text
stringlengths 519
60.4k
|
|---|
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ w/ hx of HTN and NIDDM who is
presenting after MVC. She was on a bus which crashed into taxi
round noon yesterday ___. She went to an OSH were CT head,
C-spine, and torso and R wrist XR were obtained, which showed C6
infart facet fx, C7 sup art facet fx, T4 compression fx, and
distal R radius fx. Here in the ED, the R radial fx was splinted
by ortho. On review of imaging w/ radiology here, additional
findings included: the T4 fx was noted to have both an endplate
fx and compression fx (compression component likely chronic),
widened SI joints (likely chronic), mild canal narrowing at
level of lumbar spine (likely chronic), mild cervical spinal
canal narrowing, thyroid nodule, and distal R ulnar fx. She
primarily complains of back pain. C-SPINE NON-TRAUMA ___ VIEWS showed In comparison with the operative study of ___, there is little change in
the anterior fusions spanning C6-C7 with interbody spur spacer in place. No
evidence of hardware-related complication.
Substantial prevertebral soft tissue swelling is seen. Radiology showed No acute fractures or dislocations are seen. Joint spaces are preserved
without significant degenerative changes. Ankle mortise is preserved. There
is normal osseous mineralization.There is a small inferior calcaneal spur. Radiology showed Left shoulder : No acute fractures or dislocations are seen. There are
degenerative changes of the AC and of the glenohumeral joints. There is
normal osseous mineralization.Visualized left lung apex is clear.
Right shoulder : No acute fractures or dislocations are seen. There are
degenerative changes of the AC joint. There is a subacromial spur. Mild
degenerative changes of the inferomedial glenohumeral joint are present.
There is normal osseous mineralization.Visualized right lung apex is grossly
clear. Hardware within the lower cervical spine is seen. CT lower extremity without contrast showed 1. Subtle lucency in the most medial aspect of the medial tibial plateau,
which may represent nondisplaced fracture, though unusual given the lack of
lipohemarthrosis or joint effusion. If clinically indicated, MRI of the knee
would be helpful to clarify.
2. Mild degenerative changes of the knee joint as described above. Radiology showed No radiographic evidence of acute cardiopulmonary disease. MRI CERVICAL AND THORACIC PT21 MR SPINE showed 1. 2 mm anterolisthesis of C6-C7. Apparent discontinuity of the ALL at this
level is suspicious for ligamentous disruption, although the degree of
prevertebral edema is slightly less than would be expected.
2. Acute fractures involving the right C5-6 facet and right C6-C7 transverse
process/articular pillar were better seen on the prior CT. Resulting
extensive soft tissue edema extends inferiorly to involve right paravertebral
soft tissues of upper thoracic spine.
3. Acute superior endplate compression fractures at T3 and T4 vertebral
bodies, with less than 25% of loss of height.
4. Edema pattern involving multiple interspinous ligament levels in the
cervical spine likely due to a combination of ligamentous injury and reactive
changes from the adjacent fractures described above.
5. Limited visualization of the V1 and proximal V2 segments of the right
vertebral artery on this non-vascular study. Recommend dedicated neck CTA to
exclude extraforaminal vertebral artery injury in the setting of significant
adjacent soft tissue edema.
6. No definite evidence of cord injury, within the limitations of this motion
degraded study.
7. Right greater than left lung base dependent consolidations, may represent
atelectasis and/or aspiration.
RECOMMENDATION(S): Neck CTA.
NOTIFICATION: Updated findings and recommendations were discussed with ___
___, M.D. by ___, M.D. on the telephone on ___ at 11:06 am, 10
minutes after discovery of the findings. WRIST(3 + VIEWS) RIGHT showed Cast material overlying the right forearm, wrist, and hand obscures fine
detail. Again seen is transverse fracture through the distal radius with
similar mild radial displacement and dorsal angulation. Mildly displaced ulnar
styloid fracture appears similar. Carpal bones are not well evaluated given
large field-of-view and overlying cast material. KNEE (AP, LAT AND OBLIQUE) BILATERAL showed 1. No fracture or dislocation identified of the bilateral knees.
2. Bilateral trace joint fluid. Radiology showed Intraoperative images were obtained during C6-C7 anterior fusion. Please refer
to the operative note for details of the procedure. CTA NECK WANDW/OC AND RECONS Q25 CT NECK showed 1. No evidence of aneurysm, dissection, occlusion or stenosis.
2. Fractures of the right C6 inferior articular facet and right C7 superior
articular facet are better evaluated on the comparison CT cervical spine
study.
3. A 1.6 cm right thyroid nodule for which dedicated follow-up thyroid
ultrasound is recommended if no outside recent studies are available.
4. Status post right anterior neck drain placement with adjacent subcutaneous
air traversing superiorly along the fascial planes of the right neck.
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. WRIST(3 + VIEWS) RIGHT was done. The patient was diagnosed with Unsp disp fx of sixth cervical vertebra, init for clos fx, Unsp disp fx of seventh cervical vertebra, init for clos fx, Oth fractures of lower end of right radius, init for clos fx, Disp fx of right ulna styloid process, init for clos fx, Car passenger injured in collision w car in traf, init. The patient was treated with ___:
1. Open treatment of C6-7 fracture dislocation.
2. Anterior cervical decompression C6-7 via discectomy at
C6-7.
3. Anterior cervical arthrodesis at C6-7 using structural
allograft.
4. Anterior cervical plate instrumentation C6-7.
5. Application and removal of cranial tongs.
6. Neuromonitoring.
___
OPEN REDUCTION INTERNAL FIXATION RIGHT DISTAL RADIAL 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>Ms. ___ is a ___ yo F admitted to the Acute Care Trauma Surgery
Service on ___ after sustaining a fall while riding the bus
sustaining a C6 and C7 fracture with right wrist fracture. She
was transferred for orthopedic and spine surgery evaluation. The
patient was hemodynamically stable and neurologically intact on
presentation. She underwent further imaging of the shoulder,
knee, and MRI of the neck which showed no new injuries.
On HD1 orthopedic spine was consulted and the patient was taken
to the operating room for open treatment of C6-7 fracture,
anterior cervical decompression, and anterior cervical
arthrodesis using structural allograft. Please see operative
report for details. She was extuabated and taken to the PACU in
stable condition then transferred to the floor once recovered
from anesthesia. CTA of the neck was obtained to assess for
vascular injury of which there was none. She was seen and
evaluated by hand surgery who splinted the wrist and made plans
for inpatient operative repair.
On HD3 foley catheter was discontinued and she voided without
issues. Repeat cervical spine xrays were obtained and showed no
evidence of hardware related complications.
On HD5 she underwent CT scan of the right lower extremity due to
increased knee pain. Orthopedic surgery evaluated the patient,
reviewed the images, and determined the patient to have a medial
collateral ligament injury.
On HD6 the patient lost IV access and a midline was placed
without issues. The patient's hemoglobin/hematocrit remained
stable and therefore subcutaneous heparin for DVT prophylaxis
was started.
On HD7 the patent was taken to the operating room with hand
surgery for Open reduction and internal fixation of her right
distal radius fracture. She tolerated the operation well and
without complications.
The patient was seen and evaluated by physical and occupational
therapy who recommended discharge to rehab to continue her
recovery.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ year-old female with hx of squamous cell
esophageal cancer and jackhammer esophagus s/p ___ presenting with pain secondary to food impaction. CHEST (PA AND LAT) showed No evidence of pneumomediastinum or radiopaque foreign body. Air-fluid level
projecting over the lower neo esophagus. The patient was diagnosed with Food in esophagus causing other injury, initial encounter, Exposure to other specified factors, initial encounter. The patient was treated with EGD with dilation on ___
EGD on ___. At the time of discharge, the patient had Primary:
Food impaction
Esophageal stricture
Secondary:
Esophageal cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year-old female with hx of squamous cell
esophageal cancer and jackhammer esophagus s/p ___
___ who presented with pain secondary to food
impaction. On ___ she underwent emergent EGD with removal of
food impaction. Benign appearing stricture was visualized and
dilation was performed. She then had persistent symptoms of
dysphagia and repeat EGD was performed on ___ which did not
reveal any overt residual obstruction (benign stricture, now
11mm, was still present along with some fluid). She was started
on a clear liquid diet which she will continue for one week. She
will then advance to soft solids after one week if tolerating
liquids. She will follow up with GI clinic in two weeks for
repeat esophageal dilation. She was continued on home PPI BID
# Leukocytosis: mild leukocytosis to 10.7 on admission, likely
stress response. UA was notable for pyuria but culture returned
consistent with contamination
# Chronic pain after surgery: continued home Oxycodone ___
Q4h in liquid form
# Hypothyroidism: continued home synthroid</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ man whose PMH includes DM II, CKD stage III, fistulizing
Crohn's disease c/b multiple SBOs ___ years ago, s/p
proctocolectomy with end ileostomy, and short gut syndrome,
TPN-dependent. Crohn's disease had been relatively quiescent
until he started smoking again a few years ago. Admitted in
___ with Crohn's exacerbation, at which time biologic agents
such as anti-TNF were being considered. However, a highly
atypical prostate nodule was seen on MR, and biopsy was
recommended prior to proceeding with biologic therapy, given
risk of malignancy. He underwent prostate biopsy, which showed
HGPIN. Urology recommended prostatectomy, and he underwent
radical retropubic prostatectomy with pelvic lymphadenectomy on
___. Radiology showed 1. Postsurgical changes in the pelvis from recent prostatectomy. The absence
of contrast limits the evaluation for abscess, however, there is no new
discrete fluid collection.
2. Decrease in size of splenomegaly. Radiology showed Urine leak from the posterior base of the bladder communicates
with a 5.8 x 1.7 cm collection via a 1 cm track.
Findings were discussed with Dr. ___ by Dr. ___ by phone at 13:55 on
___, 2 minutes after discovery. Findings were subsequently discussed
with Dr. ___ by phone at ___. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, HX-PROSTATIC MALIGNANCY. At the time of discharge, the patient had Primary Diagnosis
- Urethral leak secondary to prostate surgery
- Acute Kidney Injury
- Proteus and Kidney Bacterial Infection
- Strep Viridans Bacteremia (Contaminant). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with long standing Crohns on TPN, recent prostatectomy,
presents with malasie and weakness and found to have klebsiella
and proteus UTI in the setting of a post-surgical urinary leak. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with hx of IDDM, htn, GERD, asthma, breast ca s/p
lumpectomy, chemo and XRT presenting with weakness, fever, and
cough. Pt reports that she and her husband had been taking care
of their ___ month old granddaughter, who was diagnosed with
influenza on ___. Her husband's symptoms began with cough on
___ he is now hospitalized with influenza at this
institution. Pt describes onset of coughing on ___ at about 5
pm, then awoke diaphoretic, at 7:15 am on ___. Cough is dry.
Temp at home was 100.8. She took Tylenol without improvement in
her symptoms. She endorses global weakness and fatigue. She
denies headaches, chest pain, SOB. She had slight nausea earlier
in the day which has since resolved. Chest: Frontal and lateral views showed No acute cardiopulmonary abnormalities. Low lung volumes with elevation of
the diaphragms bilaterally. The patient was diagnosed with Flu due to ident novel influenza A virus w oth resp manifest. At the time of discharge, the patient had Influenza B with respiratory symptoms. The patient was given written instructions concerning 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 IDDM, htn, GERD, asthma, breast ca s/p
lumpectomy, chemo and XRT presenting with weakness, fever, and
cough, presumed to have influenza B based on contacts and
influenza-like illness.
# Influenza B: Negative influenza by RT-PCR in ED, but given
husband positive for influenza B and granddaughter also positive
for influenza this week, reasonable to treat presumptively, as
per CDC guidelines.
- Tamiflu x5 days - received 100 mg in ED, per pharmacy renally
adjusted dose is 30 mg BID
# Acute on CKD stage III: Followed by nephrology at ___.
Acute component likely prerenal in setting of influenza.
Improved with IV fluids.
- Encouraged PO hydration
- Per renal notes, ACEI d/ced for cough, ___ is being considered
as outpatient
# Elevated troponin: TnT modestly elevated to 0.06, 0.05 on
repeat. Likely related to renal failure in combination with
demand in setting of infection. No known cardiac disease, but
multiple risk factors for underlying coronary atherosclerotic
disease. EKG without ischemic changes. Patient is without
chest pain. Continued beta blocker, baby aspirin.
# Diabetes mellitus, type II, insulin-dependent, with neuropathy
and nephropathy: Last A1c 10.2, poorly controlled, with
associated CKD. Continue home Lantus and prandial Humalog
coverage.
# Hypertension: Continue home amlodipine, spironolactone,
atenolol. Torsemide held in the setting of dehydration / ___,
but restarted upon discharge.
# Asthma: Continue home montelukast, albuterol
# HLD: Continue home statin
# Hx of breast ca: Continue home anastrozole
# GERD: Continue home PPI
30 minutes on discharge activities, home, no services</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: DH is a ___ yr. old M w/ HTN, HLD, and known CAD (s/p STEMI ___,
w multiple PCIs including LAD (Cipher ___, mid RCA (stented x2
___, LAD (DES ___, D1 (___ ___, who presented to ED today
with chest pain and was found to have new EKG changes (diffuse
ST elevations, PR depressions), so was admitted to medicine to
rule out ACS and pericarditis.
Pt stated that CP started at 5am day of admission, awoke him
from sleep, remained persistent throughout the day, ___ at its
best, ___ at its worst, was located in epigastric/sternal
regions, radiated to L shoulder, and had a burning quality with
occasional sharp quality. He stated that the pain was worse
while lying supine, better leaning forward, and worse with
inspiration. He noted that the pain relented for a period of 3
hours, for unknown reasons, as he did not use his NTG. He
reported that the pain was a/w mild SOB, anxiety, and nausea,
but not diaphoresis, vomiting, lightheadedness, dizziness, or
syncope. He denied any recent chest injury, car accident, no
recent sick contacts, URI, fever, headaches, visual changes, ___
edema, diarrhea, orthopnea. ET is unchanged ~1mile. Radiology showed No evidence of acute cardiopulmonary process. The patient was diagnosed with INTERMED CORONARY SYND, CAD UNSPEC VESSEL, NATIVE OR GRAFT. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>BRIEF HOSPITAL COURSE:
=========================
DH is a ___ yr. old M w/ HTN, HLD, and known CAD (s/p STEMI ___,
w multiple PCIs including LAD (Cipher ___, mid RCA (stented x2
___, LAD (DES ___, D1 (___ ___, who presented to ED with
chest pain and was found to have new EKG changes (diffuse ST
elevations unchanged from prior, but new PR depressions), and
was found to have acute pericarditis. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ anorexia and alcohol dependence who is being admitted
with new renal failure and severe hypercalcemia concerning for
malignancy.
Pt has been feeling unwell for the past 2 weeks with increase
malaise, fatigue, anorexia, increased thirst, nausea and a 5
pound weight loss. She has also noted bilateral lower extremity
edema for the past couple of months. She was recently referred
to orthopedic surgery for spinal stenosis and had x-rays which
incidentally noted a right 11th rib sclerotic lesion concerning
for malignancy. She was seen by her PCP, who ordered a CT scan
for further evaluation of possibly malignancy. Laboratory
studies drawn prior to the CT scan showed new renal failure so
she was referred to ___ ED for further management (CT scan was
never performed).
In the ED, initial vitals were: 97 100/69 65 18 100RA
Exam notable for profoundly cachectic, 2+ ___ edema to shins, no
LAD, no abdominal masses
Labs notable anemia (Hgb 11.1, b/l ___, thrombocytosis (plt
503), new renal failure (BUN/Cr 43/2.1, b/l 1), hypercalcemia
(Ca ___, Mg 3.3, UA 8.4. Dirty UA.
Imaging showed:
- Renal ultrasound: normal
- CXR: notable for 11th rib lesion
Received nothing
On arrival to the floor, VS: 97.8 113/70 62 18 100RA
Pt currently reports overall malaise, poor appetite, and mild
nausea. She reports 5 lb weight loss but denies fevers or night
sweats. She reports chronic bony pains but no new pains over the
past few months. Denies headache. Mild blurred vision. No chest
pain or palpitations. No shortness of breath. No abdominal pain,
diarrhea or constipation. No urinary symptoms. Has chronic
neuropathic pain in lower extremities that has not changed
recently. Reports lower extremity edema bilaterally for the past
few months.
Review of systems:
(+) Per HPI, otherwise negative RENAL U.S. showed Normal renal ultrasound. No hydronephrosis. SKELETAL SURVEY (INCLUD LONG BONES) showed 1. Nonspecific 1.5 cm area of sclerosis within the right lateral eleventh
rib. This is of unclear etiology. No definite additional sclerotic lesions
are seen. If there is high clinical concern, bone scan would be helpful to
establish the activity within the lesion and to search for additional lesions.
2. Scoliosis and compression deformities of T12 and L4.
3. Degenerative changes of the lumbar spine, bilateral acromioclavicular
joints, and bilateral hip joints.
4. Hardware within the proximal femurs related to prior femoral neck
fractures.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 9:35 AM, 5 minutes after discovery
of the findings. Chest radiograph showed 1. No acute cardiopulmonary process. Specifically, no large lung mass.
2. Previously noted eleventh rib lesion is likely at the lateral aspect of
the right rib without evidence of expansion. No definite additional lesions
identified. The patient was diagnosed with Acute kidney failure, unspecified. At the time of discharge, the patient had Hypercalcemia
___
Macrocytic 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>___ year old female with history of alcohol dependence and spinal
stenosis who presents with acute
kidney injury and hypercalcemia with concern for underlying
malignancy.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ Hx of CAD w/ BMS to LAD in ___, off of Plavix ___ GI
bleeds, HTN, GERD, OSA not requiring CPAP, hypothyroidism not
currently on Tx, OA, depression, and Hx of diverticulosis
complicated by lower GI bleeding presented to ED with 4 bloody
stools over the past day. She reports that the bleeding started
around 6 pm this evening and is similar to episodes of
diverticular bleeding she has had in the past. She tried to get
in touch with her outpatient GI physician for guidance but was
unable to, so she came to the ED. Her most recent colonoscopy
was in ___, and showed multiple diverticula throughout the
whole colon. She endorses having had similar hospitalizations at
least 7 times in the past few years. She has required blood
transfusions in the past (none since ___ in our system) but
has never required endoscopic or ___ intervention. She denies
fever, chills, abdominal pain, N/V/D, constipation, CP/SOB, or
fatigue. She endorses adequate PO intake over the last several
days and otherwise feels in her usual state of health. She is on
a baby aspirin but no other blood thinners.
In the ED, initial vitals were: 96.5 79 173/77 18 98% RA. Rectal
exam was notable for gross blood. Labs were significant for WBC
12.4 w/ normal diff, Hgb 13.0 (baseline Hgb ___, Lactate 2.1,
BUN/Cr ___, lytes WNL. GI was consulted and recommended
admission for further monitoring. The patient was given
Pantoprazole 40 mg IV and was admitted. Vitals prior to transfer
were: 98 76 120/53 20 97% RA.
Upon arrival to the floor, the patient is comfortable and has no
complaints. CTA ABD AND PELVIS showed 1. Extravasation of contrast in a segment of descending colon consistent with
an acute GI bleed.
2. In the same segment of the proximal descending colon, there is
circumferential wall thickening and mild mesenteric fat stranding which can
represent focal colitis or diverticulitis. Follow-up with colonoscopy is
recommended to exclude neoplasm, however.
3. Extensive colonic diverticulosis.
4. 2 subcentimeter enhancing foci in the right hepatic lobe may represent
hemangioma, perfusion heterogeneity and or FNH, and additional probable
biliary hamartoma or cyst is noted.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 13:13 into the Department of Radiology critical
communications system for direct communication to the referring provider. The patient was diagnosed with Hemorrhage of anus and rectum. At the time of discharge, the patient had Primary Diagnoses:
================
- diverticular bleed
- elevated lactate
- acute anemia
Secondary Diagnoses:
================
- coronary artery disease, s/p bare metal stent
- hypertension
- gastroesophageal reflux 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>This is an ___ woman with a history of CAD w/ BMS, HTN, GERD,
and diverticulosis complicated by lower GI bleeding who
presented to the ED with four bloody stools over a few hours,
found to have bleed in mid-descending colon.
# Diverticular bleed, complicated by anemia and lactic acidosis:
The patient was admitted with a GI bleed, similar to those she
has experienced in the past secondary to diverticulosis. In the
ED, initial vitals were: 96.5 79 173/77 18 98% RA. Rectal exam
was notable for gross blood. Labs were significant for Hgb 13.0
(baseline Hgb ___ and Lactate 2.1. GI was consulted and
recommended admission for further monitoring. The patient was
given Pantoprazole 40 mg IV and was admitted. On the floor
around midnight, she had another large bloody bowel movement,
around 200 cc, with clots. At 2 am she triggered for an episode
of syncope ___ sinus pause) that occurred while having a bowel
movement preceded by nausea and nonbloody emesis. She was given
a 1L LR bolus, and her hemoglobin was found to be 11.7 from 13,
with a lactate increase from 2.1 to 3.0. A CTA was done, which
showed extravasation in mid-descending colon, brisk enough for
embolization. ___ discussed embolization with patient who
declined the procedure. The patient had no further episodes of
GI bleeding throughout the day. A repeat lactate improved to
2.4, and her hemoglobin remained stable at 10.5. She was
discharged the following morning with plan for followup with her
primary care doctor and gastroenterologist. Discharge hemoglobin
9.9.
# Leukocytosis:
On admission, the patient was noted to have leukocytosis to
12.4, which increased to 14.9. Infectious review of systems was
entirely negative. This was therefore thought to most likely
represent stress demargination in the setting of GI bleeding.
Her white count trended down and was normal on discharge.
# CAD: s/p BMS, most recently in ___. On Ticagrelor
previously, switched to clopidogrel due to GIB, but clopidogrel
was also ultimately discontinued due to recurrent GI bleeding.
On admission, the patient was on aspirin 81 mg only. The aspirin
was held in the setting of bleeding, to be restarted at the
discretion of her outpatient providers.
# HTN: Patient was initially hypertensive with SBP of > 170 on
admission. However, it had improved to the 110s/50s on
discharge.
# GERD: As above, the patient was initially started on IV
pantoprazole given concern for upper GI bleed. However, given
the high probability that this was diverticular, as seen on CTA,
this was transitioned to PO pantoprazole, and then stopped prior
to discharge.
============================
TRANSITIONAL ISSUES
============================
- Discharge h/h: 9.9/30.5
- The patient's h/h should be checked at her next appointment.
- The patient's aspirin was stopped on admission due to her GI
bleeding. It can be restarted at discretion of her outpatient GI
and cardiology providers.
- If the patient has additional diverticular bleeding, she has
agreed to undergo ___ embolization of the causative artery.
- Patient reports that she would like to have regular ear
cleanings at PCP office for ear wax buildup. She was discharged
on debrox ear drops. She also is requesting an outpatient
cholesterol check for routine screening.
-Of note, she was set up with Elder Services per her request to
assist with bathing.
# CODE STATUS: Full code
# CONTACT: ___ (daughter) ___
___
Billing: >30 minutes spent coordinating discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a ___ year old man with a history of atrial
fibrillation on warfarin, vascular dementia, history of
aspiration pneumonia, who presented to the ___ ED from his
living facility (___) with fever and hypoxia. Patient
reportedly had a witnessed aspiration event earlier in the day
associated with coughing. EMS was called. Patient was febrile to
100.0, hypotensive into the 80's, hypoxic to 88%. On arrival to
the ED, he was oriented only to self, not to place or time,
which
per the patient's son, is close to the patient's baseline.
Overall, the patient is a limited historian due to mental status
and the majority of history is provided by the patient's son. CHEST (PORTABLE AP) showed No definite focal consolidation. The patient was diagnosed with Sepsis, unspecified organism. At the time of discharge, the patient had PRIMARY DIAGNOSES
Community acquired pneumonia
Acute hypoxemic respiratory failure
Acute uncomplicated urinary tract infection
Atrial fibrillation
SECONDARY DIAGNOSES
Gastroesophageal reflux disease
Peripheral neuropathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY STATEMENT:
==================
Pt is a ___ yo M with dementia (lives in ___
home), atrial fibrillation on warfarin, history of recurrent
admissions for pneumonia ___ aspiration who was admitted for
fever, hypoxia, shortness of breath, hypotension, and
leukocytosis following an aspiration event at his nursing home.
On admission had SBP to ___, responsive to fluids. Chest x-ray
showed no opacity. Was initiated on broad coverage with vanc,
cefepime, and flagyl initially. This was switched to ceftriaxone
and azithro due to concern for community acquired pneumonia.
Patient had MRSA swab return positive so received additional
dose of vanc and then switched to oral doxycycline prior to
discharge for 5 day course to end ___. Patient also found to
have UA concerning for UTI. He was treated empirically for
simple cystitis with a three day course of IV ceftriaxone.
#Aspiration pneumonitis vs community acquired pneumonia
Patient admitted for respiratory/systemic symptoms as above. SLP
was not consulted this admission, instead started pureed
solids/nectar prethickened liquids per recommendation from last
admission given that this is a recurring event for him and based
on goals of care discussion w/ patient and family he would not
want to cease eating regardless of SLP recommendation despite
knowing risks of aspiration.
#Supratherapeutic INR:
INR 3.5 on admission, warfarin was held for one day and INR then
became therapeutic and patient restarted on home 2.5 daily
warfarin. Can consider transition to DOAC as outpatient.
#Urinary retention
___ on CKD
#Bacteriuria
Patient has CKD w/ baseline Cr of 1.2. Presented with Cr 1.8
which downtrended to normal with fluids. Patient was retaining
urine and required intermittent straight cath.
==============
Chronic Issues
==============
#Atrial fibrillation
Warfarin as noted above. Continued home metoprolol.
#Prostate cancer
Continued home tamsulosin
#GERD
Continued home pantoprazole
#Neuropathy
Continued home gabapentin
TRANSITIONAL ISSUES
===================
[ ] 5 day course of doxycycline to continue through ___.
Please give after meals.
[ ] Continue pureed solids/nectar prethickened liquids as diet
as outpatient given history of multiple aspiration events. Can
liberalize diet pending decision regarding goals of care with
family.
[ ] Patient continues to take warfarin. Consider DOAC for this
patient to eliminate need for monitoring. Given Cr<1.5 and
weight>60 kg could receive 5 mg bid.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ complicated hepatobiliary history that started with a
biliary injury following CCY eventually requring HJ c/b
recurrent
cholangitis for which she underwent a left hepatic
trisegmentectomy, take-down of HJ in ___ c/b ___
abscess and wound infection s/p IV abx for VRE, JP drain removal
___. She then represented on ___ with several month of
abdominal pain and nausea/vomiting. A CT scan demonstrated a
___ fluid collection which was aspirated by ___
revealing
50cc of bilious output. This was felt to possible old from
previous surgery. However following discharge on (po linezolid
and cipro) she developed severe RUQ pain which is similar to
prior episodes. This was followed by nausea and wretching
(though
no actual emesis) as well as profuse water diarrhea. She is
passing flatus between bm's. She denies any fevers/chills, chest
pain, or shortness of breath. CT-guided drain placement showed Successful CT-guided placement of an ___ pigtail catheter into the
perihepatic collection. Samples were sent for microbiology evaluation. The patient was diagnosed with Peritoneal abscess, Right upper quadrant pain. The patient was treated with CT-guided drainage of perihepatic collection with placement of
___ drainage catheter by ___.
___ ERCP-sphincterotomy with placementof biliary stent
CT-guided drainage of perihepatic collection with placement of
___ drainage catheter by ___.
___ ERCP-sphincterotomy with placementof biliary stent. At the time of discharge, the patient had perihepatic biloma. The patient was given written instructions concerning 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 L hepatic triseg c/b abscess and wound infx ___
recent admit on ___ with ___ biloma s/p ___
re-presenting with recurrent abd pain N/V/D. CT scan reveals a
recurrent collection. On ___, under CT guidance, an ___ pigtail
drain was placed with fluid sent to micro that was negative. She
was kept on Linezolid and Cipro that she was on at home. On
___, an ERCP was performed with sphincterotomy without seeing
a bile leak. Given concern for leak and recurrent fluid
collection, a ___ Fr biliary stent was placed. She tolerated this
procedure well and was afebrile. LFTs decreased to normal and
she was continued on Cipro and Linezolid. The pigtail drain
output averaged 30cc of thin, clear slightly pink fluid. ID
recommended 5 days of antibiotic from drainage of collection.
She was discharged to home in stable condition, tolerating diet
and ambulating independently. She will have a f/u abdominal CT
on ___ then f/u with Dr. ___. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CC: right sided numbness and tingling Radiology showed No acute cardiopulmonary process. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the right or left lower extremity
veins. Radiology showed No evidence of venous thrombosis within the IVC or iliac veins. RENAL U.S. showed 1. No evidence of renal artery stenosis.
2. Bilateral nonobstructing renal stones.
3. Echogenic liver (partially imaged), suggestive of steatosis.
4. Mildly enlarged prostate. CT chest without IV contrast. showed 1. No evidence of pulmonary AVM.
2. Hepatic steatosis.
3. Bilateral nonobstructing renal stones measuring 9 mm on the right, and 6 mm
on the left. The patient was diagnosed with Cerebral infarction, unspecified. The patient was treated with TEE. At the time of discharge, the patient had Left sided acute ischemic stroke (internal capsule, basal
ganglia)
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>___ man, past medical history of borderline
hypertension, who presented to OSH with acute onset R face, arm,
and leg numbness and tingling. Exam notable for diffuse right
hemisensory (face, arms, abdomen, legs) and pinprick loss
without specific dermatomal lesion, and some deficits in
coordination and proprioception. Labs notable elevated LDL
(156), GGT (71), positive lupus anticoagulant. MRI showed
infarct of posterior limb of internal capsule.
Etiology was thought to be hypertensive given location and
clinical history. However, TEE demonstrated PFO, possible
pulmonary vascular malformation, but follow up CT Chest revealed
no evidence of vascular malformation. Given that the size of the
infarct was borderline large for a lacunar infarction, and
detection of PFO, paradoxical embolism could not be excluded.
Ultrasound Doppler of the legs and MRV pelvis were negative. A
hypercoagulable workup was started. This revealed elevated lupus
anticoagulant which has unclear significance and needs to be
repeated in 12 weeks. Blood pressures were somewhat refractory
but better controlled ultimately on Amlodipine 10mg daily and
Lisinopril 20mg daily.
Stroke risk factors included hemoglobin A1c 5.5, TSH 2.5, LDL
156. As a result, patient was started on Atorvastatin 40mg daily
for elevated LDL.
Patient was placed on aspirin 81mg for secondary prevention.
He received gabapentin for symptomatic treatment of
paresthesias.
His LFTs revealed elevated GGT,and ALT, likely caused by
hypoperfusion. Elevated GGT w/ normal Alk phos suggests possible
liver disease in the setting of alcohol use.
************</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: PAtient is a ___ year old female with history of breast and
lung cancer who presents to ___ for evalaution of 2 days of
chills, headache, nasuea, vomiting, and dizziness. She was
imaged
and found to have at least two distinct cerebellar lesions as
well as 1 supratentorial lesion on the left side consistent with
metastatic disease. Neurosurgery was consulted for assistance
with her continued management and care. CT HEAD WITHOUT CONTRAST showed 1. At least 3 hyperdense neoplastic lesions, one in each inferior cerebellum
and one in the left parietooccipital region are compatible with metastases.
2. Mass effect from the cerebellar masses results in low lying cerebellar
tonsils with crowding of the foramen magnum as well as effacement of the ___
ventricle. No hydrocephalus identified. MR HEAD W AND W/O CONTRAST showed 1. Multiple intracranial mass lesions, as described above, consistent with
metastatic disease.
2. Mass effect from the bilateral cerebellar mass lesions results in low
lying cerebellar tonsils, crowding of the foramen magnum, effacement of the
cisterna magna/prepontine cistern, fourth ventricle, and narrowing of the
cerebellar pontine angle. No evidence of hydrocephalus.
3. A T1, T2, and FLAIR hyperintense lesion in the inner table of the right
parietal bone may represent a focus of fat, however an osseous metastatic
lesion could also be considered, close attention in the followup examinations
in this area is advised. Radiology showed 1. No findings to explain the patient's back pain.
2. No evidence of intra-abdominal metastatic disease. CT CHEST W/CONTRAST showed 1. New lower right paratracheal mediastinal lymphadenopathy, highly
suspicious for metastatic involvement.
2. Stable appearance of prior treated malignancy in the left lower lobe.
3. No evidence of new pulmonary metastases. MRI CERVICAL, THORACIC, AND LUMBAR showed 1. There is no evidence of osseous, epidural, or leptomeningeal metastatic
disease within the cervical, thoracic or lumbar spine.
2. Mild cervical and lumbar spondylosis as described above, unchanged from
prior exam of ___.
3. Bilateral cerebellar masses were better assessed on the ___ brain
MRI.
4. Thyroid nodules. Radiology showed No acute cardiopulmonary abnormality. MR HEAD W/ CONTRAST showed 1. Multiple bilateral supratentorial, cerebellar and pontine enhancing lesions
are stable from prior exam.
2. Previously noted left cerebellar hemispheric lesion again exerts mass
effect on the brainstem and inferior aspect of the fourth ventricle.
3. New subtle rounded apparent left post central gyral 3 mm enhancing focus,
which may represent artifact, although subtle new lesion is not entirely
excluded. Close attention to this region on followup examination is
recommended.
RECOMMENDATION(S): RE 3: Recommend clinical correlation and close attention
on followup imaging.. US INTRA-OP ___ MINS showed Intraoperative ultrasound evaluation of two cerebellar masses. MR HEAD W AND W/O CONTRAST showed Postoperative changes are identified with resection of cerebellar metastatic
lesions. No definite residual parenchymal enhancement seen with some mild
meningeal enhancement noted. Persistent mass effect on the fourth ventricle
and quadrigeminal cistern. No hydrocephalus. No change in previously seen
enhancing supratentorial and brainstem lesions. CT HEAD W/O CONTRAST showed 1. Postsurgical changes related to the patient's interval posterior craniotomy
and multiple cerebellar tumor resection.
2. Stable bilateral cerebellar edema. CHEST (PORTABLE AP) showed As compared to the previous radiograph, the patient has received a nasogastric
tube. The tip of the tube projects over the pre-pyloric region of the stomach.
The course of the tube is unremarkable. The patient has also been intubated.
The tip of the endotracheal tube is approximately 1 cm above the carinal, next
to the orifice of the right main bronchus. The tube should be pulled back by 2
cm. No evidence of complications, notably no pneumothorax. No pleural
effusions. No pulmonary edema. CT HEAD W/O CONTRAST showed 1. Interval development of a right cerebellar hemisphere hemorrhage, measuring
up to 2.3 cm, with additional blood in the visualized spinal canal. This
results in mass effect and effacement of the quadrigeminal plate cistern and
mild hydrocephalus.
2. Unchanged hyperdense foci within the right pons and left posterior frontal
lobe
3. Status post occipital craniotomy, with decreased pneumocephalus.
NOTIFICATION: These findings were discussed via telephone by Dr. ___
___ with Dr. ___ at 1245 on ___, immediately upon
discovery. The team was already aware of the findings, and had taken the
patient to the OR that morning for placement of a drain. CTA CHEST WANDW/O CANDRECONS, NON-CORONARY showed 1. Filling defects in the right middle lobar pulmonary artery, as well as
multiple bilateral segmental and subsegmental pulmonary arteries are
consistent with pulmonary emboli. No CT evidence of right heart strain.
2. Right apical, lingular, and bibasilar atelectasis is new over the
interval.
3. Stable enlarged right lower paratracheal lymph node.
NOTIFICATION: Impression point 1 was discussed with Dr. ___ by Dr. ___
___ telephone at 9:40am on ___, 2 minutes after discovery.
Additionally, these findings were discussed with Dr. ___ by Dr. ___
telephone at 11:15 on ___. PORTABLE HEAD CT W/O CONTRAST showed Status post interval placement of a right frontal approach extraventricular
drain, which terminates in the third ventricle, with minimally decreased size
of the ventricles. The quadrigeminal plate cistern, although still diminutive,
appears slightly more patent than on prior exam. BILAT LOWER EXT VEINS showed No evidence of deep venous thrombosis in the bilateral common femoral veins. Radiology showed Intraoperative images were obtained during an IVC filter placement. Please
refer to the operative note for details of the procedure. CHEST (PORTABLE AP) showed The patient is intubated. The tip of the endotracheal tube projects
approximately 1.7 cm above the carina, the tube could be pulled back by 1-2
cm. The tip of the nasogastric tube is not visualized on the image. Low lung
volumes. Mild bilateral areas of atelectasis. No overt pulmonary edema. No
pleural effusions. No pneumonia. CT HEAD W/O CONTRAST showed Expected postoperative changes status post occipital craniectomy without
evidence of new hemorrhage. CHEST (PORTABLE AP) showed As compared to the previous radiograph, no relevant change is seen. The right
hilar and mediastinal enlargement is consistent with the known history of lung
cancer. An area of retrocardiac atelectasis is unchanged. Mild cardiomegaly.
The monitoring and support devices are in constant position. CT HEAD W/O CONTRAST showed 1. Status post suboccipital craniectomy. Known intracranial metastases are not
adequately reassessed on this noncontrast CT.
2. No new hemorrhage or mass effect.
3. Stable position of the right frontal approach EVD catheter. Stable
ventricular size without hydrocephalus. CHEST (PORTABLE AP) showed Patient has been extubated and lung volumes have improved. Heart is normal
size. There is no appreciable pleural abnormality.
Fullness in the right tracheobronchial angle of the mediastinum could be
distended veins, but adenopathy can't give the same appearance. CT HEAD W/O CONTRAST showed 1. Interval development of focal hyperdensity adjacent catheter tip, near the
interventricular foramen of ___, concerning for a new focus of hemorrhage.
No interval change in ventricular size since ___.
2. Stable appearance of the suboccipital craniectomy with no new posterior
fossa hemorrhage.
3. Please note that CT is suboptimal for evaluation of intracranial
metastases. CT HEAD W/O CONTRAST showed Focus of extra-axial hemorrhage along the right frontal convexity and adjacent
to the catheter tip are stable from the prior examination.
6 mm hyperdense focus in the left parietal lobe corresponds with a focal
metastatic lesion on prior MRI, however is more conspicuous on the current
examination. Given the lesion appears increased in density from the prior
examination, this may represent a small, focal area of hemorrhage into the
metastatic lesion. Attention on followup exam.
NOTIFICATION: These findings were communicated to ___ via
telephone at 18:39 on ___ immediately upon discovery by Dr. ___
___. CTA chest showed 1. Bilateral segmental and subsegmental pulmonary emboli with decreased
embolic distribution and burden compared to recent CT chest ___.
2. No acute aortic pathology.
3. Improved bibasilar aeration. Residual bibasilar peripheral opacities likely
secondary to infarct with superimposed atelectasis.
4. Unchanged right paratracheal lymph node. ___ DUP EXTEXT BIL (MAP/DVT) showed No evidence of deep venous thrombosis in the bilateral lower extremity veins.
Slow flow is noted in the left popliteal vein. The patient was diagnosed with BRAIN NEOPLASM NOS, HX-BRONCHOGENIC MALIGNAN, HX OF BREAST MALIGNANCY. The patient was treated with ___: Midline suboccipital craniotomy, excision brain
tumor
___: Craniotomy for pfossa decompression and clot
evacuation
___: IVC filter placement
___: Right VP shunt placement (nonprogrammable). At the time of discharge, the patient had Brain lesions
Cerebral vasogenic edema
Hydrocephalus
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>Patient was admitted to Neurosurgery for further workup of her
brain lesions. She was given Dexamethasone and admitted to the
Step Down Unit. A MRI brain was ordered. A consult for neuro and
rad onc was obtained. She remained stable overnight and on ___
she remained stable. Pt c/o back pain and left hip/pelvic pain.
A CT torso was ordered and showed a new lower right paratracheal
mediastinal lymphadenopathy concerning for metastatic disease.
Dr. ___ hem/onc has been following closely.
On ___, the patient remained neurologically stable. She was
consented for tumor resection and possible VPS placement on
___. Neuro oncology recommended an MRI of the spine with
contrast due to + hyperreflexia on exam. Rad onc recommended
WBRT and resection of tumor vs VPS. The patient stated she has a
daughter that is ___ ___ old and a son that is ___ ___ old and she
feels her son is having a difficult time the mom's condition and
poor prognosis. A social work consult was obtained for family
support. Also, due to her poor prognosis a palliative care
consult was obtained to aid in additional family support in end
of life discussion.
Over the weekend of ___ the patient remained
neurologically and hemodynamically stable waiting for surgery on
___.
On ___, the patient remained stable. The MRI wand of the head
was done this morning. The patient was brought to the OR for
resection of her cerebellar lesions and for placement of a VPS.
Her intraoperative course was uneventful, please refer to the
operative note for further informant ion. She was extubated in
the OR and brought to the ICU for close monitoring. A ___
demonstrated expected post operative changes. ___ showed
expected post operative changes and stable edema.
___, Ms. ___ continued to be neurologically stable. Her
steroids were continued. The post operative MRI was completed
which demonstrated persistent mass effect with no evidence of
hydrocephalus.
___, in the early morning, the patient acutely decompensated
becoming hypoxic and bradycardic. She was re-intubated with
first attempt in the right brainstem and was subsequently
extubated and re-intubated. She was started on pressors and
taken for a stat ___ which showed an acute bleed in resection
bed with increased posterior fossa swelling and enlargement of
temp horns. A 23% bolus of saline was given and her steroids
were increased. Family was contacted to come in and they
consented for an EVD placement as well as a suboccipital
craniotomy for clot evacuation and decompression. A CTA of the
chest was obtained which demonstrated bilateral pulmonary
embolisms. An echocardiogram was performed which was within
___ limits. The patient was taken to the operating room for
her decompressive posterior fossa. Surgery then placed an IVC
filter. Strict blood pressure parameters were maintained.
On ___, the patient's serum Na was 144. She was extubated later
in the day. A repeat serum Na was obtained and was 139.
On ___, the patient remained neurologically stable on
examination. The EVD was raised to 20. Her SBP was liberalized
to <160. A CSF sample was obtained and was sent for cytology.
___, Ms. ___ had a ___ which demonstrated stable
ventricles. Her EVD was clamped and two hours later unclamped
for elevated intracranial pressures. The EVD was lowered to 10.
Her head was wrapped over top of incision.
___, the patient remained neurologically stable and her drain
remained at 10. She was restarted on SC heparin.
On ___, patient was neurologically intact. Her EVD was clamped
at 1pm without any ICP issues. She was pre-oped for the OR for
possible VP shunt.
On ___, patient remained clamped overnight without any changes
in ICP or neurologic exam. Head CT performed showed stable
ventricular size, but new IVH. On exam, her posterior incision
was more larger and boggy. She was taken to the OR for a
placement of a R VP shunt. Post operatively, she remained
intact. Head CT showed that the catheter was in a good location
and no acute hemorrhage. She was transferred to the floor in
stable condition.
On ___, the patient remained neurologically intact on the
floor. She had complaints of gas pain, so she was started on
simethicone. ___ re-evaluated the patient and recommended that
she be discharged to a rehab facility. She was screened for an
available bed. Her discharge was pending insurance
authorization.
On ___ Ms. ___ developed midsternal chest discomfort that
worsened with deep breathing and was found to have an elevated
WBC 28.4. Blood cultures were sent and are negative at
discharge. UA showed moderate Leuks but negative nitrites. CXR
performed was stable. With a history of PE, bilateral ___
dopplers were performed and were negative. CTA chest showed
improving clot burden compared to ___.
On ___ WBC was 10.9. At the time of discharge on ___ she 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: ___ is a ___ male with a history of stage IV
renal cell carcinoma s/p left nephrectomy with adjuvant targeted
therapy (received treatment in home country of ___ and DVT
on currently on Xarelto who presents for evaluation after a
unwitnessed syncopal episode and fall. According to the
daughter, patient was feeling dizzy when he fell forward onto
his knees and then hit the right side of his head. He had no
loss of consciousness. He had no chest pain, shortness of
breath, or abdominal pain prior to the event. Of note, the
patient is currently visiting from ___. Daughter states that
on the flight over he heard a pop on the left side of his face
and has numbness to the left side assays. He states that he has
seen a neurologist since his flight and is being worked up as an
outpatient. He was otherwise in normal state of health prior to
this episode. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Findings consistent with 4 brain parenchymal metastases. Largest mass is
in the left inferolateral frontal lobe near the expected Broca's area; this
lesion is partially hemorrhagic..
2. 7 mm rightward shift of frontal midline structures.
3. 2.3 cm enhancing mass in left Meckel's cave, differential considerations
metastasis, meningioma, schwannoma. BILAT LOWER EXT VEINS showed 1. Deep venous thrombosis of the right common femoral vein extending
inferiorly to the right popliteal vein, consistent with history of known left
femoral vein thrombus. Additional occlusive thrombus within 1 of the paired
posterior tibial veins.
2. No thrombus within the left lower extremity deep veins. RENAL U.S. showed 1. Small area around the inferior right renal pole demonstrating slightly
___ compared to the rest of the kidney, this could represent the
site of the previously noted subcapsular hematoma. No hydronephrosis.
