar Hyponatremia Essential Hypertension CLL with thrombocytopenia Hypothyroidism. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr ___ is a ___ nurse ___/ CLL/SLL, hypogammaglobulinemia, hypothyroidismcurrently on treatment with ibrutinib presents with dizziness and oliguria on ___ found to have hyponatremia and new onset afib with RVR. CTPE and echocardiogram was pursued without evidence of acute heart failure or pulmonary embolism as cause of afib. Patient had an elevated JVD and increased crackles that improved but not resolved on discharge. # Atrial fibrillation w/ RVR - new onset. No chest pain. trop neg x2, EKG neg. TSH 9 - normal T4 known hypothyroidism. CTA neg for PE. TTE without right heart strain or heart failure. Uncontrolled rate with po dilt and iv push on ___ transitioned to metop 12.5 QID titrated to 25 QID ___ with still HR 110s-150s. sBP now ___. Cardiology consult recommended diuresis and then uptitration to 37.5 mg po q6hr on ___. However, this did not control her rapid ventricular rate. She underwent a Successful DCCV ___ now in NSR. - Appreciate Cardiology recommendations, they are arranging a follow-up appointment with a cardiology specialist and will call the patient for information - Toprol XL 25 qdaily -Coumadin x 1 month post ___ for coverage. INR 2.5 on discharge. DCCV occurred ___. 1 month ___. -6% possibility of ibrutinib causing afib, oncology requested to hold until f/u. Will need to monitor CBC closely to ensure that Coumadin benefit of stroke prevention outweighs risk of bleeding. # volume overload. Ms. ___ was consistently net negative during this admission. She was placed on a fluid restriction and continued to obtain diuresis. TTE did not show signs of heart failure so likely due to her medication ibrutinib. - d/c on Lasix 40 mg x 7 days until re-evaluation with PCP. - If still elevated JVD on f/u appointment will continue Lasix 40. If not, will change to Lasix 20 mg qdaily. # Hyponatremia- presented hypervolemic with Na 121 and urine studies showing Na 20 and Osm 112 making hypervolemic hyponatremia likely. This improved with diuresis but then worsened when gave back fluids attempting to help with HR. Still mildly volume overloaded on exam so Lasix given on discharge. Na 125 on discharge but stable over several days. Repeat studies revealed a Na 40 and Osm 265 making a component of SIADH. Fluid restriction was started at 2L. - Continue fluid restriction 2L - Continue Lasix 40 mg po qdaily until f/u with oncology on ___ and PCP ___ 7 days. If JVD has improved could decreased down to 20 mg qdaily # Bronchiectasis Minimal improvement of symptoms, stable cough, afebrile. WBC likely due to hemoconcentration. Levaquin dc'd ___ (14 day course). - cont inhalers, IS # CLL/SLL WBC/plt dropping since held ibrutinib on admission. - hold ibrutinib due to afib, expect labs to drop. Plan to hold until f/u with oncologist # Hypogammaglobulinemia - t/b BMT team re next infusion, will be as outpatient # Pleural effusion, Left She was found to have this on POCUS in ED, left sided. Chronic per patient with no oxygen requirements. CTA no focal infiltrate. # Mouth sores Will start magic mouthwash, encourage oral hygiene # Hypothyroidism - cont levothyroxine 75 mcg. Pending Free T4 1.6. Will keep levothyroxine at 75 for acute illness and repeat in 6 weeks. # Essential HTN- controlled - hold amlodipine as above - hold valsartan, Toprol 25 XL started FEN: Low salt diet, 2L fluid restriction CODE STATUS: Full code HCP: Health Care Proxy: ___ PCP: ___, MD CONSULTS: ___ signed off, Cardiology ___ DISPO: Today # Active meds: reviewed >3o minutes was spent on this discharge and planning.</s>