2. Nonvisualization of the previously noted lower pole lesion. CHEST PORT. LINE PLACEMENT showed Distal tip of right central venous catheter is at the caval atrial junction. Radiology showed Successful deployment of Denali retrievable infrarenal IVC filter. MR HEAD W/O CONTRAST T___ MR HEAD showed 1. Large metastatic lesion in the left frontal lobe with unchanged surrounding
T2 signal abnormality.
2. Small right parasagittal frontal metastatic lesion.
3. No acute infarct. CT HEAD W/O CONTRAST Q111 showed Stable appearance of the brain including unchanged rightward mass effect and
edema associated with subacute hemorrhagic metastatic lesion in the left
anterior frontal lobe. The patient was diagnosed with Unsp focal TBI w LOC of unsp duration, init, Fall on same level, unspecified, initial encounter, Syncope and collapse, Other specified injuries of head, initial encounter. The patient was treated with IVC filter placement ___
CyberKnife SRS. At the time of discharge, the patient had PRIMARY:
-Presumed renal cell carcinoma with metastases to the brain,
lungs, and potentially pancreas
-Acute kidney injury
-Seizure
-Intracranial metastatic disease with cerebral edema
-Type 2 diabetes mellitus
-Acute on chronic anemia
-Hyperkalemia
SECONDARY:
-Hx of Deep vein thrombosis
-HTN
-RCC. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>=======================
PATIENT SUMMARY
=======================
___ ___ male with history of presumed
renal cell carcinoma s/p left nephrectomy (___) complicated by
presumed metastatic disease (on targeted therapy since ___ and
right femoral DVT on Xarelto (___) who presented with
likely seizure and fall secondary to new hemorrhagic presumed
metastatic brain lesions. He was treated with stereotactic
radiosurgery and put on Keppra. His course was complicated by
acute renal failure of unclear etiology requiring urgent
hemodialysis, which improved spontaneously. He also was found to
have a right renal subcapsular hematoma with evidence of small
RP bleeding. He was transitioned to ___ for anticoagulation
which was well-tolerated. He was found to have a new diagnosis
of type 2 diabetes mellitus and put on insulin, especially in
the setting of dexamethasone use for his CNS disease. He will be
transitioning ongoing cancer care to ___ his application for
___ was pending at time of discharge.
=======================
TRANSITIONAL ISSUES
=======================
[] Patient was scheduled to see a new PCP, ___,
neuro-oncology, and radiation-oncology in the ___.
Please see below for appointment times.
[] Medical insurance: The patient began the process of applying
for medical insurance this admission. Please continue to work
with patient on obtaining this. Financial Counseling is familiar
with his case. Him and his daughter understand that it may take
several weeks to hear a decision and that until that time,
appointments will be self-pay
[] Medications were obtained through BI-pharmacy with discount
card that is applicable as his insurance application is pending.
Most medications have a 15$ copay which his daughter agreed to
pay. He has been given a one month supply of these medications.
[] Nephrology: He will need to be seen by Nephrology in ___
weeks after discharge given hospitalization cb by renal failure
and hyperkalemia of unclear etiology (now resolved)
[] Dexamethasone taper: The patient will need to take
dexamethasone 4mg daily for 4 additional days (___), then
2mg daily for 7 days (___), and finally 1mg daily for 7
days (___).
[] Insulin: The patient newly diagnosed with diabetes this
admission. A1c is 9. His insulin regimen is morning NPH with
standing humalog. Please continue to titrate the patient's
insulin, as he tapers down his steroid regimen. His daughter has
supplies to measure FSBGs at home.
[] Hepatitis B: Hep B non-immune, first dose received on ___.
He will need 2 additional doses.
[] Sunitinib: Please continue to hold pending further discussion
with Medical Oncology.
[] IVC filter: Please discuss optimal timing to remove the IVC
filter with his oncologic team.
[] PJP prophylaxis: Patient was given inhaled pentamidine on
___. If patient requires further prophylaxis, please consider
initiation of dapsone pending G6PD status or atovaquone if
insurance approval is obtained. Unable to provide atovaquone due
to high copay.
#CODE STATUS: Full Code
#HCP: ___ (Daughter ___
=======================
___ PROBLEMS
=======================
# Presumed hemorrhagic brain metastases
In setting of subacute neurological findings including numbness
and weakness to left face. Underwent imaging which showed
presumed metastatic lesions with associated edema and midline
shift. His presenting event was attributed to seizures. The left
facial numbness/weakness was attributed to metastatic lesion in
Meckel's cave, near the trigeminal nerve. The patient was
evaluated by Neurosurgery, who did not recommend surgical
treatment of the lesions due to lack of severe neurological
deficits and the location being near language areas.
Neuro-oncology recommended initiation of dexamethasone and
Keppra. For PJP prophylaxis, was on atovaquone in-house. Not a
candidate for Bactrim given borderline hyperkalemia and CKD.
G6PD pending on discharge, so unable to give dapsone. Atovaquone
was too expensive for the patient given lack of medical
insurance. Hence, gave pentamidine inhalation on ___, as he
will need around 11 days of additional high-dose steroids (2mg
or more of dexamethasone daily). Radiation Oncology recommended
stereotactic radiosurgery, which was given in-house and
well-tolerated. His face pain was managed with gabapentin and
prn Tylenol. Dexamethasone taper initiated as above.
# Presumed stage IV renal cell carcinoma
# Presumed metastases to lungs, brain, ?pancreas
Had previously received all care in the ___. Underwent left
nephrectomy in ___. He was started on targeted therapy in ___,
and most recently has been on Sunitinib for the past year. We
attempted to get records from ___ however his daughter was
skeptical that this would not be possible. His sunitinib has
been held given acute illness. Plan is for patient to see renal
cell carcinoma specialist outpatient at the ___ to determine
further treatment options of immunotherapy vs. tyrosine kinase
inhibitors. He will not be returning to the ___ for his
oncologic care according to his daughter.
# Acute on chronic kidney disease
# Acute tubular necrosis
# Hemodialysis
# Hyperkalemia
Presented with creatinine 1.9 with hematuria. Presumably has
CKD. Baseline creatinine unknown. He developed rapid renal
failure of unclear etiology. Nephrology was consulted and he was
initiated on dialysis ___ for hyperkalemia, anuria via
temporary HD line. All workup for possible intrinsic etiology
and renal ultrasound were unrevealing. After three sessions of
HD, his creatinine started to improve and his urine output
substantially increased which suggested ATN. He was put on Lasix
PO 40mg to manage hyperkalemia and fluid status. Cr at discharge
was 2.0
# DVT: right common femoral vein
# Intracranial bleeding
# R renal subcapsular hematoma with evidence of small RP
bleeding
Diagnosed in ___, and had been on Xarelto since then. Due to
evidence of presumed hemorrhagic metastatic lesions, the xarelto
was stopped. He underwent reversal with andexanet on admission
and IVC filter placement on ___. R renal subcapsular hematoma
with evidence of small RP bleeding was discovered incidentally
on imaging (was not felt to be contributing to patient's renal
failure). Upon initiation of treatment of brain lesions with
radiation, felt that patient could safely resume
anticoagulation. He tolerated anticoagulation well with heparin
gtt and transitioned to Lovenox on discharge. Lovenox has a high
copay of ~$600 without insurance which the daughter was willing
to pay in the first month as his application for ___ is
pending. DOACs were not felt to be a good option given CrCl and
potential need for reversal (given CNS bleed, RP bleed).
Coumadin remains an option but he would require several INR
checks as an outpatient and as his ___ application is
pending, the costs of those visits (self-pay) were felt to
outweigh the costs of Lovenox.
# Type 2 diabetes mellitus
New diagnosis. No known family history. Patient's A1C was 9.1%
on admission. With the addition of dexamethasone, patient
developed significant hyperglycemia. He was discharged on AM NPH
with standing humalog at meals. He will need to have his insulin
dosing adjusted as an outpatient, especially as dexamethasone
taper is pursued.
# Hypertension
Maintained on labetalol TID with goal SBP < 160 for active
hemorrhagic brain metastases.
# Blood loss anemia
# Right renal subcapsular hematoma
Admission hemoglobin of 13.4, decreased to 9.3 over the course
of his hospitalization and stable prior to discharge. Imaging
revealed small bleeding within the right kidney, with evidence
of small RP bleeding on the right. Per nephrology, this was
unlikely to have caused his subsequent acute renal failure.
Underwent reversal of Xarelto initially with andexanet in the
setting of hemorrhagic brain mets. Anemia currently stable and
likely ___ acute insults as above and anemia of CKD.
# Perirectal sebaceous cyst
Patient noted just before discharge that he has had this for
many years and it was untreated in ___. Exam notable for
small, possibly sebaceous cyst a few cm to the right of the
rectum which was draining a small amount of blood-tingled,
mucoid material. Area was nontender or erythematous, not c/w
infection. Discussed with patient and daughter that he will need
this to be followed up as an outpatient.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a h/o nephrolithiasis who presents with 3 days of
right-sided abdominal and flank pain and CT showing a 5mm
obstructing right mid-ureteral stone. Physical exam is
remarkable for mild R CVAT and right-abdominal tenderness. The
patient is comfortable, non-toxic appearing, afebrile, and
hemodynamically stable. UA is not concerning for concomittant
UTI. Labs are remarkable for ___ with Cr of 2.0. The patient's
baseline Cr is unknown, but after IVF hydration, his creatinine
did not go down. Given the likelihood that his ___ is due to
ureteral obstruction, the patient will proceed to the OR for
cystoscopy, right ureteral stent placement. He will be admitted
to urology. CT ABD AND PELVIS W/O CONTRAST showed 1. 5 mm obstructing stone in the right mid-ureter causing mild right
hydroureteronephrosis. Density of the stone is 505 ___.
2. Normal appendix.
3. Marked hepatic steatosis. RETROGRADE UROGRAPHY showed Intraoperative images were obtained during urologic procedure. Please refer to
the operative note for details of the procedure.
Total fluoroscopy time: 51 seconds The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED. The patient was treated with ___ - R ureteroscopy, laser lithotripsy, stent placement. At the time of discharge, the patient had R ureteral stone. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to Dr. ___ service from
the ___ ED after undergoing cystoscopy w/ left ureteroscopy,
laser lithotripsy and stent placement. No concerning
intraoperative events occurred; please see dictated operative
note for details. The patient received ___ antibiotic
prophylaxis. Patient's postoperative course was uncomplicated.
On POD0 the pt was tolerating a regular diet, nausea had
resolved, and pain was well-controlled on PO analagesics.
Flomax was given to help facilitate passage of stone fragments.
Creatinine improved from 2.0 -> 1.6. At discharge, patient's
pain was well controlled with oral pain medications, tolerating
regular diet, ambulating without assistance, and voiding without
difficulty. He was given explicit instructions to call Dr.
___ follow-up for stent removal and his PCP to ensure
resolution of ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ M w/ CMV colits, UC, and c. dif colitis requiring
subtotal colectomy and end ileotomy ___ with Dr. ___
presents with left groin pain. His post-op course was c/b wound
infection that was drained (POD 11), and readmission from rehab
on ___ for HCT of 21.1, found to have LUQ and RLQ abscesses
drained by ___. He was most recently discharged to rehab on
___, and was sent home from rehab ~ 1 week ago. He reports
doing well at home until yesterday when he began to have severe
left groin pain extending down his thigh. This has been
associated with some swelling. His symptoms progressed and he
presented to the ED today for further evaluation. CTA
abdomen/pelvis demonstrates extensive thrombus in his L femoral
vein, EIV, and CIV extending to he IVC as well as some clot in
his R IIV and CIV. Radiology showed Extensive thrombus extending from the left superficial femoral vein into the
IVC and also from the right internal iliac into the common iliac. The
etiology of these thromboses is unclear; however, they may be related to
chronic inflammation of the ___ pouch as al internal iliac veins have
thrombus. Left lower extremity ultrasound is recommended for further
evaluation. Radiology showed Acute deep venous thrombosis in the left common femoral vein
extending distally into the calf veins. Superficial thrombosis involving the
left greater saphenous vein as well. No evidence of deep vein thrombosis in
the right lower extremity. Radiology showed No evidence of DVT in the bilateral upper extremities veins. Radiology showed 1. No DVT in the left upper extremity.
2. Hematoma in the axilla. The patient was diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF DISTAL LOWER EXTREMITY. The patient was treated with ___: IVC filter, LLE + pelvic venogram
___: angiojet, lysis catheter placement
___: L CIV thrombectomy with stent / pelvic venogram
___: ___ brachial evacuation/fasciotomies. At the time of discharge, the patient had Deep Venous Thrombosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient was found to have extensive extensive thrombus extending
from the left superficial femoral vein into the IVC and also
from the right internal iliac into the common iliac. The
etiology of these thromboses was unclear. He got ___ Duplex that
showed acute deep venous thrombosis in the left common femoral
vein extending distally into the calf veins. Superficial
thrombosis involving the left greater saphenous vein as well.
No evidence of deep vein thrombosis in the right lower
extremity. Patient received 4400 units of heparin in the ED and
was admitted to the Vascular surgery service. He was started on
a heparin drip at 1000U/hr.
On ___, he was taken to the operating room with Dr. ___
ultrasound-guided access to right jugular vein for placement of
___ sheath, Ultrasound-guided access to right common
femoral vein, ___ sheath, Ultrasound-guided access to left
soleal vein for placement of a ___ sheath, Cavogram, Pelvic
venogram, Venogram of left lower extremity, Placement of
inferior vena cava filter, Placement of catheter in the third
order vessel soleal vein on the left, AngioJet thrombectomy and
Placement of venous lysis catheter for overnight thrombolysis
with tPA. Patient had an uneventful postoperative course other
than mild pain in his left arm with a benign exam.
The next day ___. Patient was taken back to the operating room
for placement of first-order venous catheter in the left common
iliac vein, pelvic venogram, including inferior vena cava,
venous AngioJet thrombectomy and placement of Wallstent times 2
(size 20 x ___s 18 x 60 mm), to the left common
iliac vein as well as the inferior vena cava. Te venogram showed
external compression of left iliac system, with residual clot in
the proximal left common iliac vein as well as in the distal
IVC. Contrast load was 40mL for a total fluoroscopy time of 10.8
mins.
A Left venous sheath was left in place with heparin infusion and
the right venous sheath was locked in the OR. 2 hours post
transfer to the PACU, the right sheath was removed without
complications. However, patient started complaining of pain in
his left arm with marked increase in swelling and warmth from
the mid upper arm down to the forearm with palpable radial
pulse. Upper extremity ultrasound was obtained in the PACU and
revealed a heterogeneous rounded collection in the axilla
measuring at least 4 x 2 x 5.9 cm. An impending compartment
syndrome was of concern so the patient was taken back to the
operating room with Dr. ___ surgery) for
exploration and found extensive hematoma throughout biceps and
triceps muscle bellies area, and much of it had infiltrated into
the muscle bellies.
We identified the artery and during our dissection came upon a
branch of the artery that was actively bleeding. It was
possible that this was the source of his hematoma. This branch
was ligated using silk ties, and hemostasis was
achieved. We inspected the remainder of the brachial arteryfor
approximately 5 cm and there was no other evidence of injury or
bleeding. We made several attempts to evacuate hematoma from
the arm, but much of it was in the muscle and
not easily evacuable. The rest of the brachial artery
tributarier were ligated and Left superficial and deep forearm
fasciotomy and Left carpal tunnel release was performed. A JP
drain was placed in the anterior compartment of the arm and his
arm was in an elevated postion on a sling. Patient was extubated
immediately posteoperatively and was transferred to the PACU in
a stable condition where he remained overnight. He received 2U
PRBC for a drop in HCT to 15 which he responded well. On POD1,
patient's LLE sheath was removed, his hep drip was continued and
he was started on coumadin at a dose of 5mg. On POD2, his foley
was discontinued without event, he was transitioned to PO pain
medications and a regular diet. On POD3 he received 1U PRBC for
HCT of 21 and responded to HCT 27. His coumadin was redosed at
the same dose for POD3 and POD4 with an uptrending INR. On POD3,
patient's left arm splint was removed and he started working
with physical/occupational therapy with great progress.
By POD4, patient was out to chair, his heparin drip was
discontinued with a transition to Lovenox at an INR of 1.7. Hi
JP drain was removed with an output of less than 30cc/day.
Patient's vitals remained stable with palpable pulses throught
his postoperative stay. By the time of discharge, patient was
tolerating a regular diet with good pain control and voiding
without difficulty. He is to be discharged to a rehab facility
where he will regain more strength. He has a follow up
appointments with vascular and hand surgery as shown below. He
is also to get daily INR levels to dose his coumadin while being
bridged with Lovenox he is being discharged with. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o female with PMHx CKD, DM, HTN, asthma, breast cancer,
multiple SBO, presents with several weeks of right lower back
pain, and dyspnea worsening over the past one week. Radiology showed Blunting of the right costophrenic angle is unchanged and may
reflect a small pleural effusion. Otherwise, no acute cardiopulmonary process. The patient was diagnosed with PLEURAL EFFUSION 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>PRIMARY REASON FOR HOSPITALIZATION:
===============================================
___ y/o female with PMHx significant for CKD, DM, HTN who
presents with several weeks of dyspnea and right lower back
pain, with acute worsening in her dyspnea over the last several
days.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ y/o M with PMHx significant for alcohol
abuse and alcohol withdrawl seizures (documented) as well as
reports of DTs (not documented), depression with suicide
attempts (documented w/pills and alcohol), as well as HTN, GERD,
and recently diagnosed right subclavian vein thrombosis on
coumadin sent in from his PCP for medical clearance so that he
can enter an alcohol detox program. CHEST (PA AND LAT) showed No acute intrathoracic process. Radiology showed No acute intracranial process.Global atrophy, advanced for the patient's age. CHEST (PA AND LAT) showed In comparison with the study of ___, there is little interval change.
Mild hyperexpansion of the lungs suggests some underlying chronic pulmonary
disease. However, no acute pneumonia, vascular congestion, or pleural
effusion. The patient was diagnosed with CHEST PAIN NOS, ALCOHOL ABUSE-UNSPEC. At the time of discharge, the patient had clostridium difficile colitis
alcohol withdrawal
DVT. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o M with PMHx significant for alcohol abuse and alcohol
withdrawl seizures (documented) as well as reports of DTs (not
documented), depression with suicide attempts (documented
w/pills and alcohol), as well as HTN, GERD, and recently
diagnosed right subclavian vein thrombosis on coumadin sent in
from his PCP for medical clearance so that he can enter an
alcohol detox program.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Per ED: This patient is a ___ year old male who complains of
SHORTNESS OF BREATH. The patient admits to alcohol. He was
walking and fell down 7 or 8 steps. He denies hitting his head.
He was noted to have a blank stare at the bottom of the stairs.
He then went to bed and then developed left-sided rib pain and
shortness of breath. There is no history of abdominal pain.
There's no headache or back pain or neck pain. He does have left
rib pain Radiology showed No acute intracranial abnormality. Radiology showed 1. No fracture or malalignment of the cervical spine.
2. Mild degenerative changes at C6-7. Radiology showed 1. Splenic laceration for roughly 4 cm without perisplenic hematoma or
hemoperitoneum.
2. Left sixth-tenth rib fractures. The eighth rib fracture is segmental.
Findings were reviewed in person by Dr. ___ With Dr. ___ at 2:59
a.m. On ___. The patient was diagnosed with FRACTURE ONE RIB-CLOSED, UNSPECIFIED FALL. At the time of discharge, the patient had Left-sided rib fractures: ___
Splenic laceration. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ was admitted to the trauma surgical service a ___
after suffering an witnessed fall. Imaging obtained upon
presentation included a chest x-ray, Head CT, Spine CT, Chest
CT, Abd/Pelvic CT which were revealing for left-sided rib
fractures (___) and a splenic laceration without
hemoperitoneum. He was initially admitted to the TSICU, but he
was doing well, tolerating a diet and his hcts were stable so he
was transferred to the floor on HD1.
On the floor, the patient's pain regimen was transitioned from a
dilaudid PCA to oral prn oxycodone with effective pain control.
He remained stable from both a cardiovascular and pulmonary
standpoint; incentive spirometry and frequent ambulation were
strongly encouraged. The patient continued to tolerate a
regular diet and voided adequate amounts. His hematocrit
remained stable and was noted to be 37.1 on day of discharge on
HD3. He will follow-up in the ___ clinic within 2 weeks.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with PMH of HTN, poorly controlled diabetes
who was admitted to CCU for management of LAD STEMI. Patient
reports episodes of severe chest pain associated with shortness
of breath, palpitations, diaphoresis and nausea about three
weeks ago. He went to ___ at that time and was
treated with Levaquin for pneumonia. He reports not being able
to sleep for 3 nights due to chest pain and shortness of breath.
His symptoms then improved however he was still not back to his
baseline. He overall felt more tired and fatigue. Then last
night he had recurrence of his chest chest tightness of ___
associated with tachycardia and shortness of breath. He then
presented to ___ this morning and was found to have
wide-complex tachycardia and HR in the 190s. He was then given 2
doses of adenosine and 1 dose of amiodarone with no relief of
symptoms. He was then cardioverted successfuly with 200J then
360J. Repeat EKG showed sinus rhythm with ST Elevations of 2mm
in V2, 0.5mm in V1 and 1mm in V3. He was then asymptomatic with
no chest pain or shortness of breath. He was given aspirin and
started on Heparin gtt. He was then transferred to ___ for
further evaluation and management. CHEST (PORTABLE AP) showed The lung volumes are low. Minimal blunting of the left costophrenic sinus
could be caused by a minimal pleural effusion. The retrocardiac atelectasis is
visualized. Mild pulmonary edema is present. No evidence of pneumonia. No
pneumothorax. Borderline size of the cardiac silhouette. CHEST (PA AND LAT) showed Small left pleural effusion and moderate left lower lobe atelectasis are
probably unchanged since ___. There is no pneumothorax. Transvenous
right atrial pacer and right ventricular pacer defibrillator leads follow
their expected courses from the left pectoral generator. Heart is normal
size. There is no mediastinal widening. Right lung is clear. The patient was diagnosed with CHEST PAIN NOS, TACHYCARDIA NOS. The patient was treated with s/p cardiac catheterization with DES to the LAD ___
s/p ICD placement on ___. At the time of discharge, the patient had ventricular tachycardia
acute coronary syndrome s/p DES to the LAD
poorly controlled diabete Type II
systolic heart failure (EF 30%)
LV thrombus (on coumadin)
s/p ICD 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>___ with PMH of HTN, poorly controlled diabetes who was admitted
to CCU for management of LAD STEMI s/p DES. Now s/p ICD for VT
and newly-dx LV thrombi being managed with Coumadin.
#) ACUTE CORONARY SYNDROME: Patient most likely had the LAD
STEMI about three weeks ago as evidenced by his q waves. He had
complete occlusion of his LAD s/p ___ on ___. Was
subsequently treated with tirofiban for 8 hours, and was started
on Aspirin 81mg daily, Clopidogrel 75mg daily (after being
loaded with 600 mg initially), and Atorvastatin 80mg Daily. Also
treated with heparin gtt for multiple LV thrombi seen on ECHO
(as below). Dose of lisinopril increased from 10 mg to 40 mg
daily. Was started on metoprolol succinate 100mg po qam and 50mg
po qpm.
#) APICAL THROMBUS: multiple LV thrombi seen on ___ ECHO - a
large (2.7 x 2.3 cm) apical thrombus, as well as two smaller
thrombi along the distal inferior wall. Heparin gtt started
___. Started on coumadin, which was titrated to 4 mg qd on
discharge. INR on ___ was 3.5. Patient will f/u with Dr. ___
___ for INR management. Will need repeat ECHO in 3 months to
reassess LV thrombi.
#) SYSTOLIC HEART FAILURE, TTE ___ with EF 30%: Patient has
clinical symptoms of heart failure with shortness of breath,
orthopnea and PND for the past three weeks. Patient initially
diuresed with 20 mg IV lasix, and then transitioned to 40 mg PO
lasix daily. Managed with metoprolol and ACEI as above.
#) V TACH: initially presented to ___ on ___ with
ventricular tachycardia @ 205 bpm. VT likely in setting of
infarct. Was cardioverted to sinus rhythm, and transferred to
___ for further management. On ___, a ___
Energen dual-chamber ICD was successfully implanted for
secondary prevention of sudden cardiac death. Patient was
treated with 1 dose of vancomycin, followed by 3 days of
cephalexin. Will f/u with EP and device clinic.
#) DIABETES: Uncontrolled; HbA1c now 12.6. ___ consulted.
Patient treated with lantus + HISS while in-house. Patient will
be discharged with ___ f/u, on Lantus + Humalog ISS, while
continuing metformin.
#)HYPERTENSION: increased dose of lisinopril and started on
metoprolol as above.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ woman with history of CAD s/p PCI to DES to pLAD and
dLAD ___, NSTEMI ___ with POBA of mLAD (no stent given ITP
and platelets of 80k), diastolic heart failure (EF 60%), Type A
aortic dissection s/p emergent repair ___, hypertension,
chronic thrombocytopenia, who presents for evaluation of
weakness. CHEST (AP AND LAT) showed Status post type A aortic dissection repair with unchanged widened and
tortuous mediastinal contour. Patchy bibasilar airspace opacities likely
reflect atelectasis and scarring. Radiology showed No acute fracture or dislocation. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial process.
2. Atrophy and chronic small vessel disease. CT C-SPINE W/O CONTRAST Q311 CT SPINE showed 1. No acute fracture or traumatic malalignment.
2. Unchanged appearance of lucency at the distal tip of the screw transfixing
the chronic type 2 dens fracture.
3. Stable moderate multilevel degenerative changes. CT ABD AND PELVIS W/O CONTRAST showed 1. No acute intra-abdominal process identified.
2. 1.9 x 1.8 cm cystic lesion in the pancreatic head, stable from ___.
This may reflect a side branch IPMN, and follow up with ultrasound or MRI can
be performed in ___ years.
3. Dense consolidation at the right lung base may represent atelectasis but
pneumonia is not excluded in the appropriate clinical setting.
RECOMMENDATION(S): 1.9 x 1.8 cm cystic lesion in the pancreatic head, stable
from ___. This may reflect a side branch IPMN, and follow up with
ultrasound or MRI can be performed in ___ years. The patient was diagnosed with Sepsis, 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 an ___ lady with CAD s/p PCI w/ DES to
pLAD and dLAD ___, NSTEMI ___ with POBA of mLAD (no stent
given ITP and platelets of 80k), HFpEF (EF 60%), Type A aortic
dissection s/p emergent repair ___, HTN, chronic
thrombocytopenia, who presents with weakness found to have
evidence of hypovolemia with concentrated labs, ___, new TWI in
anterior and lateral leads with mildly elevated troponin
concerning for type II NSTEMI.
#Hypovolemia: Patient has had reduced appetite/poor PO intake
over last several days and has had diuresis with high doses of
torsemide 300 mg PO QD and metolozone 5 mg PO QD as outpatient.
Lactate 4.0 on admission which improved to 1.6 with IVF
(1750cc). On admission, patient w/o elevated JVD and 1+ pitting
edema to ___ way up to knees from ankles bilaterally on exam.
Her torsemide was reduced to 100 mg daily and remained even with
I/Os on this dose. Her discharge weight was 138.1 lbs, which was
her outpatient dry weight. She was continued on her
spironolactone, however her metolazone was discontinued.
#Chest Pain, ECG Changes: Patient with chest pain with exertion
with deep TWI in inferior leads on ECG, trop on admission 0.02
in setting ___ with repeat <0.01 most likely c/w type II
NSTEMI. Of note patient has been holding ASA since ___
thrombocytopenia at request of hematologist. Of note, patient is
no longer on Plavix (s/p ___ year of therapy), and ranolozine
d/c'ed ___ falls. Repeat ECG on ___ notable for QTc 475,
persistent TWI in V1-V6 and persistent LVH. No events on
telemetry since admission. Likely that persistent TWI in V1-V6
are repolarization changes associated w/LVH, although there may
have been component of Type II NSTEMI as discussed above. She
was continued on her home statin, beta blocker, and Imdur. After
discussion with her outpatient hematologist and improvement in
her platelets, her ASA was resumed.
#Acute Kidney Injury: Cr 2.1 on admission from baseline 1.8, but
after receiving 750cc in ED, Cr improved to baseline, therefore
thought to be pre-renal in setting of overdiuresis as above.
Encouraged PO intake with assistance from nutrition and SLP.
#Thrombocytopenia: Plts in the ___ on ___ (admission), 82 on
___, 81 on ___, which is her baseline ___, per OMR. She
has known chronic thrombocytopenia, followed by Dr. ___.
Thought is low platelet count immune mediated. Plan is to
monitor platelets, if downtrending treat with steroids. Patient
also has known chronically elevated WBC PCR negative for BCR
ABL, s/p BM biopsy with normal triliniage. ASA re-initated as
above.
#Rectal Burning: Patient w/known diverticulosis and internal and
external hemorrhoids on colonoscopy ___. Rectal burning
likely ___ constipation and hemorrhoids. Rectal exam notable for
___ nonbleeding, external hemorrhoids. Patient denies melena or
BRBPR. She was continued on hydrocortisone cream with
symptomatic improvement.
#Chronic Diastolic Heart Failure: LVEF 60% without acute
exacerbation. Discharged on torsemide 100 with discharge weight
138 lbs. Metoprolol and spironolactone resumed, however held
home metolazone.
#Leukocytosis: Acute on Chronic (baseline WBC ___, w/WBC 23.8
on admission (___). Likely ___ to hemoconcentration iso
dehydration, as H&H 16.1/48/8. Patient did not have any clear
evidence of infection by history, exam, or imaging. Pt received
vanc/cefepime x1 in the ED. Had 1 of 4 BCx resulting w/GPC in
clusters that are coagulase neg, likely Staph epidermidis
contaminant, as patient is still afebrile and w/no e/o infection
on exam. Urine cx w/o growth (final).
#Hypertension: Continued home metoprolol, isosorbide
#GERD: Continued home Omeprazole 40 mg PO DAILY
#Depression: Continued home Duloxetine 60 mg PO DAILY
#Gout: Continued home allopurinol ___ mg daily due to renal
function.
TRANSITIONAL ISSUES:
=====================
#1.9 x 1.8 cm cystic lesion in the pancreatic head, stable from
___. This may reflect a side branch IPMN, and follow up
with ultrasound or MRI can be performed in ___ years.
#Discharge weight: 138 lbs
#Discharge diuretic: torsemide 100 mg daily
#Would continue monitoring platelets; if falls below 40, would
consider holding aspirin
#CODE: Full code except does not want long term intubation, okay
to intubate for resuscitation
#CONTACT: HCP/Son ___ ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Patient is a ___ w/ atrial fibrillation, MDD w/ multiple
hospitalizations for psychiatric needs, HTN, DM, HLD presenting
as transfer from ___ clinic for RVR with rates to the 120's. In
brief, patient was planned for ECT today and was found to be in
RVR with rates to 120's at which point ECT was deferred.
Patient
was then transferred to the ___ emergency department for
further management. CHEST (AP AND LAT) showed Stable mild cardiomegaly with increased pulmonary vascular congestion. No
frank edema or signs of pneumonia. CT HEAD W/O CONTRAST Q111 CT HEAD showed No acute intracranial process. The patient was diagnosed with Unspecified atrial fibrillation, Tachycardia, unspecified, Palpitations, Essential (primary) 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>TRANSITIONAL ISSUES
=====================
New Medications: Lisinopril 5mg daily, coreg 12.5 BID, lorazepam
1mg PO TID
Held Medications: Furosemide, HCTZ
Changed Medications: None
[] Warfarin - per recent discharge summaries, goal INR 1.5-2.5
while on ECT though this should be confirmed as an INR of
1.5-2.0 would not offer adequate protection against stroke.
[] Hypertension - Hypertensive during admission with several
adjustments to regimen listed below. BP should be monitored as
an outpatient and electrolytes (K, Mg, Cr) should be monitored
by PCP ___ 2 weeks.
[] Patient should continue with appropriate psychiatric follow
up for ongoing depression and catatonia as well as standing
Ativan regimen
[] Family concerned about dementia, can consider outpatient
cognitive neurology follow up if necessary
___ w/ atrial fibrillation, MDD w/ multiple hospitalizations for
psychiatric needs, HTN, DM, HLD presented with RVR. Briefly,
patient presented for her scheduled ECT appointment and found to
be in atrial fribrillation with RVR and was subsequently
admitted to cardiology after being started on a diltiazem gtt in
the ED. Hospital course otherwise notable for intermittent RVR
as well as management of catatonic state and UTI described
below:
#Atrial fibrillation with RVR
Suspect medication noncompliance as the main inciting factor
with possible contribution from hypertension (SBP 160s on
presentation). Per patient's son, she has been deferring her
medications recently, and he suspects she may have been told not
to take diltiazem prior to ECT. Possible contribution from UTI,
treated with ___uring hospitilization.
Experienced relapse in setting of hypokalemia while inpatient
but has been in NSR since ___. Patient maintained on home
diltiazam ER regimen and started on coreg 12.5 BID during
hospitalization. Patient warfarin adjusted and discharged home
on adjusted regimen of 2mg daily.
#HTN
#Hypokalemia
Patient was noted to be hypertensive to SBP 160s throughout
hospitalization. Patient was transitioned from
hydrochlorothiazide to lisinopril 5mg and coreg 12.5 BID regimen
which improved blood pressure control, mitigated incidence of
hypokalemia, and provided additional rate control for atrial
fibrillation.
#UTI
Patient with leukocytosis of uncertain etiology as well as low
grade temperature, pyuria on UA was deemed to have likely UTI
and treated empirically with Ceftriaxone (grew pan sensitive E
coli during prior hospitlization).
#MDD complicated by catatonia
Patient appeared increasingly catatonic over course of
hospitilization and ultimately was unable to verbalize, follow
commands, or take PO. Primary team consulted psychiatry service
who initiated standing Ativan 1 mg TID regimen as well as
inpatient ECT on ___. Patient clinical status improved, and
per psychiatry team, patient was back to previous baseline at
time of discharge.
CHRONIC ISSUES
==============
HTN, major depressive disorder as addressed above</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with depression, chronic neck/back/abdominal pain, on
intermittent narcotics and colace/senna now presenting with new
onset nausea, vomiting and diarrhea for the past day. Per pt,
symptoms started yesterday morning. She fisrt noted decreased
appetite and nausea, followed by emesis of small amounts of
bilous fluid ___ yesterday and 3 times today. States she
had liquid brown stool x >10episodes yesterday and thoughout the
night with her last episode this morning. Denies hematemsis or
hematochezia. Subjective fever with chills last night, did not
take temperature. Additionally, centralized lower abdominal pain
started yesterday (___), and has been constant in nature.
Denies sick contacts, recent travel, or food out of the
ordinary.
Remembers having a similar occurrence ___ ago with lower abd
pain and diarrhea about ___ ago. This self-resolved and she
did not seek medical attention at the time.
Of note, had transanal excision of rectal polyp on ___
(precancerous) and has been feeling at baseline since discharge.
BMs have been normal up until yesterday. Did see Dr. ___ at ___
last week for likely fibromyalgia symptoms and was started on
ambien for insomnia, given a limit prescription of
hydrocodone-tylenol, and restarted on fluxetine.
In the ED, initial vs were 98 82 106/67 18 95%RA. Exam
significant for TTP in RLQ, periumbilically R>L, no peritoneal
signs. Labs significant for nml CHEM7, CBC, LFTs, Lactate. UA
negative. Patient received zofran, Hydrocodone-Acetaminophen,
tylenol, morphine and flagyl 500mg IV with improvement in
symptoms. Transfer VS 98.0 56 122/76 18 97%RA. Admitted for
management of symptoms/diverticulitis as well as poor PO intake
and emotional stressors (informed in the ED that brother, who
has been in a coma for the last year, passed away this morning). Radiology showed 1. Extensive colonic diverticulosis with early/mild sigmoid diverticulitis.
No free air or abscess.
2. Two enhancing liver lesions, likely hemangiomas. A non-emergent
ultrasound can be obtained to confirm the same as the left hepatic lobe lesion
was not seen in the prior ultrasound studies.
3. Multiple uterine fibroids. Normal appendix.
4. A 3 mm left lower lobe ground glass nodule, based on ___ criteria if
a high risk patient follow-up chest CT in a year is recommended. The patient was diagnosed with DIVERTICULITIS OF COLON. At the time of discharge, the patient had Primary: diverticulitis
Secondary: fibromyalgia, depression, asthma, tobacco abuse. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>A/P: ___ yo F with depression, chronic neck/back/abdominal pain,
admitted with new onset nausea/vomiting, LLQ abd pain, and
diarrhea for the past day and found to have mild sigmoid
diverticulitis on CT scan.
#Abdominal Pain/Diarrhea/Vomiting: Likely from diverticulitis.
Recent colonoscopy done over ___, a rectal polyp (which was
mass-like) was removed as precaution even though it was an
adenomatous mucosa (no dysplasia). No complaints of bloody
stools, BRBPR and this episodes seems acute, no chronic
diarrhea/constipation prior to this episode. UA was negative.
Appendix normal. No fevers recorded and no elevation in white
count. CT scan showed diverticulitis. Started on Levofloxacin
(Cipro allergy) and Flagyl. IVF as needed. Pain meds as needed.
Pt was no longer experiencing nausea or pain when interview by
primary team in the morning. Diet was advanced and there was no
recurrence of sxs. Pt was discharged home with instructions to
complete a 7day course of antibiotics (Flagyl and Levofloxacin).
___ an appt with her new PCP in ___ tomorrow.
# Depression/chronic diffuse body pains: Chronic pain possibly
due to depression/fibromyalgia, but also with fibroids in CT
which could be contributing to abd pain at baseline. She was
restarted on antidepressant medications just last week, and so
is not likely deriving a benenfit from them just yet. Patient
also lost her brother ___ today and is teary eyed and
understandably upset. Pt offered SW, respectively declined. ___
need w/u for fibromyalgia as outpt.
- cont fluoxetine 20mg daily
- cont ambien 5mg Qhs prn insomnia
- close outpatient follow up and titration of medications
- would not recommend narcotic treatment of pain as this is a
poor long term solution given addictiveness of these medications
# Asthma:
- Cont prn home albuterol and flovent, currently asymptomatic
# Liver lesions: Thought to be hemangiomas
- Non-emergent US can be obtained for confirmation as outpt
# Pulmonary Nodule: Consider f/u CT Chest in one year if patient
is high risk (current smoker) to assess nodule.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with a PMH notable for
nonischemic cardiomyopathy, permanent atrial fibrillation, RA,
and diabetes, who presents with worsening leg swelling.
The patient at baseline has chronic leg swelling. However, over
the course of the past few weeks, she has noticed increased
swelling and pain. She admits to having missed some doses of
medications because she depends on her daughter for help with
medications. Otherwise, she has felt ok with no chest pain,
palpitations, and lightheadedness. She has been having shortness
of breath and coughing.
In the ___ ED, she was given furosemide 40 mg IV and admitted
for further volume management.
On arrival to the floor, patient reports having severe pain in
her legs in addition to the history above. She also mentions
having dysuria sometimes.
Of note, per documentation from her PCP, ___, on
___, there is concerns about the patient's ability to care
for herself. "There are issues with the sanitation of her home
(infestation with cockroaches) as well as concerns about her
living situation with a husband who is also ill and with a
mentally-ill daughter who is also a ___. The patient refuses
to go to a ___ facility because her husband does not wish
to go also. ___ has discussed bubble-packing medications with
the patient as well as a need for doing pill counts to ensure
medication compliance."
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. Radiology showed Mild to moderate pulmonary edema, more prominent on the right. Unchanged
moderate cardiomegaly. The patient was diagnosed with Heart failure, unspecified, Urinary tract infection, site not specified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with a PMH notable for
nonischemic cardiomyopathy (HFrEF now 25%), atrial fibrillation,
seronegative rheumatoid arthritis, and diabetes, who presented
with worsening lower extremity edema concerning for acute on
chronic heart failure exacerbation. Her course was complicated
by acute kidney injury and flare of rheumatoid arthritis.
# Acute on Chronic Diastolic and Systolic Heart Failure: Her
exam is consistent with subacute heart failure from volume
overload. BNP was 2983 and CXR showed mild/moderate pulmonary
edema. Likely cause was thought to be poor medication compliance
(TSH elevated and Digoxin sub-therapeutic on admission
supporting non-compliance; patient admitted to difficulty taking
medications due to home situation- lives with daughter who is a
___) and dietary salt intake. History is not suggestive of
an MI precipitating this decompensation; TTE was without focal
wall motion abnormalities. Troponin was slightly elevated with
normal CK-MB, likely secondary to demand and/or renal
dysfunction. Repeat ECHO on ___ showed worsening global
biventricular systolic function with EF now reduced to 25% (from
50% in ___. Diuresis was initially achieved with a Lasix gtt
that resulted in significant improvement in her volume status.
She was transitioned to daily Torsemide alternating 20mg/10mg
for her diuretic regimen. Her weights were unreliable this
admission, as they were bed weights and fluctuated widely from
day to day; therefore this was not used as a metric of her
volume status. Digoxin was discontinued secondary to
bradycardia. Home metoprolol was switched to 100 mg daily.
Hydralazine and Imdur were started for afterload reduction.
# Acute kidney injury. Cr was 1.5 on admission, stable from
prior in ___, but higher than a baseline of 1.2 established
on ___ and ___. Likely cardiorenal in the setting of
slowly progressive volume overload, given that her Creatinine
initially improved with diuresis. However, Creatinine rose to
2.0 likely secondary to over-diuresis; urine microscopy did not
show evidence of casts. Creatinine on discharge was 1.9; she
will require re-check BMP at her next cardiology outpatient
appointment.
# Atrial Fibrillation. Rate controlled with metoprolol. Home
apixaban was initially continued but given development of acute
kidney injury with Cr > 2.___pixaban was held and
heparin gtt was started temporarily. She was transitioned to
apixaban prior to discharge.
# Hypothyroidism: TSH elevated to 34 on admission, likely in the
setting of medication non-adherence. Patient was continued on
home levothyroxine. She will require re-check of TSH within 4
weeks of discharge for titration of levothyroxine dose.
# Diabetes mellitus. Treated with insulin sliding scale. Home
glimepiride was held.
# Rheumatoid Arthritis. Home hydroxychloroquine and methotrexate
were continued. She was also supposed to be on prednisone 5 mg
daily at baseline. Pain control was achieved with Tylenol and
Oxycodone PRN. She was seen by rheumatology, who recommended
Prednisone 15mg for ten days, followed by prednisone 10 mg until
her next rheumatology appointment. If she will be on chronic
steroids, please consider monitoring of bone health; she also
requires monitoring for MTX and hydroxychloroquine toxicity as
an outpatient.
# Hyperlipidemia. Continued home atorvastatin
# GERD. Continued home omeprazole
# CAD Prevention. Continued home aspirin
# Urinary tract infection: Per NF admission note, patient
reports intermittent dysuria. UA on admission was positive for
infection. Previous cultures with Klebsiella (resistant to
amp/sulbactam and nitrofurantoin) and pansensitive E.coli. She
remained afebrile without CVA tenderness or suprapubic
tenderness on exam. Urine culture on this admission ___
speciated to Klebsiella and was treated with five day course of
ceftriaxone. Repeat UCx was sent on ___ and grew >10^5
Enterococcus. At that time, patient had Foley in place and was
asymptomatic (NO fever, rigors, altered mental status, malaise,
or lethargy with no other identified cause; flank pain;
costovertebral angle tenderness; acute hematuria; pelvic
discomfort); hence per ___ ___ guidelines treated as
asymptomatic bacteruria and did not cover with antibiotics.
Transitional issues
====================
- Discharge weight: Her weights were unreliable this admission,
as they were bed weights and fluctuated widely from day to day;
therefore this was not used as a metric of her volume status.
She was euvolemic on exam.
- Discharge diuretic regimen: daily Torsemide, alternating 20mg
and 10mg every day.
- Discharge heart failure medication regimen: Metoprolol XL 100
mg daily, Imdur ER 30mg PO daily, Hydralazine 10mg PO TID.
- Please note that patient is not on ACE-I ___ due to
angioedema.
- Consider adding spironolactone as outpatient; held off due to
unstable renal function and question of medication compliance as
outpatient
- If after 3 months of optimal medical management, LVEF < 35%,
consider ICD
- Discharge Cr 1.9.
- She will require repeat BMP to be drawn in one week, ___.
- Management of seronegative rheumatoid arthritis: Prednisone
15mg x10 days (day 1= ___, then start prednisone 10mg
daily until her next outpatient Rhuematology appointment.
- Consider outpatient DEXA scan as well as MTX and
hydroxychloroquine toxicity toxicity monitoring
- PCP ___ of repeat TSH in 4 weeks post discharge for
further titration of levothyroxine dosing.
# CODE: FULL
# CONTACT: ___, daughter, Phone: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with a history of CAD status post CABG ×2,
CKD on dialysis, severe AS s/p TAVR, dementia presenting from
dialysis with chest pain.
Patient is a poor historian and unable to give full history.
She reports she was at home watching television when she had a
sudden onset of chest pain, which lasted for 2 hours and resoled
on its own, and was not accompanied by dyspnea, palpitations,
nausea/vomiting, or pain in the arm or jaw. She reports that
this has never happened before. Per ED report, patient was in HD
when chest pain started and was sent from either HD or her rehab
facility because of the chest pain.
In ED, initial vitals were T 96.9 HR 78 BP 116/78 RR 18 O2 sat
96% RA. Exam unremarkable; labs notable for microcytic anemia
near baseline and Cr 2.7, and troponin 0.05->0.06 with normal
MB. EKG showed sinus rhythm with PACs, and TWI in V1-V2 and aVL,
largely unchanged from prior. CXR notable for mild pulmonary
edema. Plan was for DC to rehab, however patient was admitted to
cardiology when BNP found to be elevated to ___. Patient was
given 80 mg IV Lasix prior to transfer to floor.
On the floor, patient first reports never having chest pain,
then endorses one episode as described above that resolved on
its own. She has no chest pain, shortness of breath, or other
complaints at this time.
REVIEW OF SYSTEMS:
Positive per HPI. 10-points ROS reviewed and otherwise
negative. Radiology showed Cardiomegaly without superimposed acute cardiopulmonary process. The patient was diagnosed with Chest pain, unspecified, Athscl heart disease of native coronary artery w/o ang pctrs, Essential (primary) hypertension. At the time of discharge, the patient had Atypical 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>Ms. ___ is a ___ year old woman with a past medical history
of CAD status post CABG ×2V, grade I diastolic HF (EF 60-65%),
CKD on dialysis, severe AS s/p TAVR, dementia presenting from
dialysis with chest pain. Problems addressed during her hospital
admission are listed below:
ACTIVE ISSUES:
=================================
# CAD s/p CABG
# Chest pain:
Patient reported one episode of stabbing ___ anterior chest
pain in hemodialysis that lasted < 1 hour, self resolved without
intervention in the morning of ___ during hemodialysis session.
No additional chest pain. EKG changes with TWI in V1-V2, aVL
unchanged from prior. Troponin 0.05->0.06->0.06 in setting of
renal failure. Continued home metoprolol, ASA, atorvastatin.
# S/P TAVR:
# Elevated BNP:
BNP elevated >42000, however in the setting of end stage renal
disease on dialysis is difficult to interpret. Received 80 mg IV
Lasix in ED, without significant urine output. No other signs of
volume overload.
CHRONIC/STABLE ISSUES:
====================================
# Renal failure:
ESRD on dialysis.
# Microcytic anemia:
Likely secondary to renal failure. Remained at baseline
(8.3-8.5).</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ who presents from OSH for finding of cerebral aneurysm.
Pt was seen at ___ in ___ for evaluation
of her L eye visual changes and intermittent headaches that she
has been having for roughly three months. Her L eye visual
changes are described as "white light smudge" in her central
vision that is intermittent and self resolving. She saw her
ophthalmologist with full exam roughly 1 month ago. Her
headaches
are described as behind her left eye and temporal area that
radiates to the back of her head. These headaches seemed to
improve when she was taking Flonase periodically. Diagnostic cerebral angiogram and pipeline embolization of 2
left internal carotid artery aneurysms, unruptured
During the procedure the following vessels were selectively catheterized
angiograms were performed:
Right common carotid artery
Left vertebral artery
Left common carotid artery
Three-dimensional rotational angiography of the left common carotid artery
circulation requiring post processing on an independent workstation and
concurrent attending physician interpretation and review
Left common carotid artery after pipeline placement
Three-dimensional rotational angiography of the left common carotid artery
circulation after pipeline placement requiring post processing on an
independent workstation and concurrent attending physician interpretation and
review
Right common femoral artery showed Large back wall ophthalmic segment left ICA aneurysm and smaller more proximal
left ICA aneurysm successfully treated with pipeline embolization
Right cavernous internal carotid artery aneurysm
Evidence of fibromuscular dysplasia in the V3 segment of the left vertebral
artery
RECOMMENDATION(S):
1. Continue dual anti-platelet. Follow-up per protocol with angiogram in ___
years time CHEST (PRE-OP PA AND LAT) showed No pneumonia. The patient was diagnosed with Cerebral aneurysm, nonruptured. The patient was treated with ___ - Cerebral angiogram and pipeline/coil of left ICA
aneurysm. At the time of discharge, the patient had Left ICA aneurysm. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo female with left eye visual changes presents after
outpatient MRA showed a 9mm Left ICA aneurysm.
# Patient presents after MRA shows left ICA aneurysm near the
optic nerve. She remained Neurologically intact. She was
loaded with Brilinta and ASA. She underwent cerebral angiogram
and pipeline embolization of the left ICA aneurysm on ___
and was transferred to PACU. She remained neurologically and
hemodynamically intact. She ambulated well with nursing on POD
1 and was discharged home.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M w/ PMH HTN, HLD, DMII, who presents with acute onset,
worsening chest pain of 3 day duration. Describes symptoms as
left sided pain ___ with radiation to left back and shoulder.
Started at rest, not worse with exertion or positional changes.
Of note has recent history of herpes zoster 3 months prior with
residual burning sensation, mildly tender with palpation. States
that his current pain is separate from burning and tenderness.
Biked 40 min without pain, not aggravated by physical exertion.
Denies any SOB, nausea, chills, numbness, weakness, dizziness,
palpitations, ___ swelling. Reports feeling warm on ___ but no
measured fever and occasional tingling sensation in feet. Family
at bedside states he has been complaining of loss of appetite
and
fatigue, (was observed to have difficulty going up stairs 3 days
ago due to fatigue), and increased thirst. CHEST (PA AND LAT) showed No acute intrathoracic process. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had Noncardiac chest pain
Heart failure with newly reduced ejection fraction. The patient was given written instructions concerning 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
===================
- Recommend CT angiogram to assess for presence of proximal
blockage leading to global hypoperfusion and decreased ejection
fraction discovered on nuclear stress and echo.
- Consider adding spironolactone to management of HFrEF
- Encourage alcohol cessation and medication compliance
- Ongoing evaluation of reduced EF (40%).
HOSPITAL COURSE
===================
___ yo M w/ PMH HTN, HLD, DMII, who presented with chest pain of
3 day duration. Chest pain had some features concerning for
angina (left sided with radiation to left back and shoulder)
though was not worse with exertion. Patient underwent pMIBI that
showed good functional capacity without anginal symptoms, but
did show septal hypoperfusion with EF 40%. TTE was obtained that
confirmed EF 40% but was not of good enough image quality to
exclude regional wall motion abnormalities.
ACUTE ISSUES
=================
#HFrEF
#Dilated cardiomyopathy
LV dilation and reduced EF 40% discovered on pMIBI despite
normal stress portion and no perfusion deficits on nuclear
imaging. Dilated cardiomyopathy was confirmed on TTE but images
were image quality was not adequate to exclude focal wall motion
abnormalities. Our highest suspicion is for nonischemic dilated
cardiomyopathy, though outpatient cardiologist could consider
coronary CT angiogram to assess for proximal lesion leading to
global hypoperfusion (low suspicion given excellent exercise
tolerance). Per ___ records, he was previously diagnosed with
hypertension induced cardiomyopathy and had a recovered normal
EF on prior echo. In light of persistently elevated BP, we
increased carvedilol dose to 25mg BID to optimize hypertension
and heart failure. Chagas antibodies were pending at time of
discharge. Patient should also be encouraged to quit alcohol
completely. Cont carvedilol, lisinopril.
#Chest pain, atypical
Patient remained HDS throughout, without any SOB. Found mild,
non-sustained relief with sublingual nitroglycerin. Thought
chest pain likely to be due to non-cardiac causes given
excellent exercise tolerance with improved sx with exercise,
normal perfusion images, and relief with Maalox. Had low concern
for PE or dissection.
CHRONIC ISSUES
=================
#HTN
- Increased home carvedilol from 12.5 to 25 mg BID
- Cont chlorthalidone 25 mg
- Cont amlodipine 10 mg
- Cont lisinopril
#NIDDM; most recent A1c 7.7
- Continue SSI
- Hold home metformin
- ASA 81 mg
#HLD
- Cont Atorvastatin 80 mg
#GERD
- Cont omeprazole 20 mg</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with a history of
deprsesion and anemia (currently being evaluated as an
outpatient) who presenting with sudden onset of nausea,
vomiting, and vertigo. Patient was on her way to an outpatient
CT abdomen/pelvis (to evaluate for source of bleeding) and she
began to feel the world spinning around her while walking on the
street. This was accompanied by nausea and vomiting X 1,
nonbloody and she needed to sit down. She did not fall or pass
out. She feels a worsening sensation of a ringing sound in her
ears which she states she has been present for one year. She
denies abdominal pain, chest pain, dyspepsia, recent viral
illness or palpitations. She has no exertional symptomas and has
an irritated feeling on her right chest "left over" from her
pneumonia 2 months ago, though she denies cough. She denies any
numbness/tingling/weakness/urinary or bowel incontinence,
hearing problems, or vision problems. Radiology showed No evidence of acute disease. Radiology showed No evidence of intracranial process. Radiology showed 1. No acute intra-abdominal process.
2. Large hiatal hernia.
3. Nodular opacity at the left base likely represents residual disease of
multifocal pneumonia, though atlectasis or new focus of infection are not
excluded. The patient was diagnosed with VERTIGO/DIZZINESS, ANEMIA NOS. At the time of discharge, the patient had PRIMARY DIAGNOSES:
- Abnormal EKG
- Depression
- Anxiety
- Pseudoseizure. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with a history of
depression and anemia (currently being worked-up by PCP) who
presented with the sudden onset of nausea, vomiting, and
vertigo. She was admitted due to anterior T-wave inversions seen
on EKG changes. Admission EKG also showed a new prolongation in
QTc.
ACTIVE ISSUES
1. EKG changes: Upon review of prior tracings, patient's
anterior T-wave inversions were present as early as ___, but
the one tracing showing a newly prolonged QTc was concerning for
possible ischemia. She was without chest pain (with exception of
symptoms during an episode of severe agitation; please see
below) but did endorse fatigue in the setting of anemia
(currently undergoing outpatient work-up). Patient had multiple
sets of cardiac enzymes, all of which were negative. She
underwent a stress ECHO, which suggested possible inducible
ischemia of the mid-to-distal anterior septum. She then
underwent a stress MIBI, which was negative for inducible
ischemia. Patient was reassured that, with these results, she is
unlikely to have a significant arterial blockage. She was
started on an aspirin and scheduled for outpatient Cardiology
___ with Dr. ___.
___. Agitation: On the evening before MIBI scan, patient became
acutely agitated. She was seen by her roommate to be flailing
her arms and legs in bed. Her nurse came to see patient, who was
not responsive, and a Code Blue was called and then canceled, as
patient had pulses and was following commands, spitting
purposefully, and tracking with her eyes. Patient then became
behaviorally dysregulated, using abusive language towards her
providers. She complained of chest pain and asked for her heart
to be cut out of her chest. EKG and enzymes were negative.
Patient was seen by the psychiatry consult service on the
following day, who felt her behavior may have been a
dissociative episode in the setting of stress vs. volitional vs.
pseudoseizure. She was cleared by psychiatry for discharge and
encouraged to ___ with her outpatient psychiatrist at ___.
3. L Carotid Bruit: Consider carotid ultrasound as outpatient.
4. Vertigo: Given association with tinnitus, Meniere's disease
was considered most likely, She did not have recurrent symptoms
during her hospitalization. She was referred back to her PCP.
Please consider outpatient audiology/ENT referral.
5. Anemia: Patient's anemia is microcytic and has been chronic,
currently undergoing outpatient work-up. She did not have
melena, hematochezia, or hematemesis during hospitalization. HCT
trended down during admission, which may have been due to
phlebotomy. Patient was instructed to walk in to her PCP's
office for repeat CBC.
CHRONIC ISSUES
1. Depression: Patient reported stopping her previous outpatient
psychiatric medications on her own, which included fluoxeting,
quetiapine, bupropion. She was referred back to her outpatient
psychiatrist as above.
2. Barretts Esophagus: Continued home Prilosec.
TRANSITIONAL ISSUES
- Repeat HCT
- Consider referral to outpatient audiologist/ENT for further
evaluation of vertigo
- Schedule with ___ psychiatrist within next week
- Continue anemia work-up
- Patient was noted to have a left carotid bruit. Consider
outpatient carotid dopplers. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ PMH HIV (undetectable, on Tivicay &
Descovy), recurrent invasive anal SCC s/p lap/robotic proectomy
w/ end colostomy, V-Y flaps ___ (___), presenting with
fevers. Mr. ___ was discharged home on ___, and initially
did well at home. The day prior to his presentation on ___,
he felt warm and had a temperature of
100.8F. This evening he felt even warmer and had shaking chills,
with a temperature of 101.2F. This prompted him to seek care at
the ___ ED. He reports some increasing pain in the V-Y flap
incisions, some moderate pain in the lower abdomen around bowel
movements, and occasional mild burning with urination. He denies
nausea, vomiting, chest pain, shortness of breath, productive
cough, diarrhea, or bloody bowel movements. Chest radiograph showed Please note change from the original posted preliminary interpretation:
Probable acute left lower lobe pneumonia.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 09:05, 15 minutes after the
initial page was placed immediately following discovery of the findings. CT abdomen and pelvis showed 1. Patient is status post prostatectomy with end colostomy. Pelvic and
peroneal drains appear in place without deep pelvic collection. There is
postoperative inflammation in the deep pelvis. No small bowel obstruction.
There is no drainable collection.
2. Multiple prominent retroperitoneal and mesenteric lymph nodes, measuring up
to 1.1 cm in short axis, may be reactive, although neoplastic involvement is
difficult to exclude. These lymph nodes appear larger compared to ___. Lymph nodes did not appear FDG avid on recent PET-CT. CHEST (PA AND LAT) showed No substantial interval change from the prior radiograph obtained earlier in
the day. Persistent patchy left basilar opacity, potentially atelectasis or
reflective of pneumonia in the correct clinical setting. Background mild
interstitial abnormality lung bases is unchanged and better characterized on
the prior CT chest from ___. UNILAT LOWER EXT VEINS LEFT showed No evidence of deep venous thrombosis in the left lower extremity veins. The patient was diagnosed with Cellulitis of left lower limb. At the time of discharge, the patient had Recurrent rectal cancer s/p robotic proctectomy, diverting end
colostomy, perineal ___ flap. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient presented to ED with reported fevers at home. Since
admission he had remained afebrile and hemodynamically stable.
His WBC was 8.1, no bands on CBC diff, electrolytes were normal,
urinalysis was normal. He had a CT abdomen and pelvis with
contrast which did not show any abscess or intra-pelvic or
abdominal infection. Patient was evaluated by the colorectal
surgery team who did not believe there was any indication for
admission or surgical intervention, no significant intrabdominal
process. The patient was also evaluated by the plastic surgery
team, who noted well healing ___ flaps without signs of infection
or abscess. They did recommend a short course of bactrim for
prophylaxis and acyclovir due to some small lesions at the flap
and the patient's history of HIV. On imaging workup, CXR showed
left basilar opacity but CT abdomen pelvis showed L lower lung
which showed no consolidation, and patient did not have symptoms
consistent with pneumonia. Patient was admitted for observation,
where he remained afebrile and HDS. His exam was unchanged and
he was in stable condition for discharge home with services. He
was advised to take PO Benadryl PRN for itching at the flap
site. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ presenting to the ED w/ weakness, fatigue, exertional
shortness of breath and weight loss. Patient was in her USOH
until ___ whewn she notes "Bronchitis" started -
describes this as severe cough with productive sputum,
rhinorrhea, malaise, no fevers/chills. Did have flu vaccine this
season. Never a smoker. Patient was evaluated by PCP who rx
___ without much improvement. Also tried cough codeine which
also did not help her cough. As symptoms persisted patient
noticed more pallor of skin, poor appetitie and weight loss
(1llbs since ___ so went to see PCP in ___. PCP noticed ___
mass and labwork that concerned him, encouraged patient to be
admitted for further evaluation. Radiology showed No acute cardiopulmonary process. Radiology showed 1. Enlarged spleen, measuring 24 cm in the craniocaudal dimension.
2. No pulmonary embolism.
3. Right sided position of a portion of small bowel lateral to the ascending
colon, possibly representing an internal hernia. The patient was diagnosed with OTHER MALAISE AND FATIGUE, ABDOM/PELV SWELL/MASS OTH SITE, HYPERCHOLESTEROLEMIA. The patient was treated with Bone marrow biopsy. At the time of discharge, the patient had PRIMARY:
- Splenic Marginal Cell Lymphoma
- Massive Splenomegaly
SECONDARY
- 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>___ yo female with several month history of malaise now with
Anemia, Thrombocytopenia, massive splenomegaly, elevated DDimer,
low hapto and elevated LDH.
.
# Splenic Marginal Zone Lymphoma - Patient presented with FTT
with Massive Splenomegaly, Low Hapto, elev LDH,
Thrombocytopenia, Anemia, Positive Direct Coombs, atypical
Lymphocytes - Patient's presentation was in the setting of URI
she experienced ___, however, given further evidence noted
in her labs, we pursued a malignancy work up. Moreover, a
Spleen of 24cm is atypical for viral infections. Hematology was
consulted after atypical cells were seen in periphery. Patient
was never in any acute distress and her vitals remained stable.
Her symptoms of malaise and cough improved during her stay. Her
symptom of early satiety, likely related to the massive spleen,
did not resolve fully. She remained in the hospital to have a
Bone marrow biopsy. The preliminary results, as described
verbally by the HemeOnc fellow showed "Splenic Marginal Zone
Lymphoma". On the last day of the patient's stay, we discussed
these results with first the patient's daughters. At the time
of our discussion we presumed a diagnosis of MZL. Family and
patient were made aware that the final results will not be back
until ___, the day of her appointment with Dr. ___. The
family insisted not to use the term "Cancer" with the patient,
and we respected this wish. The hematology fellow did describe
the findings and how she can be treated with Rituximab. The
prognosis of ___ years as a median number was given to the
family, if indeed this is the final diagnosis. The family was
very thankful and understanding. They were anxiously awaiting
the appointment on ___. At discharge, final results were
pending, as were Hepatitis serologies.
.
.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o F with PMH orthostatic hypotension and iron-deficiency
anemia presenting with worsening lightheadedness when standing
up and dyspnea on exertion. She notes symptoms have worsened
over past week, becomes LH when standing up or lying down, and
worsening heart racing and shortness of breath after walking
short distances. Has felt cold the past day, no fevers, no chest
pain/pressure, no abdominal pain, n/v/d, dysuria. Underwent
colonoscopy/EGD ___ for iron-deficiency anemia without any
significant findings. No falls or syncope. Has had issues with
orthostatic hypotension for several years now, on florinef since
then. Symptoms have worsened over the past month-has had to
receive IVF for orthostatic sx 4 times in the past month. Blood
pressure has responded to fluids in those circumstances. Has
been drinking plenty of fluids, urinating fine. No diarrhea,
nausea/vomiting. Had not been wearing compression stockings.
In the ED, initial vitals: 97.9 99 123/77 19 96% RA.
Orthostatic vitals: 131/99 (lying), 116/76 (Sitting), 109/52
(Standing). Repeat s/p 1L NS: 143/74 (Laying Down), 108/69
(Sitting), 84/54 (Standing) CHEST (PA AND LAT) showed No evidence of pneumonia. Hiatal hernia. The patient was diagnosed with Orthostatic hypotension. At the time of discharge, the patient had Primary Diagnosis
- Orthostatic hypotension secondary to adrenal insufficiency
Secondary Diagnosis
- Anemia
- OSA
- GERD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o F with long history of orthostatic hypotension and
iron-deficiency anemia presenting with lightheadedness,
dizziness and DOE found to have orthostatic hypotension.
#Orthostatic Hypotension: The patient has a two year history of
orthostatic hypotension without clear etiology, with worsening
of sx over last month requiring multiple visits to ED/UC for IVF
despite use of florinef. She appeared hypovolemic on exam and
endorsed thirst, making hypovolemia a likely cause of her
orthostatic hypotension. There was low suspicion for cardiac
etiology given lack of cardiac history, negative troponins x 2,
and reassuring ECG. No recent ECHO on file. Her oxygen
saturation remained above 94% with ambulation. Repeat
orthostatics on ___ showed lying BP of 150/90, standing
128/78. he was given a total of 4L of IVF, and her orthostatic
hypotension resolved after IVF. As per new guidelines about
supine hypertension, positive orthostatics include systolic BP
drop >30 and diastolic drop >20. Patient does not meet criteria
for orthostatic hypotension. We arranged follow up with ___
Autonomics (Neurology) for further workup of her orthostasis.
Of note, AM cortisol level ___ was low at 5.3, but it was
normal (7.2) when it was checked the morning of 11.29. She
responded appropriately to the cosyntropin stimulation test
(7.2-->25.3-->32.2). ACTH level was normal at 10 (reference
range ___ pg/mL). She does not have primary or secondary
adrenal insufficiency.
#Dyspnea on Exertion: She has been having increasing dyspnea on
exertion since ___ but states that it has been worse over the
past month, and particularly the past week as she has begun to
notice dyspnea with minimal exertion. As above, there is low
suspicion for cardiac etiology. She may have other respiratory
pathology contributing to progressive dyspnea including a mass
not visualized on CXR or pulmonary HTN given history of OSA. She
presents with anemia, however her Hgb is consistent with her
baseline iron-deficiency anemia. Ambulatory O2 saturation
remains in mid to high ___. It would be beneficial to obtain a
TTE as an outpatient. Further consideration of outpatient PFTs
and a non-contrast CT of the chest may also be helpful. ___
evaluated the patient and recommended outpatient physical
therapy.
TRANSITIONAL ISSUES
===================
#Orthostasis
- The patient should follow up with ___ Neurology
(specifically ___ who specializes in autonomic
neurology) for further management of her orthostatic
hypotension.
- Consider discontinuing fludricortisone (since it does not
appear to be effective), and consider starting midodrine 2.5mg
TID for orthostatic hypotension. Patient would need close blood
pressure monitoring for supine hypertension given that she is
also on Adderall.
#Shortness of Breath
- It may be beneficial to obtain a CT of the chest and PFTs to
further evaluate the patient's shortness of breath.
- The patient should get an echocardiogram to evaluate cardiac
function or pulmonary hypertension given persistent shortness of
breath.
- Patient should begin outpatient physical therapy
# CODE STATUS: Full code (confirmed)
# CONTACT: ___ (daughter, ___,
___ (daughter, ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o crohns (on pred taper and ___ with recent adission for
flair presents with n/v and epigastric pain x 2 days, which she
feels is similiar to prior flairs. No fever, diarrhea, denies
dark or bloody stool and she vomitted once yesterday. The pain
is epigastric and similar to the pain she had on prior adission
and it radiates to the back. Of note a typical crohns flair
invovles lower abd pain, no diarrhea. She denies taking
narcotics at home, only when she is hospitilized.
Of note Since d/c her pred was decr from 60-->40mg daily and and
___ was started. Recent admission ___ for crohns flair. pt
was made NPO, tx w cipro/flagyl, IV solumedrol then PO
prednisone 60mg, course c/b Transaminitis which was felt to be
medication effect and cipro/flagyl were d/c'd.
In the ED intial vitals were: 99.4 96 143/94 20 100% RA
- Labs unremarkable
- Patient was given ondansetron, morphine
Plan was to admit to medicine for crohns flair
On the floor she described epigastric pain relieved by morphine Radiology showed 1. Stable appearance of the gallbladder with dense sludge and early stone
formation. No evidence of cholecystitis.
2. Echogenic liver consistent with fatty deposition. Other forms of liver
disease and more advanced liver disease including steatohepatitis or
significant hepatic fibrosis/cirrhosis cannot be excluded on this study. The patient was diagnosed with ABDOMINAL PAIN RUQ. At the time of discharge, the patient had PRIMARY DIAGNOSIS
1. Biliary Colic
SECONDARY DIAGNOSIS
1. Crohn's 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>___ obese, h/o crohns (on pred taper and ___ with recent
adission for flair presents with epigastric pain x 2 days
ACUTE ISSUES
#Epigastric pain:
Patient's abdominal pain was most likely due to biliary colic
given the location of her pain, the fact that food precipitates
her pain, and biliary sludge seen on RUQ ultrasound. Her pain
was less likely to be due to a Crohn's flare given that her
inflammatory markers were decreased from her last admission 1.5
weeks prior, and the location and quality of her current pain is
not typical of Crohn's disease. She denied any fevers, was
afebrile during admission, and did not have an elevated white
blood cell count making infection or abscess as a complication
of her Crohn's Disease less likely.
The patient tolerated a PO trial of food without nausea or
emesis. Her out-patient gastroenterologist Dr. ___ was
contacted and it was decided that the patient could follow up
with the surgical staff to discuss possible cholecystectomy as
an out-patient.
CHRONIC ISSUES
# Chronic anemia:
The patient's anemia is likely related to IBD. She would likely
benefit from IV iron infusion which she can get as outpatient.
Hct at baseline of 33. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with Sneddon syndrome (necrotizing vasculitis),
CVA (___), anti-phospholipid syndrome, history of uterine
hemorrhage on warfarin, DVTs with IVC filter in place since ___
who presented to her PCP at ___ and found to have LLE DVT and
RLE cellulitis referred to ___ for treatment. She was
hospitalized previously for leg pain, cellulitis, DVTs. She had
an appointment with PCP today, LENIs were done, and she was
found to have a DVT in LLE. There was also concern for
cellulitis of the right leg. CHEST (PA AND LAT) showed No acute intrathoracic process. BILAT LOWER EXT VEINS showed 1. Partially occlusive DVT is identified involving left common femoral vein.
2. Linear echogenicity in the left popliteal vein may reflect the sequela of
prior dvt or partial thrombosis. The vein is otherwise normal with normal
compressibility.
3. No evidence of DVT is identified in right lower extremity veins.
4. Left popliteal ___ cyst. The patient was diagnosed with Cellulitis of right lower limb. At the time of discharge, the patient had deep vein thrombosis of the left lower extremity. The patient was given written instructions concerning 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 episode of necrotizing
fasccitis in ___ s/p skin grafts, provoked DVT (___) s/p IVC
filter placement and later treated with Coumadin for about ___
years (which was later stopped after she had an episode of
vaginal bleeding in the context of a supratherapeutic INR), and
also carries a dx of Sneddon syndrome (a form of vasculitis with
livedo reticularis) with prior stroke (residual L sided
symptoms) on mycophenolate mofetil complicated by recurrent
infections and chronic pancytopenia (followed by hematology Dr.
___ as outpatient on IVIG injections); who presented
to her PCP at ___ with R leg swelling and redness, found to
have RLE cellulitis and LLE DVT (admitted for management of the
latter.
___ Hematology was consulted while inpatient who reviewed her
prior hypercoagulability workup and noted that although she has
a history of "antiphospholipid syndrome" in her chart, she has
only had one marginally positive lupus anticoagulant but has
since had negative testing so she does not carry any known
clotting diathesis. Regardless, this is at least her second clot
and this time appears unprovoked. After a discussion with the
patient, we decided to continue her on lovenox and she will
follow up with her hematologist to discuss newer novel
anticoagulants as well as the goal duration of therapy (?
indefinite). Rest of hospital course and plan are outlined
below.
# Deep venous thrombosis: patient with history of clotting in
past, with confirmed antiphospholipid syndrome, found to have
LLE DVT at PCP's office. Patient has significant history of
bleeding while on warfarin. She reports being on an herbal
anticoagulant called Nattokinze.
-hypercoagulability workup to date including normal homocysteine
level, negative factor V Leiden testing (___). Note that she
had a transient marginally positive lupus anticoagulant which
was negative on subsequent testing and does not constitute APLS.
-given complicated bleeding complications, Dr. ___
hematology did not recommend starting DOAC/NOACs
-prothrombin ___ gene mutation which was not available to be
ordered while inpatient and will need to be ordered when she
follows up with her hematologist. Other thrombophilia testing
was not possible at this time given current anticoagulation.
- per hematology, started on lovenox 50mg q12h
-note that I believe the patient may have an IVC filter in place
since ___ (the patient wasn't sure if this had been removed or
not) which needs to come out, the patient is aware of this.
-pt requesting home services for lovenox injections (because of
hand weakness relating to stroke), which was arranged.
-prior auth was completed for one month supply of sc lovenox
50mg q12h at ___, ___. Address: ___, ___
# Cellulitis: patient with erythema of left leg and pain to
palpation. Dx of cellulitis was questionable but given
immunosuppression and apparent improvement with one dose of
linezolid given in the ED, we opted to treat. Given multiple
allergies to oral and IV antibiotics and amox allergy listed as
"AIN" would avoid all beta lactams and cephs. Has tolerated
moxifloxacin in the past which has good strep coverage so opted
for this.
-repeat ___ ultrasound ordered to r/o clot in R leg to explain
the redness there which showed no clot so infection was felt
more likely so we proceeded with antibiotics.
- given one dose of linezolid in the ED but we avoided
continuing this due to potential exacerbating effect on
pancytopenia
- advised to keep legs elevated
- moxi x 5 days (___)
# Pancytopenia: relatively new finding, may be related to immune
suppression from mycophenolate. stable this admission
# Hyponatremia: chronic, stable to improved since admission,
unclear cause.
# Vasculitis: continue home mycophenolate
# Hypertension: continue home lisinopril, carvedilol
# Asthma: continue home albuterol, Advair, montelukast,
tiotropium
# Transitional Issues:
- moxi x 5 days (___)
- patient will need to schedule herself for follow up with
hematology (since this is a ___ Dr. ___ for follow
up and to decide on duration of anticoagulation and continued
prescription of lovenox injections.
-our hematology consultant recommended checking a prothrombin
___ gene mutation which was not available to be ordered while
inpatient and will need to be ordered when she follows up with
her hematologist.
-note that I believe the patient may have an IVC filter in place
since ___ (the patient wasn't sure if this had been removed or
not) which needs to come out at some point, the patient is
aware of this. Will need eventual outpatient ___ referral for
evaluation.
-note the patient is on aspirin, would defer the decision as to
whether to continue this medication to outpatient hematologist
given increased risk of anticoagulation plus antiplatelet,
especially in the setting of chronic mild thrombocytopenia.
# DVT ppx: enoxaparin
# Diet: Regular
# Code status: Full, confirmed
# Dispo: was at home with services. D/c home with continued
services on ___ after teaching and if tolerates injections.
> 30 minutes were spent seeing the patient and organizing
discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with HTN and recently diagnoses HepC cirrhosis and
metastatic HCC who presents with N/V. Per report symptoms began
approximately 2 days ago. Emesis is no bloody in nauture and
associated with midepigastic discomfort. She reports she has
been having regular bowel movements. She denies chest pain,
shortness of breath, or urinary symptoms. She reported to an OSH
where labs were notable for a bili of 6 from a value of 3.9 at
discharge, a HCT of 40 and sodium of 130. She was given 500 mL
of normal saline, morphine 4 mg IV x 2 and 4 mg of zofran x 2
and transferred to ___ for further management.
Of note pt was recently admitted to ___ in ___ with
intractable N/V at which time she was found to have labs c/w
cirrhosis. HCV VL that admission was 3.4 million. CT abd/pelvis
showed cirrhosis and raises concern for HCC with mets to
lung/colon, subsequent liver bx showed HCC. Pt was also found to
have a portal vein thrombus. She was briefly anticoagulated but
developed guaiac stools and anticoagulation was stopped. She was
discharged on antiemetics and pain medications.
In the ED, initial vs were: 98.2 111 103/61 24 94% 2L (patient
is not on home O2). Labs were remarkable for Na 129 (131 at
recent discharge), AST/ALT 352/90 (c/w last admission), Tbili
6.3. Patient was given zofran, morphine. Dx para was negative
for evidence of SBP. Vitals on Transfer: 96 126/64 16 92%.
On the floor, the patient was sleepy but arousable. She denied
current pain.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative. Radiology showed ? infiltrate vs. atelectasis right mid lung. The patient was diagnosed with LIVER DISORDER NOS. The patient was treated with Diagnostic paracentesis. At the time of discharge, the patient had Metastatic/Stage IV HCC
HCV cirrhosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with HTN and newly diagnosed HCV cirrhosis and metastatic
HCC who presents with poorly controlled abd pain and
nausea/vomiting.
# Metastatic Stage IV HCC, HCV cirrhosis: Pt with ongoing N/V
likely related to her metastatic HCC. Diagnostic paracentesis
negative for SBP. Family meeting was held in conjunction with
Palliative care service with plan to transition to home hospice
and focus on comfort care measures only. Prognosis very poor and
given the rapidity of her decline, life expectancy of weeks to
months was relayed to the family who supported patient's wish to
return home as soon as possible. Pt was made DNR/DNI. There was
no evidence of acute process and it was felt that her symptoms
are secondary to her end stage underlying malignancy. She
responded well to low dose oral dilaudid (standing) for pain.
She received compazine and reglan for antiemetics with good
control. She exhibited poor appetite and the family was
encouraged to focus on comfort eating - small bites, frequently
throughout the day and de-emphasized focus on nutrition. No
indication for percutaneous gastric or jejunal feeding tube
given her ascites. Family deferred nasogastric ___ given her
current goals of care and ongoing nausea. Her current bilirubin
level would exclude any palliative chemotherapy. Further w/u of
her elevated bilirubin with repeat CT scan to assess for biliary
obstruction and possible percutaneous drain placement were
declined by the patient and her family.
# Hypoxia- patient with new O2 requirement in the setting of
mild tachycardia. She is wheezy on exam. most likely related to
high degree of malignant pulmonary infiltrate. She was treated
with albuterol nebulizer treatments with plan for treatment of
any SOB or air hunger with opioids.
# Hyponatremia: Na 129 at admission, largely unchanged from 131
at recent admission. Na improved with IVF last admission. Most
likely hypovolemic hyponatremia ___ poor po intake. Improved
with colloid administration consistent with hypovolemia.
# HCV Cirrhosis with metastatic HCC: LFTs at recent baseline,
bili elevated compared to prior. Not anticoagulated for portal
vein thrombosis as it is not clear if this is tumor or clot.
Given short life expectancy and risk of bleeding, will continue
to hold anticoagulation.
# CODE: DNR/DNI, comfort measures only
# CONTACT: ___ (husband) ___
+
=
=
=
=
=
=
=
=
=
================================================================
Transitional issues
- dc home with hospice
- Pain control with oral dilaudid, decadron. Antiemetics with
compazine, reglan. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ yo F with a PMHX of pancreatic divisum and chronic
pancreatitis, congenital choledochoal cyst s/p multiple
surgeries to correct and is 8 weeks post partum who now p/w
epigastric pain.
.
The patient reports having right axillary pain that is not
similar to her pancreatitis pain during her pregnancy.
Following her delivery, this pain resolved and 2 weeks after
pregnancy she began to have different pain that was epigastric,
radiating to the right, ___ and bearable. She managed the pain
at home and then this ___, the patient had this pain again,
which she took oxycodone 5 mg and made herself NPO. The pain
resolved on ___. Then on ___ she had hot flashes without
fevers and ___ at 4 am, she woke up with ___ epigastric
pain. She can't think of anything that may have changed that
caused this exacerbation. She recently re-started nortriptiline
1 month ago for pain. She intially went to ___
where they noticed her lipase was elevated, they did a RUQ US
which was reportedly normal.
.
AT ___, the patients VS were stable. She was given pain
medications and sent to the floor.
.
On the floor, the patient endorses ___ pain in the epigastric
region and denies rash, n/v. Describes the pain as grabbing in
the infracostal margin on the right side. Had an episode of
flatus and diarrhea this am. She acknowledges that she had a GI
illness about 3 weeks ago with n/v and diarrhea but her bowel
habits have returned to normal since that episode.
.
ROS is positive for nausea, flushing both of which were self
limited, also parathesias in BUE while holding the baby since
giving birth to baby 8 weeks ago Radiology showed 1. MR findings compatible with acute interstitial pancreatitis. No evidence
for necrosis.
2. Dorsal dominant duct configuration.
3. Status post resection of choledochal cyst with CBD remnant within the
pancreatic head, unchanged from the prior study.
4. Linear atelectasis in both lower lung lobes.
5. Status post hepaticojejunostomy with pneumobilia within the left lobe of
the liver.
6. Stable subcentimeter cystic lesions in the spleen.
These findings were communicated by Dr. ___ by phonee to Dr. ___ at
9am on ___. The patient was diagnosed with ACUTE PANCREATITIS. At the time of discharge, the patient had acute pancreatitis
history of chronic pancreatitis due to pancreas divisum
dyspepsia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ yo F with a PMHx of congenital choledochal cysts
s/p resection and multiple procedures, chronic pancreatitis and
pancreas divisum who p/w acute on chronic pancreatitis with a
lipase in the 3K range
.
##Acute on chronic pancreatitis
The patient presented with signs and symptoms typical of prior
flares of pancreatitis from an OSH. At the OSH, her RUQ was
found to be normal and her lipase was found to be elevated.
Upon transfer to ___, the patient was treated for acute
pancreatitis with IV fluids, pain medications and bowel rest.
MRCP showed interstitial pancreatitis without necrosis. He pain
improved with conservative treatment. Her nortripyline was
stopped. The exacerbating factor of her pancreatitis is unclear
but the thought is that it was either medication induced from
TCA's, from a small stone in the pancreatic duct remnant or from
alteration in hormones in the post partum period. Her diet was
advanced slowly without worsening pain. She has oxycodone at
home for moderate pain and she was sent home with 6 dilaudid
pills for moderate to severe pain. She was discharged on a BRAT
diet and with close follow up with GI and her PCP.
.
##Transitional Issues
-Follow up with PCP ___ ___ weeks and with GI in ___ weeks.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with no PMH presenting with 2-day history of epigastric
pain and malaise. Has had 1 episode of NBNB emesis at onset of
pain. Tolerating diet but decreased appetite. Seen in ED 2 days
ago and felt to be GERD or gastritis, but pain has not resolved.
Had subjective fever/chills this afternoon, which prompted
repeat
eval by her PCP. Ultrasound and CT consistent with
cholecystitis,
so referred to ___ ED. Currently c/o mild epigastric and RUQ
pain, but otherwise feels well. Had some juice and food in the
waiting room at 6:30pm prior to being seen in the ED. CT abdomen and pelvis with contrast showed 1. Enlarged hyperemic gallbladder with surrounding edema and mild fat
stranding, concerning for acute cholecystitis. A RUQ ultrasound is
recommended for further evaluation. No evidence of appendicitis.
RECOMMENDATION(S): A RUQ ultrasound is recommended for further evaluation
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 3:28 ___, 2 minutes after discovery of
the findings. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Upon correlation with CT abdomen pelvis that was obtained on the same day
and laboratory values, and in the absence of acute appendicitis, this most
likely represents acute cholecystitis.
2. Cholelithiasis.
3. Limited images of the liver and gallbladder were obtained.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ by
telephone on ___ at 16:10, 10 minutes after discovery of the
findings. The patient was diagnosed with CHOLELITH W AC CHOLECYST. The patient was treated with laparoscopic cholecystectomy. At the time of discharge, the patient had acute cholecystitis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound revealed Cholelithiasis with
acute
cholecystitis. The patient underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor,
on IV fluids, and dilaudid and Tylenol for pain control. The
patient was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is an ___ with a history of coronary artery disease s/p
CABG, diastolic congestive heart failure, hypertension,
hyperlipidemia, type 2 diabetes requiring insulin, end stage
kidney disease on dialysis ___ and recent hospitalization
___ for seizures and superior mesenteric artery stenting
for chronic mesenteric ischemia who was admitted ___ with
hypoxemia and status epilepticus possibly secondary to
antibiotics who comes in today from her rehab with fatigue,
cough, and loose stools. Radiology showed 1. Retrocardiac opacity may represent atelectasis, however cannot exclude
superimposed infection in the appropriate clinical setting.
2. Very low lung volumes and crowding of normal bronchovascular structures.
3. Pulmonary venous congestion without overt edema. CT HEAD W/O CONTRAST Q111 CT HEAD showed 1. No acute intracranial abnormality.
2. Chronic infarcts of the left cerebral peduncle and pons are better
evaluated on ___ MRI. The patient was diagnosed with Pneumonia, unspecified organism, Altered mental status, unspecified. At the time of discharge, the patient had #Nausea/Vomiting/Diarrhea
#Viral Gastroenteritis
#Seizure disorder
#End stage renal disease
#Hypertension
#Type 2 diabetes
#Peripheral vascular 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>Brief Hospital Course:
========================================
___ PMH of CAD (s/p CABG), HFpEF, HTN, HLD, T2DM, ESRD on HD
___, with recent hospitalization for seizures and SMA stenting
for chronic mesenteric ischemia, who presented from rehab with
fatigue, vomiting, diarrhea, thought to be ___ viral
gastroenteritis as resolved within 24 hours of presentation and
therefore returned to rehab</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a prior history of CAD s/p angioplasty in ___ presents
evaluation of palpitations. Patient states that last night
around midnight she began to have a sensation of palpitations
described as irregularly irregular heart rate that woke her from
sleep. States this lasted for approximately an hour or 2, she
took her sublingual nitroglycerin as well as p.o. Ativan and her
symptoms improved. She denies any chest pain, shortness of
breath, nausea, vomiting, diaphoresis.
When she awoke this AM her symtpoms were gone.
She presented to ___ and ___ urgent care today, was
noted to have new T wave inversions and ST depressions in the
lateral leads. Referred to ED for further evaluation. Full dose
aspirin provided prior to arrival.
In the ED intial vitals were: 96.9 69 163/73 18 98%
Labs were significant for troponin .02, and D-Dimer 1805. A
subsequent CTA was performed that showed subsegmental pulmonary
emboli in R and L lobes.
Patient was initiated on a heparin gtt.
Vitals on transfer: 67 144/56 19 94%
On the floor patient is symptoms free with no complaints. On
further questioning on the floor, the patient reports she just
returned on a flight 11 days ago from ___ (5.5 hour
flight). Denies recent leg swelling or pain.
ROS: On review of systems, s/he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope. CHEST (PORTABLE AP) showed The lung volumes are normal. Normal size of the cardiac silhouette. Mild
tortuosity of the thoracic aorta. The structure of the lung parenchyma as
well as its transparency are normal. There is no evidence of pulmonary edema
or pneumonia. No pleural effusions. Radiology showed 1. Subsegmental pulmonary emboli in the left lower lobe and probable embouls
in the right lower lobe as well. No radiographic evidence of right heart
strain
2. 6 mm nodule in the thyroid could be further evaluated with nonemergent
thyroid ultrasound if clinically indicated.
3. Small focus of air in the liver could represent pneumobilia; although
portal venous gas is possible. Correlate with any history of sphincterotomy or
recent biliary instrumentation and with any abdominal symptoms.
Telephone notification regarding change in wet read #3 to Dr ___ by Dr
___ at 19:45 ___. BILATERAL LOWER EXTREMITY ULTRASOUND showed No evidence of deep vein thrombosis in both lower extremities to the popliteal
level. The patient was diagnosed with PALPITATIONS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA. The patient was treated with Cardiac Catheterization. At the time of discharge, the patient had PRIMARY DIAGNOSIS
1. Pulmonary Embolism
2. Coronary Artery Disease
SECONDARY DIAGNOSIS
1. Osteoarthritis
2. Gastroesophageal Reflux 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>___ with past medical history of RA on adalimumab, CAD s/p
angioplasty in ___ presented with sudden onset palpiations and
found to have troponin leak and subsegmental PE's.
ACUTE ISSUES
# Provoked Subsegmental Pulmonary Emboli: Found on CTA after a
positive D-Dimer in ED. ECG showed ST depressions anteriorly but
no overt evidence of RV strain. No evidence of RV enlargement of
CT scan, though troponin mildly elevated (0.02, less than cutoff
for acute MI) which could indicate an element of strained
myocardium. .The cause of the PE ___ be a combination of recent
plane flight and her treated RA. Adalimumab has been linked to
arterial/venous thrombosis. The mechanism is unclear, but some
postulate that anti-adalimumab antibodies ___ contribute.
(___ et al. Arthritis and Rheumatism Vol 63. No 4, ___ Patient is likely at higher risk for these antibodies
because she was already exposed to adalimumab in the past.
Patient was treated with heparin drip then started on warfarin
with an enoxaparin bridge at discharge. Symptoms resolved by
time of discharge.
-___ to manage INR (confirmed).
# CAD s/p Angioplasty in ___: ECG changes were concerning for
ACS though given CTA findings entire presentation was most
likely from PE. Patient remained chest pain free. In addition,
her anginal equivalent in the past was jaw pain that radiated
down the arm. She has had no such symptoms recently. She had
cardiac catheterization that showed RCA had a 30% proximal
tubular plaque and otherwise mild luminal irregularities, but
otherwise normal coronary arteries. She was treated with
standard medical therapy including aspirin, statin, beta
blocker.
CHRONIC ISSUES
# Aortic Stenosis: Recommend repeat echo in ___ yrs.
# Rheumatoid Arthritis: Patient has had complicated history of
RA with several different medication regimens over the years
(See PMHx). Continued MTX and leucovorin for now
# Osteoporosis: Continued calcium, vitamin D, and PTH analogue
# GERD - Continued home lansoprazole </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ ___ male with sickle
cell disease, for which he does not see a physician and presents
complaining of "sickle cell pain," that started while at work
yesterday at 9PM as a ___ at ___. He said that he
worked an 8AM-11PM shift, did not eat or drink throughout the
entire day with the exception of breakfast at 7:30 AM. He states
that the pain is in the sides of his ribs on both sides of his
body, bilaterally on the shoulders, and on the upper and lower
back. He states that it is sometimes difficult to take a deep
breath, but attributes this to rib pain. Otherwise, he denies
SOB, chest pain, HA, dysuria/urinary frequency. He has not taken
any pain medications. Patient states that his episodes have
occurred more frequently during the ___ months, at which time
he required a blood transfusion, and more recently beginning in
___. He discontinued taking his hydroxyurea about 4 months ago
because he went to jail. While in jail he was hospitalized twice
with similar presentations. After he was released, he was not
able to establish care and shortly thereafter moved to ___.