<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx ___ disease, prostate CA s/p prostatectomy, SBO presenting with LLQ pain and abdominal distention. Patient reports over last few weeks, has been having intermittent spasms in LUQ. Mild mid abdominal pain, non-radiating, worse with eating. No alleviating factors. Associated distention and decreased flatus/BM, with thinner BMs than normal. Patient reports last BM this morning. Pain feels like previous bowel obstruction. Notes he has been vomiting, poor PO intake, noted collared greens from Christmas dinner in recent vomuit. Denies f/c, chest pain, shortness of breath, diarrhea, melena, hematochezia, urinary symptoms. CT abdomen and pelvis with contrast showed 1. High-grade small bowel obstruction with dilatation of the small bowel measuring up to 76 mm. Etiology of obstruction is somewhat unclear. Equivocal mesenteric swirling ___ sign) involving decompressed small bowel loops just distal to the maximally distended small bowel can suggest volvulus as the obstructing point though this does not fit the clinical picture. However, wall thickening and hyperemia of the distal involved small bowel suggests Crohn's involvement as the far more likely etiology. However, this finding along with trace ascites is can be seen with early ischemia. Close clinical monitoring and emergent surgical consultation is advised. 2. Anasarca. 3. Centrilobular emphysema. 4. Bilateral hip configuration suggestive of mixed pincer/CAM type femoroacetabular impingement. Associated mild to moderate bilateral degenerative hip joint change. NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the telephone on ___ at 3:11 AM, 2 minutes after discovery of the findings. Examination was reviewed in person with Dr. ___ of ACS in person on ___ at 03:25. Per report, patient's clinical status does not support a volvulus and high-grade small bowel obstruction from Crohn's flare is more likely. CHEST PA AND LATERAL showed New left lower lobe opacities concerning for pneumonia. NOTIFICATION: The above findings were communicated via telephone by Dr. ___ to Dr. ___ at 11:00 on there is ___, 5 min after discovery. CHEST PORT. LINE PLACEMENT showed After passing into the upper SVC the new PIC line is angulated and may extend into either the azygos system or left brachiocephalic vein. Withdrawing the line 3 cm would reposition it in the upper SVC. No pneumothorax or mediastinal widening. Small left pleural effusion is unrelated. Heart size normal. Lungs clear. CHEST PORT. LINE PLACEMENT showed Right PIC line ends in the upper SVC. Lungs hyperinflated but clear of heterogeneous opacification at the base of the left lung is new since ___. This could be atelectasis, reflected in mild relative elevation of the left hemidiaphragm, or it could be aspiration with or without early pneumonia. Careful followup advised. Blunting of the left lateral pleural sulcus is chronic and more likely thickening than small pleural effusion. Right pleural surfaces are normal. Heart is normal size. CHEST (PRE-OP PA AND LAT) showed Right PICC line tip is at the level of superior SVC. Heart size and mediastinum are stable. Lungs are essentially clear with substantial interval improvement of left basal consolidation. Minimal amount of left pleural fluid is noted, unchanged since the prior study. The patient was diagnosed with INTESTINAL OBSTRUCT NOS. The patient was treated with ___: Small-bowel resection and ileocecectomy. At the time of discharge, the patient had Crohn disease with obstruction.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ hx ___ disease, prostate CA s/p prostatectomy, SBO presenting with LLQ pain and abdominal distention, SBO on imaging. # Small bowel ___: Likely due to known stricturing ___. Less likely volvulus given pt not in significant pain. No e/o abdominal sepsis. Rapid recurrence and stricturing nature of disease points to the need for operative management. Malnourished. He was started on IV steroids, mIVF with dextrose, thiamine, folate, MVI. ___ held per GI. Attempts at diet advancement failed after NGT removed and the pt was transferred to the colorectal surgical service for a Small-bowel resection and ileocecectomy which he tolerated well. At the time of discharge he was tolerating PO, was passing flatus and having bowel movements. He will follow up in Colorectal surgery clinic and will continue to follow with his PCP and GI physicians. # Osteoporosis: Cont vit D, Ca held as it interfered with Phos repletion. # Nutrition: Pt was started on TPN while in the hospital, which he tolerated well. Post op he was began on a clear diet, then transitioned to a regular diet, which he tolerated well. His PICC was d/ced prior to discharge # Pneumonia: He was treated for Hospital acquired pneumonia with vancomycin and Levofloxicin, which he tolerated well. </s>