Of note, the patient was admitted on ___ for sickle cell pain
crisis with lower back pain, left sided rib pain, and b/l ___
pain (similar to his presentation during other pain crises). He
left AMA on ___ after receiving fluids, hydromorphone PCA for
pain control because he had missed two days of work. Prior to
leaving he was encouraged to establish a relationship with a PCP
and ___ hematologist. Radiology showed No acute cardiopulmonary process. The patient was diagnosed with Hb-SS disease with crisis, unspecified. At the time of discharge, the patient had Sickle cell pain 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 ___ man with sickle cell disease s/p
splenectomy and cholecystectomy, that has been complicated by
multiple pain crises, prior acute chest syndrome, most recently
left AMA on ___ for back pain, hip pain, and rib pain c/w acute
pain crisis, now admitted with upper body pain.
#SICKLE CELL VASOOCCLUSIVE CRISIS:
Patient presented on ___ with diffuse upper body pain, most
prominently in upper and lower back, shoulder and lateral ribs,
c/w the sx he has experienced during his prior episodes of pain
crisis. Of note, patient left ___ AMA on ___ because he had
missed two days of work. During that time social work provided
him contact information to ___ programs. Prior to that
hospitalization he had been to 4 hospitals in 2 weeks for
similar episodes. Likely triggers are dehydration, overexertion,
heat exposure at work iso of current hot temperatures (___
season). On presentation he did not show signs/symptoms or lab
e/o acute chest syndrome, hand-foot syndrome, or renal crisis.
Patient was given 2L IVF, and acetaminophen 1000mg,
hydromorphone 1mg IV, and oxycodone 5mg for pain management.
Patient left AMA before receiving folic acid. Patient should be
evaluated to see if vaccinations are updated and whether he
should be started on hydroxyurea. Lifestyle changes should be
discussed to limit sickle cell crisis. Patient was informed to
remain hydrated. Establishment of care with a PCP and
hematologist was strongly encouraged.
#ANEMIA:
Anemia is secondary to sickle cell disease. Current Hgb is 8.7,
unchanged from at time of AMA discharge, but significantly
decreased from prior Hgb in ___ of 13.5. He had no signs of
acute bleeding. LFTs wnl. LDH 220 and Tbili 0.4, not suggestive
of hemolysis. Reticulocyte % is 1.9 with abs retic count of
0.06, and retic index of 0.8, suggesting insufficient response
to anemia. Iron studies were not able to be drawn, however
should be considered as low ferritin on prior admission. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ AF on sub therapeutic lovenox, hx DVT/PE, and hx renal
papillary adenoCA s/p resection now with new diagnosis lung
adenoCA presenting with 3d history of intermittent left leg
numbness/tingling with acute pain 7am morning of admission
waking
her from sleep, associated with noticeably pale toes, leading to
ED presentation. AF diagnosed ___, started on pradaxa,
switched to lovenox 90'' ___, then changed to lovenox 90mcg
QHS 2 weeks prior to presentation by cardiologist secondary to
gross hematuria which has since resolved. Last dose of lovenox
___. Radiology showed No evidence of DVT in either the right or left lower extremity. Interval
resolution of non-occlusive clot in the right popliteal vein and occlussive
clot in the right posterior tibial vein. Radiology showed There is mild heterogeneous plaque at the level of the left CFA.
The left anterior tibial artery is patent, however the left dorsalis pedis
artery is occluded. The left posterior tibial artery is patent. Radiology showed 1. Normal doppler flow study of the right lower extremity at rest.
2. Significant left distal tibial disease at rest. Please note no exercise
was done. Radiology showed 1. Embolus in the left common iliac artery.
2. Two-vessel runoff in the left lower extremity to the level of the ankle, at
which point both tibial artery disappears. The dorsalis pedis artery is not
visualized on the left. It is unclear whether this is due to decreased inflow
from the embolus in the left common iliac artery or whether there are
additional emboli to these vessels.
3. Increase in size in multiple lymph nodes in the celiac axis region,
retroperitoneum, and para-aortic region from prior exam one month ago
concerning for metastatic disease.
4. Improvement in pulmonary infarct in the right lower lobe without complete
resolution
5. Small residual right pleural effusion.
6. Status post left partial nephrectomy. Radiology showed 1. No acute intracranial abnormality; specifically, there is no evidence of
hemorrhage.
2. Allowing for the (delayed) post-contrast acquisition, no pathologic focus
of enhancement to suggest intracranial metastatic disease.
COMMENT: These findings were discussed with Dr. ___ requesting
clinician, Vascular Surgery service), by telephone, at 1635H, ___. Radiology showed 1. New left common iliac stent with a filling defect within the stent
concerning for an in-stent thrombosis. Location of this thrombosis is similar
to the preoperative filling defect. There does appear to be reconstitution of
flow distally.
2. Small defect just at the takeoff of the right common iliac artery, series
3A, image 90, which appears more apparent on this exam and may be a tiny
non-occlusive thrombosis with soft plaque. Remainder of the vasculature again
demonstrates a two-vessel runoff in the left calf and a three-vessel runoff on
the right.
3. New stranding and subcutaneous air in the left groin, likely secondary
from the patient's recent procedure.
4. Unchanged abdominal lymphadenopathy concerning for malignancy.
5. Interval increase in the bilateral small pleural effusions, right greater
than left. Radiology showed 1. New left sided groin hematoma measuring up to 9-cm (CC).
2. New occlusion of the right common iliac stent graft, with immediate
retrograde reconstitution. Three vessel run off is seen well until the level
of the mid-tibia, at which point the anterior tibial, peroneal, and posterior
tibial arteries become difficult to visualize due to poor contrast inflow.
3. Patent left common iliac artery with a two vessel run-off in the left lower
extremity to the level of the distal tibia, at which point the anterior and
posterior tibial arteries are not well visualized. No dorsalis pedis artery is
seen on the left.
4. Slight interval increase in the bilateral pleural effusions (right greater
than left). The patient was diagnosed with PERIPH VASCULAR DIS NOS, AMI ANTERIOR WALL NEC, INITIAL EPISODE OF CARE. The patient was treated with ___: left lower extremity thrombolysis
___: bilateral common iliac artery icast stents, Left
superficial femoral artery thrombectomy and patch. At the time of discharge, the patient had Lung cancer
Arterial thrombus lower extremities. The patient was given written instructions concerning 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 from the ER and started on a heparin
gtt immediately. CTA showed an embolus in the left common iliac
artery, as well as concern for a distal embolus. She was taken
to the angio suite on ___ where she underwent a left lower
extremity arteriogram with lysis(please see op note for details)
. Lysis catheters were left in, and the pt has alteplase running
in over night. She was taken back to the angiosuite the next
morning, and was found to have good flow. All catheters were
removed, and she was transfered back to the floor. Later that
day she had diminished signals , her heparin gtt was bolused and
increased. A CTA showed concern for bilateral iliac artery
thrombus. The pt was taken back to the OR and underwent kissing
CIA stents , and a left SFA thrombectomy with patch. She had
good signals post-op and was transfered back to the VICU. She
was continued on heparin/coumadin bridge. She made steady
progress. Hematology/Oncology consulted and recommended stopping
heparin/coumadin and switching to lovenox 1mg/kg bid for life,
and this was done. Pt did well on lovenox and continued to
remain stable. On ___ she was deemed stable for discharge home.
She had a PET scan while in house, and this will be followed up
by her primary oncologist tomorrow. SHe will be on lovenox for
life. SHe is being discharged with physical therapy and a ___.
She will follow up with vascular surgery in 2 weeks. </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 muscle
invasive transitional cell carcinoma of anterior bladder wall
s/p cystectomy with ileal conduit and chemotherapy (4 cycles of
DDMVAC) in ___, thought to be in remission, hypothyroidism, who
presents as transfer from ___ with ___, hyperkalemia and
bilateral hydronephrosis from soft tissue mass causing ureteral
obstruction.
Patient notes that she has been told that she had 17 negative
nodes, negative cytology, normal bloodwork, and that her bladder
cancer is thought to be in remission. However, she had
ultrasound that demonstrated bilateral hydronephrosis in
___. She presented to her outpatient urologist (Dr. ___
___, who obtained CT scan showing bilateral
hydronephrosis. Her creatinine was monitored and found to be
rising, with Cr 2.0 and K to 5.5 so she was sent to ___.
Initial vitals:
99.5 F (37.5 C). Pulse: 108. Respiratory Rate: 16.
Blood-pressure:
123/67. Oxygen Saturation: 100%.
Labs at ___:
- WBC 15.5 Hgb 8.3 Plt 455
- Na 126 K 5.5 Cl 92 CO2 16 BUN 39 Cr 2.0 (baseline 0.5) AG =
18
- UA WBC TNTC RBC ___ ULER large, UCx pending
CT A/P (___) showed significant bilateral hydronephrosis from
soft tissue mass to the right of L5, causing ureteral
obstruction, invasion of the right L5 vertebral body anteriorly,
and circumferential involvement of the proximal right common
iliac artery.
CXR without cardiopulmonary abnormality.
She was given CTX 1gm and insulin/dextrose and transferred to
___ for nephrostomy tubes.
___ Course here:
Initial vitals: 100.3 93 128/81 16 97% RA
Labs notable for:
- WBC 13.6 Hgb 8.0 Plt 387 -> WBC 1.6 Hgb 7.6 Plt 273
- Na 130 K 5.5 Cl 95 CO2 14 BUN 39 Cr 1.9
-> Na 132 K 5.3 Cl 100 CO2 11 BUN 38 Cr 2.1 Anion Gap = 21
- Lactate 1.1 -> 3.7
- U/A WBC 37 Leuk large Nitr neg
- ALT 9 AST 9 AP 88 Tbili 0.3 Alb 3.0
- PTT 28.1 INR 1.4
Imaging: None here
Patient received:
- NS 5L
- Acetaminophen 650 mg + 325 mg
- Cefepime 500 mg
Consults:
- Urology: Rigoring, tachycardic to 140s, right PCN with clear
red urine, left PCN with cloudy red urine, urostomy pink and
patent of clear yellow urine, no abdominal pain. Trend
creatinine, empiric antibiotic coverage, closely monitor for
signs of sepsis
- Interventional radiology: Bilateral PCN placement ___.
Received cefazolin intraoperatively. Patient rigoring and
tachycardic post procedure, can be seen post decompression.
Close monitor needed.
Upon arrival to FICU, patient edorses feeling very weak and
fatigued, with 20 lb weight loss over the past 2 months in the
setting of decreased appetite. No nausea or vomiting. No
nightsweats. She denies change in urine output, hematuria, flank
pain, fevers, chills, nausea, vomiting, diarrhea, rhinorrhea,
chest pain, palpitations. She is having some dyspnea on
exertion, but is still able to go down 15 steps, no ___ edema, no
orthopnea. She does also note that she has had worsening back
pain since ___ but attributes this to helping her sister fix
up windows Radiology showed Increased bibasilar opacities may reflect atelectasis or aspiration/pneumonia.
There is new mild pulmonary vascular congestion as well. No pneumothorax. The
size of the cardiac silhouette is within normal limits. A right chest wall
power injectable Port-A-Cath tip projects over the right atrium. CT abdomen and pelvis without IV contrast. showed 1. Status post placement of bilateral percutaneous nephrostomy tubes, which
appear appropriate in position. Improvement in the previously visualized
bilateral hydronephrosis. Moderate bilateral perinephric stranding, likely
procedure related.
2. Status post radical cystectomy with a right lower quadrant ileal conduit,
which is unremarkable in appearance. Small volume nonhemorrhagic free fluid
within the pelvis, unchanged.
3. Cholelithiasis.
4. Degenerative changes at L5-S1 with osteolytic changes involving right
aspect of the L5 vertebral body. Second opinion CT abdomen and pelvis showed Infiltrative retroperitoneal soft tissue mass at L5 level invading bilateral
distal ureters leading to upstream moderate bilateral hydroureteronephrosis,
with encasement of right common iliac artery and erosion of the L5 vertebral
body. Findings are consistent with disease recurrence.
NOTIFICATION: The impression and recommendation above was entered by Dr. ___
___ on ___ at 15:51 into the Department of Radiology critical
communications system for direct communication to the referring provider. VENOUS DUP EXT UNI (MAP/DVT) RIGHT showed 1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. Slow flow within the right greater saphenous vein.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 11:45 pm, 25 minutes after discovery of
the findings. Radiology showed Successful placement of bilateral 8 ___ nephrostomy tubes. The patient was diagnosed with Urinary tract infection, site not specified. The patient was treated with Bilateral nephrostomy tube placement. At the time of discharge, the patient had Bilateral hydronephrosis likely due to cancer recurrence
Septic shock due to urinary tract infection. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ female with history of bladder cancer s/p cystectomy
and ileal conduit ___ and chemotherapy who presents with
bilateral hydronephrosis and ___ now s/p bilateral percutaneous
nephrostomy tube placement admitted to the ICU for concerns of
urosepsis.
# Urosepsis
# Septic Shock
The patient was initially admitted to the ICU in the setting of
leukopenia, tachycardia, and fever to 103 after bilateral
nephrostomy tube placement/decompression concerning for
urosepsis and possible transient bacteremia. She was started on
broad-spectrum antibiotics with vancomycin and cefepime given
recent instrumentation and altered GU anatomy. There were no
prior urine cultures available for sensitivities however, the
patient had no recent history of antibiotic use. Blood and
urine cultures were sent and the patient was given approximately
89 L of IVF. On ___, she was started on vasopressors-
norepinephrine, vasopressin, and phenylephrine due to MAPs in
the ___. An arterial line was placed to closely monitor blood
pressures. Her 3 pressor shock slowly resolved with continued
antibiotics and she was completely weaned off vasopressors on
___. She remained off vasopressors for more than 24 hours and
was thought to be stable enough to transfer to the medical
floors for further care. After transfer to the floor, pt
continued to improve with leukocytosis that improved from 33 to
10 on day of discharge. Her abx were de-escalated to CTX and
subsequently Cipro for completion of 14-day course.
# Acute kidney failure
# Bilateral hydronephrosis
An outside hospital CT read with R ureteral obstruction from
soft tissue mass to right of L5 causing ureteral obstruction.
Her Cr improved with placement of bilateral PCN tubes and with
volume resuscitation, though the slow rate of renal recovery
also suggested that there was likely a component of
post-obstructive ATN as well.
# Hyperkalemia->hypokalemia
Her K was mildly elevated at 5.3 upon presentation likely d/t
ARF. This improved with relief of urinary obstruction and pt
developed post-obstructive diuresis and associated hypokalemia.
K was aggressively repleted and was stable at 4.1 on discharge.
# ___ Edema: Pt noted to have 2+ R>LLE edema upon transfer to the
floor. Etiology felt to be ___ aggressive volume resuscitation
in the ICU, considered diuresis but pt noted to be orthostatic
after ambulation (likely due to venous pooling in the ___ due
to venous insufficiency). RLE dopplers were obtained and were
negative for DVT. She will be given compression stockings to
help with venous pooling.
# Transitional cell carcinoma of bladder
# R abdominal soft tissue mass
# Weight loss
The patient was followed at ___ by Dr. ___. Patient
presented with a possible new R paravertebral mass and 20lb
weight loss, concerning for recurrence of known transitional
cell carcinoma versus a new malignancy. Her outpatient
oncologist was contacted for further management recommendations
and plans to f/u with her post-discharge.
# Macrocytic anemia
Per patient her anemia was chronic but there was some thought of
whether she was having GI blood loss as an outpatient. She had
no e/o active bleeding, most likely inflammatory cause. She
received 2U pRBC transfusions during this hospitalization with
discharge Hb stable at mid 9's-10.
# Hypothyroidism
She was continued on home levothyroxine 125 mcg daily.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: Dr. ___ is an ___ year old right handed (although he feels
he was actually left handed) with history of ITP, who presents
6
days after a mechanical fall at home in which he struck the back
of his head. On ___ he was in his home when he opened a
Kitchen cabinet that struck him in the face knocking off his
glasses and he fell backward onto the floor. He did not loose
consciousness, but got up and felt dizzy and had some nausea.
The next day he had a severe headache over the right
parieto-occipital area. ___ the headaches worsened and he
had a
severe nausea and dry heaves. ___ the headache improved a
bit
but felt his coordination was off and he lost fine hand
movements
in both hands. ___ he made an appointment with his PCP for
today where he was sent for a noncontrast head CT. This CT
demonstrated and acute rt cerebral (along the rt temporal lobe)
SDH measures 9-mm in max thickness with some local mass effect,
but no shift or signs of herniation. Radiology showed 1. Acute right cerebral subdural hematoma measuring 9 mm.
2. Possible 2-mm SDH along the left inferior frontal lobe. Radiology showed No acute fracture or traumatic malalignment. Multilevel
degenerative changes with loss of disc space and fusion at C4-C5 bodies. Radiology showed 1. Multiple bilateral subdural hematomas of varying chronicity.
2. New hyperdense left occipital subdural hematoma. Stable hyperdense right
frontotemporal subdural hematoma and interval decreased conspicuity of a tiny
left frontal subdural hematoma. No significant increase in mass effect.
3. Slightly larger right occipital isodense subdural hematoma.
4. Stable chronic hypodense bifrontoparietal subdural collections.
Findings reported to Dr. ___ phone at approximately 6 p.m. via phone on
___. Radiology showed 1. Stable right frontotemporal subdural hematomas. No mass effect.
2. Slightly smaller left occipital SDH.
3. Stable bifrontal and right parietal extra-axial fluid collections. The patient was diagnosed with SUBDURAL HEM W/O COMA, UNSPECIFIED FALL, HYPERTENSION NOS, DIABETES UNCOMPL ADULT, CARDIAC PACEMAKER 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>Dr. ___ is an ___ year old right handed (although he feels he
was actually left handed) with history of ITP, who presents 6
days after a mechanical fall at home in which he struck the back
of his head. He had nausea, headache, generalized
weakness for several days afterward. Outpatient CT of the head
showed a subdural hemorrhage and he was transferred here for
further evaluation. Neurologic examination in the emergency
department demonstrates a peripheral neuropathy and a right
upper motor neuron pattern of weakness. Neurosurgery was
consulted, recommended Keppra, but did not feel that he needed
any surgical intervention. They recommended platelet transfusion
and admission to the neurology service for observation. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is an ___ man with a history of squamous
cell cancer of the lung off current treatment who is admitted
with chest pain. He also reported >10 episodes of emesis over
the
course of the night PTA. He also felt sweaty. He had abdominal
pain but no diarrhea. CHEST (PA AND LAT) showed As above. Radiology showed Findings described above concerning for a small bowel obstruction. CHEST PORT LINE/TUBE PLCT 1 EXAM showed Comparison to ___. The feeding tube was newly inserted. The tip
projects over the gastroesophageal junction. To be correctly positioned in
the stomach, the device needs to be advanced by approximately 5-10 cm. No
pneumothorax or other complications. The extensive pre-existing left apical
changes are stable. No acute abnormalities. Radiology showed 1. Small-bowel obstruction with transition in the mid lower abdomen, likely
secondary to adhesions. No free air.
2. Infrarenal abdominal aortic aneurysm measuring 3.4 x 3.3 cm.
3. Cholelithiasis and unchanged compression fractures of T12 and L3.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:57, 5 minutes after discovery of
the findings. CHEST (PORTABLE AP) showed Comparison to ___. The advanced feeding tube now projects over the
central parts of the stomach with its tip. No complications. Otherwise
unchanged radiograph. Chest radiograph two views showed Infiltrate in the right lower lobe, suspicious for pneumonia. CHEST (PORTABLE AP) showed Compared to chest radiographs since ___ most recently ___ and ___.
Heterogeneous opacification right lower lung has worsened since ___. This
could be due to early aspiration pneumonia. Patient has severe emphysema.
Severe left upper lobe scarring and pleural mass are long-standing. No
pneumothorax
Mild cardiomegaly has increased; atypical cardiac decompensation should be
considered. Transvenous right atrial right ventricular pacer leads are
continuous from the left pectoral generator. Radiology showed Persistent small-bowel dilation with some air in the colon, which given the
findings on prior CT, likely represents persistent small obstruction rather
than ileus. Radiology showed Improvement of small distension since the prior radiograph. UNILAT UP EXT VEINS US LEFT showed 1. No evidence of deep vein thrombosis in the left upper extremity. Left
cephalic vein not well visualized.
2. Subcutaneous edema throughout the left upper extremity. The patient was diagnosed with Vomiting without nausea, Chest pain, unspecified, Athscl heart disease of native coronary artery w/o ang pctrs. At the time of discharge, the patient had Small bowel obstruction
Aspiration pneumonia
Hypercalemia. The patient was given written instructions concerning 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: ___ man with a history of stage IIIA squamous
cell lung cancer, currently off any treatment, who presents with
hypertension and nausea/vomiting.
# Small Bowel Obstruction: Patient presented with N/V, abdominal
pain, and no BM in 3 days. On initial report he reported
continued flatus but then on the afternoon of ___ he vomited
feculent material. A KUB confirmed a likely SBO. NG tube was
placed and quickly self d/c'd. Replaced on morning of ___ and 2L
of feculent material was removed from his stomach with
improvement in symptoms. CT scan initially concerning for a
closed loop obstruction but on final read consistent with a
single transition point. No evidence of bowel wall ischemia on
CT scan. Treated conservatively with NG tube for decompression,
IVF and a bowel regimen. He started passing gas on ___ and had a
BM on ___. NG tube removed. He had several BMs from ___.
His diet was advanced and he did well initially. Unfortunately,
on ___, he had recurrence of nausea and vomiting. AXR was
consistent with another SBO. An NG tube was attempted to be
placed again but the patient pulled it out and refused to have
another NG tube replaced. He was treated with supportive care
including IV fluids, antiemetics, and bowel rest. His bowel
regimen was increased. He was then able to pass several stools.
His AXR improved and diet was advanced. He tolerated a regular
diet on discharge.
# Aspiration pneumonia
He had worsening leukocytosis, cough, and RLL infiltrate on CXR
concerning for aspiration pneumonia. He was started on Unasyn
(while unable to reliably take PO) on ___ for a planned 7 day
course. Once he was tolerating PO he was transitioned to
augmentin.
# Hypercalcemia: Patient presented with an elevated calcium
level to 11.4 on presentation. This in the setting of
constipation small bowel obstruction. Given his stage III lung
cancer would be concern for calcium the hypercalcemia due to
malignancy. He was given IV fluids and the Ca the significantly
improved. PTH low, vitamin D normal. PTHrP low (normal to be
low). Bone scan negative to ___ malignancy. This improved with
IV hydration and may have been related to dehydration in the
setting of small bowel obstruction. His calcium was monitored on
PO hydration and was stable.
# Hypokalemia: Likely due to GI losses. Repleted.
#Hypertensive urgency:
#Hypertension:
#Chest pain:
Was complaining of chest pain in the ED, which has resolved.
Troponins were negative x 2. ECG consistent with prior except
for T-wave changes (T waves now upright where then had been
flipped in the past). Also has a history of radiation
esophagitis which
could be contributing to chest pain. This is likely due to pain
from the SBO as well as lack of absorption of his
antihypertensives. His BP improved when he was tolerating a diet
and absorbing his medicaitons. Increased amlodipine to 5mg PO
daily for better control.
#Radiation esophagitis:
-Continued famotidine and lansoprazole
#Stage IIIA Squamous cell carcinoma:
-Currently under active surveillance and off treatment.
-Continue supportive care with tessalon pearls, inhalers. He
will have follow up with oncology as previously scheduled (on
___.
#PVD/CAD:
-Continued ASA and Plavix. Revived PR aspirin while NPO.
- Continued Statin.
#BPH:
-Continued tamsulosin once taking PO
-Continued finasteride once taking PO
#CODE: Full Code confirmed
Name of health care proxy: ___ and ___
___: both sons
Phone number: ___
___ phone: ___
Mr. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a PMH rhematic heart disease with Mitral Valve Stenosis
s/p MVR in ___ course c/b tachy-brady syndrome s/p pacemaker
placement in ___ presenting to the ED with palpitations,
worsening fatigue, exertional SOB, and weakness for 3 weeks. She
presented to her primary care doctor's office the day prior to
admission complaining of fatigue and she was noted to be
tachycardic to 100s, so she was sent to the ER for further
evaluation. The patient states that she has felt weak and
fatigued x ___enies CP, orthopnea, dizziness, PND,
n/v, or ankle swelling. Radiology showed No nodules or masses seen in the thyroid. Radiology showed Cardiomegaly with mild pulmonary vascular congestion. The patient was diagnosed with ATRIAL FIBRILLATION, HYPOTHYROIDISM NOS. At the time of discharge, the patient had Atrial fibrillation with rapid ventricular response. The patient was given written instructions concerning 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 a PMH rhematic heart disease with Mitral Valve Stenosis
s/p MVR in ___ course c/b tachy-brady syndrome s/p pacemaker
placement in ___ presents with symptomatic a.fib with rvr. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ is a ___ F with a remote h/o stroke in ___
(the
details of this are not available on admission), bipolar
disorder, EtOH abuse
with withdrawal related seizures, depression, anorexia/bulimia,
cardiomyopathy, prior cardiac arrest from electrolyte
abnormalities, anxiety who is transferred from ___
___. The details of the patient's presentation to the OSH
are sparse. CTA HEAD AND CTA NECK showed 1. No intracranial hemorrhage or mass effect.
2. Minimal intracranial atherosclerotic disease without significant stenosis
or occlusion.
3. Enlarged parotid glands containing numerous small cystic lesions. The
appearance is most consistent with Sjogren syndrome, but may be related to the
patient's known history of bulimia. Radiology showed New right internal jugular line ends in the proximal right
atrium. Possible early pulmonary edema. VIDEO SWALLOW showed No gross aspiration. One episode of deep penetration with thin liquids.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations. CHEST (PORTABLE AP)CHEST (PORTABLE AP)i showed SINCE ___ MILD PULMONARY EDEMA AND PULMONARY VASCULAR CONGESTION HAVE
RESOLVED AND HEART SIZE HAS DECREASED CONSISTENT WITH RESOLVED CARDIAC
DECOMPENSATION. LUNGS ARE CLEAR AND THERE IS NO PLEURAL ABNORMALITY. THERE
ARE NO FINDINGS TO SUGGEST ASPIRATION OR PNEUMONIA. The patient was diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY, HYPOTENSION 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>PRE-HOSPITAL COURSE
___ is a ___ F with bipolar disorder, anorexia/bulemia
requiring inpatient psych care, EtOH abuse with withdrawal
seizures, questionable non-epileptic events in the past, remote
h/o stroke (without residual deficit and no obvious CT
abnormalities) transferred from ___ with 4
reported GTCs,short in duration lasting 15 seconds.
The history noted here was obtained from ___
records and confirmed with her home residential facility ___
___. Due to her extensive psychiatric/eating disorder
history, she was previously admitted (___) to an
inpatient anorexia unit, recently discharged to a sober house
Day Program/ ___ Residential home. On ___ she was noted by
nursing staff to be more somnolent than usual, falling asleep
throughout the day. Her SBP at the day program was noted to be
___ and the program direct her sent her to the ___
ED. In the ED, notes indicate a questionable history of
seizure. There were 2 brief events of convulsions lasting 15
seconds with spontaneous resolution, it is unclear if these
events actually had post-ictal confusion. A third episode was
longer and she was given 2mg ativan with cessation. After a ___
event she was given another 2mg ativan and loaded with keppra
and dilatin 1mg. She was transferred to ___.
ICU COURSE
Upon arrival she was difficult to arouse due to sedating meds
and hypotensive to SBP ___. She was admitted to Neuro ICU for
pressors and IV fluids, and had good response to treatment. The
Neuro admission exam documents question of RUE weakness and gaze
abnormality but her exam a few hours later was nonfocal.
#NEUROLOGY
Prior to being connected to EEG (initially refusing) she had one
brief episode of bilateral had tremors while becoming anxious
about her hospitalization. This progressed to irregular
right-sided twitching that was nonrhythmic and sometimes
involved the left hand. These were exacerbated by movement, and
suppressed when distracted. These are all features typical of
non-epileptic events. Psychiatry was consulted for further
management, see psychiatry section below. She was continued on
her home lamictal. It was unclear if she was prescribed
valproate at home (level on admission was undetectable), this
was restarted.
In regards to the possible right upper extremity weakness, she
did have a CT and CTA at the outside hospital which were normal.
LDL 106, A1c 5.1%. This weakness was gone on our exam, and was
unlikely to be organic.
#CV - hypotensive, likely due to sedating medications and
hypovolemia (with ___, which resolved with aggressive IVF and a
very short course of pressors.
#ID: Her white cells were initially low at 3.2 and have come up
to 3.5. Blood cultures were negative, UA and CXR were clean.
#RENAL: ___ at OSH, which resolved with IVF, likely to be
pre-renal in etiology.
#FEN - evaluated by speech and swallow and failed, made NPO
until re-evaluation.
FLOOR COURSE (NEUROLOGY + MEDICINE)
#NEUROLOGY - EEG was continued, with no electrographic seizures
(no correlate with crying episodes, agitation, or jaw motion).
Depakote was discontinued (she was not taking this at home and
said it made her "sick" meaning it caused her to gain weight).
She had no change in her EEG after removing this medication.
# MEDICALLY UNSTABLE EATING DISORDER - Ms. ___ was
psychiatrically decompensated during this admission, displaying
a pseudobulbar affect, with exaggerated crying and significant
psychomotor slowing (with normal mental status testing). The
psych consult team was following, and recommended doubling her
home buspar to 20mg TID, starting standing ativan 1g TID with
meals, increasing her fluoxetine from 30 to 40 mg, and giving
Seroquel 25mg PRN for anxiety in an attempt to wean patient off
Ativan. Of note, on ___, when discussing dispo options, patient
threatened to leave AMA out of fear she would be sent to an
inpatient unit. A Code Purple was called, though the patient
voluntarily returned to her room. The next day, the patient's
lab values appeared consistent with purging, showing ___ and
hypochloremic metabolic alkalosis. She was placed on the eating
disorder protocol and these abnormalities resolved after several
days. On ___, again when discussing dispo options, patient
again tried to leave AMA and a Code Purple was called, resulting
in chemical and physical restraints due to severe agitation.
After this event pt was more cooperative, however, she was
frequently tearful when visited by primary team and exhibited
labile affect and frequent changes in her answers when asked
questions about her care plan and what she would consent to,
including simple, non-medical decisions such as how to obtain
clothes for herself. Due to her lability and evidence of
continued purging behavior even during this hospitalization, she
was deemed unable to care for herself and placed on a ___. Upon discharge, her QTc on serial EKGs were all <480 and her
electrolytes were all within normal limits. She was also
hemodynamically stable without symptomatic orthostatic
hypotension, her weight was >75% ideal body weight, and her
glucose was well controlled. Thus, she was deemed medically
stable. Patient did not show evidence of refeeding syndome
throughout hospitalization.
#NUTRITION - Speech and swallow re-evaluated the patient, and
approved her for a pureed solids and thin liquids diet. Video
swallow was performed on ___ which was largely unremarkable
except for a small focal area of "deep penetration." Nutrition
then reevaluated a third time and recommended a normal solid
diet (for eating disorder protocol) without complication. No
major aspiration events noted over the course of her admission.
#CHEST PAIN: Upon admission, patient complained of atypical
midline chest pain radiating to L shoulder, worse with palpation
of sternum. Several EKGs were obtained over the course of her
admission, which found no focal ST changes. Likely ___ to hx of
anxiety. She was continued on her home aspirin, gabapentin,
ibuprofen, tylenol, and ativan as above for pain control. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo F with morbid obesity, asthma, OSA on CPAP and recent
admission for hypoxia (___) thought to be ___ OSA/obesity
hypoventilation presents today with shortness of breath, fever,
and chest tightness.
.
Of note, after last admission, patient was discharge to rehab
for about 2 weeks, during which she was weaned off oxygen. She
was then discharged home by the beginning of ___, feeling
better overall, able to ambulate with walker at home although
sleeping on the first floor because she wasn't able to climb up
the stairs yet due to SOB. Since last week, she noticed more
swelling and pain in her LLE which is normally larger than the
RLE. She decided to self-medicate with Avelox. She then had
fever up to 102 for about 2 days after starting Avelox. Fever
than subsided, but she continued to have pain in her LLE that is
worse than baseline. On the day prior to admission on ___, she
felt more fatigued and lost her appetite. In addition, she had 2
episodes of loose BM without blood. By 6PM prior to admission,
she developed chill, rigor, and body ache. She felt out of
breath and sweaty. Denies vomiting or abdominal pain but does
have mild nausea. She also thinks that her BP is lower than
baseline, which is usually in the 140s systolically. Because of
how ill she felt, she came to the ED.
.
In the ED, initial VS: ___ 108 130/p 34 100%. Labs are
significant for WBC 30.8, 94.2% neutrophils, Hct 34.7, MCV 67,
INR 1.3, proBNP 531, Cl 95, Crt 0.9, VBG 7.38/56/41/34, lactate
2.0, UA negative. CXR showed possible RLL pneumonia. She
received 750 mg IV levofloxacin and 1L NS. She also got
albuterol and ipraropium nebs, tylenol and ibuprofen. Foley was
placed due to incontinence. VS upon transfer T 102.7, HR 95, BP
112/49, RR 28, O2Sat 95% 4L NC.
.
Currently, feels slightly better than last evening. Radiology showed Recurrent heart failure. Basal pneumonia and pleural effusions,
even moderate in volume are open questions due to limitations of conventional
radiography with a patient of this size. Radiology showed No focal lesion identified. Diffuse subcutaneous edema with no
focal fluid collection. Radiology showed Limited examination, however, IUD appears in satisfactory
position. Radiology showed No evidence of abscess. Marked subcutaneous edema overlying the
calf. Radiology showed Right-sided PICC line with the tip terminating in the upper SVC. The patient was diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, NEUTROPENIA, UNSPECIFIED , FEVER, UNSPECIFIED. The patient was treated with ___ Right PICC placement. At the time of discharge, the patient had Cellulitis
Bacteremia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo morbidly obese female with h/o OSA on CPAP, obesity
hypoventilation syndrome, chronic lymphedema, HTN, who presents
with fever, chills, SOB found to have cellulitis and group G
strep bacteremia.
.
ACTIVE ISSUES BY PROBLEM:
# Cellulitis and Bacteremia - Patient presented with fever of
104, tachycardia, relatively low BPs, and WBC count of 48K.
Blood cultures on admission positive for BETA STREPTOCOCCUS
GROUP G, likely from impressive RLE cellulitis. Urine culture
negative, CXR with no infiltrate. LLE and RLE ultrasound
negative for focal fluid collection. Started on penicillin and
clindamycin IV, however clinda was stopped after 2 days.
Infectious disease was consulted, who recommended TTE to eval
for endocarditis. TTE did not show vegetations, however it was a
limited study, so TEE was recommended but patient refused.
Given the inability to rule out endocarditis, she will need to
undergo 4 weeks IV PCN therapy as empiric treatment, with
possible continued PO abx after that. Subsequent blood cultures
from ___ bottle), ___ all with no growth on
discharge. Fevers abated, WBC count came down (15K at
discharge), and ___ was placed on ___ for continued IV abx.
She will need weekly safety labs at rehab and will follow with
the ___ clinic. Decision on need for PO penicillin as
suppressive antibiotic therapy will be left to her ID team in
outpatient follow-up.
# Shortness of breath - Patient reports on day prior to
presentation was increasingly short of breath and required use
of her nebulizers. She was initially satting well on 4L of o2
which was eventually tapered to room air. She did
intermittently have wheezes on exam, so may have had component
of bronchospasm and asthma flare. She was diuresed for 2 days
with improved symptoms. Continued home flovent with albuterol
and ipratropium scheduled nebs.
# HTN: BP meds initially held on admission given SIRS. Once
clinically stable, restarted home doses of losartan, diltiazem,
metoprolol and lasix. Lasix was then decreased from 80mg BID to
80 mg daily due to incontinence issues, which is how she's been
taking at home.
# OSA/obesity hypoventilation state: continued nighttime BiPAP.
# Arthritis: continued diclofenac, tylenol, and oxycodone. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Pt is a ___ F s/p breast reconstruction w/ silicone
implants 10d ago at ___ now presenting with fever.
Pt had drain removed from R breast ___ without any purulence
noted. Pt states she had fever up to 101.7 last night along with
a burning sensation in her breasts bilaterally with R>L. Has had
chills last night as well as night sweats and pm coughs. Went to
___ where she was given 1gm vancomycin at 2am and
transferred here. BILATERAL BREAST ULTRASOUND showed 1.1 x 1.2 x 0.7 cm organized left breast fluid collection at 7 o'clock in a
background of bilateral subcutaneous fluid and edema especially at the 8
o'clock and 6 o'clock positions of the right and left breasts. Infected fluid
collections are not excluded. Please clinically correlate.
RECOMMENDATION(S): Please note that dedicated follow-up breast ultrasound
should be performed.
BI-RADS: 2 Benign. FOCUSED BREAST ULTRASOUND showed No fluid collections are identified within the right breast at the 6 o'clock
Radian. At the left breast 6 o'clock Radian a few dilated ducts are
demonstrated. This requires further assessment with a dedicated breast
ultrasound.
RECOMMENDATION(S): Dedicated bilateral breast ultrasound
NOTIFICATION: Findings reviewed with the patient at the completion of the
study. The findings were also discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 11 AM, immediately after the exam.
No fluid collections within the right breast. The patient was diagnosed with POSTPROCEDURAL FEVER. At the time of discharge, the patient had Breast 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>The patient was admitted to the plastic surgery service on
___ for breast cellulitis. The patient tolerated the
procedure well.
.
Neuro: Pain well controlled on oral medications. Pt has been
taking tylenol and dilaudid.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: Pt has had good UOP and having BM. Has been on a bowel
regimen with colace.
.
ID: Pt on vanc/ancef for antibiotics and transitioned to bactrim
DS and cefadroxil at discharge.
.
Prophylaxis: The patient is low risk for VTE. Was wearing SCDs
throughout hospital stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ year-old man with h/o epilepsy since
age ___ followed by Dr. ___ presents with clustering of
seizures. CT HEAD W/O CONTRAST showed No acute intracranial process.
NOTIFICATION: No acute intracranial process. Radiology showed Cardiac silhouette is prominent but stable. There are low lung volumes with
atelectasis at the lung bases. No definite consolidation is seen. There are
no pneumothoraces. MR HEAD W AND W/O CONTRAST T___ MR HEAD showed 1. Multiple scattered foci of high signal intensity in the subcortical white
matter and left temporal lobe which are non-specific but which most likely
represent early changes due to small vessel ischemic disease, however given
the age of the patient cannot exclude other etiologies such as chronic
migraines, changes due to chronic hypertension, vasculitis, or infections such
as Lyme disease, please correlate.
2. Tail and body of the hippocampus slightly more prominent on the left
(802:41), probably reflecting nonspecific volume loss on the right, along with
associated elevation of the right mamillary body and right fornix pillar,
additionally this area appears slightly hyperintense on coronal 3D FLAIR
sequence (image 111, series 505b) . Findings are suggestive of, although not
definitive for, possible mesial temporal sclerosis. The patient was diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY. At the time of discharge, the patient had Intractable 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>Mr. ___ is a ___ year-old man with h/o epilepsy since age ___
followed by Dr. ___ presented with clustering of
seizures, admitted for cvEEG monitoring.
He was monitored with cvEEG four days which showed slow
background activity and further slowing in a bitemporal
independent fashion with rightsided appearing more prominently
than the left.
There are several features playing into his increased seizure
frequency including partial medication compliance, and sleep
deprivation. During this admission we have optimized his
medications. Trileptal and acetazolamide were discontinued. He
was started on Vimpat. He was maintained on an ativan bridge.
On discharge, he was on Ativan Bridge 1mg q8h, and tapered 1mg
TID x 1 week, then 1mg BID x 1 week, lamotrigine 400mg bid,
keppra 1500mg bid, and Vimpat 150mg bid.
In terms of his labs, sodium level was monitored and upon
discharge improved to 134 from 129 on admission after stopping
trileptal.
In terms of imaging, CT Head showed no acute intracranial
process. MRI with seizure protocol performed showing multiple
scattered foci of high signal intensity in the subcortical white
matter and left temporal lobe which are non-specific but which
most likely represent early changes due to small vessel ischemic
disease. Tail and body of the hippocampus slightly more
prominent on the left. Findings suggestive of, although not
definitive for, possible mesial temporal sclerosis. These
findings were discussed with the patient, and the possibility of
surgery was discussed. He firmly refused.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ F with PMH significant for HTN, gout presents for eval of RLE
cellulitis. The patient reported that on ___, she noted that
her R first MTP was swollen and believed that it was going to be
secondary to her gout as this is how her previous gout attacks
had presented. The patient then reported that the erythema,
edema, and pain spread more proximally as well as laterally to
include the rest of her foot. At that time, she also noted that
she was having tactile fevers, chills, and generalized malaise.
She also noted that her toes began to turn darker in color. The
patient was seen at OSH ED where she received ceftriaxone and
would return for an additional 4 days to received IV ceftriaxone
until approximately 3 days prior to admission. She also had an
US performed that was negative for DVT. She was discharged on
keflex ___ QID as well as Bactrim 1 DS tab BID. She saw her
PCP ___ ___ who recommended she continued on these antibiotics
and also started on fluconazole 150mg x 1 and ketoconazole
ointment for persumed tinea pedis. She returned to her PCP the
day of admission and she was advised to go to the ED for further
evaluation and admission for IV antibiotics. She denies chest
pain, SOB, palpitations, fevers, chills, nausea, vomiting. Radiology showed Prominent soft tissue swelling without radiographic evidence of osteomyelitis.
If there is high clinical suspicion, consider MRI for its greater sensitivity. Radiology showed No evidence of deep vein thrombosis in the right lower extremity. The patient was diagnosed with CELLULITIS OF LEG, HYPERTENSION NOS. At the time of discharge, the patient had Cellulitis
Tinea Pedis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ y/o F PMH significant for HTN, pre-diabetes, gout who is
admitted with cellulitis and tinea pedis that has failed
outpatient treatment (5d Ceftriaxone and Bacrim/Keflex). R leg
ultrasound was negative for DVT and R leg radiograph was
negative for signs of osteo. Course c/b new onset afib w/RVR in
ED that responded well to diltiazem.
ACTIVE ISSUES
# Cellulitis: Seen by podiatry. Received 2days Vanc/Unasyn
(___) w/good effect. Started Bactrim/Keflex on ___ to cover
for community acquired MRSA. BCx neg. Vanc was given slowly for
?redman. R leg erythema/pain/edema was improving by discharge.
# Tinea Pedis: Seen by podiatry for maceration and area of
blackened skin on the toes of her right foot. Recommeded
Ketoconazole 2% cream BID with betadine dressings to
interdigital spaces for at least one month. She should follow-up
with ___ clinic in the next ___ weeks.
# Afib w/RVR to 170s. Mr. ___ says she has felt
palpitations and a racing heart race in the past, although
previous EKGs were all in sinuts. While in the ED, she received
Diltiazem with good effect and she returned to sinus rhythm.
Repeat EKGs throughout the rest of her admission were in sinus
rhythm. She was stated on Aspirin 325 given a CHADS score of 1.
I would consider whether she should continue Aspirin and whether
she needs further work-up for a-fib although ongoing infection
is most likely etiology.</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 a past medical history of
HTN, HLD, peripheral neuropathy who presented to the ED with flu
like symptoms and diarrhea. Patient was in her usual state of
health until about one day ago when she developed generalized
myalgia, cough, subjective fevers and nonspecific abdominal
pain. She also developed nonbloody diarrhea.
In the ED, initial vitals: T 98.7, BP 114/63, RR 18, 94% RA.
Patient was ill appearing and diffusely tender over her abdomen.
Labs were notable for a WBC 15.9 with 14% bands, lactate 2.2, Cr
2.0 (up from a previously normal baseline), and positive UA with
>182 WBCs and many bacteria. CT abdomen/pelvis showed increased
fat stranding about the cecum and terminal ileum with equivocal
bowel wall thickening, findings which may represent mild
inflammatory or infectious enterococlitis. She initially
received 1L IVF, vanco/zosyn, however she became hypotensive
with SBPs in the ___ and was not responsive to additional IVF
boluses and was started on levophed. She received a total of 3L
IVF. A CVL was placed down in the ED and she was admitted to the
ICU for further management.
On arrival to the MICU, T 97.7, BP 127/65, HR 66, RR 20, 98% 2L
NC and she was quickly weaned to RA. Daughter was at the bedside
and was able to interpret. Patient was comfortable and denied
pain. Still having a large amount of diarrhea. Reports
improvement in her abdominal pain, however it is still present
and located in her RLQ. Denies dysuria, urinary frequency or
urgency.
Review of systems:
In addition to the above, she denies chest pain, shortness of
breath. Reports having a mild cough at home productive of yellow
sputum. Denies nausea or vomiting. Otherwise negative unless
stated above. CHEST (PORTABLE AP) showed Patchy left basilar opacity may reflect atelectasis, but infection or
aspiration cannot be excluded in the correct clinical setting. CHEST (PORTABLE AP) showed Right internal jugular central venous catheter tip in the mid SVC. No
pneumothorax. Mild pulmonary vascular congestion. CT abdomen and pelvis showed 1. Study is limited without intravenous or oral contrast material. Subtle
increased fat stranding about the cecum and terminal ileum with equivocal
bowel wall thickening, findings which may represent a mild inflammatory or
infectious enterocolitis.
2. Large amount of fluid throughout the colon is compatible with patient's
history of diarrhea.
3. Normal appendix.
4. Colonic diverticulosis.
5. Pelvic floor dysfunction. The patient was diagnosed with Sepsis, unspecified organism, Pneumonia, unspecified organism, Urinary tract infection, site not specified, Severe sepsis with septic shock. The patient was treated with Central line placement and removal. At the time of discharge, the patient had Primary: septic shock; UTI; Ileocolitis secondary to
campylobacter infection
Secondary: Anemia; uterine prolapse; Hypothyroidism;
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>Summary
==================
___ y/o female with a past medical history of HTN, HLD,
peripheral neuropathy who presents with septic shock.
Acute issues
==================
# Septic shock
# UTI
# Campylobacter infection
She was found to have a UTI and signs of colitis on CT scan. She
was initially managed in the ICU with pressors and IV
antibiotics. She was stabilized and transferred to the floor.
She remained stable on oral antibiotics and was discharged home
in good condition. Stool cultures were positive for
campylobacter. She was discharged on Ciprofloxacin 500mg BID for
a 10-day course. She should continue to take ciprofloxacin
through ___. It is not clear if the source of patient's sepsis
was campylobacter colitis or occult urosepsis in the setting of
obstruction due to severe uterine prolapse (urine cultures grew
mixed flora).
Chronic issues
====================
# Normocytic anemia: does not appear to be chronic. No recent
iron panel or B12. Could also be secondary to aggressive fluid
resuscitation. B12 and iron panel were wnl. Recommend rechecking
CBC as an outpatient following resolution of acute illness.
# Uterine prolapse. Prominent prolapse on exam. Unclear
chronicity of the prolapse as patient denies having had this
evaluated in the past. Was evaluated by gynecology and will
follow with them as an outpatient.
# Hypothyroidism: chronic, stable.
- Continued home levothyroxine
# Hypertension: was normotensive during admission and home HCTZ
was held on discharge.
# Hyperlipidemia: chronic, stable.
- Continued home simvastatin and aspirin
# Peripheral neuropathy: chronic, stable.
- Continued home gabapentin
# GERD: chronic, stable.
- Continued home omeprazole</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CHEST (PA AND LAT) showed No acute cardiopulmonary abnormality. RENAL TRANSPLANT U.S. showed 1. Stable mildly elevated intrarenal arterial resistive indices. Patent
transplant renal vasculature.
2. No hydronephrosis or perinephric fluid collections. RENAL U.S. showed Bilateral atrophic kidneys. No hydronephrosis. The patient was diagnosed with Dysuria. At the time of discharge, the patient had PRIMARY DIAGNOSIS
================
Multi-drug resistant klebsiella urinary tract infection
SECONDAY DIAGNOSES
==================
Acute on chronic kidney injury
Type 1 diabetes
Anemia
Hypertension
Hyperlipidemia
History of breast cancer
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>TRANSITIONAL ISSUES
==================
Discharge wt: 76.93kg or 169.6 lbs
Discharge Cr: 1.0
[] consider checking iron studies for anemia workup
[] f/u fosfomycin sensitivities on urine culture
[] needs urology outpatient f/u for urodynamic studies
[] ___ outpatient f/u
[] Transplant ID f/u with Dr. ___ outpatient (ID team
will try to set up appt ___ at 2pm); will discuss
suppressive abx regimen then
[] Renal transplant f/u with Dr. ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with PMH diastolic CHF, DM on insulin, HTN, HLD, who was
referred to the ED by his PCP after he was found to have
hyperkalemia on routine labs. He visited his PCP because he had
been feeling "unwell" since ___ and possibly prior to that.
He noticed low blood sugars and low blood pressures which is new
for him. He also endorses diarrhea that he descirbes as
explosive, usually three loose stools with associated cramping.
He otherwise denies abdominal pain. He also lost 20 pounds in
that time frame. He denies fevers, chills, night sweats, cough,
hematochezia, or melena. On his PCP visit on ___ his K was
noted to be 6.3 with lipase of 741 and was referred to the ED,
where he was found to have a K of 6.8
- Imaging: ___ 1545 EKG with peaked T waves, appeared
improved on repeat.
Patient was given: insulin and dextrose X 2, 500cc NS, 1g IV
ceftriaxone, and 1g calcium gluconate Radiology showed 1. Essentially normal CT appearance of the pancreas (noncontrast). A slightly
bulky configuration to the pancreatic tail is noted as described above. In
the setting of the provided history, could obtain laboratory values to exclude
autoimmune pancreatitis. However, given that this appearance is unchanged
since the CT of ___, the finding is of doubtful significance and is likely
configurational.
2. Stable splenomegaly.
3. Indeterminate bilateral enlargement of otherwise morphologically normal
pelvic lymph nodes. Significance is uncertain, particularly given the
concomitant finding of splenomegaly. However, it is noted that those lymph
nodes included in the CT chest of ___ are also stable.
4. Stable bibasilar pulmonary nodules consistent with granulomas.
RECOMMENDATION(S): Please consider laboratory evaluation to exclude
autoimmune pancreatitis and evaluate indeterminate-significance splenomegaly
and pelvic lymph node enlargement, also stable to the extent that comparison
can be made with a prior chest CT. The patient was diagnosed with Nausea with vomiting, unspecified. At the time of discharge, the patient had Primary Diagnosis
Hyperkalemia
Urinary tract infection
Secondary Diagnosis
Diabetes ___ on CKD
Hypertension
chronic diastolic congestive heart failure. The patient was given written instructions concerning 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 (___) after referral from his
PCP due to hyperkalemia. He had a K of 6.8 and peaked T waves on
EKG. This was felt to be secondary to his spironolactone and
lisinopril, which were held. He was given insulin and dextrose,
calcium gluconate, and he was admitted for hyperkalemia. On the
floor (___), his was given a low potassium diet and treated
with IV fluids and Lasix, however the Lasix was held after a
mild rise in Cr. He was given kayexalate and his K decreased to
5.1. Patient was also complaining of intermittent urinary
retention over the last 2 weeks and he was also found to have a
leukocytosis of 11.8 and his urine culture grew E. coli. He was
treated with ciprofloxacin and his leukocytosis resolved upon
discharge (to 9.5). Mr. ___ also presented with a 2 month
history of diarrhea, which he did not experience during his
stay. He underwent a CT abdomen scan, which showed no
hydronephrosis and was overall stable from his CTA in ___. Mr.
___ was instructed to follow up for a Chem 7 within 48 hours,
to call to schedule an appointment with nephrology, and to adopt
a low potassium diet.
TRANSITIONAL ISSUES
=======================
-K was 5.3 and Cr 1.9 on discharge, ordered chem 7 within 48
hours of discharge. Will need to be followed-up.
-Will need follow up with Nephrology (Dr. ___
clinic ___ to follow up hyperkalemia and ___ on CKD.
Patient will schedule.
-Pt should follow up with cardiology as an outpatient given new
medication changes below
-Blood sugars were 200-300 during admission on 35 glargine in
AM, 50 glargine in ___, sliding scale humalog. His liraglutide
and metformin were held initially but restarted on discharge. He
should have follow up with endocrinology
-Patient should continue to take a low-potassium diet until
potassium normalizes and remains normal
-Stopped medications: lisinopril, spironolactone
-New medications: Ciprofloxacin, 7 day course for UTI ending
___
-Labs pending at discharge: Renin, ___, IgG1234, Ova and
Parasites culture
-Instructed to make an appointment with your primary care
physician within one week of leaving the hospital. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with CAD, T2DM,
HTN, HFrEF (___), atrial fibrillation, AV nodal disease s/p
PPM, COPD on intermittent home O2, severe TR/moderate AS,
moderate pHTN, and ESRD (HD TTS) with recent admission to ___
for atrial fibrillation with complete heart block who presented
from nursing home this evening with lethargy, weakness, and
sleepiness and was found to be bradycardic to the ___ and
hypotensive to ___. Interrogation of his pacer showed
evidence of failure of his Micra to capture. CHEST (PORTABLE AP) was done. Radiology showed Interval placement of a left chest wall single lead pacemaker with no evidence
of a pneumothorax.
New mild pulmonary edema, small bilateral pleural effusions and left basilar
atelectasis. CHEST (PA AND LAT) showed Compared to chest radiographs since ___ most recently ___.
Opacification in the left lower lobe has worsened accompanied by ipsilateral
mediastinal shift suggesting this is due to atelectasis progressing to
collapse of the left lower lobe. Pulmonary vascular congestion has increased.
New opacification at the right lung base could be atelectasis or early
pneumonia. Small pleural effusions are likely. No pneumothorax.
Transvenous right ventricular pacer lead is continuous from the left pectoral
generator. Right supraclavicular dual channel central venous catheter ends in
the right atrium. Radiology showed Small left pleural effusion with left basilar atelectasis and trace right
pleural effusion are unchanged. Left-sided pacemaker and right-sided 8
minutes catheter also unchanged. Moderate cardiomegaly is stable. There is
evidence of stable pulmonary arterial hypertension, unchanged. No
pneumothorax is seen The patient was diagnosed with Bradycardia, unspecified, Mech compl of unspecified cardiac device, initial encounter, Exposure to other specified factors, initial encounter. The patient was treated with Successful single lead PPM via L axillary generator (___). The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Summary
___ with CAD, HFrEF, ESRD on HD TTS, and atrial fibrillation
with complete heart block s/p recent PPM explantation in the
setting of bacteremia and Micra PPM
implantationon ___ presents with bradycardia likely secondary
to Micra malfunction (possible dislodgement).
#CORONARIES: Unknown
#PUMP: EF ___
#RHYTHM: Regularized atrial fibrillation, ventricular rate 34
# Hypotension
Patient was intermittently hypotensive since admission requiring
low dose phenylephrine. Weaned off pressors slowly with normal
mentation and lactate. Unclear exactly what caused this but
likely severe aortic stenosis and CHF. Lisinopril and Metoprolol
were held and should only be restarted carefully as an
outpatient.
# Bradycardia
# Atrial fibrillation with complete heart block
Patient with history of atrial fibrillation with complete heart
block s/p PPM implantation with recent explantation in the
setting of MRSA bacteremia. Underwent placement of Micra PPM on
___ with device check 1 week later that showed acceptable
function. On presentation, was found to have bradycardia in the
setting of device not capturing initially, although it began
capturing when the rate was increased to 80. He underwent single
lead PPM placement on ___ with good results. He was
continued on outpatient warfarin.
# HFrEF
# Pulmonary hypertension complicated by cor pulmonale
TTE on ___ with EF 30% with moderate global RV free wall
hypokinesis. Severe AS and severe TR. Mild pulmonary artery
systolic hypertension. As above, held his Metoprolol and
lisinopril on discharge.
# Severe AS
Noted on echo with a valve area ~0.6 and high valve gradient
(mean 49). Should follow with ___ cardiology as outpatient for
consideration of TAVR.
# ESRD on HD TTS
Receives HD on TTS via right tunneled dialysis catheter.
Continued HD TTS per renal,
nephrocaps, sevelamer.
# CAD
Continued atorvastatin 80mg daily.
# OSA on BiPAP
On BiPAP per nursing home records, though on previous
hospitalization notes appears to be on CPAP (and consistently
refusing). Will defer BiPAP at this time and readdress if
necessary.
# COPD
On intermittent home O2. Satting well on room air on discharge.
Continued ipratropium/albuterol
# GERD
Continued famotidine 20mg PO daily.
# Anemia
Thought to be secondary to CKD. Continued ferrous sulfate 325mg
PO daily.
# Depression
Continued fluoxetine 40mg PO daily.
Transitional issues
- Will follow-up with Dr. ___ in 4 weeks for PPM followup.
- Should follow with BI cardiology for evaluation of TAVR
placement for severe aortic stenosis.
- Metoprolol and ACEi where held on discharge. Could be
restarted carefully as outpatient if blood pressures stable.
- Patient reported ride from his nursing facility to HD unit is
painful on his back. He reports better when he is able to go in
a wheelchair. I also gave him a short script of oxycodone 5mg to
be used prior to transportation for the pain.
Code: DNR/DNI (has MOLST form)
Name of health care proxy: ___
Relationship: Spouse
Phone number: ___ </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ old man with HFpEF, severe diffuse CAD
being medically managed, HIV (VL undetectable ___, CD4
unknown), cirrhosis complicated by grade III varices that have
bled, HTN, stage III CKD, and dyslipidemia who presented with a
3 day history of chest pain and dyspnea. He reports that he has
been having intermittent dull, substernal chest pain for the
past 3 days which acutely worsened at midnight to a severe,
___ pain which woke him from his sleep. He reports that the
his chest pain is present both at rest and with exertion. He
also notes increased chest pain in settings of poorly controlled
blood glucose and anxiety. The chest pain is better when he lies
down or sits down. He has been taking approximately 4 SL
nitroglycerins a day without significant improvement in his
pain. Of note, he has had multiple recent hospitalizations for
chest pain, most recently he was found to have an NSTEMI in ___
(no PCI, stent, or heparin given at the time due to his risk for
bleeding). His CAD is currently managed with maximal medical
therapy, but he has angina at baseline. He denies fevers,
chills, dyspnea, hematochezia, or melena. He also reports that
he had sharp bilateral flank pain and increased abdominal
distension. He denies urinary retention, urgency, dysuria, or
hematuria. Chest radiograph. showed Mild left lower lobe atelectasis. No definite pneumonia. ABDOMEN US (COMPLETE STUDY) showed 1. No hydronephrosis or ascites.
2. Nonobstructing renal stones on the left. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had Primary: chest pain
Secondary: acute kidney injury, HIV, cirrhosis, 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>___ is a ___ year old man with a history of HFpEF, 3V CAD
being medically managed, HIV, HIV medication and NASH-induced
cirrhosis, with multiple recent hospitalizations for chest pain
who presented with a 3 day history of worsening chest pain and
sudden onset flank pain, found to have elevated troponins and
stable EKGs.
#Chest pain: Mr. ___ was admitted on ___ for a 3 day history
of chest pain at rest and with exertion which acutely worsened
the night prior to admission and was not relieved by
nitroglycerin at home. His initial troponin in the ED was
negative, however repeat troponins peaked at .07 before
downtrending on ___. There were no ECG changes on serial ECGs.
During his admission, he endorsed two episodes of mild ___
chest pain which resolved with nitroglycerin and one dose of
lorazepam. He continued to be medically managed on Imdur 240mg
daily, pravastatin 80 mg, SL NTG prn, ASA 81, and nadolol 80mg
daily. Anticoagulation was not pursued due to his history of
major GI bleeds (most recently in ___. He was discharged
with close follow-up with Cardiology within the week.
#Acute kidney injury: Mr. ___ presented with a Cr of 1.7
(baseline 1.1-1.2). He was given 1L of NS in the ED and further
work-up of his ___ included a renal ultrasound, UA, and
chlamydia/gonorrhea testing. His home Lasix 20mg PO was held,
but will be resumed upon discharge. He also had a renal
ultrasound which showed nonobstructing renal stones, but no
signs of hydronephrosis. His UA was negative. GC/Chalmydia were
negative. His ___ subsequently resolved with a Cr of 1.0 prior
to discharge. He should have a repeat BMP to assess kidney
function in the setting of restarting his home dose of
furosemide.
#Cirrhosis: Mr. ___ endorsed increased abdominal distension. An
abdominal ultrasound showed no evidence of ascites. His LFTs
were within normal limits and MELD score was 6 prior to
discharge. Weight was stable/slightly decreased over his
hospitalization.
#HIV: Mr. ___ has a history of HIV on HAART with an
undetectable viral load. CD4 count was 359 during this
admission. He was continued on his home medications.
#Anemia: Mr. ___ was 8.7 on admission and was steady
through his hospitalization, thought to be related to his
chronic diseases and recent hospitalization in ___ for GI
bleeding. He was continued on his home pantoprazole and ferrous
sulfate. He should have a repeat CBC.
#Type 2 diabetes: His glucose on admission was 302 with reported
readings into 500s at home and last HbA1c on ___ was 8.0%. He
was continued on his home insulin.
#Hypothyroidism: He was continued on his home levothyroxine.
#Hypertension: He was continued on his home amlodipine.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ yo woman with h/o of cirrhosis likely ___
NASH, presenting with worsening abdominal pain and distension. Limited abdominal ultrasound showed Large volume ascites with spot marked for paracentesis by the clinical team. Multiphasic CT abdomen. showed 1. Liver cirrhosis with sequelae of portal hypertension including small
ascites, mild splenomegaly and a large paraesophageal varices.
2. No suspicious liver lesions identified.
3. Multiple enlarged periportal lymph nodes as described above, increased in
size when compared to prior. There also multiple enlarged retroperitoneal
lymph nodes that are new from prior. The patient was diagnosed with Other ascites. The patient was treated with Diagnostic paracentesis (___)
Diagnosis and therapeutic (3L) paracentesis (___)
Diagnosis and therapeutic (6L) paracentesis (___). The patient was given written instructions concerning 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 woman with history of NASH cirrhosis
complicated by ascites and varices who presented with abdominal
distension and pain and was found to have spontaneous bacterial
peritonitis (first episode). Her diuretics were initially held,
and she was treated with albumin and a 5-day course of
ceftriaxone (Last day: ___. She was then started on
ciprofloxacin for SBP prophylaxis. She had two large-volume
paracenteses (3L on ___ and 6L on ___. Her diuretics (Lasix
80 mg/Spironolactone 100 mg) were restarted on day of discharge
and should be uptitrated as appropriate as an outpatient. She
underwent CT for ___ screening, which did not show any
concerning liver lesions. However, the CT did show
intra-abdominal lymph nodes that have increased in size from
prior; the patient may require biopsy. Of additional note, the
patient's fasting blood sugars were in the ___ so her insulin
was decreased.
=================</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI(4): Ms. ___ is a ___ female with metastatic ER+
breast CA, hx of SBO, PE on warfarin who presents with abdominal
pain. Patient notes acute onset of abdominal pain 1 day PTA
which was sharp, cramping, located in the upper quadrants.
Patient reports she does not like giving pain a number but feels
it is very severe. Last BM yesterday although small, has not
passed gas since yesterday. Had on episode of NBNB emesis when
EMS arrived at her home and once this AM. Denies f/c. Patient
was
discharged from ___ two days ago after presenting with the
same
complaint. CT showed partial SBO and large stool burden. ACS
felt
presentation more c/w with constipation therefore patient placed
on aggressive bowel regimen with relief of symptoms. She reports
she did not have these medications at home until yesterday.
Patient reports she feels mildly short of breath, worse when
pain
becomes more severe. Otherwise no CP, flank pain, fevers, has
chronic mild LLE swelling. Radiology showed 1. Several dilated loops of small bowel, with air-fluid levels, and mild
distension of the transverse colon. Findings may represent early small-bowel
obstruction versus ileus. If clinically warranted, may consider CT abdomen
pelvis for further evaluation.
2. Heterogeneous sclerotic/lytic appearance of the left hip, present going
back to at least ___, reflect fibrous dysplasia. Radiology showed 1. Small-bowel obstruction with decompressed small bowel loops in the pelvis
although no definite transition point identified. The obstruction may be
partial or early complete. No pneumoperitoneum, pneumatosis, or abnormal
bowel wall enhancement.
2. Small volume ascites limits assessment soft tissue nodularity/masses.
3. Trace bilateral pleural effusions.
4. Extensive osseous sclerotic lesions in the right sacrum, left hip, and
spine appear stable. No acute fracture.
NOTIFICATION: The updated findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 11:56 am, 10 minutes after
discovery of the findings. CHEST (PORTABLE AP) showed Comparison to ___. In the interval, the patient has received a
feeding tube. The course of the tube is unremarkable, the tip of the tube
projects over the pre-pyloric region. No complications, notably no
pneumothorax. The extensive lung parenchymal abnormalities as well as the
size of the cardiac silhouette are stable. Chest x-ray showed The NG tube has been pulled back and the side port is just distal to the GE
junction. There is otherwise no significant interval change when compared to
the prior study.
RECOMMENDATION(S): Consider advancing the NG tube 7-10 cm for more secure
positioning. Radiology showed Findings consistent with persistent small-bowel obstruction. CHEST (PORTABLE AP) showed In comparison with the study of ___, the nasogastric tube again
extends into the upper stomach, were crosses the lower margin of the image.
The side-port appears to be in the region of the esophagogastric junction, and
therefore the tube should be pushed forward at least 5-8 cm for more optimal
positioning. Continued enlargement of the cardiac silhouette with pulmonary
vascular congestion. More focal areas of opacification, especially at the
right base, are worrisome for superimposed aspiration/pneumonia. Retrocardiac
opacification is consistent with volume loss in the left lower lobe and
pleural effusion, though it would be difficult to exclude a region of
consolidation on this side as well.
Suggestion of nodular opacifications in both lungs would be consistent with
the clinical diagnosis metastatic breast cancer. DX CHEST PORTABLE PICC LINE PLACEMENT showed In comparison with the study of earlier in this date, there is an placement of
a left subclavian PICC line that extends to the lower SVC. Otherwise, little
change. DX CHEST PORT LINE/TUBE PLCMT 1 EXAM showed In comparison with the earlier study of this date, the nasogastric tube
extends to the upper stomach, though the side port is at or above the
esophagogastric junction. The tube should be pushed forward at least 5-8 cm
for more optimal positioning.
Otherwise, little change. Radiology showed At least one dilated loop of small bowel projects over the mid abdomen.
Alternatively this may represent a loop of the sigmoid colon. Air and stool
is seen throughout the colon. Radiology showed Increasing small bowel dilatation, concerning for a small bowel obstruction.
Known sclerotic metastases.
Small left pleural effusion with subjacent atelectasis. Radiology showed No change in small bowel obstruction. Radiology showed 1. Persistent small bowel obstruction.
2. Lytic and sclerotic expansion of the pelvis and hips, compatible with
Paget's disease. The patient was diagnosed with Other intestinal obstruction. The patient was treated with see discharge summary
___. At the time of discharge, the patient had small bowel obstruction
health care acquire pneumonia
Hypoxia
history of pulmonary embolism. The patient was given written instructions concerning 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 metastatic ER+ breast CA, hx of SBO
(prior venting G-tube removed recent admission), PE on warfarin,
hx C.diff who presents with abdominal pain.
#Abdominal pain:
#Small bowel obstruction:
Initial CT ___ c/f SBO, unclear whether related to metastatic
breast CA or adhesions from prior radiation. Possibly
contribution from constipation given opiate use and missed doses
of bowel regimen. She was felt to be improving and then ordered
and regular diet after which she had worsening symptoms and
distension. NG tube was reinserted and connected to intermittent
suction initially and patient puled it out overnight again and
refused to have it re-inserted. ACS followed. TPN initiated on
___ due to concern for malnutrition. She remained on bowel
regimen. She began moving bowels and passing gas.
Need for long term TPN unclear as she seems to tolerate PO diet,
but that she chooses to eat small quantities and is not eager to
eat more.
# Hypoxia:
#acute on chronic hypoxic respiratory failure
#likely multifactorial from splinting, atelectasis and now
concern for
#aspiration vs HCAP: resolved
Patient at baseline 2L requirement, likely in setting of some
atelectasis and known pulmonary emboli.
# Pulmonary emboli:
Diagnosed during ___ admission. Discharged on Coumadin
(unable to afford lovenox), which is being managed by PCP. INR 2
on admission, but Coumadin was held this admit as there were
possible procedures. Ultimately she remained on lovenox 50mg
BID sc for her PE treatment. GIven that she will be discharged
to rehab, and they can help sort out if long term lovenox will
be an issue because of payment, we opted to treat with lovenox
because of malignancy. If she is unable to afford lovenox, then
Coumadin can be initiated with appropriate bridge using lovenox.
# Metastatic ER+ breast cancer:
Metastatic to bone. On doxil (monthly) and exemestane. Last
doxil dose was ___.
- Continue home exemestane
- continue tylenol and home MS ___ 60mg q12h with dilaudid IV
PRN severe pain for cancer-related pain
- f/u with Dr. ___ as outpatient</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with HCV cirrhosis complicated by HE and
ascites, chronic abdominal pain, and recent admission for new
right sided colitis brought in by her daughter for disorganized
speech, auditory hallucinations, and anxiety for 3 days. Though
she does have some confusion at baseline, her daughter reports
that she has never seen the patient this severe before. The
voices are telling her to repeat herself and she is not making
sense. She denies SI/HI and any substance use. She states she
has been compliant with her lactulose, but her daughter reports
otherwise. She continues to have her chronic abdominal pain,
which she has had for decades, but denies vomiting, fever,
chills, chest pain, sob, palpitations. Her last BM was this
morning. She has been "racing" for the past three days and has
been unable to sleep. She reports increased anxiety and
depression, and felt as if she was "about to freak out". She
reports not acting like her normal self. Daughter reports that
patient has been seeking to spend time with and talk with all of
her children because voices in her head are telling her to do
so.
She was previously hospitalized here just a few weeks ago
(___) with acute on chronic abdominal pain, fever, and
altered
mental status with radiographic evidence of right-sided colitis.
She was treated with ceftriaxone and flagyl until HOD 2 when
they
were discontinued, with subsequent improvement in her abdominal
pain. Colonoscopy showed normal mucosa throughout the TI and
colon. Biopsies were taken and additional polyp was biopsied,
showing normal colonic mucosa without colitis and fragments of
an adenoma. However, given concern for IBD, the patient was
started on mesalamine prior to discharge. Her altered mental
status was felt to be secondary to hepatic encephalopathy,
although she continued to report compliance. She was treated
with rifaximin and lactulose, with negative infectious work-up,
and mental status improved by discharge.
Of note, she was on triple therapy for her chronic hepatitis C
with excellent virologic response. She unfortunately developed
severe anemia and colitis requiring admission. Her therapy was
stopped and her virus relapsed. Given an elevated MELD at the
time of her last discharge, plan was to initiate the transplant
evaluation at her last outpatient appointment.
In the ED, initial vitals were 98.6 97 186/68 18 100% on rA. She
repeated "liver acceptance, liver acceptance, liver acceptance.
need to slow down" throughout the ED assessment. She was
initially very anxious and agitated, yelling at times,
whispering at others. Shortly after arriving she got 1mg PO
Ativan and has been calm and was agreeable thereafter. EKG sinus
at 82. CXR without acute process. RUQ u/s with patent veins. ED
resident reported that they did not see good pocket for
paracentesis on u/s. She was placed on a 1:1 sitter for racing
thoughts and auditory hallucinations. Most recent vitals prior
to transfer: 82 172/78 14 98% on RA.
ROS: +cough, denies diarrhea, negative unless noted above. Radiology showed No acute cardiopulmonary process. Radiology showed Patent hepatic and portal veins. No ascites. The patient was diagnosed with ALTERED MENTAL STATUS . At the time of discharge, the patient had PRIMARY:
hepatic encephalopathy
insomnia
SECONDARY:
hepatitis C cirrhosis
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>___ year old female with decompensated HCV cirrhosis complicated
by encephalopathy and ascites and chronic abdominal pain,
brought in by her daughter for disorganized speech, auditory
hallucinations, and anxiety for 3 days
# Altered mental status (Delirium): Resolved overnight. Given
her recent admission, liver failure, and particularly the
insomnia and that she's never had psych symptoms like these
before, our highest suspicion was that this is was mild hepatic
encephalopathy, with secondary possibility of an early
adjustment-type episode on underlying depression and anxiety
about her diagnosis. Patient also having severe incomnia. Other
toxic metabolic workup has been negative (including infectious).
Time course too short for mania. Patient no longer symptomatic,
and no SI/HI. Treated with lactulose/rifaximin for
encephalopathy. After discussion with patient and attending,
Ambien was chosen as sleep aid as only an occasional, prn
medication if she truly cannot sleep by 1 or 2 AM. Continued
fluoxetine. She was back at baseline by discharge after close
monitoring.
CHRONIC ISSUES
# HCV cirrhosis: Previously c/b ascites, encephalopathy. EGD
without varices. Now with bilateral ___ edema. Currently
decompensated. MELD 17. Continued lasix/spironolactone,
lactulose and rifaximin.
# Right sided colitis: biopsies without evidence of colitis, CT
findings only. Per Dr. ___ knows this patient, she
had done well whenever mesalamine has been started, and has
colitis type symptoms when it is stoppped, so continued it.
# Chronic abdominal pain: Treated with prn tylenol, less than 2
grams max per day
# h/o ___ esophagus: continued home PPI
# Hypertension: continued home atenolol</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o asthma, seizures presents to the ED from OSH with
c/o seizure. She reportedly had a witnessed seizure on the
commuter rail. At OSH was she as given 1g Ativan and then 500mg
Keppra. She requested transfer to ___. En route she had
another seizure lasting approximately 3-minutes. She received
1mg Versed with resolution. According to the report the patient
is on Lamictal but reportedly not compliant and has had
breakthrough seizures (approximately 1/month). Prior to arrival
at ___ she received 1mg Ativan, 1mg Versed, 500g Keppra
ED Course notable for:
While in ED patient had another seizure. Notable rigid upper
extremity movements with forced right eye deviation. Given an
additional 1g Ativan. Will give another 500mg Keppra (total 1g). CT HEAD W/O CONTRAST showed No acute intracranial abnormality. Slightly age advanced involutional
changes. CHEST (PORTABLE AP) showed No acute intrathoracic process. The patient was diagnosed with Epilepsy, unsp, not intractable, with status epilepticus, Altered mental status, unspecified. At the time of discharge, the patient had PRIMARY DIAGNOSIS: 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>SUMMARY:
___ year old female with complex partial seizure with secondary
generalization, admitted for further monitoring and AED
titration.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr ___ is a pleasant ___ with HTN, s/p ERCP ___ for
obstructive jaundice now s/p stenting, that re-presents to the
ED with complaint of nausea, itching, decreased appetite. Today
the patient was called by pcp to come ___ a lab draw
revealing his Alk Phos and T. Bili remain elevated. Of note the
patient was recently hospitalized on ___ on the ___ for
one day for obstructive jaundice where he underwent ERCP with
stent placement. Brushings were taken (non-diagnostic). The
patient was then discharged with outpatient follow-up. He was
discharged on PO Ciprofloxacin. The patient returned back in ED
with symptoms of nausea and increased jaundice. Radiology showed 1. Technically successful upsizing of right and left biliary drains, 10
___ drains are now in situ.
2. Successful but technically challenging percutaneous removal of a retained
plastic biliary stent impacted in the duodenal lumen . Radiology showed 1. 3.5 cm mass-like lesion at the hepatic hilum which is obstructing the right
and left hepatic ducts, appearance most concerning for Klatskin type
cholangiocarcinoma. However, it is notable that with the presence of a focal
pancreatic lesion (described below) which has the appearance of autoimmune
pancreatitis, that IgG4-related cholangiopathy can present with
circumferential biliary wall thickening and stricturing with obstructive
jaundice, and can be difficult to differentiate on imaging from
cholangiocarcinoma.
The common bile duct is thickening and enhancing, it is not possible to
delineate if this is secondary to the indwelling stent or a ___ lesion.
There is a biliary stent within the common bile duct; however the stent does
not extend through this lesion to decompress either the right or left
intrahepatic ductal systems. There is a 1.8 cm node adjacent to the inferior
vena cava.
2. 7 cm mass within the pancreatic tail which is unusual appearance. While
primary pancreatic tumors such as primary pancreatic adenocarcinoma or
neuroendocrine tumor might have this appearance, appearances are more
suggestive of focal autoimmune pancreatitis. Cytology from EUS aspiration is
pending.
3. Bilateral simple renal cysts, the largest measuring 15.6 cm at the left
upper pole.
4. Marked atherosclerotic disease of the abdominal aorta.
This result was discussed with Dr ___ # ___ by telephone at 2pm on
___.
5. Recommend correlation with IgG4 levels given the possibility of autoimmune
pancreatitis and IgG4 related biliary strictures. This was emailed to Dr.
___ on ___, at 12:16 AM. Radiology showed 1. Bilateral PTBD, resulting in placement of right and left internal-external
biliary drains.
2. Brushings and radial forceps biopsies from central hilar stricture.
3. Pushing of ERCP placed plastic stent into the duodenum. The patient was diagnosed with JAUNDICE NOS, OBSTRUCTION OF BILE DUCT. The patient was treated with ___: Upper EGD with EUS with biopsy
.
___: Flex bronch/EBUS-TBNA
.
___:
1. Bilateral PTBD, resulting in placement of right and left
internal-external biliary drains.
2. Brushings and radial forceps biopsies from central hilar
stricture.
3. Pushing of ERCP placed plastic stent into the duodenum.
.
___:
1. Right-sided pullback cholangiography.
2. Balloon dilatation of a stenosis in the right anterior
system duct.
3. Percutaneous removal of the ___ endoscopically placed
plastic biliary stent.
4. Placement of a new 10 ___ internal-external biliary drain
via the right-sided access.
5. Pullback cholangiography via the left-sided access.
6. Placement of a new 10 ___ internal-external biliary drain
via the left-sided access.. At the time of discharge, the patient had 1. Common bile duct stricture
2. Hepatic hilum mass
3. Pancreatic tail mass
4. Mediastinal lymphadenopathy. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ DMII (diet), HTN, recently undergoing ERCP for obstructive
jaundice s/p stenting now presenting with increased Alk Phos and
T. Bili.
Obstructive Jaundice: The pt was admitted following a recent
ERCP bx that revealed atypical cells. A CT Scan on admission
showed a malignant appearing strictures along the CBD. The pt
was without fever, leukocytosis or other SIRS criteria to
suggest ascending cholangitis, however was empirically started
on Cipro. CA-19 slightly elevated. Patient's abdomina CTA and
MRCP demonstrated hepatic hilum lesion, common bile duct
stricture, and pancreatic tail mass.
The patient was transferred from Medicine Service to HPB Surgery
Service on ___.
His Cytology report from pancreatic mass and common bile duct
brushing was non-diagnostic. On ___ patient completed
cardiac evaluation by Medicine Service and was found to have low
risk level for cardiac complications. On ___ patient
underwent flexible bronchoscopy with mediastinal lymph node
biopsy, and bilateral PTBD placement with brushing. Patient was
empirically started on Cipro and Flagyl to prevent cholangitis.
Patient's T.Bili started to downward on ___. The patient's
diet was advanced to clears and patient tolerated diet well.
Cytology from mediastinal lymph biopsy and CBD brushing was non
diagnostic. Patient's diet was advanced to regular on ___. On
___ patient underwent cholangiography, which demonstrated liver
hilar mass extending into both lobes and a possible second area
of involvement of the mid-to-lower CBD. The patient continue to
have large daily output from his bilateral PTBDs, and his T.
Bilirubin decreased to 15. Dr. ___ PTBD catheter
upsize. On ___, patient underwent CT-guided biliary catheter
exchange to ___. Post procedure patient's diet was advanced to
regular. Patient's IGG 4 result returned back high (525). The
patient was discharged home on ___ in stable condition. He was
discharged home with open drains to gravity drainage as T. Bili
and output still high. The patient was discharged home with ___
service to check his labs on ___ and help to monitor PTBDs
output. Prior discharge the patient was educated about signs and
symptoms of dehydration and importance to drink adequate amount
of fluid while drains still open. He verbalized understanding.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
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 received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with history of Type I DM, CAD, 2 MI, stroke,
CABGx4, on hemodialysis QOD receives all her care here at ___
and ___. Came in to ___ today with confusion and
vomiting blood. She is awake and non verbal. At the outside
hospital, chest x-ray was performed which was reportedly normal.
She was reportedly hypotensive with a lactate of 4. Her
fingerstick blood glucose was 900. She was transferred here for
further evaluation. CHEST RADIOGRAPH showed No acute cardiopulmonary abnormality. Specifically, no pleural effusion or
pneumothorax. CT HEAD W/O CONTRAST showed No acute intracranial abnormality. Radiology showed New mild pulmonary interstitial edema.. Radiology showed Lungs are low volume with bibasilar atelectasis. The Dobhoff tube projects
over the stomach. Right IJ line is unchanged. Trace bilateral effusions are
stable. Mild interstitial edema is unchanged. No pneumothorax is seen. The patient was diagnosed with Urinary tract infection, site not specified. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female with history of Type I DM c/b
ESRD on HD, CAD s/p 2 MI and CABG, stroke, and CVA without
residual deficits who presents vomiting with hematemesis, found
to have UTI, DKA, NSTEMI, and encephalopathy.
# DKA:
Patient was found to have acidemia and elevated glucose on
admission. Patient was admitted to the ICU on DKA protocol and
placed on insulin drip. She was quickly transitioned to
subcutaneous insulin when the anion gap closed. Patient had
temporary feeding through NG tube. She was tolerating p.o.
intake on discharge. Her discharge insulin regimen is 3 units of
glargine in the morning and 2 units in the evening, with 2
Humalog with meals. Since the patient is going to rehab, a
appointment which also was not able to be placed. However upon
discharge from rehab, patient should have close follow-up with
___ for diabetes.
# UTI
# Sepsis:
On admission, patient required norepinephrine for hypotension
and was found to have urinary tract infection. Final cultures
grew Klebsiella, so she was briefly on cefepime and switch to
ciprofloxacin. She completed a seven-day course of antibiotics
on ___. No further antibiotics are needed.
#NSTEMI
Patient initially presented with a troponin of 0.22 which peaked
to 3.45 on ___. This was thought to be type II demand
NSTEMI. Patient was briefly maintained on heparin drip for 48
hours. She was restarted on aspirin and home statin. Her statin
was changed from her low-dose simvastatin to rosuvastatin 40,
given her history of coronary artery disease. Cardiology was
consulted, but they elected to defer cath in the setting of her
altered mental status as well as history of ___ tear
prior to presentation. She is to follow-up with cardiology as an
outpatient with consideration for outpatient catheterization.
Phone number provided in case cardiology clinic is unable to get
a hold of patient to set up appointment. Her discharge troponin
was 2.31.
# Hypertension: Patient reports that she has always been
hypertensive and has had blood pressures in the 180s at home.
She has had episodes of hypotension with dialysis in the past.
Her amlodipine was discontinued and replaced with lisinopril
10mg for renal protective and cardioprotective effect. Of note,
she reported no history of allergy to an ACE inhibitor, and it
is not documented in her chart. However she has been on losartan
in the past, so should she develop symptoms such as dry cough
related to lisinopril, consider switching to losartan if she
gets side effects. She did not have hypotension with dialysis
here.
#ESRD
Patient has known end-stage renal disease related to diabetic
nephropathy. She did receive dialysis ___ while inpatient.
#Hematemesis
Patient reportedly presented with hematemesis, likely ___
___ tear from emesis related to DKA. Her anemia remained
stable and she was briefly maintained on IV PPI while in the
hospital. This was transitioned to oral PPI. There is low
suspicion for bleeding varices due to stable hemoglobin. She
required no transfusions.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo M with PMH of CAD s/p CABG ___, COPD, inguinal hernia
repair, recently diagnosed pancreatic cancer s/p admission to
___ for pancreaticoduodenectomy ___ with post-op course
complicated by intermittent AFib, pan-sensitive Pseudomonas PNA,
urinary retention and pan-sensitive Serratia maracescens UTI now
presenting from ___ with left groin pain. Patient
reports doing well at rehab until 2 days prior to presentation
when he developed left groin pain which has progressively
worsened. He attributes pain to over-activity at rehab. Patient
has no pain at rest but ___ pain with movement of left leg.
Describes it as nonradiating and sharp. He has otherwise been
feeling well. Denies CP, SOB, N/V/D/C, dysuria, and hematuria.
Notably, patient was found to have Na 122 on ___ at rehab and
has been on 1.2 L fluid restriction for ___ days. Radiology showed No evidence of deep vein thrombosis in the left lower extremity. The patient was diagnosed with HYPOSMOLALITY/HYPONATREMIA, ABDOMINAL PAIN OTHER SPECIED, PAIN IN LIMB, HYPERTENSION NOS, HX OF GI MALIGNANCY NEC. At the time of discharge, the patient had Primary: Groin muscle strain, hyponatremia
Secondary: Pancreatic cancer, 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>___ yo M s/p pylorus-preserving Whipple discharged ___ after a
prolonged hospital course presenting from rehab with left groin
pain and hyponatremia found on admission labs.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ YOF with a history of GERD, IBS, CAD s/p
stent, and cholelithiasis who initially presented to ___
___ with sharp abdominal pain, nausea, vomiting, and
diarrhea of sudden onset at 1.30pm yesterday. No recent eating
out, shellfish, etc. No tylenol use. No mushroom picking. She
was noted to be febrile on arrival. Labs showed CBC: no
leukocytosis or leukopenia, no bandemia, no anemia. BUN 25, ALT
186, AP 191, AST 407, Lipase 198, tbili 1.3. trop 0.6. EKG
showed: Sinus rhythm 79 bpm, no acute ST elevation. She was not
complaining of any chest pain. CXR showed no acute process. CT
abdomen performed to rule out SBO, which was not present.
However, it did show multiple hepatic lesions and a dilated
billary duct 1.3 cm. Gastroenterology was consulted who
recommended empiric antibiotics for cholangitis and transfer to
___ for ERCP. The patient became hypotensive prior to
transfer. She was given Levofloxacin and Flagyl. MRCP. showed 1. Large hiatal hernia with resulting intrathoracic stomach.
2. Four T2 hyperenhancing liver lesions, three of which have the MR
characteristics of benign hemangiomata, though slightly atypical. The
largest, fourth lesion in segment VII could represent an atypical hemangioma
but is not definite. Targeted ultrasound could be obtained to exclude a fluid
collection.
3. Moderate extrahepatic biliary dilation, even in a patient post
cholecystectomy, with no CBD calculous or obstructing extrinsic lesion
identified.
The findings were conveyed by Dr. ___ with Dr. ___ on ___. The patient was diagnosed with ABDOMINAL PAIN OTHER SPECIED, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, HYPERTENSION NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT. The patient was treated with ERCP with sphincterotomy. At the time of discharge, the patient had Acute hepatitis likely due to biliary obstruction and
cholangitis
CAD, native
GERD
Hypothyroidism
Anemia of chronic disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo F with h/o cholelithiasis p/w abdominal pain, nausea,
found to have acute hepatitis and dilated bile ducts on CT.
1) Acute hepatitis, likely cholangitis: The patient presented
with an acute hepatitis of unclear etiology. Due to primarily
transaminitis initial work up appropriately focused on
infectious, toxic, and metabolic hepatitides. This work up was
negative and hepatitis serologies were negative as was work up
for celiac disease and autoimmune hepatitis. Pt was
concurrently having fevers and had initial hypotension, which
was concerning for cholangitis and patient did have abdominal
pain. Due to fevers, hypotension, and concern of cholangitis pt
received antibiotics (ciprofloxacin/metronidazole) empirically
and fluids and hemodynamic issues resolved. MRCP was not
revealing for a clear causative process and had several benign
appearing lesions. She continued to have fever and pain,
however, so decision was made to proceed to ERCP though
bilirubin remained normal. She had an ERCP that showed
obsructed ampulla with appearance of obstructing mass.
Sphincterotomy performed, fever resolved, and pain steadily
improved. She was tolerating a full diet without distress at
time of discharge. Regarding the etiology of her biliary
obstructing masses brushings and needle biopsies are pending at
time of discharge for pathological diagnosis. Doctors ___
and ___, who performed the procedure, will follow up the
pathology and plan on contacting the patient and facility to
help coordinate follow up plan as this is partially dependent on
biopsy results. She will complete 10 days of
ciprofloxacin/metronidazole post ERCP.
2) CAD, native vessel: She had no signs or symptoms of ACS
during her hospitalization and no chest pain. Her aspirin was
held around procedure and should be held until 7 days
post-sphincterotomy (can restart on ___. Her metoprolol
was help when hypotensive but then restarted without issue. Her
statin has been held given hepatitis and should ideally be
restarted after LFTs normalize.
3) Likely Viral URI/ Reactive Airway Disease: After a few days
in the hospital the patient developed nasal congestion, cough,
and some wheezing. She has a history of asthma that has been
quiesent for several years but this was felt most consistent to
mild reactive airway disease exacerbation in the setting of a
viral URI. She was managed with guaifenesin and albuterol with
good benefit. She is being discharged on standing albuterol for
a week to help treat airway reactivity around URI.
4) Diarrhea: Patient developed mild diarrhea on antibiotics but
C diff assay was negative. She may receive loperamide PRN for
symptomatic diarrhea.
5) HTN, benign: Initially she was hypotensive but this resolved
with hydration. Her BPs were well controlled on metoprolol at
home dose prior to discharge.
6) Hyperlipidemia: Statin was held given hepatitis, should be
restarted as LFTs normalize.
7) GERD: esomeprazole was converted to formulary omeprazole,
this can be converted back on discharge
8) Hypothyroidism: continued home levothyroxine
9) Depression: Sertraline was continued at home dose</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ with a recent L MCA stroke (___) and
hypertension who presented with sudden onset of dyspnea and
rapid heart rate. She was at home and felt suddenly dyspneic.
She checked her BP and HR and found a BP of 180s/90s and HR in
110s that climbed to 130-40s. She was brought in by EMS and
received 10 of an unknown medication en route with a heart rate
to the 110s.
In the ED, patient was bolused 20 IV diltiazem with improvement
in heart rate to ___ with acceptable pressure. She endorsed some
but not complete improvement in her dyspnea at that time. She
was p.o. loaded with 30 of diltiazem. On reevaluation, she had
complete improvement in her symptoms, was sinus ___ with
acceptable blood pressure.
She is not sure if she has a history of afib but says she had a
holter study in ___ in which she was told she may have had
this rhythm. She does not remember feeling the way she felt
during her most recent presentation of Afib at any prior time.
Regarding her CVA history, she had a large MCA stroke ___ in
___. She thinks the stroke happened in her sleep, but when
she woke up she couldn't dial the phone to her daughter. She was
seen in vascular neurology clinic at ___ ___. Read of the
MRI acquired in ___ showed a left parietal MCA stroke without
evidence of hemorrhagic conversion. She was scheduled to undergo
cardiac work up which she has not yet done.
She has otherwise been feeling well without fevers, chills,
nightsweats, dysuria, abd pain, n/v/d. She has noticed some
increasing DOE with going up stairs. No CP or lightheadedness.
As of today, she is no longer experiencing dyspnea or
palpitations. CHEST (PORTABLE AP) showed As above. CTA CHEST showed 1. No pulmonary embolism or other acute process in the chest.
2. Top-normal heart size. The patient was diagnosed with Unspecified atrial fibrillation. At the time of discharge, the patient had Primary diagnoses
===============
Atrial fibrillation
Secondary diagnoses
==================
Hypertension
Peptic ulcer disease. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo female with h/o L MCA stroke and hypertension who
presented with DOE + rapid heart rate, found to be in Afib with
RVR. Converted with 50 mg (20 IV, 30 PO) of diltiazem. The
patient was transitioned to metoprolol for rate control and
started on apixaban for anticoagulation.
# Paroxysmal Atrial Fibrillation with RVR: Patient presented
with DOE and palpitations, found on ECG to be in AF with RVR.
The patient was thought to have a prior history of afib, given
report of prior episodes of palpitations and tachycardia, noted
prior to immigration to the ___. No e/o infection, anemia,
obvious volume overload as trigger. Most likely secondary to
hypertension. CHADS-Vasc 6, suggesting ~10% risk of stroke per
year. Patient reverted to sinus rhythm with 20 mg IV diltiazem
and 30 mg PO diltiazem. Patient was subsequently switched from
home bisoprolol to metoprolol tartrate 12.5 mg BID, which was
then transitioned to metoprolol succinate 25 mg QD PO. She was
also started on apixaban 5 mg BID. The patient will follow up
with cardiology as outpatient for TTE to rule out structural
etiology of arrhythmia.
# Dyspnea: Patient reportedly dyspneic while in atrial
fibrillation. Dyspnea thought to be most likely secondary to
this arrhythmia as it resolved when the patient reverted to
normal sinus rhythm. Pt did have a history of possible
mild/borderline HF diagnosed in ___, which may have also
contributed to her intolerance of rapid heart rate. Her BNP was
not elevated and CXR was without evidence of pulmonary edema to
suggest acute decompensation. There was a low index of suspicion
for alternative etiologies, including CAD (as ECG unchanged and
prior stress test at ___ was negative), PE or
pulmonary process given negative CTA.
# h/o CVA: Patient without neurologic deficits in house.
Continued on rosuvastatin 5 mg qPM while in house. The patient's
CVA may have occurred due to paroxysmal atrial fibrillation
which was diagnosed on this admission. Her aspirin was
discontinued as she was anticoagulated with apixaban as above
(and her prior stroke was felt to be cardioembolic in etiology
given afib).
# HTN: On bisoprolol at home but with some elevated BPs. Patient
switched to metoprolol 12.5 mg BID PO while in house, which was
then transitioned to metoprolol succinate 25 mg PO QD.
#PUD: Patient with history of gastric ulcers. Last EGD in ___
___ showed clean based, non-bleeding gastric ulcer. Patient
continued on omeprazole while in house.
Transitional Issues:
- TTE scheduled as outpatient to establish baseline and rule out
structural cause of heart disease (previously followed by
cardiologist in ___.
- Consider repeat evaluation for CAD (prior stress test done at
___ reportedly negative) </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: HPI: ___ with hx of HTN, HLD and alcohol abuse who is presenting
as a transfer from ___ after fall while intoxicated and
was found to have right ankle trimalleolar fracture. She was
reduced at the OSH and splinted with post-reduction films that
showed improved alignment, but persistent displacement. She was
feeling well on ED arrival, but then started having tremors,
nausea, vomiting and heart racing consistent with alcohol
withdrawal. She has no hx of alcohol withdrawal or seizures, but
she has been drinking ___ beers daily with more on the weekends.
She had a mechanical fall tonight with subsequent right ankle
pain. CT scan of the head, c-spine and torso at OSH that were
unremarkable. She had hypotension that was fluid responsive at
the OSH. ANKLE (2 VIEWS) RIGHT IN O.R.
IMPRESSION:
Fluoroscopic images show placement of a fixation device about fracture of the
distal fibula. Further information can be gathered from the operative report. showed Fluoroscopic images show placement of a fixation device about fracture of the
distal fibula. Further information can be gathered from the operative report. ANKLE (AP, MORTISE AND LAT) RIGHT showed improvement in alignment of fracture fragments since the prereduction
radiographs. ANKLE (AP, MORTISE AND LAT) RIGHT showed Overlying cast material obscures fine bony detail. Improved alignment of the
trimalleolar fractures. Marked improvement of the tibiotalar joint alignment,
now anatomic. The patient was diagnosed with Displaced trimalleolar fracture of right lower leg, init, Fall on same level, unspecified, initial encounter. The patient was treated with Right ankle ORIF. At the time of discharge, the patient had right ankle trimalleolar 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 fracture of the right ankle, and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF of R ankle, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report.
After the procedure the patient was taken from the OR to the
PACU in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications. The patient
was given ___ antibiotics and anticoagulation per
routine. The patient's home medications were continued
throughout this hospitalization. She was also closely monitored
on CIWA protocol and treated with Ativan for concern of EtOH
withdrawal.
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
touch down weight bearing in the right lower extremity, and will
be discharged on Aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with a history of frequent inpatient
admissions for alcohol intoxication and withdrawal ((>10
withdrawal seizures and DTs) who was recently discharged on ___
now presents 12 hours later with chest pain and possible
pneumonia on imaging. She was discharged to an appointment in
___, however, drank alcohol prior to her appointment and
arrived to her appointment intoxicated. She then later presented
to the ED with chest pain, pain over right arm at site of
cellulitis and persistent cough. In the ED, CTPA was negative
for PE, but showed possible upper lobe pneumonia. She received 1
dose of vancomycin for her cellulitis and ceftriaxone for
pneumonia. CTA CHEST AND CT ABDOMEN AND PELVIS. showed 1. No evidence of pulmonary embolism.
2. Subtle ground-glass opacity within the superior segment of the left upper
lobe, concerning for atypical infection.
3. No acute intra-abdominal process. The patient was diagnosed with ABDOMINAL PAIN UNSPEC SITE, CHEST PAIN NOS. At the time of discharge, the patient had Primary diagnoses:
alcohol abuse
cellulitis
possible pnuemonia. The patient was given written instructions concerning 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 frequent inpatient
admissions for alcohol intoxication and withdrawal ((>10
withdrawal seizures and DTs) who was recently discharged on ___
with seizure in the setting of alcohol abutse who re-presented 1
day later with chest pain and possible pneumonia on imaging.
Immediately after leaving the hospital, she drank alcohol, then
went to her scheduled ___ appointment, and later to the
emergency room complaining of chest pain and worsening cough.
CTPA showed no evidence of PE, but a possible left upper lobe
pneumonia. Her cellulitis over right antecubital fossa was also
very inflammed. She was started on azithromycin and ceftriaxone
for pneumonia and cellulitis. She was monitored on telemetry and
CIWA protocol during stay, although she was on the phenobarbital
protocol during previous admission with some residual effect of
phenobarbital remaining. Her cellulitis improved, her cough
persisted, but she remained afebrile and without leukocytosis.
She completed antibiotic course for pneumonia and cellulitis
before discharge. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with pmhx significant for cystic fibrosis
with chronic recurrent pancreatitis, who presents from home with
nausea, vomiting, abdominal pain, occurring ~2 days ago. Radiology showed 1. Colon is distended with large fecal load, similar to ___. The patient was diagnosed with Epigastric pain, Nausea with vomiting, unspecified. At the time of discharge, the patient had Primary Diagnosis
=============
Acute on chronic pancreatitis
Secondary Diagnoses
================
Hypertension
Normocytic Anemia
Anxiety
Depression
Migraine headaches. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with a history of CFTR mutation
complicated by chronic pancreatitis (with frequent admissions)
without pulmonary symptoms, acute ischemic colitis, chronic
pain, polysubstance abuse, and depression with prior suicide
attempts who presented to the ED with 2 days of vomiting and
epigastric abdominal pain radiating to the back similar to prior
episodes of pancreatitis. The patient was made NPO and treated
with continuous intravenous fluids and intravenous pain and
anti-emetic according to her outlined ___ pain protocol. The
patient initially did not tolerate PO and her diet was slowly
advanced. She was continued on IV pain medication, Ativan, and
anti-nausea medication until discharge. She tolerated a full
diet the day prior to and the day of discharge without nausea or
vomiting. Of note, there was difficulty accessing patient's port
(similar to last admission), TPA was administered, and patient
should plan to visit clinic every ___ weeks for flushes of the
port.
# Chronic pancreatitis - Patient with a history of CFTR mutation
with frequent admissions for chronic pancreatitis. Her
presentation on this admission was consistent with previous
pancreatitis flares, however labs (including lipase) were normal
on admission. There was no concern for infectious process or
other etiology. She was started on her pancreatitis pain control
protocol in ED. She was able to tolerate POs after a few days
and her PO regimen was restarted.
# Normocytic Anemia - Hb at baseline. Most likely ACD, though
there may be some component of malabsorption as well. Hb 8.7 at
time of discharge.
# Migraine Headaches: Continued home Fiorocet
# Depression/Anxiety - Prior history of suicide attempts,
patient denies any current SI/HI. Continued
lorazepam/quetiapine/lamotrigene.
# GERD: Of note, patient has history of Cdiff. Continued
Omeprazole
TRANSITIONAL ISSUES
=================
[ ] Patient required TPA to access port due to difficulty
drawing back, will need clinic appointments Q4-6weeks for port
flushes
[ ] Discussion regarding outpatient pain regimen to prevent
frequent hospital readmissions, with consideration to celiac
plexus block.
# Code Status: Full
# Contact: ___ (wife), home ___, cell
___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female past history of PBC, ___ s/p DEB TACE with
recent admission for secondary SBP s/p tx, who presents with
worsening dyspnea, fatigue, abdominal distention, and diarrhea.
Patient also notes that she frequently has chills, however they
have been more frequent since her discharge. She wanted to come
in tonight so she would not be stuck at home during the storm
feeling ill. CHEST (PORTABLE AP) showed Bibasilar opacities appear improved compared to the prior study, possibly
representing atelectasis/scarring. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic morphology with mild to moderate volume ascites. Patent portal
veins.
2. Fullness of the right renal collecting system is incompletely evaluated,
may have been present on CT dated ___. CTA CHEST WITH CONTRAST showed 1. No evidence of pulmonary embolism or aortic abnormality.
2. Small left pleural effusion and bibasilar atelectasis.
3. Soft tissue prominence in the subcarinal station may suggest mediastinal
lymphadenopathy, likely reactive. Triphasic liver CT. showed 1. Liver cirrhosis with stigmata of portal hypertension including moderate
ascites and paraesophageal varices.
2. Status post TACE procedure within the right hepatic dome within
embolization cavity measuring 11.6 x 7.4 cm containing multiple foci of gas
likely reflecting coagulative necrosis and is unchanged in size from prior.
However along the periphery of the embolization cavity, there are multiple
focal nodular areas of enhancement that demonstrates minimal washout on the
more delayed phases as described above suspicious for residual tumor.
3. Remainder liver enhances homogeneously without arterially enhancing nodules
meeting OPTN Class 5 criteria for HCC.
4. Just posterior to the chemoembolization cavity within the right
subdiaphragmatic space, there is a well-defined rim enhancing fluid collection
measuring 8.2 x 2.8 cm suspicious for subdiaphragmatic abscess collection.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:22 pm, 10 minutes after
discovery of the findings. Radiology showed No significant interval change since the prior chest radiograph. The patient was diagnosed with Unspecified atrial fibrillation. The patient was treated with Diagnostic paracentesis. At the time of discharge, the patient had PRIMARY:
=================
liver microabscess
atrial fibrillation with rapid ventricular response
SECONDARY:
===================
hepatocellular carcinoma
primary biliary cirrhosis. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Patient is a ___ female with h/o primary biliary
cirrhosis, large ___ status post TACE, and recent admission for
SBP who was admitted for low-grade fevers and malaise as well as
atrial fibrillation with RVR.
#Fevers, malaise
She had negative blood cultures, negative C. difficile test,
negative stool cultures, no SBP, and urine with coag negative
staph (likely contaminant or colonization given lack of pyuria).
She underwent a triphasic CT of the abdomen which found a
ring-enhancing lesion just below the dome of the right diaphragm
concerning for an abscess. She was discussed at the
multidisciplinary liver tumor conference and it was felt like
this represented expected post-TACE changes rather than a true
abscess amenable to drainage, but that she may have micro
abscesses as result of the procedure. She was initially treated
with levofloxacin but transitioned to amoxicillin/clavulanate
prior to discharge. Her fevers resolved.
#Atrial fibrillation with rapid ventricular response
Her atrial fibrillation resolved spontaneously and her heart
rate was well controlled on an increased dose of metoprolol.
This was likely triggered by her infection. A discussion of
anticoagulation was deferred to the outpatient setting given the
concern for bleeding risk with the ___.
#Primary biliary cirrhosis
Her lactulose was stopped and she was started on miralax given
significant abdominal discomfort. Her diuretics were restarted.
#GAVE with chronic GI bleeding and iron deficiency anemia
She was given an infusion of IV ferric gluconate 125 mg on ___.
#Hypertension
Her losartan and verapamil were both held in the setting of
normal blood pressures and good heart rate control with the
increased dose of metoprolol.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with HCV and EtOH cirrhosis, HCC s/p TACE ___, RFA
___ who presents with increasing abdominal distension,
referred to ED by outpatient hepatologist for leukocytosis,
elevated Cr after 8L paracentesis ___. He was seen by his
hepatologist on day prior to admission and was called to come to
ED due to leukocytosis. He has been taking oxycodone since TACE
but notes that he takes it for back pain, not abdominal pain.
Last documented fever was ___ 101.5 and was associated with
chills. Denies recent fevers, chills, nausea, vomiting,
diarrhea, urinary symptoms. RENAL U.S. showed Normal appearance of the kidneys and bladder. Moderate ascites. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Patent portal vein. No thrombus is identified.
2. Moderate ascites. The patient was diagnosed with OTHER ASCITES, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, ALCOHOL CIRRHOSIS LIVER, MAL NEO LIVER, PRIMARY. The patient was treated with Diagnostic Paracentesis. At the time of discharge, the patient had Primary:
Ascites
Spontaneous Bacterial Periotonitis (SBP)
Hepatitis C
Alcoholic Cirrhosis
Hepatocellular Carcinoma
Secondary:
Hypertension
Chronic Back Pain. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ with HCV and EtOH cirrhosis, ___ s/p TACE ___, RFA
___ who presents with increasing abdominal distension and
was referred by outpatient hepatologist due to leukocytosis,
elevated Cr concerning for SBP.
# Worsening ascites: Concern for SBP with elevated WBC however
no evidence from diagnostic paracentesis that this is the source
of infection. Last paracentesis ___ removed 8L, received
37.5g albumin at the time, also with >250 PMNs in that sample,
culture negative. Per patient, he experienced little relief
after paracentesis but after that day did not notice much of a
difference in the size of his abdomen. Denies abdominal pain,
feels oxycodone helps his back pain primarily. Concern for
potential malignant component to his ascites but will likely
require large volume tap during this admission. Currently
comfortable, no urgent need and would avoid given renal
function. Gave 1.5 g/kg 25% albumin x 1 (137.5g) Day ___= ___,
and 1 g/kg 25% albumin x1 (92g) on Day 3. Restarted
lasix/spironolactone at half home dose as well as metoprolol
once renal function stabilized. continued CTX 2g Q24H for 5
days (Day 1= ___ treat SBP. Pt had therapeutic parancetesis
___ prior to discharge; 6 L removed.
# Leukocytosis: Most likely source was SBP given large ascites,
cirrhosis. No respiratory symptoms, GI symptoms, fevers, chills,
urinary symptoms to suggest another source of infection. urine,
blood cultures were negative. f/u peritoneal fluid culture.
# ___: Baseline Cr 0.6, increased to 1.3-1.4 post-large volume
paracentesis. There was also concern for HRS, but will need to
rule out other etiologies. Trended Cr, which trended down to 0.9
on day of discharge.
# HCV and EtOH Cirrhosis: No known varices but no EGD in our
system. No history of hepatic encephalopathy per patient, no
record in OMR. Not on home lactulose but is taking Mg oxide BID.
MELD 10 and has just initiated transplant eval. Screening EGD
done ___ showed low-grade esophageal varices. Will need to
follow up pending transplant eval labs
# ___ s/p TACE, RFA: No acute issues at this time. Pending
transplant.
# Coagulopathy: INR stable at 1.4, no previous episodes of
bleeding.
# Back pain: Continued home oxycodone 5mg q4h:prn
# Nutrition: Vitamin D deficiency noted, started weekly vitamin
D supplementation with 50,000 units.
# HTN: Held lasix and spironolactone due to renal function,
restarted them at half dose once kidney function recovered;
continued metoprolol and could continue to uptitrate metoprolol
for further BP control, though not a potent antihypertensive
medication. Continued amlodipine 5 mg PO daily, consider
increase to 10mg from 5mg PO daily. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ hx of morbid obesity, chronic venous stasis, lymphedema and
cellulitis treated in the past with Unna boot and mechanical
compressions presents from home with complaint of increased
swelling in her legs since ___ that has been diuretic
resistant. She was admitted to the medicine service and found to
be have mild ___ and BNP of ___. She was followed in Dr.
___ several years ago for chronic venous
stasis/lymphedema and managed with a combination of unna boot
and other mechanical therapy. More recently she has been
followed in cardiology clinic for the edema and intermittent
cellulitis. Upon interview today she reports increased swelling
and pain of ___ days right worse than left. She denies fevers
but has had subjective chills. She has had periods of increased
swelling, blisters, and cellulitis over the last several years.
She was swollen in ___ and this resolved with diuresis. She
has not been reliably wrapping her legs as she cannot do it
herself at home and has lost the visiting nurses who were doing
it correctly. She denies any recent trauma. She is
anticoagulated for afib and her admission INR was 2.0. She has
had multiple ultrasounds for DVTs which have been negative most
recently in ___. Chest radiograph showed No evidence of congestive heart failure. No acute cardiopulmonary
abnormality. The patient was diagnosed with Heart failure, unspecified. At the time of discharge, the patient had Primary diagnosis:
Lymphedema. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ hx of chronic venous stasis, lymphedema and cellulitis
treated in the past with Unna boot and mechanical compressions
presents from home with complaint of increased swelling in her
legs since ___ that has been diuretic resistant.
# Bilateral lower extremity lymphedema: Ms. ___ has a long
history of bilateral lymphedema, and has followed with cariology
and vascular in the past for this. She reports that sh was not
able to compress her legs adequately on her own and reports that
her home services have not been wrapping her well for some time.
Because of this, she accumulated fluids in her legs which has
been painful and limiting her mobility at home. She was seen by
vascular surgery who recommended changing her compression to
juxtalyte for ease at home. New home services were arranged. Of
note, patient known what works ___ for her and just needs help
with the application of her compression. Future caregivers
should take her input seriously. She will be discharged home
with PCP and ___ clinic follow ups.
# ___: Cr 1.3 from baseline of ~1. BUN:Cr >20. Likely prerenal
in the setting of over diuresis. She reports that she was
instructed to take double dose of home diuretic in the week
prior to admission. She was discharged with a reduced dose of
diuretic and PCP follow up. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ y/o woman with PMH asthma/COPD, PE (___) on apixaban,
interstitial lung disease on prednisone, DM, HFpEF, presenting
with subacute progressive SOB, fatigue, and difficulty
swallowing/drooling for the past week. CHEST (PA AND LAT) showed As above. CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK showed No evidence of Ludwig's angina or other deep space infection. CT CHEST W/CONTRAST showed 1. Allowing for lower lung volumes, scarring and atelectasis in the lung
bases, and the paramediastinal upper lobes is unchanged from ___. The patient was diagnosed with Pneumonia, unspecified organism, Dyspnea, 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>___ with PMH asthma/COPD 3L home O2, PE (___) on apixaban,
interstitial lung disease on prednisone, DM, and HFpEF
presenting with subacute progressive SOB and mouth pain.
#Dyspnea:
#HFpEF:
#Asthma/ILD:
The patient presented with dyspnea worse than baseline, although
on her home oxygen requirement. She was found to be wheezing and
with volume overload. She was diuresed with IV Lasix to
euvolemia. Her oxygen requirement decreased to 2 L (3 L when
ambulating up stairs). She was continued on home prednisone,
Lasix, albuterol, zafirlukast, and fluticasone. Breathing
improved to baseline before discharge.
#Mouth Pain:
Initially concerning for deep space infection given swelling.
OMFS was consulted. CT was negative for deep space infection.
Panorex without evidence of obvious infection. The patient had
extraction of all remaining teeth ___. She was restarted on
apixaban without bleeding. Her mouth pain improved after
extraction. She should continue chlorhexidine mouthwash for 7
days (END: ___. Follow-up with OMFS and dental.
#Urinary tract infection:
Urinalysis suggestive of bacteriuria. Difficult history and
uncertain if she was symptomatic. She was treated with a course
of ceftriaxone in house.
#Herpetic lesions:
Found to have lesions on R buttock suggestive of VZV. Started on
acyclovir course for VZV for 7 days (END: ___. Follow-up with
dermatology as outpatient if indicated.
#Pulmonary embolism. Diagnosed ___, thought to be
unprovoked. However, the patient does have a history of colon
cancer and melanoma. She was placed on apixaban for life.
Apixaban was held ___ and resumed without
bleeding.
#Postmenopausal vaginal bleeding: Patient endorsed vaginal
bleeding a few weeks prior to admission. No active bleeding
during admission. She should follow with OB/GYN for endometrial
biopsy and ultrasound.
#Immature WBC forms:
The patient has had laboratory evidence of immature white blood
cell forms that are chronic. Hematology/oncology was consulted
during hospital lesion. Likely represents response to infection
versus MDS. ___ repeat CBC with differential as
outpatient as well as at annual visits with referral to
outpatient hematology/oncology if CBC shows rising immature
cells or new cytopenias.
#Iron deficiency anemia:
Iron deficient by labs. No evidence of active bleeding.
Hemodynamically stable. However, the patient does have a history
of vaginal bleeding as above, as well as a history of colon
cancer in the past. Recommend repeat CBC as outpatient as well
as GI/gyn onc follow-up. The patient was started on iron
repletion.
#Diabetes mellitus:
Glucose was dramatically elevated on admission likely due to
dose of IV steroids at presentation. Her last hemoglobin A1c was
9.8% in ___. Glargine was increased to 18U. Recommend
glucose check and A1c in clinic with titration of regimen as
appropriate.
# HTN: Continued home lisinopril 10 mg PO daily.
# HLD: Continued Atorvastatin 10 mg PO/NG DAILY.
# Osteoporosis:
# Vitamin deficiency: Continued home calcium, vit D/B, MVI.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ hx of TIA, DMII, chronic vertigo, recent carpal tunnel
surgery who presents with lightheadedness. Began this morning in
bed, has persisted but waxes and wanes. Nonpositional, does not
describe it as room spinning. No headache, diplopia, but feels
that eyelids are drooping more than normal. However, her
daughter reports that her eyelids are unchanged. No fever,
chills, cough, nausea, vomiting, CP, SOB. Also has generalized
weakness. Has had persistent numbness and pain in median nerve
distribution since carpal tunnel surgery earlier this month.
States that she had similar lightheadedness when she was
diagnosed with a TIA at mass gen (found on MRI).
In the ED, initial vs were: 98 89 131/56 14 96%. Labs were
unremarkable. Patient was given oxycodone for wrist pain. She
was seen by neurology.
On the floor, she continues to complain of wrist pain. She
denies lightheadedness, vision changes. Radiology showed No evidence of pneumonia. Radiology showed No acute intracranial process. The patient was diagnosed with DEHYDRATION, VERTIGO/DIZZINESS. At the time of discharge, the patient had Primary: Lightheadedness
Secondary: none. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ w/ hx of TIA, DMII, chronic vertigo, recent carpal tunnel
surgery who presents with lightheadedness.
# Lightheadedness: Occurred intermittently during this
hospitalization. She was offered meclazine as needed, which she
only took once. She was seen by neurology in the ED, who felt
that her symptoms were consistent with peripheral vertigo, of
which she has a history. She was seen by both ___ and OT to
evaluate her functionality and ability to be at home. Based on
their assessment, she was discharged with both ___ and OT home
services, as well as home nursing and evaluation for home health
aide.
# S/P Carpal Tunnel Release Surgery: Patient reported pain over
the surgical site. Examination of the wound revealed a black
eschar. She was seen by the orthopedic surgery service, who felt
that the wound was healing well. She was discharged with ___ for
wound checks, and with close follow-up in ___ clinic.
# Bacteriuria: Denied any urinary symptoms. Was found to have
Enterococcus 10,000-100,000 CFU on urine culture, which was read
as contaminated with mixed flora. We did not treat her with
antibiotics.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ year old female s/p pancreaticoduodenectomy
on ___ duodenal adenocarcinoma (moderately
differentiated, T2N0). Her postoperative course was significant
for postoperative delerium and chylous output from posterior
drain (noted to have a high triglyceride level). Radiology showed 1. Status post Whipple procedure, with the expected postsurgical changes
including air in a small amount of free fluid in the surgical bed. No rim
enhancing fluid collection within the surgical bed to suggest an abscess.
2. Fluid collections in the anterior subcutaneous tissues in just deep to the
anterior abdominal wall likely represent postsurgical seromas, without
significant peripheral enhancement to suggest abscess.
3. GJ tube in appropriate position. Drain extending from the surgical bed and
exiting the abdomen in the right lower quadrant.
4. Diverticulosis without evidence of acute diverticulitis.
5. Enlarged mesenteric lymph node as seen on preoperative films for which
continued followup will be necessary. US ABD LIMIT, SINGLE ORGAN showed Status post Whipple procedure with no evidence of drainable abscess by
ultrasound. CHEST (PA AND LAT) showed Heterogeneous right infrahilar opacity may represent developing infection or
atelectasis. The patient was diagnosed with URIN TRACT INFECTION NOS, PNEUMONIA,ORGANISM UNSPECIFIED. At the time of discharge, the patient had UTI
Wound infection
Pancreatic leak. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ female s/p Whipple procedure for duodenal
adenocarcinoma (moderately differentiated, T2NO) who presented
to the ED from the rehab facility 3 days after discharge with
fevers. On presentation, she had an elevated white count,
positive UA, and opacities on CXR concerning for developing
infection. She was started on IV antibiotics (vancomycin and
levofloxacin) in the ED then admitted to the surgical service
for further evaluation and management.
IV antibiotics were continued on admission - vancomycin,
cefepime, and metronidazole per recommendations from Infectious
Disease. Blood cultures drawn at presentation and on HD2
(___) when she spiked a temperature of 102.4 were pending on
day of discharge. Despite a positive UA, urine culture showed no
growth. Her surgical wound was opened at bedside with drainage
of thick, purulent material -culture showed GNRs on Gram stain
and growth of mixed bacterial flora. The viscous, murky quality
of the drainage suggested a pancreatic leak even with a normal
JP amylase (10). CT abd/pelvis and RUQ ultrasound showed
expected post-operative changes but no intra-abdominal fluid
collections or abscesses. Her WBC normalized on HD2. On HD3
(___), given her improving clinical status and non-convincing
culture data, she was transitioned off the IV antibiotics and
started on oral ciprofloxacin and flagyl to complete a two week
total course of antibiotic therapy (___) per ID
recommendations.
She was maintained on a clear liquid diet and tube feeds (Vital
1.5) were continued. On ___, tube feed rate was
increased to 70cc/hour, cycled 6pm to 10am, as her pre-albumin
was low (14). She continued on her outpatient medications,
including Lovenox. Her opened wound received TID dressing
changes with WTD gauze; it continued to express small amounts of
thick, purulent material. After HD2, she had no additional
fevers and WBC was normal. Her vital signs were stable
throughout her course. She was discharged back to rehab on HD4
(___) to continue her post-operative convalescence. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old female with long standing autoimmune disease of
unclear quality who is admitted for R hallux cellulitis and
"rheumatologic work-up".
She has been suffering from bilateral foot pain for several
months in addition to knee pain from ___ cysts. Last week
when she woke up and her R distal foot around her MTP joint at
all toes was black. She went to the ED at ___, and
received 1 dose of CTX. Xrays there reportedly negative for
osteomyelitis. She went back again the next day and got another
dose. She was subsequently given a prescription for Augmentin.
She was also continued on doxycycline, which she was initially
prescribed two months ago after she tested positive for lyme
disease and was continued for scalp MRSA infection. She
subsequently went to see her PCP, who sent her to Dr. ___
(___). At this point her R distal hallux was bright red and
painful, and he was concerned for MRSA cellulitis. As she had
seen Dr. ___ on ___ in consultation for MRSA infection
prior to ___ cyst removal, she called him on the phone on
___ at the end of the day. He recommended formal evaluation in
our ED, and she presented on ___.
In the ED, initial vitals were: 97.0 114 138/77 18 96% RA
- Labs were significant for CRP 2.3, lactate 2.4, coags WNL, K
3.3, BUN/Cr ___, CBC WNL
- Imaging revealed near dislocation of secont MTP joint and
hammertoe defomity as well as non-displaced fracture of first
distal and fifth proximal phalanges with soft tissue swelling
- She was seen by vascular surgery who felt there was no
threatened limb and recommended medicine admission and NIAS
- The patient was given IV vancomycin and IV morphine 2 mg x 2
Vitals prior to transfer were: 98.1 106 126/77 16 95% RA
Of note, she has had extensive rheumatology evaluation in the
past with a positive ___ 1:80 (speckled pattern) in the past,
but negative inflammatory markers and no clear rheum diagnosis.
She has had pigmentation issues in her bilateral distal feet for
the past ___ months. She also has multiple scalp superficial
lesions that were concerning for MRSA infection, though these
have been healing.
Upon arrival to the floor, she is tired and suffering from R toe
pain. She states the erythema in her toe has been getting
better. She also provides this author with a list of her
symptoms, which are provided below:
- swollen ankles
- chronic pain for years
- lump on forearm
- foot and leg spasms
- lymph nodes are swollen
- low grade fever
- sores on head that bleed and ooze
- pimply skin and rashes
- off balance
- nausea and dizziness
- shooting ___ pains in legs that she has to stop and hold a
wall until they pass
- runny nose
- sores in nose that won't heal
- bumps behind knees (likely ___ cysts)
- bladder repair
- sore joints - elbows and knees
- hand swelling
- teeth problems, lost and chipping
- arm pain
- fatigue and easy bruisability
These have occurred intermittently per the patient over the past
___ years. RIGHT FOOT RADIOGRAPHS showed Age indeterminate nondisplaced fractures involving the first distal phalanx,
and the fifth proximal phalanx. Dislocation, or near dislocation, of the
second metatarsophalangeal joint. Radiology showed No evidence of arterial insufficiency to the lower extremities bilaterally. The patient was diagnosed with PAIN IN LIMB. At the time of discharge, the patient had Right hallux 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>Ms. ___ is a ___ with unclear autoimmune history and hx of
scalp MRSA currently on doxycycline who presents for R hallux
cellulitis, concern for vascular insufficiency, and bilateral
foot pain.
# R hallux cellulitis: On presentation R hallux appeared
erythematous, swollen, and tender, with no exudate or
fluctuance, concerning for cellulitis. Pt was treated
empirically for MRSA with IV vancomycin given hx of recent MRSA
infection and failure of outpatient IV Ceftriaxone, Augementin,
and doxycycline. Pt improved rapidly and was transitioned to PO
clindamycin 450mg TID for a 7 day course. She was discharged
with planned follow up with podiatry.
# Concern for vascular insufficiency: Right DP pulse by doppler
only, ___ palpable. Initial concern for vascular insufficiency,
particularly given dusky discoloration of foot. Pt was seen by
vascular surgery and underwent non-invasive arterial studies
which were normal. She was discharged with instructions to call
for follow up appointment with Dr. ___ in one months time.
# Toe fractures: Unclear chronicity, although likely from
earlier trauma. Unlikely osteo given negative Xrays x2 and
timeliness of improvement on antibiotics. Podiatry consulted,
recommended post-op boot temporarily for 1 week upon discharge,
will re-evaluate in clinic during scheduled follow up on ___.
# Bilateral foot pain and discoloration: Unclear etiology. Given
acute nature of her infection and potential fractures, it was
decided to focus on the more acute problems, recognizing that
she merits a full workup as an outpatient for her more chronic
concerns. Pt has seen rheumatology at ___ in the past, but not
for many years, and requests that she be provided with
rheumatologist at ___ as she is hoping to transition her care.
Pt provided with follow up appointment with rheumatology.
# HTN: During hospitalization pt's home atenolol and
triamterene-HCTZ were discontinued. Her BP's remained stable
without meds in the 110-130's.
# Diabetes: Metformin held during hospitalization, restarted on
discharge.
# CODE STATUS: Full code, confirmed
# CONTACT: sister, ___, ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ male with a PMHx significant for
non-ischemic cardiomyopathy (EF < 20%) on palliative milrinone
s/p HMII LVAD implant ___ with subsequent device explant
___ due to pump failure and driveline infections, HIV (on
ART, last viral load undetectable ___, HTN, and a history of
DVT/PE in ___ who presents with possible infection of ___
line.
He was recently hospitalized ___ for volume overload and
VZV infection and had his diuretics adjusted. He saw ___
___, NP on ___, who increased his diuretics due to ongoing
symptoms of GI upset. He was then hospitalized again from
___ w/ volume depletion and ___ which improved with
gentle IVF and holding his diuretics for several days. CT HEAD W/O CONTRAST showed No acute intracranial process. Radiology showed Successful removal of a right chest tunneled line. Radiology showed Successful placement of a double-lumen Hickman tunneled line via the left
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use. The left chest was chosen based
on patient's preference and request for ease of infusions at home. CHEST PORT. LINE PLACEMENT showed The tip of a new left tunneled central venous line projects over the right
atrium, approximately 3 cm beyond the cavoatrial junction. No pneumothorax. The patient was diagnosed with Local infection due to central venous catheter, init encntr, Exposure to other specified factors, initial encounter. The patient was treated with Tunneled double-lumen ___ line placement via the left
internal jugular venous. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
==================
#Infected ___ site cellulitis
SECONDARY DIAGNOSIS:
====================
#Chronic systolic heart failure on Palliative Milrinone
___ on CKD
#HIV
#Gout. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>SUMMARY
========
Mr. ___ is a ___ year old male with history of dilated
cardiomyopathy thought to be secondary to lymphocytic
myocarditis s/p HeartMate II LVAD implant at ___ in ___ with
subsequent device explant ___ due to pump failure and
driveline infection in setting of decreased compliance, now on
palliative milrinone with last EF 17%, presenting with ___
line site infection.
==============
ACTIVE ISSUES:
==============
#Infected ___ site cellulitis
Patient admitted on ___ with ___ day of progressively
worsening discomfort around ___ line. Also recently
developed purulent drainage coming from this line. Reassuringly
without systemic symptoms. ___ contacted and the line was removed
and sent for cultures. Swab cultures around the skin grew
pan-sensitive pseudomonas. The patient was started on Vancomycin
and Ceftazidime while in-house pending blood culture results.
Blood and catheter tip cultures remained negative. The patient
is thought to have site infection without systemic/blood stream
seeding. Per infectious disease team recommendations, the
patient was started on ciprofloxacin 500mg PO q12h for a total
of 2 weeks (day 14: ___. On ___, a double-lumen
___ tunneled line was successfully placed via the left
internal jugular venous approach. The tip of the catheter
terminates in the right atrium. The catheter is ready for use
after the procedure.
#Chronic systolic heart failure on Palliative Milrinone
Patient with known reduced EF to 17% w/ tenuous volume status
and
recent admissions for both volume overload/depletion. On
admission, the patient was volume overloaded with JVP of 13-14
cm. He was continued on home torsemide 100mg BID. Milrinone
infusion was continued at a rate of 0.5 mcg/kg/min using PIV
prior to ___ placement. His weight on discharge was
77.2 kg (170.1 pounds).</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old male with history of BPH, neurogenic bladder,
recurrent hematuria and ___ who presents with gross
hematuria. He is referred by Dr. ___ at ___. The
patient has a history of BPH and neurogenic bladder s/p
suprapubic tube placement. He began having hematuria several
years ago with clot retention requiring inpatient admission for
CBI. The episodes used to be spaced several months apart but
have become more frequent over the last year with minimal time
between hospitalizations. COMPLETE GU U.S. (BLADDER AND RENAL) showed 1. Markedly echogenic mural based lesions in the posterior bladder wall may
represent adherent clot. Please note that urothelial lesions can have a
similar appearance, however per the OMR a recent cystoscopy was negative.
2. Suprapubic balloon is inflated halfway between the tract and the bladder
lumen. ___ consider repositioning.
3. Visualized prostate appears heterogeneous and measures up to 6.2 cm. Radiology showed 1. Constellation of findings consistent with postoperative ileus.
2. Small pneumoperitoneum is likely postsurgical. CHEST (PORTABLE AP) showed No previous images. Nasogastric tube extends to the upper outer portion of
the fundus of the stomach. Low lung volumes accentuate the prominence of the
transverse diameter of the heart. No appreciable vascular congestion.
Opacification at the bases most likely represents atelectasis. However, in
the appropriate clinical setting, would be difficult to unequivocally exclude
superimposed pneumonia. CT abdomen and pelvis with contrast showed 1. Mild jejunal dilatation may represent a postoperative ileus. There is no
evidence of obstruction.
2. Status post prostatectomy. Marked thickening of the bladder wall with
surrounding fat stranding and edema. No evidence of urinoma. DX CHEST PORTABLE PICC LINE PLACEMENT showed New right upper extremity PICC appears to terminate in the azygos vein.
NOTIFICATION: The findings were discussed with ___, R.N. by ___
___, M.D. on the telephone on ___ at 10:25 am, 20 minutes after
discovery of the findings. CHEST (PORTABLE AP) showed Heart size and mediastinum are stable. Right PICC line tip is current ___ at
the level of mid to lower SVC, appropriately position. Lungs remain
unchanged. The patient was diagnosed with Hematuria, unspecified, Dizziness and giddiness. The patient was treated with PROCEDURE ___: Robot-assisted laparoscopic simple
prostatectomy. At the time of discharge, the patient had Benign prostatic hyperplasia, urinary retention and recalcitrant
gross hematuria.
Ileus, post-operative
Bleeding disorder concerning for ___ 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>Mr. ___ was transferred from OSH with refractory hematuria
(prostatic origin) for consideration of ___ embolization verse
simple prostatectomy. He was evaluated and ultimately optimized
for the robot-assisted laparoscopic simple prostatectomy that
was completed on ___. No concerning intra-operative events
occurred; please see dictated operative note for full details.
Mr. ___ received ___ antibiotic prophylaxis. At
the end of the procedure the patient was extubated and
transported to the PACU for further recovery before being
transferred to the general surgical floor. He was transferred
from the PACU in stable condition. His post-operative course was
complicated by delayed return of bowel functions, postoperative
ileus requiring nasogastric placement (twice) and placement of a
PICC for nutritional support with TPN. His pain was well
controlled, initially with PCA, then with oral pain medications.
He was continued on DVT/PE prohpylaxis with SQH and SCDs. With
the eventual passage of flatus and bowel movements, his diet was
slowly advanced to regular and TPN was discontinued. He
underwent a void trial prior to discharge and his drain was also
removed. Mr. ___ was discharged in stable condition, eating
well, ambulating independently, and with pain control on oral
analgesics. On exam, incision was clean, dry, and intact, with
no evidence of hematoma collection or infection. Mr. ___ was
given explicit instructions to follow-up with Dr. ___
post-operative evaluation and pathology findings.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is a ___ who initially presented with
abdominal pain thought to be secondary to cholecystitis and
underwent an aborted cholecystectomy on ___ in the setting
of a new pelvic mass, which was visualized intraoperatively.
Labs on admission were notable for a leukocytosis of over 20,000
___s an ultrasound showing possible abdominal ascites. At
the time of diagnostic laparoscopy, an intraoperative GYN
consult was performed where aspiration of the mass was performed
for what was thought to be a tubo-ovarian abscess. The right
lower quadrant drain was left in place. A subsequent CT scan
showed a 9 cm heterogeneously enhancing lower abdominal mass,
likely arising from the right adnexa. There was no pelvic or
inguinal lymphadenopathy. There was scattered increased
attenuation of the omentum thought to be post-surgical or
represent metastatic disease. A CT scan of the chest showed no
evidence of intrathoracic disease. A CA-125 was also ordered in
the postoperative setting and was elevated at 3550. She
remained in house and all fluid cultures were negative.
Cytology from her diagnostic laparoscopy was negative. She was
counseled regarding the need for a second surgery for definitive
diagnosis and management. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed Sludge within the gallbladder.
Small amount of ascites. Clinical correlation is recommended. CT ABD AND PELVIS WITH CONTRAST showed 1. Large heterogeneously enhancing lower abdominal mass likely arises from
the right adnexa and is worrisome for ovarian malignancy. This is unlikely to
represent a tubo-ovarian abscess.
2. Scattered increased attenuation of the omentum may be postsurgical or
represent metastatic disease.
3. Small volume ascites.
4. Trace bilateral pleural effusions with mild subjacent atelectasis. CT CHEST W/CONTRAST showed 1. No evidence of thoracic malignancy or metastasis.
2. No acute thoracic process.
3. Resolved trace bilateral pleural effusions with associated compressive
atelectasis. Residual linear bibasilar atelectasis. The patient was diagnosed with Right upper quadrant pain. The patient was treated with ___- Aborted Laparoscopic Cholecystectomy, Diagnostic
Laparoscopy, Drainage Ovarian Cyst
LAPAROSCOPIC RIGHT SALPINGO OOPHORECTOMY; TOTAL LAPAROSCOPIC
HYSTERECTOMY, LEFT SALPINGO-OOPHORECTOMY; BILATERAL PELVIC AND
PARA-AORTIC LYMPHADENECTOMY, OMENTECTOMY. At the time of discharge, the patient had Ruptured Ovarian Cyst. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female who presented to urgent care
with right upper quadrant pain, nausea/vomiting, and
chills/sweats x1 day. She was mildly tachycardic at 107 bpm but
otherwise hemodynamically stable. Labs were remarkable for white
count elevated at 20 with normal LFTs and lipase. Liver
ultrasound showed sludge in the gallbladder. She was referred to
the Emergency Department and evaluated by Acute Care Surgery and
her signs and symptoms were concerning for acute cholecystitis.
Informed consent was obtained and she was taken to the operating
room and underwent an aborted Laparoscopic Cholecystectomy after
noting a normal appearing gallbladder and drainage of a right
ovarian cyst via an intra-operative consult by ob/gyn. The gram
stain of the fluid collected was noted to have PMNs with no
growth on culture or pelvic washings. She was initially started
on vacomycin, ciprofloxacin, and flagyl for a presumed
tuboovarian abscess. A JP was placed in her left lower quadrant
for drainage of the mass.
Patient was subsequently admitted for further evaluation and
management of her mass. During her inpatient stay, tumor markers
were collected and notable for a CA 125: 3550. CEA and ___
were within normal limits. She underwent further imaging. A CT
Abdomen & Pelvis was notable for a heterogeneously enhancing
lower abdominal mass likely arises from the right adnexa. Due to
concern for malignancy vs an infectious process, her antibiotics
were discontinued and was consented for surgical exploration.
On ___, she underwent a Total Laparoscopic
Hysterectomy, bilateral salpingo-oophorectomy, para-aortic and
pelvic lymph node dissection, omentectomy for endometrioid
ovarian cancer that was confirmed by frozen section
intra-operatively. Please see the operative report for full
details.
Her post-operative course is detailed as follows. Immediately
postoperatively, her pain was controlled with dilaudid and
toradol. Her diet was advanced without difficulty and she was
transitioned to oral pain medications. On post-operative day #1,
her urine output was adequate so her Foley catheter was removed
and she voided after a formal trial of void. She was ambulating
independently, and pain was controlled with oral medications.
She met with Social Work to discuss coping strategies regarding
her new cancer diagnosis. 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: MR HEAD W AND W/O CONTRAST ___ MR HEAD showed 1. New enhancing, hemorrhagic lesion with associated FLAIR/T2 hyperintensity
in the left insula, concerning for new metastatic disease.
2. New area of vasogenic edema in the right frontal lobe. Findings are likely
secondary post-radiation changes, however please note that the exam is
severely degraded by motion artifact, which may limit evaluation of small
enhancing lesion.
3. Unchanged 1 cm T1 hyperintense lesion in the posterior right parietal lobe,
nonspecific, and may represent a focus of hemorrhage, calcification, or
metastatic lesion given the patient history of melanoma although there has
been no interval change.
4. Stable postsurgical changes related to resection of the right orbital in
anterior cranial fossa mass with unchanged thickening and enhancement of the
dura underlying the craniotomy site and along the left lateral ethmoid space,
which may represent postsurgical changes with residual neoplasm not excluded. The patient was diagnosed with Unspecified convulsions. At the time of discharge, the patient had Primary:
Seizure
Metastatic melanoma. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ y/o M w/ metastatic melanoma followed by
Dr. ___ ___ ___, locally advanced SCC of the right
orbit s/p extensive resection by Dr. ___ ___
___, who presented with at least one unwitnessed and
one witnessed syncopal episodes that seem most consistent with
seizure. MRI brain showed new hemorrhagic focus and metastatic
lesion in addition to previously noted abnormalities. He was
started on IV Keppra in the emergency department. He was seen by
neuro-oncology who recommended radiation therapy. He underwent
initial planning session while hospitalized, and will receive
cyber knife treatment as an outpatient. He was discharged on
keppra 1g BID. He was counseled that due to the seizures he is
not allowed to drive, but he reports that he already stopped
driving prior to this.
> 30 minutes spent on discharge coordination and planning</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms ___ is a ___ yr old female with left-sided
infiltrating ductal carcinoma, grade III with significant
lymphovascular involvement. She is status post four cycles of
chemotherapy and recently completed radiotherapy in ___.
history Also hx of atrial arrhythmia, chronic hepatitis C and
ETOH abuse. She was referred to ED after MRI at ___ earlier
today showed innumerable brain metastases and extensive
leptomeningeal disease.
Patient reports that about 2 weeks ago she started having L
sided
HA and pain over the L side of her face, also now having pain in
her L eye. Reports pains as sharp and stabbing. Is using
percocet
w/ some relief. She also began noting some L blurry vision and
double vision and was due for her regular biannual eye exam so
she waited. Was told at the exam last ___ she had ___ nerve
palsy
and was referred for MRI. Denies any numbness or extremity
weakness, in fact says her strength is better than after chemo,
now she is able to get up from her knees or the ground on her
own
which she couldnt do few weeks ago. Denies any fever/chills,
back
pain, bowel/bladder incontinence, confusion or balance
disturbance. Does have tingling in her R foot but this has been
present for some time, not new. MRA BRAIN W/O CONTRAST T9711 MR HEAD showed 1. Normal brain MRA.
2. Please refer to separate dictation of an MRI of the brain and orbits
performed concurrently for brain findings. MRI BRAIN AND ORBITS showed 1. Innumerable intracranial metastasis from patient's known breast cancer. No
midline shift is seen. Asymmetric dural thickening along the left tentorium
in keeping with leptomeningeal carcinomatosis with large tumor deposit along
the left tentorium possibly invading the left cerebellar hemisphere.
2. Tumor deposits along multiple cranial nerves including left internal
auditory canal, left abducens nerve, right trigeminal nerve and left optic
canal as described above. CHEST (AP AND LAT) showed No acute intrathoracic process. Radiology showed No evidence of intra-abdominal metastases. Radiology showed Subpleural opacities in the anterior left hemi thorax, likely represent post
treatment changes from left breast cancer.
No new suspicious pulmonary nodules, lymph nodes or bony lesion suggest
metastatic disease in the thorax. The patient was diagnosed with SEC MAL NEO BRAIN/SPINE. At the time of discharge, the patient had Primary Diagnosis:
1. ___ Nerve Palsy
2. Metastatic breast cancer
Secondary Diagnosis:
1. Diabetes
2. Hypertension. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms ___ is a ___ yr old female with history of breast
cancer s/p L mastectomy and axillary LND, 4 cycles chemotherapy
and adjuvant XRT who presented with left ___ nerve palsy, found
to have innumerable brain mets on MRI. Patient received 5 cycles
of whole brain radiation during her admission and was started on
steroids. There was no change in her ___ nerve palsy with
consistent paralysis of her left lateral gaze. With regards to
her pain control regimen, she was seen by palliative care team.
Her pain was mainly due to headache and retro-orbital pain. Her
opiod regimen was adjusted to standing MS ___ 15 mg q12 hours
and PRN ___ morphine. She also received tylenol. Her pain control
was good prior to discharge. She was also noted to have some
intermittent hallucinations / agitation which were thought
likely secondary to her steroids. She was started on olanzapine
2.5 mg daily. There was a family discussion regarding
disposition. It was determined that given her brain mets and
risk for resumption of alcohol consumption at home, that she be
discharged to a facility where she could receive assistance and
be more closely monitored.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of alcohol use disorder complicated by
withdrawal, hepatic steatosis, hypertension, tobacco use, and
GERD who presents with chest pain and flank pain found to have
hyperbilirubinemia and AST predominant transaminitis concerning
for alcoholic hepatitis and/or decompensated cirrhosis. CHEST (PA AND LAT) showed Bibasilar opacities, presumably due to atelectasis given low lung volumes.
Possibility of infection would be difficult to exclude entirely. LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT showed 1. The liver is heterogeneously hyperechoic, which may be due to areas
regional areas of fat. Thus, given patient's history of hepatitis, recommend
further evaluation with the liver MRI to evaluate for underlying lesion.
2. The portal vein is patent.
NOTIFICATION:
1. The liver is heterogeneously hyperechoic, which may be due to areas
regional areas of fat. Thus, given patient's history of hepatitis, recommend
further evaluation with the liver MRI to evaluate for underlying lesion.
2. The portal vein is patent CHEST (PORTABLE AP) showed 2 sequential images demonstrate advancement of a Dobhoff into the stomach.
There are low bilateral lung volumes however no focal consolidation, pleural
effusion or pneumothorax is identified. The size of the cardiac silhouette is
within normal limits. MRI of the Abdomen showed 1. Exam is limited by non breath hold technique.
2. Patchy moderate hepatic steatosis.
3. Increased diffusion signal in the remainder of the hepatic parenchyma, may
be due to acute hepatitis.
4. No focal suspicious hepatic lesions.
5. Sequela of portal hypertension including a recannulized paraumbilical vein
and small ascites. No splenomegaly.
6. Small right pleural effusion. The patient was diagnosed with Chest pain, unspecified. The patient was treated with ___ - NGT placement. At the time of discharge, the patient had Primary diagnosis: alcoholic hepatitis with decompensated
cirrhosis, severe malnutrition, alcohol use disorder
Secondary diagnosis: tobacco use disorder, coagulopathy. The patient was given written instructions concerning 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 a history of alcohol use disorder complicated by
withdrawal, hepatic steatosis, hypertension, tobacco use, and
GERD who presented with chest pain and flank pain found to have
hyperbilirubinemia and AST predominant transaminitis consistent
with alcoholic hepatitis.
TRANSITIONAL ISSUES
===================
[] Vaccinate for HBV
[] Will need EGD screening for varices as outpatient
[] Consider re-introduction of furosemide and spironolactone as
___ outpatient. This was held at discharge as patient with
unclear follow up due to his leaving prematurely
[] Will need intensive nutrition rehabilitation to manage his
alcoholic hepatitis
[] Patient counseled to avoid alcohol and should continue to
receive support for this </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year-old ___ man with a history of CAD s/p DES ___,
afib on coumadin, ___ with LVEF 35%, ICD implant ___,
CKD, who presents to the ED after a syncopal event today.
The patient has been doing well until this morning when he
experienced abdominal gas pains. He was in his bed trying to "do
abdominal exercises" "crunches" to help relieve gas pains. He
felt a warm sensation in his belly that rose through his body
and when he stood up quickly from edge of bed he fell back onto
the bed and passed out. His wife witnessed the event indicated
then he became unresponsive and had bilateral hand shaking. He
had initial confusion when aroused and then returned to normal
within ___ minutes. No urinary/fecal incontinence, no tongue
___. No prior similar episodes though does report ___
previous events of feeling warmth in his body and lightheaded
after gas pains but never passed out.
Of note, the patient recalls ___ years of abdominal bloating,
distension and "gas pains" which he describes as often sharp,
sometimes bloating and most often focal, today located over
right flank but moving to left flank occasionally. This usually
improves with burping though recurrs shortly after. It does
arouse him from sleep as well. There is no correlation with tpye
of food, he denies weight loss, there is no association with
nausea, vomiting, diarrhea or poor PO intake. He reports when
the pain is sever it radiates to his shoulder, both right and
left sides when it occurs. The medical record reveals multiple
prior presentations for similar symptoms. He was admitted in ___ to ___ where Renal US, RUQ US and rib films
completed without acute process. Prior abdominal films were
unremarkable. Primary care visits for abdominal bloating and gas
pains for which Amiodarone dose was reduced. Of note he also has
pancreatic IPMNs s/p EUS with biopsy consistent with IPMN,
precancerous cyst also s/p with gastric biopsy negative for
HPylori ___.
ROS: Denies headache, lightheadedness, or confusion, loss of
vision, blurred vision, double vision. Denies fevers, chills,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation. No recent change in bowel or bladder
habits. Denies dysuria or hematuria. Denies myalgias,
arthralgias, or rash. Radiology showed Cardiomegaly with mild pulmonary vascular congestion, no overt pulmonary
edema. Improved lung volumes relative to prior study. CT HEAD W/O CONTRAST showed No evidence for an acute intracranial abnormality. Radiology showed Moderate to large fecal loading. No evidence of obstruction. Portable supine abdominal plain film showed Nonspecific bowel gas pattern with no evidence of obstruction or free air.
Clinical correlation is advised. Supine and upright views of the abdomen showed Nonspecific bowel gas pattern without evidence of obstruction. Mild ileus is
possible. CHEST (PORTABLE AP) showed Left pacer remains in place. The heart remains stably enlarged. Mediastinal
contours are unremarkable. There is persistent perihilar vascular congestion
with no evidence of overt pulmonary edema. There is possibly a small left
effusion. No pneumothorax is appreciated. Patchy bibasilar opacities may
reflect atelectasis although pneumonia or aspiration cannot be entirely
excluded. Clinical correlation is advised. RENAL U.S. showed 1. Bilateral simple cysts as well as a 1.6 cm right upper pole cyst with a
thin avascular septation or two adjacent small cysts.
2. No hydronephrosis or renal stones. CT ABD AND PELVIS W/O CONTRAST showed 1. No retroperitoneal hematoma.
2. Diffuse hepatic hyperattenuation, likely related to amiodarone
administration.
3. Pancreatic cystic lesion is unchanged from ___, most likely a side branch
IPMN.
4. Diverticulosis without diverticulitis. CHEST (PORTABLE AP)CHEST (PORTABLE AP)i showed Moderate to severe cardiomegaly is chronic, but previous pulmonary vascular
engorgement and hila hilar arterial enlargement have improved and there is no
pulmonary edema or substantial pleural effusion. Lungs are clear of any focal
abnormality.
Right atrial, right ventricular defibrillator, and left ventricular pacer
leads are in standard placements, continuous from the left pectoral generator.
There is no pneumothorax. Radiology showed No obstruction. CHEST (PORTABLE AP)CHEST (PORTABLE AP) showed Is chronic. Pulmonary congestion is slightly more pronounced, while the
caliber of mediastinal vessels has decreased. There is no pulmonary edema,
evidence of infection, or pleural effusion.
The right ventricular defibrillator lead and left ventricular pacer lead are
little changed in their respective positions over many previous chest
radiographs since ___. CHEST (PORTABLE AP)CHEST (PORTABLE AP) showed Transvenous right atrial and left ventricular pacer and right ventricular
pacer defibrillator leads follow their expected courses. There is no
pneumothorax pleural effusion or mediastinal widening. Moderate to severe
cardiomegaly is chronic. Pulmonary vascular distention is mild, and also
chronic. There is no pulmonary edema. CHEST (PA AND LAT) showed In comparison with the study of ___, there is little interval change.
Continued enlargement of the cardiac silhouette with minimal elevation of
pulmonary venous pressure. Pacer leads are unchanged and there is no evidence
of pneumothorax. The patient was diagnosed with SYNCOPE AND COLLAPSE, DIABETES UNCOMPL JUVEN. The patient was treated with 1. ICD Lead Placement
2. Right Heart Catheterization. At the time of discharge, the patient had Active:
- tachybrady syndrome
- systolic CHF
- acute kidney injury
- hypertension
Chronic
- IDDM
- CAD
- atrial fibrillation
- GERD
- GOUT. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ year-old ___ man with a history of CAD s/p DES ___,
afib on coumadin, Systolic CHF with LVEF 35%, s/p ICD also with
CKD baseline Cr around 2.8 admitted for syncopal event.
# VT: History with corroboration from wife initially seemed
consistent with a vasovagal event. EKG at baseline, trops at
baseline, no new significant lab changes. Neuro consulted by ED
who also agreed with this assessment. Orthostatics negative and
patient had no events on tele in 24 hours of initial
observation. No additional testing was pursued given history.
However given presence of ICD, EP interrogated device on ___,
which revealed an episode of VTach, which degenerated into vfib
and then shock. Pacer was previously set at rate of 40 which was
increased to 50 on ___ by EP. On ___, when ___ was placed
for UOP monitoring, pt was found to have clots and required
placement of 2-way catheter by Urology. On ___, he had
worsening R flank pain. His ICD was adjusted to pace in ___ and
pt was placed on Dobutamin gtt for renal perfusion. He developed
multiple runs of sustained VT. During one such episode, a code
was called, and pt was transferred to CCU. In CCU, pt had
several episodes of VT, one of which terminated in ICD shock. He
was evaluated EP, who recommended DC Dobutamine which resulted
in improvement in his VT. He was transferred to the floor where
he had symptomatic 60-100 beat runs of VTach overnight. He was
transferred back to the CCU for monitoring and started on
lidocaine drip and switched him to mexilitine after numerous
runs of NSVT, these stabilized and he was transferred back to
___. He then went for a lead revision procedure to help control
his VTach. He tolerated the procedure well and his VTach
improved.
# Abdominal Pain: Patient described right sided flank pain
radiating to shoulder which is very similar to presentation in
___ where he described "left-sided lateral chest wall pain
extending to his mid-back". There is tenderness on exam
reproducible but without ___ sign. Troponins and EKG
completed in the ED at baseline. CXR negative for PNA as cause
of pleuritic type pain, no rib fractures seen. This has been an
ongoing issue for several years and already extensive work up
has been completed, see OMR and HPI for details. During
admission he had recurrence of symptoms but more localized to
paraspinal muscles and lat dorsi reproducible with palpation of
muscle consistent with muscle spasm related pain. Started on
standing tylenol and tizanidine with good effect. Celiac's ruled
out by tTg IgA, UA without blood to invoke kidney stones, LFTs
relatively normal. Prior upper endoscopy biopsy negative for
HPylori so Ag testing likely of low yield. Prior normal Renal
US, RUQ US and rib film during admission for similar symptoms so
did not repeat this work up. After reviewing workup, his pain
was felt to be related to constipation though unclear
precipitant to event. No recent narcotic use (did receive some
Oxycodone during admission for extreme back pain but
constipation started prior to narcotic). KUB completed and
showed large fecal load and without obstruction. No recent
abdominal surgeries (appendectomy ___ years ago). Given an
aggressive bowel regimen including Senna, Colace, Miralax,
Bisacodyl supp, Mag Citrate and Fleet enemas with good effect.
# ___ Chronic Kidney Disease: Stage IV with baseline Cr around
2.5-2.8. Admitted at baseline thought Cr up trended during
hospitalization which was that to be consistent with renal
disfunction secondary to hemodynamic changes. His bradycardia in
the setting of low EF was thought to cause to low effective
arterial volume and increased in renal venous pressures. His BP
in the hospital was labile, ranging from 180-90mmHg (systolic).
The change in renal function occured 3 days after admission with
no evidence of nephrotoxic meds or contrast exposure. His Cr
gradually downtrended to 1.9 on discharge.
# Chronic Systolic CHF: with LVEF ___ secondary to ischemic
cardiomyopathy. He developed evidence of decompensated diastolic
heart failure with hypoxia in the setting of monomorphic VT. His
repeat echocardiogram demonstrated improved left ventricualar
function from prior, with low normal RV function and moderate
pulmonary hypertension. In the past, right heart catheterization
has demonstrated elevated biventricular filling pressures,
suggesting that pulmonary hypertension may be secondary to CHF,
but suspect that untreated OSA is contributing. His response to
diuretics was confounded by development of urinary obstruction
from blood clots. His urinary output improved with relieved
obstruction. He was weaned from supplemental O2 following . He
was taken again for another right heart catheterization on this
admission which confirmed elevated filling pressures in both the
left and right heart confirming his heart failure. He continued
diursesis with furosemide and transitioned to torsemide PO.
Discharge weight 101.9 kg.
# Atrial fibrillation: Chronic, rate controlled and
anticoagulated. CHADS2 score of 4. Continued Coumadin,
Amiodarone at reduced dose per PCP, ___.
# Coronary artery disease: s/p DES to LCX in ___, most recent
cath ___ with 2VD. Continued ASA, pravastatin 80 mg,
carvedilol, hydral and Imdur.
# DM II. Chronic insulin dependent DM II, poorly controlled and
complicated. Last A1c 8.9%. Continued glargine and pre-meal
humalog</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ year old gentleman with PMH of HCV cirrhosis (Child
C/___, MELD 24), HIV co-infection, portal hypertension (c/b
rectal varices, ascites, hepatic encephalopathy), and HCC with
metastatic disease to the left shoulder s/p resection and
palliative XRT recently admitted for refractory ascites and
abdominal pain s/p therapeutic paracentesis now re-presenting
with worsening RLQ abdominal pain. Chest: Frontal and lateral views showed Mild bilateral pulmonary vascular congestion. LIVER OR GALLBLADDER US (SINGLE ORGAN) showed 1. Cirrhotic liver with moderate ascites. No splenomegaly. Radiofrequency
ablation site again demonstrated in the right hepatic lobe. No new lesions.
2. Poor visualization of the main portal vein. Radiology showed Air in multiple loops of small bowel, several of which may be minimally
dilated. Air seen within the colon and rectum. Findings are most compatible
with ileus. SHOULDER ___ VIEWS NON TRAUMA LEFT showed Apparent interval progression of lytic lesion in the acromion. Extent of the
osteolysis is compatible with a nondisplaced pathologic fracture. Suspected
osteolysis of the distal edge of the clavicle, not well depicted on these
views.
Elsewhere, no focal lytic or sclerotic lesion is detected. No other evidence
of fracture. No dislocation.
Osteopenia and glenohumeral joint degenerative changes again noted. Ultrasound paracentesis showed Technically successful ultrasound guided diagnostic paracentesis. 30 cc of
fluid were removed. The patient was diagnosed with Right lower quadrant pain. The patient was treated with Ultrasound-guided diagnostic paracentesis ___
___ diagnostic paracentesis ___. At the time of discharge, the patient had PRIMARY:
========
Spontaneous bacterial peritonitis
HCV cirrhosis
Metastatic HCC c/b left acromion fracture
HIV
Refractory ascites
SECONDARY:
==========
Hypertension
PTSD. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PATIENT SUMMARY:
================
Mr. ___ is a ___ year old gentleman with history of HCV
cirrhosis (Child C/___, MELD 24) in the setting of HIV
coinfection, complicated by portal hypertension (rectal varices,
ascites, hepatic encephalopathy), and metastatic HCC with mets
to shoulder s/p resection and palliative XRT, who presented with
recurrent abdominal pain following recent admission for
RUQ/epigastric abdominal pain and refractory ascites s/p LVP.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o DMII, CAD, and sCHF (LVEF <25% in ___ s/p
recent L salpingoopherectomy (discharged ___ for an enlarged
adnexal mass admitted with tachycardia and vomiting. The patient
reports that she has had about 2 days of vomiting bilious, non
bloody emesis. She reports her last BM was 2 days prior to
presentation, and she denies flatus to me but endorsed it to the
ER physicians.
On ___, pt underwent LSO for L adnexal mass (found to be serous
cystadenoma, peritoneal cytology negative). Surgery was c/b
extensive adnesions and omental bleeding and pt required
laparotomy, L salpingo-ooperectomy and intubation over night.
She was admitted to the ICU with post-op course complicated by
respiratory failure, HCAP and e. coli/enterococcus UTI, as well
as L shoulder pain. She was treated with clindamycin -->
levofloxacin ___ - ___ 10d course intended). Discharged
home, but developed nausea, vomiting, diarrhea and readmitted
with symptoms felt secondary to viral gastroenteritis
(___). She returned ___ with palpitations, nausea,
vomiting x 3 days with worsening pain, most tender in her
midepigastrium to LUQ, and was found to have UTI, discharged on
7 day course of nitrofurantoin. Also with chronic R shoulder
pain s/p surgery.
In the ER, her admission vitals were: 98.4 120 151/66 30 100%.
She received zofran x2, fentanyl, ativan, metoclopromide and
nitroglycerin x1. The patient was seen by cardiology, who
discussed the patient with the ER and felt that this was
baseline stable angina worse in setting of stress due to
vomiting. She underwent CTA chest, CT abd/pelvis, and abd xray
which were negative for obstruction or acute process to explain
her sx. The patient was also seen by gynecology and by ACS, who
felt that there were no acute surgical indications but the
patient should be admitted to medicine for hydration and pain
control.
On transfer, her vitals were: 99.6 120 140/73 16 99%.
On evaluation, the patient is quite tired but arouses to voice.
She says that she has not vomited since she left the ER and no
longer feels nauseous. She denies chest pain, abdominal pain,
diarrhea, fevers and denies current pain except during palpation
of the abdomen. Radiology showed No evidence of bowel obstruction or free air. Moderate to
abundant colonic fecal loading in the right colon. Radiology showed 1. No large or central pulmonary embolus with limited subsegmental vessel
evaluation due to poor bolus timing.
2. No aortic dissection or acute aortic pathology.
3. 5 mm pulmonary nodule is unchanged since ___. Follow up as per protocol
for the patient's known malignancy.
4. Postsurgical changes in the anterior abdomen. Persistent minimal
mesenteric fluid/possibly tiny hematoma. Subtle misty mesentery again seen,
non-specific; could relate to postsurgical change or mesenteric panniculitis.
5. Partially calcified anterior uterine fibroid with central hypodensity
which may reflect degeneration. Radiology showed No evidence of cholelithiasis or common bile duct dilatation. The patient was diagnosed with VOMITING, ABDOMINAL PAIN OTHER SPECIED, CHEST PAIN NOS. The patient was treated with Endoscopy ___. At the time of discharge, the patient had Nausea
Vomiting
Oral Thrush. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ year old female with a history of type two
diabetes, coronary artery disease, and systolic congestive heart
failure (Ejection fraction <25% in ___ who underwent a recent
left salpingoopherectomy (discharged ___ for an enlarged
adnexal mass. Now admitted with tachycardia and vomiting.
# Nausea and Vomiting: Initial concern for small bowel
obstruction although imaging was not consistent with this
diagnosis. Patient was found to have a large right sided fecal
load seen on her xray, which may explain some of her symptoms,
however her nausea and vomiting persited even after regualr
bowel movements. She had no infectious signs or symptoms and she
remained afebrile. Her symptoms improved with reglan but did not
completely resolve. Zofran was avoided due to a prolonged QT on
EKG. A endoscopy with gastroenterology was unremakable. She was
discharged home with a out patient gastric emptying study for
___ to further evaluate her motility. Her abdomen remained
tender but non-peritonitic. She was placed on an agressive bowel
regimen with bisacodyl, colace, senna, and milk of magnesium.
# Tachycardia and Chest Pain: The patient had consistently been
tachycardic on admission to 110-140. This tachycardia resolved
with hydration. The patient had chest pain while in the
emergency department and there was concern for ACS, she was
given nitro with complete resolution of symptoms. Troponins were
negative and an EKG was unchanged. The cardiology attending in
the emergency department felt that the patient was likely
experiencing demand ischemia in the setting of dehydration. Her
EKG does not meet Scarbossa Criteria for acute coronary syndrome
in a left bundle branch block. While inpatient and with IV
fluids here tachycardia and chest pain completely resolved. We
continued her home aspirin and home metoprolol.
# Urinary tract Infection: Positive urinalysis for infection.
The patient is completed her course of macrobid on ___
# Acute Kidney Injury: Baseline creatine is 1.0; currently 1.3,
which is likely in the setting of dehydration. During the
patient's hospitalization, fluids improved her creatitine back
to baseline of 1.0.
# Oral thrush: White inta oral exudtate. Thought to be thrush.
Unclear why a immunocompentant patient would develop thrush
unless diabetes is poorly controlled. Discharged with nystatin.
# Asthma: This is a chronic stable issue. We continued her home
Advair and albuterol.
# Hypertension: This is a chronic stable issue. We continued her
home isosorbide dinitrate, metoprolol, and valsartan
# Type Two diabetes: This is a chronic issue however during her
admission her blood sugars were markedly elevated. We placed her
on lantus and a sliding scale with good blood sugar control.
She will need close follow up for this issue. We did not
discharge her on lantus given concern for hypoglycemia when she
resumes her home insulin.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with mental retardation, aspiration
pneumonias, previous TIA/CVA, CAD who was transferred to ___
from OSH with a large left thigh hematoma. The patient cannot
answer questions and is currently mute. History obtained from
medical record and his caretaker ___ who is at his bedside.
His hematoma was discovered about a week ago by his caretakers.
He went to his PCP's office who suggested conservative
management. The lesion progressed with increasing pain and
involvement of the scrotum, and so he was brought to ___ and
subsequently transferred here. Radiology showed 1. Relatively acute intramuscular hematoma of the proximal thigh involving
the obturator externus and adductor magnus muscles. No evidence of
intra-abdominal or retroperitoneal hematoma.
2. Small left pleural effusion.
3. Focal consolidation of left lower lobe, likely pneumonia.
4. Atherosclerosis of the coronary arteries and aorta. Radiology showed Left lower lung consolidation, better visualized on the recent CT
and compatible with pneumonia. The patient was diagnosed with CONTUSION OF THIGH, ACCIDENT NOS, HYPERTENSION NOS, DOWN'S SYNDROME. At the time of discharge, the patient had left thigh hematoma
left lower lobe pneumonia, possibly aspiration. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Mr. ___ is a ___ with mental retardation, previous CVA/TIA,
previous aspiration pneumonias who was admitted with a left
thigh hematoma which stabilized without intervention.
1. LEFT THIGH INTRAMUSCULAR HEMATOMA: He developed a hematoma
in the left obturator externus and adductor magnus muscles about
a week prior to presentation that was worsening. CT and plain
films in the ED showed no evidence of fracture. He was evaluated
by vascular surgery in the ED who felt no need for urgent
intervention. He was admitted for serial HCT, which were stable
over the next ___ hr. His caretakers suspect the hematoma was
incited by the straps of his ___ lift causing local trauma to
the left thigh. They purchased a different harness to alleviate
the problem. There was no suspicion for physical abuse. His
aspirin was continued due to multiple CVA/TIA in the past.
2. LEFT LOWER LOBE PNEUMONIA: A LLL consolidation was discovered
incidentally on CT ABD/PELVIS done to evaluate the thigh
hematoma. Because he was coughing more frequently, we chose to
treat a community acquired pneumonia as well as an aspiration
pneumonia with levofloxacin and flagyl. He was afebrile with
excellent oxygen saturations.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with a history of fibromyalgia, asthma presenting with
elevated liver enzymes. She was in her usual state of health
until ___ when she developed acute nausea/vomiting, chills
and muscle aches. She was admitted to ___, where she
was diagnosed with autoimmune hepatitis and started on
Prednisone. She has also had 6 weeks of loose stools (light
brown/white in color) with a 35 lb weight loss in the past ___
weeks as she notes that everything she eats "passes through."
She also endorses diffuse abdominal pain and distention x6
weeks. Pain is worst in RUQ. Pain is steady, dull, improved with
immobility and worsened with movement. She has had a liver
biopsy, a CT and other labwork.
She notes that she was seen by her outpatient gastroenterologist
(Dr. ___ who spoke with the liver team at ___, who
recommended admission to the hospital.
She denies active nausea, vomiting, fevers, dyspnea, chest pain.
She endorses chills, back pain (chronic), jaundice, easy
bruising, headache behind her eyes associated with photophobia
(new today), and pruritis relieved with benadryl.
In the ED intial vitals were: 97.6 HR 63 BP 126/88 18 98% RA.
Patinet was found to have guaiac positive rectal exam, bedside
u/s with trace ascites, RUQ u/s with no portal vein thrombosis.
Labs were notable for ALT 1414, AST 695, AP 160, Tbili 20.2, INR
2.0
Patient was given: Zofran, Morphine, Ceftriaxone
On the floor, patient complaining of ___ headache, pruritis,
mild abdominal discomfort. Radiology showed Normal chest radiograph. Radiology showed 1. Patent portal and venous hepatic vasculature
2. Cholelithiasis without evidence of cholecystitis. The patient was diagnosed with ABDOMINAL PAIN RUQ. At the time of discharge, the patient had Primary diagnosis: autoimmune hepatitis
Secondary diagnosis: 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>Impression: Ms. ___ is a ___ yo F with a history of asthma,
fibromyalgia who presents with acute severe hepatitis, most
likely ___ autoimmune hepatitis.
**ACUTE ISSUES**
# Acute severe hepatitis: Most likely ___ autoimmune hepatitis:
Patient initially presented to OSH 1 month prior with
transaminitis to 3000. Liver biopsy at that time was consistent
with autoimmune hepatitis and patient was initiated on 40mg
prednisone. This dose was confirmed with patient's pharmacy and
on visual inspection of the pills. She was referred to ___ for
persistently elevated LFTs to 1000. Repeat workup revealed
negative hepatitis serologies, normal immunoglobulin levels,
positive ___, negative anti-smooth muscle,
anti-liver-kidney-microsome antibody, HSV, and equivocal VZV.
RUQ u/s showed patent vasculature. Infectious work-up was
unrevealing. Patient continued on 40mg prednisone and started on
imuran 50mg daily. Her LFTs were downtrending at discharge.
# Diarrhea: Unclear etiology. Patient presented with reported 1
month history of diarrhea. It improved with cholestyramine
initially, but worsened when cholestyramine was transitioned to
ursodiol. C. diff was negative. Ttg-IgA also within normal
limits. Would recommend outpatient EGD and colonoscopy for
continued work-up.
# Pruritis: Most likely ___ hyperbilirubinemia. Initially
controlled with cholesytramine, which helped, but then
transitioned to ursodiol. Ursodiol discontinued when patient
developed increasing diarrhea and she was discharged with
cholesytramine.
**CHRONIC ISSUES**
# Asthma: Well controlled during hospitalization, particularly
in the setting of prednisone.
**TRANSITIONAL ISSUES**
- Patient initiated on Imuran 50mg in addition to 40mg
prednisone. Would continue monitoring LFTs for continued reponse
and prednisone taper.
- TPMT genotype pending at discharge
- Will need immunization for hepatitis B and hepatitis A
- Will likely need endoscopy and/or colonoscopy to evaluate for
causes of diarrhea, such as Celiac's</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ right-handed woman with
clinically definite MS, single attack onset progressive type, on
dimethyl fumarate and dalfampridine, who presents with worsening
of ambulation. Pt at baseline can walk with a rollator or a few
steps with a cane, and has a left AFO. Over the last week or so,
has noticed worsening leg function. She has had a cough,
hoarseness, nasal congestion and postnasal drip. Yesterday was
completely unable to ambulate. It appears to her that the left
leg is significantly worse than usual and the right leg and left
arm also seem weaker. No associated sensory deficits.
Pt usually gets methylpred every ___ months or so, and last
treatment was in ___.
Pt was taken to ___ where she underwent basic
infectious workup which was unrevealing apart from leukocytosis
to 13.3K. After discussion with her outpatient neurologist
decision was made to transfer to ___ for further management. Radiology showed Multiple supratentorial unenhancing white matter lesions, some of which are
chronic, consistent with demyelination grossly stable in size, number and
configuration compared to the prior examination (given the differences in
technique and slice selection). No new or enhancing lesion/mass identified. Radiology showed Motion degraded examination limiting full evaluation, particularly of the
thoracic ___. New nonenhancing cord lesions at left C4 and right C5 levels.
Apparent demyelinating spinal cord plaques at the T7 and T8 levels without
associated enhancement. Previous enhancing cervical cord lesions are less
conspicuous and nonenhencing.
Multilevel cervical spondylosis most prominent at C5-C6 with loss of disk
space height and endplate degenerative changes.
Right middle and left lower lobe nodular pulmonary opacities which may related
to atelectasis and or pneumonia; underlying mass cannot be excluded and should
be followed to resolution.
Probable left renal cyst. The patient was diagnosed with MULTIPLE SCLEROSIS, OTHER MALAISE AND FATIGUE. At the time of discharge, the patient had Primary diagnosis
1. multiple sclerosis exacerbation
2. community acquired pneumonia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ was admitted to the general neurology service for an MS
exacerbation. MRI brain and spine was performed, there were new
nonenhancing cord lesions at left C4 and right C5 levels. She
was started on IV solumedrol for a 5 day course (last two days
will be given at home). Her exam improved significantly with
steroids, and by day 3 she was able to transfer to chair on her
own. She was also found to have pneumonia, and was treated with
a 7 day course of levaquin, started here to be continued as
outpatient.
On the day of discharge, she was noted to be mildly tachycardic
(sinus), which resolved with 1L of IVF.
She was discharged home with home ___, and has close follow up
with Dr. ___.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ presents with increased pain and erythema surrounding
the dry gangrene of the left great toe and left heel ulcer
despite outpatient antibiotics with HD. He has no
revascularization targets and toe amputation was not indicated
given severity of PVD. CHEST (PORTABLE AP) showed Dialysis catheter tip is in the right atrium. Heart size and mediastinum are
unchanged but there is interval substantial improvement in bibasal
consolidations. CHEST (PORTABLE AP) showed No relevant change as compared to the previous image. Sternotomy wires in
correct alignment. Moderate cardiomegaly and elongation of the descending
aorta. Minimal fluid overload. Minimal right pleural effusion. No
pneumonia. The right central venous access line is unchanged. The patient was diagnosed with CELLULITIS OF LEG. The patient was treated with ___: Left guillotine below knee amputation
___: Below the knee amputation closure. At the time of discharge, the patient had left lower extremity non-healing ulceration and 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>Mr. ___ is a ___ y/o male with dry gangrene of the left great
toe with osteomyelitis and nonhealing left heel ulcer with
persistent cellulitis on outpatient vancomycin p/w increased
left lower extremity erythema and pain concerning for worsening
infection. He was treated with IV antibiotics with some
improvement however required left BKA on ___ for definitive
source control.
# Acute on Chronic Left Great Toe Gangrene and LLE Cellulitis:
Patient recently admitted in late ___ where he was started on
vancomycin for planned 6 week course (due to end ___. MRI on
___ showed evidence of osteomeylitis of the distal phalanx of
the left first toe with dry gangrene on exam. Venous ulcer on
LLE with poor wound healing likely related to severe PVD. As he
was a poor revascularization candidate as there were no adequate
distal targets. While on the medicine service he was covered
broadly with Vancomcyin and Ceftazidime with mild improvement of
his LLE.
He remained hemodynamically stable and blood cultures returned
negative. Pain was controlled with oral dilaudid in the pre-op
period. He was evaluated by the Cardiology consult service with
assessment that he was moderate risk surgical candidate for high
risk vascular procedure however benefits of surgery outweighed
the risks. He eventually underwent left guillotine amputation
on ___ for source control. After we were confident the
infection was cleared, he was brought to the operating room for
closure on ___.
Post-operatively, patient did have a few episodes of hypotension
especially with HD and was started on midodrine with good
results.
Patient was seen by Cardiology post-operatively given his
complicated cardiac history who felt that patient was
progressing well. Patient worked with ___ who recommended rehab
and was discharged to rehab in stable condition on post
operative day 5 after the ___ closure.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a ___ y/o woman with a medical history significant for
HTN, HLD, osteoporosis, CVA, and recent fall in ___
complicated by maxillary fracture and subdural hematoma and a
past psychiatric history of Major Depressive Disorder without
psychotic features, and alcohol use disorder (in remission) who
presented to the ED with her family on ___ with concerns for
ongoing depression, anxiety, and passive suicidal ideation.
.
Ms. ___ describes a very lengthy history of depression dating
back to when she was ___ years old. She states that she has tried
___ anti-depressants in the past but says that the relief
she gets from them "never lasts". She states that her current
episode of depression started approximately 4 months ago. She
describes her depressive symptoms as dysphoric mood, decreased
appetite with concomittant weight loss, initial hypersomnia
followed by insomnia, and passive suicidal thoughts. She states,
"I have a beautiful house with a yard and a supportive family, I
have no reason to be depressed. But I am". Describes enjoying
life as impossible with depression and can't remember when the
last time was that she was able to truly enjoy life.
.
She expresses preoccupation with "feeling like I was dying",
which she describes as both a physical and mental sensation. She
denies any recent diagnosis or prognosis that would indicate
imminent death. She denies any specific symptom that makes her
believe she is dying, but rather says "I know I am". Says that
she hopes she won't die so that she can live longer and spend
time with her ___ year old granddaughter, ___.
.
Ms. ___ has had ongoing passive suicidal ideation, though she
initially says that she would never actually hurt herself. Runs
through several options, and notes why they would not work for
her (wouldn't want driver to have the grief of hitting her,
doesn't own a gun and wouldn't buy one, wouldn't know how to
hang herself, etc.). Alludes to the fact that if she were to
die, she
would be okay with it. Recalls a time on a beach when she was
sitting in a metal chair and it started lightning and how she
decided to stay on the beach. When asked what she hoped would
happen she said, "I don't know". Notes that if no one could find
an anti-depressant that would work and she became so helpless
she could ___ herself actively trying to commit suicide.
States
that she would probably start drinking again and use alcohol
(has been sober for ___ years). She says that if it got to
that point, she would not tell anyone since they would stop her.
States that she is not yet at the point where she would actively
try to harm herself.
.
In ___ she sustained a fall which resulted in a
subdural hematoma (medically treated, no neurosurgical
intervention) and maxillary fractures. She denies any changes in
her mental status or memory since this event. Collateral from
Ms. ___ daughter, ___, was obtained by Dr. ___.
The following is from his initial consult note from ___
states:
___ describes that since her most recent medical
hospitalization, the patient has continued to experience short
term memory loss (repeating herself, getting lost in the
conversation, misplacing things), making statements that she
does not want to live anymore, sleeps all day long, and other
unusual
experiences...".
.
On psychiatric review of symptoms she endorses a depressed mood
(see above) as well as ongoing anxiety. She denies any history
of elevated mood, impulsivity, or unnecessary spending. She
describes a 1 month period ("I can't remember when") of staying
up all night and cleaning. She denies a history of psychotic
symptoms including AH/VH/TH. She also denies any HI.
.
Physical ROS is only significant for feeling "tired". She denies
any headache, changes in vision, cough, cold, CP, SOB, abdominal
pain, n/v/d, parasthesias. Of note, in the ED was found to have
a UA positive for 35 WBC, large leukocytes, and few bacteria.
She denies any dysuria and states that she urinates
infrequently. Endorses foul odor in her urine. She notes that
she had a pessary placed yesterday by her Obgyn.
. Chest radiographs. showed No evidence of acute cardiopulmonary disease. Head CT. showed No evidence of acute intracranial process.
DOSE: 891.9 mGy-cm. The patient was diagnosed with DEPRESSIVE DISORDER, ANXIETY STATE NOS, OTHER MALAISE AND FATIGUE. The patient was treated with ECT. At the time of discharge, the patient had Mood disorder NOS
Alcohol use disorder, in remission. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>PSYCHIATRIC
#Depressive symptoms/Anxiety: On admission, patient was acutely
depressed in setting of long history of treatment-refractory
depression, with active suicidal ideation with plan (though
patient refused to specify plan details).
During hospitalization, we continued patient's home medications
of lamictal 250mg PO QD, seroquel 37.5mg QHS, modafinil 300mg
qAM, and fetzima 80mg PO QD. We stopped the patient's topamax in
setting of recent decreased appetite with weight loss.
Additionally, we added hydroxyzine PRN for anxiety, with poor
effect, which was then changed to seroquel PRN for anxiety with
fair effect. Given her difficulty with sleep and appetite,
mirtazapine 7.5mg was started. She was also started on Adderall
2.5 mg at 8am and 2pm. She did well with these medications. Also
given she did well with risperdal in the past, the seroquel was
changed to risperdal. The patient consented to ECT treatments
for management of her acute on chronic depressive episode. She
underwent 8 treatments, with good improvement in her mood and
appetite, as well as resolution of her active suicidal ideation.
On discharge, mood was "better", and mental status exam was
pertinent for bright affect.
Safety: The patient remained in good behavioral control
throughout this hospitalization and did not require physical or
chemical restraint. The patient remained on 15 minute checks,
which is our lowest acuity level of checks.
GENERAL MEDICAL CONDITIONS
#)Hypertension: Patient's HTN inadequately treated at home/on
initial presentation to the unit. Medicine was consulted, and
recommended atenolol 25mg PO AD, amlodipine 10mg PO QD, and HCTZ
12.5mg PO QD, with good effect while on the unit.
-Recommend f/u with outpt providers as clinically indicated
#)HLD: continued home statin
-Recommend f/u with outpt providers as clinically indicated
#)
-Recommend f/u with outpt providers as clinically indicated
PSYCHOSOCIAL
#) MILIEU/GROUPS
The patient was euthymic, and participatory in the milieu. The
patient was very visible on the unit and frequently had
conversations with her peers. She attended some groups. She
never engaged in any unsafe behaviors. The pt ate all meals in
the milieu, slept well, and cooperated with unit rules.
#) FAMILY CONTACTS
Family meeting was held with the patient's ex-husband and
daughter and was notable for discharge planning. They understand
and are in agreement with the current treatment and discharge
plan.
#) COLLATERAL We spoke with the patient's therapist and
psychiatrist, who both agreed with plan.
LEGAL STATUS
The pt remained on a CV throughout the duration of this
admission.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ with Primary Biliary Cirrhosis, diastolic
HF, afib on aspirin, chronic MSK pain, celiac disease, and
multiple admissions for LGIB with negative EGDs and
colonoscopies within the past month, last discharged from ___
4 days ago, who presents after an episode of BRBPR and
lightheadedness this afternoon. Radiology showed No acute cardiopulmonary abnormality. Radiology showed Right internal jugular central venous catheter tip within the upper SVC. No
large pneumothorax is detected, though assessment for pneumothorax is limited
on this supine exam. Radiology showed Nonobstructive bowel gas pattern. No large pockets of free air seen on this
supine view of the abdomen. Radiology showed 1. Active arterial bleeding from a loop of jejunum in the mid abdomen
anteriorly.
2. Cholelithiasis. There is gallbladder wall edema and minor periportal
edema likely on the basis of fluid resuscitation. Radiology showed Left common femoral artery access.
Superior mesenteric artery angiograms before and after embolization of small
bowel focus of active arterial extravasation with good angiographic result. Radiology showed Celiac, SMA, and sub-selective SMA arteriograms demonstrating active
extravasation from several distal jejunal branches, likely representing
collateralization. This extravasation was unable to be a treated with coil
embolization. Recommended evaluation by surgical service for localized
resection (using coils as landmarks). Radiology showed Continued mild pulmonary edema with small bilateral pleural
effusions. Stable monitoring and support devices. Radiology showed Cardiomegaly with bilateral pleural effusions and pulmonary edema, stable. Radiology showed Thrombus in the mid and distal left basilic vein. No additional thrombus. Radiology showed 1. Large amount of extravasated contrast throughout the colon and terminal
ileum. The source of active extravasation is not identified.
2. Status post jejunal resection with intact anastomosis and no adjacent
contrast extravasation.
3. Increased size of small bilateral pleural effusions. The patient was diagnosed with RECTAL & ANAL HEMORRHAGE, SYNCOPE AND COLLAPSE, HYPOTENSION NOS. The patient was treated with RIJ central line placement ___
Femoral trauma line placement ___
Intubation ___
Mesenteric Angiography morning of ___ and evening of ___
Small bowel resection ___. At the time of discharge, the patient had GI bleed. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ year old female with history of diastolic
heart failure, atrial fibrillation on aspirin, chronic MSK pain,
celiac disease, and multiple admissions for lower GI bleed with
negative EGDs and colonoscopies within the past month,
presenting with hemodynamically unstable active GI bleeding.
The patient presented with recurrent bright red blood per rectum
and dizziness. Previous workup during recent hospitalizations
had been largely negative. EGD demonstrated abnormal antral
mucosa but no obvious source of bleeding. MRE demonstrated
1.9cm infrarenal AAA with no small bowel mass or inflammation.
___ colonosopy limited by poor prep but no obvious bleeding
source.
The patient was admitted to the medical intensive care unit on
the evening of ___ after receiving 5 units pRBCs in the
emergency room. A GI consult in the emergency room recommended
CTA if hemorrhage recurred. ___ in the intensive care unit,
the hematocrit dropped from 27 to 16, massive transfusion
protocol was initiated, a stat CTA showed small bowel bleeding,
and the patient was taken for mesenteric angiography. ___ placed
a coil on the morning of ___. The patient was stable in the
intensive care unit for most of the day, however hct dropped
again in the evening (32 -> 20). The patient returned to
___, was intubated for airway protection, and further
coils were placed due to ongoing bleeding in the same vicinity
as prior. Unfortunately, due to collateral flow, hemostasis
could not be achieved by endovascular approach. The surgery
service was consulted and the patient was taken for a small
bowel resection on ___. At the time of transfer from MICU to
the OR (and onto surgical service), the pt had received 24 units
pRBCs, 10 units FFP, 4 units of platelets, and 4 units of cryo.
The operative findings were notable for multiple subcentimeter
and 2 cm small bowel masses
throughout the entire small intestine. Blood was noted
throughout the small bowel from the jejunum to the ileocecal
valve. Active hemorrhage was seen intraluminally via endoscopy
at the site of the coils and mesenteric hematoma in
the proximal jejunum. She had a 200 cc blood loss during the
procedure and was transported to the intensive care unit for
monitoring. After stabilization of her vital signs the patient
was extubated.
She was transferred to the surgical floor on ___. Her
hematocrit continued to be monitored and after it remained
stable, she was started on her sc heparin. She resumed clear
liquids. She did have a bout of bloody stool on ___ and
underwent a cat scan of the abdomen which showed a large amount
of extravasated contrast throughout the colon and terminal
ileum. The source of active extravasation is not identified.
She continued to have occasional episodes of bloody stool, but
her pa vital signs remained stable. No intervention was
indicated unless she had recurrent bleeding resulting in
cardiovascular instability. She was also reported to have
episodes of mild confusion which occurred mostly at night and
resolved with re-orientation. During her hospitalization, she
was noted to have swelling in her left upper arm. Because of
this, she underwent an ultrasound of her left arm which showed a
thrombus in the mid and distal left basilic vein. No additional
thrombus. Her arms were wrapped with ace bandages.
The patient was evaluated by physical therapy and because of her
physical status, recommendations were made for discharge to an
extended care facility where she can further regain her strength
and mobility. Upon discharge, she was tolerating a regular
diet. Her vital signs were stable with a hematocrit of 28. She
was voiding without difficulty. Of note, she was started on a 1
week course of ciprofloxacin for a urinary tract infection. The
course should be completed on ___. The patient was discharged
to a ___ facility on HD #10 in stable condition.
Follow-up appoinments were made with the GI, acute care service,
and recommendations made to follow-up with her cardiologist.
Anticipated lenght of stay at rehab: < 30 days
CHADS2 = 3. Pt had been on Coumadin in recent past, although
since her prior hospitalization Coumadin had been held due to GI
bleed. She had been taking 325 ASA daily in the days leading up
to this hospitalization.
Plan for anticoagulation given CHADS2 = 3.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: CC: ___ pain CHEST (PA AND LAT) showed Findings worrisome for developing pneumonia within the right midlung which are
not clearly identified on the lateral projection. No pleural effusion. CT CHEST W/O CONTRAST showed 1. Interval increase in patchy peribronchovascular and ___
nodularities in the right upper lobe which are likely infectious or
inflammatory. Given the history, an atypical infection such as tuberculosis
is difficult to entirely exclude.
2. Evidence of prior granulomatous disease. 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>Mr. ___ is a ___ male with past medical history of
PUD, CAD, hypothyroid, latent TB, who
presented with low grade fever and abdominal pain improved with
bowel movement during his visit in the ED. He was also noted to
have interval change on CT chest and given his history with
concern for latent TB and fever, he was admitted for r/o TB.
During his stay, he was unable to produce more than one sputum
for AFB/NAAT, which was found to be negative. He was continued
on Ceftriaxone IV daily and Azithromycin for three days while
hospitalized for community acquired pneumonia, and discharged
with oral Cefpodoxime and Azithromycin to complete a 5 day
course of antibiotics. He will follow-up with outpatient
pulmonary to reassess for further evaluation and repeat CT
imaging as outpatient with next pulmonary appointment. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ female with a history of breast cancer currently on
chemotherapy, most recent Taxol treatment on ___, presenting
with cough and fever. Patient reports that for 1 week she has
had
cough. In past 24 hours, she developed fever and chills, noted a
fever at home to 101.4. Denies any chest pain or shortness of
breath, reports feeling of chest congestion. cough is productive
with greenish phlegm. No runny nose. Has occasional headaches,
unchanged. no urinary or bowel complaints. no port
tenderness/redness. no rash. CHEST (PA AND LAT) showed Patchy bibasilar opacities may reflect atelectasis with infection or
aspiration not excluded in the correct clinical setting. The patient was diagnosed with Pneumonia, unspecified organism. At the time of discharge, the patient had Acute viral bronchitis
Community Acquired Pneumonia
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>Mrs. ___ is ___ female with a history of breast
cancer currently on weekly paclitaxel and trastuzumab presenting
with fever and severe cough suggestive of viral bronchitis with
bacterial pneumonia.
#Bronchitis
#Community Acquired Pneumonia
Patient presented initially with non-productive cough as her
family went througha could but then had significant fevers up
to 101.7. CXR cannot exclude pneumonia. She defervesced after
starting antibiotics but continued to feel and appear ill
prompting additional 24h of observation. To complete at 5 day
course of levofloxacin on ___.
#Breast Cancer: Will be seen in clinic on day after discharge to
evaluate whether OK to get next dose of chemotherapy. Underwent
radiation mapping while in-house on ___.
#T2DM: Held metformin in favor of lispro ISS
#Hypothyroidism: Continued on levothyroxin.
TRANSITIONAL ISSUES
===================
1. Antibiotic course of levofloxacin through ___.
35 minutes spent formulating and coordinating this patient's
discharge plan</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: The patient is a ___ yo F who underwent LN excision on the
right level II with Dr. ___ 2 days ago. She was doing
well at home but over the past 24hrs has developed worsening
dysphagia and erythema of the neck. She presented to ___ this
AM for evaluation. Radiology showed 1. Post-surgical changes right upper neck with foci of air and fat stranding
most pronounced between the sternocleidomastoid muscle and the submandibular
gland and extending medially to the parapharyngeal space with mild narrowing
of the hypopharyngeal airways.
2. No vascular injury and no abscess formation.
3. No evidence of a prevertebral or retropharyngeal abscess. The patient was diagnosed with OTHER SPEC COMPL S/P SURGERY, SWELLING OF LIMB, ACCIDENT NOS. The patient was treated with ___ Right neck lymph node excisional biopsy.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>This is a ___ yo F who underwent right level II lymph node
dissection on ___. She was doing well at home but two days
later she developed worsening dysphagia and erythema of the
neck. She presented to ___ after 24 hours of these symptoms
(morning of ___ for evaluation. She was readmitted that day
for IV antibiotics. She was started on Levo/clinda but was
switched to cipro/clinda due to what appeared to be an allergic
rash to the Levofloxacin.
A CT scan of her neck revealed Post-surgical changes right upper
neck with foci of air and fat stranding most pronounced between
the sternocleidomastoid muscle and the submandibular gland and
extending medially to the parapharyngeal space with mild
narrowing of the hypopharyngeal airways. There appeared to be no
vascular injury and no abscess formation, and no evidence of a
prevertebral or retropharyngeal abscess.
She remained afebrile and her condition improved on IV
antibiotics over the next three days, with reduction of
aryepiglottic fold edema on FOE exam and improvement of her R
neck swelling/erythema.
She was discharged on po Bactrim and Kelex on ___ in stable
condition, and a follow up Dr. ___ was planned for the
next week. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ female with history significant
for IV drug use who presents with several days of worsening left
hand swelling and pain.
Per history obtained ___ the ED, she has associated subjective
fevers and chills but is otherwise asymptomatic. Her pain is
___. She last used heroin a day ago.
___ the ED, initial vitals were: T 97.8 HR 97 BP 125/77 RR 16 O2
98% RA
Exam was notable for:
EXTREMITIES:
-Left hand and distal forearm edema
-2 to 3 cm indurated area on the dorsum of the left hand with
surrounding erythema, warmth, and exquisite tenderness to
palpation
-Left hand pulse intact and capillary refill normal
MSK:
-Decreased range of motion of the left wrist and fingers due to
pain and swelling
NEURO:
-Intact sensation of the left hand
Labs were notable for:
-Na 142, K 4.3, BUN 12, Cr 0.7
-WBC 9.3, hemoglobin 12.3
-Lactate 0.7
-UA: WBC 26, few bacteria, moderate leukocytes, negative
nitrite, protein 30
-UCG negative
Studies were notable for:
-Hand and wrist XR: No evidence of fracture or erosions ___ the
left wrist. Extensive softtissue swelling about the wrist and
dorsum of the hand. 6 mm cystic lesion within the scaphoid, may
represent an intraosseous ganglion cyst and is of doubtful
clinical significance. Punctate radiopaque densities are seen
projecting over the fifth PIP joint.
The patient was given:
-___ IV clindamycin 600 mg
-___ IV vancomycin 1000 mg
-___ IV hydromorphone 1 mg
-___ IV Augmentin 3 g
-___ IV hydromorphone 1 mg
Consults:
- MERIT: Agrees with vancomycin given MRSA risk factors. Notes
that we cannot exclude Streptococcus. Recommends oral anaerobe
coverage given patient habit of licking needles. Notes the pain
control is warranted, which should help suppress symptoms of
withdrawal from IV drug use.
- Hand surgery: Notes the patient refuses multiple attempts at
bedside I&D. Recommends keeping NPO for OR.
On arrival to the floor, she states that the swelling started 4
days ago and complains of significant ___ throbbing left hand
pain. She endorses fevers and chills over the past several days.
She has a mild headache currently. She has had nausea and
vomiting throughout this time, but not since yesterday. She
otherwise denies other symptoms, including vision changes, chest
pain, palpitations, lightheadedness/dizziness, dyspnea, cough,
sputum, abdominal pain, changes ___ bowel movements, and changes
___ urination.
When asked about her substance use, she states that she uses 2
to 3 g of heroin per day, and injects drugs ___ times per day.
She does not know how much fentanyl is ___ her heroin supply. She
gets her needles from ___, and does reuse them. She likes
the needles. She also smokes cocaine, though not for a few days. WRIST(3 + VIEWS) LEFT showed 1. No evidence of fracture or erosions in the left wrist. Extensive soft
tissue swelling about the wrist and dorsum of the hand.
2. 6 mm cystic lesion within the scaphoid, may represent an intraosseous
ganglion cyst and is of doubtful clinical significance.
3. Punctate radiopaque densities are seen projecting over the fifth PIP joint. CHEST (PORTABLE AP) showed No acute intrathoracic abnormalities identified. The patient was diagnosed with Cutaneous abscess of left hand. The patient was treated with ___ Incision and Drainage. At the time of discharge, the patient had Primary diagnosis:
==================
Left dorsal hand abscess
Cellulitis
Secondary diagnosis:
===================
Active IV drug use. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ female with history significant
for current active IV drug use who presents with several days of
worsening left hand swelling and pain, found to have left dorsal
hand abscess and cellulitis without features of sepsis, now s/p
OR I&D. She left AMA because she did not want to stay ___
hospital for IV antibiotics. She was evaluated by psychiatry who
felt she had capacity to leave.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ is a ___ female (M-to-F transgender) with PMH reported hx
PE/DVT, MI, stroke, congenital prothrombin, known hx
schizoaffective disorder, depression, anxiety, unclear seizure
disorder, presenting with chest pain. Chest pain started 30
minutes prior to arrival. Pain is substernal, nonradiating. Pt
reports hx blood clots, is supposed to be on Coumadin, but ran
out 3 weeks ago. Pt reports slight dyspnea, but otherwise not
other complaints. CHEST (PA AND LAT) showed In comparison with the study of ___, there is little interval change and
no evidence of acute cardiopulmonary disease. No pneumonia, vascular
congestion, or pleural effusion.
Port-A-Cath again extends to the cavoatrial junction or upper right atrium. The patient was diagnosed with Chest pain, unspecified. At the time of discharge, the patient had Musculoskeletal 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>___ is a ___ year old male-to-female transgender with
an extremely complicated social history and psychiatric history
with medical history further complicated by history of
prothrombin mutation, ? seizures, PE ___, most recently ___
on V/Q scan in ___, chronic pain, who presented to the ED
for elevation of chest pain. Workup for serious etiologies
remained negative. Heparin drip was started with the goal of
bridging to Coumadin on discharge, though patient left AMA prior
to a therapeutic level. Anticoagulation on discharge was
deferred because of the patient's lack of safe follow-up
monitoring as outpatient and reported increased rates of falls
as an outpatient. She was encouraged to establish care with a
PCP and was given ___ number at discharge.
#Chest Pain
Unclear etiology. Reassuringly normal CXR, normal BNP, and
negative trop. While she is hypercoagulable and is non-compliant
to anticoagulation, no signs of PE. Most likely musculoskeletal
in nature. After extensive discussion, we let ___ know that
narcotics would not be an appropriate medication for her pain.
We discussed ___ alternative medications to which she
reports previous allergies, including NSAIDs and Tylenol, and
she deferred. We also counseled that pain management
consultation would not be necessary at this time, to which she
expressed
extreme frustrated, including requesting to fire her medical
team and to speak to the social worker. She ultimately left AMA
and expressed her motivation for this was lack of adequate pain
control.
#Hx of DVT
#Hx of Prothrombin deficiency
Per patient - her INR goal is 3.5. This was established by a
physician in ___ in the setting of HRT. Multiple MI,
strokes, and PEs per patient report. Has not been on
anticoagulation as an outpatient for several weeks as she has
run out. She does warrant life-long therapy in this setting, but
due to her difficulty obtaining primary care and the frequency
monitoring of Coumadin, a NOAC would be more ideal. Per patient,
she has had several strokes and PEs through this, though we do
not have records at this time to confirm. Does endorse abdominal
discomfort to lovenox and she deferred this. She was initially
started on a heparin drip for bridging with started heparin
7.5mg, but she left AMA prior to therapeutic levels.
#Threatening behavior toward staff
During stay, patient bit the phone cord and broke the phone and
continues to make threatening comments towards staff, including
threatening to strangle ucos and requiring security to come to
bedside. Also refuses majority of care, including physical
exams, PTT monitoring, and iron infusions. Multiple attempts
were made to form therapeutic alliances with her, though she
expressed ongoing frustration and anger due to lack of pain
control with narcotic medications.
#Frequent falls
Patient feels ___ to spine issue, no dizziness or pre-syncope
with this. Neuro exam was limited due to participation at this
time, but declines any bowel or bladder dysfunction. She
deferred ___ evaluation during her hospital stay
#iron deficiency anemia
Patient has a history of anemia with a hemoglobin baseline of 9.
She with hemoglobin of 7.7. No evidence of ongoing upper or
lower GI bleeds. Discussed this with patient and she refused
iron infusions, due to the belief it would make her at increased
risk of clotting. It was explained this would not increase her
risk of clotting, but she deferred treatment while in house
#Hx of seizure disorder
Patient had not taken this at home as she had run out of
prescriptions for this. Continued keppra 750mg while in house.
#Hormone therapy
At higher risk of blood clots I/s/o hereditary clotting disorder
and current smoking. This was discussed with ___, though she
said the risk of thrombosis was outweighed by the benefit of the
estrogen treatment. estrogen patches were non formulary, so
Estradiol PO 0.3mg twice a week were used and she was continued
on finasteride.
#Housing insecurity
A social work consult was placed, but the patient would not
discuss resources during this time.
I have seen and examined the patient and agree with the note by
the medical resident on the day she chose to leave the hospital
against medical advice.
TRANSITIONAL ISSUES
-==================
[] In the future, would defer anticoagulation initiation while
in house until patient has a safe plan for follow-up due to the
risk of unmonitored anticoagulation
[] Needs iron transfusion or PO for severe iron deficiency
anemia
[] Ongoing discussion around risk of estrogen therapy with
hypercoagulable condition</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ with h/o gastric bypass in ___, G-tube placed most recently
in ___ who presents with abdominal pain for three days.
She reports stepping on her feeding tube, feeling a tug with
immediate pain, never returned to her baseline. She has had
recurrent difficulty with her G-tube requiring multiple
replacements in the past, however she currently stats that feeds
are going in okay. Noticed more abdominal erythema, yellowish
discharge. Denies nausea, vomiting, or diarrhea. Radiology showed Patent G tube with the tip positioned in the stomach and no
evidence of extraluminal contrast leakage. The patient was diagnosed with COMP D/TO GRAFT/IMPLANT, ABDOMINAL PAIN OTHER SPECIED, ABN REACT-EXTERNAL STOMA. At the time of discharge, the patient had G-tube malfunction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ presented on ___ with abdominal pain and
increasing g-tube discharge since tripping on it three days
prior. She was admitted for observation and radiographic
imaging to rule out a gastric leak. She had no peritoneal
signs, and her abdomen had signs consistent with poor dressing
care with significant g-tube site discharge including
rash-appearing erythema.
She was made NPO with cessation of TF, placed on IVF, and given
intermittent dilaudid for pain control. She had a g-tube study
that indicated no free air in the abdomen, as well as passage of
20cc of contrast into the gastric body that extended into the
small bowel with no evidence of leakage. The g-tube appeared to
be well positioned per this study. Her TF was restarted which
she tolerated well without nausea or vomiting. Her rash nearly
resolved with proper dressing changes and wound care. She
continued to have abdominal pain at the site of granulation
tissue of the g-tube. She had persistent g-tube site discharge
well managed with dressing changes.
On the day of discharge, she was tolerating her TF and her pain
was well controlled. She was ambulating without assistance and
voiding freely. She will follow up with Dr. ___ at his
next available appointment in two weeks. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Mr. ___ is a ___ with history of metastatic NSCLC to
T-spine and adrenal who presents with back pain and bilateral
hip pain. He was recently discharged from the hospital on ___
for similar problems with pain. MRI of the T-spine on last
admission did not show cord compression or progression of
metastasis. X-ray of the right hip did not show fracture or
osteolytic lesions. He has a history of chronic pain which is
believed to be related to his metastatic disease to his spine.
He reports that his pain was stable after discharge and that he
was able to walk and go about his daily routine without
difficulty. Although he has been requiring his PO dilaudid every
three hours. However, on the morning of admission, he woke up
with severe pain in his back and bilateral hips and could not
move without triggering severe pain. He called his primary
oncologist, Dr. ___ told him to come to the office. After
evaluation, Dr. ___ that the patient come to the
hospital to be admitted for pain control. Patient denies
numbness, weakness, incontinence, impairment of balance or gait. Radiology showed 1. Faint linear enhancement of the nerve roots of the cauda equina, which
raises the possibility of leptomeningeal disease. If clinically relevant,
this could be correlated to spinal fluid analysis.
2. Hypointense foci in the T8 vertebral body as well as in the medial portion
of the right T11 rib. These correspond to the areas of known sclerosis on CT
and show no evidence of enhancement to suggest metastatic disease.
3. Abnormal, non-mass-like, bilateral lumbar paraspinal muscular enhancement.
This is not a specific finding, possibly reflecting myositis.
Results discussed via telephone by Dr. ___ with Dr. ___ at
14:15 on ___. Radiology showed 1) Diffuse low T1 signal marrow is consistent wwith hematopoietic marrow and,
given its extent, could reflect anemia.
2) No focal lesion suspicious for metastatic disease identified, thuogh early
marrow infiltration might not be apparent given the background marrow pattern.
3) No evidence of acute fracture, femoral head osteonecrosis, hip joint
effusion, or significant hip osteoarthritis.
4) Mild edema in upper right gluteus minimus muscle could be related to more
generalized dependent edema or could represent a mild muscle strain. It is
associated with mild assymetric muscle atrophy. Radiology showed No evidence of abnormal leptomeningeal or other enhancement. If
concern for the findings in the spine persists, would correlate to CSF
sampling. The patient was diagnosed with BACKACHE NOS, JOINT PAIN-PELVIS, SECONDARY MALIG NEO BONE. At the time of discharge, the patient had Primary:
-Back/hip pain
Seconday:
-Metastatic non-small cell lung cancer. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Brief Course:
Mr. ___ is a ___ with history of metastatic NSCLC to
T-spine and adrenal who presents with back pain and bilateral
hip pain. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ w/ hx of dementia, afib on coumadin who presented s/p fall.
The pt attempted to stand without walker and fell, hitting the
back of her head. The fall was witnessed and was without LOC.
She is a poor historian but denied presyncopal symptoms. This is
the second time ___ patient had fallen in 2 days.
In the ED the pt was 96 82 160/68 16 100%RA. She denied neck
or back pain. Labs were significant for INR of 5.1 and Cr 1.3
(which is baseline). Head/cspine were neg, and cxr and pelvic
xray were wnl. The laceration was initially stapled but due to
continue oozing it was sutured. U/a was checked and found to
have large Leuks, 65 wbc, few bacteria. She was given
ciprofloxacin 500mg PO x1 in the ED. The pt was also noted to
have a stage 2 decub ulcer.
On the floor the pt was 96 145/80 92 18 99%RA. She denied
presyncopal symptoms, dysuria, or frequency. She denied current
pain, lightheadedness or dizziness.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias. Radiology showed Possible right ninth lateral rib fracture. Clinical correlation
for pain is recommended. Discussed with Dr. ___ by Dr. ___
___ by telephone at 18:40 on ___. Radiology showed No acute intracranial hemorrhage or mass effect. Correlate
clinically to decide on further workup. Radiology showed No acute cervical fractures or malalignment. Multilevel,
multifactorial degenerative changes are noted as above. The patient was diagnosed with HEAD INJURY UNSPECIFIED, OPEN WOUND OF SCALP, UNSPECIFIED FALL. At the time of discharge, the patient had Primary: Mechanical fall. Asymptomatic bacteriuria.
Secondary: Advanced ___ Body Dementia.. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo W w/ ___ Body dementia, Afib on coumadin, hx of frequent
UTIs and other chronic medical problems presents to ___ s/p
fall at home. She was found to have head laceration,
supratherapeutic INR, and a positive UA.
.
# Fall. Mechanical fall by history as there were no symptoms of
presyncope, no witnessed LOC and no systemic infectious
symptoms. Although she has a history of diagnoses of
asymptomatic UTIs in the past (Proteus, VRE) and was found to
have positive UA, it was unclear how much suspected UTI
contributed to her fall (see below). There was no clinical
evidence for seizure activity. Imaging evaluation in the ED
revealed no acute abnormalities. It appears that she has had
progressively more difficulty with safe ambulation, despite the
___ care at home with the family. After ___ evaluation and
discussion with her daughter, a decision was made to pursue a
short course of rehabilitation in hopes of having the patient
return to home with 24 hour care and improved gait/mobility.
# Head laceration: Pt with head lac s/p fall, stitches placed in
ED.
Remove stitches s/p 1 week.
# ? UTI. Positive UA and we were unable to ascertain any
symptoms. She was treated with CFTX empirically x 3 days. UCx
grew strep viridans, felt to be a contaminant from foley
placement, removed on admission. ABx were discotinued. Patient
had a low grade fever (___) that evening. UA was repeated and
was felt to be contaminated, UCx pending at time of discharge.
CFTX was discontinued on ___. Patient remained afebrile for
over 36 hours prior to discharge without clinical signs of UTI.
Should she develop sx of UTI or a fever, it is recommended to
repeat a UA and UCx and call her PCP, ___ at
___, ___.
# Afib on Coumadin. Initailly with supratherapeutic INR.
Coumadin was held and restarted on ___ at 5mg (INR 1.8). No
bridge was felt to be required. INR at time of d/c was 1.2,
coumadin was increased to 7.5mg on ___. INR increase prior was
felt to be due to ABx. Will need monitoring EOD and dose
adjustment.
# Coccygeal ulcer was approx 1.4 x 1 x 0.2cm with yellow wound
bed and moderate serous drainage with no erythema and the
dressing was intact despite urinary incontinence. Right gluteal
ulcer exhibited fresh epithelial tissue. Care as per orders in
discharge plan.
# ___ Body Dementia: continued on home risperdal and donepezil.
Of note, mirtazapine was recently started by PCP with some
improvement in sleep pattern. This may need further
optimization.
# ARF on CKD. Cr peaked at 1.5 and baseline 1.3. Likely due to
decreased PO intake and home lasix dose. Due to fever, lasix
was decreased to 40mg daily. Cr. returned to 1.1. She had mild
___ edema at time of d/c. She was discharged on home lasix at
80mg daily.
# Diastolic heart failure: Pt with mitral regurgitation that
worsened in severity between ___ and ___ on echo, but EF
remained >55%. Discharge weight was 143lbs.
- see above
# Seizure disorder. Stable. Patient continued on home phenobarb
and phenytoin
.
# Code: DNR/DNI </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ yo male with a history of metastatic gastric cancer who is
admitted with abdominal pain. The patient states he has been
having increased abdominal pain for the last five days. He
states
it is worse than it usually is. He also has been having some
nausea associated with the pain. He denies any fevers. Due to
the
distention of his abdominal he sometimes has trouble breathing
or
urinating but known this only occurs when his abdomen gets
bigger. He does have some constipation with his last bowel
movement two days ago. He does state he doesn't always take the
morphine when he needs it because it causes him to be
constipated. Of note he has been requiring recurrent
paracentesis
for reaccumulating malignant ascites. His last paracentesis was
done on ___.
In the ED he was noted to be borderline hypotensive and
tachycardic. He also had a new leukocytosis. He was given
ceftriaxone empirically for coverage of SBP. However the ED did
not want to perform a diagnostic paracentesis. He was also given
morphine, Zofran, and IV fluids. Paracentesis showed 1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 3 L of fluid were removed. Post pyloric Dobhoff tube advancement showed Successful post-pyloric advancement of a Dobhoff feeding tube. The tube is
ready to use. Chest radiograph to evaluate for feeding tube placement. showed Unremarkable bowel gas pattern, no evidence of obstruction. Enteric feeding
tube is seen with its tip projecting over the distal esophagus. Portable chest x-ray showed The tip of the Dobhoff tube is in the distal stomach. Low lung volumes
compromise evaluation Radiology showed Successful peritoneal PleurX catheter placement Dobhoff tube advancement. showed Confirmation of post-pyloric placement of a Dobhoff feeding tube. The tube is
ready to use. Radiology showed There is a Dobhoff tube whose distal tip appears to be post pyloric. There is
a Port-A-Cath with the distal tip in the mid right atrium. Heart size is
within normal limits. Lungs are grossly clear. There are no pneumothoraces. The patient was diagnosed with Unspecified abdominal pain. The patient was treated with ___- Interventional radiology guided thoracentesis
___ catheter placement. At the time of discharge, the patient had Primary
=======
Recurrent ascites
Secondary
=======
Metastatic gastric cancer
Moderate protein malnutrition. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>___ yo male with a history of gastric cancer, Her2 not over
expressed, MSS, metastatic to peritoneum, admitted with
increasing abdominal pain and distension. Was initially
concerned for SBP, but culture negative and stable without
treatment. Had pleurx placed for comfort with continuing
drainage requirement and underwent 5 fractions of palliative
radiation to gastric outlet. Also temporarily had enteral
nutrition. Was discharged home with hospice care services.
Active Issues
========
#Abdominal Pain
#Ascites
The patient originally presented with signs and symptoms
concerning for SBP. Because of his abdominal pain, worsening
swelling, and leukocytosis, he was started on ceftriaxone
empirically. A diagnostic tap was done and the cell counts were
not consistent with SBP. Pt also had remained afebrile, appeared
clinically stable, and blood cultures remained negative, so
treatment was stopped. Pt also had a therapeutic tap, at which
time 3L were removed. The pt continued to have abdominal pain
and swelling, with worsening ascites, so for improved comfort, a
pleurX catheter was placed for daily drainage. The patient
required twice-daily drainage of fluid of ___ liters each
drainage. On discharge, the patient can do larger volume
removals once daily in the morning to improve comfort. His wife,
___, also received education on how to utilize the drainage
symptom and plans to continue to do so at home.
#Pain control
#constipation
Pt was experiencing pain prior to admission, but was not taking
his home dose morphine secondary to constipation and nausea. He
was originally transitioned to oxycodone 10mg q3h PRN pain and
morphine IV ___ PRN for breakthrough. Pallative care was
consulted and recommended fentanyl patches for longer acting
pain regimen. He was slowly titrated up from 12mcg/h to 25mcg/h
to 37.5mcg/hour with good response. He was continued on
oxycodone 10mg a3h PRN breakthrough pain. The patient also
experienced a great deal of pain relief with the pleurx drainage
as above. The patient was started on a bowel regimen of
scheduled miralax, senna, bisacodyl, and lactulose with daily
bowel movements and improved discomfort.
#Nutrition
Pt had experienced weight loss at home secondary to poor
appetite in the setting of increasing abdominal pain and
distention. He had also experienced gastric outlet obstruction
symptoms and had previous duodenal stent placement and repair.
In order to optimize nutrition, a NG tube was place at bedside
and advanced post-pyloric by ___. Nutrition was consulted and
their recommendation for tube feeds were followed. The tube came
out of place several times and started to malfunction later in
the course. After a meeting with the patient and his HCP ___,
it was decided to discontinue the tube feeds and encourage PO
intake with liquid supplements and not to place another tube.
The patient was discharged home able to tolerate PO intake.
#Stage IV Gastric Adenocarinoma
Pt diagnosed in ___ and has continued to progress in the
setting of treatment with FOLFOX and Ramucirumab/Taxol. Not
currently on treatment. His outpatient oncologist discussed
treatment options with patient throughout the hospital stay. The
patient wished to further pursue treatment at this point.
Radiation oncology was consulted for palliative radiation to the
tumor where it caused gastric outlet obstruction. The patient
received 5 fractions of radiation therapy ___,
___, and ___ without complication. The post pyloric feeding
tube was placed as above to optimize nutrition and was d/c'd
after it stopped functioning. A goals of care meeting was had
with the patient and his wife ___, and it was agreed that the
patient would be best cared for at home with home hospice care.
The pt hoped to utilize this service and eventually pursue
further chemotherapy, if his functional status improved. He was
discharged home with directions to call his oncologist as
needed.
#Social Issues
Pt is was without health insurance and had been using a bike to
get himself to and from appointments. Also has issues affording
medications at home. Social work, case management, and
palliative care helped to get patient hospice care on discharge
to help with nursing issues and supplies. Also, patient was
given extra supplies for his pleurx and plans were made for the
patient to be able to obtain medications, including fentanyl, on
discharge.
Transitional Issues
============
[]New medications: Fentanyl 37.5 mcg/h, oxycodone 10mg q3h PRN
pain
[]Stopped medicines: Morphine (replaced with oxycodone)
[]Pt had a pleurX catheter placed inpatient, which could
increase his risk of SBP. Careful monitoring should be done
[] Pt had severe nausea with morphine, avoid if possible in pain
regimens.
[]Pt did have severe constipation on admission, can add
lactulose to bowel reg if needed
[] Patient has Pleur-X catheter in place, and has the phone
number to call if he needs more supplies
CODE STATUS: Full code
EMERGENCY CONTACT HCP: ___ ___</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: Ms. ___ is a ___ woman with a history of nephrolithiasis and
chronic headache and myofascial pain syndrome ___ prior back
surgery who presents with acute onset shaking, shivering, and
left sided flank pain. She was in her usual state of health
until two evenings ago, when she experienced acute onset
"tremors" which she describes and shakes and chills. This was
associated with urinary frequency without urgency or dysuria, as
well as severe flank pain that was consistent with pain during
prior episodes of nephrolithiasis. She also experienced
worsening of her usual chronic back pain and headache, for which
she takes tramadol, Tylenol, ibuprofen, and duloxetine. She was
concerned about these symptoms and presented to ___ ED. RENAL U.S. showed No evidence of hydronephrosis. Tiny echogenic foci in the bilateral kidneys,
likely representing small nonobstructive stones.. The patient was diagnosed with Acute pyelonephritis. At the time of discharge, the patient had PRIMARY DIAGNOSIS:
1. Acute complicated pyelonephritis
2. Nephrolithiasis
3. Myofascial pain syndrome
Secondary diagnoses:
1. Tension-type headache
2. Anemia. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>Ms. ___ is a ___ woman with a history of nephrolithiasis,
chronic headache and myofascial pain syndrome admitted with
pyelonephritis and worsening headache.
.
>> ACTIVE ISSUES:
# Acute complicated pyelonephritis: Ms. ___ was found to have
acute complicated pyelonephritis based on clinical presentation,
urinalysis, and renal ultrasound demonstrating bilateral renal
stones. She was treated with IV fluids and ceftriaxone and
transitioned to PO ciprofloxacin before discharge to complete a
10-day course. Patient urine culture grew pan-sensitive E. coli.
Her chills/rigors resolved and flank pain improved significantly
with antibiotics. For her pain, she did receive limited supply
of toradol and then was discharged with limited number of
ibuprofen.
.
# Headache: Patient presented with ___ headache. Of note, she
has a history of chronic headaches, but they are usually
intermittent and less severe. The pattern of pain was deemed to
be consistent with a tension-type headache and thought to be
triggered by active infection. Her headache was treated with her
home duloxetine, tramadol and tylenol with ketorolac as needed
for breakthrough pain.
.
>> CHRONIC ISSUES:
# Anemia: Patient was found to have a Hb of 9.6 which remained
stable during hospitalization. She mentioned that she has
chronic anemia, though our hospital has no records of previous
CBCs to confirm this. CBC was trended but otherwise no
intervention was performed.
.
# Myofascial pain syndrome: Patient has a history of myofascial
pain syndrome, with exacerbation of back pain early in the
hospitalization. This improved on her home medications plus
ketorolac, and she did not experience significant back pain at
the time of discharge.
.
>> TRANSITIONAL ISSUES:
# E. coli pyelonephritis: Urine cultures grew pan-sensitive E.
coli. Please continue antibiotics through ___ for 10-day
course. Patient will need a negative U/A to confirm clearance of
infection and should follow up in urology given bilateral kidney
stones.
# Anemia: Hb was stable at 9.7 at discharge. Recommend
re-checking H/H and pursuing anemia workup as outpatient.
# EMERGENCY CONTACT HCP: husband ___ ___
# Code Status: Full</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ h/o HTN & seizure disorder who presents with nausea/vomiting
& abdominal pain x5 days with decreased PO intake. She has had
___ episodes like this per year but they are often self limiting
with diet regulation within one week. She
denies fevers, chills, diarrhea or dizziness. Her last BM was 2
days ago and she last passed gas last night. Upon presentation
to the ED, she underwent CT Abdomen which noted diffuse
gallbladder wall edema with minimal peripancreatic fat
stranding; she subsequently underwent RUQ US which showed
cholelithiasis but no gall bladder distension or wall
thickening; Surgery was consulted
to evaluate for possible acute cholecystitis. MRCP showed 1. Cholelithiasis with gallbladder wall thickening and pericholecystic edema.
In the absence of gallbladder distension, these findings are equivocal for
acute cholecystitis.
2. Findings consistent with pancreatitis. No focal drainable collection or
evidence of pancreatic necrosis is identified.
3. No intra or extrahepatic biliary ductal dilatation.
4. Simple right renal cysts measuring up to 12 mm. CHOLANGIOGRAM,IN OR W FILMS showed 1. Small filling defect within the distal CBD may represent a focus of air,
however a small stone cannot be entirely excluded.
2. Correlation with real-time findings and, when appropriate, correlative
radiographs is recommended for full assessment. The patient was diagnosed with Cholangitis. The patient was treated with ___: Laparoscopic cholecystectomy and intraoperative
cholangiogram. At the time of discharge, the patient had ___ 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>Ms. ___ is a ___ y/o F w/ hx of HTN & seizure disorder who
presented to ___ with nausea/vomiting & abdominal pain x5 days
with decreased PO intake. Upon presentation to the ED, she
underwent CT Abdomen which noted diffuse gallbladder wall edema
with minimal peripancreatic fat stranding. She subsequently
underwent RUQ US which showed cholelithiasis but no gallbladder
distension or wall thickening. Labs were notable for
transaminitis. The Acute Care Surgery service was consulted and
recommended ERCP for gallstone pancreatitis. The patient was
initially admitted to the Medical Service and ERCP was
consulted.
On HD1, the patient was started on IVF, IV abx, pain medication
and anti-emetics as needed. Carbamazepine was continued for the
patient's known seizure disorder and home baclofen was ordered.
HCTZ was temporarily held as the patient was hypotensive on
presentation to her PCP's. The patient was noted to have a
Stage III Decubitus ulcer. A wound nursing care consult was
placed and santyl was applied to the wound.
The patient's LFTs continued to improve and there was the
possibility that she had passed a gallstone. MRCP revealed no
ductal dilation or choledocholithiasis, so no ERCP was warranted
at the time.
On HD2, the patient was taken to the operating room and
underwent laparoscopic cholecystectomy with intraoperative
cholangiogram (IOC). IOC was concerning for a small filling
defect within the distal CBD which may have represented a focus
of air, however a small stone could not be entirely excluded.
The patient tolerated the surgery well (reader, please refer to
operative note for further details). After remaining
hemodynamically stable in the PACU, the patient was transferred
to the surgical floor. ERCP was reconsulted and ___ the
patient had an ERCP with sphincterotomy and sludge swept. The
patient tolerated this procedure well. LFTs and lipase were
trended.
The patient was kept NPO after her ERCP and then diet was
advanced to regular which was well-tolerated. She was
prescribed a 5 day course of ciprofloxacin. The patient was
alert and oriented throughout hospitalization; pain was managed
with acetaminophen and oxycodone (although the patient reported
pain was well controlled without pain medication). The patient
remained stable from a cardiovascular and pulmonary standpoint;
vital signs were routinely monitored. Good pulmonary toilet, and
incentive spirometry were encouraged throughout hospitalization.
Patient's intake and output were closely monitored. The
patient's fever curves were closely watched for signs of
infection, of which there were none. The patient's blood counts
were closely watched for signs of bleeding, of which there were
none. The patient received subcutaneous heparin and ___ dyne
boots were used during this stay and was encouraged to get up
and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
voiding without assistance, and pain was well controlled. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.</s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: This is a case of ___ man with significant perianal
Crohn's complicated by coccyx osteomyelitis who underwent
laparoscopic loop ileostomy, now presets to the ED with
abdominal
pain. condition started yesterday in the morning when he starts
feeling sudden onset of abdominal pain associated with nausea
but
no vomiting. He noticed that the ostomy stopped being productive
as well as no gas. He said he usually wait and do worm bathing
and that most of the time help, but this time it seems like it's
not aid to reduce his symptoms. He denies having any fever or
chills or no other complaints. Of notes: he has been complaining
of redness around the ostomy site extending to the right flank
which he is currently taking Abx started on last ___. CHEST (PORTABLE AP) showed NG tube tip is in the stomach, with its tip being below the inferior margin of
the film. Heart size and mediastinum are stable. Lungs are overall clear.
There is no appreciable pleural effusion. There is no pneumothorax. The patient was diagnosed with Unspecified intestinal obstruction. At the time of discharge, the patient had Parastomal Hernia causing small bowel obstruction. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the colorectal surgery service for
management of small bowel obstruction secondary to a parastomal
hernia. He presented with abdominal pain, nausea/vomiting, and
cessation of ostomy output. CT imaging showed small bowel
obstruction with transition point in the parastomal hernia. He
underwent placement of an NGT in the ER for decompression and
manual reduction of the hernia in the ER. He was admitted to the
surgical floor and treated conservatively with NGT, IVF, and
bowel rest. He was closely monitored with serial abdominal exams
and manually reduced once more for recurrent incarceration with
worsening abdominal pain. On HD2, he started having stool per
ostomy and increased NGT output, with improvement in his
abdominal pain and tenderness on exam. He was bolused with
fluids as needed given high NGT output to maintain adequate
urine output. On HD3, he had flatus per the stoma and felt
significantly improved. His NGT was clamped then removed after
the clamp trial was tolerated well. He was started on clear
liquid diet, which he tolerate well, then advanced to regular
diet on HD4. He ambulated and voided appropriately. He was
afebrile and hemodynamically stable throughout his stay. He
additionally was noted to have erythema around his stoma, for
which he was seem by dermatology and had a kenalog injection
performed for pyoderma gangrenosum prior to discharge. He will
be seen in follow up in colorectal surgery clinic in ___ weeks. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ presents with 3 day history of sudden onset RLQ and
periumbilical abdominal pain ___ in severity, nausea and
several episodes of non-bloody, non-bilious emesis. She also
complains of anorexia since the pain began. Additionally, she
complains of myalgias and chills, and was febrile to 101.4 at
home earlier today. CHEST (PORTABLE AP) showed NG tube tip is in the very proximal stomach and should be further advanced.
The side hole is in the distal esophagus. Bibasal atelectasis are present. UNILAT UP EXT VEINS US LEFT showed No evidence of deep vein thrombosis in the left upper extremity. ___ DUP EXTEXT BIL (MAP/DVT) showed No evidence of deep venous thrombosis in the bilateral lower extremity veins. The patient was diagnosed with ACUTE APPENDICITIS NOS. The patient was treated with ileocectomy. At the time of discharge, the patient had acute gangrenous 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>Patient underwent diagnostic laparoscopy, open ileocecectomy for
gangrenous appendicitis, resection of mesenteric nodule, and JP
drain placement. Pathology report of surgical specimens
identified necrotizing appendicitis with perforation,
unremarkable colon and small intestine. Specimen labeled
mesenteric nodule consisted of encapsualted fat necrosis,
consistent with infarcted epiploic appendage. Please see
operative note for further details regarding the operation.
Post operatively, patient received 500cc fluid bolus x2 for low
urine output. She was started on IV Cipro/Flagyl. On POD2, NGT
and foley were removed. On POD3, patient was triggered for low
urine output and a foley was replaced for close urine
monitoring. Urine output was adequate and foley was removed the
following day. On POD6, she had flatus and she was given sips.
On POD7, she was noted to have a elevated WBC (13.6-18.4). UA
and Urine culture were negative. She was also noted to have
bilateral leg swelling and left upper arm swelling (IV site).
She has history of left leg swelling ___ chronic lymphedema. She
underwent noninvasive venous duplex studies of bilateral lower
legs and left arm, which were all negative for deep vein
thrombosis.
By POD8, she was having bowel movements and her leukocytosis was
resolving (18.4-16.7). She was advanced to regular diet and
transitioned to PO Cipro/Flagyl. However, she had an episode of
bilious vomiting at dinnertime. She was transitioned back to
clears. On POD9, her leukocytosis continued to decrease (WBC
16.7-15.8). On POD 10, she was given a regular diet which she
tolerated with no complications of nauseas, vomiting, or
abdominal pain. JP drain was removed as output was minimal for
multiple days. At time of discharge, she was tolerating regular
diet, having normal bowel movement, and ambulating. She
understood the risks of developing an abscess after a perforated
gangrenous appendix and is aware of concerning signs and
symptoms. She was discharged on 4 more days of PO Cipro/Flagyl
to complete a 2 week antibiotic course. She was arranged ___
services for midline abdominal wound (moist-to-dry) and close
follow-up in ___ clinic. </s> |
<s>[INST] <<SYS>> Act as a health expert <</SYS>> create brief hospital course of the following text: ___ year old gentleman otherwise healthy presents with right jaw
pain,
swelling, bruising over neck. He left a bar on ___ night,
___ and there was fight outside of the bar where he sustained
a
closed fist punch to his right lower jaw. He had mild discomfort
on ___ but this morning he woke up with worsening pain and
developed swelling, ecchymoses over neck. He went to ___ where a CT scan revealed a R mandible fracture and he
was sent here. Pain is tolerable currently. Complains of change
in his bite. Denies LOC at the time of injury. Has only been
able
to eat liquids/soft foods, can't chew well. Denies SOB,
difficulty breathing, CP, fevers, chills, HAs, vision changes. Radiology showed Normal chest radiographs. Radiology showed Fractures through the body of the mandible on both sides with displacement on
the right. Radiology showed Expected appearances following open reduction internal fixation
of right and left mandibular fractures with additional removal of two teeth
from the right lower dentition. The patient was diagnosed with FX ANGLE OF JAW-CLOSED, STRUCK BY OBJECT OR PERSON WITH OR WITHOUT FALL. The patient was treated with ___ ORIF left and right manibular fractures. At the time of discharge, the patient had trauma: right manbibular fracture. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge. The patient expressed readiness for discharge. [/INST] </s><s>The patient was admitted to the hospital after he was punched in
the jaw. Upon admission, he was made NPO, given intravenous
fluids, and underwent imaging. The patient was reported to have
fractures through the body of the mandible on both sides with
displacement on the right. The patient was taken to the
operating room on HD # 2 where he underwent an ORIF of he left
and right manibular fractures. His operative course was stable
with a 100 cc blood loss. At the close of the procedure, a
drain was placed. The patient was extubated after the procedure
and monitored in the recovery room.
His post-operative course has been stable. He resumed a full
liquid diet. His vital signs have been stable and he has been
afebrile. His surgical drain was removed prior to discharge.
The patient was discharged home on POD # 2. He will continue a
full liquid diet for ___ weeks, per OMFS. He will be discharged
on peridex mouth rinse and 1 week of keflex, per OMFS. He will
follow up with OMFS. This was communicated to the patient prior
to discharge. </s> |